Counselor Magazine - Drug Abuse in Rural America: A Growing Problem

Newsflash

The Association for Medical Education and Research in Substance Abuse will hold its 32nd Annual AMERSA National Conference on November 6-8, 2008, in Washington DC.

The meeting will reflect on AMERSA's interdisciplinary strengths and the commitment to disseminate the latest developments in substance abuse education, prevention, treatment and research that challenge all health care professionals.

Confirmed plenary sessions include:

Carlo DiClemente, PhD and Thaddeus Herzog, PhD in a Spicy Debate - Contemplating Change: The Pros and Cons of the Transtheoretical Model for Understanding Changes in Substance Use

John Rodolico, PhD, Terence Keane, PhD and Susan Storti, PhD, RN in a Plenary Panel Session on Combat Stress and Substance Abuse in the Wake of War

Randolph D. Muck, MEd, Center for Substance Abuse Treatment, speaking on Adolescent/Emerging Adults

John Cunningham, PhD, Senior Scientist Centre for Addiction and Mental Health, speaking on the Internet and New Media as Tools to Recovery

Jerome Jaffe, MD, University of Maryland School of Medicine, will be the recipient of the distinguished John P. McGovern Award

Stephanie O'Malley, PhD, Director, Division of Substance Abuse Research, CMHC, will receive the prestigious Betty Ford Award honoring her valuable contributions to the substance abuse field.

Call for Abstracts now open. Submit abstracts and workshops online by May 15.

For further information, visit www.amersa.org or contact This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

Polls

Can Recovering Drug Addicts Drink?

	Yes
	No
	I don't know

20% + off all books

Drug Abuse in Rural America: A Growing Problem

Feature Articles - Cultural

Saturday, 30 November 2002

Although the percentage of the U.S. population living in mostly rural areas has declined approximately 10 percent over the past 50 years, information from our national data systems have indicated growing rates of use of illicit drugs in rural areas, particularly among the young (http://www.censusgob/population/census data/table-4.pdf). Concern about this problem prompted three major efforts to review what is known about the problem in rural areas and to identify areas requiring both short- and long-term responses.

In 1994, staff from three federal agencies - the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, and the U.S. Department of Agriculture's Agricultural Research Service - held a conference to discuss the problem and to identify gaps requiring further investigation. Papers summarizing available information were presented on: (1) the social context of substance abuse, (2) health consequences of substance abuse, (3) interventions and social services and (4) drug abuse among rural ethnic and migrant populations. The National Institute on Drug Abuse published the presentations and the groups' recommendations for future research (Robertson et al., 1997).

Thirteen research areas were mentioned in the monograph covering issues from epidemiologic and etiologic studies to health, social, and economic consequences of use and the accessibility and availability of both prevention and treatment services (see Table 1). In 1996, a similar symposium was held at the University of Kentucky. The focus of this conference was on substance use-related issues that bridge the rural-urban continuum (Leukefeld, 1999). In this symposium, defining the terms, rural and urban, were important, as use of varying definitions have been found to lead to misunderstanding or masking significant differentiating factors. As in the 1994 conference, several recommendations were made with a greater emphasis on the consequences of substance use.

Subsequent to these meetings, the National Center on Addiction and Substance Abuse at Columbia University (CASA) compiled a comprehensive report (2000) that more closely examined the drug situation in rural America, analyzing data from a variety of sources, No Place to Hide: Substance Abuse in Mid-Size Cities and Rural America (2000).

Dispelling the myth
Although those involved in these three efforts point to gaps in our knowledge base, they accumulated a great deal of information on the subjects of substance use in rural settings and among rural populations that serve to guide both policy makers and program planners. The most significant contributions these scientists made were to dispel myths held by most professionals in the field about attitudes and behaviors in rural settings. The advent of the car, major highways, radio, television and now the Internet has reduced some of the cultural differences between urban and rural communities. Similar fashion, music, food products, books, magazines, movies found in urban settings can be found in rural communities. Rural communities are not as isolated today as they were even 50 years ago. More importantly are economic issues that drive the mobility of populations; who comes into a rural area, who remains, and who moves out. Changing job opportunities and transportation impact the characteristics of the population, their service needs, and the availability of services.

