April 2019

PREPARED BY:

East Tennessee State University and

NORC at the University of Chicago 

ISSUE BRIEF

Health Disparities Related to 

Opioid Misuse in Appalachia

Practical Strategies and

Recommendations for Communities

Photo: Ryan Parker on Unsplash

An initiative to identify and explore Appalachian communities with better-than-expected health outcomes
Health Disparities Related to Opioid Misuse in Appalachia | Practical Strategies and Recommendations for Communities i

ACKNOWLEDGMENTS 

Robert Wood Johnson Foundation

The Robert Wood Johnson Foundation (RWJF) is the nation’s largest philanthropy dedicated to health. 

For more than 40 years, RWJF has supported research and programs targeting some of the nation’s most 

pressing health issues. RWJF provided funding for this research project as part of its Culture of Health 

Initiative.

Appalachian Regional Commission

The Appalachian Regional Commission (ARC) provided funding, leadership, and project management for 

the project. ARC is an economic development agency of the federal government and 13 state 

governments focusing on 420 counties across the Appalachian Region. ARC’s mission is to innovate, 

partner, and invest to build community capacity and strengthen economic growth in Appalachia to help

the Region achieve socioeconomic parity with the nation. Julie Marshall, PhD, Senior Economist, 

Division of Research and Evaluation, served as the Project Director, with support from Kostas Skordas, 

Director, Division of Research and Evaluation. 

Foundation for a Healthy Kentucky

The Foundation for a Healthy Kentucky served as the grantee and fiscal agent for the project. Funded by 

an endowment, the nonpartisan Foundation’s mission is to address the unmet health needs of Kentuckians 

by developing and influencing policy, improving access to care, reducing health risks and disparities, and 

promoting health equity. Since the Foundation opened its doors in 2001, it has invested more than $27 

million in health policy research, advocacy, and demonstration project grants across the Commonwealth.

Research Team

Kate Beatty, PhD, and Nathan Hale, PhD, at the Center for Rural and Appalachian Health in the College 

of Public Health at East Tennessee State University (ETSU), along with researchers at NORC at the 

University of Chicago’s Walsh Center for Rural Health Analysis, led the development of this brief. The 

NORC team included Michael Meit, Megan Heffernan, Michelle Dougherty, Luciana Rocha, and Kelsey 

Ruane. Additional contributors from ETSU included Rob Pack, Stephanie Mathis, Bill Brooks, Angela 

Hagaman, and Sam Pettyjohn. 
Health Disparities Related to Opioid Misuse in Appalachia | Practical Strategies and Recommendations for Communities ii

TABLE OF CONTENTS

Why Address Opioid Misuse in Appalachia?..........................................................................2

Assessing Community Need for Prevention of Opioid Misuse and Treatment of Opioid 

Use Disorder .............................................................................................................................4

Practical Strategies and Recommendations...........................................................................5

Recommendation #1: Prevent Opioid Misuse.........................................................................6

Recommendation #2: Increase Access to Treatment for Opioid Use Disorder....................8

Recommendation #3: Implement Strategies to Reduce the Harmful Consequences of 

Opioid Use Disorder ...............................................................................................................10

Recommendation #4: Support Long-Term Recovery from Opioid Use Disorder...............14

Recommendation #5: Implement Community-Based Solutions to Prevent Substance 

Misuse .....................................................................................................................................15

Strategies and Recommendations for Funders ....................................................................16
Health Disparities Related to Opioid Misuse in Appalachia | Practical Strategies and Recommendations for Communities 1

Creating a Culture of Health in Appalachia: Disparities and Bright Spots is a health research 

initiative sponsored by the Appalachian Regional Commission (ARC) and the Robert Wood Johnson 

Foundation (RWFJ), and administered by the Foundation for a Healthy Kentucky. This multipart research 

initiative has produced an interactive website, HealthinAppalachia.org, along with three reports: 1) Health 

Disparities in Appalachia,

1 2) Identifying Bright Spots in Appalachian Health: Statistical Analysis,

2 and 

3) Exploring Bright Spots in Appalachian Health: Case Studies.

3

The Appalachian Region continues to experience higher rates of opioid misuse and overdose deaths than 

other parts of the country. While the impact of the burgeoning epidemic is being felt nationwide, states 

and counties within the Appalachian Region are particularly hard hit, with opioid overdose rates more 

than double national averages. Drawing on the research presented in the health disparities and Bright Spot 

reports, this brief:

■ summarizes statistics on opioid misuse and overdose deaths in Appalachian communities,

■ discusses key strategies and resources for addressing opioid misuse and overdose deaths, and

■ provides recommendations for community leaders, funders, and policymakers.

This brief features promising practices, intervention strategies, and policy development and 

implementation ideas to reduce health disparities related to opioid misuse and overdose deaths. 

This brief discusses five recommendations in detail: 

1. Prevent opioid misuse.

2. Increase access to treatment for opioid use disorder.

3. Implement harm reduction strategies to reduce the consequences of opioid use disorder.

4. Support long-term recovery of opioid use disorder.

5. Implement community-based solutions to prevent substance misuse. 

Table 1 provides definitions for key terms used in this brief.

Table 1: Key Terms

Opioid A class of pain-relieving drugs. Some opioids are illicit (e.g., heroin), while 

others are available by prescription (e.g., oxycodone).4

Heroin A highly addictive opioid drug derived from morphine.5

Opioid misuse Opioid misuse refers to 1) the use of prescription opioids without a 

prescription or in any way not directed by a clinician, or 2) the use of heroin.6

Opioid misuse can lead individuals to develop opioid use disorder. 

