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Alcoholism, Substance Use, and Other Addictive Disorders

  • Venkata Lakshmi Narasimha
  • Arun KandasamyEmail author
Living reference work entry
Part of the Mental Health and Illness Worldwide book series (MHIW)

Abstract

Urban-rural divide across the world plays an important role from economy to health. Health related gap in general and addiction services in specific take a toll on rural population. Variations round the globe in terms of defining these population groups, problems, and barriers faced by rural areas exist. Dynamic changes in prevalence of substance use disorders (SUDs), epidemiological differences across the countries make it difficult to study and understand these differences. The differences across the countries based on the economies have been described in the article. Special population like pregnant women, prisoners, migrant laborers have been observed to get effected by the urban rural divide. Factors like availability of treatment centers, use of evidence-based services, perceived ease of access, screening and follow-up services, financial status, perception of substance use as problem, gender inequality have been shown to contribute for urban rural differences. These inequalities also play an important role in preventive dimension, i.e., in initiation of substance use. Urban-rural differences play an important role in planning, organizing, and implementation of preventive programs. Understanding/studying urban-rural differences is important in allocation of resources, policy making, planning interventions for the management of SUDs. Further research is required in this area.

Keywords

Substance use disorders Rural Urban Alcohol 

Introduction

Globally, approximately one half of the population lives in rural areas, but less than 38% of the nurses and less than 25% of the physicians work there (WHO 2010). While appointing and sustaining health workers in rural and remote areas is a challenge for every country, the situation is worse in the 57 countries that have an absolute shortage of health workers. When it comes to specialty services like deaddiction, these numbers fall further and implementation of these services by primary health care physicians is indeed a difficult task. Starting from population dynamics to implementation of health programs, there is a lot of difference between urban and rural populations. In this chapter we tried to discuss urban-rural differences across the globe and how it becomes an important in substance use disorders.

Defining Urban and Rural Areas

The challenge starts with the difficulty to define what is a rural or an urban area. The definition varies from countries to countries. For example, in highly developed countries like United States, the first definition developed by the census bureau identifies two types of urban areas: Urbanized Areas (UAs) of 50,000 or more people; Urban Clusters (UCs) of at least 2500 and less than 50,000 people. The Census does not actually define “rural.” “Rural” encompasses all population, housing, and territory not included within an urban area (HRSA 2017). According to the United Nations Office of Economic and Social Affairs system, counties have been categorized into three types: “rural” (nonmetropolitan counties with urban population less than 20,000), “urbanized nonmetropolitan” (nonmetropolitan counties with urban population 20,000 or higher), and “metropolitan” (counties in metropolitan areas with 500,000 or more inhabitants) (Gfroerer et al. 2007; United Nations Department of Economic and Social Affairs). This plays a major role not only in understanding the dynamics of population but also for planning the interventions.

In most of the countries, the rural economy plays a major role in the economy. For example, India has about 650,000 villages. These villages are inhabited by about 850 million consumers making up for about 70% of population and contributing around half of the country’s Gross Domestic Product (GDP) (Chandrasekhar and Murali 2016). The picture is same across many countries in world. And the differences between the two are not restricted to the population number alone. It is well known from the population based studies that there are fairly significant amount of differences between rural and urban area with regards to their health index and the economy.

Urban-Rural Differences in Terms of Health and Economy

Rural population is different from urban in terms of health and economy (https://www.unodc.org/documents/drug-prevention-and-treatment/16-10463_Rural_treatment_ebook.pdf) in various parameters, which includes,
  • Higher rates of poverty.

  • Child marriages are more common.

  • Rural youth are less likely to stay in school, with young men having higher educational advantages and higher completion rates in both settings than young women (with the United States being one exception).

  • Higher infant mortality rates and a lower likelihood of receiving antenatal care and skilled care at delivery.

  • Rural women have more children than urban women.

  • A greater percentage of children who are underweight, a greater incidence of food insecurity, and lower access to safe drinking water and sanitation.