Illicit drug use in rural areas
The best estimates regarding the prevalence of illicit drug use for the general population of the U. S. come from two major sources. The first is the National Household Survey on Drug Abuse (NHSDA) that had been sponsored by the NIDA from 1975 through 1992, and subsequently by the Substance Abuse and Mental Health Services Administration (SAMHSA). The second is the Monitoring the Future Study (MTF) conducted annually in our nations' schools since 1975 by the University of Michigan through a grant from NIDA. The NHSDA selects persons aged 12 and older from a representative sample of households across the country. MTF conducts surveys with 8th, 10th and 12th graders attending a representative sample of both public and private high schools across the country. Reports from these two surveys have included comparisons of illicit drug use by areas represented by population density based on the "Rural-Urban Continuum Codes" developed by the U.S. Department of Agriculture (SAMHSA, 1996; NIDA, 1998).

The CASA report had access to unreleased data from the 1997 NHSDA and the 1999 MTF to allow special analyses of rural drug use for adults and adolescents. For those 18 and older, no differences were found between large cities, mid-size cities, and rural areas for illicit drugs and alcohol use. Tobacco was more likely used in mid-sized cities and rural areas than in the large cities. The analyses of the MTF data showed that 8th graders living in rural areas had significantly higher annual rates of illicit drug use than those living in urban areas.

The drug category for which they were most at risk was amphetamines, including methamphetamines (9.3 percent vs. 5.2 percent, respectively). Other drugs for which past year rates of use were higher for rural 8th graders included crack cocaine, cocaine, marijuana and the "gateway" substances - alcohol and tobacco (particularly smokeless tobacco). Past year rates for rural 10th graders also were higher than those for urban 10th graders for all drugs except Ecstasy and marijuana. And, finally, past year rates for rural 12th graders exceeded those of urban seniors for cocaine, crack, amphetamines, inhalants, alcohol, cigarettes, and smokeless tobacco. Information from the 2001 MTF shows similar results for 8th and 10th graders. In all cases drug use has increased with continuous increases noted for seniors and 10th graders in smaller urban and rural areas. In addition, there appear to be increases in use in recent years among 8th graders in smaller urban areas.

Detailed information regarding the characteristics of illicit drug users is available only for respondents to the 1994 National Household Survey. With special funding from the U.S. Department of Agriculture rural areas were over sampled and a special report on the information gathered for this group was prepared (SAMHSA, 1996). The overall rate of past month use of an illicit drug reported by rural respondents in 1994 was lower than for the total surveyed population (4.6 percent compared to 6 percent). Differences in the characteristics of illicit drug users also should be noted (SAMHSA, 1995). Whereas the rates of use tend to be much higher for males than females among all reported users, in rural areas, the rates by sex are comparable. Rates of use vary also by age with more of those aged 18 to 25 from the total group being higher than for the rural population. In addition, in the rural population, rates of use are comparable for white and black populations whereas in the total group, the rates of use are higher for blacks than for either whites or Hispanics.

Special studies of rural subpopulations show the diversity of drug use patterns and rates by various ethnic and cultural groups. In these studies, it has been found that Native Americans, Latino and Hispanic migrant workers as well as rural African-Americans are particularly at risk for health consequences of alcohol and illicit drug use. For instance several studies (Beauvais and Segal, 1992; Beauvais and Trimble, in press; Stubben, 1997) indicate higher drug use rates for Native Americans. They also show that rates vary by environment with on-reservation youth reporting higher rates of use that non-reservation youth. Migrant populations, particularly young men who work away from their families and the children of migrant families are also at risk for increased use of alcohol and illicit drugs. For lone males, these patterns may be mitigated by the presence of significant others including spouses and children (Watson, 1997). Social isolation is the major contributing factor for these population groups.

