Five Levels of Cost-Effective Harm Reduction for Rural Communities
Every year, thousands of Americans die from drug overdoses in places where the nearest ambulance is 20 minutes away, the closest clinic is in another county, and the only person who might have helped did not call 911 out of fear of arrest.
People living in rural areas are now at greater risk of overdose death than urban Americans, with most of those deaths happening at home. Communities could prevent many of these deaths by investing in harm reduction, an evidence-backed approach proven to save lives, improve well-being, facilitate recovery, and keep communities safer. It works just as well in small-town Arizona as it does in San Francisco; however, the majority of rural communities lack harm reduction-friendly policy or programs.
Cost is one of the most significant barriers to adopting harm reduction in rural areas, especially considering the challenges of geographic isolation, low population density, and below-average incomes. Here, we provide a resource-conscious overview of five levels of harm reduction—ordered by cost and complexity—to help lawmakers build an approach tailored to their specific needs.
The Cost of Doing Nothing
Opioid use disorder costs state and local governments an estimated $94 billion annually in criminal justice expenses, lost tax revenue, and substance use treatment. A single overdose death costs roughly $27,000; add in direct healthcare expenses, and expenditures rise further. Hospitals spend approximately $11 billion annually treating overdoses.
Injecting drugs brings a range of additional health risks including skin wounds, infectious disease transmission, and endocarditis. Treating these issues can be complex and expensive, and the costs are often borne by Medicaid. The lifetime medical costs associated with HIV alone range from over $300,000 to more than $1 million for an individual whose diagnosis was delayed by just three years.
These expenses impact rural communities disproportionately: Longer emergency medical services (EMS) response times drive higher hospital costs, the low density of HIV patients and treatment providers means a higher cost per individual, and every overdose death removes a working-age person from small communities’ already limited workforce and tax bases. Therefore, investing in harm reduction programs that reduce overdose, mortality, and disease transmission while connecting participants to treatment does not mean taking on new expenses. Instead, it addresses costs that are already accumulating.
Level 1: Zero-Cost Policy Reforms
The most important thing about Level 1 is in the name: It costs nothing. Good Samaritan laws protect overdose witnesses who call 911, increasing their willingness to contact EMS. Naloxone access laws allow pharmacists to dispense the overdose reversal medication without a prescription. Expanding pharmacists’ scope of practice to include prescribing medication for opioid use disorders increases access to evidence-based treatment. These policies require no new budget line, no grant, and no new infrastructure (although training and educational campaigns can increase their efficacy). Every overdose prevented saves communities tens of thousands of dollars, and connecting individuals to evidence-based treatment reduces criminal activity while increasing their employability and economic productivity.
Level 2: Expanded Naloxone Availability
In rural areas, fear of stigma and criminalization often deters overdose witnesses from calling 911. When people do call for help, medical first responders average 14 minutes to arrive on scene—about twice as long as in urban communities. Consequently, ensuring family and friends have access to naloxone is often the only way the intervention can arrive in time.
Getting naloxone into the hands of laypeople most likely to be present during an overdose is an upstream money-saving intervention that is relatively affordable for communities. Two doses of the medication typically cost governments and nonprofit organizations $3 to $48 depending on formulation. Agencies can help keep costs down by taking advantage of group purchasing benefits and offering clients the option of injectable naloxone, which is on the lowest end of that cost spectrum. They can also extend the reach of distribution efforts via leave-behind programs, where first responders leave doses of the medication after every overdose call.
Community naloxone programs can reduce overdose mortality by 25 to 46 percent across a variety of contexts and can even reduce hospital visits. Because a single visit to the emergency room for a non-fatal overdose costs thousands of dollars, distributing naloxone and encouraging its use not only saves lives—it can save money, too. In fact, a New York state analysis found that every dollar spent on naloxone distribution saved taxpayers over $3,000.
