Newly released data reveals a 'virtual opioid belt' developed over about 15 years in West Virginia, Virginia and Kentucky

Average number of pills distributed per person per year, ranked by county from 2006 to 2019. White is equal to zero pills and scarlet is 120+ pills; shades of pink are ranges between those two. (Post via Openmap, with DEA Automation report data)

America's battle with pain-pill prescriptions might be tapering off, but deaths spawned by its spin-offs, heroin and fentanyl, have increased, and deeply affected regions are still clawing toward a recovery.

A database maintained by the Drug Enforcement Administration shows how the use of pain pills increased dramatically, particularly in Appalachian counties. The database "tracks every single pain pill sold in the United States, tracing the path from manufacturers and distributors to pharmacies in every town and city," reports Steven Rich, Paige Moody and Kevin Schaul of The Washington Post. "These records provide an unprecedented look at the surge of legal pain pills. . . which resulted in more than 210,000 overdose deaths during the 14-year time frame ending in 2019. It also sparked waves of an ongoing and raging opioid crisis first fueled by heroin and then illicit fentanyl."

The information can help people "understand the impact of years of prescription pill shipments on their communities," the Post reports. "A county-level analysis shows where the most oxycodone and hydrocodone pills were distributed across the country over that time — more than 145 billion in all."

The DEA's database, known as ARCHOs, was not willingly shared with the public. The Post and HD Media, which publishes the Charleston Gazette-Mail in West Virginia, "waged a year-long legal battle for access to the database, which the government and the drug industry had sought to keep secret," Rich, Moody and Shaw add. "The initial release of data covered 2006 to 2012, and was later updated through 2014. . . . The Post analysis shows that the volumes of the pills handled by the companies climbed as the epidemic surged, increasing by 52 percent from 8.4 billion in 2006 to 12.8 billion in 2011."

Appalachian counties have maintained that their regions were targeted by pharmaceutical companies' greed. The maps show how those areas suffered more than other areas of the country. The Post reports, "Comparing county-level maps of prescription opioid overdose deaths and pill shipments reveal a virtual opioid belt of more than 90 counties stretching southwest from Webster County, W.Va., through southern Virginia and ending in Monroe County, Ky. This swath includes 18 of the top 20 counties ranked by per-capita prescription opioid deaths nationwide and 15 of the top 20 counties for opioid pills distributed per capita."

The maps show a 'virtual opioid belt' through Appalachia. (Post map, from DEA and CDC data)

Deadline is tomorrow to register for free Rural Health Journalism Workshop in Cincinnati June 9

The Association of Health Care Journalists is hosting a free workshop on covering rural health on June 9 in Cincinnati. The keynote speaker will be Julie Willems Van Dijk, director of County Health Rankings and Roadmaps, an annual measure of vital health factors revealing a snapshot of how health is influenced by where people live, learn, work and play. The registration deadline is Friday.

Five workshops will cover a variety of areas, including "Finding rural health stories: What reporters need to know," featuring Trudy Lieberman, contributing editor of Columbia Journalism Review and Laura Ungar, investigative and enterprise reporter for The Courier-Journal and USA Today. The workshop will moderated by Al Cross, director of the Institute for Rural Journalism and Community Issues, publisher of The Rural Blog.

Another workshop, "Challenges of keeping a rural health workforce," will include Timothy L. Putnam, president and chief executive officer of Margaret Mary Health and Brent Wright, associate dean for rural health innovation at the University of Louisville School of Medicine. This workshop will be moderated by Melissa Patrick, a journalist for Kentucky Health News, which is published by the Institute for Rural Journalism and Community Issues.

Other workshops include: "How the battle over health reform is impacting rural residents;" "The geographic divide: Reporting on disparities;" and "Covering the opioid epidemic beyond cities." To register for the event click here.

Deadline Friday to register for free June 9 workshop for journalists on covering rural health

The Association of Health Care Journalists is hosting a free workshop on covering rural health on June 9 in Cincinnati. The keynote speaker will be Julie Willems Van Dijk, director of County Health Rankings and Roadmaps, an annual measure of vital health factors revealing a snapshot of how health is influenced by where people live, learn, work and play. The registration deadline is Friday, May 26.

