Rural Adolescents Are More Likely Than Their Urban Peers to Abuse Prescription Painkillers

October 22, 2015

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Key Findings

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Over 1.1 million adolescents aged 12 to 17 (4.7 percent of this population) abused prescription painkillers in 2014.
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Rural adolescents are more likely to abuse prescription painkillers than their urban peers.
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Greater use of emergency department treatment and lower perceptions of risk about the harmfulness of illegal drugs place rural youth at greater risk of painkiller abuse.
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Rural teens are more likely than urban teens to obtain the pills they abuse directly from physicians.


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U.S. media and popular culture historically portrayed drug abuse as an urban problem, but in recent years, there has been more media attention on rural drug issues. Part of this growing attention pertains to the growing epidemic of narcotic painkiller abuse in rural America. Although all areas of the country experienced increases in painkiller prescribing, abuse, and mortality over the past two decades, the increases have been most pronounced in small towns and rural areas.1 This rural drug epidemic requires immediate attention from policy makers and practitioners.

During the 1980s and 1990s, pharmaceutical companies aggressively marketed OxyContin® and other opioids in Appalachia,2 and physicians regularly dispensed painkillers to coal miners and other heavy-occupation laborers.3 In the 2000s, prescription painkillers became more difficult to obtain in Appalachia due to the introduction of prescription drug monitoring programs and a Drug Enforcement Administration crackdown on “pill mills.” Consequently, addicts and dealers from rural Kentucky, West Virginia, Tennessee, and Ohio regularly travelled along what journalists nicknamed the “Oxy Express” to purchase pills in Florida, where prescribing laws were more lax.4 Since 2000, prescription painkiller abuse has spread to other rural areas where it was previously uncommon, including New Hampshire and Maine.5

Over 1.1 million U.S. adolescents (4.7 percent of youth aged 12–17) abused prescription painkillers in 2014. Among teens, only marijuana and alcohol are more frequently abused than prescription painkillers. Adolescents abuse painkillers more than crack/cocaine, ecstasy, heroin, hallucinogens, inhalants, and methamphetamine combined. Painkiller abuse during adolescence has significant implications for later life. Individuals who abuse painkillers before age 18 are more likely to become addicted than those who first abuse them as adults. Painkiller addiction in youth also increases the likelihood of economic precariousness, criminal justice involvement, poor health, and accidental overdose in adulthood.

Figure 1. Percent of Adolescents reporting lifetime, past year, and past month abuse of prescription painkillers, 2014

The Rural Teen Painkiller Problem

Prescription painkiller abuse is more common among rural than urban adolescents. In 2014, 8.6 percent of rural adolescents, 8.1 percent of adolescents in small urban areas, and 6.5 percent of adolescents in large urban areas reported ever abusing prescription pain relievers. Past year and past month use were also higher among rural adolescents.

Rural teens’ interactions with the health care system increase their risk of painkiller abuse. They are more likely than urban teens to use emergency department (ED) services, where painkillers are more commonly prescribed, and to more frequently visit EDs. Although most teens illicitly acquire painkillers through family or friends (67 percent), rural teens are less likely than urban teens to do so. Rather, they are more likely to obtain the pills they abuse directly from physicians (23 percent of rural versus 18 percent of urban). Rural adolescents also perceive substance abuse as less risky than their urban peers. Adolescents with less risky attitudes about substance abuse are more likely to abuse painkillers and other substances. In addition to painkillers, rural teens are also more likely than urban teens to binge drink and smoke cigarettes daily.

Our research shows that some features of rural life do buffer rural teens against painkiller abuse. These include stronger religious beliefs and less peer substance use compared to their urban peers and the geographic isolation that limits access to drugs more than in urban areas. If not for these protective factors, rural teen prescription painkiller abuse would be even higher.

Painkiller abuse is often a pathway to heroin use, particularly when painkillers become too expensive or difficult to acquire.7 Recent declines in adolescent prescription painkiller abuse are encouraging, but civic leaders, policy makers, public health experts, and parents should remain vigilant of the risk of adolescents transitioning to heroin. Heroin contains the same active ingredient as prescription painkillers, and heroin is now easier and cheaper for teens to purchase than a pack of cigarettes or a six-pack of beer.8 Risk of accidental heroin overdose is especially high because the drug is sometimes tainted with other substances, including fentanyl, which can be lethal even in small doses. Whether today’s rural teen painkiller abusers will become tomorrow’s rural adult heroin addicts remains an open question. The answer depends on how quickly and resolutely government leaders and public health professionals address the current painkiller problem.


We examined prescription painkiller abuse for over 32,000 youth aged 12–17 using data from the National Survey on Drug Use and Health, an annual nationally representative survey of the non-institutionalized U.S. population. Large urban counties are in metro areas with at least 1 million residents. Small urban counties are in metro areas with under 1 million residents. Rural counties are outside of metropolitan areas.

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Endnotes are available in the pdf version. Download

About the Author(s)

Shannon M. Monnat
Shannon M. Monnat, PhD, is an associate professor of  Sociology and the Lerner Chair for Public Health Promotion in the Maxwell School of Citizenship and Public Affairs at Syracuse University. Her research examines U.S. population health along the rural-urban continuum. Read More...
Khary K. Rigg
Khary K.