Opioid use disorder A problematic pattern of opioid use—typically prescription drugs or heroin—

leading to clinically significant impairment or distress.7

Substance use 

disorder

A medical condition in which one or more substances leads to clinically 

significant impairment or distress.8 Opioid use disorder is a type of

substance use disorder. 
Health Disparities Related to Opioid Misuse in Appalachia | Practical Strategies and Recommendations for Communities 2

WHY ADDRESS OPIOID MISUSE IN APPALACHIA? 

Nationally, drug overdose deaths due to opioids have increased substantially since 1999.9 In 2017, 

opioids were responsible for approximately 47,600 overdose deaths, or 67.8% of all overdose deaths.10

Recent data indicate that the number of opioidrelated deaths has now surpassed the number of 

deaths from motor vehicle accidents.10 Marked 

increases in opioid-related deaths have been cited as 

a key driver of decreasing life expectancy in the 

United States.11

These patterns are also evident in the Appalachian

Region. Existing evidence suggests that residents of 

Appalachia are more likely to die prematurely than 

those who live outside of Appalachia. Among those 

living in Central Appalachia and in economically 

distressed counties, those differences are even 

greater.12 While multiple factors contribute to 

decreasing life expectancy, notable trends in opioidrelated deaths significantly contribute to the loss of 

life in Appalachia.13

The Creating a Culture of Health in Appalachia

initiative has produced a series of detailed reports 

documenting key health challenges and 

opportunities in Appalachia. The Health Disparities

in Appalachia report noted that poisoning mortality 

rates—which include poisoning from medication 

abuse, both pharmaceutical and illicit—were 

markedly higher (41.6%) in Appalachia than in the 

non-Appalachian United States (see Figure 1).

1

While not limited to opioid-related drug overdose 

deaths, findings from the initiative’s reports provide 

important context for understanding and addressing 

opioid misuse and overdose-related disparities by

identifying factors that support a culture of health in 

Appalachian communities. 

Figure 1: Poisoning Mortality Rate per 100,000 

in Appalachia, 2008–2014

Image source: Health Disparities in Appalachia. 

https://www.arc.gov/assets/research_reports/Health_Disparities_in_

Appalachia_August_2017.pdf.

Data source: National Center for Health Statistics. Compressed 

Mortality File, 1999–2014 (machine-readable data file and 

documentation, CDROM Series 20, No. 2T) as compiled from data 

provided by the 57 vital statistics jurisdictions through the Vital 

Statistics Cooperative Program. Hyattsville, Maryland 2015. 

http://www.cdc.gov/nchs/data_access/cmf.htm.
Health Disparities Related to Opioid Misuse in Appalachia | Practical Strategies and Recommendations for Communities 3

Opioid Misuse in Appalachia 

Since 1999, opioid overdose deaths have increased more than four-fold in the United States—and the 

Appalachian Region has been disproportionately impacted.

9 In 2017, four states within the Appalachian 

Region (West Virginia, Ohio, Pennsylvania, and Kentucky) had the highest rates of drug overdose deaths 

in the country.13 In addition, most Appalachian states experienced increases in drug overdose deaths 

between 2016 and 2017.13

Data from a recent report documenting “diseases of despair” in Appalachia noted that overdose mortality 

rates are considerably higher in Appalachia than in the non-Appalachian United States.

14 The North 

Central and Central Appalachian subregions in particular experience poisoning mortality rates that are 

strikingly higher than what is observed outside the Appalachian Region (see Figure 2). 

Contributing Factors

Several factors contributing to higher rates of opioid misuse and overdose deaths converge in Appalachia. 

Higher rates of injury-prone employment, aggressive marketing of prescription pain medications to 

physicians, and an insufficient supply of behavioral and public health services targeting opioid misuse 

contribute to higher rates of opioid misuse and mortality in the Region.

15 These factors, coupled with 

limited access to treatment and high rates of poverty, create a multifaceted public health threat.

5 Equally 

multifaceted intervention strategies are needed to address opioid misuse and overdose deaths in 

Appalachia.

Figure 2: Poisoning Mortality Rate (per 100,000) by Appalachian Subregion, 2008–2014

Image source: Health Disparities in Appalachia. 

https://www.arc.gov/assets/research_reports/Health_Disparities_in_Appalachia_August_2017.pdf.

Data source: National Center for Health Statistics. Compressed Mortality File, 1999–2014 (machine-readable data file and 

documentation, CDROM Series 20, No. 2T) as compiled from data provided by the 57 vital statistics jurisdictions through the 

Vital Statistics Cooperative Program. Hyattsville, Maryland 2015. http://www.cdc.gov/nchs/data_access/cmf.htm.
Health Disparities Related to Opioid Misuse in Appalachia | Practical Strategies and Recommendations for Communities 4

ASSESSING COMMUNITY NEED FOR PREVENTION 

OF OPIOID MISUSE AND TREATMENT OF OPIOID USE 

DISORDER

Conducting a Needs Assessment

Needs assessments are formative research activities that can help communities understand important 

cultural norms and attitudes that may affect efforts to reduce opioid use disorder and opioid overdoses. 

They can help community leaders, funders, and policymakers understand the prevalence and nature of the 

opioid problem in a particular community, including which populations are at a disproportionately high 

risk of developing an opioid use disorder. Conducting a needs assessment will also help leaders take stock 

of which programs and policies are already addressing opioid misuse and the extent to which they are 

working successfully.

The Centers for Disease Control and Prevention (CDC) provide a guide to how to conduct a community 

needs assessment that includes data sources and strategies.

