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

Subst Abus. 2020;41(1):35-69. doi: 10.1080/08897077.2019.1635555. Epub 2019 Aug 12.


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.

Publication types

  • Research Support, N.I.H., Extramural
  • Systematic Review

MeSH terms

  • Adult
  • Clinical Clerkship*
  • Curriculum
  • Drug Overdose / prevention & control
  • Epidemics / statistics & numerical data*
  • Female
  • Harm Reduction*
  • Health Knowledge, Attitudes, Practice
  • Humans
  • Male
  • Naloxone / therapeutic use
  • Opioid-Related Disorders / epidemiology*
  • Rural Population / statistics & numerical data*
  • Surveys and Questionnaires


  • Naloxone