Drugs of abuse play another important role in mostly rural areas. The Drug Enforcement Administration has shown that drugs such as methamphetamines and methcathinone, whose production require highly volatile and malodorous chemicals, are produced in clandestine laboratories located in very isolated and rural areas. These laboratories pose both environmental and health risks to rural settings. Naturally growing "drugs" such as cannabis also are protected in these less populated areas. Rural populations then serve not only as consumers, but also as traffickers and distributors of these products (O'Dea et al., 1997; CASA, 2000). Proximity to interstate highways allows easy transport of these drugs and with smaller law enforcement resources and regulation; drug production is lucrative (CASA, 2000).

Easy access is only part of the consumption picture. There have been a number of studies to determine those factors, processes, or characteristics that make some people more vulnerable to drug use than others (Hawkins et al., 1992; Weinberg et al., 1998). Several researchers specifically have examined the level of risk across rural-urban areas. Spoth and colleagues (2001) reviewed this sparse literature and concluded that rural children are at increased risk for substance use if their family members had a history of drug use, if there was early initiation of problem behavior, and if there was low school achievement. The positive nature of rural communities is their smallness and closeness. Networks are formed and can be both supportive and intrusive. However, in general, rural populations are dependent on few industries for their income (Conger, 1997). When the factories and mines are closed and farms begin to fail, the whole community is affected. Parents stressed by lack of income may not have patience or the time to effectively parent their children. Other studies point out that the risks associated with the onset of substance use may not vary across the rural-urban continuum (Scaramella and Keyes, 2001). However, as indicated above in discussing increased risks for rural subpopulations (e.g., the migrant populations and changing drug trafficking patterns), some factors within the rural setting make certain groups more vulnerable than others.
What does this information tell us?

First it tells us that drug use rates vary across areas of the country with varying population densities and within these areas, certain population groups are more at risk than others. The epidemiologic information also shows us that for the youngest groups, rates of use are higher among rural students for specific drugs. The highest "stressed" areas, i.e., those areas in which youth drug use is increasing, seem to be both the mid-sized cities and rural areas. It is perhaps these areas that have undergone the most environmental changes over the past several decades.

Availability of prevention and treatment services
Given the similarities between urban and rural areas in drug use patterns and in the consequences associated with use of illicit drugs, how comparable is the availability of prevention and treatment services? It is in this area that we see the most discrepancies. Clearly, a number of constraints and barriers face rural areas: lack of funding to build infrastructures and facilities, less access to professionals who are in short supply across the country, and, for some populations, lack of trust in existing service delivery systems and service approaches continue to create a gap in service availability and utilization between rural, not-so-rural and urban areas (Robertson, 1997).

Although sparse, existing data confirm this discrepancy; this, despite evidence of increasing drug use. The CASA report summarizes a number of studies on manpower needs for mental health services from the 1990s that indicate that rural areas suffer significantly compared to urban areas. Indeed, these findings are not only true for mental health services overall but also for specialized substance abuse services. Recent analyses by SAMSHA show, for instance, that heroin treatment admission rates were highest in and around large urban areas but since 1993, the largest heroin treatment admission rates occurred in non-metropolitan areas and while the proportion of admissions for heroin inhalation increased; the proportion for heroin injection decreased at all urbanization levels except non-metropolitan areas (SAMSHA, 2002). Drug treatment services are less likely to be stand-alones and more likely to be within a mental health or general health facility in rural areas. Failure in service delivery is also limited by accessibility. Unless appropriate facilities and services can be easily reached by public transportation or are within reasonable driving distances, affected individuals and their families will be more resistant to using them. Furthermore, fewer rural families have health insurance than their urban counterparts. The nature of the economy of rural areas, i.e., seasonal work with periods of lay-offs and farming and small businesses, limits the number of families with comprehensive coverage. As a result more families are either dependent on public insurance (Medicaid and Medicare) or self-pay. Reimbursement policies and co-payment requirements all impede service utilization and motivation to comply with treatment regimen.

