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Substance Abuse in Rural Pennsylvania: Present and Future Laurie Roehrich, Ph.D., William Meil, Ph.D., Jennifer Simansky, M.A., William Davis, Jr., M.A., and Ryan Dunne, M.A.
This project was sponsored by a grant from the Center for Rural Pennsylvania, a legislative agency of the Pennsylvania The Center for Rural Pennsylvania is a bipartisan, bicameral legislative agency that serves as a resource for rural policy within the Pennsylvania General Assembly. It was created in 1987 under Act 16, the Rural Revitalization Act, to promoteand sustain the vitality of Pennsylvania’s rural and small communities.
Information contained in this report does not necessarily reflect the views of individual board members or the Center for Rural Pennsylvania. For more information, contact the Center for Rural Pennsylvania, 200 North Third St., Suite 600,Harrisburg, PA 17101, telephone (717) 787-9555, fax (717) 772-3587, email:
The focus of this project was to study the current status and trends in substance use and treatment in rural Pennsylvania tobetter understand present needs for prevention and treatment programs, and to make recommendations regarding future needs. To do so, the research team reviewed current trends inalcohol and drug use in rural areas of the state, reviewed literature on the cost effectiveness of drug and alcohol treat- ment, reviewed model science-based treatment and prevention Substance abuse rates and trends in rural programs, and surveyed rural treatment providers and ruralSingle County Authority (SCA) members across the state. The team also created a treatment center directory for all rural drug and alcohol facilities across Pennsylvania.
From their review of current trends in alcohol and drug use in rural areas, the researchers found data indicating that tobacco use is higher in rural areas, and that alcohol and drug use may be higher among rural teens when compared to urban teens.
Recent data also show high school seniors in Pennsylvania Single County Authority (SCA) survey . 1 0 drink, smoke, and use other drugs more than their counterparts across the country. Perhaps most alarming is the rate of binge drinking reported among these students, a behavior typicallyhighest among those in rural areas. The data also show that rural communities are worried about methamphetamine and heroinuse and that the use of OxyContin and other pharmaceuticalshas increased and appears to be somewhat more concentrated inrural areas.
In terms of cost effectiveness of treatment, the researchers found that even brief outpatient treatments appear to signifi-cantly decrease costs to the individual and to society as awhole. Compared to many other types of health care interven-tions, alcohol and drug abuse treatments are significantly lessexpensive than most medical procedures.
The researchers also found that there are a large number of both treatment and prevention intervention methods currentlyin existence, which are science-based and widely considered tobe effective. However, it is important to note that, to date,almost none of these interventions have been researched in ruralareas, including Pennsylvania. This is one area where the statecould be collecting data to determine how best to use thesemethods in rural settings.
The survey of SCAs and treatment centers in rural Pennsylva- nia also yielded interesting results. The SCA survey indicatedthat barriers exist to substance abuse prevention and treatmentprograms in rural areas and there was uncertainty amongrespondents about the prevention and treatment services intheir communities and the adequacy of funding for the services.
The survey of treatment centers helped the researchers to createa profile of providers in rural Pennsylvania and found that theretention and recruitment of treatment center personnel willdepend highly on continuing education and training andadequate compensation.
• Low population density may result in a lack of treatmentcenters, funding, and specialists; The focus of this project was to study the current status • The distance rural clients must travel may be considerable; and trends in substance use and treatment in rural Pennsyl- • A lack of trained professionals may result in decreased vania to better understand present needs for prevention and availability of treatment and potentially inadequate or treatment programs, and to make recommendations regard- ing future needs. The Center for Rural Pennsylvania’s 2004 • Rural clients’ reluctance to disclosure personal informa- attitudinal survey of rural Pennsylvanians shows that drug tion and find treatment in a small community for privacy and alcohol (D&A) abuse is one of the issues rated most highly among rural Pennsylvania residents as needing • Conflict between enrollment in a treatment program and higher priority in the years ahead. Sixty-four percent of respondents to this survey indicated D&A abuse required Operating hours of treatment facilities and client work greater attention in the future. In response to another schedules are typically the same, so if the distance between question, 49 percent of respondents said a future priority for the two are great, conflicts may exist. In addition, Campbell the state should be “strengthening programs to deal with et al. (2002) discuss the difficulty in attracting and funding drug and alcohol abuse” (Willits et al., 2004). In general, mental health providers and services in isolated areas and people in rural areas, when compared to urban populations, note that there is less likelihood of medical insurance have been found to experience higher poverty rates, more coverage for rural residents and a lack of information geographic barriers, greater isolation, fewer telephone and available about various entitlement programs. According to transportation options; are less likely to possess health the federal government’s Substance Abuse and Mental insurance or information about entitlement programs; and Health Services Administration’s (SAMHSA) website, have fewer employment opportunities (American Psycho- flawed views of rural America also represent a significant logical Association, 2002). These variables suggest that barrier for these communities, and this inaccurate picture many significant barriers to treatment are already present in results in an underestimation of how much funding and rural areas. Moreover, substance abuse should not be viewed services are really needed to effectively run treatment as an urban plight. Drug and alcohol problems are wide- spread across all areas of the nation and state. Given thatmore than 70 percent of Pennsylvania’s counties are designated as rural, according to the Center for RuralPennsylvania’s definition that is based on populationdensity, creating and maintaining a network of accessible, This research pulled data from a number of resources to affordable, well staffed and successful D&A prevention and understand the current treatment system in Pennsylvania treatment programs should be a priority (Harwood, 2000).
and predict how to best prepare for the future.
