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 prescription drug
misuse and heroin use has grown in towns of every size.
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
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 17 (in the past month)
|Smokeless tobacco use
|Illicit drug use
|Misuse of Opioids
Source: Substance Abuse and Mental Health Services Administration (SAMHSA), Results from the 2020
National Survey on Drug Use and Health: Detailed Tables.
Frequently Asked Questions
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
- Car accidents
- 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
- Persistent dishonesty
- 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.
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 a formal substance use 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 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
For additional activities and evidence-based interventions to combat substance use, 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 2020
National Survey on Drug Use and Health: Detailed Tables, tobacco use for young adults aged 18-25 was
38.6% in nonmetro areas, compared to 26.9% 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.
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.
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 RHIhub's
Rural Health Models & Innovations.
How prevalent is underage drinking and binge drinking in rural communities?
According to SAMHSA's Results from the
2020 National Survey on Drug Use and Health: Detailed Tables, alcohol use in the past month among 12-20
year olds was 18.9% in nonmetro areas, compared to 15.2% 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 11.6% in nonmetro areas compared to
8.6% in large metro areas and heavy alcohol use (binge drinking 5+ times in 30 days) was 2.5% in nonmetro areas
and 1.6% 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).
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 of underage drinking
- 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?
According to the report Traffic
Safety Facts, 2020 Data: Rural/Urban Comparison of Motor Vehicle Traffic Fatalities, there were 11,654
people in the U.S. killed in crashes involving alcohol-impaired drivers in 2020. Rural areas accounted for 43%
(4,990) of these fatalities and 30% of all rural traffic fatalities were alcohol-related.
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
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 misuse, and what effect has it had in rural communities?
Opioid misuse refers to any use of prescription pain relievers, such as oxycodone, hydrocodone, codeine, and
morphine or synthetic pain relievers such as fentanyl, outside their prescribed or intended use, as well as the
use of heroin. According to the 2020
National Survey on Drug Use and Health (NSDUH), 8.9 million adults misused prescription pain relievers
at least once in the previous year, with approximately 1.3 million of those adults in a nonmetropolitan area.
According to the 2020 report listed
above, 3.4% of adults in nonmetro areas and 3.3% of adults in large metro areas reported non-medical use of
prescription opioids in 2020. 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 has led to the increased use of heroin. 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 2019 report from the Centers
for Disease Control and Prevention (CDC), the rate of drug overdose fatalities was slightly higher in urban
areas (22.0 per 100,000) than in rural areas (20.0 per 100,000) in 2017, which is a significant increase from
1999 when the urban rate was 6.4 per 100,000 and the rural rate was 4.0 per 100,000. The CDC's Annual Surveillance
Report of Drug-Related Risks and Outcomes for 2018 shows that opioids were responsible for approximately
66% of drug overdose deaths across the country in 2016, including in rural areas.
Hepatitis C Virus (HCV) and Human Immunodeficiency Virus (HIV)
A May 2015 MMWR article reports an
increase in the number of persons in the U.S. living with 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.
Although not as prevalent in injection drug users as
HCV, HIV infections can potentially increase concurrently 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
equipment used for preparing drugs, 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.
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.
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
According to SAMHSA's Results from the
2020 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, 0.5% for small metro areas, 0.7% for nonmetro areas.
This pattern of higher use in rural areas continues to be a great concern.
According to the Drug Enforcement Administration (DEA) report, 2019
National Drug Threat Assessment Summary, police reports for methamphetamine has risen 87% since 2010
and had gone from 8% of all drug reports in 2009 to 40% in 2017. 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
of information for youth about meth.
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.
According to the 2014 Substance Use & Misuse article, Barriers to Substance Abuse Treatment in Rural
and Urban Communities: Counselor Perspectives, rural areas lack not just basic treatment services but
also 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 use. 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 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.
In some cases, medical professionals need special training to prescribe and monitor medication that is
in treating addiction, such as buprenorphine, which is used to treat opioid use disorder. Qualifying clinicians
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 a DEA
waiver according to Geographic Distribution
of Providers With a DEA Waiver to Prescribe Buprenorphine for the Treatment of Opioid Use Disorder: A 5‐Year
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.
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. For an in-depth look at medication treatment in rural America, see the 2018
Rural Monitor article, What's MAT Got to Do
with It? Medication-Assisted Treatment for Opioid Use Disorder in Rural America.
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 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. RHIhub's 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
Project ECHO® – Extension for Community Healthcare Outcomes connects
rural primary care providers with academic specialists to address patients’ chronic care, including substance
The Vermont Hub-and-Spoke Model of Care for Opioid Use Disorder expands
access to medication-assisted treatment for opioid use disorder to rural areas through urban hubs throughout the
The Indiana's Integrated Care Training Program: Community Health
Worker/Certified Recovery Specialist 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 more substance use treatment and prevention models, see RHIhub's Models and Innovations for Substance Use
For a step-by-step guide to implementing a rural substance use treatment program, see the Rural Prevention and Treatment of Substance Use Disorders Toolkit.