Five workshops will cover a variety of areas, including "Finding rural health stories: What reporters need to know," featuring Trudy Lieberman, contributing editor of Columbia Journalism Review and Laura Ungar, investigative and enterprise reporter for The Courier-Journal and USA Today. The workshop will moderated by Al Cross, director of the Institute for Rural Journalism and Community Issues, which publishes The Rural Blog.

Another workshop, "Challenges of keeping a rural health workforce," will include Timothy L. Putnam, president and chief executive officer of Margaret Mary Health and Brent Wright, associate dean for rural health innovation at the University of Louisville School of Medicine. The workshop will be moderated by Melissa Patrick, a journalist for Kentucky Health News, which is published by the Institute for Rural Journalism and Community Issues.

Other workshops are: "How the battle over health reform is impacting rural residents;" "The geographic divide: Reporting on disparities;" and "Covering the opioid epidemic beyond cities." To register for the event click here.

Sessions seeks more 'severe penalties' for drug offenders, reversing Obama-era policy

Jeff Sessions Thursday at the University of
Charleston (Gazette-Mail photo by Kenny Kemp)

Attorney General Jeff Sessions wants federal prosecutors to charge drug offenders "with the most serious, provable crimes carrying the most severe penalties," Sari Horwitz and Matt Zapotosky report for The Washington Post. There had been a push in recent years to direct some defendants towards treatment, rather than incarceration, or lesser sentences. Also, prisons in many states have struggled with overcrowding.

In 2013, then-Attorney General Eric H. Holder Jr. "instructed his prosecutors to avoid charging certain defendants with drug offenses that would trigger long mandatory minimum sentences," reports the Post. "Defendants who met a set of criteria such as not belonging to a large-scale drug trafficking organization, gang or cartel, qualified for lesser charges—and in turn less prison time—under Holder’s policy. But Sessions’s new charging policy, sent to more than 5,000 assistant U.S. attorneys, orders prosecutors to 'charge and purse the most serious, readily provable offense' and rescinds Holder’s policy immediately."

Sessions memo stated: "By definition, the most serious offenses are those that carry the most substantial guidelines sentence, including mandatory minimum sentences. There will be circumstances in which good judgment would lead a prosecutor to conclude that a strict application of the above charging policy is not warranted. In that case, prosecutors should carefully consider whether an exception may be justified.”

Sessions said on Thursday in West Virginia, which leads the nation in deaths from the disproportionately rural opioid epidemic, that the growing push to step away from intensifying criminal prosecution of drug criminals misses the point, Eric Eyre and Jake Zuckerman report for the Charleston Gazette-Mail. Sessions said, “They would say, which is pretty much true, ‘We can’t arrest our way out of this problem,’ and that is true, we can’t. But it is a big political part of it, and people should not diminish the power and effectiveness of good law enforcement. But prevention, I truly believe, is the greatest part of our challenge and, over time, prevention will be the most effective.”

Eyre and Zuckerman note that although Sessions advocated for drug abuse prevention, he was speaking at an event co-hosted by the Drug Enforcement Administration Community and the Anti-Drug Coalition of America, which is funded by the Office of National Drug Control Policy. Trump's budget would cut the office 95 percent.

Heart infection on the rise among intravenous drug users in Central Appalachia

Ohio Valley Resource graphic; click on it for large version

A rising number of intravenous drug users in Central Appalachia are contracting a form of heart infection called endocarditis that requires costly, repeated surgery, Mary Meehan reports for Ohio Valley Resource. The endocarditis rate has doubled in the past decade, leading to annual Medicaid spending on treatment of $700 million, according to the Centers for Disease Control and Prevention.

"Endocarditis is a result of bacteria accumulating around and infecting a heart valve. It can appear initially as mild, flu-like symptoms or chest pains and extreme discomfort," Meehan writes. "Emergency surgery to replace heart valves is required in the most extreme cases, but standard treatment involves weeks of sustained doses of antibiotics to make sure the infection is completely cleared."

