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U.S. media and popular culture historically portrayed drug abuse as an urban problem, but in recent years, there has been more media attention on rural drug issues. Part of this growing attention pertains to the growing epidemic of narcotic painkiller abuse in rural America. Although all areas of the country experienced increases in painkiller prescribing, abuse, and mortality over the past two decades, the increases have been most pronounced in small towns and rural areas.1 This rural drug epidemic requires immediate attention from policy makers and practitioners. During the 1980s and 1990s, pharmaceutical companies aggressively marketed OxyContin® and other opioids in Appalachia,2 and physicians regularly dispensed painkillers to coal miners and other heavy-occupation laborers.3 In the 2000s, prescription painkillers became more difficult to obtain in Appalachia due to the introduction of prescription drug monitoring programs and a Drug Enforcement Administration crackdown on “pill mills.” Consequently, addicts and dealers from rural Kentucky, West Virginia, Tennessee, and Ohio regularly travelled along what journalists nicknamed the “Oxy Express” to purchase pills in Florida, where prescribing laws were more lax.4 Since 2000, prescription painkiller abuse has spread to other rural areas where it was previously uncommon, including New Hampshire and Maine.5 Over 1.1 million U.S. adolescents (4.7 percent of youth aged 12–17) abused prescription painkillers in 2014. Among teens, only marijuana and alcohol are more frequently abused than prescription painkillers. Adolescents abuse painkillers more than crack/cocaine, ecstasy, heroin, hallucinogens, inhalants, and methamphetamine combined. Painkiller abuse during adolescence has significant implications for later life. Individuals who abuse painkillers before age 18 are more likely to become addicted than those who first abuse them as adults. Painkiller addiction in youth also increases the likelihood of economic CARSEY RESEARCH

Rural Adolescents Are More Likely Than Their Urban Peers to Abuse Prescription Painkillers