  • Higher rates of maternal mortality among women living in rural areas and poorer communities, with 99% of all maternal deaths occurring in developing countries (Alkema et al. 2016).

  • While 56% of the global rural population lacks health coverage, only 22% of the urban population is not covered (Scheil-Adlung 2015).

  • The situation is aggravated by extreme health workforce shortages in rural areas impacting on the delivery of quality services: in rural areas a global shortfall of about seven million health workers to deliver services is observed, compared to a lack of three million staff in urban areas. Due to these rural health workforce shortages, half the global rural population lacks access to urgently needed care.

  • Deficits in per capita health spending are twice as large in rural areas as in urban areas.

  • These deficits result in unnecessary suffering and death, as reflected, for example, in rural maternal mortality rates that are 2.5 times higher than urban rates.

Problems and Barriers to Treatment in Rural Areas

Barriers to effective substance use treatment experienced by rural residents (https://www.unodc.org/documents/drug-prevention-and-treatment/16-10463_Rural_treatment_ebook.pdf).
  • Fewer treatment options for rural clients

  • Lack of service providers delivering services (Mpanza and Govender 2017)

  • Challenges in getting to treatment facilities, including the lack and cost of public transportation, long travel distances, geographic isolation

  • Reliance on friends and family for transportation

  • Lack of good facilities, inadequate infrastructure (e.g., building resources)

  • Challenges in meeting housing and other support needs of people in treatment

  • Lack of educational resources for clients and early education about substance use risks

  • Limited continuing education opportunities for counselors

  • Higher rates of unemployment, financing issues, and poverty

  • Poor prioritization and lack of monitoring

  • Health gap

  • Cultural differences

To explain the importance of each factor, we have taken an example of cultural differences. Indigenous people form a part of rural population. Around 370 million indigenous people are there worldwide who are culturally different from the rest of the population. Prevention and treatment programs are more effective when they recognize and understand these contextual issues. Culture and ethnicity plays an important role. For example, in 1992–1997, National Treatment Improvement Evaluation Study, a prospective cohort study of substance abuse treatment programs and their clients found that racial/ethnic minorities are underserved compared to whites in the substance abuse service system. Different racial/ethnic groups come into treatment with distinct needs and receive distinct services. Although groups respond differentially to service types, substance abuse counseling and matching services to the cultural needs is an effective strategy both for retaining clients in treatment and for reducing posttreatment relapse for African Americans and Whites (Marsh et al. 2009).

Even though we tried to highlight problems faced by rural areas, there are problems which the urban areas do face. In a study (Pullen and Oser 2014), counselors’ perspective revealed that there is predominantly lack of funding and bureaucratic challenges which includes heavy caseloads with understaffing, lack of technological support, language barriers, cultural differences, lack of case management. Apart from these, there are common challenges between these two populations for example lack of interagency cooperation.

Constantly Changing Pace of Prevalence of SUDs

Research demonstrated that there are continued shifts in trends in illicit drug use in the United States and called attention to rising rates of prescription drug misuse and abuse. This is also true with other parts of the world. Findings have also continued to highlight the substantial co morbidity of SUDs with other psychiatric disorders and with the ongoing HIV epidemic (Schulden et al. 2009).

Epidemiology of Substance Use Disorders and Its Importance

Studying epidemiology of substance use disorders and trying to understand urban-rural differences in substance use disorders help in planning the prevention programs to providing the rehabilitation services (Schulden et al. 2009).

The key to developing effective policies, practices, and interventions related to the substance use disorders is to select the spatial units and characteristics of rurality that are most important and relevant to stakeholders and capture demographic and population changes as they occur.

An enhanced understanding of these types of differences may enable policymakers and treatment providers to direct limited resources more effectively and increase the quality of care received in different geographic contexts and suggest a diverse set of needs.

However, studies also suggest that there are methodological issues in studying epidemiology. Building on these foundations, future challenges for research in substance abuse epidemiology will include using novel methodological approaches to further unravel the complex interrelationships that link individual vulnerabilities for SUDs, including genetic factors, with social and environmental risk factors.