16 Communities may also consider the 

following local sources of data:

17

■ Civic and non-profit organizations, for lists of current projects, more information about who 

and how many individuals are served, and plans for the future

■ Community colleges/local universities, for academic research related to the community

■ Faith-based groups, for membership numbers and community needs

■ Health departments/healthcare providers, for local prevalence rates

■ Libraries, for local history/information unique to the county

Quantitative data in conjunction with qualitative data from community forums and focus groups can help 

reveal how changes have occurred over time as well as current barriers to creating change. Identifying 

community assets is equally important to identifying challenges, and community leaders can take stock of 

existing resources systematically through asset mapping. Additional resources for conducting community 

needs assessments, including asset mapping, are provided at the end of this section.

Using State- and County-Level Data to Prioritize Resources

To target limited resources appropriately, community leaders, funders, and policymakers may consider 

leveraging county-level data to understand how the opioid crisis has impacted their community and to 

facilitate community planning. Several factors, including unemployment, poverty, disability, and age, 

influence high rates of opioid use and overdose in Appalachia. Assessing community needs will help 

program planners determine which of the recommendations presented in this brief have the greatest 

potential to reduce opioid overdoses. The Appalachian Overdose Mapping Tool can also help 

communities understand the impact of, and contributors to, the opioid epidemic in the Appalachian 

Region (see Figure 3).18 Users can assess the overall drug overdose rate and the opioid overdose rate per 

100,000 population in rural and urban Appalachian counties. Sociodemographic variables include 

race/ethnicity, age, educational attainment, and disability rates. Economic variables include median 

household income, poverty rate, unemployment rate, and accident-prone employment (e.g., 

manufacturing and construction). HealthinAppalachia.org provides a comprehensive overview of health 

in the Appalachian Region using 41 county-level measures, including poisoning mortality.
Health Disparities Related to Opioid Misuse in Appalachia | Practical Strategies and Recommendations for Communities 5

PRACTICAL STRATEGIES AND RECOMMENDATIONS 

Preventing and treating opioid use disorder in Appalachia could help decrease the number of opioid 

overdose deaths in the Region. In this section, we present policies, programs, and initiatives that show 

promise or have successfully reduced opioid misuse and/or overdose. We also provide examples of 

intervention strategies taking place in Appalachia. 

While this issue brief focuses on opioids, Appalachian communities are also facing high rates of other 

forms of substance use disorder. As described in the Health Disparities Related to Smoking in Appalachia 

issue brief, approximately 20% of Appalachian adults report being smokers, compared to 16% of adults in 

the non-Appalachian United States.1 Appalachian residents also have higher rates of alcoholic liver 

disease/cirrhosis than non-Appalachians, which is a consequence of alcohol use disorder.19 Appalachian 

communities whose members experience other forms of substance use disorder may also benefit from the 

recommendations presented in this issue brief, because opioid misuse may co-occur with misuse of other 

substances. For example, one study of two rural Appalachian counties found that current users of 

benzodiazepines were significantly more likely to misuse prescription opioids and use other illicit drugs, 

including cocaine.20

Recommendations for reducing opioid misuse and overdose disparities include the following:

1. Prevent opioid misuse.

2. Increase access to treatment for opioid use disorder.

3. Implement harm reduction strategies to reduce the consequences of opioid use disorder.

4. Support long-term recovery of opioid use disorder.

5. Implement community-based solutions to effect change.

Figure 3: Drug Overdose Deaths in the Appalachian Region as Displayed in the 

Appalachian Overdose Mapping Tool

Image source: Appalachian Overdose Mapping Tool. http://overdosemappingtool.norc.org/
Health Disparities Related to Opioid Misuse in Appalachia | Practical Strategies and Recommendations for Communities 6

RECOMMENDATION #1: PREVENT OPIOID MISUSE

Overprescribing opioids can lead to increased diversion of unused pills for opioid misuse and increased 

rates of opioid use disorder. The Appalachian Region has experienced historically high rates of opioid 

prescribing compared to other regions in the United States.

21 In 2016, congressional districts with the 

highest rates of opioid prescribing were concentrated in Appalachia, the South, and the rural West.22

Community-Based Strategies 

Engage Youth to Prevent Initiation of Opioid Use

The U.S. Department of Education 

recommends educating students and their 

families about the risks of opioid misuse 

and ways to prevent youth from developing 

opioid use disorder.23 The National 

Academies of Sciences, Engineering, and 

Medicine’s Institute of Medicine describes 

three types of prevention interventions that 

address mental, emotional, and behavioral 

disorders.24 First, universal interventions 

are typically low-cost programs that serve a 

whole population, regardless of individuallevel risk. These could include schoolbased or community-based interventions 

that teach youth skills to resist substance 

use. For example, in Grant County, West 

Virginia, a community profiled in the Bright Spot case studies report, schools are implementing the Too 

Good for Drugs and Students Against Destructive Decisions programs to prevent substance misuse 

among students.25 In McCreary County, Kentucky, another community profiled in the Bright Spot case 

studies report, the Adanta Regional Prevention Center works with local school staff to implement 

evidence-based programs to prevent substance use disorder. Many communities are also implementing 

Communities That Care (CTC), a prevention system that empowers coalitions to identify protective and 

risk factors that affect behavioral issues among youth. CTC guides communities through implementation 

of effective interventions to address the identified needs of youth, including illicit substance use.

Second, selective interventions target youth who are at higher risk for developing substance use disorder. 

For example, West Virginia’s Handle with Care program is a collaboration between schools, law 

enforcement, and health providers that helps students access resources and support after they undergo a 

traumatic event, such as a parent’s overdose. Third, indicated interventions help prevent students who 

exhibit early substance misuse or other risky behaviors from developing substance use disorder.

