A study published this month by the Centers for Disease Control and Prevention shows that overdose death rates have risen to the point that they are greater than overdose death rates in metropolitan areas.
Joel Reece, the Tennessee director of Appalachia High Intensity Drug Trafficking Area, said a large part in the growth of rural death rates is lack of prompt medical care for users.
"There's nowhere in Knox County where a first responder is not going to get to you pretty quick, and when you stop breathing you don't have much time," Reece said.
Appalachia HIDTA operates in 31 counties in Tennessee, most of which are considered rural by data used in the study.
"In rural areas most of the folks are found by family members and here, I know for a fact that a lot of overdoses take place in parking lots where somebody's going to see you," Reece said. "And if you are in a rural area, by the time a first responder gets there, it may be too late. And if they get there, will they have naloxone?"
Reece said the number of overdose deaths in rural areas are often under-reported.
"Part of that is the system a lot of states and counties have set up," Reece said. "If you don't have the luxury of having what we have here with the medical examiner's officer that we have in Knoxville, there are a lot of them that slip through the cracks."
Overall, six times more overdoses occurs in urban area than in rural areas, but a smaller percentage of the population dies from overdoses in cities.
Reece thinks without the effective medical care in place, the number of deaths in metropolitan areas would be even more staggering. He points to data from Knox County's Drug Related Deaths Taskforce, which follows every overdose subject who is transported to a hospital.
"Right now the people that are transported and live, they're running about four-to-one to the people that actually die," Reece said. "So you figure if we're sitting at 224 (suspected overdose deaths in Knox County), without naloxone we might quadruple that, and that would certainly skew the figures to where maybe the urban areas might be even more."
The most glaring fault of the study is the time frame. Although it uses the latest comprehensive national data, overdose deaths have grown sharply since the last data set collected in 2015.
Reece and others in law enforcement say the introduction of fentanyl changed the landscape. Data from the CDC shows that law enforcement encounters with fentanyl more than doubled from 2014 to 2015.
"Two years ago we were talking about heroin, that it was coming, and we couldn't get much interest," Reece said. "People didn't believe that, but it's gotten here that quick."
Reece said the heroin and fentanyl in East Tennessee come from gangs in Detroit and Mexican cartels with operations in Atlanta. Reece says heroin laced with fentanyl is usually mixed before the drugs are trafficked into East Tennessee, so the chances of impure or contaminated heroin does not differ for users in the city versus those in rural areas.