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SUD in Urban vs. Rural Communities

Elena Hill, MD, MPH profile image
Medically Reviewed By Elena Hill, MD, MPH • Updated Oct 11, 2023 • 9 cited sources

Urban communities and rural communities both struggle with substance misuse but in slightly different ways. Rates of fatal overdose might be slightly higher in urban areas in recent years, due to increased availability of fentanyl. On the other hand, rural communities often lack accessible treatment resources as compared to more urban communities. Learn more about the unique challenges faced by different demographics when it comes to SUD treatment here. 

Comparing SUD in Urban Vs Rural Communities

Substance use disorder (SUD) can impact any community, but there are some key differences between how drug misuse affects urban and rural communities. Depending on where you live – in an urban, suburban or more rural community – SUD and SUD treatment may vary. 

Health Outcomes 

Rural communities often have worse health outcomes related to SUD compared to urban communities.[1] This is partially because urban communities, even poor urban communities, often have better access to quality health care and medical resources than more remote or rural communities. 

Overdose Rates

Overdose death rates in urban vs rural communities are generally similar. Urban areas tend to be slightly higher according to the CDC: The 2020 rate of urban overdose deaths was 28.6 per 100,000, and the 2020 rate of rural overdose deaths was 26.2 per 100,000.[1] These numbers are only small differences and are negated by other studies from other years which have actually shown higher overdose deaths in rural communities [1]. In addition, they might vary state by state: In the study cited above, 23 states had higher overdose death rates in urban areas, compared to eight states that had higher rates in rural areas.[1] The other 19 states weren’t included in the study. 

Access to Treatment

Generally, access to addiction recovery resources is better in urban communities. Urban areas see about 31.4% of all treatment admissions compared to the most rural areas, which see 7.2% of admissions.[4] There are multiple likely explanations for this: Urban areas have higher, denser populations, so they are more likely to have more people locally who need SUD treatment.In rural areas, there may be limited SUD treatment options, and even the options that are available may require significant travel to reach. In addition, there are fewer medical providers that are able to prescribe medications for addiction treatment (MAT) such as Methadone, Suboxone or Naltrexone. Lastly, there may be fewer therapists or behaviorists available in rural areas. 

Cultural Differences 

There may be different stigma and cultural differences around SUD treatment in urban vs rural areas. The Substance Abuse and Mental Health Services Administration found that Rural treatment facilities are much more likely to receive patients referred to them by the criminal justice system (at a rate of 51.6% compared to 28.4% of patients in urban areas) and less likely to receive self-referred patients. [4] The reasons for this are not clear, but it is possible that stigma in small or rural communities make it more daunting for patients to seek treatment on their own initiative.  

Which Drugs Are Hitting Each Community the Hardest?

It’s very hard to say which substances are hitting urban vs rural communities hardest. This is largely because the demographics of drug use vary greatly by State and geographic location, not just whether a community is urban or rural. For example, the west coast tends to have higher rates of stimulant use as compared to the east coast, whereas the east coast tends to have slightly persistently higher rates of opioid use (although that gap is narrowing in the era of fentanyl). Learn more here: 


The United States is currently in what has been a decades long opioid epidemic, made worse by the introduction of synthetic opioids. These opioids include fentanyl, fentanyl analogs, and tramadol are potent and fairly cheap to make illicitly, accounting for their widespread availability. 

Fentanyl is MUCH more potent than previously available synthetic opioids. For reference, fentanyl is 50 times stronger than heroin and 100 times stronger than morphine. [2] 

We do not know the exact rates of fentanyl in urban vs rural communities. These rates also vary greatly by State. 

Other Opioids & Stimulants

Current data suggests that urban communities see more overdose deaths involving cocaine, heroin and synthetic opioids. [3] Again, these numbers are just estimates, and likely vary greatly by State and region of the country. 


Alcohol misuse is also an ongoing problem in the United States. A 2021 National Survey on Drug Use and Health (NSDUH) found 29.5 million Americans ages 12 and older qualified as having alcohol use disorder (AUD), previously referred to as alcohol addiction or alcoholism. This represents 10.6% of the total age group. Men were affected more than women, and American Indian and Alaska Native people were affected the most of any minority group.[3] Alcohol use behaviors may vary between rural vs urban communities; for example, drinking culture and accessibility to alcohol may vary depending on ones location in a rural vs urban community. That being said, the rates of alcohol use disorder in rural vs urban communities, and across the population as a whole, tend to be relatively consistent/similar regardless of geographic location. 

How Treatment Differs in Rural & Urban Communities

According to SAMHSA, Patients in urban areas likely have more access to treatment: 14% of urban patients report five or more prior treatment visits compared to only 8.1% of rural patients. [4] Urban areas see about 31.4% of all treatment admissions compared to the most rural areas, which see 7.2% of admissions.[4] 

Rural communities are less likely to have good access to detox and inpatient care facilities, as well as fewer providers to offer medications. This leads to real disparities in SUD treatment in rural areas as compared to more urban areas. 

Co-Occurring Mental Illness

Other mental health issues commonly co-occur with SUD. The rates of co-occurring mental health problems are similar between members of urban and rural communities according to SAMHSA. However, people in urban areas with co-occurring mental health problems were almost five times as likely to report being homeless at time of admission into care compared to those in rural areas.[4] 

Some of the most common mental health issues patients with SUD also have include the following:[5]

  • Depression
  • Bipolar disorder
  • Anxiety disorders
  • Attention deficit hyperactivity disorder (ADHD)
  • Schizophrenia
  • Personality disorders

Just as there are fewer resources for SUD treatment in rural communities, there are often fewer resources for mental health treatment as well. This is another factor that can account for worse SUD treatment outcomes for patients in rural areas. 

The Emergence of Telehealth Companies for Substance Misuse

Telehealth is a relatively recent innovation in treating SUD and is majorly advantageous to helping patients in rural areas access care. This is a type of health service conducted digitally, usually through a smartphone or home computer. A patient can download an app and then use these services through the internet, talking with a medical professional who may be many miles away without needing to leave their home.

The Importance of Telehealth SUD Services for Rural Communities

Telehealth has proven very useful to help patients with SUD in rural communities get access to MAT for OUD.[7,8] 

The CDC notes that telehealth is “an effective approach for communication and counseling” when properly conducted. Telehealth services make it easier for doctors to monitor patients with chronic conditions. This not only includes conditions like heart or lung disease but also chronic mental health issues, including SUD.[9]

Efficacy of Telehealth for Addiction

While telehealth can’t replace all types of treatment, studies have found that this type of care works just as well as in person visits for those seeking SUD treatment. 

A 2021 review of telehealth interventions and outcomes across rural communities in the United States found that telehealth can have real benefits for patients, including increased access, higher levels of patient satisfaction, convenience and efficiency, and decreased direct and indirect costs.[9] 

Access Telehealth Care for SUD

Telehealth is a new way to increase access to SUD treatment to people in rural communities or in circumstances that might not be able to access in person treatment. 

At Bicycle Health, we offer MAT for OUD via our telehealth services. We can reach you, no matter where you live. Often, we can provide you with a same-day prescription for Suboxone if appropriate. Contact us today to get started.

Medically Reviewed By Elena Hill, MD, MPH

Elena Hill, MD; MPH received her MD and Masters of Public Health degrees at Tufts Medical School and completed her family medicine residency at Boston Medical Center. She is currently an attending physician at Bronxcare Health Systems in the Bronx, NY where ... Read More

  1. Urban-rural differences in drug overdose deaths. Centers for Disease and Prevention. Published July 28, 2022. Accessed September 6, 2023.
  2. Fentanyl facts. Centers for Disease and Prevention. Published May 12, 2023. Accessed September 6, 2023.
  3. Alcohol use disorder (AUD) in the United States: Age groups and demographic characteristics. National Institute on Alcohol Abuse and Alcoholism. Published 2023. Accessed September 6, 2023.
  4. A comparison of rural and urban substance abuse treatment admissions. Substance Abuse and Mental Health Services Administration. Published July 31, 2012. Accessed September 6, 2023.
  5. Substance use and co-occurring mental disorders. National Institute of Mental Health. Published March 2023. Accessed September 6, 2023.
  6. Khokhar JY, Dwiel LL, Henricks AM, Doucette WT, Green AI. The link between schizophrenia and substance use disorder: A unifying hypothesis. Schizophr Res. 2018;194:78-85. doi:10.1016/j.schres.2017.04.016
  7. Telehealth in rural communities. Centers for Disease and Prevention. Published September 8, 2022. Accessed September 6, 2023.
  8. Hser YI, Ober AJ, Dopp AR, et al. Is telemedicine the answer to rural expansion of medication treatment for opioid use disorder? Early experiences in the feasibility study phase of a National Drug Abuse Treatment Clinical Trials Network Trial. Addict Sci Clin Pract. 2021;16(1):24. Published 2021 Apr 20. doi:10.1186/s13722-021-00233-x
  9. Butzner M, Cuffee Y. Telehealth interventions and outcomes across rural communities in the United States: Narrative review. Journal of Medical Internet Research. 2021 Aug 26;23(8):e29575.

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