Though often perceived to be a problem of the inner city, substance use and misuse have long been prevalent in
rural areas. Rural adults have higher rates of use for tobacco and methamphetamines, while opioid use has grown
in towns of every size. Rural adolescents and young adults use alcohol at higher rates and are more likely to
engage in high-risk behaviors, like binge drinking or driving under the influence, than their urban
Substance use 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 use treatment admission rate for nonmetropolitan
counties was highest for alcohol as the primary substance, followed by marijuana, stimulants, opiates, and
Factors contributing to substance use in rural America include:
Low educational attainment
Lack of access to mental healthcare
Isolation and hopelessness
A greater sense of stigma
Substance use disorders 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 use on rural communities, broadly. For information and resources
specific to the opioid crisis, see the Rural Response to the Opioid Crisis topic
Rural and Urban Substance Use Rates (ages 12 and older, unless noted)
Alcohol use by youths aged 12-20
Binge alcohol use by youths aged 12 to 20 (in the past month)
What is the difference between substance use disorder, substance use, and misuse?
Substance use, in the broadest terms, is any ingestion of mood- or behavior-altering substances, such as
nicotine, and illegal drugs. Substance misuse is the use of any substance that is outside the prescribed or
intended use of that substance, such as off-label usage of prescription drugs or underage drinking.
Prolonged use of these substances can result in substance use disorder (SUD), which can affect not only the
individual, but the person's family and community.
According to the Substance Abuse and Mental Health Services Administration (SAMHSA), substance use
“occur when the recurrent use of alcohol and/or drugs causes clinically significant impairment,
including health problems, disability, and failure to meet major responsibilities at work, school, or home.”
The behavioral signs of substance use disorder may include:
Lack of motivation
Repeated absences or poor work performance
Neglect of children or household
Interference with sleeping or eating
Need for privacy
Outbreaks of temper
General changes in overall attitude
Deterioration of physical appearance and grooming
Need for money and stealing money or valuables
Secretive or suspicious behavior
What effects does substance use have on a rural community? What challenges do rural communities face in
addressing substance use and its consequences?
Substance use and misuse 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
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 use disorder may need to travel long distances to access
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.
Law enforcement and prevention programs may be sparsely distributed over large rural geographic areas.
Patients seeking substance use disorder treatment may be more hesitant to do so because of privacy issues
associated with smaller communities. Rural communities often lack housing and support services for long-term
How can rural communities combat substance use?
Prevention programs can help reduce substance use in rural communities, particularly when focused on
Programs using evidence-based strategies that involve parents within schools and churches may discourage
substance 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 use 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
Inviting speakers to talk to school-aged children and help them understand the consequences of substance
Conducting routine screening in primary care visits to identify at-risk children and adults
Collaborating with churches, service clubs, and employers to provide a strong support system for individuals
in recovery, which might include support groups and tobacco quitlines
Training volunteers to identify and refer individuals at risk
Developing formal substance use prevention, treatment, or recovery programs 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 use disorder have adequate food, housing, and mental health services
Providing emergency departments (EDs), first responders, and the public with training and access to overdose
Existing healthcare facilities in a community can play an important role in combating and addressing substance
use and substance use disorder. In Engaging
Critical Access Hospitals in Addressing Rural Substance Use, the Flex Monitoring Team outlines a
framework for Critical Access Hospitals to address their communities' needs, from prevention to treatment to
What are the options for addressing tobacco use in rural communities?
According to the Results from the 2021
National Survey on Drug Use and Health: Detailed Tables, tobacco use for young adults aged 18-25 was
35.5% in nonmetro areas, compared to 22.7% in large metro areas. Given the link between tobacco use
and diseases such as cancers, chronic pulmonary obstructive disorder (COPD), heart disease, and stroke, this
high rate of tobacco use is an important contributor to rural health disparities.
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, lozenges, and
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 from starting to
use tobacco. Programs working to change tobacco policies on the local and state level are another resource.
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.
