Kratom Use in Rural Regions of the United States

"These latter two opioid-related motivations for use indicate that kratom use in the US may vary by region. Kratom’s relevance to people’s needs (and thus its prevalence of use) may be greater in rural communities that experienced higher per capita rates of opioid prescribing during the early 2000s and subsequently experienced changes in the licit and illicit prescription opioid market (Thomas et al., 2020). Findings consistently indicate high opioid-related risk for those living in rural settings: opioid prescribing is up to 33% higher in rural counties than elsewhere; rural-residing adolescents are more likely than those in urban-metro counties to initiate nonmedical use of opioids; rural justice-involvement carries a five-fold greater likelihood of nonmedical use of opioids; and overdose death rates for nonmedical use of opioids are 20–30% higher in rural counties (Havens et al., 2007; Paulozzi and Xi, 2008; Havens et al., 2011; Mack et al., 2017; Mosher et al., 2017; Ayres and Jalal, 2018; Luu et al., 2019). These outcomes are compounded by the practical and social difficulties of accessing treatment for opioid use disorder (OUD) in rural counties, including stigma surrounding medication for OUD (MOUD) (Bunting et al., 2018; Jones, 2018; Jacobson et al., 2020; Lister et al., 2020; Cole et al., 2021; Franz et al., 2021). Recent findings suggest that only half of physicians authorized to prescribe MOUD had the availability to accept new patients (Andrilla et al., 2018), and though MOUD access is increasing nationally and gains have been made to increase prescriber capacity in underserved areas (Barnett et al., 2019), more than half of small and rural counties lack a physician waivered by the Drug Enforcement Administration to prescribe MOUD (Andrilla and Patterson, 2021). Given the high prevalence of prescription opioid misuse, poor psychiatric (Snell-Rood and Carpenter-Song, 2018) and physical health (including high rates of chronic pain) (Meit et al., 2017), and the difficulty in obtaining MOUD in rural areas (Sexton et al., 2008; Prunuske et al., 2014; Woolf et al., 2019; Monnat, 2020), it is possible that kratom use might be more prevalent in rural counties than in urban-metro counties. Although heroin use is increasing in many rural communities that had elevated rates of opioid prescribing (Nolte et al., 2020; Schnell et al., 2020; Hedegaard and Spencer, 2021; Strickland et al., 2021), kratom might be more accessible or more attractive than heroin to people whose sole prior opioid use had involved prescribable pills. To date, kratom use has not been well characterized in terms of rural/suburban/urban differences. Only two large US survey studies have noted the geographic region of kratom users in their sample, both finding that a slightly greater proportion resided in the US South (Coe et al., 2019; Garcia-Romeu et al., 2020). However, in separate analyses, Nicewonder et al. (2019) found that kratom use was more widely distributed across the US, with higher rates in Florida, as well as Oregon, California, and Idaho, and still noteworthy use in the Northeast. These findings were from data collected in 2017; given the relatively recency of kratom’s emergence in the US, an update would probably be informative."