Substance Abuse in Rural Areas

Substance abuse has long been perceived to be a problem of the inner city. However, alcohol abuse has long been a problem in rural areas, and illicit drugs have infiltrated towns of every size. Substance abuse can be especially hard to combat in rural communities due to limited resources for prevention, treatment, and recovery.

Factors contributing to substance abuse in rural America include:

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

Substance abuse results 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.

Rural and Urban Substance Abuse Rates
(ages 12 and older, unless noted)
  Non-metro Small metro Large metro
Underage alcohol use 11.3% 11.4% 11.7%
Binge alcohol use by youths aged 12 to 17 6.6% 6.2% 6.2%
Illicit drug use 7.8% 9.8% 9.6%
Illicit drug or alcohol dependence 6.6% 8.4% 8.6%
Cigarette smoking 26.6% 22.4% 19.0%
Smokeless tobacco use 6.7% 3.7% 2.1%

Source: Substance Abuse and Mental Health Services Administration (SAMHSA), 2013 National Survey on Drug Use and Health, Summary of National Findings.

Frequently Asked Questions

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 affect not only the individual, but the person’s family and community.

The behavioral signs of substance abuse and addiction 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
  • 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 rural challenges:

  • 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 the rural hospital ER staff may have limited experience in providing care to a patient presenting the physical effects of a drug 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 control substance abuse in rural communities, particularly when focused on adolescents. Programs using evidence-based strategies within schools and churches that involve parents 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
  • 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
  • Training adults as volunteers to identify and refer individuals at risk
  • 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
  • Collaborate with human services providers and local service organizations to ensure families affected by substance abuse have adequate food, housing, and mental health services

For additional activities and evidence-based interventions to combat substance abuse see the Models for Communities section of RAC's Rural Mental Health and Substance Abuse Toolkit.

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

According to a 2012 study published by the Maine Rural Health Research Center, alcohol use and binge drinking are more common among rural youth aged 12-13 than among urban youth the same age. This study 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 binge drinking and driving under the influence (DUI) than urban adolescents. Several other characteristics may affect the attitude of adolescents and influence the prevalence of underage drinking and binge drinking:

  • Lower levels of parental disapproval
  • Higher tolerance for alcohol use among rural adolescents
  • Increased availability of alcohol in households with a higher income level
  • 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.

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 schools, churches, and other organizations who want to work with youth to discourage them from using drugs and alcohol.

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 off of drugs and alcohol.

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. Several school-based prevention programs can be found in RAC’s Rural Mental Health and Substance Abuse Toolkit: Evidence-Based Interventions for Schools.

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 evidenced-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:

  • Drug Abuse Resistance Education (D.A.R.E.)
    Teaches students good decision-making skills to help them recognize and resist the pressures that influence them to experiment with alcohol, tobacco, marijuana, and other drugs.
  • 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.
  • Underage Drinking Enforcement Training Center
    Works to support, improve, and increase the ability of states and communities to enforce underage drinking laws, prevent underage alcohol use, and remove the effects of underage drinking by conducting training and offering technical assistance.

Which illicit drugs are the most abused in rural communities and what problems do they bring?

Illicit drugs include illegal drugs as well as prescription drugs or over-the-counter drugs used for purposes other than those for which they are indicated, or in a manner or in quantities other than directed. According to The 2014 Update of the Rural-Urban Chartbook, the substance abuse treatment admission rate for non-metropolitan counties was highest for alcohol as the primary substance, followed by marijuana, stimulants, opiates, and cocaine.

However, a 2014 JAMA Psychiatry article concluded that heroin users entering treatment over the past 50 years have demonstrated a changing geographical composition, with an increasing percentage in more recent years arriving from communities outside of large urban areas. This study found users were introduced to heroin as an alternative to the illicit use of prescription drugs, as heroin is more available and affordable than prescription drugs.

Several problems are associated with heroin and other illicit drugs including nonmedical prescription opioids.

Hepatitis C Virus and Human Immunodeficiency Virus (HIV)
A Morbidity and Mortality Weekly Report 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 through IDU. A study published in Public Health Reports found 48% of the participating patients who had been screened for hepatitis B or C in rural health departments of Appalachia in Kentucky had injected substances that were nonmedical prescription drugs with OxyContin. This drug is not designed for IDU and requires some preparation further increasing the risk of HCV transmission.

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 the Centers for Disease Control and Prevention (CDC). A study published in the journal Addiction has shown the prevalence of HCV can be an indicator of HIV risk among injecting drug users. See Rural HIV and AIDS for additional information regarding HIV in rural areas.

