Dan Krouse is a sixth-generation egg farmer from Manchester, Indiana. When he returned to his family’s operation with an MBA in 2013, Krouse was prepared to help manage Midwest Poultry Services and its 9.5 million hens. But he never expected to confront opioid addiction head on.

An employee who began showing up late for work confided in Krouse that he was struggling to control his opioid use after suffering injuries from a car accident. Krouse offered work accommodations and personal support, even going to the employee’s house following a call for help. But a short while later, the man was found dead in his home from an overdose.

“I wish I had known then what I know now,” he said later, referring to the resources available for helping people with addiction. “It’s a horrible problem and very difficult to deal with.”

Rampant drug abuse has long been perceived as an urban plight. But when it comes to opioid painkillers—including oxycodone, hydrocodone, fentanyl, and heroin—rural communities are on the frontlines.

Five of the states with the highest rates of drug overdose deaths—Ohio, Kentucky, West Virginia, New Hampshire, and Pennsylvania—are predominantly rural. The Centers for Disease Control (CDC) has reported that rates of overdose death in rural areas have been rising higher than they have in urban areas since 2006. Today, the agency says, people living in rural areas are almost twice as likely to overdose on opioids as urban residents.

Drug overdoses killed 72,000 people in 2017, according to the most recent estimates from the CDC. Claiming nearly 200 victims per day, drug overdose has become the leading cause of death for people under 50 years of age. But it does not only affect the young: In 2015, adults in the 45-to-54 age group experienced the highest death rate from overdose.

In rural areas where demographics skew older, the societal impacts of nonmedical opioid use run deep. And that population is declining not only due to lower birth rates, out-migration of young adults, and an aging population, but also from mortality of working-age adults from opioid overdose, according to a report from the Economic Research Service (ERS).

And for those working in agriculture, the impact was even higher. Three-quarters of farmers, ranchers, and farmworkers polled had been directly affected by opioid misuse, addiction, or overdose—this may be caused in part by the fact that agriculture workers do such physical work, and are more likely to be prescribed opioid painkiller than many other Americans. The CDC reports that every day, approximately 100 farmers and agricultural workers incur injuries that prevent them from working, and one out of five has at some point received a prescription for opioids.

A recent survey of rural residents found that 45 percent of adults were “directly impacted by opioid abuse, either by knowing someone, having a family member addicted, having taken an illegal opioid, or dealing with addiction themselves.”

It’s a dire situation that has put pressure on farming organizations and rural development agencies to step out of their comfort zones and address the crisis. Two national membership organizations, the American Farm Bureau Federation (AFBF) and National Farmers Union (NFU), have banded together for the first time. In October 2017, they jointly commissioned the rural survey and have since built a cooperative awareness-building campaign called Farm Town Strong.

“Opioids have been too easy to come by and too easy to become addicted to,” AFBF president Zippy Duvall said in a statement. “And because opioid addition is a disease, it’s up to all of us to help people who suffer from it and help them find the treatment they need.”

Likewise, the Office of Rural Development heeded the call to action after President Trump declared opioids a national public health emergency in October 2017. As the agency within the United States Department of Agriculture (USDA) charged with economic development, housing, and utilities in rural communities, the Office has targeted the problem as an urgent matter of rural prosperity. Over the past year, it convened a series of regional roundtables in cooperation with AFBF and NFU to identify programs and funding for prevention, treatment, and recovery as well as resource-sharing initiatives.

“Perhaps you are from a community or a region of our country where we can no longer pretend that all of rural America is ‘Friday Night Lights’ and your town has had to face this issue head on,” said Anne Hazlett, assistant to the Secretary for Rural Development, at a roundtable in February 2018.

Hazlett addressed an audience of law enforcement officials, medical and public health professionals, and business people, along with AFBF and NFU staff. Acknowledging the immense toll on civic resources, businesses, families, and quality of life in small towns across the country, she called on all rural advocates to become “engaged.”

Speaking publicly for the first time, farmer Dan Krouse stressed to the audience that opioid misuse not only incurs real costs and lost productivity but also puts untold stress and emotional toll on everyone involved. “I would rather just spend my time farming,” he said, “but unfortunately this is an issue that demands my time.”

