The opioid and related drug epidemics in rural Appalachia: A systematic review of populations affected, risk factors, and infectious diseases

Abstract

Background/aims: To examine trends in rural Appalachian opioid and related drug epidemics during the past 10 years, including at-risk populations, substance use shifts and correlates, and associated infections. Methods: We conducted this review in accordance with the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. Seven databases were searched for quantitative studies, published between January 2006 and December 2017, of drug use, drug-related mortality, or associated infections in rural Appalachia. Results: Drug-related deaths increased in study states, and a high incidence of polydrug toxicity was noted. Rural substance use was most common among young, white males, with low education levels. A history of depression/anxiety was common among study populations. Prescription opioids were most commonly used, often in conjunction with sedatives. Women emerged as a distinct user subpopulation, with different routes of drug use initiation and drug sources. Injection drug use was accompanied by risky injection behaviors and was associated with hepatitis C. Conclusions: This review can help to inform substance use intervention development and implementation in rural Appalachian populations. Those at highest risk are young, white males who often engage in polysubstance use and have a history of mental health issues. Differences in risk factors among other groups and characteristics of drug use in rural Appalachian populations that are conducive to human immunodeficiency virus (HIV) spread also warrant consideration.

Keywords:

• Drug epidemic
• hepatitis C
• opioids
• rural Appalachia
• substance use

Author contributions

C.A.S. developed inclusion/exclusion criteria, conducted searches, served as primary reviewer for abstract/title and full-text review, extracted article data, synthesized results, and drafted manuscript. K.L. developed inclusion/exclusion criteria, served as a secondary reviewer for abstract/title and full-text review, assisted with manuscript drafting, and reviewed and edited manuscript. B.N.G. assisted with review strategy/inclusion and exclusion criteria, provided guidance during review process, and reviewed and edited manuscript. V.W. served as a secondary reviewer for abstract/title and full-text review, and reviewed manuscript. B.W.P. reviewed and edited manuscript. W.C.M. conceptualized review, developed inclusion/exclusion criteria, oversaw review process, and reviewed and edited manuscript. V.F.G. conceptualized review, developed inclusion/exclusion criteria, oversaw review process, and reviewed and edited manuscript.

Additional information

Funding

This work was supported by National Institutes of Health National Institute on Drug Abuse grant UG3DA044822 (Principal Investigators: W. C. Miller; V. F. Go). The funding organization had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.