Rural Community 

Action Guide

Building Stronger, Healthy, Drug-Free Rural Communities
Inside Front Cover
Table of Contents 3

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

Table of Contents

Letter from ONDCP Director, James W. Carroll. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Letter from ONDCP Senior Advisor for Rural Affairs, Anne C. Hazlett. . . . . . . . . . . . . . . . . . . . . . . . . 7

Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

SECTION 1: Face of Addiction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

The Changing Face of Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Moving Beyond Stigma in Rural Communities by Addiction Policy Forum....................... 16

Using Data to Better Understand Substance Use Disorder and Opioid Use Disorder 

by NORC Walsh Center for Rural Health Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

SECTION 2: Impact of Addiction on a Rural Community. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Managing the Push and Pull on Fiscal Resources during the Opioid Crisis 

by National Association of Counties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Workforce Development: Increasing Opportunities for Employment During the Opioid Crisis 

by National Association of Development Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Rural Broadband is Fundamental to Increasing Healthcare Access in Rural Communities 

by The Rural Broadband Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Bridging the Transportation Gap for Access to Substance Use Disorder Services 

in Rural Communities by National Rural Transit Assistance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Overcoming Economic Challenges Amid the Opioid Crisis 

by Appalachian Regional Commission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

SECTION 3: Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Stop Drug Use Before It Starts, Early Prevention and Early Intervention Strategies that Work 

by the U.S. Department of Agriculture, National Institute of Food and Agriculture . . . . . . . . . . . . . . . 41

Community Driven and Shaped Solutions Change Lives 

by Community Anti-Drug Coalitions of America . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
4 Table of Contents

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

Taking Action to Address Substance Use Disorder in the Farming Community 

by American Farm Bureau Federation and National Farmers Union . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

SECTION 4: Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Strengthening the Rural Healthcare Network for Persons Seeking Treatment 

by National Rural Health Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Understanding Why Medication Assisted Treatment is Different in Rural Communities 

by The Pew Charitable Trust . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Moving from Lock’em Up to Providing Treatment and Support 

by National Sheriffs’ Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Making Drug Courts Work for Rural America by Center for Court Innovation..................... 63

SECTION 5: Recovery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

How Faith Communities Can Help Rural Communities Address Substance Use Disorder 

by the U.S. Department of Agriculture, Center for Faith-Based and Neighborhood Partnerships . . . . . 70

Building a Strong Recovery Community in Rural Areas 

by National Alliance for Recovery Residences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Mobilizing the Recovery Community in Rural Areas by Faces & Voices of Recovery . . . . . . . . . . . . . . . 77

Increasing Housing Options for Persons in Recovery in Rural Communities 

by Housing Assistance Council . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Closing Thoughts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Rural Community Action Guide Partners. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Endnotes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
5

Notice and Disclaimer:

The Rural Community Action Guide is a compilation of qualitative data collected from numerous 

community organizations, and data arranged by category. The guide aims to educate the public by 

providing an overview of the key challenges rural communities face when addressing the consequences 

of prescription opioid misuse and the use of illicit substances. It also showcases localized efforts 

implemented to help mitigate the impact of substance use disorder. The information provided herein 

should not be construed as the Federal Government’s official policy position on these issues nor does 

it serve as an endorsement of the varying local practices included as examples throughout the guide.

Further, this document is not intended to serve as legal advice, medical advice, or a substitute for seeking 

professional services. For more information on the Federal Government’s policy position on Substance 

Use Disorder and Opioid Addiction, please consult the National Drug Control Strategy published by the 

Office of National Drug Control Policy.

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
6

Dear Rural Leader,

In small towns, suburban neighborhoods, tribal communities, and big cities, our Nation faces an 

unprecedented crisis of drug addiction. In 2017, more than 70,000 Americans, or nearly 200 people each 

day, died due to a drug overdose. And, while no corner of our country has escaped the devastation of 

this crisis, rural America has been particularly hard hit.

As the Nation’s drug czar, I have seen firsthand the impact that addiction is having on small towns and 

rural places across our country. Traveling to places like Henryetta, a small farming and oil community 

in southeast Oklahoma, I have met with many local elected officials, law enforcement, healthcare 

providers, and families who have lost loved ones and seen the toll that drugs are taking on America’s 

hometowns. In Henryetta and beyond, I have seen the drain of this crisis on already limited resources 

for public safety. And, I have visited rural places where there are no treatment options in the county, or 

even the surrounding region, to help people who are struggling with addiction.

To reverse course and ensure that rural America continues to be a place of prosperity for agriculture, 

manufacturing, and small business for generations to come, we must take bold action and do things 

differently than we have done in the past. We must be relentless.

Working with Federal, State, tribal, and local leaders, the Trump Administration has deployed an allhands-on-deck approach to make critical resources available to rural communities. Thanks to these 

efforts, America saw the first decline in drug deaths in decades, with drug overdose deaths falling from 

their peak levels by as much as 24 percent in the hardest hit States like Ohio and Pennsylvania. Last year, 

my office, the White House Office of National Drug Control Policy, teamed up with the U.S. Department 

of Agriculture to compile a Federal rural resource guide to help rural leaders navigate the many Federal 

programs available to address the addiction crisis in small towns. In addition to funding, however, the 

Administration is helping rural communities with information to help create real change.

The Rural Community Action Guide is an important tool to equip rural leaders with critical information 

from lessons learned on the frontlines of prevention, treatment, and recovery in rural America. While 

no two rural communities are the same, there are promising practices gleaned from rural leaders in 

one town that can be replicated in another. With this information, local leaders can then design a more 

effective strategy for deployment in their own community.

As we step up to do even more to help small towns deal with the scourge of drug addiction, we are 

beginning to see signs of progress. Yet we know there is still much work to be done. In arming local 

leaders with tools like the Rural Community Action Guide, we will continue to be relentless in our attack 

and our commitment to serve as a strong partner to rural America in this fight. Together, we can defeat 

the crisis of addiction and build strong, healthy, and drug-free communities now and for generations 

to come.

James W. Carroll

Director of National Drug Control Policy

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
7

Dear Rural Partner,

From Montana to Maine, North Dakota to Texas, rural leaders are facing a monumental challenge: the 

crisis of drug addiction. Once thought to be a problem only in big cities, the addiction crisis is crippling 

small towns and rural places across rural America. No community, geography, or zip code has escaped 

its reach.

For rural communities, drug addiction poses a very real threat to the future prosperity of rural America.

However, this challenge also creates an enormous opportunity for Federal, State, tribal and local leaders 

to set a new vision and build strong, healthy, and resilient places for the future. Working together as 

partners, we can save lives and keep our family, friends, and neighbors safe.

Over the past two years, I have had a chance to meet dozens of rural leaders who are on the frontlines of 

the response to this crisis. From the local judge who can’t find enough foster homes for children at risk 

to farmers and rural business owners who are searching for a workforce, there are countless needs to be 

met. And, each community has different assets to be tapped in building a response.

Traveling to numerous small towns throughout rural America that have been impacted by drugs, I am 

frequently asked what I have seen that is making a difference. Local leaders are overwhelmed and 

looking for answers to help their communities in need. Beyond my own travels, I have also worked with 

many rural stakeholder leaders who, like me, are in constant search of lessons learned and activities 

from one community that can be replicated in another town.

The purpose of the Rural Community Action Guide is to arm rural leaders with information they can put 

into immediate action to create change. The urgency of this issue and its impact on quality of life and 

economic opportunity in rural America demands nothing less. Building strong, healthy, and drug-free 

communities will take all of us stepping up and playing our role at the Federal, State, or local level. With 

tools to build an effective response and a shared passion for the future of rural communities, we can 

defeat the crisis of drug addiction and create places of opportunity for today and hope for tomorrow.

Anne C. Hazlett

Senior Advisor for Rural Affairs

Office of National Drug Control Policy

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
8 Abbreviations

Abbreviations 

BJA Bureau of Justice Assistance

COAP Comprehensive Opioid Abuse Program

DOJ Department of Justice

DOT Department of Transportation

ECHO Extension for Community Healthcare Outcomes

EMS Emergency Medical Services

EMT Emergency Medical Technician

FDA Food and Drug Administration

FQHC Federally Qualified Health Center

HIV Human Immunodeficiency Virus

HRSA Health Resources and Services Administration

IHS Indian Health Service

MAT Medication Assisted Treatment

NAS Neonatal Abstinence Syndrome

OTP Opioid Treatment Program

OUD Opioid Use Disorder

SAMHSA Substance Abuse and Mental Health Services Administration

SUD Substance Use Disorder

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
Glossary of Terms 9

Glossary of Terms1

Addiction A chronic, relapsing disorder characterized by compulsive (or difficult 

to control) drug seeking and use despite harmful consequences, as well 

as long-lasting changes in the brain.

Agonist A chemical substance that binds to and activates certain receptors on 

cells, causing a biological response. Oxycodone, morphine, heroin, 

fentanyl, methadone, and endorphins are all examples of opioid 

receptor agonists.

Antagonist A chemical substance that binds to and blocks the activation of certain 

receptors on cells, preventing a biological response. Naloxone is an 

example of an opioid receptor antagonist.

Buprenorphine  An opioid partial agonist medication prescribed for the treatment of 

opioid addiction that relieves drug cravings without producing the high 

or dangerous side effects of other opioids.

Drug Misuse The use of a substance for a purpose that is not consistent with legal 

or medical guidelines, most often with prescription medications. This 

could mean taking more than what is prescribed or taking a medication 

that was not prescribed.

Medication Assisted 

Treatment 

Treatment for opioid use disorder combining the use of medications 

(methadone, buprenorphine, or naltrexone) with counseling and 

behavioral therapies.

Methadone A long-acting opioid agonist medication used for the treatment of 

opioid addiction and pain. Methadone used for opioid addiction can 

only be dispensed by an OTP certified by SAMHSA and approved by the 

designated State authority.

Naltrexone A long-acting opioid antagonist medication that prevents receptors 

from being activated by other opioids. Naltrexone is used to treat 

alcohol and opioid use disorders.

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
10 Glossary of Terms 

Naloxone An opioid antagonist medication approved by the FDA to reverse an 

opioid overdose. It displaces opioid drugs, such as morphine or heroin, 

from their receptor and prevents further opioid receptor activation.

Neonatal Abstinence 

Syndrome

A condition of withdrawal that occurs when certain drugs pass from 

the mother through the placenta into the fetus’ bloodstream during 

pregnancy causing the baby to become drug dependent and experience 

withdrawal after birth.

Opioid Natural or synthetic chemicals that interact with opioid receptors 

on nerve cells in the body and brain and reduce the intensity of pain 

signals and feelings of pain. This class of drugs includes the illegal 

drug heroin, synthetic opioids, such as fentanyl, and pain medications 

available legally by prescription, such as oxycodone, hydrocodone, 

codeine, morphine, and many others.

Opioid Use Disorder A problematic pattern of opioid use that causes significant impairment 

or distress.

Prescription Opioids Medications used to treat moderate to severe pain often prescribed 

following surgery or injury.

Prescription 

Drug Misuse

The use of a medication in ways or amounts other than intended by a 

doctor, by someone other than for whom the medication is prescribed, 

or for the experience or feeling the medication causes.

Substance Misuse The use of any substance in a manner, situation, amount, or frequency 

that can cause harm to users or to those around them.

Substance 

Use Disorder

A medical illness caused by disordered use of a substance or substances.

According to the Fifth Edition of the Diagnostic and Statistical Manual 

of Mental Disorders (DSM-5), SUDs are characterized by clinically 

significant impairments in health, social function, and impaired control 

over substance use and are diagnosed through assessing cognitive, 

behavioral, and psychological symptoms. An SUD can range from mild 

to severe.

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
Introduction 11

Introduction

The core function of the Office of National Drug Control Policy (ONDCP) is to develop Federal drug policy 

and coordinate its implementation across the Federal Government. The 2019 National Drug Control 

Strategy (herein referred to as Strategy) sets out the President’s priorities for reducing drug use and its 

consequences, now and in the coming years. Importantly, in addition to reducing illicit drug availability 

through law enforcement and interdiction efforts, the Strategy provides strategic direction for the 

Federal Government’s efforts to prevent drug use before it starts, identify substance use disorder and 

intervene early, expand access to evidence-based treatment, and provide the ongoing recovery support 

Americans need to achieve and sustain recovery.

The Rural Community Action Guide complements 

the Strategy by providing topical insights on how 

rural leaders can and are addressing drug use and its 

consequences to build strong and healthy rural places.

Developed with input from a series of roundtables 

on opioid misuse hosted by the U.S. Department of 

Agriculture, and key partners, this comprehensive 

report presents strategies to strengthen the local 

responses to addiction in rural communities and fresh 

ideas to adopt flexible, creative solutions at the local 

level.

Rural communities face many hurdles in addressing 

opioid and other drug addiction. Research shows that 

people living in rural America who need help are falling 

through the cracks, often losing their lives. Treatment services are insufficient to meet rural demand.

Access to quality medical care, resources, and training is limited in rural communities, particularly for 

specialized populations, such as pregnant women, parents, and seniors. Further, drug courts, which are 

known to be significantly more effective than incarceration for non-violent offenders, are not available 

in many rural areas.

Between 1999 and 2015, drug overdose deaths in rural counties jumped by 325 percent2 as compared 

to 198 percent in metropolitan areas. Last fall, Harvard University3 released a survey of rural Americans 

who identified drug addiction as the biggest challenge facing their community. And, in 2017, two leading 

farm groups4, the American Farm Bureau Federation and National Farmers Union, conducted a survey 

that found nearly 50 percent of rural Americans, and 74 percent of farmers, have been directly impacted 

by opioid misuse. In the face of these challenges, rural leaders are working hard in collaboration with 

government and private sector partners to improve SUD outcomes while building strong and healthy 

rural communities

“The Rural Community 

Action Guide provides 

topical insights on 

how rural leaders can 

and are addressing 

drug use and its 

consequences to build 

strong and healthy 

rural places.” 

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
12 Introduction

Stigma prevents many people in rural America from seeking and accepting help. Once people get treatment, 

there is a substantial need for better connection to recovery support, such as stable housing, employment 

and job training, education, medical services, transportation, and childcare in a manner that takes into 

account the infrastructure challenges inherent in many rural places. In addition, local leaders need greater 

access to timely and accurate data about substance use disorder in their community, including information 

about upstream drivers that are causing higher rates of substance use.

The Administration has deployed an all-hands-on-deck approach to make critical resources available 

to our local communities. In May 2018, ONDCP stood up the Rural Opioid Federal Interagency Working 

Group to help address the opioid crisis by improving coordination and reducing potential overlap 

among Federal agencies responding to the crisis in the Nation’s rural communities. The group compiled 

a Federal rural resources guide to equip rural leaders with a comprehensive directory of the many 

Federal programs available to help small towns address the opioid crisis.