Data from the American Psychological Association (APA, The project, conducted in 2004 and 2005, included an 2002) indicate that across the U.S., more than half of all extensive review of current and predicted trends in alcohol rural counties are not served by a psychologist, psychiatrist and drug use, a literature review of cost effectiveness data or social worker. In Pennsylvania, the State Health Improve- and reviews of model treatment and prevention programs.
ment Plan Special Report and Plan to Improve Rural The research also entailed two surveys: one of SCA mem- Health Status notes that 16 of the 22 mental health profes- bers and one of rural alcohol and drug treatment center staff sional shortage areas in Pennsylvania are in rural counties (clinicians and directors) to find out more about their (Pennsylvania Department of Health, 2000).
There are substantial gaps in the research on substance abuse treatment and prevention in rural areas. Empirical inquiries that have been published are subject to method-ological issues, such as inconsistent definitions of rural,inadequate generalizations of results from urban to rural Substance abuse rates and trends in rural areas, and sampling methods that do not accurately repre- sent rural areas. All of these methodological shortcomings To understand substance abuse trends in rural Pennsylva- serve to render comparisons to rural Pennsylvania question- nia, the researchers examined the results of several national and state surveys, and reports from law enforcement.
There are countless numbers of substance abuse surveys administered at the national, state and local levels through- Despite variability across rural communities, some of the out the country. The findings reviewed here come from the barriers that rural residents face in finding and participating Monitoring for the Future Study, the Pennsylvania Youth in treatment for substance abuse appear, for the most part, to Survey (PAYS), the National Survey on Drug Use and Health be universal. Booth et al. (2001) have identified five barriers (NSDUH), and the Drug Enforcement Administration (DEA).
to treatment that rural residents face:Substance Abuse in Rural Pennsylvania: Present and Future The conclusions reached below are a general rank ticals have shown recent increases in use. Use of diverted ordering of the dangers represented by various drugs being pharmaceuticals in Pennsylvania is also high and shows used. Several variables were considered in this ranking, similar rates to those observed nationally. The use of these including the degree of use both nationwide and in Pennsyl- drugs appears somewhat more concentrated in rural areas vania, changing trends in use, the toxicity and addictive and the number of treatment admissions for their use has liability of the drug in question, and the degree to which it been rising in Pennsylvania, where law enforcement views represents a greater concern for rural communities both it as moderately to highly available.
7. Recent data show high school seniors in Pennsylvania 1. Alcohol represents a major public health concern drink, smoke, and use other drugs more than their counter- because of its widespread use and the social and health parts across the country. They are also more willing to try related consequences of that use. Continued vigilance alcohol and drugs, and drive under the influence of regarding alcohol abuse in Pennsylvania is especially alcohol or marijuana than 12th graders nationally. Perhaps warranted as it is the most commonly used drug among most alarming is the rate of binge drinking reported the state’s youth and use levels are above those seen among these students, a behavior typically highest among nationally. Moreover, alcohol use and associated prob- lems should be of particular focus in rural areas where use 8. Marijuana use is widespread, though it has shown rates are highest on some measures, such as binge drinking.
recent decreases in Pennsylvania and nationwide. In 2. Like alcohol, tobacco products remain a substantial Pennsylvania, marijuana use ranks third among the drugs problem because of their degree of use. While both used by adolescents, yet statewide use appears to be cigarette and smokeless tobacco use have shown recent below the national average on most measures. While declines, the decreases appear to be slowing (cigarettes) or readily available, though perhaps less in rural areas, have stopped (smokeless tobacco). Cigarette smoking in marijuana is viewed by law enforcement as less of a threat Pennsylvania is the second most common drug used by youths and their use is above the national average across 9. Inhalants are emerging as a class of drugs. They are the most age groups. Given that both cigarette smoking and one of the few drugs showing the clearest evidence of the use of smokeless tobacco products show higher levels increased use in recent years. Moreover, leading indica- of use in rural communities, the use of tobacco products tors of continued use, such as perceived risk, suggest this within rural regions remains a point of considerable trend may continue. Use of inhalants currently ranks fifth in prevalence among Pennsylvania’s youth. Moreover, 3. Heroin use has been relatively low and stable across inhalant use among rural communities is as high as in population densities for the last few years. However, it is viewed by law enforcement as the number one drug threat 10. The threat posed by “club drugs,” like ecstasy and in Pennsylvania. Heroin appears to be readily available GHB, is serious, but less than the dangers associated with throughout the state and has recently become responsible heroin, cocaine, marijuana, diverted pharmaceuticals, and for a growing number of treatment admissions in the state.