The CDC says "addicts with endocarditis are 10 times more likely than other patients to die or require a second surgery months after initially leaving the hospital," Meehan writes. "Research has also shown that addicts tend to leave the hospital more often before the weeks-long series of antibiotics that is necessary to complete treatment. In many cases, the patients are in withdrawal from opiate addiction during treatment." Dr. Saritha Gomadam, an infectious disease specialist at the University of Kentucky, told Meehan, "The intense atmosphere of post-surgery care only amplifies the anxiety and pain of withdrawal from opiates."

Free workshop for journalists on covering rural health to be held June 9 in Cincinnati

The Association of Health Care Journalists is hosting a free workshop on covering rural health on June 9 in Cincinnati. The keynote speaker will be Julie Willems Van Dijk, director of County Health Rankings and Roadmaps, an annual measure of vital health factors revealing a snapshot of how health is influenced by where people live, learn, work and play. The registration deadline is May 26.

Five workshops will cover a variety of areas, including "Finding rural health stories: What reporters need to know," featuring Trudy Lieberman, contributing editor of Columbia Journalism Review and Laura Ungar, investigative and enterprise reporter for The Courier-Journal and USA Today. The workshop will moderated by Al Cross, director of the Institute for Rural Journalism and Community Issues, which publishes The Rural Blog.

Another workshop, "Challenges of keeping a rural health workforce," will include Timothy L. Putnam, president and chief executive officer of Margaret Mary Health and Brent Wright, associate dean for rural health innovation at the University of Louisville School of Medicine. The workshop will be moderated by Melissa Patrick, a journalist for Kentucky Health News, which is published by the Institute for Rural Journalism and Community Issues.

Other workshops are: "How the battle over health reform is impacting rural residents;" "The geographic divide: Reporting on disparities;" and "Covering the opioid epidemic beyond cities." To register for the event click here.

Rise of drug-treatment centers brings Georgia traffic from out of state; new law will limit clinics

Georgia Gov. Nathan Deal said he will sign a bill today for stricter regulations of drug-treatment centers, which have been popping up in rural towns in the northwestern part of the state and are drawing large numbers of people from neighboring Tennessee, Ezra Kaplan reports from Ringgold for The Associated Press. The bill also limits the number of treatment centers that can open in a specific area. Georgia leads the South with the most drug treatment centers, at 71, two more than Florida, which has twice the population.

Relaxed rules in Georgia and stricter regulations in Tennessee have led to an increase in recent years of privately owned treatment centers in Georgia for heroin and prescription painkiller addicts, Kaplan reports. Data from the Georgia Department of Behavioral Health and Developmental Disabilities shows that last year one in five people treated at an opioid treatment center in Georgia came from out of state. In Northwest Georgia, which borders Chattanooga, two of three patients are from out of state.

Complaints from local residents led state Sen. Jeff Mullis, who represents much of the northwest, to lead a push this year "to pass a new set of statewide regulations on the industry," Kaplan writes. "The new rules will require programs to demonstrate a need for their services, similar to the certificate of need licensing program already used in Tennessee. Previously, open competition was really the only constraint on the number of clinics in Georgia. Mullis's bill also limits the number of centers that can open in newly established regions around the state. His region will already be at capacity as soon as the bill is signed." (Read more)

After 270% surge in painkiller prescriptions to veterans, focus redirected to therapy, exercise

Use of prescription painkillers among veterans increased 270 percent from 2001 to 2012, Jessica Lilly and Roxy Todd report for West Virginia Public Broadcasting as part of a series on opioids in Appalachia. About 24 percent of all veterans live in rural areas.