This guide continues the effort to support rural leaders by providing insight and recommended action 

steps from partners who are working on the frontlines of combating drug addiction in rural communities.

The direction offered in this guide is then supplemented by examples of promising practices which 

can be found on the USDA webpage. With this information, local leaders will be better equipped to 

take action on the ground. ONDCP extends its sincere gratitude to the many individuals, organizations, 

and stakeholders who shared personal stories and offered thoughtful input to the development of this 

resource.

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
SECTION 1: Face of Addiction 13

SECTION 1

Face of Addiction

PARTNER INSIGHT AND RECOMMENDED ACTION STEPS

To improve SUD outcomes and build strong and healthy communities, rural leaders 

must first change how they understand, talk about, and respond to addiction. This 

fundamental shift often begins with understanding the face of addiction, meaning 

who is impacted by SUD, in the community. The scope of its impact can best be 

understood by personal stories and data.

Once that collective understanding is built, community leaders are better able to 

recognize the signs of addiction and break down stigma. Stigma is one of the major 

roadblocks that keep people from seeking and accepting treatment for SUD. The 

impact of stigma is often magnified in a rural community where relationships are 

close-knit and there is less privacy.

In addition to breaking down stigma, increasing access to data is critical to answering 

many questions about addiction and rural communities. Data can help local leaders 

better understand who is being impacted, what the greatest needs are at both an 

individual and community level, and what will effectively keep people healthy. 

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
14 SECTION 1: Face of Addiction

THE CHANGING FACE OF ADDICTION 

Today, nearly every community has been affected by drug addiction. As the prevalence of SUD and 

drug overdose deaths continues to rise in rural areas, drug use can no longer be viewed as an urban 

and inner city problem. Beyond zip code, drug addiction is impacting individuals and families from all 

socioeconomic groups, changing the image of a person with SUD. Someone struggling with addiction 

could be a working mom, senior citizen, pastor, coach, high school athlete, or college student.

In 2018, USDA convened a series of rural conversations 

about opioid misuse to raise awareness and to better 

understand the impact of this crisis on small towns.

At each event, a local person in recovery shared his or 

her journey with addiction and road to sobriety. Below 

are five stories that illustrate the ever-widening scope 

of people in rural America who have been affected by 

addiction.

“Someone struggling 

with addiction could be 

a working mom, senior 

citizen, pastor, coach, 

high school athlete, or 

college student.” 

Alexis (Pennsylvania)

The youngest of nine children, Alexis Johnson never drank, smoked, or used drugs all through high 

school, earning exemplary grades and entrance to Penn State University. While attending Penn State, 

she tried ecstasy and cocaine because she just wanted to fit in and be a part of something after joining 

a sorority. Alexis graduated in 2005 with an A average in criminal justice, a double minor in sociology, 

and with every intention of going to law school. Three DUI charges later, she had moved from pain 

medication to heroin and had overdosed seven times. Now in recovery, Alexis wants to see “better after 

care programs” for persons with SUD who complete treatment, observing that people “complete these 

programs and then go back out into the streets with no life skills.” She is now a motivational speaker 

and aspires to work with teens in prevention.

Dale (Utah) 

Since boyhood, Dale Covington wanted to work at Hill Air Force Base near Salt Lake City, Utah. He 

described himself as a lonely man, a depressed man, a depressed father, and a depressed husband who 

needed people to come to him and say, “there is still hope within you.” Twelve years ago, his wife and 

four kids aged four to 16, met him at the door and said, “Dad, we love you, but unless you seek help, 

we will help you pack.” Now in recovery, he acknowledges an ongoing journey. “I still struggle with 

the temptation each and every day. I would not be a part of their lives if I would not have adapted to 

programs that helped me, that gave me hope.” Their support, coupled with coworkers who treated him 

with compassion, reached him at his lowest point. Dale joined a treatment program and moved into 

long-term recovery, later helping steer hundreds of persons in recovery toward resources along their 

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
SECTION 1: Face of Addiction 15

journey to sobriety.

Alex (Kentucky) 

Alex Elswick grew up in a healthy, happy Kentucky home without neglect, abuse, divorce, or alcoholism. As 

a youth, he struggled with anxiety. At age 15, he experimented with marijuana and his anxiety dissipated, 

helping him feel normal. His addiction surfaced when he was prescribed Oxycontin after wisdom teeth 

surgery at age 18. In the fall of 2012, he was in college studying for law school, and nine months later, after 

four treatment centers, he spent his last weeks of addiction homeless, living under a bridge in Dayton, Ohio, 

begging for money, and injecting heroin. After getting treatment, he had to confront the aftermath of his 

addiction including a criminal record, bad debt, and a poor credit rating. Now in recovery, Alex intentionally 

works to “recover out loud” and to never lose sight of the suffering people and hurting families impacted 

by addiction. Through a non-profit group, Voices of Hope, Alex and his mother provide telephone support 

to people in recovery and advocate for needs in the recovery community.

Kent (Oklahoma)

University of Oklahoma chaplain Kent Bowles served in ministry for more than two decades. He was 

a model citizen with a wife and children. Yet opioids took over his life, initially prompted by medical 

conditions. It was several years into his addiction, before he classified or categorized himself as a person 

with OUD. Because of the role he served and the life he lived, he thought he could not be that person 

struggling with addiction. One pill became two, became three, became a weekend, became a day, 

became night and then morning. He was in a position where the access was very easy because he was 

a person who was trusted and did not look the part of someone who was addicted. Kent clearly recalls 

the day he was arrested as “the most painful day of my life,” but it also became the most powerful 

opportunity for recovery. He founded the What’s Important Now (WIN) Foundation and serves as a 

connecter, networker, and recovery guide providing conversation, personal visits, transportation, and 

referrals.

Courtney (Maine)

The week before her twenty-second birthday, Courtney Allen, overdosed three times. She began using 

substances at age 13 and by age 19, Courtney was using drugs intravenously. For a decade, she struggled 

with poverty, trauma, and addictions to alcohol, heroin, Ritalin, and cocaine. On February 8, 2015, her 

life changed. Afraid that her young children would end up like her, she checked into an Augusta detox 

center for help and agreed to participate in the Augusta Family Treatment Drug Court, a civil court that 

assists parents working toward reuniting with their children. In her words, she found help from one 

of the least likely places she thought would work—the court. She received intensive counseling and 

wraparound services. After a year of treatment, she regained custody of her children and enrolled in 

school. Next spring, she will graduate at the top of her class with a BA in Social Justice and looks forward 

to continuing her education in graduate school. Her free time is spent advocating for resources to fight 

SUD and the opioid crisis.

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
16 SECTION 1: Face of Addiction

MOVING BEYOND STIGMA IN RURAL COMMUNITIES

By Addiction Policy Forum

STIGMA ACTS AS A BARRIER TO OBTAINING SUBSTANCE USE DISORDER SERVICES

Fear of stigma is one of the major roadblocks to accepting services for SUD, leading to poor health 

outcomes for patients. Stigma, the sense that something is shameful, may be felt more acutely in small 

rural towns because of the relative lack of anonymity. In a city, neighbors are less likely to know if a 

person is seeking substance use services or going to get some help. In a small town, it is more likely that 

people will know that a person visited a certain provider for help.

Stigma can inhibit a person’s access to treatment and positive recovery outcomes, alienate their families 

who fear judgment and isolation, and create unnecessary division in tight-knit rural communities. The 

difficulty of maintaining anonymity while engaging with treatment can cause a person with SUD to 

stop or avoid seeking treatment altogether. Due to the stigma surrounding SUD and a general lack of 

understanding about the disease of addiction, patients who are treated for SUD or in recovery may face 

discrimination in the courts, the workplace, and healthcare facilities, especially in rural communities 

with scarce treatment and recovery resources.

According to a study conducted by SAMHSA in 2014, more than 20 percent of people with SUD did not 

seek treatment because they worried about the negative impact on their employment, and more than 

17 percent were concerned about how their community would view them.

5

 The extent of misinformation 

about SUDs in public discussion—especially among healthcare providers, educators, policymakers, and 

media—reinforces barriers that prevent people from seeking help.

SCIENCE OF ADDICTION 

Although 20 million Americans struggle with SUD,6 about 

half of the population does not think that addiction is a 

disease7

. Misunderstandings about addiction are often 

propagated by a limited understanding about neurological 

science. This is one reason addiction is often not handled 

like other chronic illnesses, medical research is impeded, 

and counterproductive myths about treatment are 

perpetuated.

Addiction is a chronic, relapsing disorder characterized by compulsive substance seeking and use 

despite harmful consequences.

8

 Brain scans show that SUDs affect tissue function in two main parts 

of the brain: the limbic system and the cortex. The limbic system rewards completion of basic survival 

tasks, such as eating and finding shelter, by releasing dopamine. Substance use activates this dopamine 

release much more powerfully, and repeat occurrences can condition the brain to believe the substance 

is necessary for survival. SUDs also disrupt the cortex, which houses impulse control and decisionmaking abilities, by eroding the self-control and discipline required to make prudent choices, while 

“Stigma will fade in 

the face of education 

about the negative 

impacts of untreated 

addiction on families 

and communities.” 

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
SECTION 1: Face of Addiction 17

simultaneously producing intense impulses to use substances again.

The good news is that SUDs are both preventable and treatable. Brain scans show that parts of the brain 

impaired by addiction can improve during recovery. Given access to proper treatment and support, 

individuals with a SUD can transform their lives, influence their environments, and realize positive 

health outcomes.

Rural communities must also change how they understand, discuss, and respond to addiction if they are 

to win the fight against America’s spreading opioid crisis. Stigma will fade in the face of education about 

the negative impacts of untreated addiction on families and communities and increase the likelihood 

that those who need help can access it.

RECOGNIZE THE SIGNS OF ADDICTION 

Prevention begins with the observation of common danger signs. Know what to watch for and how to 

respond compassionately to those struggling with the isolating, confusing, and painful experience of SUD.

Red Flags

• Disinterest in activities that were once enjoyed

• Changes in mood and/or daily routine

• Decline in performance at work or school

• Secretive behaviors

• Change in weight or appearance

• Inability to be present in conversation

Tips

• Open and empathetic communication without blame or 

accusation works most effectively.

• Always make sure the person is not a harm to others or self.

• Early connection to resources and education can make all the 

difference.

MODIFY LANGUAGE TO HELP ADDRESS STIGMA

Being thoughtful about the language we use to talk about addiction is an important step in reducing the 

stigma surrounding SUD. Words like “addict” and “junkie” negatively and inaccurately portray addiction 

as a choice and identity. Referring to a “person with SUD” more accurately describes addiction as a 

medical condition that can be treated.

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
18 SECTION 1: Face of Addiction

Harmful Terms Positive Terms

Junkie/Addict Person with a substance use disorder, 

(opioid use disorder, alcohol use disorder)

Drug habit/drug misuse Substance use disorder

“clean” (a “negative” toxicology screen) Not currently using substances

“dirty” (a “positive” toxicology screen) Currently using substances

Replacement/Substitution Therapy Medication Assisted Treatment refers to the use 

of any medication approved to treat substance 

use disorders combined with psychosocial 

support services

ACTION STEPS TO COMBAT STIGMA IN RURAL COMMUNITIES

Stigma is one of the primary reasons that many do not take that critical step toward addressing 

their SUD—asking for help. Community leaders can help to address this challenge by engaging 

in the following four activities:

1. Understand the science. Decades of research have given us the tools to improve our 

response to addiction and empower communities to help prevent, treat, and support 

those in recovery from SUDs. Use science to debunk stigma and support local policies 

and practices that promote a science-informed response to addiction. Visit the National 

Institute on Drug Abuse at drugabuse.gov or SAMHSA at samhsa.gov to learn more.

2. Educate the community about SUDs and opioid misuse. Addiction does not 

discriminate and can impact anyone (family members, friends, and peers). Use 

statistics and the latest science to teach the community about addiction and work with 

stakeholders in the community to disseminate knowledge and resources like overdose 

reversal kits, the brain science of addiction, and other educational materials. Find free 

resources by visiting addictionresourcecenter.org.

3. Develop and implement a marketing plan to reduce stigma. The best way to counter 

inaccurate stereotypes or myths is to replace them with information. Anti-stigma 

marketing can present facts on SUDs with the goal of correcting misinformation or 

contradicting negative attitudes and beliefs. The communication strategy should 

also be tailored to the audience. Social media and online platforms may be more 

appropriate communication streams for young people, while a talk at the local Rotary 

club or having a public information ad campaign and printed pamphlets may be more 

appropriate for adults.

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
SECTION 1: Face of Addiction 19

4. Share positive stories of recovery. When people in recovery from SUD share their 

stories, the stigma is diminished. Community leaders should facilitate and support 

efforts to build the capacity of the recovery community to participate in public 

dialogue about addiction, treatment, and recovery.

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
20 SECTION 1: Face of Addiction

USING DATA TO BETTER UNDERSTAND SUBSTANCE USE 

DISORDER AND OPIOID USE DISORDER

By NORC Walsh Center For Rural Health Analysis 

More than 70,000 people in the United States died from a drug overdose in 2017, and approximately 

two-thirds of those deaths involved opioids, based on CDC data9

. Addressing SUD is a national challenge, 

but the solution lies at the local level. Rural America needs to be part of the overdose discussion because 

the stakes are so high there, yet rural research presents unique challenges. Data collection in rural areas 

is difficult due to both small numbers and the frequent reliance on survey data with insufficient sample 

sizes to allow for rural specific analysis.

Data can help rural leaders respond to the big 

questions—what causes the use of illicit substances 

in their communities, what perpetuates the problem, 

and what will mitigate the problem. After identifying 

the problem and its impact on the larger community, 

rural leadership can also utilize data to uncover 

solutions, including prevention, treatment, and 

recovery options for each community. Using data will 

help communities and leaders in the following three 

important ways.

“Rural leadership 

can also utilize data 

to uncover solutions, 

including prevention, 

treatment, and recovery 

options for each 

community.” 

Understand the changing face of the crisis

Both prevalence of OUD and deaths from drug overdoses continue to rise among people of all genders, 

races, and ages. The opioid crisis impacts individuals living in both urban and rural areas across the 

country. However, rates of drug overdose deaths have been increasing in rural areas, and in 2015, the 

rural rate surpassed the urban rate10. The crisis has continued to expand and impact growing numbers 

of people from diverse communities. In many rural communities, a large portion of population has been 

directly affected in some way. Strong data systems are needed to continue to track communities most 

affected by OUD and drug overdose deaths.