methamphetamine, according to the DEA. The rate of Once an urban problem, heroin can now be found causing ecstasy use has been declining and its use does not appear problems in many communities across the state.
to pose a greater threat to rural communities than to other 4. Methamphetamine has shown some recent declines in use nationally, but its spread across Pennsylvania is of When trying to make predictions regarding trends in rural growing concern. Production is greatest in rural regions of drug use in Pennsylvania there are several factors to be the state and many believe its spread from rural regions, taken into account. The first is that there is no single study especially the Northwestern corner of the state, is immi- that provides data directly examining rural versus urban nent. Methamphetamine is of grave concern both because differences in use across regions of Pennsylvania. Perhaps of its harmful effects on the user and the dangers associ- the most relevant data that exists comes from the PAYS study and it does not allow for direct comparisons of use 5. Cocaine and crack cocaine use remain relatively stable across population densities. Furthermore, this study is and lower than in the later part of the last decade, though limited to adolescents and fails to consider differences that some data suggest their use may be increasing among the may occur across life spans. In addition, there is little state’s youth. However, it now appears that rural commu- consistency between the definitions of various populations nities are more susceptible than ever to the problems between the available sources of information. Thus the posed by cocaine and crack cocaine. Law enforcement has conclusions of this report, stated earlier, regarding trends in designated cocaine as a drug of major concern because of rural substance use are based on projections from a variety its availability and extent of use. The degree of threat of sources and assessments made by law enforcement.
posed by cocaine and crack is magnified by the violence Acquisition of data that directly addresses rural versus associated with the cocaine and crack trade.
urban drug use differences in Pennsylvania will greatly 6. Nationwide OxyContin and other diverted pharmaceu- improve the ability to predict trends in the future.
Review of literature on cost effectiveness would be a large scale, expensive, and time-consuming Attempting to prove whether or not alcohol and substance enterprise for Pennsylvania. But, later savings and improve- abuse treatment is a solid investment is typically measured ments in the treatment delivery system would offset the costs of such a project. In the meantime, it should be noted First, some studies concentrate on cost effectiveness.
that when cost analysis has been performed at either single Outcome measures are typically not defined by dollars and sites or throughout entire states (California, Oregon), using cents but by significant improvement on variables such as cost effectiveness, cost benefit, or cost offset approaches, the alcohol and drug use, legal problems, employment status, results are quite encouraging. No matter how it is measured, mental health status or physical and medical problems. It is treatment appears to be a wise investment.
assumed that improvement on these outcome variables is One of the most widely noted projects is known as associated with decreased costs to society, but these CALDATA (Gerstein, Johnson, Harwood, Fountain, Suter, & changes are not directly quantified. If two (or more) treat- Malloy, 1994), a large-scale study that took place across the ment approaches result in similar positive client outcomes, entire state of California. The study is especially notable this would suggest that providers could safely opt to because the clients who participated in the research were whichever treatment intervention is cheapest to deliver.
randomly chosen. This significantly decreases the possibil- The second body of literature, referred to as cost benefit ity of over sampling persons who are motivated, doing well studies, uses outcomes that are translated into monetary and remaining in treatment. The study took place in 16 scales. These studies often focus on outcome measures, such countries, involved 97 different treatment centers, and as reductions in crime and victimization, productivity in the enrolled 1,850 clients, some of whom were followed for up workplace, criminal justice expenditures, or in benefit to two years. The California system of alcohol and sub- programs such as welfare or disability.
stance abuse treatment is the largest in the nation. Authors The last branch of research is a type of cost benefit study, estimated the cost of treating the approximately 150,000 but the emphasis is placed on outcome measures that clients seen in 1992 at $209 million. But, benefits to the estimate savings in the area of health care expenses. This taxpaying public totaled over $1.5 billion in savings. One research is generally labeled as a “cost offset” study.
day of treatment pays for itself, primarily through reduc- No matter which approach is taken, most studies require at tions in crime. Depending on the type of treatment (outpa- least one year’s worth of data for comparisons and standard- tient, residential, and specialty opiate specific treatments were studied) the benefits of treatment outweighed the cost Each of the approaches described above requires data by a 4:1 ratio (residential), to as high as 2:1 (methadone for about the cost of treatment. Treatment costs include the opiate users). Benefits following treatment extended across expense of delivering the services by qualified staff and the two-year period. Keep in mind that all of these studies providers, and the cost of services that are reimbursed by calculate costs/benefits generally over one to two years; health insurers. A national sample of providers shows wages thus, lifetime savings would be even more impressive and salaries for treatment personnel to account for about estimates. Overall, CALDATA research noted an average $7 half of the total costs of treatment, and administrative and return for every $1 dollar spent on treatment.