In West Virginia, which leads the nation in opioid use, VA clinics were known for prescribing painkillers for chronic pain, reports WVPB. For example, one-fourth of all veterans who visited the VA in Beckley in southern West Virginia in 2012 was prescribed opioid painkillers, well above the national average. (WVPB graphic: VA center opioid rates in West Virginia)

Since 2012 the number of opioids prescribed at VAs have decreased in West Virginia and the U.S., reports WVPB. "For the past three years, the VA has begun implementing new pain management recommendations for treating veterans who have chronic pain. In 2013 the VA released a new set of guidelines called The Opioid Safety Initiative, which concluded that opioids are not the best treatment for most types of chronic pain. Instead, VA doctors are encouraged to prescribe alternative therapies, like yoga, physical therapy and chiropractic care."

The Centers for Disease Control and Prevention last year released similar guidelines that ask doctors to encourage patients to try physical therapy, yoga, chiropractic or exercise therapy before they are prescribed painkillers, Lilly and Todd write in another story in the series. That's because a CDC study found "that one in four patients receiving long-term opioid therapy in primary care settings struggle with opioid use disorder."

Study: Older Americans more likely to die from prescription painkillers, younger from heroin

A divide exists in heroin and prescription painkiller deaths. Analysis of drug overdose and emergency room data from 2013-14 by University of Maryland professor Jay Unick, who has written several studies on health consequences of heroin use, found that people in their 50s and 60s are more likely to die of prescription drug overdoses, while people in their 20s and 30s are more likely to die from heroin overdoses. Unick presented his findings last week at the National Drug Abuse and Heroin Summit in Atlanta. (Vox graphics)

Unick "thinks the age divide is an unintended consequence of states moving to crack down on opioid prescriptions," Sarah Frostenson reports for Vox. Unick told her, “Older people have greater access to pills. But younger people are just starting with heroin and aren’t even making that shift from pills to heroin.” Opioids have become a particular problem in rural areas, especially Appalachia.

Heroin, for the first time in 2015, killed more people than prescription painkillers, Frostenson notes. But the difference in heroin and prescription painkillers is regional. Unick found that hot spots for heroin deaths were largely concentrated in the Northeast and Midwest, where emergency room admissions have steadily increased, compared to the South and West, where it has remained mostly stable. On the other hand, emergency room visits for prescription painkiller overdoses are highest in the South and West, although data shows numbers have been declining in all four regions since 2012.

State licensing laws bar treatment of opioid addiction, especially in areas that lack doctors

State laws prevent nurse practitioners and physician assistants from using a federal license to prescribe potentially life-saving medicine for opioid addiction, Christine Vestal reports for Stateline. Earlier this month two federal agencies—Substance Abuse and Mental Health Services Administration and the Drug Enforcement Administration—"gave more than 700 nurse practitioners and physician assistants the authority to write prescriptions for the anti-addiction medication buprenorphine."

But 28 states "prohibit nurse practitioners from prescribing buprenorphine unless they are working in collaboration with a doctor who also has a federal license to prescribe it," Vestal writes. The problem is that half of all counties in the U.S., mainly in rural areas, "do not have a single physician with a license to prescribe buprenorphine." (Stateline map: Barriers for nurse practitioners to prescribe treatment for opioid addiction)

Oklahoma, Tennessee and Wyoming have laws that "explicitly prohibit nurse practitioners from prescribing buprenorphine—one of three anti-addiction medications approved by the U.S. Food and Drug Administration—with or without a doctor’s supervision," Vestal notes. A law in Kentucky prohibits physician assistants from prescribing it.

In the 15 years since doctors have been allowed to prescribe buprenorphine, fewer than 39,000 have sought a license to do so, Vestal writes. Overall, there are "more than 222,000 nurse practitioners and about 109,000 physician assistants in the nation, and many of them offer primary health care in rural parts of the nation where the opioid crisis is most acute."

Pulitzers go to Iowa twice-weekly for editorials on corporate agriculture, W.Va. daily for probe of drug makers' and governments' roles in opioid crisis

This item was updated and revised at 3:10, 4:05 and 4:40 p.m.

