SUBSTANCE ABUSE - TRENDS IN RURAL AREAS
by Linnae Hutchison and Craig Blakely
A goal of Healthy People 2010 is to reduce substance abuse to protect the health, safety, and quality of life for all, especially children.1 According to the Rural Healthy People 2010 survey, substance abuse was selected by 25 percent of the respondents as a rural health priority among the 28 Healthy People 2010 focus areas. In a recent survey of state and local rural health leaders, substance abuse was one of four topics in a virtual tie for sixth place among topics most often selected as a rural health priority. Substance abuse was especially likely to be rated in the top rural health priorities by rural health leaders from the West and Northeast regions of the country.2
For the purposes of this summary, abuse of alcohol, methamphetamines, and inhalants serve as the primary focus. The discussion addresses the following Healthy People 2010 objectives:
· 26-1. Reduction in motor vehicle crash deaths.
· 26-2. Cirrhosis deaths.
· 26-3. Drug-induced deaths.
· 26-7. Alcohol and drug-related violence.
· 26-8. Lost productivity.
· 26-9. Increase age and proportion of drug-free youth.
· 26-10. Reduction in adolescent and adult use of illicit substances.
· 26-11. Binge drinking.
· 26-12. Average annual alcohol consumption.
· 26-15. Reduction of inhalant use among adolescents.
· 26-16. Increase proportions of youth disapproving of substance abuse.
In
urban and rural
Heavy alcohol use (defined in this case as consumption of five or more alcoholic drinks in one day in the last year), nationally, appears to vary little by urbanicity among 18 to 49 year olds.16 However, there is some regional variation in this level of alcohol use, with nonmetropolitan areas of the Northeast and West reporting a higher prevalence than their metropolitan counterparts in these regions.16 Binge drinking rates among nonmetro residents are also reported equal4 to or higher than rates for metropolitan residents.6
On average across all age groups, residents of large metropolitan counties have the highest rate of illicit drug use (7.65 percent), followed by nonmetropolitan (5.8 percent), and completely rural counties (4.8 percent).4 However, the prevalence of illicit drug use among youth reveals an emergent trend¾14.4 percent in rural areas, 10.4 percent in counties with small metropolitan areas, and 10.4 percent in large metropolitan areas.4 More specifically, growing evidence suggests that for certain substances such as alcohol, methamphetamines, and inhalants, usage rates are higher among rural youth than urban youth.5
Approximately 38,900 deaths are related to drug abuse.6 Illicit drug use is also associated with many health-related consequences including hepatitis, tuberculosis, sexually transmitted diseases, various bacterial infections, and HIV infection.7 Some of the adverse effects of inhalant use include depression, kidney or liver damage, and heart failure.8
Alcohol
contributes significantly to mortality in the
Alcohol consumption is associated with a myriad of health consequences from cirrhosis of the liver to diabetes.7 Abuse of alcohol is a particular concern for pregnant women and the developing fetus due to the risk of birth defects.
Alcohol abuse is associated with a number of other health-related issues. For example, a higher prevalence of driving while under the influence of alcohol is found in rural areas compared to urban areas. This may result from greater distances traveled and greater reliance on automobile transportation in rural areas.10 Additionally, alcohol is related to accidents and violence. Thirty-one percent of unintentional injury death victims, 23 percent of suicide victims, and 32 percent of homicide victims were intoxicated at the time of death.11 Finally, the link between psychiatric disorders and alcoholism is well documented, although the direction of causality requires further research.