Increase Use of Data from Prescription Drug Monitoring Programs (PDMPs)

PDMPs are statewide databases that track prescriptions of controlled substances. The utilization of 

PDMPs can help decrease overprescribing by allowing providers to identify patients who are obtaining 

prescriptions for opioids from multiple providers. Public health agencies can also use data from PDMPs 

as surveillance tools to track trends in opioid prescribing. Recommendations for effective PDMPs include 

ensuring that data from PDMPs is easily accessible to clinicians and integrated into clinical workflows.26

Adanta works closely with schools in McCreary County, Kentucky to 

help families prevent substance abuse.

© Joyce Pinson
Health Disparities Related to Opioid Misuse in Appalachia | Practical Strategies and Recommendations for Communities 7

One approach to improving accessibility involves integrating PDMP data into electronic health records 

(EHRs) and health information exchanges. In 2018, the North Carolina Department of Health and Human 

Services invested in an integration platform that allows clinicians to easily access PDMP data through 

EHRs.

27 Kentucky’s “gold standard” PDMP mandates that all providers and pharmacists register with the 

database and requires timely data reporting.28 The Prescription Drug Monitoring Program Training and 

Technical Assistance Center at Brandeis University has also developed additional best practices for 

PDMP enhancement. 

Increase Adherence to Opioid Prescribing Guidelines

Lack of clarity about the appropriate use and dosing of prescription opioids can contribute to 

overprescribing. In 2016, the CDC released guidelines for prescribing opioids for chronic pain in an effort 

to provide recommendations about initiating opioid treatments, selecting the appropriate formulation and 

dose, and assessing risks of opioid use.29 States and communities are taking steps to ensure that providers 

are aware of and adhere to the evidence-based guidelines. For example, Tennessee enacted new opioid 

prescribing laws in 2018 that reflect these guidelines.30

Communities may also seek to implement health information technology strategies in order to improve 

adherence to prescribing guidelines. Integrating clinical decision support tools into EHRs can help 

improve the ability of primary care providers to follow guidelines and decrease the number of patients 

receiving chronic opioid therapy.31 The Centers for Disease Control and Prevention also developed a 

mobile application to provide easy access to prescribing guidance, training for motivational interviews, 

and calculating total daily opioid doses.

32

Additional Resources for Preventing Opioid Misuse

Engage youth to 

prevent initiation of 

opioids

The U.S. Department of Education’s Institute of Education Science 

manages a Regional Education Laboratory in Appalachia that discusses the 

intersection of opioid misuse and student trauma. 

The Substance Abuse and Mental Health Services Administration 

(SAMHSA)’s Evidence-Based Practices Resource Center offers a wealth of 

prevention resources focused on children and youth. 

The Blueprints for Healthy Youth Development, an evidence-based program 

registry hosted by the University of Colorado Boulder and funded by the 

Annie E. Casey Foundation, includes descriptions of programs that have 

been effective at preventing illicit drug use among children and teens. 

Increase use of 

data from PDMPs

The PDMP Training and Technical Assistance Center at Brandeis University 

offers a comprehensive collection of resources and best practices for 

PDMPs. 

The Association of State and Territorial Health Officials offers a 

compendium of resources to Improve Monitoring and Surveillance for 

substance misuse through PDMPs, including considerations for 

policymakers and providers. 

The Pew Charitable Trusts developed Evidence-Based PDMP Practices to 

Increase Prescriber Utilization, which include case studies from states in the 

Appalachian Region such as Kentucky, Tennessee, and Ohio.
Health Disparities Related to Opioid Misuse in Appalachia | Practical Strategies and Recommendations for Communities 8

Additional Resources for Preventing Opioid Misuse

Increase

adherence to 

opioid prescribing 

guidelines

The CDC Guideline for Prescribing Opioids for Chronic Pain gives

recommendations for when to prescribe opioids for chronic pain and how to 

address the risks and potential consequences of opioid use. Clinical tools

can help providers adhere to the guidelines. 

SAMHSA offers additional information about earning continuing medical 

education credits for Opioid Prescribing Courses for Health Care Providers.

RECOMMENDATION #2: INCREASE ACCESS TO 

TREATMENT FOR OPIOID USE DISORDER

Community-Based Strategies 

Medication-Assisted Treatment (MAT) is an evidence-based intervention that combines U.S. Food and 

Drug Administration (FDA)-approved medications with counseling or behavioral therapy to treat opioid 

use disorder and help sustain long-term recovery from opioid addiction.

33 The three drugs that are 

approved by the FDA for treatment of opioid use disorder are methadone, buprenorphine, and naltrexone.

Methadone must be dispensed in licensed opioid treatment centers, while naltrexone and buprenorphine 

can be prescribed by waivered physicians in office settings. The FDA recommends access to all three 

treatments, with the physician deciding which one to prescribe based on their assessment of the severity 

of the individual’s opioid use disorder and needs. Despite strong evidence demonstrating the effectiveness 

of MAT in treating opioid use disorders, access and coverage remain limited in Appalachia. For example, 

state Medicaid programs in Kentucky, Tennessee, and West Virginia do not cover methadone treatment.34

To improve access to MAT, communities may seek to increase the number of providers who offer MAT, 

invest in telehealth programs, and integrate behavioral health into primary care and emergency 

department settings. 

