Non-medical use of prescription pain relievers (PPRs), heroin, and more recently fentanyl, continue to have major public health consequences in the United States. This article analyzes trends in PPR and heroin use, emergency department and hospital stays, substance use treatment services, and mortality to assess the relative impact of the opioid crisis on rural versus more urbanized counties in the United States. Our findings suggest that while more urbanized counties have had greater increases in opioid use, rural and less urbanized counties tended to be more negatively impacted than larger and non-rural counties. Disparities in service availability highlight the need for a serious discussion on how resources are allocated in counties that have lower tax bases. Based on these results, we conclude that rural and less urbanized counties can benefit from real increases in resources for substance use prevention and treatment services, including the expansion of prescribers trained to screen and treat opioid use. Understanding the unique challenges of rural and less urbanized counties may help decrease the disparity in consequences found in this study
