Statement of Purpose Rural counties in the United States have higher firearm suicide rates and opioid overdoses than urban counties.

We determined whether rural counties can be grouped based on ‘diseases of despair’ by firearm suicides, drug deaths, opioid prescriptions, and socioeconomic characteristics.

Methods We performed a cross-sectional study of all rural county residents in the United States from 2012 to 2016. Age-adjusted firearm suicide death rates; drug-related death rates; homicide rate, opioid prescribing rate, %black, %Native American and %veteran population, median home price, violent crime rates, primary economic dependency (non-specialized, farming, mining, manufacturing, government and recreation), and economic variables (low education, low employment, retirement destination, persistent poverty, persistent child poverty).

Results Hierarchical clustering using complete linkage yielded five distinct rural county clusters. The firearm suicide rates in the clusters were 5.9, 6.8, 6.4, 8.5 and 3.8 per 100,000 respectively. The counties in cluster 1 were poor, mining dependent, with population loss, cluster 2 were non-specialized economies, with high opioid prescription rates, cluster 3 were manufacturing and government economies with moderate unemployment, cluster 4 were recreational economies with substantial veterans and Native Americans populations, high median home price, drug death rates, opioid prescribing, and violent crime and cluster 5 were farming economies, with high population loss; low median home price; low rates of drug mortality; opioid prescribing; and violent crime. Cluster 4 counties were spatially adjacent to urban counties.

Conclusions Interventions to reduce firearm suicides should be community-based and include programs to reduce other diseases of despair.

Significance Focusing on prevention related to firearms alone without considering the built environment may not be effective. A targeted approach towards high-risk areas identified by intersectionality between opioid and firearm use particularly in recreational counties that abut urban areas may be a better-tailored strategy for prevention.