Tom Cullen, his father Art and Art's brother John, the paper's co-owner

Art Cullen, editor and co-owner of the Storm Lake Times, a twice-weekly newspaper in Iowa, won the Pulitzer Prize for editorial writing in 2016 today. The Pulitzer board said Cullen's writing for the 3,000-circulation paper was "fueled by tenacious reporting, impressive expertise and engaging writing that successfully challenged powerful corporate agricultural interests in Iowa." The paper has written extensively about the pollution of the Raccoon River by farmers and Big Ag's paying for the county's defense of a lawsuit filed by the Des Moines Water Works.

Eric Eyre of the Charleston Gazette-Mail won the Pulitzer Prize for investigative reporting for revealing the role of the pharmaceutical industry and the fecklessness of government officials in the opioid-abuse crisis in West Virginia. His work also won the Scripps Howard Foundation First Amendment award and was cited by the Selden Ring Award judges at the University of Southern California Annenberg School.

A runner-up in the investigative category was Steve Reilly of the USA Today Network for his "far-reaching investigation that used two ambitious data-gathering efforts to turn up 9,000 teachers across the nation who should have been flagged for past disciplinary offenses but were not," as the Pulitzer board put it.

Stories with rural angles have been honored with other awards this year. Alec MacGillis of ProPublica won the national-reporting prize in Long Island University’s George Polk Awards for his story identifying "trends among voters in Rust Belt states that 'the political establishment ignored, dismissed or overlooked', according to the Polks," Roy J. Harris Jr. reports for the Poynter Institute. "In addition, the Scripps Howard Foundation’s awards, which were announced in early March, honored MacGillis’s work with an award titled the 'Topic of the Year'."

FDA nominee compares opioid epidemic to Ebola, Zika viruses; calls crisis 'most immediate priority'

The nation's opioid epidemic, which is especially problematic in Appalachia and other rural areas, is a “public-health emergency on the order of Ebola and Zika," President Trump's nominee to head the Food and Drug Administration said at his Senate confirmation hearing on Wednesday. Scott Gottlieb, a physician and entrepreneur, said the crisis "requires dramatic action by the agency and the rest of government."

"Gottlieb described the FDA as 'complicit, even if unwittingly,' in helping to fuel the opioid epidemic, Laurie McGinley reports for The Washington Post. "Officials, he said, 'didn't fully recognize the scope of the emerging problem' several years ago and needed a new strategy to combat the issues involved. Developing that strategy, he added, would be his 'highest and most immediate priority' and would involve taking a hard look at the FDA's framework for approving painkillers and pressing for greater availability of nonaddictive painkillers."

"Gottlieb said he would take an 'all-of-the-above approach' in trying to find solutions to the opioid problem but also added that the issue has become too big for the FDA to solve on its own," McGinley writes. He said, “This is a staggering human tragedy that is going to require dramatic action on the part of the agency." Gottlieb, a high-ranking FDA official during the George W. Bush administration, is popular with Republicans and "his confirmation seems all but assured," McGinley reports.

More states get or seek federal waiver to let Medicaid pay for addiction treatment

To help combat the opioid epidemic among low-income residents, several states have been granted a waiver, or are seeking permission for a waiver, to "an obscure Medicaid rule that prohibits the use of federal dollars for addiction treatment provided in facilities with more than 16 beds," Christine Vestal reports for Stateline. California, Maryland, Massachusetts and New York have been granted waivers, while Arizona, Indiana, Illinois, Kentucky, Michigan, Utah and Virginia are seeking similar permission.

Of the estimated 22 million Americans who have a drug or alcohol addiction that needs treatment, only 10 million receive it, Vestal reports. The opioid epidemic killed 33,000 people in 2015, and the epidemic is especially problematic in rural areas and Appalachia. (Stateline map: Where Medicaid pays for longer addiction treatment or has been asked to)

Tom Price, secretary of the Department of Health and Human Services, said in March that he "would continue the Obama administration’s waiver policies for residential facilities with 16 or more beds," Vestal writes. "The 16-bed provision was originally intended to discourage investment in what the 1965 Medicaid law called 'institutions for mental disease,' and to instead promote the expansion of smaller, community-based mental health and substance abuse centers."

