Bringing Excellence to Rural and Frontier America: Advocacy for Substance Abuse Services in the 1990s

This paper is adapted from a speech presented by Susan L. Becker, Associate Director for State Programs, Center for Substance Abuse Treatment, at the eighth annual conference of the National Rural Institute on Alcohol and Drug Abuse. The speech was the keynote address for the Harold E. Hughes Awards Luncheon on June 10, 1992.

Since President Nixon declared the first modem war on drug abuse in 1974, America has been concerned with substance abuse. While there is acknowledgement that alcohol and other drug use are problems for all of society, media and political attention seem locked on scenarios suggesting that substance abuse is predominantly, if not uniquely, a problem of the inner cities. Participants in this eighth annual conference of the National Rural Institute on Alcohol and Drug Abuse are acutely aware that this is not so. For too long, the national consciousness and the national agenda of the "War on Drugs" have been oblivious to the alcohol and drug problems of rural and frontier America.

Prevalence of Substance Abuse Problems in Rural America

The question is not whether alcohol and other drug use is a problem in rural and frontier areas. Prevalence data provide ample evidence that the problem exists. In 1990, a report on rural drug abuse by the General Accounting Office stated that total substance abuse rates are about as high in rural and frontier States as in nonrural States. What differentiates between rural and nonrural areas is that the prevalence rates for particular drugs may vary. For example, the rate of cocaine use appears to be lower in rural areas than in cities, whereas prevalence rates for other drugs, such as inhalants, may be higher.

Alcohol is the most widely abused substance in rural areas. However, more than 4 of every 10 rural high school seniors have tried marijuana; 1 in 11 rural high school seniors reports having tried cocaine. Among students in rural areas, the lifetime, annual, and 30-day prevalence rates for stimulants, inhalants, sedatives, and tranquilizers are comparable to those of seniors in nonrural areas Johnston et al. 1989, pp. 4246). Most prison inmates in rural States have abused alcohol, other drugs, or both (U.S. General Accounting Office 1990).

Clearly, the problem exists and has been documented. This presents rural and frontier States with a dilemma. When a problem and its constituency are invisible to the majority of the public, how can a rural State develop the necessary support not only to acknowledge the problem and the need, but also to develop excellence in the State's prevention and treatment services? Louis Swanson, in assessing rural development problems, identified six current barriers to action. I believe these barriers apply to the problem of how we can achieve excellence in the delivery of substance abuse services in rural and frontier America. These barriers include:

1. Flawed views of rural America
2. Serious limitations to the social and health data on rural areas
3. Failure to see rural areas as connected to the larger U.S. society
4. A perception that many rural problems do not have a viable political solution
5. Absence of a unified rural constituency, combined with the presence of formidable opposition to rural programs other than farm price supports
6. State and Federal fiscal crises (Swanson 1990, pp. 21-29).

Barrier #1: Flawed Views of Rural America

I believe the most formidable barrier to excellence lies in the flawed views of rural America that are commonly held. This barrier concerns the economics of health care delivery in rural and frontier areas. It is commonly believed that wages, labor costs, and building space are less costly in rural areas and that, as a result, rural health care services are less expensive to deliver compared to their costs in urban areas (Public Law 102-371, Section 1933 and Section 707).

This view is flawed, however, in that it fails to consider the "diseconomies of scale" and the available infrastructure that differentiate urban and rural settings (U.S. General Accounting Office 1990). Thus, while building costs may be lower in rural settings, rural and frontier areas face a unique challenge—that of providing physical access to services for clients who may live significant distances from the treatment or prevention site. Rural States also face the challenge of recruiting and retaining qualified professional staff who live in proximity to the site, but who must be willing to travel almost continuously.

Similarly, the coordination of services may prove more costly and more labor intensive within the rural delivery system because of the difficulties posed by distance, service availability, and accessibility. When calculating per client expenditures, it is imperative to include such critical expense items as travel, availability of specialized personnel, accessibility of other needed health and mental health services, and infrastructure costs. Inclusion of these expenses can drastically affect the accuracy of cost projections on providing substance abuse services to the population in need.

Barrier #2: Serious Limitations to Social and Health Data

The second barrier—the limits imposed by the scarce social and health data concerning rural and frontier areas—exacerbates the first barrier of flawed views. This information gap could be remedied through utilization of existing indicator data or through the planning and health resources of the States and State universities. Unfortunately, most rural and frontier jurisdictions and providers have been slow to utilize these available resources.

Available National Data
The National Household Survey is one example of data available for rural and frontier States to use in documenting their need for services. The 1988 survey, conducted by the National Institute on Drug Abuse, compared the relationship of drug use to demography by analyzing age-controlled data for large metropolitan areas, small metropolitan areas, and nonmetropolitan areas (National Institute on Drug Abuse 1989).