Opioid Misuse in Rural America

America’s rural communities constitute 72 percent of the nation’s land mass and just 16 percent of the U.S. population. Rural life is characterized by wide open spaces, which translates into long distances to services, including medical care, and a lack of resources ranging from broadband communication to treatment centers. A large segment of the rural workforce is employed in agriculture, manufacturing, and natural resource industries including forestry, mining, gas, and oil. But there are wide economic disparities from county to county; in many, the job opportunities can be limited, low-paying, and seasonal.

For the first time in recorded history, America’s rural population is declining. The ERS report projected that this trend would increase the “dependency ratio,” a reduction in the population of wage earners relative to other non-working residents, including children and the elderly. And it would further impede the economic recovery that has lagged in most rural areas since the 2008 recession.

The opioid epidemic compounds these obstacles: The National Advisory Committee on Rural Health and Human Services stated in 2016 that “widespread drug abuse inhibits the growth of industry, increases the difficulty in attracting new residents, and creates bleak futures for current residents.”

As a researcher at the Center on Drug and Alcohol Research at the University of Kentucky, Jennifer Havens was not familiar with the AFBF/NFU survey results, but she wasn’t surprised by the high rate of impact among farmers. “When you’re in a town of 5,000 and there are 100 people using, that’s a lot of people,” she said. “There are so many more social connections than in urban drug-using communities.”

In the AFBF/NFU survey, 77 percent of farmers reported that it would be easy for them to obtain large quantities of opioids without a prescription, compared to 46 percent for all rural adults, a striking finding that has put a spotlight on farmers as an especially high-risk group.

So why are people who work in agriculture hit harder by the opioid crisis than other rural residents?

Farmers at Risk

While the farming community has been caught off guard, Havens, along with several other researchers, investigated the reasons behind this rural phenomenon in a 2014 study. Because agriculture is one of the most hazardous occupations with a high rate of injury, there is widespread availability of the drugs, the authors hypothesized. It’s an ideal formula for over-prescribing in the most under-resourced communities. And the issue has only compounded as it went largely unnoticed for decades.

“This did not happen yesterday,” said Randy Parker, Utah state director for USDA Rural Development.

Like other officials covering rural areas, Parker sees the source of the problem of physicians overprescribing opioids compounded by the distances to medical care. “Many times, physicians will prescribe 10 days [of opioids] and see how you’re doing,” he said. “With people out there 100 miles from a physician, they may give them 30 days [worth].”

And while opioid prescriptions have been dropping nationally since 2012, Parker noted that local officials, business people, and the medical community are just beginning to grapple with the Gordian knot of legal, economic, and social problems associated with addictions in small towns. Meanwhile, deaths from illegal fentanyl and other synthetic opioids in the drug trade have shot up since 2013, according to a report from the Pew Charitable Trust. Fentanyl-related overdoses vary from state to state, but constitute what the CDC calls the “third wave” of the opioid crisis (after prescription drugs and heroin) that are affecting even “far-flung parts of the country.”

Farm economics have played a role, too. As another state farm bureau official put it, “When you can’t feed your family and you sink into a depression you turn to self-medicating.” According to a 2018 study, overdoses rose by 10 percent above the national average for every $10,000 reduction in net farm income. Along with declining farm incomes, natural disasters, and other weather events are all potential factors in exacerbating the rural opioid crisis. “Our results confirm that economic factors, including income and especially unemployment, as well as population density—or rurality—are important,” the authors wrote.

The challenge of addressing the epidemic is only compounded by the fact that it’s occurring in places where stoicism has cultural currency. “These folks out in rural parts of Utah, they’re hard-working and they get hurt in some way and are looking for some relief,” Parker said. “‘I’m a hardworking guy and I’m going to get through it.’ That’s a little bit of what’s going on out there.” Parker, who was the longtime CEO of the Utah Farm Bureau and has a history with member farmers and ranchers, sees the roots of the problem in the “self-sufficiency mentality.”

With so many pills in circulation, nonmedical use of opioids skyrocketed as relatives and friends purchased or helped themselves to the available supply. In the rural-urban opioid study, Havens and her co-authors hypothesized that the close social and familial networks within small towns has also greatly facilitated drug sharing. Additionally, they identified that using pain relievers like Oxycontin and Vicodin carries less of a stigma than with other illicit drugs that are smoked or snorted. Only alcohol and marijuana are perceived as less harmful.