Better understand the impact on the local community

Increased access to data that identifies the problem at a local level is critical to help local leaders 

understand the impact on rural communities. The opioid crisis has strained healthcare providers, local 

economies, law enforcement, emergency response, and social services, including the foster care system 

and schools. It has also amplified the need for broadband and rural transportation systems. Recruiting 

and retaining businesses can be difficult in regions with significant burden of the opioid crisis, which 

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
SECTION 1: Face of Addiction 21

can create cascading effects in terms of overall poverty in these communities.

Identify prevention, treatment and recovery models that work

Data on individual recovery success reveals the effectiveness of a community’s overall response to the 

opioid crisis. Initially, data and evidence-based research reveal the types of prevention, treatment, 

and recovery models that are most effective for different populations within a particular community.

Continuing to collect data on interventions also helps build the evidence-base for successful prevention 

of opioid misuse. Data is critical to identify where access to treatment options is limited, often the 

case in many rural communities. Understanding where current treatment resources are available also 

helps local communities decide where additional resources need to be allocated. When leadership 

understands where the burden of opioid misuse and mortality is highest, they can more prudently invest 

adequate resources in local infrastructure, treatment, 

and emergency services. “The Community 

Assessment Tool 

demonstrates the utility 

of data visualization in 

support of community 

health planning.” 

THE COMMUNITY ASSESSMENT TOOL

The Community Assessment Tool (CAT)

11 developed 

by NORC in partnership with USDA provides local 

stakeholders, policy makers, and residents with access 

to overdose mortality data for their communities. CAT 

users can also learn about factors that provide additional context around opioid addiction and death, 

including the strength and diversity of local economies, race, ethnicity, educational attainment, and 

disability status of residents. This tool puts overdose statistics in socioeconomic context, delivering 

added value to communities seeking to develop comprehensive strategies that address the crisis.

CAT demonstrates the utility of data visualization in support of community health planning and 

response. Insights can be used to target resources and interventions for communities that most need 

support. By allowing those on the front line to access local data and compare rates to those across 

their States and across the nation, CAT users can better understand the magnitude of the opioid crisis 

in their communities, as well as trends over time. By overlaying socioeconomic and demographic 

information, CAT users can also begin to consider local factors that may contribute to higher rates in 

their communities. Armed with this information, stakeholders and policy makers can begin a dialogue 

to increase understanding and to begin the process of identifying and implementing local solutions.

Overdose mortality rates are provided for two time periods, 2008-2012 and 2013-2017, which allows 

CAT users to see a visual representation of how the data has changed over time within the borders of 

each county on a national map. Additionally, CAT users can zoom into specific States or regions and 

move the cursor over a county to show overdose mortality rate information or create a data fact sheet 

about the county, overdose mortality data, socioeconomic and demographic data, and how the county 

compares with the State and the nation. The tool delivers access to user-friendly and relevant data that 

assists rural leadership in building grassroots solutions for prevention, treatment, and recovery.

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
22 SECTION 1: Face of Addiction

ACTION STEPS TO USE COMMUNITY DATA BETTER

Communities looking to improve the way data is used should:

1. Determine the magnitude of the problem in the community. Many communities 

still don’t understand the extent of the SUD problem in their region. Communities 

should use the CAT as a starting point to learn how their local rate of drug-overdose 

deaths compares to state and national data. It provides access to user-friendly 

and relevant data to assist them in building grassroots solutions for prevention, 

treatment, and recovery.

2. Begin a community dialogue to inform and engage leaders and build grassroots 

solutions. The CAT allows users to see a visual connection between overdose 

numbers and socioeconomic factors. It does not provide specific answers or 

solutions; it provides information that can be used to drive the conversation and 

spur tailored action.

3. Consider whether more resources are needed. Determine when current resources 

are sufficient to address the problem or whether additional resources are needed.

Implement interventions and ensure mechanisms are in place for ongoing data 

collection and evaluation of effectiveness.

4. Build community coalitions to help drive solutions. Rural leaders should support 

and develop technical assistance resources to assist in implementing broad-based 

coalitions. Learn from other regions, evaluate the effectiveness of community 

coalitions, and use the results to develop a model and targeted strategies specific 

to the issues in their rural community.

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
SECTION 2: Impact of Addiction on a Rural Community 23

SECTION 2

Impact of Addiction 

on A Rural Community

PARTNER INSIGHT AND RECOMMENDED ACTION STEPS

Drug addiction in rural America is more than just a health issue. This is a matter of 

rural prosperity. A 2017 report by the White House Council of Economic Advisors 

estimated that the impact of the opioid crisis on the U.S. economy in just one year 

was more than $500 billion dollars. This crisis is impacting worker productivity, 

increasing healthcare demands, and putting enormous stress on already limited 

resources for emergency response, law enforcement, and social services. This crisis is 

also making economic development even more difficult for rural communities, which 

often struggle to attract new investment.

With that impact, rural leaders must develop the knowledge, capacity, and 

infrastructure to effectively deliver the resources needed to build a strong and 

healthy community. An effective local response will encompass resources to meet a 

wide range of needs at both an individual and community level, such as healthcare, 

public safety, workforce training, rural broadband, transportation, and economic 

development. Rural leaders are best positioned to meet these needs and maximize 

the impact of taxpayer dollars invested when they coordinate and collaborate with 

neighboring jurisdictions as well as Federal, State, and non-profit partners.

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
24 SECTION 2: Impact of Addiction on a Rural Community

MANAGING THE PUSH AND PULL ON FISCAL RESOURCES 

DURING THE OPIOID CRISIS

By National Association of Counties 

CHALLENGING FISCAL FACTORS IN RURAL COUNTIES

Rural counties in America are making progress on the ground level in the fight against opioid addiction, 

but the costs have been high and are mounting. Counties work on the frontlines to advocate for and 

protect the health and safety of residents affected by the opioid crisis. Counties directly experience the 

human toll and shoulder a large share of the costs required to respond to the crisis. They deliver key 

prevention, treatment, and recovery resources for SUDs through local agencies, as well as public safety 

resources and emergency first response teams. Due to the increased demand for services resulting 

from the opioid crisis, local governments are acutely feeling the strain on resources, from a shortage of 

hospital beds to overworked foster care systems and overcrowded jails.

As a result, local governments are struggling to contain the scope and costs of the opioid crisis in their 

jurisdictions and provide adequate addiction response and recovery support services. Not surprisingly, 

handling the different challenges that flow from the opioid crisis is straining county resources. The national 

opioid crisis has been playing out most markedly in remote, rural areas, which presents a challenge for 

healthcare providers already hindered by rising healthcare costs. In rural counties the costs can be 

attributed to services surrounding overdose deaths and burdens to the criminal justice system.

REDUCING COSTS IN RURAL COMMUNITIES

Leaders in county and city governments are 

exploring innovative strategies to address the fiscal 

strain of dealing with the ongoing opioid crisis. In 

2016, Boulder County established an Opioid Advisory 

Group in Colorado to improve the community-based 

response to the crisis through coordination across 

county medical providers and law enforcement 

officials, and in tandem with harm-reduction and 

faith-based organizations in the county. In the two 

years since the group’s creation, the county reported a 

36 percent decrease in opioid prescribing at the county’s largest hospital and 191 lives saved by naloxone 

administered by community members and law enforcement.

Other locally-led programs are meeting patient needs on an individual level. In New Jersey, Ocean County 

launched the “Recovery Coach Program,” a voluntary initiative connecting individuals who are revived by 

naloxone with treatment options once they are stabilized in emergency rooms. In cooperation with local 

hospitals, the program matches overdose victims with recovery coaches. If the patients are willing, coaches 

provide mentoring for up to eight weeks and help guide them toward recovery. Treatment is free or partially 

subsidized for those willing to participate. Program coaches are often working through the recovery phase 

of addiction themselves and can add a valuable perspective to the individual’s recovery.

Local leaders are finding resourceful and impactful ways to confront the opioid crisis in their jurisdictions 

thereby helping to relieve the strain on local services. However, as the Nation seeks to bring an end 

to the crisis, cities and counties recognize that these efforts are more effective when carried out in, 

“Counties directly 

experience the human 

toll and shoulder a 

large share of the costs 

required to respond to 

the crisis.” 

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
SECTION 2: Impact of Addiction on a Rural Community 25

partnership with State, Tribal and Federal counterparts. The National Association of Counties has been 

working diligently toward this goal in recent years with intergovernmental partners to emphasize the 

importance of expanded prevention, treatment, and recovery resources. They are also identifying policy 

recommendations for Federal, State, and local officials that could maximize the intergovernmental 

response to opioid overdoses and deaths.

ACTION STEPS TO MANAGE FISCAL RESOURCES DURING THE OPIOID CRISIS

As rural community leaders look to build healthy and prosperous communities and deliver 

services while dealing with the opioid crisis, they must maximize government efficiency and 

ensure responsible stewardship of taxpayer dollars. Here are four ways to manage the crisis 

more efficiently at the local level:

1. Cut off illicit traffic. Stop the problem at the source. Work with Federal, State, and 

local partners to reduce the supply of illicit opioid analogues, including fentanyl 

and carfentanil. These synthetic forms of opioids are becoming a leading cause of 

overdoses in communities as drug traffickers lace drugs with stronger opioids to 

create a more potent product.

2. Calculate the total cost. Start adding up the costs associated with the opioid crisis 

in your region. The crisis consumes enormous fiscal resources in small counties and 

building awareness of that drain will motivate support and generate action within 

the community. Quantifying the causes and consequences of the crisis will help 

leaders develop and implement effective prevention, mitigation, and intervention 

policies.

3. Consider new alternatives. Look for new ways to approach needs. Counties can 

improve health and addiction treatment services for justice-involved individuals 

and embrace alternatives to punishment models to decrease short- and long-term 

healthcare, disability, and criminal justice costs to both local taxpayers and the 

Federal Government. Invest in technology to help communities work better and 

smarter and more efficiently.

4. Cross-collaborate to cut costs and improve efficiency. Solutions are more 

effective when coordinated among the various governments within a region. Explore 

ways to cross-collaborate to help minimize costs. Initiate regional cooperation and 

strengthen lines of communication with neighboring governments. By securing 

partnerships with the public, private, and nonprofit sectors, counties remove 

barriers, overlap and duplication, and better coordinate service delivery. Pursue 

public and private funding opportunities to bring programs and initiatives to the 

community. Engage with all critical community stakeholders and connect local 

efforts and community working groups with State and county efforts to make sure 

that the community is implementing coordinated responses.

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
SECTION 2: Impact of Addiction on a Rural Community

WORKFORCE DEVELOPMENT: INCREASING OPPORTUNITIES 

FOR EMPLOYMENT DURING THE OPIOID CRISIS 

By National Association of Development Organizations

26

RURAL BUSINESSES FACE UNIQUE CHALLENGES 

Rural businesses typically face unique challenges to their success, such as limited educational facilities, 

scarce professional training programs, and less than optimal infrastructure. The widespread use of 

illicit substances and the consequences of prescription opioid misuse in rural communities has ushered 

in new and unexpected problems for rural employers. It often leads to cycles of unemployment for 

many prime-age workers in rural communities and long-term, severe consequences for both workers 

and businesses.

A rural community’s economic and social well-being is also tied to worker engagement. A strong, healthy 

workforce promotes business and encourages local development. High employment propels local 

economic activity, which in turn expands city and county revenue for public services and programs.

Additionally, high workforce engagement supports community-based activities through faith-based, 

civic, and nonprofit organizations. Alignment of people and resources to address needs provides greater 

leverage leading to better outcomes for communities overall.

The most profound challenge for businesses 

associated with SUD is the difficulty in filling open 

positions with workers who can pass a standard drug 

test. Other challenges lie primarily in attracting and 

maintaining an adequate and consistently productive 

workforce. Finding ways to support employees who 

develop a substance use problem while on the job 

and retain the employees who struggle to maintain 

sobriety. Finally, finding ways to prevent employees 

without a SUD from falling into addiction and 

expanding workplace practices to include people in 

recovery from substance misuse.

“The most profound 

challenge for businesses 

associated with SUD is 

the difficulty in filling 

open positions with 

workers who can pass a 

standard drug test.” 

WORKPLACE SAFETY AND ADVERSE CAREER EFFECTS

Businesses experience poor productivity from employees coping with SUD because the ability to 

provide dependable product and services rests on the reliability of staff and consistent operations.

Business cannot act effectively without consistent employee support, and employees grappling with 

substance misuse usually underperform or fail to perform adequately in the workforce. Likewise, 

employee recruitment rates suffer in a community hit by the opioid crisis. Initial drug tests disqualify 

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
SECTION 2: Impact of Addiction on a Rural Community 27

several prospective hires during the screening process. Available personnel undergoing recovery also 

present uncertainty because of their ability to meet job responsibilities.

Workplace safety is the highest priority for employers. Workers under the influence can jeopardize that 

commitment, presenting danger to themselves and others. Employers must maintain adequate staff to 

operate a business and may not have the luxury of giving struggling personnel time to fully recover from 

SUD. Workers with SUD often struggle with commitment to their employer and ability to perform tasks, 

especially at the incremental levels necessary to advance in their careers. Workers who underperform 

or prove inconsistent in job functions cannot be trusted to carry out roles and responsibilities of their 

positions. These disadvantages put rural businesses at risk against urban and global competition that 

may employ stronger teams with better resources and capable of greater innovation and productivity.

THE ROLE OF EMPLOYMENT IN RECOVERY

Counties across the country are realizing that a quality workforce is one of the single most important 

factors for promoting county economic competitiveness. To be successful after treatment, people in 

recovery need to be part of the community—and this usually means being employed. Employment can 

aid those in recovery by providing purpose in their lives, establishing a reassuring sense of routine, and 

integrating structure that replaces negative decisions with positive choices.

However, for a person in recovery, returning to work comes with various barriers that extend beyond 

the State of the job market, the level of education, or qualifications, such as stigma in the community, 

impaired health, and an ever-present struggle to maintain sobriety. Finding a job after rehabilitation 

or during recovery may also mean making some sacrifices to prioritize that person’s sobriety, such as 

working part-time or alternative hours in order to accommodate treatment and meetings. If that person 

has been displaced from the workforce for some time, reentry into the job market may mean taking a 

lower paying opportunity.

The challenge is finding more quality programs 

in rural areas that connect people in recovery to 

employers willing to give this pool of potential 

employees a second chance. Employers may 

demonstrate empathy and support for people in 

recovery yet doubt the candidate’s ability to effectively 

and consistently carry out work responsibilities. The 

person in recovery needs an opportunity to show that 

he or she can be accountable and productive in the 

workplace and maintain his or her sobriety.