Significantly, the Household Survey showed that large metropolitan areas and rural areas had similar rates for drug use among youth aged 12 to 17 years—approximately 9 percent. Such figures suggest that youth in this age group have a comparable need for prevention and education efforts, whether they live in rural or in large metropolitan areas.

Young adults aged 26 through 34 in both large metropolitan and nonmetropolitan areas also had comparable rates of drug use—15 percent and 13 percent respectively. The rates of drug use among this age group are significant, since they imply that these young adults have a substantial level of chronic drug use and a need for appropriate treatment resources. These findings have significant implications concerning the type of substance abuse services that are needed in rural areas. More importantly, they demonstrate the extent to which drug use in rural areas is similar to use in both large and small metropolitan areas.

Local Data Sources
At a time when State and Federal resources are limited, individuals as well as service providers need to gain maximum benefit from all existing sources of data. While the most ideal data would be a quantified needs assessment for the population served, familiarity with existing local agency statistics can generate a great deal of supporting and helpful information. Local health departments can provide data about the rates of infectious diseases associated with alcohol and other drugs of abuse in their particular areas, as well as data concerning local teenage pregnancy rates. Local justice agencies can provide data concerning the rates of crime and of accidents associated with alcohol and other drug use.

Learning to use and regularly review such data would not only go a long way toward overcoming the flawed views of others, it would also convert some flawed self-views of rural America. Those who live in rural and frontier States are no longer secure from the threat of HIV, tuberculosis, or drug-related crime. Further, the needs of rural people who are being served may be changing. The service system must be sensitive, flexible, and adaptive to meet these evolving needs.

While it may once have been true that rural and frontier areas had a problem only with alcohol, this is certainly not true today. As stated earlier, existing studies demonstrate that alcohol is the most widely and commonly used substance, but that rates of drug use for rural youth and young adults are comparable to prevalence rates in large and small metropolitan areas.

The availability of heroin is limited in rural areas; however, this does not negate the possibility that rural people can be addicted to narcotics acquired through illicit trade in prescription drugs. Intravenous drug use is most commonly associated with heroin and narcotics, but abusers of methamphetamine also commonly administer their drugs intravenously. The prevalence of intravenous drug use, regardless of the agent used, has significant implications. For instance, analysis of Arkansas prison data revealed that, in the State's four rural counties with a high rate of intravenous methamphetamine use, the rate of HIV infection was also elevated.

More accurate and specific data is needed before it will be possible to understand fully the extent of substance abuse problems in rural areas. Nevertheless, there is ample evidence to suggest that the problem is extensive and that aggressive intervention is needed.

Barrier #3: View of Rural Problems as Disconnected From U.S. Society

The third barrier to excellence is the failure to view rural and frontier areas and their problems of alcohol and other drug abuse as connected to the larger U.S. society. The day for insularity has passed. We cannot afford to see substance abuse problems as a separate and distinct issue.

The abuse of alcohol and other drugs must be seen as a public health problem and addressed accordingly. When we view the abuse of alcohol and other drugs in a public health context, we can speak forcefully about the consequences of the use and abuse of these agents in a manner that connects the consequences to the local community and to the State at large. When the connection between rural substance abuse problems and the larger community is successfully made, it will create new stakeholders invested in the successful resolution of rural problems. While some control may be lost, the benefit will be a more effective network of problem solving that will develop through increased resources and the investment of more people in a positive outcome.

Direct and Indirect Costs of Alcohol and Drug Abuse
How do alcohol and other drug use relate to public health services and expenditures by society at large? Drug and alcohol use directly affect the extent of expenditures needed to provide services and also affect the type and extent of health care and support services needed by a community. The process of educating policymakers must emphasize that the direct and indirect costs of alcohol and drug abuse are shared by all of society.

Beyond the costs of treatment and prevention services, there are a wide range of health problems associated with drug and alcohol use; these associated health problems are significant factors in calculating the overall cost of substance abuse to society.

Consider the following estimates for the cost of health and remedial care for health problems related to drug and alcohol use:

• A cost of $785 is estimated for a single case of hepatitis B (CDC 1990; CDC 1992a; Alter et al. 1990)
• A cost of $50,125 is projected for the treatment of one person with the human immunodeficiency virus (HIV) (CDC 1991a; CDC 1992b; Kahn 1992)
• An expenditure of approximately $102,125 is estimated for each case of acquired immunodeficiency syndrome (AIDS) (CDC 1991b; Kahn 1992)
• Current estimates approach $1,400,000 to cover lifetime medical and institutional care for one child with the fetal alcohol syndrome (FAS) (Weeks 1990)

Each of these and many more health problems are significantly associated with the misuse of alcohol and other drugs. The indirect and direct costs of alcohol and other drug use should be presented as justification for both prevention and treatment services. The most significant point about these costs to society is that, through prevention and early intervention services, these costs may be significantly reduced. Every case of alcohol and drug abuse that effective outreach, prevention, and treatment can identify early or prevent entirely will produce cost savings for State and Federal Medicaid expenditures and for society as a whole. Those of us in the substance abuse field must learn to demonstrate not only that treatment works, but also that it is a wise investment in today's economy. Without intervention, our communities will endure the continued costs associated with drugs and alcohol—costs of accidents and injuries as well as additional expenditures for disability, lost productivity, and costs secondary to criminal activity.

