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Need for Programs in Rural Communities

Some rural areas face a high burden of substance use disorders, in part due to unique risk factors such as:

  • Geographic isolation
  • High rates of poverty
  • Lack of mental health providers, facilities, and services
  • Increased availability of prescription opioids in recent years

In 2014, treatment admissions data for substance use disorders showed that the most common substances abused in rural areas were alcohol, marijuana, stimulants, opiates, and cocaine. According to 2010 data from Rural Health Reform Policy Research Center's 2014 Update of the Rural-Urban Chartbook, treatment admissions for marijuana, stimulants, and alcohol were generally higher in nonmetropolitan counties compared to metropolitan counties. While admission rates for opioids were lower in nonmetropolitan counties compared to metropolitan counties, rates of opioid use in rural areas have increased dramatically over the past several years. This section will provide an overview of key issues related to substance use disorders in rural areas.

Alcohol Use Disorders in Rural Communities:

The 2013 National Survey on Drug Use and Health found that binge drinking was higher in rural areas compared to urban areas, and underage drinking was nearly as high as in urban areas. However, the Maine Rural Health Research Center found in 2012 that alcohol use and binge drinking were more common among youth ages specifically 12-13 in rural areas compared to urban youth of the same age. The authors suggested several factors unique to rural areas that could contribute to this disparity, including:

  • Less parental disapproval for underage alcohol use
  • Greater acceptance of alcohol use among rural adolescent peers
  • Greater availability of alcohol in wealthier households
  • Greater access to alcohol provided by adults through family gatherings and purchasing of alcohol for youth

Methamphetamine Use Disorders in Rural Communities:

Research published in 2007 found that the rates of methamphetamine (“meth”) use were twice as high among young rural adults ages 18-25 (2.9%) compared to their urban counterparts (1.5%). This difference is partially due to several factors, including that meth can be produced in homemade labs that are frequently located in abandoned buildings in remote areas, such as rural areas. There are also fewer law enforcement officers in rural areas to prevent the establishment of meth labs or shut down existing ones, and fewer treatment providers. Meth production harms rural areas not only through use of meth itself, but also through the poisonous gas released by meth production, which becomes toxic waste that can find its way into household drains and fields.

Opioid Use Disorders in Rural Communities:

The U.S. has seen a dramatic increase in rates of opioid misuse and deaths resulting from opioid overdose. According to the Agency for Healthcare Research and Quality, between 2005 and 2014, the national rate of opioid-related inpatient stays increased over 64% and emergency department (ED) visits related to opioid misuse increased 99%. Oregon, North Carolina, and South Dakota are the states with the largest increases in opioid-related inpatient hospital stays between 2009 and 2014 and almost every state experienced an increase in the rate of opioid ED visits during this time. This infographic compares the rates of opioid-related hospital stays by state.

Similar to the rest of the country, rural areas have been severely affected by the epidemic. Opioid misuse is especially high in states with large rural populations such as West Virginia and Kentucky (National Rural Health Association Policy Brief, University of Southern Maine). Populations with the highest rates of opioid misuse in rural areas include:

  • Adolescents ages 12-19
  • Adults ages 20-29
  • Men
  • Individuals with less than a high school education
  • Individuals who are uninsured
  • Individuals with low incomes

Some research shows that opioid poisonings in nonmetropolitan counties have increased at a rate over three times that of metropolitan counties. Further, the use of illicit opioids like heroin, fentanyl, and carfentanil (an elephant tranquilizer) have led to spikes in opioid overdose and overdose related deaths.

The high burden of substance misuse and substance use disorders is driven by a multitude of factors in rural communities including:

  • High rates of poverty and unemployment: According to the USDA Economic Research Service, the overall rate of poverty is significantly higher in rural areas compared to urban areas, and employment and educational attainment rates are lower than in urban areas. Poverty and unemployment have shown to be associated with drug use. Research by the University of New Hampshire documented that people are selling illegal substances to pay bills and other expenses.
  • Rural geography and isolation: Rural communities have fewer treatment facilities, mental health providers, and detoxification services. People who live in rural communities may experience longer travel distances to available facilities. These barriers prevent individuals from accessing treatment for substance use disorders.
  • Increased availability of prescription opioids: Research indicates that availability of prescription opioids in rural areas has significantly increased in recent years, more so than in urban areas. States with large rural populations also have some of the highest rates of opioid prescription, and prescription opioids have historically been prescribed to maintain productivity in heavy labor industries like mining.
  • Stigma and beliefs about substance use disorders: Negative attitudes about substance use disorders, including the belief that substance use disorders is a moral failing, may prevent individuals from seeking needed treatment. This is particularly a problem in small rural communities with few mental health and/or healthcare providers where there is less privacy for those seeking treatment for substance use disorders.

Resources to Learn More

Appalachian Overdose Mapping Tool
Map/Mapping system
This data visualization tool combines social, demographic, and economic data with county drug overdose death rates in rural Appalachia. Communities can use this information to identify key areas for discussion, prevention, and intervention.
Organization(s): NORC at the University of Chicago and the Appalachian Regional Commission

An Analysis of Mental Health and Substance Use Disparities and Access to Treatment Services in the Appalachian Region
This report analyzes disparities in mental health status, prevalence of substance use disorders, and access to treatment services in the Appalachian region. It includes both quantitative data analyses of substance use and access to care in Appalachia as well as case study findings on access to treatment for substance use disorders in six Appalachian counties.
Author(s): Zhang, Z., Infante, A., Meit, M., English, N., Dunn, M., and Harper Bowers, K.
Organization(s): NORC at the University of Chicago, East Tennessee State University, and the Appalachian Regional Commission
Date: 8/2008

Drug Overdose Deaths in the United States
Map/Mapping System
This interactive Community Assessment Tool is designed to help leaders, researchers, and policymakers assess effective actions for addressing the opioid crisis at the local level. The data tool overlays substance misuse data against socioeconomic, census, and other public information.
Organization(s): NORC at the University of Chicago and the U.S. Department of Agriculture (USDA) Rural Development

Opioid-Related Inpatient Stays and Emergency Department Visits by State, 2009-2014
This report provides data on opioid-related inpatient hospital stays and emergency department visits in the United States based on data from the Healthcare Cost and Utilization Project.
Author(s): Weiss, A.J., Elixhauser, A., Barrett, M.L., Steiner, C.A., Bailey, M.K., and O'Malley, L.
Organization(s): Agency for Healthcare Research and Quality, Truven Health Analytics, M.L. Barrett, Inc.
Date: 12/2016

Opioids' Burden on Hospital Care: A State-by-State Comparison
This infographic provides an overview of rates of opioid-related hospital stays by state.
Organization(s): Agency for Healthcare Research and Quality
Date: 12/2016

Rural Communities in Crisis: Strategies to Address the Opioid Crisis
Discusses factors contributing to the opioid epidemic in rural areas and suggests policy strategies to help rural communities address the opioid crisis.
Organization(s): National Rural Health Association
Date: 4/2016

Rural Opioid Abuse: Prevalence and User Characteristics
Discusses common demographic and economic traits of opioid users, and how they differ between urban and rural areas.
Author: Lenardson, J., Gale, J., and Ziller, E.
Organization(s): Maine Rural Health Research Center
Date: 2/2016

Substance Abuse in Rural Areas
A discussion of the problem of substance abuse in rural communities, including unique rural risk factors for and rates of substance abuse. This page also addresses frequently asked questions about substance abuse in rural areas, including availability of treatment options and what can be done to combat substance abuse in remote communities.
Organization(s): Rural Health Information Hub