Early prevention and intervention efforts in rural areas may help to mitigate future substance dependence and abuse considering the high rate of adolescent initiation among rural admissions. It can alleviate the strain which the substance abuse and its associated problems (e.g., negative health outcomes, crime) levy on rural substance abuse treatment, health care, and law enforcement systems.

Urban and Rural Differences Across World

Despite the lack of global prevalence data on drug use, available data from different countries indicate that rural areas suffer from drug use. Many studies dispel the notion that substance abuse is only an urban problem and provides information useful in developing and implementing interventions that consider the unique characteristics of rural residents.

In this section we tried to look at urban-rural differences based on their economies as defined by World Bank (2016).

High Income Economies: USA and Australia

Most of the studies on urban rural differences come from high income countries like United States of America.

Differences in adolescent substance use: In 2008, Community Youth Development Study (CYDS) done in USA (Rhew et al. 2011), stated that current alcohol use, smokeless tobacco use, inhalant use, and other illicit drug use were more prevalent among high school-aged youths living on farms than among those living in towns. Prevalence of drug use did not significantly vary across youths living in different residential contexts among middle school youths. The findings suggest that outreach activities to farm-dwelling youths may be particularly important to prevent adolescent drug use in rural settings.

Differences in inpatient admissions: In 2012 SAMSHA (2012), published a report on differences in admissions among the urban and rural areas. Rural admissions were younger and less racially and ethnically diverse than urban admissions. Rural admissions were more likely than urban admissions to report primary abuse of alcohol (49.5 vs. 36.1%) or nonheroin opiates (10.6 vs. 4.0%); urban admissions were more likely than rural admissions to report primary abuse of heroin (21.8 vs. 3.1%) or cocaine (11.9 vs. 5.6%). Rural admissions were more likely than urban admissions to be referred by the criminal justice system (51.6 vs. 28.4%) and less likely to be self- or individually referred (22.8 vs. 38.7%).

Differences in opioid misuse: In 2012, National Survey on Drug Use and Health (Monnat and Rigg 2016) observed that the prescription opioid misuse is more common in rural and small urban adolescents. Some of the important findings from this survey are that criminal activity, lower perceived substance use risk, and greater use of emergency medical treatment partially contribute to higher odds among rural adolescents, but they are also partially buffered by less peer substance use, lesser access to illicit drugs, and stronger religious beliefs. However, urban adults have more misuse compared to the rural adults (Rigg and Monnat 2015). This brings the need for early interventions in rural population and tailoring of interventions accordingly in urban populations.

Reasons for differences in Opioid misuse: Data from the 2011 and 2012 National Survey on Drug Use and Health, urban adults were more likely to engage in prescription Opioid medications compared to rural adults because of their higher use of other substances, including alcohol, marijuana, and other illicit and prescription drugs, and because of their greater use of these substances as children (Rigg and Monnat 2015).

Differences in implementation of Opioid treatment program: In 2004, National Survey of substance abuse treatment services looked at urban-rural differences. Substance abuse treatment overall and intensive services in particular is limited in rural areas, especially among counties not adjacent to metro areas. Less populated areas with greater commuting distances contain a small proportion of facilities offering a range of core services and varying levels of outpatient care. This situation is particularly striking for opioid treatment programs, which are nearly absent in rural areas. The greater proportion of rural-based facilities accepting public payers and providing discounted care may indicate greater challenges to financing treatment in rural areas (Gale and Lenardson 2007).

Differences in stimulant use: In 2002, National survey of drug use and health reported some of the important differences in the use of stimulants. The use of Ecstasy is higher among youth in metropolitan and urbanized nonmetropolitan counties than rural counties, while rural youth have a higher prevalence of stimulant and methamphetamine use than metropolitan youth. Rural adults had generally lower rates of illicit drug use than metropolitan adults, but adults in rural and urbanized nonmetropolitan areas had higher rates of methamphetamine use than those in metropolitan areas. They also found that rural youth had a higher prevalence of past month use of tobacco and alcohol. Rural adults had higher rates of tobacco use but lower rates of alcohol use (Gfroerer et al. 2007).