Increase the Number of Providers Offering MAT

According to the Drug Addiction Treatment Act of 2000 (DATA 2000), physicians who complete an 

eight-hour training course can apply for a waiver from the U.S. Drug Enforcement Agency to prescribe 

buprenorphine. Key barriers to increased access to buprenorphine treatment include lack of provider 

experience with MAT and with managing patients with opioid use disorder.35 One strategy to increase the 

number of providers engaging in MAT is Project ECHO, an evidence-based telementoring intervention 

that pairs rural providers with behavioral health specialists through videoconferencing.36 Substance use 

specialists can review specific case studies and offer didactic presentations on topics related to MAT, 

which builds the capacity of rural providers to manage treatment for their patients. For example, the West 

Virginia Project ECHO Medication-Assisted Treatment has covered the use of naltrexone and 

buprenorphine in the treatment of opioid use disorders. 37 The Ohio Opiate Project ECHO also offers 

mentoring to newly waivered physicians in order to increase their comfort with prescribing 

buprenorphine.38

Invest in Telehealth Programs 

Telehealth can help overcome provider shortages and limited access to opioid treatment programs by 

virtually connecting patients with substance use specialists. Providers can connect with a qualified 
Health Disparities Related to Opioid Misuse in Appalachia | Practical Strategies and Recommendations for Communities 9

physician to secure a buprenorphine prescription for a patient. Patients can also receive counseling 

services via video teleconference. For example, the Comprehensive Opioid Addiction Treatment (COAT) 

program combines MAT with group psychotherapy, individual therapy, and participation in weekly 

community support programs.39 Patients who live in rural communities with limited access to local 

behavioral health providers meet with a psychiatrist through telehealth to receive assessment and referral 

to COAT. An evaluation of the program found similar rates of abstinence and retention between groups 

that experienced group therapy MAT services in-person and through telepsychiatry.

40

Integrate Behavioral Health Treatment in Primary Care Settings and Emergency 

Departments

States and communities are expanding access to MAT beyond specialized treatment facilities, which can 

have long waitlists and limited capacity to meet the demand of people seeking treatment for opioid use 

disorder. One effective approach to increasing access to MAT is integrating behavioral health into 

primary care, where people with opioid use disorder can receive care in their communities. The evidencebased hub-and-spoke model in Vermont pairs opioid treatment programs (hubs) with waivered providers 

at primary care practices, Federally Qualified Health Centers, and other facilities throughout the state 

(spokes).41 The spoke MAT team—consisting of lead provider, nurse, and licensed counselor— receives 

consultations and training from the hubs in order to develop treatment plans and manage patients.41 The 

hub-and-spoke system has been effective in increasing the state’s capacity to treat opioid use disorder:

Vermont had the greatest number of people in treatment per 1,000 people among all states in 2017.42

Communities are also integrating access to MAT in emergency departments in an effort to immediately 

link patients to care. Ohio is facilitating MAT in emergency departments in order to quickly link patients 

who might otherwise experience long waitlists for office-based treatment to care.

43 Patients flow from 

induction of MAT in the emergency department to interim care by a primary care physician, after which 

they transition to care in office-based opioid treatment or an opioid treatment program. The Potomac 

Highlands Guild in Grant County, West Virginia, profiled in the Bright Spot case studies report, is also 

facilitating connections between the emergency department and intensive outpatient treatment for 

substance use disorder.44 Staff provide round-the-clock support to the local emergency department for any 

crisis related to substance use disorders.45

Both primary care practices and emergency departments are also using screening, brief intervention, and 

referral to treatment (SBIRT) to identify patients who need support for opioid use disorder. SBIRT is an 

evidence-based model that involves screening patients for substance use disorder, providing a brief 

intervention to educate patients about their substance use, and referral to treatment and additional 

services. SBIRT can help provide early intervention services for people with opioid use disorder before 

they experience more severe consequences, including overdose. Research suggests that SBIRT for opioid 

dependence can be more effective if patients also receive an initial dose of buprenorphine/naloxone until 

they receive follow-up care.46 The West Virginia SBIRT Project is increasing the use of SBIRT in rural 

community-based primary health care clinics, emergency departments, and school-based health clinics,

and connecting patients who need further care to community-based behavioral health centers that offer 

interventions tailored to Appalachian culture and values.47
Health Disparities Related to Opioid Misuse in Appalachia | Practical Strategies and Recommendations for Communities 10

Additional Resources for Increasing Access to Treatment

Increase the number of 

MAT providers 

SAMHSA offers information about Buprenorphine Training for 

Physicians and other training materials and resources for MAT. 

The Providers Clinical Support System, funded by SAMHSA, offers 

information and resources for providers seeking to obtain a waiver for 

prescribing buprenorphine. 

Invest in telehealth 

programs

The U.S. Department of Health and Human Services (HHS) has

released a brief to clarify regulations for Telemedicine and Prescribing 

Buprenorphine for the Treatment of Opioid Use Disorder.

The SAMHSA-HRSA Center for Integrated Health Solutions’

Telebehavioral Health Training and Technical Assistance Series

provides information about planning for and implementing telehealth 

programs that address behavioral health. 

Integrate behavioral 

health treatment in 

primary care settings

and emergency 

departments

The SAMHSA-HRSA Center for Integrated Health Solutions developed 

a paper to provide guidance for communities seeking to integrate MAT 

into safety-net settings. The center also provides SBIRT resources, 

including educational courses and implementation supports.

The Kentuckiana Health Collaborative’s SBIRT Toolkit for Addressing 

Unhealthy Substance Use in Primary Care Settings focuses on 

educating providers about implementing SBIRT to address opioid 

misuse. 

RECOMMENDATION #3: IMPLEMENT STRATEGIES TO 

REDUCE THE HARMFUL CONSEQUENCES OF OPIOID 

USE DISORDER

Opioid use disorder can have severe health, social, and economic consequences for people with the

disorder and their families. Communities are implementing several strategies to reduce the harm 

associated with opioid use disorder, including overdose and transmission of blood-borne infections such 

as HIV and viral hepatitis. Several of these approaches are included in the CDC’s Evidence-Based 

Strategies for Preventing Opioid Overdose: What’s Working in the United States. 

