Opioid overdose deaths drop in Missouri, but rural areas fight stigmas, barriers to care

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Narcan dispensing boxes are becoming more common across Missouri. Medicines like Narcan, also known as naloxone, help fight opioid overdose deaths, but officials say more investment is needed to treat addiction (Suzanne King/The Beacon).
After years of exponential growth, opioid overdose deaths in Missouri are dropping.
While health care workers, community groups and other officials say many factors may contribute to the drop in opioid overdose deaths, they agree that access to overdose-reversing drugs like naloxone, often provided under the brand name Narcan, is saving lives.
'I do think that Narcan is the reason for those trends statistically dropping,' said Cooper County Ambulance Chief Brandon Hicks. 'I see Narcan in a lot more homes than I used to, and I do see family members administering Narcan prior to us getting there.'
In 2014, the state saw 360 opioid overdose deaths from drugs other than heroin. By 2021, that figure rose to 1,493, state data shows.
After increasing through 2021, the trend started changing. The number of deaths flattened in 2022 and began dropping in 2023. By 2024, non-heroin opioid overdose deaths had fallen to 876.
Central Missouri and the St. Louis area saw the largest drop in drug overdose deaths, dropping 38% and 35%, respectively.
But after responding to opioid overdose calls for years, Hicks sees the need for more access to treatment and better coordination between emergency services and long-term care, especially in rural areas.
That belief is shared across community health organizations. Access to things like peer support specialists and community resources is an essential piece of the puzzle, according to Derek Wilson, who runs harm reduction at the AIDS Project of the Ozarks, which serves 29 counties in southwest Missouri.
'I think there is a particular bit of challenge when you come up against some of these societal things,' Wilson said. 'When you get into a more rural area … there's a ton of stigma. There's still a lot of shaming, whether it's self-shaming or from outside sources.'
Wilson hopes that a continued focus on naloxone distribution, coupled with community support and more access to medication-assisted long-term treatment, can continue making inroads in rural communities.
In 2016, the Substance Abuse and Mental Health Services Administration began a new grant program for states to receive federal funds for addiction treatment, recovery and harm reduction services.
The federal money and state settlement dollars from opioid litigation allowed Missouri to increase investment in addiction treatment and overdose prevention. Early funds were mostly used to support treatment efforts. But as the response evolved, the state began investing more heavily in distributing naloxone across the state.
From 2017 to 2023, the Missouri Institute of Mental Health (MIMH) distributed nearly 430,000 naloxone kits across the state. In 2023 alone, nearly 250,000 kits were given out, including more kits shipped off to local health departments, social services and first responders, according to a report from researchers at MIMH.
In their report, researchers connect the drop in overdose deaths with the availability of naloxone across the state. But other rural health researchers think more time is needed to truly understand the drop in deaths.
'It's encouraging, but I don't think we know exactly why it's changed,' said Kelly Price, a rural addiction researcher in Vermont. 'It'll be interesting to see how it plays out over time … It does sometimes seem like it takes a little bit longer to see those effects that you see nationally in some of these more isolated rural communities.'
MIMH researchers also pointed to the westward movement of fentanyl across the country. Data show that eastern parts of the country see lower levels of fentanyl-related deaths, while they are rising in western parts of the country.
Hicks sees the need for better data collection for health officials to truly understand the trends, especially in smaller counties where funds for autopsies may not align with death rates. He pointed to the prevalence of opioid-related cardiac events.
'We just did a community health assessment,' Hicks said. 'We identified that there's really not been any opioid deaths in Cooper County for quite some time. The problem is that they're getting ruled cardiac arrest.'
'At the end of the day this is a true statement, their heart stopped,' he added. 'When it comes to pulling statistics, nobody sees the opioid deaths that we do have.'
If someone's heart stops as a result of an overdose, naloxone won't revive them without chest compressions. Researchers at the American Heart Association found that of the 360,000 cardiac arrests from 2017 to 2021, 8% were caused by drug overdoses.
