Rural Communities In Crisis

A Critical Count To Save Lives

Rural communities are in dire need of accurate estimates of the number of people who inject drugs, in order to respond urgently and at the right scale.

In Cabell County, West Virginia, researchers set out to help health officials determine the level of life-saving resources, services and treatment they need to provide. To do that, they conducted a study to estimate the size and characteristics of the population of people who inject drugs.

This method can be used in similar communities across the nation.

The results can save lives.

Rural communities throughout the United States have put in place a variety of programs aimed at reducing overdose and the spread of infectious diseases. These include harm reduction programs, medication-assisted treatment programs, and naloxone distribution initiatives. But too often, rural communities don’t know how many people need services or if existing levels of service provision meet community needs.

In the West Virginia COUNTS! study, researchers adapted a method for estimating the size of a population to a rural context. The results allow the researchers to characterize the population of people who inject drugs across multiple dimensions, including demographics and substance use, enabling them to better understand population-level needs for essential public health services.

West Virginia had the highest rate
of opioid-related overdose deaths in 2017

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United States map and image of Cabell County
  • 20% of West Virginia’s 2017 overdoses were in Cabell County
  • 1,831 people overdosed in Cabell County in 2017
  • 152 overdoses in the county were fatal in 2017

Home to an estimated 94,958 people, Cabell County borders Ohio, Kentucky and the Ohio River. While more than 80 percent of this Appalachian county’s area is rural, half the population lives in Huntington, the county seat.

Facing the highest opioid overdose rate in West Virginia, Cabell County has marshaled resources from across the public, private and nonprofit sectors to implement evidence-based response strategies. There are numerous drug treatment programs available. People who inject drugs have access to harm reduction services through the Cabell-Huntington Health Department. Quick-response teams work throughout the county to prevent overdose deaths. Naloxone has been widely distributed.

Yet until now, Cabell County officials have not known just how many people inject drugs.

“By understanding the size and characteristics of populations in need, rural communities can tailor response strategies and begin turning the tide on the opioid crisis.”

Dr. Sean Allen uses quantitative and geospatial methods to examine the drivers of health disparities among marginalized populations. Through his research, he generates evidence that helps inform initiatives to reduce HIV and overdose risk among people who inject drugs. For this study, he wanted to determine if a population estimation strategy could be adapted for use in a rural area to estimate the number of people who inject drugs.

“We knew what we’d been doing for years was not working. We knew we could not arrest everybody found using drugs.”

Dr. Michael E. Kilkenny has overseen the Cabell-Huntington Health Department’s response to the opioid crisis over the past three years. In 2015, the department partnered with more than 30 local community agencies and organizations to decrease the societal and personal harms associated with opioid misuse. Its comprehensive harm-reduction program provides overdose prevention resources, drug treatment referrals and sterile injection equipment.

“Opioid use not only affects the families of people who use drugs. It affects the whole community.”

Working in Cabell County in summer 2018, the West Virginia COUNTS! research team recruited 797 people with a history of drug use. They each took a survey that included questions about drug use, drug treatment, HIV and hepatitis C risk behaviors, overdose experiences and more.

“Huntington may be a small place, but we have big problems.”

People like Thommy Hill, who is in recovery and works in the Cabell-Huntington Health Department’s harm reduction program, helped those who inject drugs engage in this study.

26 People In Huntington
Overdosed In 4 Hours In August 2016

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Project Description

The capture-recapture method for population estimation involves two phases of data collection in which members of the population being studied, such as people who inject drugs, are surveyed. Researchers then calculate a population estimate by looking at the amount of overlap between the two phases.

Many researchers have used this method to quantify the size and characteristics of vulnerable populations. However, most of these studies occurred in urban environments and not during the modern opioid crisis. In this study, researchers demonstrated how the method can be adapted to rural areas to inform response strategies to the opioid epidemic.

Pharmaceutical images

How it worked

During the first phase of the study, in June 2018, researchers spent two weeks at the Cabell-Huntington Health Department’s harm reduction program surveying people who inject drugs. Then in July 2018, researchers conducted a second round of surveys at locations in the community where people who inject drugs congregate. Researchers identified the locations by talking with local stakeholders and conducting a series of geospatial analyses using data on where overdoses took place, discarded syringes were collected and the media reported drug activity.

Members of the research team collected survey data anonymously using audio computer-assisted self-interview. Participants listened to questions and answers on headphones, a process that reduces bias.

  • Profile of people who injected drugs over the past six months
  • 83.4% are white
  • 70.9% are younger than 40
  • 59.5% are male
  • 66.0% are unemployed
  • 64.3% go to bed hungry at least once per week
  • About Reported Drug Use over past six months
  • 82.0% injected heroin
  • 71.0% injected crystal methamphetamine
  • 56.3% injected fentanyl
  • 74.3% attempted to quit using drugs
  • 66.0% reported accessing sterile injection equipment at a harm reduction program

Health officials in Cabell County now know the number of residents who use injection drugs, their demographics, the types of substances they use, their attempts to quit using drugs and access services, and other problems they face, such as homelessness and hunger. These data highlight that while existing efforts to end the opioid crisis in Cabell County are reaching those in need, gaps exist that may warrant swift action. With this information in hand, the county has an evidence base to inform the scale-up of drug treatment and harm reduction services to meet community needs.

“Cabell County may be deeply affected by the opioid crisis, but the community is resilient and making significant progress. With specific information about the population of people who inject drugs, the county is able to scale its services for the need.”

Sean Allen, DrPH, MPH
Lead Researcher

Applying Population Estimation Methods in Rural America

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Estimating the Number of People Who Inject Drugs in a Rural County in Appalachia

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