Eliminating the 16-bed prohibition "means millions in new federal Medicaid dollars will flow to treatment centers that now rely on limited state and local grants," Vestal writes. "In addition to offering inpatient treatment to patients who need it, state Medicaid addiction programs must include all available addiction medications, intensive outpatient therapy, recovery support services such as job training and housing, substance abuse prevention programs, case management and physical health services. States also must prove that adding more residential treatment slots to the list of Medicaid treatment options will cost no more than continuing to prohibit it."

Opioid epidemic hurting Maine lobster industry; part of 10-part series on opioids in state

Ben Crocker Sr. (right) who said it's hard to hire crew
who are clean, hired Tristan Nelson, a recovering
heroin addict (Press Herald photo by Gregory Rec)

High-paying jobs in the Maine lobster industry have fueled an opioid epidemic, Penelope Overton reports for the Portland Press Herald as part of a 10-part series on opioids' impact on Maine. Last year the state reported 378 opioid deaths, up from 176 four years earlier and only 34 two decades ago, Eric Russell reports in another story. The state, which has the nation's highest percentage of rural population, has an overdose mortality rate of 21.2 for each 100,000 people.

A report from the Maine Medical Association said opioids killed 272 mariners in 2015. One problem is that for years lawmakers have ignored the epidemic in the $1.6 billion-a-year lobster industry, not wanting "to risk tainting the iconic image of the Maine lobsterman, that rough-and-tumble ocean cowboy who braves the elements to hunt lobster, the backbone," Overtone writes. "And the lobstermen were intensely private, preferring to battle their demons on their own and rarely asking for help."

Pat Keliher, commissioner of the Department of Marine Resources, said "many of the 42 commercial fishing licenses suspended in Maine last year involved people who broke state fishing laws to buy drugs or hide their addictions," Overton writes. For example, "an addicted lobsterman might haul someone else’s traps to cover bills that had gone unpaid because of a drug habit." Some boat captains, such as Ben Crocker Sr., who fired four sternmen in 2016 for drug use, say it's hard to find clean workers.

Drug use also has led to "trap wars, where one lobsterman cuts the lines on another’s gear because a trap was set over his own or because he suspects the person might have stolen lobster from his traps," including a case last year that caused $350,000 in damages, Overton writes. Also, a lobsterman is currently on trial for manslaughter for last year sailing his boat into a storm, killing two crewmen, while he was high on opioids.

The problem is that the state, like most states with an opioid epidemic, doesn't know how to curb the problem, Overton writes. Arresting people doesn't work, and "suspending a captain’s fishing license can sentence a whole family to poverty and doesn’t address the issue of addicted sternmen, who are unlicensed."

Maine, like many states with large rural populations, lacks treatment centers, Russell reports in another story in the series. According to federal data, "there are 25,000 to 30,000 people with addiction in Maine who can’t get the help they need, because the "demand for in-patient treatment beds far exceeds the supply."

Study: 59.7% of poison center calls about childhood exposure to opioids concern those 5 and under

More than half of all calls to poison centers from 2000-15 concerning childhood exposure to opioids involved children five and under, says a study published in Pediatrics. From 2000-15 poison control centers in the U.S. received 188,468 calls about people under 20 being exposed to opioids. Exposures, 95.8 percent of which occurred at home, were highest among children under five, with 59.7 percent of all calls concerning that age. Second was teenagers, at 29.9 percent. Nearly one-third of all exposures, 28.7 percent, were from hydrocodone, 18 percent from oxycodone and 17 percent from codeine.

Researchers said most exposures to children five and under were because they found their parents' prescription opioids at home and gave in to curiosity, Jia Naqvi reports for The Washington Post. Researchers said teenagers were more likely to deliberately take the drugs.