maintenance expenses to account for about one quarter of One recent comprehensive review of the substance abuse the costs (CSAT, 2001). These primary budget expenditures treatment cost effectiveness literature (Harwood, Malhotra, are generally far higher than costs for facility rental or Villarivera, Liu, Chong, & Gilani, 2002) included 58 purchase and depreciation (estimated at 5 percent), utilities studies. The authors concluded that there is not a very (4 percent), or medical and laboratory costs (3 percent). It is strong body of evidence, employing good scientific important to keep in mind that for the majority of treatment methods and rigorous study designs, indicating that programs in Pennsylvania, as well as in other areas, the most receiving some or any treatment is better (and preferable) common type of staff expenditure is for counselors, includ- than receiving none, but that the economic benefits signifi- ing certified addiction counselors (CACs). In general, these cantly outweigh the costs of providing treatment. Invest- staff members are paid on a significantly lower scale than ment returns on $1 of treatment generally ranged from $4 to other types of health professionals, such as nurses, physi- $14, depending on the level of care and type of alcohol/ cians, or psychologists (who comprise only about 5 percent of the personnel expenditures in substance abuse treatment).
The second task of Harwood et al. was to explore the cost This suggests that there may be a limit to how low expendi- effectiveness issue – are some treatments better than others tures can go, given that the lower-paid CACs are the current and also cheaper to deliver? The alcohol and substance workhorses of most treatment centers.
abuse treatment system throughout the U.S. is based on a When compiling studies and publishing research litera- levels-of-care model that was designed by the American ture for this report, no studies were located that used Society of Addiction Medicine (ASAM, 2004). ASAM Pennsylvania as a study population, and only several provides two sets of guidelines, one for adults and one for projects (with data collected in other areas of the U.S.) made adolescents, and five broad levels of care for each group.
any comparisons between rural and urban populations. This Within these broad levels of service is a range of specific Substance Abuse in Rural Pennsylvania: Present and Future levels of care. This model, which is used as the standard in with additional mental health problems or cognitive Pennsylvania, emphasizes using outpatient services deficits, and clients with additional health problems such as whenever possible, and limiting residential and inpatient HIV. However, no studies have directly addressed the stays to shorter durations. Most data suggest that outpatient variable of urban versus rural populations, and it is worth treatment, and in one study even the more costly outpatient noting that most of the large multi-site trials displaying the detoxification services (Hayashida, 1989), are effective and effectiveness and utility of the Project MATCH manuals and cheaper than inpatient stays. Pennsylvania’s Intensive treatments were conducted in larger urban areas. However, Outpatient Programs (IOPs) have not been studied. However, the nine data collection sites were dispersed across the this program also advocates effective treatment for less nation, suggesting that the effectiveness of the interventions money than an inpatient treatment episode. For many was not limited to any particular geographic region.
clients, it is also preferable because they can remain at home Approaches developed primarily for the treatment of or work during the evenings rather than living in a hospital cocaine (and now methamphetamine) addiction include Cognitive-Behavioral Therapy (Carroll, 1998) and Commu- One final question explored by Harwood and colleagues nity Reinforcement (also referred to as Contingency was treatments for special populations. The research found Management; Higgins et al., 1991, 1994). Both of these that women benefited from treatment as much as men, with interventions have been studied in depth by the National cost benefits slightly lower due to women’s lower crime Institute of Drug Abuse and have been found to be effective rates both during and after treatment. Veterans, treated at the strategies. As with Project MATCH, the majority of projects Department of Veterans Affairs system, have been exten- were centered in more urban areas and rural centers have not sively studied, and this research led to changing most 28- day programs to 21 days. The longer stay did not create Relapse Prevention (Marlatt & Gordon, 1985) is an enough additional improvement to warrant the costs. The approach that can, and has, been used with all types of study of clients with dual diagnoses has played a major role alcohol and drug problems, as well as with gambling in the development of case management services and disorders and smoking cessation. It has been shown to be Mentally Ill Substance Abuser (MISA) programs. Both of effective in medical settings and outpatient clinics both in these approaches are used in Pennsylvania and appear to the U.S. and beyond. The intervention rests on the assump- result in reduced hospitalizations (cost reduction). For those tion that relapses can occur almost automatically, without with the most severe problems, residential therapeutic conscious intent, unless the client is trained to look for community (TC) placements may also be useful in symptom warning signals and employ strategies to help avoid or cope improvement and reducing high expense health costs such with situations, emotions, and even locations where alcohol as emergency room visits. Lastly, the authors reviewed prisoners/offenders receiving treatment in jail or prison, and Harm Reduction (Denning, 2000; Marlatt, 1998) is a more drug court data. These two approaches were both found to controversial approach because it recognizes that some be highly cost effective and to result in lower rates of clients may not initially be ready or capable of complete substance relapse and lower rates of criminal recidivism.
abstinence. However, the argument for Harm Reduction is Pennsylvania currently has fewer than a dozen drug courts, that even decreases in use can lead to improved quality of and may want to expand this option given the promising life, better public health and reduced crime, and many data in this area. Overall these findings suggest that special clients who begin in this modality eventually move towards populations also benefit from treatment, and while data are lacking in this area, it would be hypothesized that rural Drug therapies, particularly Methadone Maintenance, clients also experience significant clinical and cost effective have also been widely studied and shown to be effective in a variety of settings. These pharmacotherapies may alsoinclude counseling sessions, groups, or other medical care in order to stabilize patients with opiate dependence. This Model treatments
treatment is provided in specialized centers, and few of There are numerous treatment and prevention programs these are easily available or accessible to rural clients.
that are being widely used and have been studied. For The pros and cons of using any of these science-based example, three treatments for alcohol problems, funded by treatments in rural settings should be considered.
the federal government, are used in Project MATCH. The 1. Training and research are needed for practitioners to efficacy of these three psychological approaches to treat- learn the interventions and to carry out the treatments ment has been studied in great depth since the late 1980’s.
faithfully and as intended (sometimes known as “treat- Each of the approaches has been shown to have sustained ment adherence” research). This can be costly in terms of effects over one year or longer in an impressive range of both time and money. However, it would provide the state, patient populations, including males and females, ethnic researchers, and treatment center staff with quantifiable minorities, outpatient versus aftercare treatment, clients results about how, and if, their programs are working.
2. Barriers, such as transportation and stigma, may play a larger role in treating clients in rural areas. Approaches tion at the school or community level over several years.
that attempt to remove barriers, either through providing Creating Lasting Family Connections offers a family transport or other material supports or providing commu- strengthening, substance abuse, and violence prevention nity education about treatment for alcohol and drug model. Program results, documented with children 11 to 15 problems as a gift given to family and friends (rather than years, showed significant increases in children’s resistance weakness or stigma) can be compared to groups of clients to the onset of substance use and reductions in use of alcohol and other drugs. The program seems to focus on 3. Many of the large scale studies reviewed offer indi- resiliency issues, and includes the entire family rather than vidual treatment sessions, which can be too costly to just the individual child. However, it may be more difficult implement in many centers. Individual sessions may work to recruit and retain families, when compared to interven- better than group sessions, although smaller centers may tions that reach children in school settings. The plus for find it difficult to provide such a wide array of approaches rural communities would be that family oriented prevention due to limited resources and staff. However, this question may ultimately foster more large scale changes, including has not been researched extensively. Rural centers that less use of more expensive services, such as drug and adapted a program, turning it into a group format, could collect outcome data to see if these more efficient group Another program that focuses on the family would appear sessions translate into behavior change. In this case, the to be far less costly to implement. Family Matters is a home- cost outlay is not too expensive given that many centers based program designed to prevent tobacco and alcohol use do have chart data that would include drug testing results in early adolescence. The program is delivered through four for participating clients and could review those data to booklets. These are mailed to the home and then health educators make follow-up telephone calls to parents. Thebooklets include readings and activities designed to help Prevention programs
families explore general family characteristics and family The Substance Abuse and Mental Health Services Admin- tobacco- and alcohol-use attitudes and characteristics that istration (SAMHSA) published several monographs regard- can influence adolescent substance use.
ing substance abuse prevention programs (USDHHS/ Although rural communities appear to use computers and SAMHSA, 2002) and has created a website providing the internet less frequently, those numbers are likely to information about model programs and the criteria used to increase in the future. One step up in terms of sophistication and technology is the Parenting Wisely intervention. This is All SAMHSA prevention programs that have been a self-administered, computer-based program teaching implemented in rural settings were reviewed. A few of these parents and 9- to 18-year-old children skills to combat risk appeared to have possibilities for rural Pennsylvania factors for substance use and abuse. The interactive and communities. One program, Across Ages, is a school and nonjudgmental CD-ROM format accelerates learning, and community-based drug prevention program aimed at youth parents can use new skills immediately. The program has 9 to 13 years. The goal is to strengthen bonds between shown positive results regarding avoidance or reductions in adults and youth and create opportunities for positive community involvement. The program pairs older adult One model program, developed in Pennsylvania, was mentors (age 55 and above) with young adolescents. Given aimed at a very specific population and may not be ideal for that Pennsylvania has a significant aging population, a the general population or rural areas where privacy issues program like this might be quite feasible and desirable. One may be a significant concern. Trauma Focused Cognitive warning from the creators of the program was that adoles- Behavior Therapy (TF-CBT) is designed to help children, cents should only be paired with adults they do not already youth, and their parents overcome negative effects of traumatic life events including child sexual or physical All Stars™ is a school- or community-based program abuse; traumatic loss/death of a loved one; domestic, intended to delay and prevent high-risk behaviors in middle school, or community violence; and exposure to disasters. It school-age adolescents, including substance use, violence, integrates cognitive and behavioral interventions with and premature sexual activity. The emphasis is on fostering traditional child abuse therapies. The focus is on enhancing development of positive personal characteristics. All Stars children’s interpersonal trust and empowerment and includes nine to 13 lessons during its first year, and seven to targeting any Posttraumatic Stress Disorder (PTSD) symp- eight booster lessons in its second year. The program is toms as well. Significant reductions in alcohol and sub- based on strong research that has identified the critical stance use were seen as a byproduct of the intervention.
factors that lead young people to begin experimenting with In summary, there are a large number of both treatment substances and participating in other high-risk behaviors.
and prevention intervention methods which are science- Given the positive outcomes found with this program, it based and considered to be effective. However, it is impor- would appear to be a good alternative to DARE. However, it tant to note that, to date, almost none of these interventions may be cost and time intensive to implement an interven- have been researched in rural areas, including Pennsylvania.