Australia: Prevalence and patterns of illicit drug use vary between rural and metropolitan residents. People living in remote and very remote areas were twice as likely as people in major cities to have recently used meth/amphetamines, but less likely to have used ecstasy compared with those from major cities. Cannabis use and the use of pharmaceuticals not for medical purposes are higher in remote/very remote areas than in major cities.

Aboriginal and Torres Strait Islander people, of whom 70% live in rural Australia, were 1.7 times more likely to have used illicit drugs recently compared to the general population. Social disadvantage is a contributing factor to illicit drug use and strategies to combat illicit drug use should address its social determinants.

Rural residents face barriers to accessing drug treatment services, including limited access to health services in general and drug treatment options in particular, greater distance from services and a lack of transport. Drug services that are particularly limited in rural areas include methadone programs, withdrawal and detoxification services, as well as needle and syringe programs.

Other barriers include lack of motivation to seek treatment, unfavorable attitudes, such as resistance to treatment and fear of what may be involved, and concern about confidentiality. Rural residents may also be more reluctant to disclose their drug use to healthcare professionals who are more likely to be personally known to them. Programs targeted at rural communities must consider their diversity and unique perspectives and be locally tailored to maximize their chances of success. These strategies should be aimed at promoting social inclusion, building individual and community resilience, enhancing protective factors, reducing risk factors, and providing support to families affected by illicit drug use. Interventions designed to target illicit drug use among rural residents will require strong community consultation so as to engage and empower rural communities.

Higher Middle-Income Economies

Middle East-Iran Rural Prevalence

Rural household survey looked at substance abuse in one of the rural areas of southeast Iran, in a 12-year period (2000 and 2012 (Ziaaddini et al. 2013)). Demographic characteristics, frequency of substance abuse, and ease of access to various drugs were studied. Majority of the participants (61.8%) were below 30 years of age and among them 54.4% were male. Cigarette (17.0%), opium (15.7%) and opium residue (9.0%) were the most frequent substances abused on a daily basis. Based on the participant’s opinion, they concluded that the ease of access to cigarette, water pipe, and opium contributed to their increase in consumption compared with earlier years. The steady rise in substance abuse in rural communities demands immediate attention and emergency preventive measures from policy makers.

Lower-Middle Income Economies

Urban-Rural Differences in India

Earlier studies identified urban-rural differences in prevalence of mental disorders (Ganguli 2000; Reddy and Chandrashekar 1998). Chandrasekhar (1998) mentioned that the urban rates were twice as much as the rural prevalence rates, whereas quite contrastingly, Ganguli (2000) showed that for every 100 rural persons afflicted with a mental disorder, there existed about 157 urban people with a mental disorder double in urban when compared to rural.

In the latest National mental health survey 2015 (National Mental Health Survey of India 2015), the prevalence of substance use disorders was more in rural areas (24.1%) as compared to urban non metro (20.3%) and urban metro areas (18.3%). The burden of use of tobacco was relatively more in rural areas (22.7%). The prevalence of other substance use disorders excluding tobacco and alcohol in the urban metro areas (1.0%) was twice as much as in the urban nonmetro or rural areas.

In a country with diverse cultures like India, society is very much concerned for substance related issues, but sometimes promotes (cultural sanctioned use of cannabis and alcohol) it; “especially in rural places, alcohol use is a societal norm during celebrations and there are many events round the year to celebrate” in states like Jharkhand; “Bhukki (opium) and alcohol use are socially sanctioned and so less stigmatizing” in states like Punjab.

While the causes, risk factors, and protective factors vary in urban and rural populations, availability, accessibility, and affordability of care are different in both areas; awareness is still limited. Thus, the need for coverage of mental health services across India on an equal basis merits importance. Factors ranging from awareness to affordability, varying between rural and urban areas, need to be critically delineated to address specific issues in bridging treatment gap.