“The person in recovery 

needs an opportunity 

to show that he or she 

can be accountable 

and productive in the 

workplace and maintain 

his or her sobriety.” 

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
28 SECTION 2: Impact of Addiction on a Rural Community

RURAL ECONOMIC COLLABORATION WORKS

When rural leaders and business owners work together with healthcare providers and law enforcement, 

the community can collaboratively develop innovative solutions for connecting people in recovery to 

economic resources and opportunities. Collective engagement acknowledges the severity of this epic 

public health issue and utilizes resources more effectively than separately.

Employee recruitment and workforce training are two of the 

most difficult business development challenges for small 

communities. Ostracizing those in recovery only limits 

the pool of available workers. A community-wide support 

system led by employers and public service organizations 

can offer support to job seekers in recovery. Additionally, 

local and regional educational opportunities and skills 

training benefit both employers and employees. Workforce 

boards and related training programs can adopt curriculum 

and methods that acknowledge the effects of addiction.

Service providers can better assist those in recovery to gain 

skills and improve job prospects.

For example, Pennsylvania community leaders joined together to form Somerset County Recovery and 

Reentry Center, which connects treatment, skills training, and employers to support job seekers in 

recovery. The initiative grew out of a lack of qualified workers and the community’s desire to help people 

with a SUD with sustainable employment. The program relies on a strong partnership between area 

employers, treatment providers, law enforcement, and the workforce development board. Participants 

in the program follow guidance provided by addiction counselors in various stages from skills training 

to employment. Employers accept people enrolled in treatment and training who maintain good 

standing. Many employers even provide compensation through training and skills development for 

eligible workers in their respective fields.

Engagement on SUDs requires comprehensive awareness of the health, environment, economic, and 

social aspects of this complex issue as well as the community impact. For example, in West Virginia, 

Mercer County’s assessment of its economic and social status revealed a number of issues specific 

to the locality, impacting economic development, community well-being, and overall quality of life 

including the use of illicit substances and prescription opioid misuse.

12 Broad-based assessments of 

this type allows employers to better understand the root causes of addiction and can help increase 

local business efforts to prepare outreach and skills training for job seekers in recovery.

“A communitywide support system 

led by employers 

and public service 

organizations can 

offer support to job 

seekers in recovery.”

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
SECTION 2: Impact of Addiction on a Rural Community 29

ACTION STEPS TO INCREASE EMPLOYMENT OPPORTUNITIES 

Local leaders and employers should consider the following steps to increase employment 

opportunities for people with SUD:

1. Invest in training to help employers and staff recognize the signs of addiction.

Addiction is a disease with a range of harmful conditions and behaviors. The signs 

and symptoms of SUD can vary with the individual. Consider training for managers 

and supervisors so they can identify the early warning signs. Recognizing these 

signs can help a person with SUD receive the treatment they need.

2. Encourage recovery friendly workplace initiatives. Give the business community 

and employment organizations the resources and support they need to foster a 

supportive environment for people in recovery. Encourage initiatives that support 

community health and wellness and encourage those in addiction recovery to 

devote themselves to positive activities. Community recreation centers and parks, 

exercise classes and fitness clubs, diet and nutrition programs, and other wellness 

services can all promote healthy lifestyles and deter people from substance use.

3. Support second chance initiatives. Reentering the workforce is a key barrier 

preventing people in recovery from transitioning to a more productive lifestyle.

A person in recovery has the potential to be a great employee. Test innovative 

approaches and support employers that develop second-chance policies and hire 

individuals in recovery.

4. Engage the employment sector early. Every aspect of the community is impacted 

by substance use. Businesses are particularly critical partners to support workforce 

development. Rural employers need to understand the path from addiction to 

recovery and the role employment plays in recovery. Better understanding of the 

dynamics of addiction recovery could dispel myths about people in recovery and 

inspire support for second chance initiatives.

5. Build partnerships and coordinate to leverage resources. Collaborative 

partnerships in the public and private sector are necessary for successful 

implementation of plans to combat opioid crises in rural communities. Different 

programs and services help a person in recovery become “work ready” (e.g., 

recovery-oriented services, peers support and mentoring, career development, 

etc.). Employers can build trust and minimize risk by partnering with different 

stakeholders and businesses.

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
SECTION 2: Impact of Addiction on a Rural Community

RURAL BROADBAND IS FUNDAMENTAL TO INCREASING 

HEALTHCARE ACCESS IN RURAL COMMUNITIES

By The Rural Broadband Association

30

CONNECTIVITY SPURS RURAL PROSPERITY

Reliable and affordable broadband is a catalyst for rural prosperity that unlocks economic development, 

innovation, advancements in technology, workforce readiness, and an improved quality of life. Modernizing 

infrastructure, building partnerships, and driving innovation is the key to success in strengthening 

e-connectivity across the rural heartland. Most importantly, e-connectivity in rural areas can save lives 

when public health disasters strike, especially complex occurrences like the opioid crisis.

When the President declared the opioid crisis a nationwide 

public health emergency in October 2017, many agencies 

began gathering critical resources and implementing 

innovative ideas to combat the deadly crisis. NTCA–The 

Rural Broadband Association represents nearly 850 

independent, community-based telecommunications 

companies and cooperatives and more than 400 other 

firms that support or provide communications services in 

the most rural areas of America. This organization’s work toward strengthening broadband connectivity 

in rural areas helps meet two major goals of the battle against opioid misuse: (1) improving access 

to prevention, treatment, and recovery support services; and (2) strengthening public health data 

reporting and collection.

“Reliable and 

affordable broadband 

is a catalyst for rural 

prosperity.”

THE OPIOID CRISIS HAS A DISPROPORTIONATE IMPACT ON RURAL AREAS

According to the Centers for Disease Control, more than 130 Americans died each day in 2017 from an 

opioid-related event.

13 The Appalachian and the Southwest regions have been among the hardest hit 

by the crisis.

These impacts are particularly devastating for rural areas that already face challenging healthcare 

situations. Rural residents are on average poorer and older than in urban areas.

14 And, although 

19.3 percent of the U.S. population resides in rural areas15, only 10 percent of the Nation’s physicians 

practice in rural America.

16 Additionally, rural areas are home to 70 percent fewer specialists per 

100,000 people. Numerous studies, however, have demonstrated both health and economic benefits of 

telemedicine across multiple medical conditions.

17 These same benefits can be deployed to address the 

opioid crisis, if sufficient broadband connectivity is achieved.

AVAILABILITY OF SUFFICIENT BROADBAND

Broadband deployment in rural areas is challenged by intensive capital costs that are compounded 

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
SECTION 2: Impact of Addiction on a Rural Community 31

by the geographic distance over which facilities must be deployed. Costs must be recovered from a 

much smaller number of users, as compared to more densely populated urban areas. Moreover, rough 

terrain in some rural areas can cause additional deployment and maintenance expenses that are not 

encountered in urban areas.

Small, locally operated providers (such as NTCA members) that operate exclusively in rural markets are 

driven by a commitment to provide the best service possible to the community in which they serve.

According to NTCA survey data, approximately 50 percent of NTCA members provide fiber to nearly 

50 percent of their customers, and 60 percent of NTCA members report that nearly 70 percent of their 

subscribers can receive service at 25 Mbps (megabits per second) or higher. More than 150 NTCA members 

have been certified as gig capable providers. However, many types of providers serve rural areas, and 

more than 30 percent of Americans in rural and tribal areas lack access to terrestrial broadband of 25 

Mbps/3 Mbps. More connectivity work is required to connect everyone who needs access.

RESPONSES TO THE OPIOID CRISIS RELY ON BROADBAND

Broadband connectivity increases economic activity, enables social interaction, provides educational 

opportunities, and facilitates better medical care—all critical tools to combat those conditions. Social 

connectivity enabled by broadband can bridge distance and help to dispel loneliness or feelings of 

disconnection. Broadband-enabled medical responses include prescription monitoring, e-prescribing, 

counseling, and prevention campaigns. A rural community with insufficient broadband cannot provide 

citizens with these benefits, potentially resulting in poorer health outcomes and decreased ability to 

serve those in recovery from OUD.

Limited employment and educational opportunities in rural areas lead to lower prosperity, and these 

factors can also contribute to hopelessness that fuels addiction. However, broadband connectivity can 

spark industrial and entrepreneurial economic development in these remote communities. For example, 

broadband-enabled distance education supports a much wider range of vocational and career training 

available on a variety of online platforms, including virtual internships. Dispersed secondary-school 

students can take coursework from specialized teachers far away. All these experiences allow students 

to gain the skills necessary to secure better, higher-paying jobs and brighter futures.

EXAMPLE OF HOW BROADBAND CAN ADDRESS HEALTHCARE NEEDS

Critical elements of the programs described below can be transferred to address the opiate crisis by 

modeling the social, medical, and therapeutic connections enabled by broadband. These measures, in 

turn, will support critical elements in the prevention of, treatment for, and recovery from SUD.

Hocking County Court 

A county court in Appalachia helps clients schedule probation and counseling appointments through 

videoconferences with court and counseling personnel. These broadband-enabled solutions avoid 

significant time and costs for clients who live far from town and enable those who may be restarting 

their employment to avoid missing work. The program also reduces the likelihood of driving under 

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities
32 SECTION 2: Impact of Addiction on a Rural Community

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

suspension charges for individuals who may drive to appointments without a valid driver’s license, and 

it reduces the incidence of missed appointments where public transportation does not exist.

Virtual Living Room

A broadband-connected workstation in a private room at a county library in McKee, Kentucky enables 

veterans to access U.S. Department of Veterans Affairs (VA) telehealth and other online services at no 

charge. This solution supports standard medical appointments as well as mental health and other 

therapies. The eastern Kentucky site saves veterans an approximately three-hour drive to the VA medical 

center in Lexington.

Remote Health and Care

An in-home technology pilot in Brandon, Minnesota, connects hospice patients with their loved ones, 

caregivers, and medical team. In-home hospice patients can view pictures, receive incoming messages, 

watch medical videos, video chat with family and friends, and listen to music. The system also connects to 

a variety of wireless activity sensors placed in the patient’s home that can alert designated caregivers by 

phone, email, or text message, and offers the capability for real-time biometric feedback from the system.

PROJECT ECHO 

Project ECHO is a teleservices model that can help to bridge the gap in delivering 

substance use disorder services

Accessing specialty healthcare in rural America can be challenging, and patients must often 

travel many miles to see a provider, especially those in far-flung areas without adequate 

healthcare facilities or widely available public transportation. Project ECHO® (Extension 

for Community Healthcare Outcomes) helps meet this challenge by facilitating access to 

specialty care through rural health front-line providers in a hub-and-spoke model.

Founded in 2003 at the University of New Mexico, Project ECHO® operates more than 130 

programs throughout the U.S. today, addressing more than 65 diseases and conditions.

Expert specialists at academic hubs connect with rural primary care physicians in local 

communities through spokes using widely available teleconferencing technology. Primary 

care providers present patient cases to hub experts and other call participants, cases 

are discussed, and treatment options are provided. Through these virtual grand rounds, 

local providers gain access to cutting-edge information, receive support, and refine skills, 

allowing them to provide their patients with the best possible treatment. To learn more visit 

the Project ECHO® website at https://echo.unm.edu/.
SECTION 2: Impact of Addiction on a Rural Community 33

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

ACTION STEPS TO FACILITATE SMALL SCALE BROADBAND PROJECTS

Meeting the opioid crisis will require a diversified, multi-faceted approach, but many 

effective tools will be powered by rural broadband. Local leaders may consider the following 

steps to facilitate small-scale broadband projects to increase access to SUD services. They 

call for local leaders to Identify, Assess, Deploy, Involve, and Communicate:

1. Identify the prevalence of SUD and illicit substance use in the community.

Prioritize the greatest needs against existing and possible future resources.

2. Assess broadband resource needs. Determine what is possible to achieve with 

respect to prevention, treatment, and recovery; existing broadband availability 

(e.g. neighborhoods served, maximum broadband speeds, technology available, 

number of providers); pinpoint where service gaps exist and where new wireless 

capacity could be used to deliver services to people with SUD; and, identify 

broadband activities most appropriate to each location.

3. Deploy the “right” technology and/or service needed to expand access to 

broadband and match it with the SUD service that is needed. The potential 

technology solution will vary depending on the community. Take steps to learn 

about the technology and service options from broadband providers, equipment 

suppliers, and other communities about what technology and services they chose 

and what factors were important.

4. Involve SUD stakeholders in the community right from the outset. Stakeholders 

active in driving services for SUD should be engaged early to work with broadband 

partners to help develop and guide prevention, treatment, and recovery technology 

goals and how to implement projects to achieve those goals. They can include 

medical professionals, educators, economic development officials, faith-based 

organizations, treatment and recovery professionals, social service organizations, 

law enforcement and local judiciary, and local broadband providers. Find local 

champions to take the lead and help make the case for action.

5. Communicate opportunities to leverage resources and support. Broadband 

projects need partners—often from the private sector. Identify potential partners 

to support broadband small projects. Expanding broadband networks and gaining 

access to higher broadband speeds does not just happen; it takes a concerted effort.

All parties must work together to ensure that the distinct strengths and skills that 

each party contributes are leveraged effectively.
34 SECTION 2: Impact of Addiction on a Rural Community

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

BRIDGING THE TRANSPORTATION GAP FOR ACCESS TO 

SUBSTANCE USE DISORDER SERVICES IN RURAL COMMUNITIES

By National Rural Transit Assistance Program

RURAL PUBLIC TRANSPORT

Public transportation in rural communities is often scarce, runs infrequently, and is under resourced.

Access to treatment, food, jobs, or education can be improved by working closely with a nearby system’s 

planners to amend a project in an existing regional transportation plan. Bridging the transportation 

gap to SUD treatment access requires an understanding of the underlying mission of the system.

Government transportation systems view human service and medical programs as client-based. Transit 

is part of a system of mobility services and infrastructure integral to the health of a community and its 

citizens, especially when public health crises hit the region.

TRANSPORTATION IN RURAL COMMUNITIES

Some rural communities may have limited transportation options, and even those that exist could be 

difficult to find. State Department of Transportation transit divisions and the National Rural Transit 

Assistance program can be helpful in identifying regional resources. Often in rural areas the transit will 

serve several counties or be managed from local community programs or nonprofits. Transit agencies 

have training and knowledge to manage vehicles and trips. In the absence of a comprehensive transit 

system, they can help improve mobility for clients.

The Federal Transit Administration provides capital, planning, and operating assistance for rural transit 

in the Formula Grants for Rural Areas program, which is 

allocated to rural areas in all fifty States and U.S. territories.

Approximately $750 million was provided for this program 

in FY 2019. In the current environment of rampant opioid 

addiction, planning must consider transportation needs 

related to the treatment and recovery from addiction. There 

are three types of transportation service: demand response, 

deviated fixed route, and fixed route. These services are 

managed in Community Action Programs, Area Agencies on 

Aging, cities, counties, and even hospitals. They serve the 

general public, and some agencies serve specific programs 

as well or exclusively.

REGIONAL PLANNING

In rural communities, it is important to think about rural 

transit on a regional level. However, while the actual 

planning for transit may happen at the State or regional level the implementation is local. In addition, 

transportation planning and need identification is often separated by years so gaps in the system may 

have to be addressed in the regional level plans as well as the local transit plan.  To improve the system 

“It is important to 

think about rural 

transit on a regional 

level. However, while 

the actual planning 

for transit may 

happen at the State 

or regional level the 

implementation is 

local.”
SECTION 2: Impact of Addiction on a Rural Community 35

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

in your local community you must first identify the programs that service your area.  

HOW DO YOU FIND A RIDE?

The below chart provides an example of the process of finding local transit.

I need a ride

Find out what is 

near youGoogle 

transit 

Google your town 

transit or your county 

transit

near me

No search results 

that work for me

Bus information 

and schedule

Look at a map 

to find the next 

large town

Find the closest 

transit service to you

Call the State DOT 

Transit Office and ask 

for their help

Find the closest 

intercity or 

regional service

Nothing is 

near you

Add these search terms: Senior transit; Tribal 

transit; Community action program; Demand 

response program; Community transportation

Call to schedule a ride at least 24 hours in advance

My clinic

My workplace

My school

Stay home 

forever!

You found a ride!

You found a ride!

DESIGN MOBILITY SOLUTIONS TO MEET LOCAL NEEDS

Health services often do not know how to assess patient 

access to transportation. Transportation is usually the 

second most important priority, after the delivery of the 

program services. Medicaid agencies may not be aware of 

every person who needs transportation services. Depending 

on how the Medicaid program is set up in each State, access 

to transportation may provide access to medication and 

other necessary services or only access to treatment.

When designing mobility solutions, assess a client’s 

full transportation needs. Once transit programs are 

located, schedule time to meet and discuss client needs 

with the transit agency. They can work jointly to develop 

a project scope and description for services. Through 

discussion, identify ways to maximize the value of existing 

transportation resources to meet local community needs.

Determine if the agency has a Coordinated Human 

Service and Transportation Plan. The planning process 

assesses resources and needs for seniors and persons 

with disabilities. The definition of disabilities was recently 

expanded by the Dept. of Transportation to include persons 

with SUD. New priorities can be amended into the plan if you work with your transit agency. The below 

table provides a few examples of local transit strategies.

“Determine if 

the agency has 

a Coordinated 

Human Service and 

Transportation Plan. 

The planning process 

assesses resources 

and needs for 

seniors and persons 

with disabilities 

(including persons 

with SUD).”
36 SECTION 2: Impact of Addiction on a Rural Community

Rural Community Action Guide: Building Stronger Healthy, Drug Free Rural Communities

MODELS AND STRATEGIES TO IMPROVE TRANSPORTATION IN RURAL COMMUNITIES

Fixed-route 

Systems

Fixed-route bus systems operate on a predetermined route and schedule and are 

mainly used for general public, commuter (no paratransit), regional connectors, and 

intercity bus services. These may be managed by public transit agencies, public private 

partnerships, or private nonprofits, or local and tribal governments.

Demandresponse 

Transportation

Demand response transportation (DRT), often referred to as dial-a-ride, are transportation 

services where individual passengers can request a ride from one specific location to 

another specific location at a certain time. These services are often used to provide 

medical access but meet a spectrum of mobility needs including first mile last mile, 

general public, using ride hailing services, airporters, taxi, taxi voucher, volunteer, and 

public transit programs.

Flex-route 

Transportation 

Systems

Flex-route transportation systems or deviated fixed-route systems, feel like fixed route 

services but can pick up and drop off passengers at locations within a defined distance 

from the scheduled stops on request. This is a strategy to increase access and usability 

of existing transit services. DRT can schedule stops so people do not have to call 24 

hours in advance or fixed-route services can expand service areas incrementally to 

reach people who would require DRT to access transit.

Volunteer Model Volunteer transportation programs rely on volunteer drivers. This supports access 

to medical care, shopping, or nutrition programs. Area Agencies on Aging, hospitals, 

veteran programs, and other targeted population programs use this strategy to assist 

program participants. Volunteer reimbursement, if any, does not usually cover full 

costs of mileage and gas. Some programs trade driving for a voucher for transportation 

services.

Coordinated 

Services Model

This model involves identifying shared mobility interests between agencies and 

programs. The goal is to maximize mobility and minimize duplication of services 

through coordinating and sharing resources, knowledge, and funding. Coordinated 

services fill gaps in transportation services to efficiently build mobility networks.

Key partners for coordinated services include human service agencies, nonprofits, 

worksites, transit providers, and local or regional economic development agencies.

Mobility on 

Demand

Mobility on demand utilizes technologies, such as smartphones and mobile apps, to 

increase access to transportation options, increase convenience, simplify payments, 

and lower costs. Companies like Uber and Lyft, also known as Transportation Network 

Companies (TNCs), are a form of DRT and sometimes ridesharing.

Ridesharing 

Model

Ridesharing is demand response transportation where a vehicle is shared between one 

or more persons (vehicle sharing), combining passenger trips with a common destination 

(carpooling and vanpooling), or using technology to arrange shared rides on short notice 

or en-route (real-time ridesharing). TNCs have shared ride features in some markets, 

such as Lyftline and Uberpool.

Regional Service 

Model

Feeder services or regional connector services provide transportation to or from service 

centers or multimodal transportation hubs. Connector services are implemented to 

help community members reach medical, educational, and transportation resources.

These can be part of a transit system through public or private partnerships or private 

businesses providing long-distance transportation (i.e., airports or inter-city buses) to 

specific destinations like health centers or hospitals.

Mobility 

Management 

Model

Mobility management (MM) helps people connect to transportation options. These 

programs use trained staff who are knowledgeable about transportation services 

available regionally. The MM role is to facilitate navigating different transportation modes 

and options to help riders find and use accessible services.

Mobility as 

a Service

Mobility as a Service is a combination of public and private transportation services 

within a given regional environment that provides comprehensive, optimal, and 

person-centered travel options, to enable end-to-end journeys paid for by the user 

or group of agencies as a single charge, and which aims to achieve key public equity 

objectives.
SECTION 2: Impact of Addiction on a Rural Community 37

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

ACTION STEPS TO BRIDGE THE TRANSPORTATION GAP 

Transportation is a significant challenge for persons with SUD who lack access to public 

transit or other modes of transportation. Rural communities can implement programs 

that provide transportation to people on demand, for any reason. Communities that are 

interested in implementing transportation programs to help address the need should 

consider the following action steps:

1. Bring transportation to the table. Make sure that representatives from the State 

or local transit office are engaged early. Invite them to join working groups or the 

taskforce that is formed to address SUD in the community.

2. Understand the level of transportation that people seeking SUD services need.

Engage in a community prioritization exercise to identify the transportation needs 

of clients and the areas with the greatest needs.

3. Put the transportation need on the DOT radar. Make sure that the transportation 

need is reflected in the transit plan. Transportation is funded through the U.S. DOT 

and the Federal Transit Administration only if it is in a plan. If a transportation need is 

included in the transit plan for the region, that need may be considered for funding.

4. Identify service gaps and the systems that are available to help. Identify the 

closest transit program that can help as well as the clear service gaps. Be sure to 

address special considerations like disabilities that may impact these needs. Special 

housing areas for those dealing with SUD will need direct routes to treatment and 

recovery centers.

5. Consider whether plans or projects can be adapted to provide support.

Coordinate with the transit program and stakeholders locally or at the State level to 

develop and amend a project to the State or local Coordinated Human Service and 

Transportation Plan.

6. Know the costs and leverage resources. Work with the local transit to identify 

the costs for developing the mobility the clients need to be successful. Seek 

opportunities to leverage resources, engage with other programs, and find public 

and private stakeholders that share an interest in addressing SUD.

7. Add access to transportation to the treatment or recovery plan. SUD programs 

do not always provide transportation as part of the clinic services. Yet, people 

seeking substance use services usually lack financial, personal, or physical 

resources to meet their mobility needs. Find ways to build access to transportation 

into treatment and recovery modalities.
38 SECTION 2: Impact of Addiction on a Rural Community

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

OVERCOMING ECONOMIC CHALLENGES AMID THE OPIOID 

CRISIS

By Appalachian Regional Commission

Our Nation’s drug crisis is more than a public health emergency. It is increasingly becoming an economic 

development issue. The harmful impacts of opioid misuse on economic development and the people 

who make up the workforce cannot be ignored. Local efforts to help build a strong economy—through 

investments in basic infrastructure, in strengthening entrepreneurship, in expanding transportation 

options—cannot achieve maximum success if a region does not have a healthy workforce and 

development options. SUD and opioid misuse drains regional resources, both human and financial, 

reshapes the fabric of families and communities, slows productivity, and can ultimately make the 

region less economically competitive.

IMPACT ON THE ECONOMY IN RURAL AREAS

The Appalachian Regional Commission (ARC) understands that to battle the drug crisis, there is a need 

for a strong response that addresses not only access to treatment and prevention methods, but also 

the impact on economic development. ARC is an economic development agency that provides Federal 

assistance to 420 counties in Appalachia for the creation of long-term employment opportunities and 

economic growth. ARC programs can assist in planning, technical assistance, job training, and the 

physical infrastructure needed to attract employers and jobs in communities to spur economic growth.

In a study commissioned in 2017 by ARC, the NORC Walsh Center for Rural Health Analysis found 

Appalachian Region opioid-related overdose mortality rates 49 percent higher than in the nonAppalachian parts of the country (24.6 deaths per 100,000 population ages 15-64 in Appalachia, 

compared to 16.5 per 100,000 in the non-Appalachian U.S.).

18 Though this study focused on overall 

mortality rates, age-specific figures are illustrative of the workforce issue facing Appalachia. Among 

Appalachians aged 25-44, the overdose mortality rate—which includes overdose deaths due to both 

opioid and non-opioid substances—is more than 70 percent higher than for those living outside the 

region. Typically, this group includes those in their prime working years, which creates a significant 

challenge to economic development in rural communities.

There is a clear cyclical relationship between economic challenges 

and the drug crisis that is visible in Appalachian communities.

Some characteristics include an underperforming workforce, 

challenges of recruiting drug-free workers, higher rates of 

worker turnover, employee retention, workplace safety, and 

companies and industries reluctant to do business in the region 

due to workforce challenges. Anecdotal evidence suggests 

that sometimes, even in healthy economic environments, 

companies have to turn away work due to labor shortages, 

which employers are attributing to substance misuse.

“There is a clear 

cyclical relationship 

between economic 

challenges and the 

drug crisis that is 

visible in Appalachian 

communities.”
SECTION 2: Impact of Addiction on a Rural Community 39

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

COLLABORATIVE APPROACHES TO MITIGATE OPIOID CRISIS IMPACTS

Rural communities are adopting collaborative approaches that bring together stakeholders across 

sectors to respond to the crisis in a more comprehensive manner. ARC, Robert Wood Johnson 

Foundation, and Foundation for a Healthy Kentucky have jointly released a series of three reports19 that 

explore health in the Appalachian Region and ways to improve health outcomes.

First, researchers measured population health in the Appalachian Region and documented disparities 

between Appalachia and the Nation. The second report describes the methodology used to identify 

Bright Spots, or Appalachian counties with better-than-expected health outcomes given their 

characteristics and resources. The third report explores the programs, activities, and initiatives in ten of 

those Bright Spots through case studies.

Many of the ten Bright Spot counties are taking creative, 

proactive steps to face the substance misuse issue 

directly. These efforts include organized substance misuse 

support groups for addicted individuals and their families, 

initiatives to curb addictive behaviors, and low-cost 

disposal sites. Often, these initiatives involve agencies 

working collaboratively across sectors. These Appalachian 

communities are addressing substance misuse by working 

together and dedicating scarce resources to recovery and 

rehabilitation efforts.

For example, Grant County in West Virginia has launched 

several initiatives to combat opioid misuse. The county and 

local organizations are collaborating to form coalitions and 

offering training in the administration of naloxone, which 

can rapidly reverse an opioid overdose.

Their Prevention, Intervention, Treatment, Anti-Stigma, and Recovery (PITAR) coalition is helping 

coordinate an effort in Grant County that spans all aspects of addressing addiction, from education to 

mental health counseling to treatment and recovery support services.

The Grant County Health Department has also approved a program to minimize the harmful effects of 

SUD and is considering providing training in administering naloxone for overdoses. Another regional 

agency, Potomac Highlands Guild, provides intensive outpatient treatment for SUD. In addition, the 

Russ Hedrick Recovery Resource Center is a nucleus for recovery activities in the area, serving as a dropin site to help people with SUDs get into treatment, begin recovery, and find the resources they need for 

successful recovery.

“These efforts 

include organized 

substance misuse 

support groups for 

addicted individuals 

and their families, 

initiatives to curb 

addictive behaviors, 

and low-cost 

disposal sites.”
40 SECTION 2: Impact of Addiction on a Rural Community

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

ACTION STEPS TO DRIVE ECONOMIC DEVELOPMENT

Local leaders looking to mitigate the impact of the crisis on local economic 

development should: 

1. Utilize data to better understand the extent of the substance use problem 

on the economy in your community. Hard data will not adequately capture the 

devastating impact of the drug crisis on communities, but it is an important starting 

point that allows for the creation of better-targeted solutions. Communities within 

the ARC region can refer to the ARC tool (http://overdosemappingtool.norc.org/) 

and communities outside the ARC region should refer to the USDA-NORC Community 

Assessment Tool (https://opioidmisusetool.norc.org/).

2. Learn more about the (Federal, State, and local) resources available to help 

combat the opioid crisis. At the Federal level, the ONDCP-USDA Rural Federal 

Resource Guide20 is a one-stop-shop for rural leaders looking for Federal funding 

and partnership opportunities. It includes information on ARC funds and other 

partners.

