Progress 07/01/23 to 06/30/24

Outputs
Target Audience: Nothing Reported Changes/Problems: Nothing Reported What opportunities for training and professional development has the project provided?During the reporting period, werecruited one graduate student who conducted quantitative analysis. We also involved another graduate student who sit in some of the interviews as an observer, who will conduct interviews himself during 2024-2025. How have the results been disseminated to communities of interest?During the interviews with stakeholders in WV and KY, we have discussed the results from our quantitative analysis with interviewees to acquire their insights and comments. There was great interest in our results among the interview participants. What do you plan to do during the next reporting period to accomplish the goals?For the qualitative part, we will continue to conduct interviews with health providers (particularly substance use service providers) and economic development practitioners in counties more and less dependent on coal in West Virginia and Kentucky, and in 2025-2026, we will shift to focus more heavily on those with lived experience. We will aslo extend our interviews to the mountain west coal region including Wyoming. These interviews will allow us to continue to connect the dots between the themes outlined above, including substance use patterns, economic opportunity, coal dependence, and COVID-19 developments (i.e., related to broadband and telehealth). The quantitiative analysis in 2024-2-25 will focus on coal regions, and in particular rural counties that have been historically dependent on coal mining and/or coal power plants. The analysis will explore the impacts of broadband, telehealth andeconomic development on opioid and drug use and overdose during the post-COVID era.

Impacts
What was accomplished under these goals? We conducted both quantitative analysis and qualitative study on the impacts of COVID-19 and coal decline on opioid use and overdose in rural areas. The quantitative analysis has assembled a county level panel data, covering a total of 1,938 rural counties and 1,154 urban counties in the U.S.For the qualitative portions of this study, we have conducted in-depth interviews with a total of 17 key informants in both Kentucky and West Virginia, regarding local overdose crisis and the connection of the overdose crisis to COVID impacts, broadband, telehealth, and the coal industry and economic opportunity. Quantitative Analysis We compiled a county level panel data from multiple sources. The panel spans from the first half of 2018 to the first half of 2021, structured in six-month intervals. The county-level data on opioid-related overdose deaths, by race (White and non-White), gender (male and female), and age group (under 25, 25-54, and 55 or older), were sourced from the CDC's WONDER database.The broadband coverage data was based on the FCC (Federal Communications Commission)Form 477 form, which collects information biannually (June and December) from all facilities-based broadband providers . We conducted analysis separating rural counties (1,938 in total) and urban counties (1,154 in total). The dependent variable is the opioid-related overdose death rate (OODR, deaths per 100,000 population), for the half-year period t in county c of state s. The key interested variable is the share of population covered by broadband for the half-year period t in county c of state s. There could be potential correlation between broadband coverage and unobservable determinants of opioid overdose deaths, which could lead to biased estimate on the impacts of broadband coverage on OODR.To address such endogeneity concerns, we applied an instrumental variable (IV) identification strategy, usingthe average broadband coverage of neighboring counties as IV. Results For the period before COVID-19, the impact of broadband on OODRs was insignificant in both urban and rural counties. For the period after COVID-19, however, the IV estimates are insignificant for urban counties but significantly negative for rural counties. These findings imply that the expansion of broadband had no impact on opioid overdose mortality in rural counties before COVID-19, but it significantly mitigated opioid overdose mortality in rural counties after COVID-19. We further separated rural counties, based on the availability of local OUD treatment facilities. Broadband had significantly negative impacts on OODR incounties without local MOUD treatment resources, suggesting thatindividuals with OUD in underserved areas improved access to MOUD treatment through telehealth. We further explored the impacts of broadband expansion onopioid overdose mortality among different demographic populations in rural counties without MOUD facilities, for the period during COVID. The results showthat (1) broadband expansion had significant impacts on mitigating OODRs for males but not for females; (2) broadband hadsignificant impacts of broadband for both white and non-white subgroups, though the magnitude is larger for non-whites; and (3)the impact of broadband on OODRs is significant for individuals aged 25-54 years and those over 55 years (with a larger magnitude for the 25-54 age group), but not significant for those under 25 years. Quantitative Interview For the qualitative portions of this study, we have been making steady progress on in-depth interviews with key informants in both Kentucky and West Virginia. We have thus far interviewed 17 key informants, including substance use treatment providers (n=7), people with substance use disorder (n=1), rural health organizations (n=4), and economic development practitioners (n=5). Results Our interviews underscore the importance of broadband access for substance use disorder prevention, treatment, and recovery. In terms of treatment, telehealth access has expanded options of services for those with substance use disorders. COVID inspired relaxations in medications for opioid use disorder (MOUD) regulations that allow for patients to access buprenorphine through telehealth. Most clinics do not allow patients to solely participate in their programs virtually, continuing to believe that providers must see patients in person to recognize possible continued illicit drug use and other behavioral health concerns. However, once patients have been induced in person, allowing for virtual check-ins has lowered the bar to sustaining treatment. This simply makes seeking treatment logistically easier, as people must travel far distances to substance use treatment providers less often--something that can be particularly tricky for those with inconsistent transportation due to low incomes or losing driver's licenses amid criminal legal involvement. But access to the Internet also extends beyond medical services. Respondents explained that broadband access also opens doors to broader recovery communities that can provide ongoing support. In small towns in Appalachia, especially, there are limited numbers of recovery support groups. Those groups that do exist also tend to follow the 12-step model, which while is successful for many, can be exclusive or limiting for some, such as those using MOUDs or those who are agnostic. In rural areas especially, where stigma towards substance use disorder is high, providers also believe that virtual options lower fears about anonymity and reputation, which may keep people from wanting to engage with others in the local recovery community. Accessing support groups virtually allows for greater time flexibility, greater anonymity, and more options of support modality. While access to treatment is important for jumpstarting recovery for those with SUDs, access to these recovery resources is crucial to help people sustain recovery and reduce return to use. Interviews have provided a clear explanation for the more commonsense connection between age and the broadband-overdose relationship found in our quantitative analyses. Respondents overwhelmingly agree that older adults have a more difficult time engaging in telehealth, and thus broadband access has not necessarily increased access to treatment and recovery resources for this population. But our interviews have also suggested some reasons why the relationship between broadband access and substance use harms might differ by gender. Providers suggest that virtual treatment and recovery support may lower the bar to participation for men, who they find are less likely to want to seek and stay in counseling services in person. On the contrary, they find that virtual treatment options do not necessarily lower the bar for mothers who do not seek treatment either due to childcare needs (as women still must attend appointments in person at first before switching to telehealth) or due to fear of the child welfare system becoming involved in their children's lives. These barriers prevent women from being able to benefit fully from the improved treatment access offered by telehealth.

Publications