For decades, cities have been cast as the center of substance abuse and addiction. But as research shows, this view is an increasingly outdated one, with stereotypes and resources struggling to keep up.

Rural and Urban

To start, it’s worth pointing out what the rural and urban demographic groups have in common when it comes to addiction. As laid out in a 2012 report by the Substance Abuse and Mental Health Services Administration (SAMHSA), parallels can be found in the gender makeup of those admitted for treatment in urban and rural settings. In both cases, findings showed men overwhelmingly outnumbered women, with the former representing 70 percent of admissions in cities and 68 percent in the country.1

Another similarity the two regions shared according to the report is the educational levels of the two groups. In both cities and the country, roughly a third of those admitted for treatment had not completed high school, while a little less than half had their diplomas. Similarly, slightly more than 21 percent had completed some college.2

Next on the list of things the two groups share is co-occurring psychiatric conditions. According to the SAMHSA report, 30 percent of rural admissions and 27 percent of urban admissions reported a mental health issue along with their addiction. As the National Alliance on Mental Illness points out, this category, also known as dual diagnosis, is a broad one, covering a person with mild depression brought on by binge drinking to an individual with bipolar disorder who frequently finds him or herself turning to harder substances as a coping mechanism.3

Rural vs. Urban

Even longer than the list of what the two groups share is what separates the experience of the two, starting with the primary substance of abuse among urban and rural admissions. While cocaine and heroin rule in cities, alcohol, non-heroin opiates and marijuana lead in rural America.430 Percent of Rural admissions are co-occuring while 27% of urban admissions areThe exception to all this is methamphetamine. When it comes to this mind-altering substance, use of the drug is most clearly divided by region. The numbers are stark. In 2014, populous states such as California and Texas reported just 47 and 13 meth lab incidents (lab, dumpsite and chemical and glassware seizures) respectively. That same year, Indiana, a state of 6.6 million residents, reported 1,471 such incidents. And while Indiana is an outlier in the region, other states like Missouri (1,034), Ohio (939), Tennessee (961) and Illinois (729) are not too far behind.5 Despite all of these states having significant rural populations, the SAMHSA study reports an almost dead-even 6.1 and 6.3 percent admittance rate for meth in urban and rural areas.6 Meth, it seems, it is the great equalizer, with all other substances generally favoring either the city or the country.

Age is another variable that’s impossible to overlook when examining the experience of the rural and urban addict. Nearly half of those living in an urban area who were admitted to a treatment center in 2009 first began abusing when they were 18 or older. Move to the country, and that number drops to a third.

Finally, there is the issue of seeking treatment. Less than a fourth of those living in rural areas sought treatment independent of a healthcare provider. Half were referred by the criminal justice system. In cities, it’s a different story. In 2009, just under 40 percent of those surveyed referred themselves, and 28 percent were sent by the court.

Left Out in the Cold

K. was living in a Wyoming town of just 13,000 when she decided she needed help.

“I walked out of the bathroom after taking a hit of heroin and saw my seven-year-old daughter making a bottle for by baby. I just thought, ‘What am I doing?'” she told Foundations Recovery Network in this exclusive interview.

Determined to make a change, K. picked up the phone and started calling every treatment center in an 80-mile radius from where she lived. “I probably called 20 different places,” she said. Each time, the story was the same. There was simply no room for someone seeking treatment independent of a court order. “The waiting lists were months long.” K. didn’t have months. She needed help—ASAP.

Compounding the problem was the fact that K., at 33 years old, was both broke and uninsured. “I talked to one place that suggested I borrow money from my parents. But they were already putting me and my kids up, and I didn’t want to burden them anymore.” Besides, she figured if they were going to offer financial help, they would have done so already.

Desperate, K. decided to trade her clean criminal record in for help from law enforcement. She turned her drug paraphernalia in, and they arrested her. For two months, she remained in jail, where she finally received treatment.

According to the 2014 paper “Barriers to Substance Abuse Treatment in Rural and Urban Communities: A Counselor Perspective,” K. isn’t alone in her struggle. The study includes data from 28 substance abuse counselors in four focus group sessions conducted in 2008—two with counselors working in urban Kentucky and two working in a rural portion of the state.7

Here again, the comparisons resulted in similarities and divisions that were equally stark. Unanimous among the two groups was a suffocating amount of paperwork, lack of interagency cooperation and a dearth of adequate funding. This, counselors of both groups said, made it challenging to not only hire and retain qualified counselors, but to meet client needs.

But even within this complaint, the researchers noted a division at least in the perception of how resources were allotted between urban and rural treatment centers. As one counselor put it, “In the urban areas such as the Louisville metropolitan area or whatever, they have more resources available and they have funding, just more of everything.” Supporting this quote is the fact that when the researchers asked both groups to cite specific evidence of budget constraints, members of the urban group described, among other things, a shortage of computers, while counselors from rural regions reported leaking roofs and a lack of heating in the winter.

Furthermore, while both urban and rural counselors cited transportation as an obstacle for many clients, the researchers agreed that the problem was worse for those far from city centers. As one counselor explained: “Without public transportation these people are having to rely on rides from other family members who have been enabling or using with them or friends who have been enabling or using with them.”

M. knows firsthand what it’s like to decide to seek help, only to find there is no way of getting to it. She was living in a Utah township comprised of fewer than 1,000 people when she found herself in need of help. Besides being uninsured and unable to pay for treatment out-of-pocket, M. didn’t have a car.

“It’s terrible,” she said in an interview with Foundations Recovery Network.

Finally, when it comes to rural areas, there are simply fewer free or cost-reduction services like those offered by many public health clinics, university hospitals and other non-profit agencies. As one frustrated counselor put it: “There is an undercurrent of intentionality. The more people you talk to on the street, the more you will hear this, this isn’t by accident that this stuff happens. Let’s keep them down in the mountains…I don’t think that I am undervalued by accident. I think my clients are supposed to die.”8

Not everyone the researchers interviewed felt that way. That said, the authors are adamant that the statements “represent an undercurrent of frustration common to many of the rural participants.” In order for the situation to improve, they say, things have to change, starting with tailoring treatment to its cultural setting, as well as funneling additional free and cost-reduction services to the country. Sure, they write, “this suggestion is by no means a solution to larger problems like the underfunding of substance abuse treatment programs.” But it’s a start.

Sources1. Ibid.3. Ibid.Written by Tamarra Kemsley

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