More OD's in Appalachia.

WASHINGTON — People in rural areas of Appalachia are more likely to die early deaths than in other parts of the country.

A big reason, researchers say, is that people in places such as Leslie County, Ky., or Boone County, W.Va. — both part of coalfield regions — die from drug overdoses at greater rates than the rest of the country.

In Leslie County, an average of 79 of every 100,000 residents overdose each year, based on data collected from 2012 to 2014. That’s six times the national rate.

In Boone County, 81 of every 100,000 people die of drug overdoses, according to a recent report by the Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute.

By comparison, only 14 of every 100,000 residents of Washington, D.C., die from overdoses.

Addiction experts say a key factor in the disparity is that opioid addicts in some parts of the country get turned away by doctors and are not given a drug called buprenorphine that is used to kick opioid addictions. Buprenorphine causes less euphoria and physical dependence and can ease withdrawal and cravings.

Federal law caps the number of patients to whom a doctor is allowed to prescribe the drug, out of concern of creating places where large numbers of addicts receive opioid-based medication. Such treatment hubs, much like methadone clinics, bring unwanted community opposition, said Mark Parrino, president of the American Association for the Treatment of Opioid Dependence.

That limits treatment choices in rural areas, where one doctor might be the only one licensed to prescribe buprenorphine for hundreds of miles. Physicians in those areas are unable to take any more patients, said Dr. Kelly Clark, president-elect of the American Society of Addiction Medicine.

“Turning people away from the most evidence-based treatment we have for a chronic, life-threatening disease is heart wrenching for a doctor,” Clark said.

The U.S. Department of Health and Human Services is in the process of easing the limits. A bill sponsored by Sens. Ed Markey, D-Mass., and Rand Paul, R-Ky., would go even further.

But some addiction experts are concerned that raising the caps on buprenorphine will nudge the country toward treating addiction with medication rather than counseling.

The County Health Rankings and Roadmaps report illustrates a growing gap between cities and the country.

Premature deaths — counted as those before age 75 — increased in about one-fifth of rural counties between 1999 and 2013. No major urban areas saw an increase during that time.

Rural counties also have higher rates of obesity, smoking, teen births and accidental deaths.

People who live there are less likely to be insured and have less access to mental health care.

Raging opioid abuse in the United States — which has doubled the number of overdose deaths in the country since 2012 — is helping drive the disproportionate number of people dying prematurely.

Counties nationwide tally 13 drug overdose deaths per 100,000 residents each year from 2012 through 2014, based on data tracked by the U.S. Centers for Disease Control and Prevention.

But in 16 percent of counties — generally in rural areas — more than 20 per 100,000 die from drug overdoses.

Hardest hit are counties in the West and Appalachia, such as Boone County, W.Va., which had the second-highest rate of drug deaths nationally.

Several other counties in the state rank among the highest in the country for overdose death rates.

The report noted 470 deaths per 100,000 West Virginians each year of people who were not yet 75.

In Kentucky, Leslie County’s opioid death rate ranked third in the country. Much like West Virginia, several other Kentucky counties rank among the highest.

Statewide, 440 deaths for every 100,000 Kentucky residents involved people who died before age 75.

“Rural areas have been hit hardest by this round in overdoses, which is the worst round of overdose deaths in our country,” Clark said.

Medication is especially important to help addicts stay clean in rural areas, she added, because opioid use spreads among families.

“In rural areas, you’re treating the person, their parents and grandparents,” she said. “Entire families are addicted. It’s not like saying, ‘Stay away from certain friends,’ if they’re shooting up with their sister and their mother.”

Doctors now certified to prescribe buprenorphine may treat up to 30 addiction patients at a time for the first year. Doctors may then ask for permission to prescribe up to a maximum of 100 patients.

Federal officials say that’s not enough. Only 1 million of an estimated 2.5 million opioid addicts were able to get any kind of treatment in 2012, according to the Department of Health and Human Services.

Health officials plan to double the cap on buprenorphine prescriptions to 200 patients.

Markey and Paul would push the limit further, to 500 patients, and allow nurse practitioners to prescribe the drug, as well.

In a statement, Paul called the existing caps “arbitrary” and ultimately harmful to addicts and their families.

But some treatment experts, like Parrino, worry about relying on medication instead of treating underlying roots of addiction.

Federal limits on buprenorphine treatment only require doctors have “capacity to refer the patients for appropriate counseling.” They do not specifically require counseling.

Given the choice of a pill or intensive therapy, most addicts will probably take the medicine, Parrino said.

The department’s proposed rules would require mental health care. The senators’ bill would not.

Clark said it’s not necessary.

There are no limits on treating other kinds of conditions, she added. Also, requiring mental health treatment may be unrealistic in rural areas.

The report on county health — which does not take a position on the issue — found that Leslie County, Ky., has one mental health professional for every 2,184 residents. Jefferson County, which includes Louisville, has a mental health professional for every 359 residents.

Kery Murakami is the Washington, D.C., reporter for CNHI’s newspapers and websites. Reach him at The County Health Rankings and Roadmaps report is available online at

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