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SAMHSA News - July/August 2007, Volume 15, Number 4

Rural Substance Abuse: Overcoming Barriers to Prevention and Treatment (Part 1)

Think of rural America and tranquil images of farmland punctuated by red barns, black and white cows, and tiny towns may come to mind. But when it comes to substance abuse, the picture isn’t so idyllic.

Is substance abuse really an inner-city problem? That’s the most common stereotype. But rural residents actually abuse some substances at higher rates than their urban counterparts.

According to SAMHSA’s 2005 National Survey on Drug Use and Health, for example, young people in rural areas are more likely than big-city youth to indulge in binge drinking. Methamphetamine and oxycodone abuse is also a big problem.

Yet getting treatment can be hard in rural areas. Treatment facilities are few and far between, the lack of public transportation presents logistical problems, and the stigma attached to substance abuse can prevent many from seeking and accessing services.

A recent publication from SAMHSA’s Center for Substance Abuse Treatment (CSAT) offers solutions for overcoming these barriers to care.

The latest addition to CSAT’s Technical Assistance Publication (TAP) series—The National Rural Alcohol and Drug Abuse Network Awards for Excellence 2004: Submitted and Award-Winning Papers (TAP 28)—showcases several effective models. CSAT funded the awards competition.

“The publication promotes promising practices and innovative approaches addressing the unique and special challenges of providing substance abuse prevention and treatment services in rural and frontier areas,” said Hal Krause, M.P.A., a public health analyst in CSAT’s Division of State and Community Assistance. “These papers represent novel and innovative approaches to meeting rural residents’ needs.”

TAP 28 also presents research on demographic characteristics and treatment outcomes of rural methamphetamine users, faith- and community-based re-entry services, the differences in drug use between rural and very rural areas, and an electronic version of the Addiction Severity Index.

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Facing Barriers

The papers featured in TAP 28 describe the many factors that make providing substance abuse prevention and treatment services in rural areas so difficult.

Poverty. Inner-city residents aren’t the only Americans facing chronic economic deprivation. Over the last two decades, downturns in the farming, manufacturing, and mining industries have devastated many rural communities. Younger, more educated, and better-off residents have fled the countryside to seek opportunities in cities.

What they leave behind are their older, poorer neighbors; jobs with low wages and no health insurance; and concentrated poverty passed on from generation to generation.

Even in areas that haven’t seen sustained declines—such as the agricultural powerhouse of California’s San Joaquin Valley—a crop-damaging freeze or other sudden event can plunge residents into economic crisis. And the stress of not having enough money, the authors emphasize, puts people at increased risk for substance abuse.

Influx of drugs. At the same time, rural residents have faced an influx of drugs. In search of new markets, drug dealers from big cities have started targeting rural areas. Rural residents themselves have gotten into the game. Methamphetamine is easy to manufacture from readily available ingredients, and the isolation of rural areas helps manufacturers hide their labs.

Limited treatment options. “Treatment facilities in rural areas are often very scarce,” said Mr. Krause. In Iowa, according to one paper, the nearest treatment provider may be a hundred miles away. In addition, rural treatment facilities don’t always have the expertise they need. In the San Joaquin Valley, another paper notes, the available treatment programs all focused on alcoholism and had very little experience treating other forms of substance abuse.

Prevention efforts and support programs for those who abuse substances, and for their families, are also scarce. Although programs such as Alcoholics Anonymous may exist in rural areas, meetings may take place only once a week.

Logistical difficulties. Even when treatment is available, rural residents may not be able to get there. With the vast distances involved and the lack of public transportation, residents typically need private vehicles to get to treatment. Yet many of those most in need of help have lost their driver’s licenses, do not have reliable vehicles, or can’t afford gas or insurance. A lack of available, affordable child care adds to the logistical difficulties.

Stigma. The cultural and social norms prevalent in rural areas can make it even harder for people with substance abuse problems to seek help. As one paper notes, rural culture tends to emphasize individualism and self-sufficiency, religion, conservative beliefs, rigid norms, strong family ties, and distrust of outsiders.

In addition to community disapproval, rural residents who seek treatment for substance abuse face a lack of anonymity. “Rural communities are often very small and tight-knit,” explained Mr. Krause. “People who are suffering from a substance abuse problem face the added stigma of basically outing themselves as a substance abuse client if they present themselves at a treatment facility.”

The resulting small town chatter, say the authors, may make people reluctant to seek help until they’re in a crisis.

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Overcoming Physical Barriers

These barriers are not insurmountable. The top three papers detail effective programs, ranging from a prevention initiative for mothers in Vermont to an early intervention effort in Iowa and a drug court in rural California. Each of these award-winning papers provides solutions to specific problems.

“Empower for Recovery: An Innovative Approach to Assist Sustained Recovery in Rural Iowa,” for example, provides a model for overcoming transportation barriers. Instead of making people with substance abuse problems come to services, the services go to them.

“One of the biggest barriers to providing substance abuse services in rural areas is the lack of transportation,” said Deborah K. Rohlfs, M.A., L.M.H.C., C.A.D.C., the Hamilton County coordinator and prevention supervisor at Community and Family Resources, a state-funded treatment agency in Webster City, IA. “These people are fighting an addiction. They don’t have a driver’s license. And they don’t have any money.”

To get past those hurdles, the Empower for Recovery program provided early intervention services to substance abusers and their families in their own homes. Depending on clients’ needs, a visit might have focused on getting someone into treatment or getting them followup and support after treatment.

Ms. Rohlfs acted as a case manager, working with other service providers to ensure that families’ food, housing, mental health, and other needs were being met.

The ultimate aim of the program, which has since ceased operation, was to ensure a safe, stable home for young children.

To fulfill that goal, the program focused on the entire family rather than just the person with a substance abuse problem. “Addiction isn’t just about the user,” Ms. Rohlfs explained. “By being in people’s homes and seeing the interaction that goes on in a real setting rather than an office, we were able to deal with a lot of the families’ anger, frustration, and other feelings they had regarding the addiction.”

The program appeared to work, said Ms. Rohlfs. Of 15 families who had completed the program by the time the paper was written, 8 of the substance abusers were still sober a year after discharge. One had maintained 6 months of sobriety. Four families had left the substance abuser, resulting in safer situations for the children. And two substance abusers had relapsed but gotten back into treatment sooner than in previous instances.

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