Death or Harm to Individual
Unintentional deaths and injury from the use of nonprescription opioid drugs is concentrated in states with large rural populations, according to a 2014 article from the American Journal of Public Health. Deaths are more prevalent for individuals using alternative methods for ingesting prescription opioids including injections, than for other types of administration, according to a 2013 article in the American Journal of Public Health.  Deaths and injury may be further exacerbated in rural areas where law enforcement may not be prepared to respond to drug related crimes or with victims displaying an overdose of drugs. Also, medical facilities may not be available to provide specialized care for victims of overdose that could result in death or further harm to the individual.

Nonviolent Property Thefts
In 2009, The Atlantic reported on the increase in some rural areas of property thefts attributable to heroin users trying to support their addiction. There may be fewer law enforcement who cover large expanses of rural areas making it difficult to apprehend and/or curb property thefts.

How prevalent is nonmedical prescription opioid use and abuse in rural communities?

According to a 2015 article published in the International Journal of Drug Policy, that 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 2014 article found death and injury from the misuse of these drugs more prevalent in states with significant rural populations including Kentucky, West Virginia, Alaska and Oklahoma; and according to 2011 JAMA Pediatrics rural adolescents reported greater prevalence of lifetime non-medical prescription drug use than urban adolescents (13% vs. 10%). The authors of this report suggest that the increase in abuse of prescription drugs in rural areas may be related to the lack of availability of illicit drugs, the weakening of the traditional family unit, the diminishing rural economy, and the isolation of rural communities.

In the last 10 years nearly all states have exhibited an increase in morbidity and mortality as a result of non-medical use of prescription opioids and research regarding rural/urban differences has not been conclusive, according to an article published in the American Journal of Health. However, the 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 few and far between, 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?

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

According to a 2005 policy brief published by the Maine Rural Health Research Center, the rate of methamphetamine use by young rural adults ages 18–25 was 2.9%, or double the rate of young urban adults at 1.5%. This pattern of higher use in rural areas continues to be a great concern.

However, according to the Drug Enforcement Agency (DEA) report, 2013 National Drug Threat Assessment, and the 2014 NIDA Research Report, Methamphetamine, the demand and use of methamphetamines may be declining or stabilizing nationally. The DEA documents that seizures of covert meth labs have decreased and admissions for amphetamine-related treatment have declined. Most importantly, methamphetamine use by teens across the U.S. has dropped approximately 70% since the year 1999, according to the NIDA Key Findings on Adolescent Drug Use.

While the number of methamphetamine users may be declining, its use is not eradicated and is particularly problematic in rural areas for several reasons.

  • Meth can be produced in homemade labs, which are often located in abandoned buildings in remote locations.
  • The production of meth releases poisonous gas and creates toxic waste that is frequently dumped down household drains or in fields.
  • There are fewer law enforcement officers in rural areas to detain or halt producers from using existing meth labs or setting up new ones.
  • The lack of treatment centers is also a challenge for rural areas.

Several federal, state and local organizations have worked together to combat the use and production of meth in rural communities, and their efforts appear to be working. In 2005, the Combat Methamphetamine Epidemic Act was passed into law, requiring retailers to place the non-prescription drug pseudoephedrine, used in producing meth, behind the counter or in secure cabinets. Consumers must show an ID to purchase these drugs.

As a result of this Act, the Meth Watch Program was developed to help stop the theft and suspicious sales of pseudoephedrine products, as well as other common household products used in the manufacturing of methamphetamine in small, toxic labs. This program promotes cooperation between retailers and law enforcement to prevent the diversion of legitimate products for illegal use. Meth Watch was originally started in Kansas and developed into a highly successful program that has been adopted by several states.

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 about meth for youth. In addition, the Office of National Drug Control Policy provides information and resources on methamphetamine prevention approaches.

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 for delivering basic substance abuse services or social support, facilities available in rural areas that provide comprehensive substance abuse treatment services may be 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 detoxification services.

In addition, patients may need more advanced treatment services depending on the stage of their illness that could necessitate the need for 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 an article published in Substance Use & Misuse article, 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 to be successful in treating addiction such as the drug, buprenorphine, which is used in opioid addiction treatment. Qualifying physicians must meet certain criteria and receive a waiver to use this drug on patients. 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.

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

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. RAC’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 by a health center or by an arrangement with another provider. See RAC’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.

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

In 2012, there were 10,322 people in the U.S. killed in crashes involving alcohol-impaired drivers.  Rural areas accounted for 55% (5,724) of these fatalities. Thirty-one percent of all rural traffic fatalities were alcohol-related, according to Traffic Safety Facts, 2012: Rural/Urban ComparisonRural and Urban Differences in Kentucky DUI Offenders reports that, 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 some states are imposing stricter drunk driving laws to control this problem, some local communities are using other approaches to reduce drunk driving. For example, local 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.