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Though often perceived to be a problem of the inner city, substance abuse has long been prevalent in rural areas. Rural adults have higher rates of alcohol abuse, tobacco use, and methamphetamine use, while prescription drug abuse and heroin use has grown in towns of every size.

Substance abuse can be especially hard to combat in rural communities due to limited resources for prevention, treatment, and recovery. According to The 2014 Update of the Rural-Urban Chartbook, the substance abuse treatment admission rate for nonmetropolitan counties was highest for alcohol as the primary substance, followed by marijuana, stimulants, opiates, and cocaine.

Factors contributing to substance abuse in rural America include:

• Low educational attainment
• Poverty
• Unemployment
• High-risk behaviors
• Isolation

Substance abuse can result in increased illegal activities as well as physical and social health consequences, such as poor academic performance, poorer health status, changes in brain structure, and increased risk of death from overdose and suicide.

This topic guide covers the effect of substance abuse on rural communities, broadly. For information and resources specific to the opioid crisis, see the Rural Response to the Opioid Crisis topic guide.

Frequently Asked Questions

• What is substance abuse and what are the signs of substance abuse?
• What effects does substance abuse have on a rural community? What challenges do rural communities face in addressing substance abuse and its consequences?
• How can rural communities combat substance abuse?
• What are the options for addressing tobacco use in rural communities?
• Why is underage drinking and binge drinking prevalent in rural communities?
• How big a concern is alcohol-impaired driving in rural communities, and what are some options to reduce it?
• What can be done to discourage youth from using drugs and alcohol?
• What is opioid abuse, and what effect has it had in rural communities?
• What is the current status of methamphetamine use in rural America and what has been done to combat its use and production?
• Is treatment for substance abuse available in rural areas?
• How can rural primary care providers help address substance abuse and connect their patients to substance abuse treatment?
• How can rural areas develop local options for those who need treatment?

Boulder's Buff Onecard - Spotlight Video Cr80news What is substance abuse, and what are the signs of substance abuse?

Substance abuse is the use of a mood- or behavior-altering substance resulting in significant impairment or distress. Substances misused in rural communities include prescription medications, over-the-counter medications, alcohol, tobacco, and illegal substances.

Prolonged use of these drugs can result in addiction, a chronic condition of the brain that can affect a person's physical health and mental health. Drug abuse and addiction can affect not only the individual, but the person's family and community.

The behavioral signs of substance abuse and addiction may include:

• Lack of motivation
• Repeated absences or poor work performance
• Neglect of children or household
• Car accidents
• Interference with sleeping or eating
• Need for privacy
• Outbreaks of temper
• General changes in overall attitude
• Deterioration of physical appearance and grooming
• Association with known substance abusers
• Need for money and stealing money or valuables
• Persistent dishonesty
• Secretive or suspicious behavior

What effects does substance abuse have on a rural community? What challenges do rural communities face in addressing substance abuse and its consequences?

Substance abuse within a rural community can present many problems. Increased crime and violence, vehicular accidents caused by driving while intoxicated, spreading of infectious diseases, fetal alcohol syndrome, risky sexual behavior, homelessness, and unemployment may all be the result of one or more forms of substance abuse in rural areas.

These problems are exacerbated by several unique challenges for rural communities:

• Behavioral health and detoxification (detox) services are not as readily available in rural communities and, for those that are available, their range of services may be limited
• Patients who require treatment for substance abuse may need to travel long distances to access these services
• Rural first responders or rural hospital emergency room (ER) staff may have limited experience in providing care to a patient presenting with the physical effects of a drug overdose
• Rural, volunteer-based EMTs who have only received EMT-basics training may be prevented by state law from administering naloxone, potentially increasing the risk of overdose.
• Law enforcement and prevention programs may be spread sparsely over large rural geographic areas
• Patients seeking substance abuse treatment may be more hesitant to do so because of privacy issues associated with smaller communities

How can rural communities combat substance abuse?

Prevention programs can help reduce substance abuse in rural communities, particularly when focused on adolescents. Programs using evidence-based strategies that involve parents within schools and churches may discourage alcohol use by younger adults.