Part of the problem in collecting that data, Hicks said, was funding for autopsies. If the county only budgets for a certain number of autopsies, it can be difficult to determine whether a death was related to drugs in other ways besides an overdose.
'I have one gentleman that I have (used Narcan on) three times that's been in cardiac arrest, and after the third time, he literally told me: 'See, I can do whatever I want. You're going to be here to save me,'' Hicks said. 'We can't save somebody who is dead, and they can't save themselves either. But if they get Narcan before we get there, usually they refuse care.'
But Stephanie Malita, a health educator at the St. Joseph Health Department, says peer support specialists who are active in the area report that the number of overdoses someone experiences isn't relevant to their recovery outcomes.
'Peers will say time and time again that some of them overdosed multiple times,' Malita said. 'But eventually they got to the point in their lives where they were ready and had a support team around them to make that very scary leap into non-use.'
Studies show that despite Good Samaritan laws, which offer legal protection for people who are witnessing or experiencing a drug or alcohol overdose, skepticism remains when it comes to calling first responders in the event of an overdose.
Missouri's Good Samaritan law provides immunity from things like possession of controlled and synthetic substances or paraphernalia, as long as someone is actively seeking medical assistance. It also requires law enforcement to provide treatment resources. It does not protect against other crimes like distributing a controlled substance or active warrants.
Hicks regularly runs into that fear when he responds to overdose calls. If 911 is called, the person overdosing often has already gotten a dose of naloxone, and law enforcement almost always arrives at the scene before EMS.
'People don't want law enforcement, they feel like they've done something wrong,' Hicks said. 'So we usually encounter somebody who is angry and upset … because they're scared of getting arrested. They didn't want to go to jail, they just wanted to live.'
He and his staff take extra steps to differentiate themselves from law enforcement when responding to overdose calls. They don't wear button-up shirts or badges to try and make people feel more comfortable.
'I appreciate law enforcement,' Hicks said. 'But I don't want to be associated with them in these scenarios, because then I can't help somebody like we're supposed to help them.'
Wilson and the AIDS Project of the Ozarks are working on ways to make naloxone more available across their coverage area. The group places drop boxes with naloxone kits in places like libraries and other public settings, so it is available to the community 24/7.
To find where to access free naloxone, click here.
It's an investment that Malita and the health department, which was one of the top county recipients for naloxone kits from the MIMH, are looking at making as they continue naloxone outreach.
But more attention is needed when it comes to connecting naloxone recipients with longer-term addiction care. Things like distance to a provider, income, transportation and child care are often cited as roadblocks for rural patients seeking care.
Hicks said he hopes to see more investment in things like transportation to crisis centers. He also pointed to integrating 911 and 988, the national suicide and crisis hotline, as a way to ensure Missourians are getting the care they need.
'The emergency room is just not the place for a lot of people in these situations,' Hicks said. 'More mental health support (is needed), not a physician that tells them to go seek care elsewhere once they've fixed a very temporary problem.'
Price pointed to data that shows starting people on medication-assisted treatment, including buprenorphine or naltrexone, after an overdose and then connecting them with a long-term provider has been shown to be an effective approach.
Things like expanded access to telehealth, where people can meet with providers in the privacy of their own homes, can also help people in smaller communities seek care in ways that are more fitting for them.
Wilson said reducing stigma so everyone feels comfortable seeking care is a priority.
'I do think it is something that is thicker in rural areas, the idea of not wanting to get into it, and: 'Why don't those people just go take care of themselves? Why don't they stop?'' Wilson said. 'It's just not that simple, not with the way that substances interfere with our brain chemistry.'
'It's just a human being and things get away from them,' Wilson said. 'Then they find themselves in very, very horrible situations.'
This article first appeared on Beacon: Missouri and is republished here under a Creative Commons Attribution-NoDerivatives 4.0 International License.