The Frontlines of the Opioid Crisis

March 1, 2019
Tackling Opioids


Dear Colleagues and Students:

You need only read the daily news to understand the grip that the opioid crisis has on our country.  According to the National Institute of Drug Abuse, 130 people die every day in our nation after overdosing on these drugs (NIDA).  It’s overwhelming to witness it firsthand.

Last week I returned from a sabbatical over the course of which I traveled to 8 rural areas including small towns in Illinois, Kentucky, New Hampshire, North Carolina, Ohio, West Virginia, Wisconsin, Oregon and Vermont. I was joined by a colleague, a NIDA Scientific Officer, as we conducted site visits as part of my role as Chair of the National Institutes of Health, US Center for Disease Control and the Substance Abuse and Mental Health Services Administration (SAMHSA) Rural Opioid Initiative Scientific Steering Committee.

As an infectious disease epidemiologist who has studied people who use drugs throughout the course of my career, I know all too well the consequences of heroin, methamphetamine and opioid use.  This year of travel, to some of the most impoverished areas of our country, and witnessing the toll of the social determinants of health in action, was illuminating even for me.

These site visits have given me a much deeper understanding of the problem, a greater appreciation of the challenges of studying rural drug users, and insight into what it’s like to have a drug habit in rural areas. Stigmatization of substance use is much more widespread and there is greater resistance to methadone and buprenorphine treatment which are viewed as “drug substitution” rather than as medication for a chronic health condition. People are reluctant to come to syringe service programs or other drug user health hubs because someone in town will see them go in and soon, everyone knows about their drug use. It can be an uphill battle to get first responders to carry naloxone and I heard a bizarre story of a sheriff who would only carry naloxone in case his canine partner overdosed. On the other hand, local people who have lost someone to the opioid crisis are stepping up to defend people using drugs and demand action. Drug users are also taking the risk of speaking up and talking to their communities about the trauma that led them to substance use, like the death of a younger sibling, and the discrimination and neglect they experience seeking health care.

Rural poverty is different than urban poverty. People with nowhere to go live in tents in national forests and public beaches in communities where there are no shelters. Study participants are sometimes given Walmart gift cards to compensate them for their time and trouble, and these are frequently used to buy camping gear. In Oregon last week, I went to a makeshift encampment of tiny old trailers and lean-tos surrounded by deep mud, some with electricity supplied by a long chain of extension cords. There’s no public transportation in most places, and people who don’t have a car rely on having a friend or relative with a working car and money to pay for gas. Services are far away from where people live. Tax levies are used in some parts of Appalachia to raise money to fund health departments, sometimes for essential public health services in addition to money to address the opioid problem.

One young woman, named Anna, with whom I met left an especially indelible mark on me.  She was a 20-year old girl, really, with electric green eyes, but the prematurely aged skin and decaying teeth of someone much older and sicker.  I think of her often and just the memory of her reminds me how much work we have ahead of us.

I also returned with a renewed appreciation for what we have in progressive, urban centers like New York City. And I was inspired by all the local people I met along the way who are stepping up to do all they can in their small communities, in spite of their lack of resources, to end this epidemic.



Holly Hagan, PhD, MPH
Professor of Social and Behavioral Sciences
Co-Director of the Center for Drug Use and HIV/HCV Research (CDUHR)