Understanding Overdose Deaths and Polysubstance Use in Rural America

Most substance use is polysubstance use, which complicates treatment and overdose prevention efforts, especially in rural America.

line graph depicting percentage of respondents ranking substance use disorder-related problem areas, including overdose, as both their greatest concern and the least capacity to address

Read Time: 2 minutes


In 2022, over  105,452 drug overdose deaths occurred in the United States. Rural communities face unique challenges in the fight against overdoses, including less access to general, specialty, and behavioral healthcare due to geographic issues, rural hospital closures, and workforce shortages. Additionally, rural communities experience less access to life-saving medications designed to treat people with opioid addiction, including buprenorphine and naloxone.

Many possible factors may influence high overdose rates, including polysubstance use, which may hinder traditional preventions and treatment strategies focused on a single damaging substance.

Carolyn Carpenedo Mun and colleagues analyzed national data from the Rural Communities Opioid Response Program (RCORP), which provides funding to rural communities to reduce morbidity and mortality among their residents with opioid use disorder. In particular, the researchers tracked the use of opioids and at least one other illicit drug, related health problems, and the capacity of rural areas to address these challenges. Each program director completed progress reports collected every quarter and ranked the illicit drugs of most concern and the health consequences resulting from drug use that rural communities have the least capacity to address.

The research team found the illicit substances causing the most concern are methamphetamines and fentanyl. The figure above shows the rankings of each identified health issue caused by substance use disorder. As shown, fatal and nonfatal overdoses remain the greatest concern. This is consistent with the sharp rise of reported overdose deaths involving psychostimulants, including methamphetamines. The research team found the illicit substances causing the most concern are methamphetamines and fentanyl. Most methamphetamine deaths have been reported to involve the simultaneous use of opioids, and methamphetamine is often contaminated with fentanyl. Fentanyl accounted for over 80% of all opioid-related overdose deaths in 2021.

The researchers suggest funding communities to address prevention, harm reduction, treatment, and recovery strategies designed with an understanding that most substance use is polysubstance use. For example, community workers should provide fentanyl test strips and naloxone to those being treated for meth use due to the observed co-use of opioids and psychostimulants.

Databyte via Carolyn Capenedo Mun, Heather Schuler, Robin Baker, et al. Rural communities face more than an opioid crisis: Reimagining funding assistance to address polysubstance use, associated health problems, and limited rural service capacity. The Journal of Rural Health, 2023.