The use of e-cigarettes, or “vaping”, is the newest and most pervasive form of nicotine use among
teens and young adults. Though the effects of vaping are still being studied, there are already a number of
programs dedicated to vaping prevention in rural communities, as highlighted in the 2020 Rural Monitor
article Drug Education and Cessation Programs Help Teens Avoid or Quit
For additional program examples, see Tobacco use in Rural
Health Models & Innovations.
How prevalent is underage drinking and binge drinking in rural communities?
According to SAMHSA's Results from the
2021 National Survey on Drug Use and Health: Detailed Tables, alcohol use in the past month among 12-20
year olds was 15.0% in nonmetro areas, compared to 14.9% in large metro areas. Binge alcohol use (5+ drinks for
males, 4+ drinks for females) in the past month for the same age group was 7.7% in nonmetro areas compared to
8.0% in large metro areas and heavy alcohol use (binge drinking 5+ times in 30 days) was 1.1% in nonmetro areas
and 1.7% in large urban areas. A 2013 JAMA Pediatrics article
that rural high school students are more likely to participate in extreme binge drinking (15+ drinks).
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 rural
county developed the Staggered Sentencing for
Repeat Drunk Driving Offenders program, which allows offenders to serve their sentence in segments of
time and potentially have future segments waived pending full compliance with the program's guidelines.
The goal of this program was to reduce the occurrence of repeat DUI violations and improve public safety by
providing 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. A 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 schools, churches,
organizations, and parents who want to work with youth to discourage them from using alcohol and
Family-centered prevention programs work to improve the 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 use 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 use prevention.
Several evidence-based prevention programs designed to reduce substance use 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 use information and prevention program resources for youth
National Institute on Drug
Lists websites and materials that teachers and parents can use for prevention activities and education of
children and teens.
Helping Kids PROSPER
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
Several other prevention programs can be found in the Rural Prevention and Treatment of Substance Use
Disorders Toolkit's section on Prevention Models.
What is opioid misuse, and what effect has it had in rural communities?
Opioid misuse refers to any use of heroin, synthetic opioids such as fentanyl, or prescription pain relievers,
such as oxycodone, hydrocodone, codeine, and morphine outside their prescribed or intended use. According to the
National Survey on Drug Use and Health (NSDUH), 8.2 million adults misused prescription pain relievers
at least once in the previous year, with approximately 1.2 million of those adults in a nonmetropolitan area.
According to the 2021 report listed
above, 3.2% of adults in nonmetro areas and 3.1% of adults in large metro areas reported non-medical use of
prescription opioids in 2021. A 2015 study from the Carsey
School of Public Policy showed that rural adolescents were more likely to misuse prescription painkillers than
Prescription drug misuse in the early 2000s led to the increased use of heroin, followed by synthetic opioids,
such as fentanyl. A 2013
study from SAMHSA's Center for Behavioral Health Statistics and Quality found that people who used
opioids non-medically were 19 times more likely to initiate heroin use. According to a 2014 JAMA Psychiatry article, heroin became
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 human immunodeficiency virus (HIV) infection, as
well as the risk of unintentional overdose.
According to a 2021 report from
the USDA Economic Research Service, the rates of overdose deaths from synthetic opioids, such as fentanyl,
tramadol, and meperidine, surpassed both the rates for heroin and prescription opioids around 2015 and
continues to rise over the latter half of the decade.
According to a 2022 report from the Centers for
Disease Control and Prevention (CDC), the rate of drug overdose fatalities was slightly higher in urban areas
(28.6 per 100,000) than in rural areas (26.2 per 100,000) in 2020. For opioids specifically, urban counties had
31% higher mortality for heroin and 28% higher mortality for synthetic opioids, but rural counties had a 13%
higher mortality rate for natural and semisynthetic opioids. The CDC's Annual Surveillance
Report of Drug-Related Risks and Outcomes for 2019 shows that opioids were responsible for approximately
63% of drug overdose deaths in rural (micropolitan and noncore) areas of the country in 2017.
