This letter is in response to the "The Opioid Crisis: Staff Empowerment Strategies" by Brooke Schaefer, MSN, RN, FNP-C (April 2019). I've been an ED nurse manager and educator at a rural Level IV trauma center for 6 years. My facility is 2 hours and 20 minutes away from the nearest Level I trauma center and almost 2 hours from the nearest substance abuse and mental health center. I hope my response brings mindfulness to considering the rural perspective.

Of the 49,000 opioid-related deaths in the US reported by the CDC in 2017, the majority occurred in rural communities. Often, rural facilities struggle to admit or place a patient within the appropriate care resource facility due to limited or unavailable bed space-a process that can take up to 6 hours or longer, creating a ripple effect on staff and in-house resources. Unfortunately, the revolving door continues to swing because of limited resources, frequently bringing these patients right back into the ED with unresolved, worsening conditions.

Nurse executives, both rural and urban, need to collaborate to assist in developing more resources and outreach programs to aid in the opioid crisis. The US Department of Agriculture and the CDC offer strategies for which nurse leaders can advocate. Examples of community outreach include drug treatment and harm reduction programs in which clean needle use is supported. Our advocacy plan must include increasing health resources for our rural communities.

-Rayna Knox, BSN, RN, CEN