Substance Abuse in Rural Pennsylvania: Present and Future This is one key area where the state could be collecting data and Alcohol Advisory Council, a Student Assistance to determine how best to use the methods in rural settings.
Program, and a Comprehensive K-12 Tobacco, Alcohol, andOther Drugs Curriculum.
Effective treatment and prevention strategies for
To summarize, there have been a handful of studies rural Pennsylvania
produced on effective treatment and prevention strategies Overall, the trend in treatment strategies in rural Pennsyl- for rural Pennsylvania, but there are some problems inherent vania is toward collaborative efforts between governmental in predicting trends from such scant research. Anecdotal and private organizations to provide integrated treatment support, generally in the form of case studies or simple and prevention strategies. For example, Zielinsky (1995) evaluation studies of program effectiveness, lack the proposed an Intensive Outpatient Vocational Rehabilitation methodological and analytic rigor that is used to character- Program (IOVRP) for residents of Fayette County. IOVRP, ize interventions as effective or not.
which was designed to holistically address the intertwinedissues of acquiring gainful employment and recovery from substance abuse, is especially promising because it is To receive state and federal substance abuse treatment and vocationally based. To address barriers to treatment such as prevention funds, counties in Pennsylvania are required to transportation, decreased funding, and availability of establish SCAs, which are responsible for program planning services, the designers of IOVRP formed a collaboration and administration of funded grants and contracts. The SCA with the Fayette County Drug and Alcohol Commission, system is governed by the Bureau of Drug and Alcohol Goodwill Industries, and the Office of Vocational Rehabili- Programs (BDAP). Some of the state’s 67 counties have tation to provide individual and group therapy, merged to share administrative costs and resources, referred psychoeducation, and vocational training, at a centralized to as joinders, resulting in the establishment of 49 SCAs.
SCAs are the primary contractor/or grantee for state and Another program that exemplifies the collaborative and federal allocated funds from BDAP. BDAP allocates funds to integrated movement of substance abuse treatment in rural the SCAs through two mechanisms. The first is based on Pennsylvania was conducted by Pinter (1995) in county population data and constitutes the majority of state Northumberland County. Pinter proposed Project SWAP and federal funding provided to the counties. The second is (Seniors With Addiction Problems) as an interagency effort through requests for applications (RFAs) in which BDAP to: promote effective identification and treatment of seniors identifies critical populations or important service needs with additional problems living in Northumberland County, across the state, and through grants, attempts to address conduct outreach substance abuse education to isolated and these issues. In most counties D&A education, prevention, stay-at-home seniors, and foster a concise and effective intervention, and treatment services are provided by referral system among collaborating agencies. Staff members independent facilities under contracts with the SCAs (BDAP, of the local Area Agency on Aging were trained to make referrals to the Northumberland County Single Authority for Because the SCAs are the county’s extension of the state’s drug and alcohol treatment that was provided in-home to D&A programs, they represent the intersection between the avoid the stigma that accompanies going to a psychological state’s objectives and goals and the local service needs of clinic. Prior to the implementation of Project SWAP, each county. Therefore, the research team surveyed SCA virtually none of the elderly in Northumberland County members from Pennsylvania’s rural counties to garner were identified as potential substance abusers. The results of information about the D&A service needs of these commu- this study indicate a substantial increase in referral and nities and the extent to which the state’s D&A programs treatment of elderly substance abusers.