Policy-Based Strategies 

Expand Naloxone Programs 

Naloxone is a medication used to rapidly reverse opioid overdoses. Certain formulations of naloxone can 

be administered by anyone who has received training, including emergency medical services (EMS),

other first responders, and community members. Efforts to expand access to and use of naloxone often 

focus on offering training that identifies the signs and symptoms of an opioid overdose and how to 

administer naloxone to reverse it.

48 Research demonstrates decreased rates of opioid overdose deaths in 

communities that received overdose education and naloxone distribution training compared to 

communities that did not undergo training.49 Many programs in Appalachia are implementing training 

programs in order to decrease opioid-related overdoses. For example, Full Circle Recovery Center in 

Franklin, North Carolina, worked with EMS, law enforcement, and other first responders to provide 

tailored education about opioid use disorder and naloxone administration.50 Project REVIVE in 
Health Disparities Related to Opioid Misuse in Appalachia | Practical Strategies and Recommendations for Communities 11

Southwest Virginia provides free community training and naloxone response kits to increase the ability of 

lay rescuers to reverse opioid overdoses. 51

Implementing coprescription of naloxone can also effectively reduce opioid-related overdoses.52 HHS 

recommends that clinicians consider coprescribing naloxone to patients who are prescribed opioids and at 

risk of an overdose, including those who are taking large doses or have a co-occurring substance use 

disorder.53 HHS also recommends that clinicians prescribe naloxone to patients at risk of an opioid 

overdose, including those who are using illicit opioids or receiving treatment for opioid use disorder.53

Other strategies to improve access to and use of naloxone include providing immunity from criminal 

prosecution, civil liability, and professional sanctions to prescribers and dispensers for distributing 

naloxone to a layperson. Many states also allow for standing orders for naloxone, which allow prescribers 

to authorize pharmacies to distribute naloxone to eligible individuals without a prescription. Appalachian 

communities should be aware of state and local laws that affect the ability of community members to 

access and administer naloxone. The Prescription Drug Abuse Policy System provides a map of naloxone 

laws that were enacted before July 1, 2017. 

Promote the Use of Drug Courts

Drug courts aim to keep people who are recovering from opioid use disorder out of the criminal justice 

system. Participation in drug courts is often a condition of pretrial release programs, wherein individuals 

must complete a behavioral health treatment plan in order to avoid incarceration. Drug court models 

typically involve a screening process to identify risks and needs, periodic interaction with a judge, regular 

monitoring and supervision, incentives and sanctions based on the participant’s progress, and access to 

recovery services.54 Many communities in the Appalachian Region are implementing drug courts:

■ As profiled in the Bright Spot case studies report, Potter County, Pennsylvania, is implementing a 

pretrial diversion program and specialty drug courts to link people with substance use disorder to 

treatment.55 These programs have contributed to decreased recidivism, increased cost savings, 

and improved opportunities for community members to achieve long-term recovery. 

■ In Appalachian Tennessee, the 4th Judicial District’s Recovery Oriented Compliance Strategy (TN 

ROCS) offers a pathway to treatment for offenders who have substance use disorders and are 

considered low-risk for recidivism. TN ROCS participants meet with criminal justice liaisons to 

receive behavioral health screenings, corrections officers to complete regular check-ins, and the 

district judge to provide updates on their progress. Key successes have included prevention of 

neonatal abstinence syndrome (NAS) among infants born to pregnant women participating in TN 

ROCS.

■ Some Appalachian communities are implementing specialized Family Treatment Drug Courts

that also involve child welfare services, with the ultimate goal of promoting safe and healthy 

environments for children. For example, the Tompkins County Family Treatment Court connects

parents who have substance use disorder with treatment and parenting classes. The program has 

been successful in reducing the amount of time in foster care placement among children of 

parents with substance use disorder.
Health Disparities Related to Opioid Misuse in Appalachia | Practical Strategies and Recommendations for Communities 12

Community-Based Strategies 

Implement Syringe Services

Syringe services programs (SSPs) offer sterile syringes and safe syringe disposal sites to people who 

inject drugs. SSPs are effective in reducing the spread of HIV and viral hepatitis.56 Comprehensive SSPs

also provide linkages to care and other resources in order to treat opioid use disorder and offer early 

interventions for health complications.57 For example, programs could also refer clients to MAT and 

behavioral therapy, naloxone training, prenatal and women’s health resources, and screening for HIV and 

hepatitis C and B.57 Access to SSPs has grown in some Appalachian states that have been heavily affected 

by the opioid epidemic. From 2013 to 2017, the number of SSPs in Kentucky, North Carolina, and West 

Virginia has grown from 1 (in West Virginia) to 53 across the 3 states.57 Many of these SSPs are located

in Appalachian eastern Kentucky and western North Carolina.58,59 For example, the Olive Branch 

Ministry in Appalachian North Carolina operates a mobile SSP that provides clean syringes and refers 

individuals to treatment and peer support services. Other Appalachian SSPs include the LENOWISCO 

Harm Reduction Program in Virginia, which provides referrals to social services and medical care; preexposure prophylaxis; non-occupational post-exposure prophylaxis for people at risk of contracting HIV;

counseling; and other services in addition to syringe exchanges.60

Implement Safe Drug Disposal Programs

Safe drug disposal programs allow people to anonymously dispose of 

expired and unused prescription opioids in order to prevent misuse 

and diversion. One study found that permanent drug donation box 

collections in Appalachian Tennessee were effective in removing 

controlled substances from communities.61 Communities may work 

with law enforcement to implement permanent donation boxes in 

locations that are accessible and convenient, including pharmacies, 

medical facilities, local police departments, and other locations. For 

example, Wirt County, West Virginia, profiled in the Bright Spot case 

studies report, has a permanent receptacle in front of the courthouse

that allows community members to drop off medications and other 

substances.62 The U.S. Drug Enforcement Administration also 

encourages National Prescription Drug Take-Back Day events in 

order to promote safe disposal of drugs. 63 A study of 11 drug takeback events in Appalachian Tennessee and Virginia collected almost 

17,000 containers of medications from 752 participants.64

Prevent and Treat Neonatal Abstinence Syndrome (NAS)

Neonatal abstinence syndrome (NAS) occurs when newborns who were exposed to substances in the 

womb experience withdrawal symptoms after birth.

