Abstract

BACKGROUND: In 2020, 2.8 million people required substance use disorder (SUD) treatment in nonmetropolitan or 'rural' areas in the U.S. Among this population, only 10% received SUD treatment from a specialty facility, and 1 in 500 received medication for opioid use disorder (MOUD). We explored the context surrounding barriers to SUD treatment in the rural United States.

METHODS: We conducted semi-structured, in-depth interviews from 2018 to 2019 to assess barriers to SUD treatment among people who use drugs (PWUD) across seven rural U.S. study sites. Using the social-ecological model (SEM), we examined individual, interpersonal, organizational, community, and policy factors contributing to perceived barriers to SUD treatment. We employed deductive and inductive coding and analytical approaches to identify themes. We also calculated descriptive statistics for participant characteristics and salient themes.

RESULTS: Among 304 participants (55% male, mean age 36 years), we identified barriers to SUD treatment in rural areas across SEM levels. At the individual/interpersonal level, relevant themes included: fear of withdrawal, the need to "get things in order" before entering treatment, close-knit communities and limited confidentiality, networks and settings that perpetuated drug use, and stigma. Organizational-level barriers included: strict facility rules, treatment programs managed like corrections facilities, lack of gender-specific treatment programs, and concerns about jeopardizing employment. Community-level barriers included: limited availability of treatment in local rural communities, long distances and limited transportation, waitlists, and a lack of information about treatment options. Policy-level themes included insurance challenges and system-imposed barriers such as arrest and incarceration.

CONCLUSION: Our findings highlight multi-level barriers to SUD treatment in rural U.S. communities. Salient barriers included the need to travel long distances to treatment, challenges to confidentiality due to small, close-knit communities where people are highly familiar with one another, and high-threshold treatment program practices. Our findings point to the need to facilitate the elimination of treatment barriers at each level of the SEM in rural America.

Document Type

Article

Publication Date

4-1-2024

Notes/Citation Information

0277-9536/© 2024 Elsevier Ltd. All rights reserved

Digital Object Identifier (DOI)

https://doi.org/10.1016/j.socscimed.2024.116660

Funding Information

This work was supported by the National Institute on Drug Abuse (NIDA) [UG3DA044829/UH3DA044829, UG3DA044798/ UH3DA044798, UG3DA044830/UH3DA044830, UG3DA044823/ UH3DA044823, UG3DA044822/UH3DA044822, UG3DA044831/ UH3DA044831, UG3DA044825, UG3DA044826/UH3DA044826] with co-funding from the Centers for Disease Control and Prevention (CDC), Substance Abuse and Mental Health Services Administration (SAMHSA), and the Appalachian Regional Commission (ARC). Research presented in this manuscript is the result of secondary data harmonization and analysis and was supported by grant U24DA048538 from NIDA. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, CDC, SAMHSA, the Department of Health and Human Services, or ARC.

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