The availability of prevention programs or services directed to drug abuse is less well documented. Hallfors and colleagues (2000) surveyed a sample of Safe and Drug Free School Coordinators and found that over 80 percent of school districts in the U.S. provide prevention services within schools. Whether these programs have demonstrated long-term effectiveness is open to question. Many of the schools offer prevention programming primarily in elementary grades and it is not clear what percentage of these elementary programs are supported with booster programs in middle and high school when students are most at risk of initiating substance use. Given the multiple problems within rural communities that affect family functioning, several researchers have implemented family education and management counseling interventions in these areas. Several have demonstrated effectiveness with rural populations (Kosterman et al., 1997; Spoth et al., 2002).

Both the drug abuse treatment and prevention research fields have demonstrated a variety of models that have been found to be effective among diverse groups living mostly in urban or suburban areas. These models focus on the individual, peer groups, families and communities. NIDA and SAMHSA have published guides for practitioners and policy makers using available research findings. The NIDA publications include: Preventing Drug Abuse Among Children and Adolescents-A Research-Based Guide (www.nida.nih.gov/Prevention/Prevopen.html), Principles of Drug Addiction Treatment-A Research-Based Guide (www.nida.nih.gov/PODAT/PODATindex.html), and, Principles of HIV Prevention in Drug-Using Populationshttp://www.nida.nih.gov/POHP/Index.html). SAMHSA's guides include evidence- and experience-based strategies: The Treatment Improvement Exchange (http://www.treatment.org/); Changing the Conversation: The National Treatment Plan Initiative to Improve Substance Abuse Treatment (http://www.natxplan.org/) and Effective Substance Abuse and Mental Health Programs (http://modelprograms.samhsa.gov/).

Facing the 21st century
The evidence that drug abuse and its associated health, social, and economic sequelae are a growing problem for rural and non-metropolitan areas is clear. Only integrated, comprehensive services that include law enforcement, directed prevention and treatment programs can have any impact on reducing it (Biglan et al., 1997). The movement to develop community coalitions that form infrastructures to support such an approach is having resurgence. Although the evaluations of the Robert Wood Johnson Foundation- supported Fighting Back coalitions and of the CSAP's community partnerships have been inconsistent, much has been learned about the development of effective community groups (Kaftarian and Yin, 1997; Saxe et al., 1997).

This movement is opportune at this time for rural areas and holds promise for addressing their special needs.
However, as Donnermeyer states in his 1997 article, "Stereotypes about rural areas as crime-free environments, despite evidence to the contrary, persists in the minds of many, and are reinforced by media stories that consistently focus on the worst-case scenarios from inner-city areas. Further contributing to this myopia is the unwillingness of leaders in many rural communities to come to grips with the reality that substance use affects young people and families in their neighborhood ... Obviously, these attitudes make it difficult for the local community to understand the true extent of economic and social costs and to support appropriate strategies to address the problem. As long as information on the economic and social costs of drug use remains vague, researchers will be ineffectual in changing attitudes that, in turn, affect policy on enforcement, prevention, and treatment strategies and resources devoted to rural areas" (1997). Until more policy makers recognize that the problem of drug abuse in rural communities is growing, affecting young children, and that these communities are not adequately prepared to address it, the spiraling sequence of illicit drug use and its devastating consequences will undermine our nation's potential for economic growth.