65 While long-term effects of opioid withdrawal on the 

newborn brain are poorly understood, short-term symptoms include excessive crying, irritability, fever, 

hyperactivity, poor feeding, sleep problems, and slow weight gain, among others.

66 Many communities in 

Appalachia have experienced growing rates of NAS as a result of the opioid crisis. For example, cases of 

NAS tripled in Kentucky from 2008 and 2014, and the rate of NAS in Appalachian counties was double 

that of non-Appalachian counties.67 The CDC recommends that clinicians discuss the risks of NAS before 

prescribing opioids to pregnant women and suggests increasing access to family planning resources for

women who use opioids.

68 Some Appalachian communities are also involving public health and social 

Efforts to support appropriate use and 

disposal of prescription drugs include 

a drug take-back program in Wirt 

County, West Virginia.

© Joyce Pinson
Health Disparities Related to Opioid Misuse in Appalachia | Practical Strategies and Recommendations for Communities 13

service agencies in efforts to prevent NAS. For example, the Sullivan County Regional Health 

Department in Appalachian Tennessee is providing educational sessions on NAS prevention and referring 

eligible women to home visiting programs. Appalachian communities are also working with payers to 

seek reimbursement for NAS treatment. In 2018, West Virginia became the first state to receive Centers 

for Medicare and Medicaid Services (CMS) approval to offer NAS treatment services. 

Additional Resources for Implementing Harm Reduction Strategies

Expand naloxone 

programs

HHS released guidelines for coprescribing naloxone to patients at 

high risk for an opioid overdose to help providers understand which 

patients could benefit from receiving a naloxone prescription.

SAMHSA developed a fact sheet that describes resources for first 

responders and others that are preparing to distribute naloxone. 

Promote the use of drug 

courts 

SAMHSA’s brief, Adult Drug Courts and Medication-Assisted

Treatment for Opioid Dependence, educates drug court personnel

about MAT. 

Implement syringe 

services and proper drug 

disposal programs 

The Harm Reduction Coalition developed the Guide to Developing 

and Managing Syringe Access Programs to provide a comprehensive 

overview of the process of implementing an SSP.

CDC’s Syringe Services Programs (SSPs) Developing, Implementing, 

and Monitoring Programs fact sheet offers a compendium of 

resources for communities seeking to implement an SSP with a

comprehensive prevention approach.

Implement safe drug 

disposal programs

The U.S. Food and Drug Administration offers information, resources, 

and frequently asked questions about disposal of unused medicines. 

Prevent and treat NAS The National Center on Substance Abuse and Child Welfare provides 

links to publications, webinars, videos, and research studies focused 

on NAS. 
Health Disparities Related to Opioid Misuse in Appalachia | Practical Strategies and Recommendations for Communities 14

RECOMMENDATION #4: SUPPORT LONG-TERM 

RECOVERY FROM OPIOID USE DISORDER

Policy- and Community-Based Strategies 

Address Upstream Factors That Affect Long-Term Recovery 

The root causes of opioid use disorder are influenced by larger social, economic, and environmental 

factors. These social determinants of health also affect the ability of individuals to access treatment and to 

address risk factors that pose challenges to long-term recovery. The President’s Commission on 

Combating Drug Addiction and the Opioid Crisis released recommendations that address the social and 

environmental context of opioid misuse. Policy-based recommendations include implementing 

reimbursement for recovery support services for job training and supportive housing, allowing individuals 

with felony convictions to apply for business and occupational licenses, and promoting cross-agency 

collaboration to support the development of recovery residences. Community-based recommendations 

include implementing family-centered treatment programs, supporting sober housing programs on college 

campuses, and developing best practices for employers about hiring and supporting employees with 

substance use disorder. 

Community-Based Strategies 

Promote the Use of Peer Recovery Programs 

Individuals and their families may require additional support in the process of recovering from opioid use 

disorder. Effective strategies to extend support include peer recovery programs69 that involve people in 

long-term recovery from substance use disorder—sometimes called peer support specialists or peer 

recovery coaches—who can share their experiences with those in similar circumstances. In addition to 

providing mentorship, peer support workers can help individuals navigate court systems, connect to 

community resources, and build healthy social networks. For example, the Tennessee Department of 

Mental Health and Substance Abuse Services funds the Lifeline Peer Project, in which peer support 

representatives start self-help support groups for youth and adults in recovery.70 Sequatchie County, 

Tennessee, a Bright Spot case study community, implemented Project Lifeline to address stigma related 

to addiction and build community support for policies that provide treatment and recovery services.3

Additional Resources for Supporting Long-Term Recovery

Address upstream 

factors that affect 

long-term recovery

The Center for Health Policy at the Brookings Institution and the University 

of Southern California’s Schaeffer Center for Health Policy & Economics

collaborated on a report, Un-burying the Lead: Public Health Tools Are the 

Key to Beating the Opioid Epidemic, which describes the importance of 

addressing social and environmental risk factors for opioid misuse. 

