Small-town America. It conjures Norman Rockwell images of pastoral settings, secluded homesteads, and wholesome, healthy families. Issues such as alcohol and drug abuse don't fit this tranquil picture. Those are big city problems.

Unfortunately, substance abuse is not confined to city limits. The substance abuse problems of rural areas now rival those faced by their urban counterparts, says Larry Monson, president of the National Rural Alcohol and Drug Abuse Network, Inc.

Preliminary results from the National Household Survey on Drug Abuse, released in late August and conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), show that the percentage of people 12 and older who identified themselves as current alcohol users was slightly higher for respondents in large and small metro areas (54 and 52 percent, respectively, compared with 45 percent for rural area people); little difference was reported among these groups for binge drinking and heavy alcohol use. Analysis of past National Household Surveys reveal that rural residents report a greater incidence of problems associated with alcohol use than do urban residents. Similar to alcohol use, the incidence of "illicit drug use" (marijuana, cocaine, hallucinogens, heroin, inhalants) was a little higher for urban respondents. But rural area respondents reported slightly higher rates of "current tobacco use"32 percent compared with 27 percent for large metro area and 31 percent for small metro area.

Perhaps most alarming is that more and more young people in rural areas are surfacing as addicted or problem users. For young people ages 12-17, research suggests that illicit drug use is still a little less than that reported in urban areas, with the exception of inhalants and stimulants. The age of onset for substance abuse in rural areas keeps going down, said Monson, program director of L.E. Phillips-Libertas Treatment Center in Chippewa Falls, Wis. Children as young as 8 years old are receiving services, he adds.

A number of factors help explain substance abuse in rural America. "In the last few years we've seen an influx of illicit drug trafficking and manufacturing in rural areas," Monson said. "The methamphetamine makers and others can go longer without detection in rural areas, and gang activity is up."

Rural unemployment is 50 percent higher than in urban areas, and poverty and substandard housing are also problems. Population declines in rural areas have led to church closings, hospital closings, and consolidation of schools. "Kids often have to ride 1 1/2 hours to school, so they lose some of their local identity and sense of belonging," said Monson. "People get bored and depressed. Suicide attempts for adolescents in rural areas are 15 times greater than the national average."

Rural residents often exhibit beliefs and attitudes that deter people from seeking and receiving help. "They see themselves as independent and self-reliant," Monson said. "When you're in trouble, you 'pull yourself up by your own bootstraps' or get help within your family or church. You don't air your dirty laundry in public. As a result, outside agencies are often frowned upon or distrusted. Anonymity can be a challenge in a small town."

Small-town America also tends to more commonly view addiction as a moral weakness, instead of the chronic disease that it is. Thus, a greater stigma is attached to alcoholism and fewer people are likely to seek treatment. Greater awareness about the disease is needed to change attitudes.

When treatment is sought in rural areas, access to recovery services may be limited because the cost of providing special services to a few people is often prohibitive. A holistic approach -- one that coordinates social services, health services, programs for the elderly, juvenile and school services, court services, church programs, etc. -- is critical. Rural areas need to network and integrate their services to maximize use of their resources.

To offer assistance to rural providers, the National Rural Alcohol and Drug Abuse Network hosts an annual conference to provide education and training for professionals addressing addiction needs of their areas. SAMHSAs Center for Substance Abuse Treatment publishes a Technical Assistance Series on treating alcohol and other drug abuse in rural areas. To receive free copies, contact the National Clearinghouse for Alcohol and Drug Information at (800) 729-6686.

--September 17,1998