A demographer’s view of the opioid crisis

Posted: May 2, 2016

As opioid abuse has escalated to a full-blown national crisis, many wonder why people start using these drugs, how they become addicted, and which communities are most at risk. Shannon Monnat, a Penn State rural sociologist and demographer, has studied these questions in depth, and shared some of her findings at a recent event at Penn State.
Source: US Centers for Disease Control and Prevention, National Vital Statistics System, mortality data

Source: US Centers for Disease Control and Prevention, National Vital Statistics System, mortality data

In her Research Unplugged lecture, Monnat explained that many people start out using prescription pain killers for valid medical reasons, and that liberalization of physician prescribing of these drugs has led to enormous increases in both the number of prescriptions and the strength of doses prescribed. Historically, drugs like Oxycodone were used to treat only very serious injuries and cancer pain. Now, they are prescribed to one in 25 adults for treatment of more-common chronic pain.

“When [prescription painkillers are] used appropriately, the risk of addiction is really low,” she said. “The problem is they’re so easily abused, that risk of addiction is high.” In fact, an estimated 25 percent of those taking opioids to manage pain will struggle with an addiction problem.

Opioids are so easily abused because of the effects they have on the brain. They reduce the perception of pain, but also combine with the body’s chemistry to create “a far more intense euphoria than anything the body is able to produce on its own,” Monnat said. With prolonged use, the body shuts down its own ability to produce feel-good endorphins, leaving the user dependent on the artificial ones delivered by the drugs and unable to endure the same level of pain as they could before.

The longer someone abuses these drugs, the more their tolerance builds. Therein lies a huge problem, she said, “because with both prescription painkillers and heroin, when a person quits, they almost always go back to it.” During detox, this tolerance declines, unbeknownst to most users. When they return to using, they think they can handle the same dose as before, which often turns out to be a fatal miscalculation resulting in overdose.

Deaths rates from overdoses are the fastest growing cause of death in the US, and have more than tripled since 1999. The majority of that tripling has been related to prescription painkillers. Monnat’s research shows that places with the highest overdose mortality rates also have much higher rates of overall opioid prescribing, benzodiazepine prescribing, and extended release and high-dose opioid prescribing than places with lower rates of overdose deaths.

There are a number of other similarities shared among these high-mortality counties. They have a high percentage of Whites, a low percentage of African Americans, a high percentage of veterans and people who rely on Social Security and Disability Insurance, and a high percentage of people who report poor health. They also have higher-than-average incidence of poor mental health. These counties have lower median income, lower educational attainment rates, and higher rates of unemployment. They also have experienced greater loss in manufacturing employment, particularly among manual-labor jobs.

The wide-spread belief that this is mostly a rural problem isn’t necessarily true, said Monnat. “Non-medical use of prescription opioids is slightly higher, on average, in small metropolitan and larger non-metropolitan counties, which probably has something to do with access and supply of those drugs. However, certain rural areas, including large swaths of Appalachia and rural counties in New England, Oklahoma, and the U.S./Mexico border have extremely high rates of drug overdose.”


“Some rural places seem particularly vulnerable and other rural places seem to be immune,” she said. “I think that’s interesting, because it says something about the composition of the populations living in these places, and it says something about the characteristics of the places themselves.”

For more in-depth coverage of Monnat’s research, check out these Penn State News stories: