substance abuse - TRENDS IN RURAL AREAS: A Literature Review

by Linnae Hutchison and Craig Blakely

 

 

SCOPE OF PROBLEM

 

  • Substance abuse is one of the 10 “leading health indicators” selected through a process led by an interagency workgroup with the U.S. Department of Health and Human Services.15
  • Men and women in metropolitan areas of the Northeast and West are less likely to report consumption of five or more drinks in one day in the preceding year than their nonmetropolitan counterparts.16
  • Alcohol has been ranked as the third leading “actual cause of death” in the United States, i.e., contributing to the diagnosed condition associated with a death.17
  • Illicit use of drugs has been ranked as the ninth leading “actual cause of death” in the United States, i.e., contributing to the diagnosed condition associated with a death.17
  • Substance abuse was identified as a major rural health concern among state offices of rural health.18

 

GOALS AND OBJECTIVES

 

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 Addressing the issue of substance abuse treatment and prevention in rural areas begins with understanding the complex etiology underlying substance abuse and utilizing this information to develop effective drug prevention programs. Fundamental to this understanding is identification of the unique barriers and limitations encountered by rural Americans in seeking effective substance abuse prevention programs and treatment.

 

While tremendous strides have been taken to educate Americans, particularly youth, on the devastating effects of substance abuse, emerging patterns suggest the drug prevention message is failing to reach one sector seemingly immune to substance abuse¾rural America. New evidence indicates not only a convergence of rural and urban usage rates but also, for certain substances, higher usage rates in rural areas compared to urban areas.

 

For the purposes of this review, abuse of alcohol, methamphetamines, and inhalants serve as the primary focus[i]. Tobacco use is addressed in depth in the section on tobacco use. This 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.
  • 26-17. Perceiving risk associated with substance abuse.

 

Understanding the problem begins with defining substance abuse and identifying the major substances of abuse.

 

·        Substance abuse is a “maladaptive pattern of substance use”19 that contributes to a myriad of health problems and, for certain individuals, leads to increased incidence of violence and accidents.

·        Current use is defined as one incidence of substance use in the last 30 days. For instance, consumption of one alcoholic drink in the past 30 days is considered current use.

·        Licit drugs are a category of substances including alcohol, tobacco, and inhalants.

·        Illicit drugs are a category of substances including methamphetamines, marijuana, and cocaine.

 

Compounded by access barriers, including shortages of substance abuse treatment service centers and providers, substance abuse in rural areas is an increasingly important rural public health concern.

 

identified by people living in rural areas as a high priority health issue for them

 

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. Substance abuse, ranked sixth, was virtually tied with education and community-based programs and with maternal, infant, and child health¾the seventh, eighth, and ninth place rankings among the priority nominations.2 There were no significant differences across four groups of state and local rural health respondents. However, there were differences across geographic regions. Respondents from the Northeast and West were significantly more likely than those from the Midwest or South to nominate substance abuse as one of their five rural health priorities.

 

Prevalence and disparities in rural areas

 

In urban and rural America, alcohol and tobacco are by far the most frequently abused substances. In a 2001 national survey, 48.3 percent of respondents ages 12 and older reported current alcohol use, up from 46.6 percent in 2000.4, 20 Tobacco use, nonetheless, is clearly the drug that claims the most lives (430,000 per year).1 Approximately 24 percent of adults and 15 percent of adolescents between the ages of 12 and 17 report current cigarette use.16

 

The abuse of alcohol spans across geographic, demographic, social, and economic boundaries. Nationally, an estimated 15.1 million people abuse alcohol,3 with rates of binge drinking among adults remaining relatively constant since 1988. The highest prevalence of binge drinking is reported in the 18 to 25 year old group at 32 percent.1 Among 12 to 20 year olds, alcohol is the drug of choice, with 28.5 percent of this age group reporting having used alcohol in the last month.4 Usage rates and associated health conditions also vary by gender. Men have higher rates of alcohol use than women; however, women experience a faster progression of alcoholism with less consumption.21

 

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

 

Drug abuse, though considerably less prevalent than tobacco and alcohol abuse, affects 7.1 percent of the population, or 15.9 million users.4 Illicit drug use by adults has remained relatively steady at 6 percent since 1980, with men experiencing a higher rate of substance abuse (7.7 percent) than women (5 percent).20 Youths exhibit a higher incidence of drug use than adults. Among 12-17 year olds, approximately 10.8 percent reported using an illicit drug in 2000.4

 

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 pattern¾14.4 percent in rural areas, 10.4 percent in counties with small metropolitan areas, and 10.4 percent in large metropolitan areas.4

 

While substance abuse was once considered a problem confined to urban areas, growing evidence suggests not only a convergence in substance abuse patterns9, 22 between metropolitan and non-metropolitan areas but for certain substances such as alcohol, methamphetamines, and inhalants, usage rates by youths are actually higher in rural than in urban areas. This upward trend is disturbing in light of the fact urban usage rates are simultaneously declining, prompting questions regarding availability of drugs, effectiveness or lack of prevention programs, or change in social factors facilitating the increase in rural areas.5

 

Cocaine and marijuana use among youth are higher in urban areas, whereas methamphetamine use is higher in rural areas.20 The annual prevalence of methamphetamine use among rural eighth graders is 3.5 percent versus 2.2 percent in urban areas. In 1999, 6.4 percent of non-metro 12th graders used methamphetamines versus 4.2 percent of metropolitan 12th graders.23

 

The disparity in urban and rural substance abuse patterns is most striking in the use of inhalants among youth. In one study, 6 percent of intercity children (age 8-12) used inhalants compared to 16 percent of rural children.24 In this age group, inhalants were the drug of choice for rural children (under age 12) compared to urban children for whom the drug of choice was alcohol. For ages 12 to 17, one study estimated 8.9 percent, or 2.1 million, youth used inhalants¾a percentage significantly higher for rural youth than for urban youth. Common inhalants include the following readily available products: glues, solvents, butane, gasoline, and aerosols.25 Most of these products are not only ubiquitous in many homes but relatively inexpensive and easily accessible, making these products highly attractive to youth.

 

Rural areas, like urban areas, are not uniform in their demographic and economic profiles. Similarly, substance abuse patterns vary among rural communities based on the communities’ unique attributes. According to the Monitoring the Future Study, prevalence rates for substance abuse, in aggregate, among adolescents are lower for youth residing in open country and on farms than for youths in small towns.9 Overall youth drug involvement is highest in the non-metropolitan South, followed by Midwestern metro 12th graders.26

 

One measure of drug use prevalence is treatment admission data. Treatment admissions for alcohol use are substantially higher in rural areas, particularly in those areas with a central city of 10,000, while admission rates for opiates and cocaine tend to be higher in urban areas than in rural areas.16 The significantly lower number of hospital admissions for alcohol use in entirely rural areas may indicate a lack of access to services locally rather than significantly lower rates of admissions.

 

Native-American Indians (particularly teens) exhibit the highest levels of illicit drug use27 compared to youth studies nationwide. While the majority of Native-American Indians live in rural areas, there are a number of cultural risk factors exclusive of rurality that influence substance abuse rates in this population.

 

Impact of the condition on mortality

 

Annually, over 100,000 deaths are related to alcohol consumption (5 percent of all deaths), making alcohol consumption the fourth leading cause of death in the United States.9 This mortality rate translates to nearly 1.5 billion years of potential lost life before age 65.9 Alcohol-related mortality is further divided into accident and non-accident categories. A significant non-accident-related cause of death is alcohol-related cirrhosis of the liver, which contributed to 11,755 deaths in 1999.28 Alcohol-related accidents comprise the larger proportion of total alcohol-related deaths. In 1994, 44 percent of U.S. traffic fatalities (17,461 lives) were alcohol related, with the highest rates among 21-24 year olds.7 Despite these dismal statistics, the number of alcohol-related traffic fatalities is declining from an all-time high during the 1980s. In addition to traffic fatalities, alcohol is also associated with accidental deaths such drownings wherein 47-65 percent of adult drownings are alcohol related.7

 

Approximately 38,900 deaths are related to drug abuse.6 Determining the number of deaths related to inhalant abuse is difficult due to the lack of a national database to document these deaths.

 

Impact of the condition on morbidity

 

Alcohol consumption is associated with a myriad of health consequences. Chronic health problems include alcoholism; chronic liver disease or cirrhosis; impaired cognitive function; brain damage; acute pancreatitis; heart and skeletal muscle degeneration; reproductive disorders; hypertension; increased risk of certain cancers of the liver, esophagus, nasopharynx, and larynx; fetal alcohol syndrome; immune system depression; nutritional and blood disorders; and acceleration of diabetes.7

 

Abuse of alcohol is a particular concern for pregnant women and the developing fetus. Fetal Alcohol Syndrome (FAS) is a series of birth defects resulting from alcohol use by the mother during pregnancy. In 1999 and 2000, 12.4 percent of pregnant women used alcohol, and 3.9 percent were binge drinkers.20 While this number is significantly lower than for nonpregnant women in 1999 and 2000 (48.7 percent current users and 19.9 percent binge drinkers), the effects on the developing fetus can be devastating.20 The birth defects include growth retardation, central nervous system effects, mental handicaps, facial morphological abnormalities, and hyperactivity. The incidence of FAS is estimated between .5 and 3 per 1,000 live births.7

 

Illicit drug use health-related consequences include hepatitis, tuberculosis, sexually transmitted diseases, various bacterial infections, and HIV infection.7 Adverse effects of inhalant use include depression, nosebleeds, headaches and eye pain, kidney or liver damage, chronic fatigue, heart failure, slurred speech, anemia, loss of muscle control, personality changes, muscle and joint pain, and poor balance and coordination.8

 

Finally, the link between psychiatric disorders and alcoholism cannot be overlooked. In one study of rural women, alcoholism was preceded by a psychiatric co-morbid disorder,3 while for men the reverse was true¾depression followed the development of alcoholism. Diagnosis of co-morbid psychiatric disorders, especially in women, is vitally important in reducing the incidence of substance abuse.

 

contributor to many other health problems

 

Understanding the breadth and depth of the substance abuse problem requires looking beyond prevalence data alone and examining the role of substance abuse as a contributor to other health risks. Alcohol and drug use act as agents in the host-agent-environment risk factor paradigm. The correlation between substance abuse and driving under the influence is an example of this paradigm and a particular concern in rural areas where there is an increased dependence on automobile transportation. In 1985, over 50 percent of all auto accident fatalities were alcohol related. However, this number decreased to 38 percent in 1999.29 Contrary to popular perception and media focus, most alcohol-related auto accidents occur among moderate drinkers and not binge drinkers, reinforcing the need for prevention campaigns to include moderate drinkers in their target audience.

 

Research suggests that due to greater distances traveled and greater access to and reliance on automobile transportation, a higher prevalence of driving while under the influence is found in rural areas compared to urban areas. Driving under the influence arrests are most prevalent in non-metropolitan areas with cities less than 10,000 and in rural areas (818.2 per 100,000 persons and 735.7 per 100,000 persons, respectively).10 Rural youth are particularly at risk. For ages 12-17, the incidence of driving while intoxicated is higher in rural than in urban areas.26 Forty percent of rural 12th graders reported using alcohol while driving compared to 25 percent of their urban counterparts.7

 

As mentioned earlier, alcohol is also 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

 

Other health-related consequences of substance abuse (including alcohol and illicit drugs) such as teen pregnancy, injury, low worker productivity, and homelessness resulted in an annual economic cost of $277 billion in 1995.1 Substance abuse also contributes to higher absenteeism and higher job-related accidents, which is a concern because rural adults are engaged in some of the most dangerous and injury-prone occupations.30

 

BARRIERS

 

While rural and urban areas experience drug use problems, the consequences are not the same due to the limited ability of rural areas to offer effective substance abuse treatment. In rural areas, the hospital, rather than a treatment center, is responsible for delivery of substance abuse treatment. Only 10.7 percent of hospitals in rural areas offer substance abuse treatment services compared to 26.5 percent of metropolitan hospitals.12 Furthermore, only 79.5 percent of rural counties offer mental health services compared to metro area counties wherein 95.7 percent offer these services.12 Adding to the burden is 6.6 percent of rural substance abuse treatment providers hold a specialization in drug and alcohol abuse as opposed to 17.8 percent of providers in urban areas.27

 

The perceived social stigma associated with substance abuse treatment also plays an increased role in rural areas. Rural life inherently does not lend itself to anonymity. Therefore, for certain populations, seeking treatment is difficult due to the stigma associated with substance abuse and desire to remain anonymous. This is a particular concern for rural women not seeking treatment.3

 

Physical distance also plays a role in the pursuit of treatment. According to one study, patients are not willing to travel as far for substance abuse treatment as they are for general medical treatment.13 While this factor impacts treatment-seeking behavior, the National Longitudinal Epidemiologic Survey found no difference in treatment attendance for rural and urban inhabitants.31

 

Financial burden is another factor impacting treatment-seeking behavior. Although managed care has not penetrated the rural market to the extent it has the urban market, health plans are shifting toward cost sharing. This trend effectively shifts greater financial responsibility to the patient, especially for behavioral health services (including substance abuse treatment). It is well documented that an increase in cost sharing on the patient reduces services used.13 Combined with the stigma surrounding the perceived need for treatment, rural residents may be less apt to seek drug abuse treatment services.

 

There is an urban bias built into the federal funding allotment formula for substance abuse services. Urban residents ages 18 to 24 are double weighted, resulting in greater funding directed toward urban substance abuse services; however, alcohol dependence is higher in rural areas, and drug use is not significantly different in urban and rural settings.14 In fact, a study by the Rand Corporation concluded that in order to achieve greater equity between urban and nonurban areas, up to 22 percent of the Substance Abuse Services Block Grant would need to shift between states.14

 

Despite the enormous economic and social costs associated with substance abuse, the majority of entitlement spending is directed toward addressing the consequences of substance abuse rather than treatment and prevention. Nearly 92 percent of entitlement monies are spent on treating health-related consequences, with a meager 8 percent directed toward prevention.32

 

Known causes of the condition or problem so effective interventions or solutions cAN be identified

 

While access to effective treatment for substance abuse is a major barrier to substance abuse treatment, a key issue is also the low propensity for individuals to seek treatment in rural and urban areas.13 Lack of access coupled with a low affinity to seek treatment may contribute to the growing prevalence of substance abuse in rural areas.

 

The role of parents and peer groups cannot be overemphasized in youth substance abuse. It is known that not only does parental approval of alcohol use increase frequency of use,33 but children of alcoholics are four times more likely to develop alcoholism3 than children of non-alcoholics.

 

On the drug supply side, national data collected by the Drug Enforcement Administration (DEA) points to an increase in drug trafficking activities in rural areas.10 In cities less than 10,000, the number of drug violations per capita has increased 10.2 percent from 1990 to 1998.27 One reason for the rise in methamphetamine use in rural areas is increased ease of access and supply due to the fact that the majority of clandestine methamphetamine labs are seized in rural areas.34

 

Other challenges to substance abuse prevention and treatment relate to regulatory and legislative policy. While age 21 is the legal drinking age in all 50 states, controls over sales, marketing, and possession are variable by region.7 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 substances of abuse by youth may be one indicator of the gap between regulation and enforcement. Unlike other disparities between rural and urban areas, the perception of ease of access to alcohol and other substances of abuse is fairly uniform between the two regions. Seventy-eight percent of eighth graders and 96.5 percent of 12th graders in the smallest rural areas said access to alcohol was “easy” or “fairly easy” compared to 81 percent of metro eighth graders and 96.2 percent of 12th graders. Perceived ease of access to inhalants was 67 percent for rural eighth graders and 82.6 percent for 12th graders compared to 68.8 percent and 81.1 percent of metro eighth and 12th graders, respectively.7 These statistics suggest there is little difference in the ease of access perception among rural and urban youth.

 

Efforts to provide more formalized leisure activities may decrease the opportunity for youth to abuse alcohol or other substances. According to one study,35 substance abuse takes place, not surprisingly, in informal locations such as parking lots and friends’ homes. Considering the number one reason cited for drinking is to “have fun” (61 percent), followed by avoidance of peer pressure and pressure to conform (7.1 percent) and to forget problems (4.5 percent),36 the need to provide formalized activities as a method to combat drug abuse cannot be overlooked. Alternative activities should include those that are incompatible with substance abuse.

 

PROPOSED Solutions or interventions that are feasible in rural communities

 

A number of studies have analyzed the effectiveness of drug prevention programs ranging from scare tactics that are punitive in nature to peer-focused prevention programs targeting the small peer group to knowledge-based programs such as Drug Abuse Resistance Education (DARE). Their effectiveness is directly correlated with the link to the underlying etiology of substance abuse. At least three factors impact the likelihood of substance abuse among youth: peer use, parental use, and self-esteem.24

 

According to Nan Tobler’s 1992 meta-analysis of 143 drug prevention programs, there is no difference in effectiveness of programs in rural versus urban areas;36 however, programs that focus on peers are more effective than knowledge-based programs. Peer programs are based on peer cluster theory, which asserts that adolescents of families who advocate and communicate an anti-drug message tend to gravitate toward peers who share similar values. Conversely, adolescents with weak family ties or families who communicate a pro-drug message are more likely to associate with problem youth. In fact, “90 percent of adolescents who use drugs have friends who use the same drugs.”22 Furthermore, the pressure to conform (including the use of drugs) among peer groups is often a greater predictor of drug use than the influence of external pressures such as that of “pushers.” Therefore, anti-drug campaigns should focus on the small peer group rather than solely on external influencers.

 

Finally, Social Inoculation Theory asserts that a child’s decision to use drugs depends on his/her ability to resist situational social pressure.24 Therefore, programs that focus on building self-esteem and teaching social refusal skills are often effective in combating substance abuse.

 

Access to treatment services is a fundamental hurdle to addressing substance abuse in rural areas. One method to decrease access hurdles is to focus on the role of the rural health provider as an active member of the behavioral health continuum of care. As Fortney13 points out, “…rural providers should focus on detection and brief counseling rather than detection and referral.” Traditional avenues of treatment seeking are often unavailable to rural residents. Many rural residents are self-employed and do not have the benefit of employee assistance programs. Therefore, it is necessary to investigate alternative methods to provide education and counseling such as through Alcoholics Anonymous meetings, schools, churches, and community-sponsored awareness campaigns.13

 

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 are feasible community-level interventions for reducing substance abuse among youth. These programs should also involve parents, as research indicates parental perception and attitude toward substance use is correlated with the child’s perception toward substance use¾particularly for alcohol.

 

Combating Fetal Alcohol Syndrome begins with education especially for rural disadvantaged pregnant mothers. In rural Vermont, a study integrated an alcohol assessment tool into Women, Infants, and Children (WIC) program visits. Not only did nurses educate at-risk pregnant mothers on the risk to the fetus, but they also addressed alcohol use after the pregnancy. Rather than focusing solely on the pregnancy, the study focused on the mother and the family on a long-term basis¾beyond the term of the pregnancy.37

 

Another theory associated with substance abuse is the risk factor theory, which asserts a myriad of factors contribute to the decision to abuse drugs and alcohol. These factors include individual, peer, family, school, workplace, media, community, and economic conditions.39 The literature provides evidence of a number of strategies available to providers and treatment centers in addressing risk factors associated with substance abuse. A universal finding seems to suggest that interventions that target a single factor are likely to fail. Most successful treatment and prevention programs tend to operate at several levels, addressing several risk factors simultaneously.

 

Finally, socioeconomic conditions, such as poverty and low educational attainment, are also linked to substance use and abuse. These factors are particularly onerous in rural regions, as these areas tend to experience lower socioeconomic conditions. As Rebhun38 suggests, “it is probable that substance use rates can be affected by programs not directly targeting them: for example, improvements in economic status, educational attainment, and mental health in general could reduce the numbers of people who decide to use substances or who use them excessively.”

 

Community models known to work

 

See the Models for Practice section in Volume 1 for a catalog of models.

 

Summary AND CONCLUSIONS

 

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, therefore requiring an increased focus on preventative programs and initiatives. As with any health-related concern, the tendency has been to respond more aggressively to the often more visible conditions in urban areas, translated through development of policies that have short-changed rural communities to some degree. There is little question that economies of scale dictate that equal resources are not plausible. However, inefficiencies aside, rural needs cannot be ignored. Certainly, 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, providers may play a vital link by educating 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. Providers must also focus attention on the etiologic continuum to significantly impact the real problem. Ultimately, the ability to quell the growing problem of substance abuse in rural areas hinges on a clear understanding of not only the behavioral and social conditions associated with substance abuse but also the unique barriers to prevention and treatment.

 

REFERENCES

 

1. U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. Washington, DC: U.S. Government Printing Office, November 2000.

 

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). Rockville, MD: SAMSHA, Office of Applied Studies, 2002.

 

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. Indiana Prevention Resource Center. 1999. <http://www.drug.indiana.edu>November 13, 2001.

 

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. Washington, DC: U.S. Department of Justice, 1998.

 

11. Smith, G.S.; Branan, C.C.; and Miller, T.R. Fatal non-traffic injuries involving alcohol: A meta-analysis. Annals of Emergency Medicine 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 United States. New York, NY: Oxford University Press, 1999, 159-178.

 

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.; Adams, J.L.; et al. Review and evaluation of the substance abuse and mental health service block grant allotment formula. Santa Monica, CA: Rand Corporation, 1997.

 

15. U.S. Department of Health and Human Human Services. Leading Health Indicators.

<http://www.healthypeople.gov/LHI/>2002.

 

16. Eberhardt, M.; Ingram, D.; Makuk, D.; et al. Urban and rural health chartbook. Health, United States, 2001. Hyattsville, MD: National Center for Health Statistics, 2001.

 

17. McGinnis, J.M., and Foege, W.H. Actual causes of death in the United States. Journal of the American Medical Association 270:2207-2212, 1993.

 

18. National Rural Health Research Center Director’s Meeting. Research Opportunities for Rural Health Research Centers and State Offices of Rural Health. Washington, DC, March 5, 2001.

 

19. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed., DSM-IV. Washington, DC: American Psychiatric Association,1994.

 

20. SAMHSA. Summary of findings from the 2000 national household survey on drug abuse. Rockville, MD: SAMHSA, Office of Applied Studies, 2001.

 

21. Piazza, N.J.; Vrbka, J.L.; and Yeager, R.D. Telescoping of alcoholism in women alcoholics. International Journal of Addiction 24(1):19-28, 1989.

 

22. Oetting, E.R.; Edwards, R.W.; Kelly, K.; et al. Risk and protective factors for drug use among rural American youth. NIDA Research Monograph Series 168:90-130, 1997.

 

23. Johnston, L.D.; O'Malley, P.M.; and Bachman, J.G. Monitoring the future national survey results on drug use, 1975-2000. Volume I: Secondary school students. NIH Pub No. 01-4924. Bethesda, MD: National Institute on Drug Abuse, 2001.

 

24. Finke, L., and Williams, J. Alcohol and drug use of inter-city versus rural school age children. Journal of Drug Education 29(3):279-291, 1999.