Table 1

Recommendations from 1994 Technical Review: Rural Substance Abuse: State of Knowledge and Issues*

Both epidemiologic studies of drug and alcohol consumption patterns in rural settings as compared to urban and suburban areas and studies of the social/economic/environmental context associated with these use patterns with special attention to in- and out-migration.
* Descriptive studies of health problems related to substance abuse to include HIV infection and AIDS, other sexually transmitted disease, hepatitis B and C, tuberculosis and other social-legal and economic consequences of drug and alcohol use with a focus on community-family factors.
* Specification of the processes associated with initiating drug and alcohol use and progression to abuse/dependence, including periods of discontinuation with special emphasis given to determining protective factors that prevent or interrupt progression.
* Examination of differential use and abuse patterns across cultural, ethnic, gender, generational and occupational subgroups.
* Development and testing of innovative, single-channel and multistrategy, comprehensive prevention and treatment models that are community-based.
* Evaluation of existing prevention and treatment services being delivered to rural populations particularly those in economically depressed communities and in mobile communities.
* Assessments of community, state, regional or national level laws or regulations on patterns of use of drugs and alcohol.
* Development and assessment of outreach strategies that expand prevention or treatment services to underserved populations.
* Research methods for the diffusion of innovative clinical practices and management techniques to improve prevention/treatment services and their delivery.
* Research on consumer choice, prevention/treatment program selection and service retention.
* Research to integrate drug and alcohol abuse prevention with interventions targeting other related behavioral and societal problems (e.g., violence, teen pregnancy, school dropouts, domestic abuse, and sexually transmitted diseases.
* Prevention intervention research focused on preschool and elementary students with possible drug- and alcohol-induced learning disorders.
Source: Sloboda, Z., Rosenquist, R. & Howard, J. 1997.

