Flooding, Substance Use Disorder, and the Devastating Impact on Rural Communities

When a severe flood hit southeastern Kentucky in 2022, McKayla’s life was forever changed. The intense storm had been raging outside her trailer, but she never expected the water to rise so high. As the creek in front of her home overflowed, McKayla and her children were forced to take refuge on their roof, waiting for a National Guard boat to rescue them. The trauma and instability of the flood upended McKayla’s recovery from substance use disorder, causing her to relapse into drug use.

McKayla’s story is more common than people may realize. When flooding hits rural areas like Appalachia, it can weaken support systems that have taken years to build. At the same time, residents in drug or alcohol recovery are under extraordinary stress from the loss of homes, jobs, and sometimes friends and family. In a recent study, researchers found large increases in overdose deaths in flood-damaged areas and evidence that the harm continues for years.

The Overdose Crisis in Rural Appalachia

Rural Appalachia has long been considered an epicenter of the overdose crisis. The region has seen high rates of overdose deaths due to the proliferation of prescription opioids in the 2000s and the subsequent spread of heroin and synthetic opioids like fentanyl in the 2010s. West Virginia, for example, had the highest overdose mortality rate of any state from 2014 to 2024, with 81.9 overdose deaths per 100,000 residents in 2023, compared to the national rate of 31.3.

Despite the progress made in expanding access to treatment, substance use-related harms still persist in rural communities. For example, while nearly two-thirds of West Virginia’s counties are considered rural by the federal Office of Management and Budget, only 18% of West Virginia’s 140 certified recovery houses for people seeking recovery from addiction are in rural counties.

Connecting Floods to Overdose Deaths

Looking at data from 2000 to 2017, researchers found that severe floods, which were defined as a flood that received a presidential disaster declaration and caused at least one fatality, were associated with an increase in opioid overdose deaths in rural Appalachian counties. The elevated risk didn’t subside quickly, with the annual overdose death rate in flood-hit counties being 26% higher than in similar unaffected counties during the 10 years following a severe flood.

These effects add up over time, with a total of 11,744 opioid overdose deaths officially recorded in rural Appalachia from 2000-2017. By comparing overdose rates in flooded and nonflooded counties, researchers estimate that 1,368 of those deaths were connected to the devastating impacts of severe floods.

Why Flooding Contributes to an Overdose

To understand why overdose deaths increased after flood damage, researchers talked with people who were working in fields such as substance use treatment and harm reduction when the 2022 flood hit their areas. They described how the flood disrupted access to treatment, recovery, and harm reduction services, either because people could not travel to services or because facilities themselves flooded.

They also talked about the stress people faced after losing jobs and homes and the lasting trauma from widespread devastation in their communities. People displaced from their homes were often separated from their social support networks, leading some people in recovery to use drugs again and leading to drug use among people who had never used before.

Such drug use also got riskier when people lost access to tools like Naloxone and fentanyl test strips that help prevent overdoses and related deaths. Together, these factors interacted to increase the risk of overdose death, both immediately and longer term.

Fostering Rural Resilience

Our study underscores the long-term impact of natural disasters on mental health and drug use. But we also found ways communities can try to keep substance use treatment and recovery services operating in the toughest circumstances.

We heard stories of methadone providers traveling to patients’ homes in ATVs to bring them into the clinic for treatment. Harm reduction providers used boats to deliver Naloxone, food, and water to flooded homes. Primary care providers and community health workers visited emergency shelters to provide counseling and ensure people had access to their medications.

Ensuring treatment providers have contingency plans for patients amid disaster, and including these providers in community disaster preparedness and recovery planning, are two key steps that could help limit future harm elsewhere. Additionally, policies and programs that make substance use treatment more flexible – such as supporting the use of telehealth or mobile clinics – would allow providers to adapt after a disaster and lower barriers to treatment in rural communities.

Ultimately, local support services and family helped McKayla enter recovery again and rebuild her life after the flood. Infusing disaster preparedness into substance use treatment and recovery services could prevent others from experiencing the instability that McKayla faced in the first place.