The study also noted that the stress of living in economically disadvantaged areas with high concentrations of poverty “create greater vulnerability to drug use in these populations.” After studying the coal-mining regions of eastern Kentucky, which was “ripe for abuse,” Havens has recently documented the rise of opioid misuse on the western side of I-75, where agriculture predominates.

“Ten years ago, in western Kentucky, there was a lot more meth and eastern was opioids,” she said by phone. But now programs administered by the Center on Drug and Alcohol Research are focused on statewide opioid interventions. “It’s not just in Appalachia anymore,” Havens said.

Rural Community Resources

“Everybody knows somebody who has been affected by this epidemic,” said Michele Specht with the Ohio Farm Bureau. As an organization director, Specht works in four counties bordering the Appalachians, a region full of hay, dairy, sheep, and cattle production.

For Specht, opioid addiction has hit too close to home: Her office assistant’s son is an addict. “He had like 20 friends, and he is the only one remaining alive.” Even her own mother—an 82-year-old dairy farmer’s wife—received dozens of prescriptions over the years for various ailments and became addicted to opioids. And she’s not alone among the senior population. “I think people are finally recognizing that this is not just happening to drug addicts on the streets,” Specht said. “This is happening to everyone and it’s all ages.”

Specht was one of the first to recognize that the Ohio Farm Bureau as a membership organization needed to get involved. “We knew nothing about this topic,” she said, “But it’s a Farm Bureau issue because this is a community issue.”

Although drug overdose is far outside of its wheelhouse, the AFBF is a national organization with the resources and the reach to confront an industry-wide problem. And it strengthens that position with it partnership with the NFU, a farm policy and advocacy group with 200,000 members largely ranging from the Great Plains to the Corn Belt.

The partnership has been hailed as exceptional, since these two farming organizations are often at odds over policy issues such as free trade versus fair trade. But the opioid problem was outside of the political arena, and it spurred the organizations’ presidents to work together, first on the survey and then to create the Farm Town Strong campaign.

“Time and time again, farmers and ranchers have come together to help their families and their neighbors through challenging situations,” NFU president Roger Johnson said in a statement. “Farm and rural communities currently face major challenges in the fight against addiction, like access to services, treatment, and support.”

But so far, these organizations don’t appear to be pushing for any new farm or drug policies. Instead, their focus is on erasing the stigma of drug addiction and increasing information sharing. According to the AFBF/NFU survey results, 68 percent of rural residents believe that public education and information about resources would be effective in dealing with the problem of opioids.

In actuality, much more than education may be needed to stem the tide of addiction. For now, AFBF president Duvall and NFU president Johnson have focused more on publicizing national hotlines, treatment options, prevention resources, and drug disposal information.

In the eyes of Utah state director Parker, the USDA roundtables have helped to “elevate an open and honest communication.” They led attorney general Sean Reyes, previously focused on urban opioid issues, to create a rural opioid task force, which Parker now co-chairs, to target opioid addiction initiatives with civic leaders, health professionals, and law enforcement.

And he’s seen more county and regional roundtables bringing together county commissioners, faith groups, drug court judges, medical and mental health providers, business people, and farmers to learn about the scope of the problem and identify solutions in their own communities. Because it’s widely acknowledged that every rural community is unique, there’s a need for localized plans for prevention, treatment, and recovery.

One outgrowth of the attention on the opioid issue in Ohio is a youth drug prevention program called “I’ve Got Your Back.” Drawing on the Farm Bureau’s relationships with 4H and Future Farmers of America, the training program has the potential to reach 400,000 Ohio youth with this program. “We cannot solve this crisis. We cannot make people better who are already addicted. But we can prevent it,” Specht said.

Education and prevention are essential, but is talking about the problem enough?

Public health departments in states across the country have instituted public education programs on top of stricter Federal Drug Administration oversight and prescription drug monitoring programs for health care providers, but some advocates—and legal experts— say the pharmaceutical industry has used tactics out of the tobacco handbook and needs to be held accountable

Rural areas face critical gaps in services for addiction treatment and recovery services. In many counties, the only treatment option for people with an opioid addiction is jail. And even if people do receive treatment, they often return to the same communities where they lack the support and resource they need to keep themselves from relapsing.

