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Retail Opioid Sales Sales Poverty Rate Unemployment Rate 4 All measures of substance use and opioid prevalence increased relative to those in the initial reporting period, though prescribing rates are now on the decline. Our data on retail opioid sales began to decline in 2012 after nearly doubling from 2006 to 2011. Other sources of data on opioid sales indicate a peak in 2011 rather than 2012.11 Medicare Part D prescriptions follow a similar trend, although they did not decline as substantially in the more recent period. Opioid-related hospitalizations increased by over 20 percent from 2011 to 2014, the last year for which data are available. Finally, accidental drug overdose deaths have increased considerably: at the start of the analysis period, there were roughly 18,000 deaths per year in the United States. This figure rose to 28,000 deaths in 2006 and then continued to rise to over 50,000 deaths in 2016. Stated another way, the number of accidental overdose deaths was nearly three times higher in 2016 than in 2000. While not all drug overdose deaths are caused solely by opioids, the opioid epidemic is linked to the vast majority of these deaths.Average Stays per 100,000 Opioid-Related Hospitalizations Large Metro Small Metro Rural Figure 3. Measures of Substance Use and Opioid Prevalence, by Urbanicity Sources: Retail prescription opioid sales: DEA Automation of Reports and Consolidated Orders System (ARCOS), measured in kilograms of morphine equivalence per 100,000. Medicare Part D Prescriptions: CMS Prescription Drug Event File. Drug overdose deaths: CDC Small Area Estimates. Hospitalizations: HCUP State Inpatient Databases and State Emergency Department Databases. 5 Rural Areas Had Higher Prevalence of Opioids and Greater Increases in Substance Use Than Other Areas Overdose deaths, opioid-related hospitalizations, and prescription opioids are not uniformly present in communities across the United States. As Figure 3 indicates, rural counties have historically had higher rates of per capita retail opioid sales and Medicare opioid prescriptions. In 2016, retail opioid sales per capita were around 50 percent higher in rural areas than in small and large metropolitan counties. Although metropolitan counties have historically had higher drug overdose death rates and opioid-related hospitalization rates, rural counties had a higher growth rate of these two measures.8 In 2016, the drug overdose death rate in rural areas surpassed that of other types of counties, with an estimated 18.7 deaths per 100,000 persons. The overdose death rate in rural counties was 4.8 times larger in 2016 than it was in 2000. GEOGRAPHIC ASSOCIATION BETWEEN ECONOMIC OPPORTUNITY, SUBSTANCE USE AND OPIOID PRESCRIBING Counties with higher poverty and unemployment rates generally had higher rates of retail opioid sales and Medicare opioid prescriptions, as well as drug overdose deaths and opioid-related hospitalizations. This relationship was clustered in specific areas of the country. Despite the strong relationship, some counties had high poverty and unemployment rates but did not have relatively high substance use and opioid prevalence indicators as