Although popular coverage tends to identify the drug crisis with rural America, a report released Friday by the Centers for Disease Control indicates that urban areas now have higher rates of overdose deaths.
As the most recent data indicate, America is still in the middle of a drug crisis, with nearly 70,000 deaths from drug overdose in 2018. A number of states have seen slight declines in deaths, predominantly from prescription opioids, but the country has also experienced an increase in the number of deaths caused by cocaine, methamphetamine, and the deadly synthetic opioid fentanyl.
The new brief from the CDC reveals a new contour to the crisis. Throughout the early 2000s, the drug epidemic was understood as primarily a challenge for rural America: so-called deaths of despair rose among middle-aged, low-status whites, predominantly in rural communities. Between 1999 and 2006 the drug overdose death rate rose faster in rural counties than in urban ones; between 2006 and 2015, the majority of overdose deaths were in rural counties, according to the CDC.
The trend appears to have reversed beginning in 2016, with urban counties eclipsing rural counties in rates of overdose deaths. It is likely that this trend has continued. According to the CDC, rates of prescription opioid and methamphetamine deaths—the former has declined in recent years, the latter is growing but comparatively small—were relatively high in rural areas. Heroin, fentanyl, and cocaine deaths were more frequent in urban areas, with fentanyl being the predominant driver of all overdose deaths today.
The CDC identified other underlying differences. Men in general overdose more than women, but there was variation within each gender. Specifically, in 2017 the age-adjusted overdose death rate was higher for rural women than urban women, while it was higher for urban men than rural men.
By age group, overdose death rates were higher for urban counties than rural counties across the board in 2017. But the rates for those who were ages 25 to 44 were barely distinguishable between urban and rural, while overdoses were much higher for urban people of other age brackets. Drugs kill people of all ages in urban counties, but mostly the middle-aged in rural counties.
The drug crisis is best understood as both an urban and rural phenomenon, with each part of the country requiring different policy interventions to target the particular pathologies associated with drug use therein. Rural counties often suffer from a lack of access to doctors able to offer comprehensive treatment, especially those licensed by the DEA to provide the medication-assisted treatment buprenorphine. The changing supply dynamics of cities, meanwhile, may need closer attention, as heroin disappears and is replaced by cheap fentanyl.