Impact of Rural Supply, Production, and Distribution of Drugs
In addition to the health care and crime costs generated by rural drug abuse, policymakers must be made to consider the crucial role that rural and frontier areas play in the overall supply, production, and distribution of drugs. Drug cultivation and drug laboratories are certainly more likely to be found in less populated rural and frontier areas.

Drug smuggling—whether overland or by air in light aircraft—is a phenomenon of extremely rural and frontier areas; this smuggling is supported by our extensive interstate transportation networks. As a result of both availability and organized and active distributors, the drug use problem at production/ importation points in rural and frontier areas may be worse than in most large metropolitan areas.

Barrier #4: Perceived Lack of A Viable Political Solution

There is a perception that many rural problems do not have a viable political solution. This flawed view acts as a barrier to effective program development and therefore must be challenged head-on with quantitative data from national and local studies.

Every rural and frontier advocate needs to educate community decision makers in local businesses and local government on scientific findings, demonstrating that rehabilitation, education, and prevention efforts in substance abuse are effective and work. Such efforts can increase the community's economic opportunities, because potential employers want safe, healthy, and reliable work forces and communities. Every program needs to participate in some formal quantitative evaluation studies. Innovative programs should be fully documented as effective treatment modalities and as cost-effective intervention models.

Overcoming each of these barriers requires that rural and frontier communities be clear in their goals. They need to be effectively organized and to be active in directing all available resources toward their achievement.

Barrier #5: Absence of a Unified Rural Constituency

Unfortunately, a fifth barrier has been the absence of a unified rural constituency able to advance concerns and needs and to propose solutions. Each rural and frontier State would benefit from having an active and organized group of substance abuse providers, a government-sponsored advisory council, and a rural caucus. When political leaders and funding agencies are making decisions, they look to organized groups who can speak with a unified voice for a given population; they look for data that can provide valid and reliable proof of a position. This requires local and State organizational efforts, as well as efforts among those across State lines who have similar interests and causes to advance.

Once organized, efforts must be made at all levels of decision making through active communication and involvement with many individuals and groups. Those who should be approached, involved, and worked with include:

• Local and county governments
• State agencies
• State legislative committees
• Coalitions with other community groups

It is important to hold meetings with State governors, to inform Federal legislators of needs and concerns, and to present the group's agenda to relevant Federal agencies. The National Rural Institute on Alcohol and Drug Abuse itself can serve as a powerful vehicle for organizing and directing the interests of rural and frontier communities. With all of the competing interests for funding and special consideration, those with an organized and active constituency are most likely to receive attention and action.

Barrier #6: State And Federal Fiscal Crises

Finally, consideration must be given to the sixth barrier—current State and Federal fiscal crises. Advocates for rural program excellence need to be aware of and to understand the elements of a particular State budget crisis. It is critical for advocates to educate themselves about how substance abuse problems relate to budgetary problems. Ask yourself these questions. How much do you know about your State budget crisis? Does your State have a problem of income, a problem of outlay, or a combination of the two? Which outlays pose the greatest strain on the budget?

The substantial outlays for prison costs, Medicare, and Medicaid can all be related to the costs associated with chronic alcohol and other drug abuse. In this circumstance, modest investments in substance abuse treatment and prevention can produce large cost offsets and can contribute significantly to the management of these "runaway" outlay problems in State budgets. To a lesser extent, costs such as unemployment compensation and food stamps are also budgetary outlays that can be related to substance abuse.

Advocates for rural programs must have an organized constituency. In addition, the organization must be armed with valid and reliable data that will serve to educate decision makers about the needs of rural and frontier areas and the means for resolving problems in a cost effective manner.

Having presented this overview of flawed views of rural America and the barriers associated with these views, where do we all go from here? As a first step, you need to evaluate yourself and your organization about how prepared you are to overcome these barriers effectively. The scale below has been prepared as a checklist to help you assess both strengths and areas of untapped potential. Using the assessment scale, score yourself and assess where you might strengthen your efforts and expand your activities.

As we all know, there is much to be done. I hope this overview will assist each of you in determining— for your State—where you go from here.

References

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