Promote the use of 

peer recovery 

programs

SAMHSA offers Peer Support Resources that provide additional 

information about the role of peers in the recovery process for substance 

use disorders.
Health Disparities Related to Opioid Misuse in Appalachia | Practical Strategies and Recommendations for Communities 15

RECOMMENDATION #5: IMPLEMENT COMMUNITYBASED SOLUTIONS TO PREVENT SUBSTANCE 

MISUSE

Many communities are creating formal coalitions to strengthen partnerships between multiple sectors 

affected by substance use disorders, including law enforcement, social service providers, schools, health 

providers, and policymakers. Community coalitions can affect change at the systems level and promote 

upstream interventions to prevent opioid misuse. Several communities in Appalachia have established 

coalitions that are addressing the opioid crisis: 

■ The Madison Substance Awareness Coalition in North Carolina brings together a broad range of 

community partners—representatives from law enforcement, schools, public health agencies, 

health care providers, social services, pharmacies, and faith-based organizations—to reduce

misuse of opioids. As profiled in the Bright Spot case studies report, coalition members provide

community education about prescription medication misuse, train community members on the use 

of naloxone, and distribute lock boxes to promote safe medication disposal.3

■ The Coffee County Anti-Drug Coalition in Tennessee developed the Count It! Lock It! Drop It!®

model to prevent diversion of prescription medications. The program educates patients about 

counting their pills, locking their medication, and disposing of unused medications in safe 

locations or at take-back events. Several community partners are involved in Count It! Lock It! 

Drop It!®, including law enforcement offices and pharmacies that host drop boxes. 

■ The Tioga County Allies in Substance Abuse Prevention (ASAP) coalition in New York, profiled 

in the Bright Spot case studies report, includes representatives from local school districts, 

nonprofits, parents, and other community members.

71 ASAP focuses on preventing substance use 

disorder among youth by facilitating panel discussions, conducting needs assessments, 

disseminating messaging about substance use, and creating positive leadership and social 

opportunities for youth.3

■ The Prevention, Intervention, Treatment, Anti-Stigma and Recovery (PITAR) coalition in Grant 

County, West Virginia, profiled in the Bright Spot case studies report, brings together 

representatives from the prosecutor’s office, sheriff’s department, drug court, and treatment 

centers to discuss solutions to the opioid epidemic.3

Additional Resources for Implementing Community-Based Solutions

The Rural Health Information Hub describes program models and considerations for community 

coalition models. 

The Community Anti-Drug Coalitions of America’s National Community Anti-Drug Coalition 

Institute developed a Handbook for Community Anti-Drug Coalitions that reviews frameworks and 

offers recommendations for establishing an effective coalition. 

The Appalachian Regional Commission released a report, Communicating about Opioids in 

Appalachia: Challenges, Opportunities, and Best Practices, which can help community-based 

organizations in Appalachia identify effective messaging to support opioid misuse prevention and 

recovery.
Health Disparities Related to Opioid Misuse in Appalachia | Practical Strategies and Recommendations for Communities 16

STRATEGIES AND RECOMMENDATIONS FOR 

FUNDERS

Funders throughout the Region have the opportunity to invest in initiatives and activities that help prevent 

and reduce opioid use and overdose deaths across Appalachia. Below, we describe strategies for funders 

seeking to reduce opioid-related health disparities in the Appalachian Region. 

 Leverage existing assets

Funders can leverage existing programs, practices, and policies by promoting the replication and 

adoption of successful programs and strategies. Appalachian communities have many assets that 

should be recognized and promoted. Community members are often connected through volunteering 

and coalition building. They also build strong social connections through faith- and community-based 

organizations, schools, local businesses, and shared culture and history. Funders can continue to 

support or increase funding for coalitions that are implementing community-based strategies to 

address substance use disorder. Funders can also support existing community or statewide efforts 

to address the opioid crisis, such as take-back events.

 Strengthen community implementation capacity

Funders can strengthen community implementation capacity in Appalachian communities. 

Opportunities to increase capacity include (1) enhancing individual-level knowledge and skills that 

facilitate community action, and (2) fostering organizational and systems-level capacity. Examples of 

organizational and systems-level capacity include engaging in community visioning and strategic 

planning, building networks and engaging community stakeholders, writing grants, and engaging in 

local and regional policy advocacy, among others. Funders can consider working with communitybased organizations to strengthen their capacity to assess community needs, identify evidencebased or promising interventions, and implement programs that address substance use disorder.

 Focus on cross-sector collaboration through philanthropic strategies

Funders can facilitate collaboration between community members, the public, and private-sector 

individuals, which is critical to addressing opioid misuse within the Region. Through a coordinated 

use of resources, leadership, and action, communities can work together towards a common goal, 

using multiple perspectives and different areas of expertise. Government, the health care system, 

schools, private businesses, and community organizations all have critical roles in this effort. A key 

strategy to support cross-sector collaboration is to fund community coalitions that focus on 

preventing substance misuse and treating substance use disorder. For example, 32 anti-drug UNITE 

coalitions receive funding from the Kentucky legislature and private donors to implement local 

solutions to substance misuse in Appalachian Kentucky. 

 Build the Appalachian evidence base

The Bright Spot case studies report identified examples of promising practices to address opioid 

misuse in Appalachian communities. However, these programs and their outcomes are often not well 

documented. For long-term changes to occur, successful programs need to be evaluated rigorously 

and shared widely. Funders should encourage evaluation among their grantees to ensure program 

effectiveness is measured and documented. Evaluation, along with increased efforts to document 

local successes, will provide a more robust evidence base for Appalachian-specific programs and 

policies to address opioid misuse. The Rural Health Information Hub, supported by HRSA, provides 

additional information about effective and promising models and innovations in the area of 

substance misuse, including examples from the Appalachian Region. 
Health Disparities Related to Opioid Misuse in Appalachia | Practical Strategies and Recommendations for Communities 17

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