BARRIERS
While rural and urban areas experience drug-use problems, the consequences may be greater in rural areas because of limited access to substance abuse treatment. For example, only 10.7 percent of hospitals in rural areas offer substance abuse treatment services compared to 26.5 percent of metropolitan hospitals.12
A number of barriers to substance abuse treatment in rural areas have been identified. Among these are the perceived social stigma associated with substance abuse treatment,3 geographical isolation,13 and financial burden as health plans shift greater financial responsibility to the patient leading to a reduction in services used.13 A related challenge is that federal funding goes mostly to urban substance abuse services rather than rural despite the fact that alcohol dependence is higher in rural areas, and drug use is not significantly different for urban and rural settings.14
There are a number of contributors to the growing prevalence of substance abuse in rural areas. Among these are the lack of access to treatment programs in rural areas combined with the reluctance of substance abusers to seek available treatment. Increased substance abuse may also be associated with a reported increase in drug trafficking.10
Other challenges to substance abuse prevention and treatment relate to regulatory and legislative policy. Commercial marketing continues to target the young, contributing to the perception that alcohol and tobacco are culturally acceptable and readily available. The perceived ease of access to alcohol and other abused substances by rural and urban youth may be one indicator of the gap between regulation and enforcement.
There are feasible solutions to substance abuse in rural areas. Since access to treatment services is a fundamental hurdle to addressing substance abuse in rural areas, increasing the participation of the rural primary care provider in substance abuse treatment may be particularly important in rural areas. In the absence of traditional treatment in rural areas, alternative methods of providing education and counseling are relevant, such as those offered through Alcoholics Anonymous meetings, schools, churches, and community-sponsored awareness campaigns.13
Feasible community-level interventions for reducing substance abuse among youth include supporting formalized activities for youth, integrating drug abuse prevention and education into existing school-based health programs, investing in peer-focused prevention programs, and programs designed to improve self-esteem. The effectiveness of drug prevention programs does not appear to differ between rural and urban areas. In general, programs that focus on peers are more effective than knowledge-based programs.
Prevention, education, enforcement of drug laws, and access to care are key to combating substance abuse in rural areas. Rural youths are particularly at risk for developing substance abuse disorders. Needed prevention programs and treatment initiatives tend to be in shorter supply in rural areas than in urban settings. Increased school-based educational efforts (beginning in elementary school) and active involvement of parents, peers, and the community are measures available to rural areas to combat substance abuse.
To address access issues, primary care providers may play a vital link by educating their office staff on identifying substance abuse in the primary care setting and providing brief counseling. Too frequently, providers only intervene when patients present with clinical conditions attributable to substance abuse. Ultimately, the ability to quell the growing problem of substance abuse in rural areas hinges on a clear understanding of the behavioral and social conditions associated with substance abuse and a recognition of the unique barriers to prevention and treatment.
The following models for practice are examples of programs utilized to address this rural health issue.
1.
2. Gamm, L.; Hutchison, L.; Bellamy, G.; et al. Rural healthy people 2010: Identifying rural health priorities and models for practice. Journal of Rural Health 18(1):9-14, 2002.
3. Boyd, M.R. Substance abuse in rural women. Nursing Connections 11(2):33-45, 1998.
4.
Substance Abuse and Mental Health Services Administration (SAMHSA). 2001
National Household Survey on Drug Abuse (NHSDA).
5. Cronk, C.E., and Sarvela, P.D. Alcohol, tobacco, and other drug use among rural/small town and urban youth: A secondary analysis of the monitoring the future data set. American Journal of Public Health 87(5):760-764, 1997.
6. Substance Abuse and Mental Health Services Administration. National Estimates of Substance Abuse. 1999. <http://www.Samhsa.gov/oas/nhsda/1999/Chapter2.htm>September 24, 2001.
7. Sloboda, Z., et.al. Rural substance abuse: State of knowledge and issues. NIDA Research Monograph Series 168, 1997.
8.
Bailey, W.J. FactLine on inhalants.
9. Donnermeyer, J.F. The economic and social costs of drug abuse among the rural population. NIDA Research Monograph Series 168:220-245, 1997.
10.
Federal Bureau of Investigation. Uniform Crime Report, 1998. Crime in the
United States.
11. Smith, G.S.; Branan, C.C.; and Miller, T.R. Fatal non-traffic injuries involving alcohol: A meta-analysis. Annals of Emergency Medicine 33(6):659-668, 1995.
12.
Dempsey, P.; Bird, D.C.; and Hartley, D. Rural mental health and substance
abuse. In: Ricketts, T.C., ed. Rural Health in the
13. Fortney, J., and Booth, B.M. Access to substance abuse services in rural areas. Recent Developments in Alcoholism 15:177-197, 2001.
