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Could transitional housing help bring the crisis to a close?

In 2016, the opioid epidemic in America continued to persist at crisis level: Each day, 91 people died of a drug overdose, and the number of opioid-related deaths has quadrupled since 2000. Rural towns and small cities have been hit especially hard. According to research from the National Institutes of Health, people in non-metropolitan areas have higher rates of drug poisoning deaths, and opioid poisonings in nonmetropolitan counties have increased at more than three times the rate in urban areas.

At the recent HAC Rural Housing Conference, national policymakers proposed a decidedly urban solution to the addition epidemic: infrastructure. Tom Vilsack, the secretary of the U.S. Department of Agriculture, cited a lack of housing as a critical driver and perpetuator of the epidemic. In August, the USDA laid out a plan to finance transitional housing for people in treatment for opioid addiction in 22 states; other speakers called on federal agencies to invest in developing more affordable housing in rural communities.

CityLab spoke with Alan Morgan, the director of the National Rural Health Association, about why housing infrastructure will be a key player in solutions to the opioid epidemic in the years to come.

What is your perspective on the scope of the opioid addiction epidemic in rural America?

The opioid crisis has impacted the whole country, but Secretary Vilsack and even former President Bill Clinton have acknowledged that this is uniquely a rural issue. It really has exploded in smaller communities, and it’s a growing problem.

It’s not just in the emergency rooms—you really see the effect in the life-expectancy data. From 1990 onwards, the life-expectancy rate has risen in urban areas, but there’s actually been a decline among rural populations (the Robert Wood Johnson Foundation’s community health rankings break it down). This is for a number of reasons: smoking, cardiovascular disease, and cancer are more common, but overdose deaths and suicides are a big part of the problem, which is unusual, because these are behavioral health issues as well.

What’s driving the disparity between urban and rural health, particularly when it comes to addiction?

When you look at the prevalence of behavioral health specialists and mental health specialists, there’s a clinical shortage when it comes to these types of professionals in rural areas. So you’ve got a self-perpetuating system where those most in need of health care services have the fewest options available. Bill Clinton, again, attributed this growing opioid crisis to a loss of hope in rural communities.

In urban area, you’ve got treatment centers, you’ve got behavioral health professionals. You have drug-recovery programs and protocols. In rural communities, you might not have that safety net available, but the health care options are built around prescription opioids: High-school kids get injured playing sports, they’re prescribed painkillers, and without good follow-up treatment, they get hooked. Same with farm workers who get in accidents. And often, this a transportation issue—the nearest health care facilities can sometimes be hours away, and when sustained treatment and follow-up is inaccessible, addiction takes the place.

The opioid addiction crisis has been at the forefront of a lot of discussion this past year, but it still seems as though there are many challenges to be worked through—especially housing. How does affordable housing intersect with the opioid epidemic in rural communities?

We have an unfortunate tendency to silo our sectors. When it comes to the opioid epidemic, we can no longer afford to do that. It’s a health issue, but there’s a transit component, and there is certainly a housing component. People need to be in a stable, drug-free environment to complete the recovery process. And in rural areas, there’s a real shortage of affordable housing that is safe and drug-free. If people get into treatment then are released back into the same housing situations where they have access to opioids, then it just exacerbates the issue.

So what often happens is that people struggling with addiction fall into homelessness: Around 35 percent of homeless individuals nationwide struggle with drug abuse. But unfortunately, rural homelessness doesn’t have the same visibility as it does in urban areas. In smaller communities, people will often bounce around the homes of extended family, but the transient nature of rural homelessness is not a visual cue that people understand. It’s been hard for communities to come up with a solution to problems they can’t see.

Secretary Vilsak and the USDA have piloted a program to increase the amount of transitional housing in rural America. What needs to happen in order to ensure that’s successful?

It’s going to have to be a cross-agency coordinated approach as we move forward. That’s a great quote—I should just leave it at that. But I have to add a cautionary note. The federal government is redirecting resources at a national level to address this crisis: The partnership between the USDA and the Rural Housing Service will get more people into stable living situations, and the agency is devoting more funds toward awareness and treatment programs.

The problem that we face is that when you have a national effort like this, it involves investing a lot of resources and funds, and you want to be able to demonstrate that those efforts have a significant impact. You want to show that the programs have dramatically reduce the prevalence of addiction and made headway in addressing the crisis. In short, you want numbers. But the most striking numbers will still come from urban areas. It’s always going to be harder to demonstrate need with rural populations, where the numbers in general are smaller.

Especially with Ben Carson appointed to lead the Department of Housing and Urban Development (HUD), it’s hard to ignore the intersection between housing and health. How do you see rural communities working to integrate the two over the next several years?

The key will be to connect the dots between health services and social services at the community level. That has played out at the federal level under the current administration—and hopefully the next—but it’s got to happen locally. How does the community hospital step up as a leader and integrate services with local housing and agencies? There’s got to be a social structure in place to tackle this crisis, but it will require support from federal departments: the USDA, the Department of Transportation, HUD, the Department of Veterans Affairs. We’ll have to talk across sectors and engage all levels of government.

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