Hepatitis C Virus (HCV) and Human Immunodeficiency Virus (HIV)
A May 2015 MMWR article reported
increase in the number of persons in the U.S. living with HCV, particularly with young adults under 30 years
old. Increases were 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.
Although not as prevalent in injection drug users as
HCV, HIV infections can potentially increase concurrently with HCV because the risk factors are similar.
According to a 2014 study, the 2011 rate of
HIV infections among people who inject drugs was 55 per 100,000 people, compared to the HCV infection rate of
43,126 per 100,000 people in the same cohort. HIV and
HCV are blood-borne diseases that are effectively transmitted through the use of contaminated needles and
equipment used for preparing drugs, according to a November 2012 MMWR article.
There are a number of societal risks from the proliferation of illicit drug use. Increased drug-related crime
may occur in a community, including crimes that result from a substance-altered mental state, crimes committed
to fund drug use, and crimes related to the production and distribution of illegal drugs.
Drug use also has physical and social consequences for the children of drug users. According to a National
Institute on Drug Abuse research report, 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 used drugs.
According to the Drug Enforcement Administration (DEA) report, 2020
National Drug Threat Assessment Summary, police reports for methamphetamine has risen 75% since 2014
and had gone from 9% of all drug reports in 2009 to 24% in 2018. 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.
Is treatment for substance use disorders available in rural areas?
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 use
services or social support, facilities available in rural areas that provide comprehensive substance use
treatment services are limited. A 2019
study found that on top of the usual barriers to healthcare access for rural people, such as travel time
and cost of care, there was a lack of treatment programs available in rural areas and a negative perception of
treatment for substance use disorder among rural providers.
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 many 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, this greater distance to substance use disorder treatment
often results in lower completion rates of substance use treatment programs. Rural communities often lack public
transportation services, which can further impede access to ongoing treatment and support groups, particularly
for clients who have had their driver's licenses revoked.
How can rural primary care providers help address substance use and connect their patients to substance use
Rural primary care providers can play a key role in addressing substance use by screening to identify patients
suffering from substance use disorder (SUD), encouraging those patients to seek treatment, and making referrals
to appropriate treatment services. The screening process is a crucial first step towards treatment for SUD but
in rural areas there are still barriers, such as a lack of training for providers, concerns about privacy and
stigma, and a hesitancy to disclose substance use when a strong patient-provider relationship is not present,
according to a 2019
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.
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 use disorder treatment and reduce the stigma
associated with behavioral health treatment. Providers are then able to network and work together rather than
work in an isolated environment. The Rural Mental Health Topic
Guide provides additional information on this topic.
There are a number of available treatment models for expanding treatment for substance use disorder in rural
How can rural communities support post-treatment recovery?
Recovery is a broad and important step in overcoming and managing substance use disorder (SUD). Because
substance use and misuse can affect every aspect of a person's life, recovery often requires support in a
variety of areas beyond clinical care, particularly in the early stages of recovery. Supports such as housing,
job training and employment, mutual aid, mental healthcare, and peer support can be instrumental in setting
people up for success following SUD treatment. Recovery programs can be sparse in rural areas, though programs
like Alcoholics Anonymous (AA) are often available.
There are a number of SUD recovery models featured in the Rural
Prevention and Treatment Toolkit that are proven to work in rural communities. These models can be used
to create a recovery program that fits the specific needs of the community.
Examples of successful rural recovery projects include:
Recovery Kentucky – Provides apartments within a congregate
living environment and an opportunity to begin recovery from SUD via a peer-led 12-step environment in 8
locations in rural Kentucky.
Addiction Recovery Mobile Outreach Team (ARMOT) – Provides case
management and recovery support services to individuals with SUD and education and support to rural hospital
staff, patients, and their loved ones.
Often recovery involves addressing the underlying psychological processes associated with substance use. For
information on mental healthcare in rural communities, see our Rural Mental
Health topic guide.