14.
Burnam, M.A.; Reuter, P.;
15.
<http://www.healthypeople.gov/LHI/>2002.
16.
Eberhardt, M.; Ingram, D.; Makuk, D.; et al. Urban and rural health chartbook.
17.
McGinnis, J.M., and Foege, W.H. Actual causes of death in the
18.
Hutchison, L., and Blakely C. (2003). Substance Abuse¾Trends in
Rural Areas. Rural Healthy People 2010: A companion document to Healthy People
2010. Volume 1.
MODELS FOR PRACTICE
FOCUS AREA: SUBSTANCE ABUSE
Location:
Problem Addressed: Substance Abuse and Mental Health
Healthy People 2010 Objective: 18
Web Address: http://www.searhc.org
The
Community Family Services Program is a non-profit health consortium of several
Native groups to pool resources for health care. The program delivers mental
health and substance abuse services on site at several remote villages in
southeast
THE MODEL
Blueprint: The Community Family Services Program is part of SEARHC
(Southeast Alaska Regional Health Consortium), the third largest Native health
organization in
The program is staffed by 18 paid employees including nine village providers, four licensed mental health clinicians, one clinical director, two administrative personnel, one health systems technician, and one health systems specialist. The village providers are cross-trained to work with both mental health issues and substance abuse disorders. Professional staff supervise the village providers by visiting each community every six to eight weeks and by providing day-to-day support via telephone.
The program’s clientele is mostly Native Alaskan with substance abuse disorders. Specifically, the program provides outreach, prevention, assessment services, early intervention, education, emergency and crisis intervention, outpatient counseling, aftercare/continuing care, relapse prevention, community development, and telepsychiatry/telehealth for individuals with substance use disorders, mental illness, or co-occurring disorders.
The services are delivered in a variety of ways. Village-based counselors and itinerant clinicians offer services to individuals, couples, families, and groups. The services are offered primarily in counseling offices but can be offered in homes, schools, and medical offices. These services employ various technologies including telephones, fax, e-mail, computers, polycom units, and palm pilots.
SEARHC
developed its own program to combat substance abuse and suicide. The program
assesses individual needs and tailors treatment to the individual. All
counselors are cross-trained in the treatment of substance use disorders and
mental health disorders, such as motivational interviewing and culturally
relevant interventions such as the
Making a Difference: Since the program began, information has been gathered and assessed based on the number of people served. Factors considered in the follow-up include client satisfaction, improvement in productive activity for clients, decrease in the use of alcohol, and increase in support from others. The program expanded its focus to include more prevention and early intervention and training concerning these issues. Initially, this may be more difficult to evaluate, but it is thought that in the long run, longitudinal studies will prove the efficacy of this direction. Additionally, prevention and early intervention are more cost-effective than treatment.
In 2000, 71 percent of the clients were treated for substance use disorders, 20 percent for mental health disorders, and 9 percent for co-occurring disorders. In 2001, 51 percent of the clients were treated for substance use disorders, 16 percent for mental health disorders, and 33 percent for co-occurring disorders. In 2001, of the 222 discharged clients, 155 completed their treatment plans compared to 104 of the 144 discharged clients in 2000. The substance abuse program does pre- and post-assessments to determine program effectiveness, as well. In 2000, 65 percent of program clients contacted for follow-up reported they had not relapsed at the six-month mark, and 59 percent of the contacted clients had not relapsed at the 12-month mark. In 2000, 90 percent of follow-up contacts rated their relationships as good or above average at the six-month mark and 97 percent as good or above average at the 12-month mark. In 2000, 83 percent of respondents rated family support as above average at the six-month mark and 88 percent as above average at the 12-month mark. In 2001, 81 percent of respondents rated family support as above average at the six-month mark and 81 percent above average at the 12-month mark.