The study found that "pediatric exposure to opioids increased by 86 percent from 2000 to 2009 but decreased overall for all ages under 20 from 2009 until 2015," Naqvi writes. Study author Marcel Casavan, medical director of the Central Ohio Poison Center and chief toxicologist at Nationwide Children’s Hospital in Columbus, told Naqvi, “When adults bring these medications into their homes, they can become a danger to the children that live there. It is important that these medications are stored up, away and out of sight of kids of all ages, in a locked cabinet is best." (Exposure to opioids)

CDC study says rural suicide rates outpacing urban ones, suggests possible link to rise in opioid use

U.S. suicide rates are growing faster in rural areas than urban ones, says a study by the Centers for Disease Control and Prevention. The study, which used annual county-level mortality data from the National Vital Statistics System and U.S. Census Bureau to analyze suicide rate trends from 1999-2015, found that after declining since 1986, the U.S. suicide rate increased from 2000-15, with 600,000 suicides during the study period.

Researchers wrote: "Geographic disparities in suicide rates might be associated with suicide risk factors known to be highly prevalent in less urban areas, such as limited access to mental health care, made worse by shortages in behavioral health care providers in these areas, and greater social isolation. Such disparities might also reflect the influence of the opioid overdose epidemic. This epidemic is known to have disproportionately affected less urban areas during the earlier part of the study period and opioid misuse is associated with increased risk for suicide."

The study found that "it's also possible that economic pressures may have played a role," Margaret Farley Steele reports for HealthDay News. "The biggest increase in the suicide gap occurred beginning in 2007-2008, when the U.S. economy was experiencing a severe recession." Researchers also noted a lack of health care providers in rural areas. (CDC graphic: Suicide rates from 1999-2015)

U.S. leads world in opioid use, and goes easy on drug makers and distributors, U.N. agency says

Post graphic of top 25 opioid consuming countries

The opioid epidemic in the U.S. is by far the worst in the world, says a report by the United Nations International Narcotics Control Board. The opioid epidemic is a major concern in rural areas, especially in Appalachia. West Virginia had the nation's highest age-adjusted death rate for drug overdoses in 2014 and 2015, the last years for which rates have been computed. Ohio had the most overall opioid deaths in 2014.

U.N. data show that the U.S. consumes nearly twice as much opioids as any other country, Keith Humphreys reports for The Washington Post. The U.S. has a daily dose of 50,000 opioids per million people, based on standard dosages. Canada is second at just over 30,000, followed by Germany at about 26,000. When it comes to hydrocodone, the U.S. consumes 99 percent of the world's supply.

"Unlike most of the developed world, the U.S. puts minimal constraints on aggressive marketing by pharmaceutical companies," Humphreys writes. Also, "When federal drug agents began holding opioid distribution companies accountable for shipping massive numbers of opioids to pill mills, lobbyists from the industry successfully pressured the Justice Department’s leadership to curtail the investigation."

Opioids and drug overdose deaths are beginning to plague farming communities

Roger D. Winemiller and his only living child
Roger T. Winemiller (Times photo by Ty Wright)

Drug addiction and overdose deaths are becoming a far too common occurrence in some farming communities, such as Clermont County, Ohio, where Roger Winemiller has lost two children to drug overdoses and a third has battled drug addiction for years, Jack Healy reports for The New York Times. "Overdoses are churning through agricultural pockets of America like a plow through soil, tearing at rural communities and posing a new threat to the generational ties of families like the Winemillers."

"Farm bureaus’ attention to seed, fertilizer and subsidies has been diverted to discussions of overdoses," Healy writes. "Volunteer-run heroin support groups are popping up in rural towns where clinics and drug treatment centers are an hour’s drive away, and broaching public conversations about addiction and death that close-knit neighbors and even some families of the dead would prefer to keep out of view."

Clermont County, located about an hour east of Cincinnati, has a low unemployment rate—4.1 percent—but "the economic resilience has done little to insulate the area from a cascade of cheap heroin and synthetic opiates like fentanyl and carfentanil, an elephant tranquilizer, which have sent overdose rates soaring across much of the country, but especially in rural areas like this one," where drug overdoses have nearly tripled since 1999.