Counselors, healthcare professionals, teachers, parents, and law enforcement can work together to identify problems and develop prevention strategies to control substance abuse in rural communities by:

• Holding community or town hall meetings to raise awareness of the issues
• Training law enforcement regarding liquor license compliance, underage drinking, and detection of impaired drivers
• Inviting speakers to talk to school-aged children and help them understand the consequences of substance abuse
• Routine screening in primary care visits to identify at-risk children and adults
• Collaborating with churches and service clubs to provide a strong support system for individuals in recovery, which might include support groups and tobacco quitlines
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• Developing a formal substance abuse prevention or treatment program for the community
• Providing care coordination and patient navigation services for people with substance use disorders
• Providing specialized programs and counseling to discourage substance use by pregnant women
• Collaborating with human services providers and local service organizations to ensure families affected by substance abuse have adequate food, housing, and mental health services
• Providing emergency departments (EDs), first responders, and the public with training and access to overdose reversal drugs such as naloxone.

For additional activities and evidence-based interventions to combat substance abuse, see the Evidence-Based and Promising Substance Use Disorder Program Models section of RHIhub's Rural Prevention and Treatment of Substance Use Disorders Toolkit.

What are the options for addressing tobacco use in rural communities?

According to the Results from the 2016 National Survey on Drug Use and Health: Detailed Tables, tobacco use for young adults aged 18-25 was 53.7% in completely rural areas, compared to 37.6% in large metro areas.

FDA 101: Smoking Cessation Products identifies a number of tobacco cessation products that can help tobacco users break their addiction, including nicotine replacement products, such as skin patches, gum, and lozenges, and prescription drugs.

There are several federal programs, such as Smokefree.gov and BeTobaccoFree.gov, that offer resources and quitlines for tobacco users looking for support. There are also a number of youth-led initiatives and programs focused on tobacco prevention among young people, such as the Truth Initiative, that work to prevent young people starting tobacco use. Programs working to change tobacco policies on the local and state level are another resource.

For a step-by-step guide to implementing a rural tobacco cessation program, see the Rural Tobacco Control and Prevention Toolkit.

The Spit It Out-West Virginia program is an example of a tobacco intervention that worked to promote tobacco cessation and prevention. The campaign employed public service advertising, education efforts, partnerships with employers, and individual counseling.

For additional program examples, see Tobacco use in RHIhub's Rural Health Models & Innovations.

Why is underage drinking and binge drinking prevalent in rural communities?

According to SAMHSA's Results from the 2016 National Survey on Drug Use and Health: Detailed Tables, alcohol use in the past month among 12-20 year olds was 17.2% in completely rural areas, compared to 19.1% in large metro areas. However, binge alcohol use (5+ drinks for males, 4+ drinks for females) in the past month for the same age group was 13% in completely rural areas compared to 11.5% in large metro areas and heavy alcohol use (binge drinking 5+ times in 30 days) was 3.1% in completely rural areas and 2.4% in large urban areas. A 2013 JAMA Pediatrics article concludes that rural high school aged students are more likely to participate in extreme binge drinking (15+ drinks).

Adolescent Alcohol Use: Do Risk and Protective Factors Explain Rural-Urban Differences?, a study from the Maine Rural Health Research Center, suggests that adolescents who begin drinking alcohol at an early age may engage in problem drinking as they get older. Additionally, rural adolescents reported higher rates of driving under the influence (DUI) than urban adolescents.

Several characteristics may affect the attitude of adolescents and influence the prevalence of underage drinking and binge drinking:

• Lower levels of parental disapproval
• Higher acceptance of peer alcohol use among rural adolescents
• Easier access to alcohol at family events and from adults purchasing alcohol for underage youth

According to the National Institute on Drug Abuse (NIDA) publication, Preventing Drug Abuse among Children and Adolescents, research demonstrates that high levels of risk are usually accompanied by low levels of protective factors or prevention.

How big a concern is alcohol impaired driving in rural communities, and what are some options to reduce it?

In 2013, there were 10,265 people in the U.S. killed in crashes involving alcohol-impaired drivers. Rural areas accounted for 48% (4,915) of these fatalities. Twenty-nine percent of all rural traffic fatalities were alcohol-related, according to Traffic Safety Facts, 2015 Data: Rural/Urban Comparison of Traffic Fatalities.

Rural and Urban Differences in Kentucky DUI Offenders reports the lack of treatment services in rural areas creates challenges for healthcare providers in evaluating and delivering treatment for DUI offenders, placing offenders at greater risk for continued driving under the influence of alcohol.