The
program received accreditation for its work, including CARF (Commission on
Accreditation of Rehabilitation Facilities) accreditation for outpatient
services for children and adolescents; and State of
Beginnings: The program began in 1989 in response to the need to address suicide and alcohol problems. Seven years later, in 1996, the program was fully implemented. The program began with the cooperation of the Native villages of Klukwan, Haines, Kake, Angoon, Pelican, Hydaburg, Hoonah, and Yakutat. Since the program began, Hoonah and Yakutat have withdrawn, and a new village, Klawock, joined. These villages range in size from 160 in Klukwan to 1,429 in Haines.
Community Family Services Program
Phone: (907) 966-8776
Fax: (907) 966-2489
E-mail: ivag@searhc.org
MODELS FOR PRACTICE
FOCUS AREA: SUBSTANCE ABUSE
Program Name: Project Forward, a Program of the Center for
Community Outreach,
Location:
Problem Addressed: Substance Abuse
Healthy People 2010 Objective: 26-6, 26-9, 26-10, 26-10b, 26-10c, 26-11, 26-15, 26-16, 26-17, 26-23
Web Address: http://www.marshfieldclinic.org/research/dept/outreach
Project
Forward is a community-based youth development program designed to address
behavioral health issues, particularly alcohol, tobacco, and drug abuse.
Project Forward is active in 24 community partnerships and three ethnic communities
(Ho Chunk Nation, the Lac Courte Oreilles Reservation, and the Hmong
Association of Wood County) in rural and urban
Blueprint: Project Forward is a program of the Center for Community Outreach, Marshfield Clinic. The program serves males and females ages 12-18 and their adult partners and families by providing technical assistance, consultation, education, training, and resources to the community partnerships and ethnic communities. Currently, 1,776 youth are enrolled in the program. Including the youth, parents, community members, and governmental officials, 3,321 members are involved in Project Forward. Surveys are administered upon program initiation to test the hypothesis that youth who are more actively involved in the learning events throughout the year will have scores that document a greater level of knowledge, more positive attitudes, and fewer alcohol, tobacco, and other drug abuse-related behaviors.
The Marshfield Clinic, a 501(c)(3), provides a base budget, facilities, and support services offset by grants and contracts that also help support the project. Staffing includes 12 full-time professional and support staff, in addition to 21 part-time Project Forward coordinators, one full-time National Guard member, and 20 AmeriCorps members. The program is administered at the community level.
The program is multiphasic and delivered through a variety of channels. Prevention specialists attend partner community meetings and organize community teams to address the issue of substance abuse. Project Forward coordinators and AmeriCorps members are also placed in the community to work with youth. Each Project Forward community has a prevention services plan that includes a goals statement, target population, measurable outcome objectives, evaluation component, and budget. Each plan is tailored to the unique characteristics of each community.
A series of learning events are designed to develop the knowledge and skills in adults and young people that are needed to change individual lives and affect community norms. These learning events are hosted by the community partnerships and ethnic communities. Camps, retreats, and single day learning events are provided to serve as educational resources for Project Forward participants.
Making a Difference: Using baseline data collected since 1998, an evaluation strategy utilizes change scores in knowledge, attitude, and behavior as key outcome measures. These measures include age or grade of onset, perception of risk and social disapproval, and recent use. Additionally, the program measures community-based citizen participation, improved partnership capabilities, and level of community participation in prevention planning.
Since the program’s inception, it has continued to expand to include new community partners. Currently, there is a waiting list of communities interested in implementing the program. Expansion decisions are based on capacity and funding.
Beginnings: The original stakeholder, the Northwoods Coalition, was founded in 1995 by a grant from the Center for Substance Abuse Prevention. The coalition compared rates of alcohol, drug, and tobacco use in the five counties and three ethnic communities comprising the Northwoods Coalition to state and national data. For grades 8, 10, and 12, the coalition member counties and communities reported higher usage rates than the state and national averages for all substances including alcohol, tobacco, inhalants, and marijuana. With a Drug Free Community Support Program grant from the Office of Juvenile Justice and Delinquency Prevention (OJJDP) and matching funds from the Marshfield Medical Research and Education Foundation, Project Forward was launched in 1998.