Zili Sloboda, ScD, is a Senior Research Associate at the Institute for Health and Social Policy, The University of Akron, Akron, Ohio. Trained as a medical sociologist and epidemiologist, Dr. Sloboda has focused on the issue of drug abuse both domestically as well as internationally. References
Beauvais, F. & Segal, B. (1992). Drug Use Patterns among American Indian & Alaskan Native Youth: Special Rural Populations. Drugs and Society 7 (1-2):77-94.
Beauvais, F. & Trimble, J. E. (In press). The effectiveness of alcohol and drug abuse prevention among American Indian youth. In: Sloboda, Z. & Bukoski, W.J. Handbook for Drug Abuse Prevention: Theory, Science and Practice. New York, Kluwer Publication.
Biglan, A., Duncan, T., Irvine, A.B., Ary, D., Smolkowski, K. & James, L. (1997). A drug abuse prevention strategy for rural America. In: Robertson, E.B., Sloboda, Z., Boyd, G.M., Beatty, L. & Kozel, N.J. Rural Substance Abuse: State of Knowledge and Issues. NIH Publication No. 97-4177.
Conger, R.D. (1997). The special nature of rural America. In: Robertson, E.B., Sloboda, Z., Boyd, G.M., Beatty, L. & Kozel, N.J. Rural Substance Abuse: State of Knowledge and Issues. NIH Publication No. 97-4177.
Donnermeyer, J.F. (1997). The economic and social costs of drug abuse among the rural population. In: Robertson, E.B., Sloboda, Z., Boyd, G.M., Beatty, L. & Kozel, N.J. Rural Substance Abuse: State of Knowledge and Issues. NIH Publication No. 97-4177.
Hallfors, D., Sporer, A., Pankratz, M. & Godette, D. (2000). Drug Free Schools Survey - Report of Results. School of Public Health, University of North Carolina, Chapel Hill, N.C.
Hawkins, J.D., Catalano, R.F. & Miller, J.Y. (1992). Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: implications for substance abuse prevention. Psychological Bulletin, 112: 64-105.
Kaftarian, S. & Yin, R. (eds.). (1997). Local and national outcomes from community partnerships to prevent substance abuse." Evaluation and Program Planning, Special Section, 20(3): 293-377.
Kosterman, R. Hawkins, J.D., Spoth, R., Haggerty, K.P. & Zhu, K. (1997). Effects of a preventive parent-training intervention on observed family interactions: proximal outcomes from Preparing for the Drug Free Years. Journal of Community Psychology, 25(4): 337-352.
Leukefeld, C.G. (ed.). (1999). Symposium on rural/urban continuum. Substance Use and Misuse, 34(4 & 5).
National Institute on Drug Abuse. (1998). National Survey Results on Drug Use from The Monitoring the Future Study, 1975-1997. Volume I - Secondary School Students. NIH Publication No. 98-4345.
O'Dea, P.J., Murphy, B. & Balzer, C. (1997). Traffic and illegal production of drugs in rural America. In: Robertson, E.B., Sloboda, Z., Boyd, G.M., Beatty, L. & Kozel, N.J. Rural Substance Abuse: State of Knowledge and Issues. NIH Publication No. 97-4177.
Robertson, E.B. (1997). Introduction: interventions and services. In: Robertson, E.B., Sloboda, Z., Boyd, G.M., Beatty, L. & Kozel, N.J. (1997). Rural Substance Abuse: State of Knowledge and Issues. NIH Publication No. 97-4177: 246-249.
Robertson, E.B., Sloboda, Z., Boyd, G.M., Beatty, L. & Kozel, N.J. (1997). Rural Substance Abuse: State of Knowledge and Issues. NIH Publication No. 97-4177.
Saxe, L., Reber, E., Hallfors, D., Kadushin, C., Jones, D., Rindskopf, D., & Beveridge, A. (1997). Think globally, act locally: Assessing the impact of community-based substance abuse prevention. Evaluation and Program Planning, 20(3), 357-366.
Scaramella, L.V. & Keyes, A.W. (2001). The social contextual approach and rural adolescent substance use: implications for prevention in rural settings. Clinical Child and Family Psychology Review, 4(3): 231-251.
Sloboda, Z., Rosenquist, E. & Howard, J. (1997). In: Robertson, E.B., Sloboda, Z., Boyd, G.M., Beatty, L. & Kozel, N.J. Rural Substance Abuse: State of Knowledge and Issues. NIH Publication No. 97-4177: 3-5.
Spoth, R., Goldberg, C. Neppl, T., Trudeau, L. & Ramisetty-Mikler, S. (2001). Rural-urban differences in the distribution of parent-reported risk factors for substance use among young adolescents. Journal of Substance Abuse, 13: 609-623.
Spoth, R.L., Redmond, C., Trudeau, L. & Shin, C. (2002). Longitudinal substance initiation outcomes for a universal preventive intervention combining family and school programs. Psychology of Addictive Behaviors, 16(2): 129-34.
Stubben, J. (1997). Culturally competent substance abuse prevention among rural American Indian communities. In: Robertson, E.B., Sloboda, Z., Boyd, G.M., Beatty, L. & Kozel, N.J. Rural Substance Abuse: State of Knowledge and Issues. NIH Publication No. 97-4177.
Substance Abuse and Mental Health Services Administration. (1995). National Household Survey on Drug Abuse: Population Estimates 1994. DHHS Publication No. (SMA) 95-3063.
Substance Abuse and Mental Health Services Administration. (1996). National Household Survey on Drug Abuse: Rural Population Estimates 1994. DHHS Publication No. (SMA) 96-3079.
Substance Abuse and Mental Health Services Administration. (2002). Heroin Treatment Admissions in Urban and Rural Areas. Drug and Alcohol Services Information System (DASIS) Report (www.samhsa.gov/oas/2k2/HeroinTX/heoinTX.htm).
The National Center on Addiction and Substance Abuse at Columbia University (CASA). (2000). No Place to Hide: Substance Abuse in Mid-Size Cities and Rural America. New York.
Watson, J. M. (1997). Alcohol and drug abuse by migrant farmworkers: past research and future priorities. In: Robertson, E.B., Sloboda, Z., Boyd, G.M., Beatty, L. & Kozel, N.J. Rural Substance Abuse: State of Knowledge and Issues. NIH Publication No. 97-4177.
Weinberg, N.Z., Rahdert, E., Colliver, J.D. & Glantz, M.D. (1998). Adolescent substance abuse: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 37(3): 252-261.

One person has commented on this article.

1. Untitled
jeremy, Unregistered