 

25. Johnston, L.D.; O'Malley, P.M.; and Bachman, J.G. Monitoring the future national survey results on adolescent drug use, 1975-1999: Overview of key findings, 2000. NIH Pub. No. 01-4923. Bethesda, MD: National Institute on Drug Abuse, 2001.

 

26. Edwards, R. Alcohol, tobacco, and other drug use by youth in rural communities. North Central Regional Educational Laboratory. 1997. <http://www.ncel.org>November 2, 2001.

 

27. National Center on Addiction and Substance Abuse (CASA). CASA whitepaper, 2000. No place to hide: Substance abuse in mid-size cities and rural America. Commissioned by the United States Conference of Mayors. Funded by the Drug Enforcement Administration with support from the National Institute on Drug Abuse, 2000.

 

28. Centers for Disease Control and Prevention (CDC). Deaths: Preliminary data 2000. PHS 2001-1120. National Vital Statistics Reports 49(12), 2000.

 

29. U.S. Department of Transportation. National Transportation Statistics, BTS01-01. Washington, DC: U.S. Government Printing Office, <http://www.bts.gov>November 2000.

 

30. Robertson, E., and Donnermeyer, J.F. Patterns of drug use among non-metropolitan and rural adults. Substance Abuse and Misuse 33(10):2109-2129, 1998.

 

31. Booth, B.M.; Kirchner, J.; Fortney, J.; et al. Rural at-risk drinkers: Correlates and one-year use of alcoholism treatment services. Journal of Studies on Alcohol 61(2):267-277, 2000.

 

32. CASA. Substance abuse and federal entitlement programs. New York, NY: The National Center on Addiction and Substance Abuse at Columbia University, 1995.

 

33. Botvin, G.J.; Malgady, R.G.; Griffin, K.W.; et al. Alcohol and marijuana use among rural youth: Interaction of social and intrapersonal influences. Addictive Behaviors 23(3):379-387, 1998.

 

34. O'Dea, P.J.; Murphy, B.; and Balzer, C. Traffic and illegal production of drugs in rural America. NIDA Research Monograph Series 168:79-89, 1997.

 

35. Sussman, S.; Stacy, A.W.; Ames, S.L.; et al. Self-reported high-risk locations of adolescent drug use. Addictive Behaviors 23(3):405-411, 1998.

 

36. Tobler, N.S. Drug prevention programs can work: Research findings. Journal of Addictive Diseases 11(3):1-28, 1992.

 

37. Ettlinger, T. In harm's way: Recognizing and addressing alcohol risk for rural disadvantaged pregnant mothers. Public Health Nursing 17(3):207-210, 2000.

 

38. Rebhun, L., and Hansen, H. Substance Abuse. In: Loue and Quill., eds. Handbook of Rural Health. New York, NY: Kluwek Academic/Plenum Publishers, 2001, 257-276.

 

39. Scutchfield, F.D., and Keck, C.W. A public health approach to alcohol and other drug problems: Theory and practice. Principles of Public Health Practice. Albany, NY: Delmar Publishers, 1997, 243-260.

 

40. Whitehead, R.; Chillag, S.; and Elliott, D. Anabolic steroid use among adolescents in a rural state. Journal of Family Practice 35(4):401-405, 1992.

 

Chapter Suggested Citation

 

Hutchison, L., and Blakely, C. (2003). Substance Abuse—Trends in Rural Areas: A Literature Review. Rural Healthy People 2010: A companion document to Healthy People 2010. Volume 2. College Station, TX: The Texas A&M University System Health Science Center, School of Rural Public Health, Southwest Rural Health Research Center.

 


Endnotes

 

i Steroid use is mentioned as a Healthy People 2010 objective. According to Monitoring the Future Data, steroid use does not appear to vary significantly by urbanicity24, 40 although it should be noted that the highest incidence of steroid use is among 10th graders in non-metropolitan statistical area (MSA) areas at 1.3 percent versus 1.1 percent in large MSAs for the same age group.