Using
funds from the Wisconsin Department of Transportation/Bureau of Transportation
Safety, Wisconsin National Service Board, and the Wisconsin Department of
Health and Family Services (DHFS)
Challenges and Solutions: Distance and weather are the major challenges faced by the program. Therefore, the program relies on video conferencing and teleconferencing as well as traditional face-to-face meetings.
Project Forward is communicated via a variety of avenues locally, regionally, and nationally. Community involvement, newspapers, a website, and word of mouth are powerful publicity measures. The project also includes an active approach to networking across the state. The Center for Community Outreach develops relationships with prevention providers as well as presenting at conferences and workshops.
Ultimately, program developers believe it is the quality of the program that has brought the most attention to the program and gained the most support. A primary goal is to develop a program that is replicable across communities. The program is currently under review as a science-based model program by the Pacific Institute for Research and Evaluation.
Ronda Kopelke, Director, Center for Community Outreach
Project Forward, a Program of the Center for Community Outreach
Phone: (715) 389-3513
Fax: (715) 389-5925
MODELS FOR PRACTICE
FOCUS AREA: SUBSTANCE ABUSE
Program Name: Project Northland
Location:
Problem Addressed: Alcohol Use and Other Substances of Abuse
Healthy People 2010 Objective: 26
Web Address: http://hazelden.org
Project
Northland is a program that effectively addresses the problem of alcohol use by
youth and has also been successful in reducing tobacco and marijuana use. While
the program is now implemented throughout the
Blueprint: Project Northland is a substance abuse program that is initiated in sixth grade and follows students through eighth grade. These grades were selected because these are the grades of first use of substances of abuse. Each curriculum year has a theme and is tailored toward the developmental level of the adolescents. In sixth grade, students learn reasons not to use alcohol. In seventh grade, students learn strategies to deal with peer pressure. Finally, in eighth grade, the focus shifts from individual and peer pressure to community-level changes. A critical element of the program’s success is the use of peer leaders and involvement of parents and the community. Successful replication of the model is achieved through student involvement during sixth through eighth grade, teacher training, and use of peer leaders.
Making a Difference: The original study was designed to follow 2,400 students from sixth through eighth grade to determine the impact of the program, if any, on alcohol-use patterns, as well as tobacco and marijuana use. After three years of study, it was found that students participating in the program were significantly less likely to be users of alcohol, marijuana, and tobacco at the end of eighth grade compared to the control group. At the end of the eighth grade, students participating in the study exhibited a 28 percent reduction in monthly drinking, a 46 percent reduction in weekly drinking, and a 27 percent reduction in alcohol and tobacco use compared to the control group. For those students who were non-users at the initiation of the study (in sixth grade), the results revealed a 37 percent lower rate of cigarette smoking and a 50 percent lower rate of marijuana use at the end of eighth grade compared to the control group.
Beginnings: The project was initially developed by the University of Minnesota School of Public Health under a grant from the National Institute on Alcohol Abuse and Alcoholism. The research-based program was designed to address individual behavioral change and environmental change. The specific goals are to delay the onset of drinking, reduce alcohol use by current users, and limit alcohol-related problems of youth. While the majority of the students were Caucasian (94 percent), American-Indian students comprised 5.5 percent of the study’s participants (seven American-Indian reservations are in the study area). The study was conducted in this six-county, extremely rural area of northeastern Minnesota because it had the highest alcohol-related morbidity and mortality in the state, with one county being number one in the state.
Challenges and Solutions: Project Northland is a research-based program designed to be
replicated in other school districts. Interested schools have turned to State
Incentive Grants (SIG) and
Project Northland has received numerous awards including identification by the Center for Substance Abuse Prevention (CSAP) as a Model Program, recommendation by the U.S. Department of Education, and an “A” rating in Making the Grade: A Guide to School Drug Prevention Programs (published by Drug Strategies). It also was published in the Journal of School Health (1994, 1996), and American Journal of Public Health (1996).
Beginning fall 2002, the program will expand to address substance abuse among high school students.
Kay Provine, Senior Training Specialist
Project Northland, Hazelden Information and Educational Services
15251
Pleasant
Phone: (800) 328-9000 ext. 4009