While various states are imposing stricter drunk driving laws in an attempt to control this problem, some local communities are using other approaches to reduce drunk driving. For example, communities may implement transportation options for those who may be too impaired to drive, such as the Isanti County Safe Cab Program in Minnesota. This program has considerably reduced the number of DUI arrests in the county. In addition, this same county developed the Staggered Sentencing for Repeat Drunk Driving Offenders program to reduce the occurrence of repeat DUI violations. The goal of this program was to improve public safety and provide some assistance to help offenders resist driving under the influence of alcohol.

What can be done to discourage youth from using drugs and alcohol?

Everyone can help educate children and youth on the dangers of illegal drugs and alcohol. The 2012 study published by the Maine Rural Health Research Center suggested that, first and foremost, parental influence is a protective factor against alcohol use. There are programs to help not only parents, but also schools, churches, and other organizations who want to work with youth to discourage them from using alcohol and other drugs.

Family-centered prevention programs work to improve knowledge and skills of children and parents related to substance use, as well as the communication within the family. For instance, the Strong African American Families–Teen (SAAF–T) program, implemented in rural Georgia, was successful and cost effective in its mission to keep rural youth engaged in school and away from illicit substances.

Schools can play a part in discouraging youth from using drugs and alcohol. Schools provide a stable and supportive environment for students where they feel cared for by teachers and staff. Children who are successful in school are less likely to drink alcohol.

Rural church and faith-based organizations can also play an important role in promoting substance abuse prevention. According to the 2012 study listed above, rural adolescents are more inclined to participate in organized church-related events and could benefit from activities focused on substance abuse prevention.

Several evidence-based prevention programs designed to reduce substance abuse by children and youth that can be implemented in schools, churches, and other settings are listed in the Appendix of the 2012 study.

Other organizations that provide substance abuse information and prevention program resources for youth include:

• National Institute on Drug Abuse (NIDA)
  Lists websites and materials that teachers and parents can use for prevention activities and education of children and teens.
• Helping Kids PROSPER
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  PROSPER (PROmoting School-Community-University Partnerships to Enhance Resilience) offers evidence-based systems for program development in rural schools and communities. Community leaders and educators can utilize PROSPER to develop programs that reduce risky behaviors, such as underage drinking and illicit drug use.
• keepin' it REAL Rural
  The rural-specific version of the keepin’ it REAL drug and alcohol prevention program for middle school students, funded by the National Institute on Drug Abuse.

Several other prevention programs can be found in RHIhub's Rural Prevention and Treatment of Substance Use Disorders Toolkit’s section on Prevention Models.

What is opioid abuse, and what effect has it had in rural communities?

Opioid abuse refers to the misuse of prescription pain relievers such as oxycodone, hydrocodone, codeine, and morphine or synthetic pain relievers such as fentanyl, as well as the use of heroin. According to the 2015 National Survey on Drug Use and Health (NSDUH), 11.5 million adults misused prescription pain relievers at least once in the previous year, with approximately California Restrictions Drivers License - Crisezoo in a nonmetropolitan area and approximately 1.2 million in small (<250K Pop.) metropolitan areas.

According to a 2015 article published in the International Journal of Drug Policy which investigated rural/urban use of these drugs, 4.9% of rural adults and 5.9% of urban adults reported non-medical use of prescription opioids in the past year. A 2015 study from the Carsey School of Public Policy shows that rural adolescents are more likely to abuse prescription painkillers than urban adolescents.

Prescription drug abuse has, however, led to an increased use of heroin in rural areas. A 2013 study from SAMHSA’s Center for Behavioral Health Statistics and Quality found that people who use opioids non-medically are 19 times more likely to initiate heroin use. According to a 2014 JAMA Psychiatry article, heroin has become more prevalent in suburban and rural areas because of its affordability and ease of access compared to prescription opioids. Heroin, a drug that is predominantly injected, presents its own health risks, such as an increased likelihood of hepatitis C (HCV) and HIV infection, as well as the risk of an unintentional overdose.

Mortality

According to a 2017 article in Morbidity and Mortality Weekly Report (MMWR), the rate of overdose fatalities was slightly higher in nonmetro areas (17 per 100,000) than in metro areas (16.2 per 100,000) in 2015, which is a significant increase from 1999 when the metro rate was 6.4 per 100,000 and the nonmetro rate was 4.0 per 100,000. The CDC's Annual Surveillance Report of Drug-Related Risks and Outcomes for 2017 shows that opioids were responsible for approximately 60% of drug overdose deaths across the country in 2015, including in rural areas.

