A Growing Rural Crisis

Death rates from opioid overdoses climb where health-care infrastructure wanes.

Indiana farmer Randy Hedrick gave up using opioid painkillers after a 20-year addiction, turning to his faith for answers, Image by Dave Charrlin

Communities across the country are looking for hopeful approaches to combat the scourge of opioid addiction.

Putting the problem back in the jar-- or bottle-- may be impossible. Victims often are faceless and nameless in a national tragedy that buries families in stigma.

Opioid overdose victims can be any family member, friend, neighbor or coworker of any generation, in urban as well as rural America. Families are losing loved ones to a crisis still on the rise nationally.

Columbus, Indiana, farmer Randy Hedrick could have been just another grim statistic. Instead, he went from taking 400 milligrams of opioid painkillers a day to zero.

“My dad, as I was growing up in the ’60s and ’70s, he was addicted to painkillers,” Hedrick says. “I fell right into the same trap. It is just off-the-wall bad right now. We’ve opened a Pandora’s box, and, we can’t get out.”

RURAL BATTLEFRONT

Rural America is a crucial battlefront where the crisis is growing. At the same time, the agriculture-based economy continues to struggle and lacks the resources to support needed health-care infrastructure improvements and growth.

Agriculture-based rural America is the center of a perfect opioid storm--the risk of injury and need for pain relief may be greater while working on farms than in any other occupation.

In 1999, the drug-overdose death rate for urban areas was higher than in rural areas, at 6.4 per 100,000 residents compared to 4 in rural areas, according to the Centers for Disease Control and Prevention (CDC). By 2015, rural overdose death rate per 100,000 residents spiked to 17 compared to the urban rate of 16.2.

From 2000 to 2014, there was a 200% increase nationally in the rate of overdose deaths involving opioid pain relievers and heroin.

The most commonly prescribed opioids are methadone, oxycodone and hydrocodone. Prescription drugs accounted for 40% of opioid overdose deaths in 2016, according to the CDC. Addiction to prescription opioids is the biggest risk factor for starting illicit heroin.

The recent rise of the synthetic opioid fentanyl has created a whole host of new and more dangerous challenges. Fentanyl is 50 times more potent than heroin and 100 times stronger than morphine: It only takes 3 milligrams to be lethal. The CDC says death rates from fentanyl doubled from 2015 to 2016, when more than 19,000 people died.

“It took a while for policymakers to think about it in the right way,” says Dr. Andrew Kolodny, codirector of the Opioid Policy Research Collaborative at Brandeis University, in Waltham, Massachusetts. “There is a flurry of activity across the country, all trying to tackle the problem through public-health interventions. The efforts are new, so, we don’t yet have a good evidence base for what works and doesn’t work.”

A FARMER’S JOURNEY

There was a dry creek bed near Randy Hedrick’s Columbus, Indiana, farm.

In his mind’s eye, he still sees his father lying dead, trapped underneath an overturned four-wheeler in loamy soil. Addiction to opioid painkillers played a role.

The choice was simple: Hedrick could end his addiction, or he could end up like his father.

The younger Hedrick became addicted after using opioids to deal with injuries on the farm.

When his father died, Hedrick had been using opioids himself for nearly 20 years. During the throes of addiction, Hedrick says he was unable to think clearly because of a perpetual fog.

Early in his recovery fight, Hedrick stayed in a rehab clinic for a week and attended support meetings. He fought withdrawal symptoms, which typically include nausea, muscle cramping, anxiety and depression.

“I started asking hard questions,” he says. “It helped me to see how I got involved in drugs. One thing I learned when I got clean, I don’t want any more secrets.”

Within months following his father’s death, Hedrick was clean.

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FAMILY AT A LOSS

Gunnison, Utah, farmers Richard and Annette Dyreng were vacationing in Texas on Jan. 11, 2017, when the phone rang.

A solemn-voiced police officer says their daughter, Cami Dyreng, 39--a former scholar, college marching band member, high school cheerleader and mother of three boys--was found dead from a heroin overdose back home.

For the first time in more than a year, Richard and Annette say Cami’s spirits were so low she sat out the family vacation at home.

Cami dabbled in heroin again less than one month before she died.

Family photos portray the life of a young, vibrant girl.

There is a young woman posing barefoot in her white wedding dress; a grade-schooler wearing a red plaid dress and two red and white bows in her hair; a smiling little girl standing still with arms stretched out wearing a white dancing suit; an energetic teenager in her blue and white cheerleading outfit and pom-poms in each hand; and a young mother holding her baby lovingly to her chest.

“She knew if she used heroin again, she would die,” Annette says, choking back tears. “She was trying to die. I think it was just her mental health. It was the emotional battle. Where her life was, it was depressing. She just had no hope. She just couldn’t see a bright future.”

Cami’s parents still had hope.

In the year leading to Cami’s death, she appeared to be on the road to recovery, they say, and was more like the cheerful girl of her youth.

“The last 16 months of her life, we had great times with her,” Richard says softly.