There have also been prevention strategies that have The researchers mailed surveys to 33 SCAs that have received support for use in rural Pennsylvania. For example, authority in rural counties of Pennsylvania. The SCAs, in Thompson (1997) describes a Community Outreach Project turn, distributed the surveys to their members. Of the 33 that was implemented by the Tussey Mountain School rural SCAs that received the surveys, 19 different SCAs District in Bedford County. In this published program (57.6 percent) responded. Eighty-two individual surveys evaluation, the local school district served as the facilitator were received from SCA members with the number of for an interagency collaborative that was gathered to respondents from each SCA ranging from one to 11. The provide educational and prevention services to identified mean number of surveys received from responding SCAs youth. The school district used data gathered from the was 2.75. Respondents were from SCAs across all geo- Primary Prevention Awareness, Attitudes, and Usage Scales, which was administered to 7th to 12th grade students. Upon Two major themes stand out from the review of the SCA review of the various intervention services available to survey: first, barriers exist to substance abuse prevention students, the school district was able to identify many and treatment in rural areas. For example: successful programs including a Community/School Drug • Close to half of the respondents did not believe therewere a sufficient number of continuing education pro- grams directed toward prevention and treatment issues in Other key observations
• When asked about changes in the numbers of clients • About 32 percent of respondents believe that BDAP does treated over the last two years for specific drugs, most not show sufficient commitment to rural substance abuse SCA respondents reported an increase in clients treated for methamphetamine (59 percent), cocaine (64 percent), • About 44 percent of respondents believe that BDAP oxycontin (79 percent), heroin (78 percent), prescription funding is inadequate for prevention needs; drugs (56 percent), and polydrug/multiple substance (62 • About 57 percent of respondents believe BDAP funding • 83 percent of respondents believed that D&A abuse and • 39 percent of respondents believe that state funding for dependence will increase in their community in the next D&A prevention and treatment is biased against rural two years while 2 percent believed it would decrease and • About 51 percent maintain the quantity of substanceabuse treatment is below that seen in urban areas; • About 48 percent believe that funding for D&A services According to the National Survey of Substance Abuse Treatment Services (N-SSATS), on a typical day in 2004, • Almost 49 percent disagreed with the statement that there were approximately 38,000 clients enrolled in D&A dependence was considered a healthcare priority by substance abuse treatment in Pennsylvania. This included both public and private facilities across the state. About 72 • About 57 percent do not believe that treatment and percent of the centers were private non-profits, 25 percent prevention programs developed for urban populations were private for-profit facilities, and the remainder included Veterans Affairs and state and local government facilities, • 44 percent believed their rural location represented a for a total of 465 centers. The majority of facilities are barrier to finding qualified treatment employees in their clustered in larger, more urban areas, as can be seen in Figure 1. For the 48 rural counties in Pennsylvania, the • Respondents ranked the following as impediments to number of available centers ranged from zero in Snyder D&A treatment within their communities - stigma and county to 13 in Mercer County. The primary treatment financial burden (26 percent), rural culture (20 percent), modality offered is outpatient (78 percent), followed by lack of access to available services (17 percent), and residential and inpatient services. About 50 percent of clients in Pennsylvania are being treated for both alcohol The second major theme from the survey was the uncer- and drug problems, suggesting that, throughout the state, tainty of the respondents regarding key questions related to polydrug use has become the most common reason for seeking prevention and treatment services within their counties and the adequacy of funding for those programs. Most notably: The number of clients served in rural counties over a one- • 44 percent of respondents were unsure of whether year period (2004) was also quite variable, with a low of 10 funding and programs from BDAP have changed to meet clients in Forest County to a high of 1,708 total admissions • 42 percent were unsure about BDAP’s commitment to To learn more about staffing and experiences of rural centers and the resources available to staff to meet the needs • 35 percent were unsure if the funding provided by BDAP of their communities, the researchers surveyed rural treat- is adequate to meet their prevention needs; ment personnel. The survey was mailed to all known • 24 percent were unsure if BDAP funding for treatment is treatment centers (for the year 2005) in 21 of the 48 rural Pennsylvania counties. The counties were chosen to reflect • About 46 percent were unsure if BDAP funding based on all the rural regions across the state.
A packet of 15 surveys (to allow for differences in staff • 46 percent were unsure if the allocation of state funds for size and lost or misplaced surveys) was mailed to the D&A prevention and treatment were biased against rural director of each treatment program, along with a cover letter explaining the project and asking the director to complete • 59 percent were unsure if RFAs have been effective in the survey and to share it with treatment staff members.
directing funds towards critical populations that are found Surveys were returned from 29 of the 80 centers, for a • BDAP has designated several goals to fulfill its mission Data from the surveys were analyzed in one large group in developing a statewide plan for addressing D&A (n=95) as there were no significant variations by county dependence and abuse, and many respondents were regarding the demographics of treatment staff, and analyz- unsure as to whether they are meeting these goals.
ing by individual centers might compromise the confidenti-ality of the participants.
Substance Abuse in Rural Pennsylvania: Present and Future In general, the rural Pennsylvania providers who re- • Offering mobile therapy, similar to home or commu- sponded to the survey tended to have the following charac- nity visits provided by the Visiting Nurses Association, teristics: female; white; college educated; not doctors, psychologists or social workers; credentialed in addiction • Widening the community net by educating physi- counseling; in the field for six years or less; at their current cians, clergy, and mental health providers about routine center for three years or less; attempt to deliver a very wide array of services and treatments; committed and hard • Offering bibliotherapy (readings and workbooks on working despite lack of funding and other resources; and addiction or prevention) to clients by delivering familiar with and use evidence-based treatments.
materials or videotapes/DVDs and other home study This group also tended to have lower salaries, statewide, compared to other health service professions, such as • Using Internet resources where clients would “meet” nursing, occupational therapy, and other professions based online, attend support groups, and receive in hospitals or local health clinics.
5. Confidentiality, stigma and stoicism are important issues in rural areas, based on the comments provided byboth SCA and treatment center survey respondents. Publiceducation and interventions may need to be designed to Based on the review of trends, research literature and address specific cultural issues within each community, as survey data, the researchers offered the following consider- a one-size-fits-all approach may not be successful.