3. Focus on investment strategies that are regional, strategic, and transformational.

There is no silver bullet to address the opioid crisis, but if a problem is present in a 

community, the solution is often community-based. In this same spirit, communities 

should consider taking more of a cross-cutting approach to this multi-faceted 

problem by bringing together health providers, law enforcement, employers, 

educators, local officials, and others to work collaboratively and not just in the 

context of their own organizational silos.

4. Change the narrative to turn the perceived negative impact into an opportunity.

For many rural areas, the SUD crisis can lead to economic opportunities that 

include the development of new sectors intended to help people maintain longterm recovery, or the strengthening of existing ones, such as healthcare services.

5. Support programs that get people with SUD back to work. For individuals in 

recovery, a job can be an important component of, and a common reoccurring 

feature in, successful recovery outcomes. Communities should consider the recovery 

supports, education, and training needed by individuals in long-term recovery to 

ultimately get them back into the workforce.
SECTION 3: Prevention 41

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

SECTION 3

Prevention

PARTNER INSIGHT AND RECOMMENDED ACTION STEPS

Preventing drug use before it starts is key to building strong and healthy communities. 

In rural America, communities are often close-knit and have unique strengths to drive 

coordinated action around prevention. For example, rural leaders can tap into assets 

like the Rotary Club, cooperative extensions, and local school systems to make big 

changes with a small investment in messaging around the dangers of substance misuse.

Amid the ever-changing face of drug addiction, rural leaders must look for opportunities 

to build new community coalitions and broaden existing efforts with additional 

stakeholders, such as a local hospice care organization. To reach targeted populations, 

such as youth, farmers, or parents, in a rural area, prevention campaigns that are built 

around peer-to-peer relationships and tailored messaging can be particularly effective. 

And, lastly, the growing impact of addiction on rural America has opened doors to 

engage new partners around prevention, like the philanthropic community. 
42 SECTION 3: Prevention

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

STOP DRUG USE BEFORE IT STARTS, EARLY PREVENTION 

AND EARLY INTERVENTION STRATEGIES THAT WORK

By USDA National Institute of Food and Agriculture

EARLY PREVENTION ADVANTAGES

Implementing population-based, preventative, educational programs and resources is a key strategy 

to achieving positive health outcomes and promoting a positive quality of life in rural America. With 

respect to effectively addressing SUD, experts have identified prevention as a critical element to curbing 

the crisis for the future. Evidence-based prevention programs and approaches implemented before 

substance misuse challenges arise can prevent or delay misuse and abuse by equipping individuals 

and families with the knowledge and skills to make healthy choices. Prevention and early intervention 

can also save critical dollars covering treatment and recovery support services by addressing factors 

leading to substance misuse before it begins.

These prevention-based strategies should be a part of a comprehensive approach for prevention, 

treatment, and recovery support services in a continuum 

of care to ensure the best opportunity for effectively 

addressing substance misuse. A key feature of preventative 

programs and approaches should be program content and 

delivery that is based in research and evidence. According 

to the 2016 Surgeon General’s Report on Alcohol, Drugs, 

and Health, evidenced-based programs can significantly 

reduce substance misuse and abuse, if implemented 

well. However, many schools and communities are using 

programs with the least evidence.

21 Prevention programs 

should aim to promote protective factors and reduce the 

impact of risk factors leading to the prevention of opioid 

misuse and abuse. These programs address substance use, but also promote overall health and wellbeing.

Protective factors are strengths that directly decrease the likelihood of substance use and behavioral 

health problems or reduce the impact of risk factors on behavioral health problems. Examples include 

strong and positive family bonds, parental engagement, spirituality, and opportunities for meaningful 

social involvement. Conversely, risk factors increase the likelihood of beginning substance use, of 

regular and harmful use, and of other behavioral health problems associated with use. Risk factors can 

include access to prescription drugs, parental separation, childhood trauma, low community cohesion, 

and permissive attitudes and policies toward substance misuse.

Youth and young adults are important target audiences for prevention efforts as research has shown 

that early substance misuse, including alcohol misuse, is related to a higher likelihood of developing a 

SUD later in life. Although, prevention measures have been proven cost-effective, these programs and 

approaches have reached only about 10 percent of youth across the country.

“A key feature of 

preventative programs 

and approaches should 

be program content 

and delivery that is 

based in research 

and evidence.”
SECTION 3: Prevention 43

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

COOPERATIVE EXTENSION; THE RESOURCE IN YOUR BACKYARD

The Cooperative Extension System provides non-formal 

education and learning to residents of rural communities by 

taking knowledge gained through research and education 

and bringing it directly to the people to create positive 

change. The service is provided by the State’s designated 

land-grant universities, and there is an extension office in 

every county and parish in the United States. It is designed 

to help people use research-based knowledge to improve 

their lives. The presence of the Cooperative Extension 

Service enables access to free or low-cost educational 

measures, such as healthy literacy skills and physical 

activity and stress management classes, designed to 

improve mental and physical health as well as reduce pain.

Extension professionals have been helping to develop and 

deliver evidence-based early intervention strategies that 

can make a difference in addressing SUD.

EVIDENCE-BASED PREVENTION STRATEGIES THAT WORK

Many programs, models, and policies exist that have been proven effective across the lifespan, suggesting 

that it is never too early or never too late to prevent substance misuse and related challenges. The 

Cooperative Extension is helping deliver several prevention models in rural communities.

The PROSPER Prevention Delivery System

The PROmoting School-community-university Partnerships to Enhance Resilience (PROSPER) is an 

innovative prevention delivery system for evidence-based programs. The PROSPER system facilitates 

sustained, quality delivery of tested and proven programs for sixth and seventh graders that reduce risky 

youth behaviors, enhance positive youth development, and strengthen families. This delivery system 

links university-based prevention researchers with established program delivery systems within a State, 

such as the Cooperative Extension System at the Land Grant University and the public-school system. The 

model has three components, local community teams, State-level university researchers, and a Prevention 

Coordinator team in the land grant university, which enables it to address financial and human resource 

barriers. Ongoing evaluation and technical assistance ensure that programs are implemented as intended, 

teams continue to perform effectively, and partnership goals are being met. A study conducted by 

researchers from Penn State University and Iowa State University revealed that children who participated 

in PROSPER showed lower rates of substance misuse after high school graduation.

“The presence of the 

Cooperative Extension 

Service enables access 

to free or low-cost 

educational measures 

designed to improve 

mental and physical 

health as well as 

reduce pain.”
44 SECTION 3: Prevention

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

PROSPER Prevention Delivery System

University-Based 

Prevention 

Researchers

Established 

Program Delivery 

Systems in the State

Public School 

System

In rural Hawarden, Iowa with a population of 2,200, the community team 

implemented the PROSPER system to stop illicit substance use in Sioux County.

They are using it to deliver two prevention education evidence-based programs—

life skills and family skills. Local students study a middle school life skill-building 

curriculum designed to reduce substance misuse among middle schoolers while the 

Strengthening Families Program (SFP) is offered to families with sixth graders. SFP is 

an evidence-based family skills training program found to significantly improve 

parenting skills and family relationships and reduce substance misuse across 

adolescence and into young adulthood. The Sioux County PROSPER team is 

comprised of County Extension, school leaders, substance use prevention 

professionals, community health providers, ministerial association, and church 

representatives from the local Youth for Christ Center, law enforcement, and parents.

Chronic Pain Self-Management Program

Finding new ways to manage chronic pain is critical to prevent addiction. The well-regarded model Chronic 

Pain Self-Management Program (CPSMP) empowers chronic pain sufferers to manage their pain more 

effectively, reducing or eliminating the need for prescription opioids. Developed in 1996 by Dr. Sandra 

LeFort, the teaching is what makes this program effective. It gives participants the skills to coordinate all 

the things needed to manage their health, as well as to help them keep active in their lives. Evaluations 

of the program found it to be beneficial for participants in terms of coping skills, education, and overall 

quality of life. CPSMP was developed for people who have a primary or secondary diagnosis of chronic 

pain. Pain is defined as being chronic or long term when it lasts for longer than three to six months, or 

beyond the normal healing time of an injury. The University of Arkansas Cooperative Extension partnered 

with health volunteers, county extension agents, healthcare providers, and pharmacists to implement the 

CPSMP program and coupled it with an exercise program in four rural counties.

Mental Health First Aid® Education and Training

Communities can also implement capacity-building approaches that promote readiness to address 

behavioral health challenges that might lead to substance misuse. One such approach is Mental Health 

First Aid® (MHFA), an evidence-based public education program that encourages early detection and 

intervention by teaching participants how to identify, understand, and respond to signs of mental 

illnesses and SUDs, and link them with appropriate professional mental health services and support 

strategies. It is not a diagnosis and does not replace the need for a professional. Instead it offers concrete 

tools and answers key questions, like “what do I do?” and “where can someone find help?” The Youth 

MHFA serves a similar purpose—it reviews typical adolescent development and provides guidance on 

a range of topics including anxiety, depression, SUDs, disruptive behavior disorders (including ADHD), 

and eating disorders. It is designed to teach parents, family members, caregivers, teachers, school staff, 

peers, neighbors, health and human services workers, and other caring citizens.

In Ohio, there are 274 instructors certified to teach MHFA and 188 instructors certified to teach Youth 

MHFA. Ohio State University Extension plans to offer Youth MHFA to adults assisting youth in several 

communities to complement other substance misuse prevention programs to build capacity around 

the State to deal with the opioid crisis.
SECTION 3: Prevention 45

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

ACTION STEPS TO IMPLEMENT UNIVERSAL INTERVENTION 

EDUCATIONAL PROGRAMS

Local and State level systems can also implement universal interventions, which are those 

that target all members of a given population. In New York, the State health education 

curriculum now requires content about opioids and heroin as a part of their overall 

prevention strategy. Implementing this curriculum involves maintaining partnerships with 

community agencies and bringing resources into classrooms. Rural communities looking to 

do more in the area of prevention should consider the following:

1. Make prevention a priority in local community planning efforts. Prevention 

should be a deliberate part of a community strategy. Promote viewing challenges 

through a prevention-focused lens and designate champions for prevention efforts.

2. Make collaboration key. Establish multi-sector community coalitions. Equally 

as important to the prevention of opioid misuse and abuse is the creation and 

sustainability of effective, innovative, cross sector, supportive partnerships 

and collaborations including patients, families, educators, health leaders, law 

enforcement officials, policy makers, and other stakeholders. Community cohesion 

is an organizing force for bringing about lasting change.

3. Engage parents and caregivers in community efforts. Adolescents and young 

adults misuse prescription opioids more than any other age group, and substance 

use during the teen years significantly increases the risk of developing addiction. Be 

sure to encourage and empower parents to engage in proper medication storage and 

disposal, talks with their teen’s doctor, and honest conversations with their teens.

4. Understand your impact. As resources allow, include an evaluation of prevention 

efforts to understand what is working for your community. This information could 

inform future planning, educate decision makers, demonstrate the value of a 

program, and improve program effectiveness.

5. Partner with your local Cooperative Extension team. Invite Extension agents 

to participate in community coalitions that focus on the opioid crisis and other 

healthcare issues, co-host events, partner in content development, and facilitate 

connections. (Find your local office.)
46 SECTION 3: Prevention

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COMMUNITY DRIVEN AND SHAPED SOLUTIONS CHANGE LIVES

By Community Anti-Drug Coalitions of America

LASTING CHANGE STARTS AT THE LOCAL LEVEL

Community-driven efforts to address the rampant opioid crisis spreading across the nation requires local 

involvement to develop and shape effective solutions. Rural communities have fewer people, smaller 

transportation infrastructures, and fewer overall resources to fight the crisis than those available to 

their urban counterparts. Yet, these rural residents are best equipped to understand the intricacies of 

their own communities and should be the primary partners in determining the destiny of their own 

regions when strategies are formulated.

The remote nature of rural communities leads to certain 

dynamics, such as innovative partnering, inter and extraregional coordination, and centralized State agencies.

External agencies often give direction to local rural 

communities, but these prescriptive efforts generally fail 

to take consideration of strong community-level dynamics.

These efforts are unable to get any real traction and usually 

dissipate after external support ends.

Stronger and longer-lasting trends are built at the rural 

community level. These approaches engage community members from the beginning, have a better 

understanding of the issues important to the rural setting, and effectively leverage available resources 

and agencies. One of the most prominent examples of community work starting from the ground up are 

anti-drug coalitions trained by Community Anti-Drug Coalitions of America (CADCA). These coalitions 

contain three critical components that are necessary for any successful community-driven effort. They 

include local coordination, the right players at the right time, and actively engaged leadership.

LOCAL COORDINATION

To be effective, efforts to address the consequences of SUD should be tightly coordinated locally. Local 

coalitions can change the way that communities respond to the threats of SUD by mobilizing the entire 

community to act. The variance in the backgrounds and development of rural communities has led to 

several innovations in prevention-related efforts. For example, CADCA coalitions are trained to work 

with several sectors of a community.

The agents with which rural coalitions work depend greatly on their unique setting. For example, 

rural coalitions in eastern Kentucky work closely with education and local churches based on a strong 

reputation in their community, but coalitions in western Pennsylvania work more closely with healthcare 

agencies because of their growth in that part of the State. Rural coalitions in Utah work closely with a 

highly centralized State health agency and strong civic organizations. The rise of the use of opioids 

in that State has also prompted increasing partnerships with parents and healthcare agents. Some of 

“To be effective, 

efforts to address 

the consequences of 

SUD should be tightly 

coordinated locally.”
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Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

these examples include coordination across the continuity of care. Rural Kentucky coalitions partner 

with treatment centers and parent groups to help spread information about the warning signs of opioid 

use and addictions. There is also a developing understanding of addiction as a disease and of the value 

of prevention against the cost of treatment.

Rural coalitions that have been in existence for more than three years have often been able to support 

policy and establish relationships and improve the capacity of their community to anticipate problems.

A rural Tennessee coalition coordinated efforts with a State public health policy initiative to reduce 

smoking through public building smoking bans. A State Quitline promotion in coordination with the 

Parks and Recreation department was leveraged for a campaign against increased vaping and electronic 

cigarette use in public areas.

THE RIGHT PLAYERS AT THE RIGHT TIME

CADCA community prevention coalitions are trained and positioned to plan and implement their 

work alongside policy initiatives using recently available data. Rural coalitions work by assessing the 

community and the issues of greatest concern, then identifying a capacity for strengthening old bonds 

and starting new partnerships before formulating a strategic direction. The information they gather 

often becomes a valuable community resource. A rural Georgia coalition was able to create a directory 

of resources that soon replaced an out-of-date State instrument.