The National Household Survey 2004 revealed that rural individuals were 1.5 times more likely to use alcohol compared with urban users. This would probably be attributed to education, income, occupation, and other social factors (Ray 2004). Subramanian et al. (2005) reanalyzed the data from the NFHS – 2 and observed that the prevalence of alcohol use among both men and women was significantly higher in towns and villages as compared to large and small cities (Subramanian et al. 2005). In the same way despite lack of good studies, earlier studies done during the last five decades reported that it is clear that the problem of alcohol use is significantly higher in rural areas, urban slums, transitional towns, and tribal areas (Neufield et al. 2005; Isaac 1998; Benegal et al. 2003; Ray and Sharma 1994; Thimmaiah 1979; Gururaj et al. 2004, 2006, 2011; Anand et al. 2007).

In the GENACIS study undertaken in the state of Karnataka, the prevalence of drinking among men was 23% in rural areas and 41% in urban areas among men, while similar rates among women was 4.4% and 7%, respectively (Benegal et al. 2005). However, NFHS-3 had opposite results with an increased prevalence in rural women compared to urban women. Among females the ratio between urban to rural was 1:5 (0.6%: 3.0%) (2007).

In India, Tobacco use is more in rural population when compared to urban slums which is significantly higher than urban areas and also reportedly nontaxed forms of nicotine product consumption is found to be higher in these areas (Gupta et al. 2010). The antitobacco policies of India need to focus on bidis in antitobacco campaigns. The program activities must find ways to reach the rural and urban-slum populations.

Low Income Economies

In Afghanistan, INL survey of drug use (which included toxicology testing) found that 31% of households and 11% of the population tested positive for one or more drugs and drug use was found to be three times greater in rural areas than in urban ones (Bureau for International Narcotics and Law Enforcement Affairs 2016).

In rural African areas, high rates of fetal alcohol syndrome and partial fetal alcohol syndromes were present especially in isolated communities (Olivier et al. 2013). The negative consequences of substance use disorders (SUDs) in rural settings are very serious and require immediate responses. However, another isolated region of rural African region has a very low prevalence of substance use disorders (Tshitangano and Tosin 2016).

Urban-Rural Differences in the Special Population

Pregnant Women

A 3 years’ study (Shaw et al. 2015), which looked at the urban-rural differences in pregnant women using alcohol from Washington state of United States of America, found results to be troubling.
  1. 1.

    Rural participants were more likely to report alcohol use and binge drinking at program intake and at the 3-year program exit.

     
  2. 2.

    Throughout the program, rural women were less likely to complete outpatient substance abuse treatment compared to urban participants.

     
  3. 3.

    Rural women also used less services during the last year including alcohol/drug support and mental health provider services.

     
  4. 4.

    At program exit, rural participants also reported higher use of alcohol and more suicidal thoughts than those residing in urban areas.

     
  5. 5.

    Implication of the study was identifying community-specific needs of substance abusing pregnant or parenting women in both rural and urban settings is crucial for the successful development and improvement of treatment and intervention programs for this vulnerable population of women.

     

Another study (Shannon et al. 2010) examined differences in substance use (predominantly opioids) among pregnant women from rural and urban areas. Rural pregnant women had higher rates of illicit opiate use, illicit sedative/benzodiazepine use, and injection drug use (IDU) in the 30 days prior to admission. Additionally, a greater proportion of rural pregnant women reported the use of multiple illegal/illicit substances in the 30 days prior to entering detoxification. The increased rates of prescription opiate and benzodiazepine use as well as IDU among rural pregnant women are concerning. In order to begin to understand the elevated rates of substance abuse among rural pregnant women, substance use must be considered within the context of demographic, geographic, social, and economic conditions of the region.

Prisoners

  1. 1.