A 2014 American Journal of Public Health article found death and injury from the misuse of opioids more prevalent in states with significant rural populations including Kentucky, West Virginia, Alaska and Oklahoma. A 2013 AJPH article finds deaths are more prevalent for individuals using alternative methods for ingesting prescription opioids including injections.

An August 2016 MMWR article states the number of drug products obtained by law enforcement that tested positive for the synthetic opioid fentanyl (which is 50-100 times more potent than morphine) increased by 426% and synthetic opioid deaths increased 79% across the U.S. from 2013-2014. Because the opioid deaths do not correlate with state-level fentanyl prescriptions, the spike is likely caused in part by illicitly manufactured fentanyl (IMF), which is often mixed with heroin and has increased fentanyl's availability across the country, including rural areas.

Hepatitis C Virus and Human Immunodeficiency Virus (HIV)

A May 2015 MMWR article reports an increase in the number of persons in the U.S. living with Hepatitis C virus (HCV), particularly with young adults under 30 years old. Increases are most noticeable in nonurban areas of Appalachia where injection drug use (IDU) has been identified as the primary risk factor for HCV. Approximately 73% of the reported HCV cases in this area were contracted by people reporting IDU. A 2010 study published in Public Health Reports found 57% of participating IDU patients in Appalachian Kentucky tested positive for Hepatitis C antibodies.

Human immunodeficiency virus (HIV), although not as prevalent in injection drug users as HCV, potentially can increase along with HCV because the risk factors are similar. HIV and HCV are blood-borne diseases that are effectively transmitted through the use of contaminated needles and the equipment for preparing the drug, according to a November 2012 MMWR article. A 2010 study published in the journal Addiction has shown the prevalence of HCV can be an indicator of HIV risk among injecting drug users.

Social Harm

There are a number of societal risks from the proliferation of illicit drug use, including drug-related crime. According to the National Council on Alcoholism and Drug Dependence, INC. (NCADD) report Alcohol, Drugs and Crime, there are three types of drug-related crime:

• Use-Related Crime: Crimes that occur while the drug user is in an altered state, such as domestic violence or driving under the influence of a controlled substance
• Economic-Related Crimes: Crimes committed in order to fund drug usage, such as theft or prostitution
• System-Related Crimes: Crimes related to the production and distribution of illicit drugs

Drug use also has physical and social consequences for the children of drug users. According to the National Institute on Drug Abuse, there is evidence that prescription pain reliever use during pregnancy can lead to a 2.2 times greater risk of stillbirth. Heroin use during pregnancy can lead to neonatal abstinence syndrome (NAS), wherein the baby is born dependent on opioids.

According to a 2015 report from the Child Welfare Information Gateway, 25.4% of child abuse victims had a caregiver who abused drugs.

Treatment for patients who use and abuse nonmedical prescription opioids is limited in rural areas. Although most rural facilities may provide intake, assessments, referrals, and basic treatment, services that provide detoxification, long-term residential treatment, and day treatment are scarce, according to Distribution of Substance Abuse Treatment Facilities Across the Rural – Urban Continuum. For additional information see Is treatment for substance abuse available in rural areas?

For more information and resources specific to the opioid crisis, see the Rural Response to the Opioid Crisis topic guide.

What is the current status of methamphetamine use in rural America, and what has been done to combat its use and production?

According to SAMHSA's Results from the 2016 National Survey on Drug Use and Health: Detailed Tables, the rate of methamphetamine use by young rural adults ages 18–25 was 0.5% for large metro areas, 0.8% for small metro areas, 1.6% for nonmetro areas, and in completely rural areas, 3.4%, or six times the rate of young urban adults. This pattern of higher use in rural areas continues to be a great concern.

According to the Drug Enforcement Agency (DEA) report, 2016 National Drug Threat Assessment Summary, the availability of methamphetamines has risen each year since 2013 and demand may be increasing nationally. Although seizures of covert meth labs in the U.S have decreased, availability is still high due to foreign production and the proliferation of small, “one pot,” or “shake-and-bake”laboratories, which are harder to track down. Admissions for amphetamine-related treatment continue to increase.