Coalitions should consist of a minimum of 12 community sectors participating in their group, including 

but not limited to youth under age 18, parents, businesses, media, schools, youth-serving organizations, 

law enforcement agencies, religious or fraternal organizations, civic and volunteer groups, healthcare 

professionals, State or local or tribal agencies with expertise in the field of substance misuse, and other 

relevant organizations involved in addressing illicit substance use in the community.

ACTIVELY ENGAGED LEADERSHIP

An actively engaged leadership and action by 

stakeholders within rural communities on any taskforce 

or coalition are necessary components for success 

in addressing substance use and its consequences.

For example, a CADCA coalition is well connected to 

most parts of its community by design and knows the 

strongest sectors with whom to work and those persons 

in leadership positions. The coalition acts as a convener, 

the agent by which sectors who would not normally 

interact can create lasting partnerships. As conveners, 

they provide a forum for sector leadership to become 

engaged in prevention, treatment, and recovery efforts.

“An actively engaged 

leadership and action 

by stakeholders within 

rural communities 

on any taskforce or 

coalition are necessary 

components for 

success.”
48 SECTION 3: Prevention

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ACTION STEPS TO CREATE COMMUNITY COALITIONS

Many States and local jurisdictions have implemented successful and innovative working 

groups, a drug focused taskforce, or a coalition to handle the opioid crisis in their 

communities. Four ways that local leaders can get started include: 

1. Identify areas of concern that could be addressed by community-level 

prevention, treatment, and recovery efforts. Wherever possible, add data to help 

tell the story.

2. Establish connections with community, county, region, and State-level 

stakeholders. Rural communities have a natural partner in county and State agencies.

3. Identify and connect with the critical stakeholders in the community affected 

by SUD such as business and healthcare related leaders. Schedule regular 

meetings to start building an action plan.

4. Seek opportunities to learn more about and connect with relevant organizations 

to learn about coalition building and training that could provide continued 

support.
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Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

TAKING ACTION TO ADDRESS SUBSTANCE USE DISORDER IN 

THE FARMING COMMUNITY

By American Farm Bureau Federation / National Farmers Union 

OPIOID IMPACTS ON FARMING COMMUNITY

A survey by Morning Consult commissioned in 2017 

by the American Farm Bureau Federation (AFBF) and 

National Farmers Union (NFU) revealed disturbing 

trends.

22 OUD is deeply affecting the farmer’s fields.

Three-in-four farmers and farm workers (74 percent) 

are or have been directly impacted by illicit opioid use, 

either by knowing someone with SUD, having a family 

member with SUD, taking an illegal opioid, or dealing 

with addiction personally. Forty-five percent of rural 

adults have been directly impacted, having experienced 

one of the above factors. Three-in-four farmers (77 

percent), as well as those who work in agriculture 

generally, say it would be easy for someone in their 

community to access opioids illegally.

These are worrisome results, not just because of their 

frequency, but also because of the difficulties farmers 

face on a regular basis. Farmers are often short-handed 

and find it difficult to take time off when they or a 

family member needs treatment. Healthcare providers 

and facilities are in short supply and often far away, 

creating multiple barriers to positive health outcomes 

for farmers in need of care.

THE FARMER’S ROLE IN FIGHTING OPIOID MISUSE

Farmers trust farmers. Often operating in isolation, they depend on each other for help. They share the 

experience of battling the elements to care for land and animals that sometimes resist their best efforts.

Farmers, then, are their own best hope. Since they understand one another in ways outsiders do not 

and cannot, they are in a unique position to come alongside and help others in the farming community.

The American Farm Bureau Federation and National Farmers Union launched the Farm Town Strong 

awareness and education campaign in 2018 based on a longstanding precedent of farmers helping 

farmers. Both organizations had been looking for ways to work together to address this crisis, and 

Ohio Farm Bureau had made opioids a major policy initiative prior to the campaign, lobbying the State 

legislature to address opioid addiction.

State organizations responded to the national call to action from AFBF President Zippy Duvall and NFU 

President Roger Johnson, who worked closely with other farm organizations to help spread the word. They 

“OUD is deeply 

affecting the farmer’s 

fields. Three-in-four 

farmers and farm 

workers (74 percent) 

are or have been 

directly impacted 

by illicit opioid use, 

either by knowing 

someone addicted, 

having an addicted 

family member, taking 

an illegal opioid, or 

dealing with addiction 

personally.”
50 SECTION 3: Prevention

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

hosted each other at their organizations’ annual conventions and shared expert opinions in a program 

about the rural opioid crisis on RFD-TV. The Pennsylvania, Ohio, and Utah Farm Bureaus, as well as Utah 

Farmers Union, participated in USDA roundtables on the issue. In addition, State and national affiliates 

of Farm Bureau and Farmers Union endorsed the efforts of an anti-addiction program developed in Des 

Moines, Iowa, to train farmers to recognize and combat signs of addiction in their communities.

FarmTownStrong.org, a website jointly developed by AFBF and NFU, raised awareness in farm media 

and farm communities. It provides farmers, ranchers, rural Americans and others with easy-to-find 

resources for treatment, crisis intervention, drug disposal, and prevention. The website features links 

to behavioral health treatment, buprenorphine for physicians, and treatment and MAT programs. There 

are also links to support services for families and children, prevention resources, and information about 

naloxone to prevent death from opioid overdose. The site also features a drug disposal locator tool, 

information on home drug disposal and the National Prescription Drug Take Back Day.

HOW THE FARMING COMMUNITY CAN HELP ITS OWN

FarmTownStrong.org is only a first step towards tackling the scourge of addiction. The problem is much, 

much bigger and more complex than anything one group can handle alone, but America’s farmers 

and ranchers can help in their own unique ways. Farm Bureau and Farmers Union are grassroots 

organizations committed to serving their members’ needs and providing forums for meeting and 

discussing key issues of importance to farmers, like the opioid crisis. State and county affiliates are 

discussing the issues raised at these forums and how to effectively address them. Committees at AFBF 

and NFU are asking what more they can do and are encouraging members to get involved.

Justice Louis Brandeis once observed that States are “laboratories of democracy,” places where free 

people can try new ideas on a small scale before suggesting they might work nationally. Farmers in rural 

America are working hard in the lab right now.

FUTURE FARMERS OF AMERICA

CAMP MUSKINGUM 

The Future Farmers of America (FFA) is a national organization dedicated to preparing 

members for leadership and careers in the science, business, and technology of agriculture.

Camp Muskingum, located in Carroll County, offers camp sessions for all Ohio FFA 

members. At a recent session in 2018, campers were polled about their experience and 

opinion regarding drug use. According to the poll of 961 people, 392 said their parents never 

talked to them about substance use and 330 said their parents only talk about it once per 

month. Students were also asked about their participation in 4-H, FFA and Farm Bureau 

and whether they felt those activities helped deter them from substance abuse. Nearly 

364 said that belonging to those groups “definitely” made a difference and 299 said that it 

“probably” does. This provided an opportunity to have an open discussion about drug use 

and prevention with youth during the camp sessions.
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ACTION STEPS THAT FARMERS CAN USE TO HELP ADDRESS ILLICIT OPIOID USE

There are many ways the farming community can help, such as sitting down with family 

members to talk about the deadly danger posed by SUD and opioid addiction, and how 

everyone can work together to avoid it. Other ways include:

1. Volunteer to help persons seeking treatment or in recovery and participate in 

initiatives to help, e.g., Drug Take Back programs.

2. Advocate for better insurance coverage for addiction treatment and recovery 

support resources.

3. Invest in training and educating the farm community about SUD, opioid misuse, 

and the Federal, State, and local resources that are available to help.

4. Work with State, regional, and local governments, banding together to apply for 

grants that will bring better services home.

5. Tap resources unique to the farming community, such as 4-H clubs, to help drive 

prevention and awareness-raising activities within the local community.
52 SECTION 3: Prevention

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HELPING STUDENTS DEVELOP INNOVATIVE SOLUTIONS TO THE OPIOID CRISIS

Successful prevention efforts take innovation and partnership.  With the breadth of their impact on a rural 

community, school systems can play an important role not only in transforming a community narrative around 

substance use but also in recreating a sense of hope and purpose for the future.  One example of such effort is 

the Kentucky Valley Educational Cooperative.

The Kentucky Valley Education Cooperative (KVEC) contains 22 rural public school districts that border West 

Virginia, Virginia, and Tennessee, which combine to create a geographic area larger than Connecticut. This region 

serves more than 50,000 students and more than 3,000 educators. The mission is to reframe the education and 

the community narrative in Appalachian Kentucky by building the human capital of educators, learners, and 

community members to work together to solve pervasive challenges. KVEC invests in people and not programs and 

embraces a transformative learning model, which is learning that engages the participant in connecting passion, 

purpose, and pathway to create real world solutions to pervasive challenges. KVEC initiatives include Building it 

Forward and the Forging Innovation in Rural Education (FIRE) Summits.

Building It Forward: Hands-on Approach to Learning

The cooperative funded three eastern Kentucky vocational schools to design and build tiny movable homes in 

2016. The “Building It Forward” project gives students experience with a wide range of construction skills, such 

as plumbing, wiring, carpentry, design, budgeting, heating, and cooling. This strategy ensures the cooperative’s 

schools offer classes that are interesting and valuable to students, and provides them with marketable skills, 

whether or not they plan to attend college. Each school involved receives a base amount of $15,000 and the 

students build the homes from August until April. Each house is equipped with air conditioning along with a 

kitchen, bathroom, and bedroom area. The program is designed to be financially self-sustaining. Eighty percent 

of the amount above the final auction bid goes to each school to build a new house the following school year.

Fire Summits Fosters Youth Innovation and Local Response to the Opioid Crisis

The FIRE Summits serve as a catalyst for energizing and accelerating strategies to improve the quality of 

education for learners everywhere. Drawing on resources made available through a U.S. Department of 

Education Race to the Top Grant, the twice-yearly event strategically drives innovation in the classroom by 

focusing on connecting students to their passions to reach goals and achieve a larger purpose. In recent years, 

students have addressed the opioid crisis in Kentucky through a series of projects, including:

• Protecting First Responders to the Opioid Crisis. National winner of the Samsung Solve for Tomorrow 

2018 competition, this project was developed by a student from Ashland Middle School. The students 

worked with local first responders, police officers, and addiction centers to develop a proprietary 

device that allows first responders to safely collect hazardous needles left behind by opioid and other 

drug users. They also used coding skills to develop an online database that local community members 

can access to learn more about the opioid crisis and report hazardous needles found in public areas.

• The Empty Chair Project. Winner of the Appalachian Regional Commission Humanitarian Award for 

2018, this project was developed by students from Pikeville Middle and High Schools. Students built 

an app that helps people learn signs and symptoms of opioid misuse and find opportunities to get 

help with addiction. A significant community partnership engaged a broad cross-section of partners to 

develop the solution.

• YMO “Yours, Mine, and Ours” Stories. Magoffin County High School Students developed a program 

to raise community awareness about the personal side of opioid abuse. They began collecting and 

publishing stories submitted by a quarter of the student population on personal experiences with 

the negative impacts of opioid abuse. A companion element of the program involved community 

awareness, supports, and resources for treatment. YMO Stories won the Appalachian Renaissance 

Horizon Award for 2018.

• P.U.R.E. KY—Providing Ultimate Recovery in Eastern Kentucky. Paintsville High School students 

developed a comprehensive initiative aimed at elevating community awareness to the opioid crisis 

through multiple communication channels that included community events, publications, focus 

groups, and community surveys.

To learn more, visit www.theholler.org/.
SECTION 4: Treatment 53

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

SECTION 4

Treatment

PARTNER INSIGHT AND RECOMMENDED ACTION STEPS

The need for greater access to treatment in rural America is vast. Healthcare providers, 

practitioners, and funders face enormous challenges in delivering treatment services 

in rural communities because of geographic distance, limited medical facilities and 

healthcare workforce, and gaps in infrastructure. Beyond access to treatment, there 

is also a continuous need to improve the quality of existing care in rural America and 

to break down the barrier of stigma that may keep a person living in a rural place 

from accepting treatment even if it is available. 

To meet these needs, rural leaders must explore new models for increasing access 

to treatment, grow the healthcare workforce, develop infrastructure and capacity to 

use technology for remote service delivery, and educate community members about 

treating addiction as a disease to encourage community support. With innovation and 

partnerships to better leverage existing services and programs, local leaders can ensure 

that people in their community get the help they need to get clean and stay healthy.
54 SECTION 4: Treatment

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STRENGTHENING THE RURAL HEALTHCARE NETWORK FOR 

PERSONS SEEKING TREATMENT

By National Rural Health Association

RURAL IMPACT OF THE USE OF ILLICIT SUBSTANCES AND PRESCRIPTION OPIOID MISUSE

The opioid crisis spreading across the United States has widened the already growing rural-urban 

healthcare gap. Effective, evidence-based treatment of SUD or OUD is urgently needed in rural 

communities. However, multiple barriers prevent appropriate treatment availability and quality, 

including decaying rural mental health treatment infrastructure, lack of regional coordination of 

treatment resources, inadequate support for rural physicians, and shortages of physicians who can and 

are willing to provide MAT for treating OUD. This approach combines behavioral therapy with one of 

three medications approved by the FDA for treating OUD—methadone, buprenorphine, or naltrexone.

To more successfully treat OUD in rural communities, public and private sector leaders must improve 

access to treatment, expand the healthcare workforce, and provide more customized treatment to the 

needs of individual rural communities.

STATE OF RURAL HEALTHCARE

Currently rural America lacks the necessary healthcare 

infrastructure to effectively treat the consequences of 

prescription opioid misuse and the use of illicit substances.

Rural providers are a critical part of their communities and 

often serve as the backbone of the rural economy. Yet, 118 

rural hospitals have closed since 201023, and due to financial 

strains nearly 700 more rural hospitals are financially 

vulnerable and at high risk of closure. If they close, rural 

patients would need to seek alternatives for 11.7 million 

hospitals visits, 99,000 healthcare workers would face 

unemployment, and $277 billion in GDP would be lost.

24

Behavioral healthcare options in rural communities have become alarmingly scarce. As of 2018, 

13 percent of rural counties employ no behavioral health providers. Nationally, 65 percent of rural 

counties do not have a psychiatrist, 47 percent lack a psychologist, and 81 percent lack a psychiatric 

nurse practitioner.

25Of the 2.2 percent of physicians who have obtained a waiver to prescribe MAT, less 

than 10 percent practice in rural counties.

