Ann Dudko
A confluence of historically unprecedented forces has driven addiction-related disease and death into the very heart of rural and frontier communities in the United States. It remains to be seen whether this perfect storm can be met by the development and mobilization of expanded recovery support resources for individuals, families, and communities.
Rural and frontier communities vary widely in their characteristics, vulnerabilities, and resiliencies, but they do tend to share some distinguishing features: geographical isolation, individualism, religiosity, cultural and political conservatism, a distrust of outsiders, and recent decades of economic distress (e.g., declines in rural farming, manufacturing, and mining) and out-migration of young adults. The perfect storm that brought rising rates of addiction-related death and disease (e.g., HIV, Hep C) must be viewed within the context of these larger strains on rural community life. In 2009, in our book Methamphetamine: Its History, Pharmacology, and Treatment, Dr. Ralph Weisheit and I suggested that drug surges could ignite rapidly within conditions of high drug availability, the absence of drug controls, a vulnerable population, and a climate of cultural demoralization, mass unemployment, poverty, or mass migration. We further went on to predict that methamphetamine could be the Trojan Horse that would lead to the rise of prescription opioid and heroin use and increased sedative addiction in rural communities that had long been immune to opioid addiction.
That sequence of cultural, family, and personal vulnerability and the transition from methamphetamine, oral use of prescription opioids, and the migration to heroin use is the perfect storm that now bears the aftermath of overdose deaths and outbreaks of HIV infection and portends potentially enduring increases in alcohol and sedative dependence in these communities. (A rarely noted fact in coverage of the surge in opioid addiction is that the majority of overdose deaths result from combinations of opioids with alcohol and other sedative drugs particularly benzodiazepines).
There are all manner of responses to the alarms rising in rural communities over surges in opioid addiction. Most focus on drug control measures, harm reduction measures aimed at reducing overdose deaths, and expanding access to treatment particularly medication-assisted treatment. These are all important efforts, but the question remains whether supports for long-term personal and family recovery from opioid addiction will be included within these strategies. Such supports would involve shifting the lens through which we examine rural areas from a pathology or intervention paradigm to a solution-focused recovery paradigm (See my 2011 paper). It will require, as it will for the whole country, shifting from models of acute stabilization (serial episodes of brief treatment) to models of sustained recovery management and creating recovery landscapes within which long-term recovery can flourish. It will require mobilizing assets within the rural community--including individuals and families in recovery, recovery mutual aid organizations, new recovery support institutions, and new technology-based recovery supports to create such models and such recovery spaces.
One of the obstacles to achieving this vision is that we have so little scientific research on addiction recovery within rural and frontier communities. Lacking such guidance, we must rely at the moment on a growing body of experiential knowledge drawn from the heart of rural communities facing this crisis. We need venues to bring professional and lay leaders within these communities together to share their experience, strength, and hope and to share the most effective recovery support strategies. For those on the frontlines of this crisis, I urge you to share in whatever ways you can what you are learning. The future of many rural communities may well rest on how quickly such lessons can be learned and exchanged.