The Meth Project Foundation, Inc. is a national program of The Partnership for Drug-Free Kids that focuses on reducing methamphetamine use through public service media, outreach programs, and the development of public policy. It also is a source for information for youth about meth.

Is treatment for substance abuse available in rural areas?

SAMHSA's Mental Health Report 2010 reports that states with proportionally large rural populations (compared to urban populations) have greater shortages of mental health providers and fewer facilities to provide treatment services. Although family doctors, psychologists, social workers, and pastors may be available in rural areas to deliver basic substance abuse services or social support, facilities available in rural areas that provide comprehensive substance abuse treatment services are limited.

According to the 2014 Substance Use & Misuse article, Barriers to Substance Abuse Treatment in Rural and Urban Communities: Counselor Perspectives, rural areas lack basic substance abuse treatment services as well as the supplemental services necessary for positive outcomes. Detoxification (detox) services, for example, provide the initial treatment for patients to minimize any medical or physical harm caused by substance abuse. The vast majority (82%) of rural residents live in counties that do not have detox services, reports Few and Far Away: Detoxification Services in Rural Areas. Often, local law enforcement or emergency departments provide the initial detox services.

In addition, depending on the stage of their illness, patients may need more advanced treatment services, such as inpatient, intensive outpatient, and/or residential care, not available in rural areas. The absence of these treatment services locally results in clients having to travel long distances to receive the proper care. According to the 2014 Substance Use & Misuse article mentioned earlier, the greater distance to receive substance abuse treatment often results in lower completion rates of substance abuse treatment programs. Rural communities often lack public transportation services, which can further impede the access to ongoing treatment and support groups, particularly for clients who have had their driver's licenses revoked.

In some cases, medical professionals need special training to prescribe and monitor medication that is proven successful in treating addiction, such as buprenorphine, which is used in opioid addiction treatment. Qualifying physicians must meet certain criteria and receive a Drug Enforcement Administration waiver to provide this medication-assisted treatment (MAT). Rural areas are less likely to have a supply of physicians with this waiver according to Geographic and Specialty Distribution of US Physicians Trained to Treat Opioid Use Disorder.

How can rural primary care providers help address substance abuse and connect their patients to substance abuse treatment?

Training opportunities and other resources are available that can help rural primary care providers to identify patients suffering from substance abuse, encourage those patients to seek treatment, and make referrals to appropriate treatment services.

The American Society of Addiction Medicine (ASAM) is a professional society dedicated to improving the quality of addiction treatment by educating physicians and other medical professionals, as well as the public. ASAM provides a variety of courses and events, including continuing medical education (CME) courses. ASAM Education Resources lists both live and distance CME courses.

The Agency for Healthcare Research and Quality offers a guide detailing the barriers and challenges to Implementing Medication-Assisted Treatment (MAT) for Opioid Use Disorder (OUD) in Rural Primary Care, which discusses some of the barriers to establishing MAT in a rural primary care setting and includes 250 tools and resources that help facilitate implementation.

SAMHSA supports an online facility locator that rural primary care providers can use to find treatment centers and services in their region:

• Behavioral Health Treatment Services Locator
  Locate treatment facilities addressing substance abuse, addiction, and mental health problems by zip code or city and state.

How can rural areas develop local options for those who need treatment?

Recently there has been a trend to co-locate or integrate mental/behavioral health services with primary care services. This approach could facilitate access to substance abuse treatment and reduce the stigma associated with behavioral health treatment. Also, the providers are able to network and work together rather than in an isolated environment. RHIhub's Mental Health Topic Guide provides additional information on this topic.

Federally Qualified Health Centers (FQHCs) increase access to healthcare by providing primary care services for underserved rural and urban communities. FQHCs must also provide mental health and substance abuse services, either directly in a health center or by an arrangement with another provider. See RHIhub's Federally Qualified Health Center Topic Guide for information on developing an FQHC within a rural community.

A successful program that might be replicated is Indiana's Integrated Care Training Program: Community Health Worker/Certified Recovery Specialist program. This program addresses behavioral health issues in rural areas by training community health workers (CHWs) to provide support services in a variety of settings, including emergency and outpatient settings. For a step-by-step guide to implementing a rural substance abuse treatment program, see the Youtube - Practice Signs Test Missouri Road.