1. Statewide data for both rural and urban areas on • Enlisting “community experts” who are in recovery outcomes assessment and cost-effectiveness are needed.
from alcohol or drug problems, and willing to provide The data should include alcohol and drug use measures public health information and referrals on an informal and at least one-year of follow-up. Undertaking this project, and comparing rural versus urban areas would • Using treatment centers and support groups, such as make Pennsylvania a model state in terms of its approach Alcoholics Anonymous, more often if they are housed to alcohol and substance abuse treatment and prevention.
with other types of medical offices, businesses, reli- 2. Pennsylvania, beginning with BDAP, should consider gious or spiritual centers, or even shopping malls viewing rural as a demographic variable, such as gender (McLellan, O’Brien, Lewis, & Kleber, 2000); and ethnicity. Statistical comparisons of rural versus • Presenting alcohol or substance use services to metropolitan areas or rural versus urban clients are individuals in the community as a positive step for lacking in the research literature and in statewide reports.
It would be important to look across age groups as well.
6. Attracting and retaining quality staff at treatment For example, a focus on adolescents and young adults centers is critical. As some areas of the state have been may aid in later prevention efforts, but Pennsylvania also designated as medical shortage areas, a similar approach has an aging population. Therefore, it will be critical to could be advocated regarding the training and retention collect data across life spans. Community specific data may also assist BDAP and the state in forming initiatives 7. Continuing education is important for staff. Rural to target specific problem areas or special populations.
treatment directors indicated their desire to offer continu- 3. The use of evidence-based, empirically supported ing education as incentives; however, they had no budget “model” treatments and prevention programs should allocation to fund the idea. Survey respondents also felt continue to be encouraged. However, both SCA members that more continuing education information should be and rural treatment staff reiterated in their survey re- sponses that it is often not all clear how well and how 8. More partnerships with universities would be benefi- easily many model programs - generally developed in cial. The state should encourage colleges and universities more urbanized areas - translate to rural settings. It also to become more involved in their community’s treatment unclear, based on the data collected through this research, and prevention system in positive ways. There is a if practitioners truly adhere to these generally manual- substantial subset of college and university faculty who possess expertise in substance abuse issues, epidemiol- 4. Accessibility and transportation to alcohol and drug ogy, medical research, and the economics of cost effec- abuse services or prevention programs appear to be major tiveness and healthcare utilization models. These experts impediments for clients. Rural centers need both funding should be encouraged to contribute to rural programs by and creativity to deal adequately with these issues.
aiding in study design, grant writing, data analysis and many other activities. Encouraging and perhaps providing • Piggybacking on existing transportation within a a jump-start to long-term partnerships between these entities may prove useful and cost effective.
9. Consider expanding the buprenorphine (pharmaco- 12. Community-based mutual support groups such as therapy for opiate dependence) program in rural areas as Alcoholics Anonymous are available in most rural commu- access to other resources, such as methadone mainte- nities, although there are generally fewer of these groups nance, is extremely limited. The state may consider when compared with urban settings. Given that the national funding research that looks specifically at this treatment, overall trend is toward treatments that are as brief as how best to recruit physicians in rural areas to join the possible, with only the most severe problems requiring program, and to employ standardized methods to assess inpatient, residential or long term outpatient care, it the efficacy and cost effectiveness of the approach.
becomes more critical to ensure that rural clients are hooked 10. For opiate dependent clients who do not qualify for into ongoing community support systems. As these groups buprenorphine treatment, or do not have that option are also free, there is no cost to the state of Pennsylvania, available in their area, referrals for methadone mainte- the substance abuser or mental health systems in the nance, methadone detoxification, or naltrexone often require traveling to another more urban county to receive 13. While it was beyond the scope of this research, it is treatment. If daily dosing is required, clients may spend important to note that alcohol and substance use are up to two to four hours per day traveling for services.
systematic problems involving a wide array of both risk and Transportation problems and the potential impact on a protective variables. The treatment and prevention systems, client’s ability to find or maintain employment are key discussed in this paper, are only one key aspect. However, hurdles for rural people requiring opiate treatment expansion of the drug court model, and the provision of services. It is not cost effective to provide a methadone or adequate assessment and treatment services in jail or in opiate specialty program in every county. However, prison facilities would also appear to be sound investments.
conflicts could be reduced and clients would be more The use of a community drug court system generally likely to remain in treatment if they are able to earn “take remands clients to the appropriate level of treatment homes.” This method allows clients to take home one or services and gauges their progress, avoiding the high more doses of methadone or other pharmacotherapy expenses associated with jail or prison stays. Simple contingent on the clients’ number of abstinent/drug free environmental changes such as seatbelt usage, server days. Research on this method indicates it may keep training for bar employees, taxes on alcohol and cigarettes clients in treatment longer, and reduces costs.
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Vice Chairman
Northeast Regional Center for Rural Development


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