This fact of rural life became apparent in the AFBF/NFU survey as well. Less than half of the rural adults who responded said they feel, “confident they could seek care that is effective, covered by insurance, convenient or affordable.” And nearly a quarter of the 46 million rural residents are on Medicaid with an additional one million uninsured falling into the “coverage gap.”

Just last week, Trump signed into law a comprehensive bipartisan opioids bill focused on strategies, including treatment centers and medication-assisted treatment while loosening Medicaid restrictions for patients with substance abuse issues. This comes on top of the $8.5 billion Congress appropriated for opioid-related programs this year. But questions remain about how much funding will reach the most far-flung areas of the country.

For its part, USDA Rural Development has targeted $10.7 million for innovative facilities, such as mobile treatment centers, transitional housing, and renovations for rural health clinics and recovery centers in 22 states. Meanwhile, local communities are struggling to equip emergency vehicles and first responders with the opioid overdose antidote naloxone and to implement Medication-assisted Treatment services, which use an approach to long-term recovery that is more available in cities.

It is too soon to know which, if any, of the current rural initiatives will help to reduce opioid misuse, addiction and overdose rates. And while the 2017 CDC figures are still preliminary, a recent analysis in The New York Times indicates the death rates from drug overdose are still climbing nationally. Data from Indiana, Kentucky, and Ohio, in particular, indicate significant increases. Mortality rates in western states, however, appear to be leveling off, with Utah dropping over 10 percent and Wyoming over 30 percent, for example.

“That’s just one data point,” cautioned Erica Matthews, substance abuse prevention program manager at the Wyoming Department of Health. “I would love to say that it’s because of all the wonderful work that me and my colleagues are doing.” But with the lag time between data collection and results, it could be years before anyone knows what strategy works best.

Destigmatizing Opioid Misuse

Many people have an understanding that addiction is a disease, including nearly half of rural Americans. And most believe that reducing the shame of drug addiction is an effective way to address the opioid crisis. But it appears that as a group, farmers don’t agree.

According to the AFBF/NFU survey, 67 percent of farmers believe that the best way to deal with drug addiction is actually to increase the stigma. Counter to the general population, this group is not on board with current understanding of addiction as a disease. “That was certainly an eye-opening figure,” NFU’s Jerome said by email, “and one we thought we must address through our campaign.”

Ohio farmer Roger Winemiller is unique. He has widely shared his story about losing two children to overdose and his fears for his youngest son who is in treatment for opioid addiction. But to date, few farmers have come forward to share their experiences. As part of the Farm Town Strong campaign, the NFU has been looking for other farmers to go public, but they are strongly resistant, Jerome said. “We know farmers who really are not willing to speak publicly about this,” he said. “They have anecdotes but they or their family doesn’t want them to speak about it.”

It appears that despite the recent spotlight on opioids, shame around drug addiction persists in farming communities. It’s a dilemma even Jerome, who grew up on a farm in Maryland, understands first hand. And he is reticent to talk directly about the impact of the drugs on his own life. “This crisis has been a scourge on my family and community for years, much like many other parts of the country,” he explained to Civil Eats in an email. Jerome catalogued the many family and friends he has lost to overdose or the ones he still worries about because of their addictions. But he said that none of them want their personal stories told.

“I think people like Roger Winemiller and his son are brave to be willing to carry that mantle and inspire others, but I also don’t fault the folks who don’t want to,” he wrote. “It’s a job for the rest of us to make talking about the problem a socially acceptable thing to do.”

This concerns Dan Krouse, who believes that destigmatizing addiction is a critical step, both in the home and workplace. He says that now that there’s an awareness of several employees dealing with addiction at Midwest Poultry Services, the conversations are no longer “hushed.”

“Everybody admits that it’s around, so it’s easier to talk about now,” says Krause. And while he’s not sure that rural America has reached full reckoning with the “horrible problem” of opioids, he knows there’s an even greater danger: “Just turning a blind eye to it and saying that it happens elsewhere.”

This story is part of a year-long series about the underreported agriculture stories in our rural communities.