    In study (Warner and Leukefeld 2001) that examined differences in drug use and treatment utilization of urban and rural offenders, chronic drug abusers from rural and very rural areas have significantly higher rates of lifetime drug use, as well as higher rates of drug use in the 30 days prior to their current incarceration than chronic drug abusers from urban areas. Nonetheless, being from a very rural area decreased the likelihood of having ever been in treatment after controlling for the number of years using and race. While problem recognition appears to explain much of the effect of very rural residence on treatment utilization for alcohol abuse, the effects of being from a very rural area on seeking treatment for drug abuse remain statistically significant even after controlling for several other variables. The findings point to the importance of providing culturally appropriate education to very rural communities on the benefits of substance abuse treatment and of providing substance abuse treatment within the criminal justice system.

     
  2. 2.

    The results of this study indicate that rural DUI (Malek-Ahmadi and Degiorgio 2015) (driving under influence) offenders have a significantly greater risk of heavy alcohol use when compared to urban DUI offenders.

     
  3. 3.

    In a study (Elgar et al. 2003) examining the role of temperament using clinical cutoffs to assess the outcome behaviors between urban and rural populations, significant differences have been noted. Urban delinquent youths showed higher rates of attention problems, delinquent behaviors, and externalizing behaviors than those in rural communities. Incarcerated young offenders show elevated rates of psychological problems that require treatment. Rural and urban differences in the rates of these problems may reflect differences in community service availability in these areas or in environmental influences on the development of child behavioral problems.

     

Migration

In a study Chen et al. (2008) to assess the effect on substance use on urban rural migration found that substance use is prevalent among rural-to-urban migrants, especially among female migrants. Workplace, income, and depression are associated with substance use interactively. Tailored substance use prevention is needed to target high-risk workplaces with specific efforts devoted to female migrants.

Factors Involved in Urban-Rural Differences

Treatment Centers

Bond Edmond et al. (2015) looked at the structural and quality differences between rural and urban treatment centers and found that the rural centers had reduced access to professionally trained counselors, were more likely to be nonprofit organizations and dependent on public funding, offered fewer wrap around services, and had less diverse specialized treatment options. This author also indicated that rural centers were less likely to prescribe buprenorphine (Opioid Substitution) as part of their treatment but were more likely to employ nursing staff and offer specialized treatment for adolescents. Increasing the resources, provision of funding, change in the policy with a continuous monitoring would be some of the strategies in improving the quality of the centers.

Using Evidence Based Services

A study (Dotson et al. 2014), which looked at delivery of evidence based practice (EBP) between urban and rural population, found that most mental health and substance abuse treatment agencies used more than 1 EBP, although rural substance abuse agencies were less likely to do so than urban agencies. Rural substance abuse agencies were more likely to be solo than group practices. Urban agencies reported significantly more collaboration with universities for EBP training, although training by internal staff was the most commonly reported training mechanism regardless of agency focus or location. Over half of agencies reported conducting no systematic assessment of EBPs, and of those who did report systematic assessment, most used outcome monitoring more than program evaluation or benchmarking. Urban and rural mental health and substance abuse prevention providers reported shortages of appropriately trained workforce and financing issues available to pay for EBPs as the greatest barriers to utilization.

Perceived Ease of Access

Ease of access to substance has been shown to have a direct and significant relationship with substance use for school-aged children. It has been shown that ease of access is an important predictor of recent drug use among the rural adolescents (Warren et al. 2015). It appeared the rural-urban differences fell along legal/illicit lines (Warren et al. 2015). Rural students reported higher level of access to legal substances and urban students reported higher level of access to illicit substances. Studies focusing on limiting the ease of access would make an impact on policy making. For middle school students, a significant difference in perceived ease of access was found for each substance, with rural students reporting greater access to smoking tobacco, chewing tobacco, and steroids and urban students reporting greater access to alcohol, marijuana, cocaine, inhalants, ecstasy, methamphetamine, hallucinogens, and prescription drugs. Rural high school students reported higher access to alcohol, smoking tobacco, chewing tobacco, and steroids, but urban students reporting higher access to marijuana, cocaine, inhalants, ecstasy, and hallucinogens. Perceptions of ease of access more than doubled for each substance in both geographies between middle and high school. More than 60% of both rural and urban high school students reported easy access to alcohol. Future research should investigate ways to decrease the perceptions of access to substances in order to prevent use and abuse.