The Dyrengs believe a lack of opportunity near their town, 130 miles south of Salt Lake City, was ultimately the missing piece in their daughter’s rocky road to health.

Even with drug counseling and other health services available in the Gunnison area, along with loving family and friends around to help, Cami struggled to find a new path.

Following a series of arrests on drug charges, her application for admission to Utah State University to study psychology was rejected. Everyone in her hometown knew her history--she couldn’t find job opportunities.

“In her death, tons of people showed up to pay tribute,” Richard says. “We stood in line for three hours shaking hands. All the help in the world would not help if communities are not willing to make a change.”

THE SPREAD OF OPIOIDS

While opioids in the form of heroin are sold illegally, opioid painkillers are widely available legally and often easily accessible in medicine cabinets across the country.

Rising rates of addiction coincide with a huge expansion in the number of opioid prescriptions in the past 20 years.

A July 2017 Centers for Disease Control and Prevention study reported opioids prescribed in the United States actually peaked in 2010, at 782 morphine milligram equivalents per capita. That number decreased to 640 in 2015, though the reasons for this are unclear.

“Despite significant decreases, the amount of opioids prescribed in 2015 remained approximately three times as high as in 1999 and varied substantially across the country,” the study says.

The U.S. Drug Enforcement Agency holds an annual national drug take-back day. Since May 2016, the event at more than 5,000 locations across the country has collected about 5,484 tons of prescription medications. It is unclear how much of that is opioids.

Amy Haskins, project director of the Jackson County Anti-Drug Coalition, public health educator and sanitarian at the Jackson County Health Department in West Virginia, says because young kids often find and use opioid painkillers from relatives’ medicine cabinets, antidrug efforts focus heavily on educating kids on dangers as early as elementary school.

“With kids, we need to tell them, ‘Don’t take anything that doesn’t belong to you,’ ” she says.

“A lot of these kids had access to meds, and, it was leftovers in the house, and, parents are not counting meds. Parents: Tell them to never go into a medicine cabinet. Nobody wants their kids to be the next one. We talk to seniors [elderly] and tell them to switch locations for their medicines, put them in a new place. Don’t put them in obvious places.”

RURAL TREATMENT LACKING

Nationally, 65% of rural counties do not have a practicing psychiatrist, 47% lack a psychologist and 81% lack a psychiatric nurse practitioner, according to the National Rural Health Association.

Gage Stermensky, director of behavioral health at Community Action Partnership of Western Nebraska, in Gering, says there’s no easy answer to address doctor shortages in rural areas.

“One of the biggest challenges is mostly in MDs [medical doctors], people in psychiatry,” he says.

Nebraska has the third worst need-to-capacity ratio for opioid addiction in the country, at 6-to-1, behind Arkansas and South Dakota, at 7-to-1, according to a 2016 University of Nebraska-Lincoln study.

On Oct. 3, the U.S. House of Representatives and the U.S. Senate both passed the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act. The measure includes dozens of bills aimed at various aspects of the crisis. The legislation was signed into law by the president on Oct. 24, 2018.

ON THE FRONT LINES

Opioid addiction has become an everyday way of life in Morehead City, North Carolina, where One Harbor Church pastor, Donnie Griggs, is on the front lines in his rural town of 9,000.

Griggs’ brother, Curtis, was addicted to drugs starting at age 12. By 17, he was hooked on Xanax and oxycodone. From there, he started using heroin daily. The town is surrounded by small towns of 100 or fewer residents—all of them facing the opioid challenge.

Griggs comes to the rescue with ambulances on overdose emergencies. He has seen friends die from suicide brought on by addiction.

“It’s affecting every facet of society,” Griggs says. “I’m in mansions, and I’m in trailer parks. It acts like a bomb and not a bullet. We can’t get foster parents as hard as we try. It is in the school system; kids are trading drugs.

“I’m not the savior for this little town. God can set them free. I can’t impose myself on people.”

Actionable Insights:

Studies show 90% of all teens who abuse pharmaceutical drugs obtain them from home medicine cabinets or friends’ medicine cabinets. One in four teenagers has taken a prescription drug not prescribed for them. That’s why it is important to store personal prescriptions safely.

If you no longer use but hold onto painkillers, find a local take-back program to dispose of them. If programs aren’t available, lock prescription drugs away, and change storage locations every couple of months.

One of the major barriers to overcoming addiction is the stigma attached to drug users. Often, stigma prevents people in need of help from coming forward for fear of public shame.

Working hard to foster a sense of community and acceptance in rural areas of people fighting addiction can be the difference between living and dying.

In many cases, drug-overdose survivors are looking for second chances. Criminal history can make it difficult for recovering addicts to find jobs. So, employer willingness to provide opportunities can make a difference.

Telemedicine can be a valuable tool in combating opioid addiction, but, many rural areas lack access to broadband internet.

Where broadband is available, schools can play an important role in providing medical services to families at schools via telemedicine. In some rural areas, families have to travel hundreds of miles to see doctors.

Teachers and school staff often are on the front lines. So, schools can train school employees to identify substance abuse in students.

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