Level 3: Drug Checking and Risk Awareness
The illicit drug market in the United States is volatile and unpredictable. New substances and contaminants are always entering the supply, and people who use drugs often do not know what they are putting in their bodies. In 2023, approximately 69 percent of all overdose deaths involved synthetic opioids like fentanyl; however, xylazine—a veterinary sedative that complicates overdose response and causes severe skin wounds—has become a common adulterant in at least 48 of 50 states. Other novel substances such as nitazenes (opioids stronger than fentanyl) and medetomidine (another veterinary sedative) are on the rise.
Drug-checking tools can help people identify what is in their drug supply so they can adjust their behavior (e.g., keeping naloxone nearby) to reduce the risk of overdose or other injury. There are several ways to conduct drug checking. For example, fentanyl test strips—which work similarly to a home COVID-19 test—cost roughly $1 each. Authorizing test strip distribution and on-site drug checking does not cost states any money; however, building a distribution infrastructure or supporting existing efforts through community organizations to help get these lifesaving tools to people who use drugs requires various levels of investment, depending on the program. On-site drug-checking and information-sharing programs have the capacity to educate more individuals about current risks than distribution programs alone. Some use low-cost test strips, while others rely on more sophisticated technology. While such devices can be expensive up front, they are far more effective in identifying novel substances in a rapidly changing market.
Rural communities have several options for incorporating drug checking into their policy and programs. All of these interventions are proven to prevent overdoses, thereby lowering the associated need for costly emergency services responses, wound treatment, transport, and hospitalization.
Level 4: Disease Prevention and Health Services
Syringe services programs (SSPs) are one of the most significant harm reduction interventions. Though expensive to set up and operate, they offer a substantial return on investment. For example, while it costs roughly $400,000 annually for a small rural SSP to provide comprehensive services to 250 clients, these programs are proven to reduce HIV and hepatitis C incidence by up to 50 percent. Given the high medical expenses related to both diseases, preventing a handful of infections saves money. In fact, SSPs produce an average savings of more than $7.50 in healthcare costs per dollar invested. Furthermore, because SSP participants are five times more likely to enter drug treatment and three times more likely to stop injecting, the programs produce an even larger return on investment when factoring in social benefits and criminal justice system savings. Communities can amplify these impacts without proportionally increasing costs by co-locating testing, wound care, and peer navigation.
Nonetheless, SSPs are chronically underimplemented and underfunded—especially in remote communities. Rural programs often operate on budgets that meet only 5 percent of minimum recommendations (versus 46 percent for urban programs), but SSPs do help save lives and dollars. Moreover, they are often the only consistent point of contact between people who use drugs and the broader healthcare system, making Level 5 possible.
Level 5: Expanded Treatment and Recovery Access
Implementing evidence-backed and comprehensive treatment for substance use disorders requires the highest level of investment and produces the greatest long-term return for communities. A person who stabilizes in recovery is better able to rejoin the workforce and less likely to interact with the emergency medical and criminal justice systems.
Medications for opioid use disorder (MOUD) are among the most effective tools for helping individuals initiate and sustain recovery while dramatically reducing overdose risk on what is often a non-linear journey. They are also extremely cost-effective, especially when considering criminal justice-related expenses, saving as much as $105,000 over the life of a single individual compared to no treatment. Lawmakers can optimize these savings by reducing barriers to access. For example, telehealth is an effective alternative to in-person visits for those in treatment for a substance use disorder and can improve access for individuals in remote communities without sacrificing treatment outcomes. Moreover, it can reduce costs substantially, increasing the already significant return on investment. Peer recovery specialists are also gaining increased attention, especially in rural communities. They improve treatment outcomes and reduce costs by roughly $2,000 per individual.
Conclusion
Each of these five levels of investment and intervention makes the next more viable: Policy protections reduce fear, naloxone keeps people alive, drug checking gives people information, disease prevention builds relationships, and treatment gives people a path forward when they are ready.
Harm reduction is not a cost to be justified; rather, it is a cost offset. Where programs fall short, it is often because the commitment was partial—a program denied stable funding, a law without public education, or overregulation that prevents evidence-based interventions, for example—not because the approach was wrong. Rural communities deserve the full version of this work, not half-measures that create the appearance of a response without the substance of one.