The economic costs of the opioid epidemic include direct costs, funds that must be allocated for purchase of any and all goods and services above that which we would normally allocate for these items were there no opioid epidemic, and indirect costs arising from the need to treat health complications related to opioid misuse, the loss of worker productivity and the long-term negative impact on the children and dependents of individuals with opioid use disorder. The opioid epidemic has significantly increased the financial burden on the criminal justice system as governments must now cover the costs for increased law enforcement, the judiciary, corrections, probation services, and parole. Medical costs directly related to the treatment ofopioid use disorder include inpatient and outpatient addiction treatment, the costs for methadone, buprenorphine, and naloxone. In this chapter we look at the specific areas in which the opioid epidemic has had a very real, and very negative effect on the world economy.

Harm reduction refers to a set of strategies aimed to limit the negative consequences associated with drug use, but without requiring complete abstinence. Some harm-reduction strategies aim to reduce the risk of overdose, such as the use of naloxone rescue kits, fentanyl testing strips, and implementation of Good Samaritan laws. Other strategies lower the risk of overdose but also the likelihood of contracting infectious diseases such as HIV and hepatitis. Syringe services programs, also referred to as needle exchange programs, and supervised consumption facilities all fall under this category. Medications for opioid use disorder (MOUD), which include methadone, buprenorphine, and naltrexone, have been proven to lower the risk of overdose, improve the likelihood of maintaining sobriety, and therefore lower rates of disease transmission. Finally, harm reduction is utilized in criminal justice system through the use of drug decriminalization, police diversion programs, and drug treatment courts.

Persons living in urban and rural areas have similar rates of alcohol use, yet the latter possess far fewer options for treatment of alcohol and other substance use disorders. There is underappreciated diversity across rural communities that compels an understanding of the broad social and economic determinants of their alcohol and other drug use and engagement with treatment. This chapter examines the delivery of treatment for alcohol use disorder in rural healthcare systems with special attention to the primary care setting, the venue most accessible to rural residents. Novel approaches for rural treatment of substance use disorders are identified that match social and cultural trends of substance use while leveraging the limited resources of the rural behavioral healthcare landscape.