Screening and Follow-Up Services

Screening for substance use disorders in population with psychiatric illness seems to be high when compared to general population. However, follow-up after the initial screening is less in rural population when compared to urban population (Chan et al. 2016). There is a need to think about generalizability of this finding, as availability of screening and follow-up for the substance use disorders at primary care may not be available at many centers all over the world.

Availability of Money

A clear association was made by respondents between greater availability of money and increasing alcohol use. In the localities where availability of money had increased due to work for pay schemes in rural areas, alcohol use had increased because a large proportion of these money were spent on alcohol (National Institute of Mental Health and Neuro Sciences 2012).

Perception of Substance Use as a Problem

In a study which looked at intimate partner violence and violence towards children between urban and rural areas from India, there appears to be a greater normalization and acceptance of alcohol use from rural respondents and therefore less of causal attribution of alcohol as a factor in violence and other harm. Urban respondents appear to attribute a greater proportion of harm to alcohol misuse (National Institute of Mental Health and Neuro Sciences 2012).

Gender

Gender differences in substance usage have been evaluated and understood. When it comes to urban rural differences, culture, specific occupations (toddy tapping), or specific communities seems to play an important factor in determining the substance usage in rural population. For example, a study done from the rural part of an Indian state (Surat in Gujarat) where alcohol is in prohibition for long period of time, historically some communities have tolerated alcohol use by women. However, alcohol use among women was generally still looked down upon with a perception: “(women) drinking will adversely affect child rearing and ruin the family. Such girls find difficulty in getting married. It is not good for her safety and culture. Her drinking is a big societal loss (National Institute of Mental Health and Neuro Sciences 2012).” Differences in mental health, substance use, and sexual behavior have been noted in transgender population (Horvath et al. 2014). Significant higher amount of cannabis use along with unprotected sexual behavior has been observed in this population.

Barriers and Facilitators

A study (Browne et al. 2016) which did a qualitative thematic analysis of stake holders and patients attending service agencies in a particular region found that four predominant themes noted as barriers and facilitators: availability of services for individuals with substance use disorders; access to the current technology for client services and agency functioning; cost of services; and stigma.

Prevention

Rural populations are often composed of numerous vulnerable subgroups with different cultural, ethnic, and/or religious belief structures or with differing levels of marginalization. Rural communities have diverse characteristics and interventions will need to be localized rather than follow a one-size-fits-all approach.

The primary goal of substance use prevention is to help nonsubstance users avoid or delay the initiation of substance use. For those who are vulnerable to be dependent on substances, prevention seeks to minimize their likelihood of developing a substance use disorder (e.g., dependence). Researchers, policy makers, and treatment providers must consider the complex array of individual, social, and community risk and protective factors to understand rural/urban differences in prevention of substance use at an early stage.

In a study that looked at prevention of adolescent prescription opioid misuse (POM), potential points of intervention to prevent POM in general and reduce rural disparities include early education about addiction risks, use of family drug courts to link criminal offenders to treatment, and access to nonemergency medical services to reduce rural residents’ reliance on emergency departments where there is a higher likelihood of prescription of opioids (Monnat and Rigg 2016).

Conclusion

Urban-rural differences play an important role in planning, organizing, and implementation of preventive programs. Understanding/studying urban-rural differences is important in allocation of resources, policy making, planning interventions for the management of SUDs. It is clear that the pattern and prevalence of SUD differ between these two parts with respect to the nature of substances, gender differences, cultural factors, accessibility to services, and other factors. Rural areas are mostly deprived of mental health care and addiction services and also suffer significant problems in terms of barriers to treatments compared to the urban areas. Studies which have been conducted to understand the urban rural differences are predominantly restricted to developed countries. More countries with predominantly rural economies need to be included in this research.

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© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  1. 1.Centre for Addiction Medicine, Department of PsychiatryNational Institute of Mental Health & NeurosciencesBangaloreIndia

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