Clermont County, Ohio
(Wikipedia map)

Ohio in 2014 led the nation in overdose deaths with 2,106, according to an analysis of the most recent federal data by the Kaiser Family Foundation. "In rural Wayne Township, where the Winemillers and about 4,900 other people live, the local fire department answered 18 overdose calls last year," Healy writes. "Firefighters answered three in one week this winter, and said the spikes and lulls in their overdose calls gave them a feel for when particularly noxious batches of drugs were brought out to the countryside from Cincinnati or Dayton."

The drug epidemic also has farmers, like Winemiller, concerned about who will take over the famly business when he's gone, Healy writes. "Winemiller and a cousin inherited the farm in 1993 when an uncle died, and they own and run the business together." While his remaining child has been clean for two months, and has said he wants to someday run the farm Winemiller "worries about what could happen to the business if he turned over his share of the farm and his son relapsed—or worse—a year or a decade down the line. He also keeps a pouch of overdose-treating nasal spray in the living room now, just in case."

Study links increase in county unemployment rate to rise in opioid deaths

Opioid overdose death rates grow fastest in counties with rising unemployment rates, says a study by researchers at the University of Indiana and the University of Virginia published in The National Bureau of Economic Research. Some of the nation's poorest counties, many in Appalachia, also have some of the highest drug overdose rates. A Centers for Disease Control and Prevention study has state-level data on overdose deaths from 2015.

Researchers used county-level mortality data for the entire U.S. from 1999-2014, finding that when the county unemployment rate increases by one percent, the opioid death rates rises by 0.19 per every 100,000, a 3.6 percent increase. Researchers also looked at county level emergency room data from 2002-2014 from Arizona, Florida, Kentucky, Maryland and New Jersey, finding that when the county unemployment rate increases by one percent, the opioid death rate rises by .95, or seven percent.

"Because of the way the study was designed, it couldn’t measure the overall effect of national changes in the economy, like the Great Recession and the subsequent recovery," Jeff Guo reports for The Washington Post. "Instead, the research tells us that places that weathered the Great Recession more gracefully were better able to resist the opioid epidemic, while places that suffered during the Great Recession were harder hit by opioid deaths."

"This is more surprising than it seems. Alcohol use actually behaves the opposite way," Guo writes. "People tend to buy less alcohol in bad times, and more alcohol in good times. In fact, there’s a well-documented correlation between economic growth and higher death rates. When the economy is booming, people tend to behave in more risky ways, and pollution also increases. When the economy is in recession, both those risk factors abate."

Heroin, other opioids led to 73% of 2015 overdose deaths, says CDC study with state-level data

Deaths from heroin and natural and semi-synthetic opioids—such as oxycodone and hydrocodone—accounted for 49 percent of all overdose deaths in 2015, says a study by the federal Centers for Disease Control and Prevention. Heroin-overdose deaths tripled from 8 percent in 2010 to 25 percent in 2015. While the percentage of deaths from synthetic opioids declined from 29 percent to 24 percent, deaths from synthetic opioids other than methadone—such as fentanyl and tramadol—increased from eight percent to 18 percent.

West Virginia had the highest age-adjusted drug-overdose death rate at 41.5 deaths per 100,000 people. New New Hampshire (34.3) was second, followed by Kentucky (29.9), Ohio (29.9), Rhode Island (28.2), Pennsylvania (26.3), Massachusetts (25.7), New Mexico (25.3), Utah (23.4), Tennessee (22.2), Connecticut (22.1), Delaware (22.0), Maine (21.2), Maryland (20.9), Michigan (20.4), Nevada (20.4), Indiana (19.5), Louisiana (19.0), Arizona (19.0), Oklahoma (19.0), and Missouri (17.9). The national average was 16.3.

Nebraska had the lowest rate at 6.9. It was followed by South Dakota (8.4), North Dakota (8.6), Texas (9.4), Iowa (10.3), Minnesota (10.6), California (11.3), Hawaii (11.3),  Kansas (11.8), Oregon (12.0), Mississippi (12.3), Virginia (12.4), Georgia (12.7),  New York (13.6), Montana (13.8), Arkansas (13.8), Illinois (14.1) and Idaho (14.2). (CDC map: Age-adjusted drug overdose death rates, by state in 2015)