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By Ella Reeve

Inadequate access to healthcare can affect any community in detrimental ways, with rural America being particularly vulnerable to the effects of lacking access to care. While there are countless examples as to how limited connection to quality healthcare can contribute to lifelong health issues, substance abuse is a major problem that disproportionately affects rural communities. The United States Census Bureau estimated that 60 million people currently live in rural areas, equivalent to one in five of all Americans, so access to care in rural communities is extremely important and relevant to such a large percentage of the population (America Counts Team). With the highest drug-involved overdose rates in American history (92,000 deaths a year), there is a clear need for structural changes starting with the most affected populations–rural communities (“Overdose Death Rates”).

When comparing the demographic makeup of drug-related overdoses, rural youth have historically been the population most likely to fall victim. Lambert et al. found that “rural youth (age 12-17 years) in all 3 rural categories have higher rates of past year use of alcohol, cocaine, methamphetamine, and inhalants than urban youth” (Lambert, 224). Substance abuse negatively affects all populations, but the consequences for youth substance abusers are specifically damaging. The Office of Juvenile Justice and Delinquency Program notes that substance abuse among youth can lead to academic decline, long-term physical health risks, mental health issues, isolation and disengagement from peers, family issues, socioeconomic costs, and delinquency (“Consequences of…”). Alongside these consequences, rural youth are also more likely to succumb to generational poverty.

These high rates of substance abuse in rural youth are indicative of a larger problem: an overarching inability to adequately treat rural patients. Karen Van Gundy notes, “there is a critical need for alcohol abuse treatment services, especially among rural youth… states with the highest rates of youth alcohol rates have the greatest unmet need for alcohol treatment; these states tend also to be the most rural” (Van Gundy, 26). This begs the following question: what makes it particularly difficult to treat rural patients? Lack of transportation, the closing of rural hospitals, distrust in medical professionals, and mass numbers of underinsured or uninsured persons, all contribute to treatment difficulties on behalf of physicians and rural patients. Van Gundy expands on this by stating that “the ability of law enforcement, public officials, and health professionals to manage treatment and other intervention programs for rural residents is hindered by the very characteristics that make rural areas unique: wide open spaces, limited funds, and a tradition of ‘taking care of our own’” (Van Gundy, 26). Kate Barnes, project manager with the Research Institute in rural Wisconsin summarizes her findings after several months of in-depth interviews with rural community members as followed: “‘A lot of times it is like a geographical distance becomes a big issue for people who are seeking meetings… if you don’t have transportation, if you don’t have peer support, if you don’t have access to jobs, access to housing, all that stuff can kind of conspire together to really challenge people’s recovery’” (Dahdah). So, even if there are providers, an aggregate of factors can still prevent many patients from receiving the care and support they need.

As for resources focused on substance abuse and mental health treatment, there is an overwhelming lack of support in the majority of rural areas. NPR reporter Bram Sable-Smith notes that an estimated 82% of rural Americans live in counties without any detoxification services (Sable-Smith). This lack of support extends beyond structural and service limitations; there is also a notable lack of social support for individuals facing addictions in rural areas. An interview with Tiffanie Cotten for the Stories to Save Lives project provides some insight into working in a substance abuse clinic as a counselor in rural America. Before attending graduate school and working at the clinic, Cotten admits “I honestly didn’t want to even deal with substance use or anybody with addiction because my mother is an addict, so I, for years, just couldn’t understand the whole disease” [01:42.2]. The stigma Cotten originally held for addicted individuals is applicable to many rural inhabitants; this social stigma, along with a lack of education and awareness can prevent many individuals suffering with substance abuse from seeking help, even if there are established resources. Biostatistician and research scientist Holly Andrilla presented this issue to the United Nations Office of Drugs and Crime, citing problems with anonymity in small rural communities. “Whether you’re having trouble with alcohol or opiates, people want their treatment to be anonymous because there’s a social stigma in many, many cultures. It’s hard to be anonymous in small communities,” Andrilla states (Toliver). This is just one more obstacle that can prevent substance abusers from receiving needed treatment.

These challenges beg another question: how can providers overcome the obstacles of rural healthcare to provide adequate support for communities in need? A 2013 study on the usage of technology in the treatment of mental health and substance abuse found one way to overcome the challenges in accessing care in rural communities: telehealth.  Benavides-Vaello et al. found that “telemedicine has been successfully used to enhance a variety of clinical services and educational initiatives in rural communities, and serves as a viable mode to increase access to specialty professional services in remote areas in a convenient and economical way” (Benavides-Vaeullo). Holly Andrilla mentions the need for mental health specialists that treat comorbidities since many people struggling with substance abuse have other underlying conditions such as anxiety and depression (Toliver). John Gale of the Maine Rural Health Research Center elaborates further on this idea, saying, “most people with a substance use disorder have co-occurring mental health and substance use problems. If we take care of [a patient’s] heroin problem and we don’t treat the underlying mental health and substance abuse problems, they’re going to go back to alcohol, they’re going to do something else” (Sable-Smith).

Inadequate access to care is not new, nor will it go away overnight. But on a hopeful note, there is more research into rural healthcare than ever before, with physicians, social workers, and community members teaming up to bring better care to marginalized communities. There is still a need to act quickly and efficiently, however, to prevent more individuals from succumbing to generational substance abuse problems. This means supporting research organizations, helping spread awareness of existing resources that can be utilized, incorporating widespread telehealth, fighting social stigma, and voting for office-holders with strong healthcare plans centered toward equity. It is only through a combination of these efforts that real progress can be made.


America Counts Team. “One in Five Americans Live in Rural Areas.”, United States Census Bureau , 9 Aug. 2017,

Benavides-Vaello, Sandra, Anne Strode, and Beth C. Sheeran. “Using technology in the delivery of mental health and substance abuse treatment in rural communities: A review.” The Journal of Behavioral Health Services & Research 40.1 (2013): 111-120.

“Consequences of Youth Substance Abuse.” Consequences of Youth Substance Abuse, Drug Identification and Testing in the Juvenile Justice System, May 1998,

Cotten, Tiffanie. Interview with Joanna Ramirez. 29 June 2018 (Y-0016). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.

Dahdah, Jeff. Researchers Explore Substance Abuse Cause and Treatment in Rural Wisconsin, Spectrum News 1, 8 June 2021,

Lambert, David, John A. Gale, and David Hartley. “Substance abuse by youth and young adults in rural America.” The Journal of Rural Health 24.3 (2008): 221-228.

“Overdose Death Rates.” National Institutes of Health, National Institute on Drug Abuse, 20 Jan. 2022,

Sable-Smith, Bram. “For One Rural Community, Fighting Addiction Started with Recruiting the Right Doctor.” NPR, NPR, 9 Dec. 2018,

Toliver, Zachary. “Talking Rural Opioid Sse at the United Nations: Q&A with Holly Andrilla.” The Rural Monitor, 10 Apr. 2016,

Van Gundy, Karen. “Substance Abuse in Rural and Small Town America.” Reports on Rural America, vol. 1, no. 2, 15 June 2006,

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