26

IMPROVING ACCESS TO TREATMENT AND RECOVERY SUPPORT SERVICES

Research has shown MAT is the most effective therapy to treat OUD. Primary care providers may be more 

likely to implement MAT into their practices with greater accessibility to relevant training, community 

“Rural providers are 

a critical part of their 

communities and 

often serve as the 

backbone of the 

rural economy.”
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Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

“hub and spoke” programs or telehealth models, such as the successful Project ECHO, and enhancing 

care coordination and management. Regulatory and community barriers to MAT can be resolved by 

easing unnecessarily restrictive licensing standards, enhancing payment for MAT by State Medicaid 

programs, and educating community members to reduce opposition to MAT.

For example, Seaport Community Health Center in Belfast, Maine provides integrated opioid and 

substance use treatment in a FQHC that includes counseling, a buprenorphine treatment program, 

group counseling, and psychiatry services. Patients must agree to participate in an intensive outpatient 

program sponsored by a local community mental health center and remain drug-free for the duration 

of treatment.

Additionally, the expansion of team-based and integrated models of substance use, mental health, and 

primary care to maximize scarce resources will help streamline OUD treatment. To ensure that rural 

residents can access services, community-based solutions are needed to develop programs to assist 

individuals, including transportation, childcare, and housing.

PROVIDING SUPPORT FOR RECOVERY

Opportunities for community involvement and connections also bear a strong impact against addiction 

challenges. Programs targeted at reducing stigma, providing supportive housing, offering vocational 

training, and providing safe opportunities for social and recreational engagement are critical to fight 

opioid misuse.

• The Vermont Recovery Network, funded by 

the Vermont State Legislature, is a statewide 

network of peer-recovery centers that help 

people find and maintain recovery, prevent 

relapse, and return to recovery if relapse occurs.

They are local, consumer-driven, nonresidential 

facilities providing peer support, sober 

recreation activities, volunteer opportunities, 

and community education.

• Project Lazarus organizes community 

resources to strategically reduce opioid use in 

all North Carolina counties as well as across the 

country. These include Project Bald Eagle in 

Pennsylvania, Winnebago County Heroin Task 

Force in Wisconsin, Clark County Collaborative 

in Ohio, and Washtenaw Health Initiative 

Opioid Project in Michigan. This communitybased public health project aims to build 

public awareness of substance use through 

“Programs targeted 

at reducing stigma, 

providing supportive 

housing, offering 

vocational training, 

and providing safe 

opportunities for 

social and recreational 

engagement are critical 

to fight opioid misuse.”
56 SECTION 4: Treatment

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broad-based educational efforts and establish coalitions to engage a broad range of community 

providers, agencies, and organizations. By identifying data needs for planning and evaluation 

to build awareness, Project Lazarus customizes programs to local needs, tracks progress, and 

sustains support and funding. Communities are urged to start “where they are” and to identify 

evidence-based prevention initiatives to address specific local needs.

• Project Vision, also based in Vermont, is a locally organized collaboration between law 

enforcement, healthcare providers, schools, government, and community agencies with goals 

to empower the community and strengthen their futures. Three committees (Crime/Safety, 

Substance Abuse, and Community/Neighborhoods/Housing) work together to implement a drug 

market intervention model and community engagement to reduce the overall supply of opioids 

(heroin and illicitly distributed prescription opioids) in rural Vermont.

EXPANDING THE SUBSTANCE USE WORKFORCE

To encourage more providers to practice in rural areas, especially those with SUD training, programs 

must focus on the challenges of providing care in these communities. Those who grow up in rural 

areas and choose to practice in those areas later are more likely to continue providing care in rural 

communities throughout their careers. Efforts to encourage healthcare professionals to practice in rural 

communities should include the recruitment of rurally based students interested in pursuing healthcare 

careers and, ideally, specializing in SUDs.

EMBRACING NEW HEALTHCARE DELIVERY MODELS

Telehealth services allow expanded care options for 

communities that cannot yet support a larger workforce 

to address SUDs, while still retaining a network of local 

healthcare providers. Patients in far-flung areas can 

meet with specialists without the regular burden and 

expense of travel, increasing the likelihood of continued 

adherence to treatment. Research has shown successful 

treatment outcomes, improved patient satisfaction, 

and cost savings.

The University of Washington School of Medicine’s 

“telepain” program focuses on pain management 

to reduce unnecessary opioid prescriptions. Project 

ROAM (Rural Opioid Addiction Management) supported 

rural providers in Montana, Washington, Wyoming, 

Alaska, and Idaho who are treating patients using 

buprenorphine. The model was successful in supporting 

rural providers but was difficult to sustain.

“Telehealth services 

allow expanded 

care options for 

communities that 

cannot yet support 

a larger workforce 

to address SUDs, 

while still retaining 

a network of local 

healthcare providers.”
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ACTION STEPS TO SUPPORT CARE NETWORKS

Positive patient health outcome objectives are more likely reached in rural communities 

with expanded access to treatment and recovery support services. This approach requires 

rural leaders to:

1. Build a sustainable continuum of outpatient and inpatient services. This should 

include MAT, psychosocial treatment (e.g., structured counseling, motivational 

enhancement, case management, care-coordination, psychotherapy, and relapse 

prevention), mental health services, community involvement in recovery, and 

integrated primary, substance use, and mental health services.

2. Expand access to telemedicine services to treat SUD. Innovative care delivery 

models enabled by technologies, such as telehealth, telecounseling, video 

conferencing, remote monitoring, and diagnostic scanning, are an important way 

to bridge the gap in healthcare access.

3. Invest in alternative treatment delivery methods. Explore models, such as 

mobile clinics, school, and workplace-based health programs, and home visiting 

programs. The effectiveness of telemedicine is reliant on the speed and quality of 

broadband. Mobile clinics can visit community sites to deliver services and can help 

people who lack access to specific healthcare services or would otherwise have to 

travel long distances to see a provider.

4. Increase the number of healthcare professionals practicing in rural areas.

Expand their capabilities, especially in the areas of substance misuse. Form 

partnerships with local and State advance practitioner training programs, medical, 

physical therapy, and pharmacy schools that help develop and maintain the 

workforce residencies in rural areas. Engage local young people in the healthcare 

industry. Use innovative strategies to educate and train those who desire to work 

and live in a rural community.

5. Encourage and support peer-to-peer community programs. These should seek 

to break down stigma and support communities during recovery.
58 SECTION 4: Treatment

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UNDERSTANDING WHY MEDICATION ASSISTED TREATMENT IS 

DIFFERENT IN RURAL COMMUNITIES

By The Pew Charitable Trust

MEDICATION-ASSISTED TREATMENT FOR OUD

MAT is the most effective therapy for OUD. Multiple studies have shown that people with OUD who 

receive MAT are less likely to die of overdose, use illicit opioids, or contract infectious diseases that can 

be spread through injection drug use, such as HIV and hepatitis C, than people who do not.

27Additionally, 

patients on MAT remain in therapy longer than people who receive other treatment.

28

MAT for OUD combines behavioral therapy with one of three medications approved by the FDA—

methadone, buprenorphine, or naltrexone. These medications work to relieve the symptoms of 

opioid withdrawal or block the effects of opioids, 

while behavioral therapies help patients improve 

coping skills and reduce the likelihood of relapse.

29

MAT can be delivered in outpatient settings, such 

as a physician’s office, or inpatient facilities, such 

as a hospital or residential facility. Although some 

patients may require inpatient services, outpatient 

settings provide an appropriate level of care for many 

patients.

The medications approved by the FDA for OUD 

treatment have different mechanisms of action, 

which is the specific biochemical interaction through 

which a drug substance produces its pharmacological 

effect, and these medications are regulated by States 

and the Federal Government differently. As with 

other chronic brain disorders, the optimal choice of 

medication varies from patient to patient.

Methadone for OUD is available only at OTPs, which are State and Federally regulated facilities 

that patients visit, usually daily, to take MAT medications under the supervision of staff and receive 

counseling and other care services. Buprenorphine and naltrexone are available at some OTPs and in 

other settings, such as primary care practices and community hospitals. Physicians, nurse practitioners, 

and physician assistants must complete training to obtain a Federal waiver to prescribe buprenorphine.

Naltrexone is available from any practitioner who is authorized to prescribe medications and can be 

delivered through a monthly injection.

ACCESS TO MAT IN RURAL COMMUNITIES

People with OUD living in rural communities often face barriers to accessing medication-assisted 

treatment, including fewer transportation and treatment options compared with those available in 

urban areas, according to a study conducted by Maine Rural Health Research Center.

30 For instance, 

patients in low or moderately populated areas must usually travel farther to access OTPs.

31 Office-based 

treatment options are particularly limited in rural communities—one study found that 29.8 percent of 

“MAT is the most 

effective therapy for 

OUD. Multiple studies 

have shown that people 

with OUD who receive 

MAT are less likely 

to die of overdose, 

use illicit opioids, or 

contract infectious 

diseases.”
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Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

rural Americans live in a county without a buprenorphine provider, compared with only 2.2 percent of 

urban Americans.

32 A survey of rural physicians published in the Annals of Family Medicine in 2017 found 

that worries about diversion (the redirection of drugs from legal, medically authorized uses to illegal 

uses), constraints on their time, and lack of access to mental health supports for their patients were the 

top barriers to incorporating buprenorphine into their practice.

33

Moreover, SUD treatment centers in rural areas often do not offer the same scope of services as their 

urban counterparts. Rural facilities are less likely to provide buprenorphine; they also offer fewer 

wraparound services, such as case management and recovery groups that have been shown to improve 

health outcomes. These facilities also rely more heavily on public funds to provide treatment than 

treatment centers in urban areas do, according to a recent assessment of treatment centers.

34 Resource 

limitations can contribute to decreased availability of evidence-based treatment, with fewer tailored 

options and specialized providers to treat patients with complex needs.

PROMISING STRATEGIES FOR RURAL COMMUNITIES

Any comprehensive approach to deliver treatment must include education on MAT for OUD, psychosocial 

services, care integration, and education to providers.

35 The following strategies incorporate these 

components and show promise in increasing access to treatment in rural communities:

Care Coordination

Care coordination facilitates the delivery of medication and behavioral health services associated with 

MAT. Research from the Agency for Healthcare Research and Quality shows that system reforms that 

emphasize care coordination can address some of the barriers to accessing MAT in rural areas. For 

example, in 2013, Vermont pioneered “hub-and-spoke” systems in which patients start treatment and 

receive a higher level of services at OTPs (hubs). Once patients are stabilized (i.e., misuse has reduced 

or stopped, and cravings are diminished), patients are transferred to long-term management with 

community-based providers (spokes). Care coordination between the hubs and spokes, which aims 

to address the patient’s evolving treatment needs, is an essential part of the model. A report in the 

Journal of Addiction Medicine found that Vermont’s treatment network resulted in the State having the 

highest per capita capacity to treat OUD patients 

in the country: 10.56 people in treatment 

per 1,000. Vermont also saw a 64 percent 

increase in physicians authorized to prescribe 

buprenorphine.

Care Integration

Integration of mental and physical healthcare 

brings together components of care delivery to 

improve health outcomes, relying heavily on 

collaboration among mental health and other 

healthcare professionals, according to the SAMHSA 

and The National Council for Behavioral Health.

For example, a FQHC in rural northern Michigan 

implemented an integrated approach to deliver MAT to its OUD patients, an undertaking documented by 

the Rural Health Information Hub. With funding from the HRSA and the SAMHSA, the FQHC established a 

partnership with a local clinical practice and a behavioral health organization. FQHC patients are screened

“Any comprehensive 

approach to deliver 

treatment must include 

education on MAT for 

OUD, psychosocial 

services, care integration, 

and education to 

providers.”
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ACTION STEPS TO ADOPT INNOVATIVE TREATMENT MODELS

Many States and local jurisdictions have implemented innovative treatment models that 

have shown promise in saving lives by connecting patients to MAT. Local leaders can help 

advance these initiatives and access to MAT by taking action to:

1. Facilitate the establishment of treatment in specialty and primary care settings in 

the community or region.

2. Educate the local community and leadership on the value of MAT.

3. Assess and leverage and leveraging local and regional resources to implement 

programs.

4. Adapt treatment delivery models to address community-specific needs, including 

needed provider training.

5. Support State leaders in their efforts to address the opioid crisis.

for OUD and referred to on-site providers who are waivered to prescribe buprenorphine and provide 

behavioral health counseling. A formal evaluation has not been completed as of 2018, but preliminary 

evaluation results indicate that 32 percent of patients remained in treatment for 18 months or more, which 

is comparable to reported outpatient treatment retention rates.

Telehealth

Rural health systems with sufficient technological capabilities may consider implementing promising 

practices, such as distance learning and telemedicine. For instance, Project ECHO—which launched 

in 2003 with the support of Federal, State, and private funds—connects primary care providers 

with a team of specialists of varying disciplines who practice elsewhere using video-conferencing 

technology. The specialists provide guidance on treating an array of diseases, including OUD, and 

consult on challenging patient cases. After starting an ECHO program in 2005, New Mexico increased 

the per capita number of providers authorized to prescribe buprenorphine, including those practicing 

in underserved areas. Moreover, an analysis published in The Journal of Addiction Medicine of West 

Virginia’s Comprehensive Opioid Addiction Treatment program, a telemedicine model that uses video 

conferencing for buprenorphine prescribing and medication management, found that outcomes, such 

as abstinence from drug use, were comparable to those who receive MAT in person.
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MOVING FROM LOCK’EM UP TO PROVIDING TREATMENT 

AND SUPPORT

By National Sheriffs’ Association

In rural communities, jails have become a revolving door for individuals struggling with mental health and 

SUD. More than 10 million people, at least half with SUDs, are incarcerated around the country annually.

People suffering with mental health and SUD come in and out of jail with arrests and incarceration.

Without effective intervention before they are released, 

the disorder typically continues, and the cycle begins 

upon release often with a dramatic crime rate increase, 

while those who are most vulnerable, remain sick.

In some cases, incarcerated persons with SUD face fewer 

barriers to treatment access, like the absence of negative 

social networks and family obligations. There is no need 

for health insurance. Medical care and treatment beds 

are always available, and inmates can immediately see 

their treatment specialists and caseworkers without the need to secure transportation. The opportunity 

for freedom from SUD is greatest within this controlled environment.

Jails are in a unique position to initiate treatment to individuals struggling with SUDs and withdrawal in 

a controlled, safe environment. To achieve optimum outcomes with jail-based MAT, leaders must look 

beyond basic law enforcement tactics to create a comprehensive and strategic approach with local 

communities, State, Tribal and Federal government. The present substance use problem underscores 

the need for law enforcement to take a more active and compassionate role in addiction treatment.

ADOPTION OF MAT IN PRISONS 

Traditional approaches to public safety, including, the threat of arrest and incarceration, are not 

enough to deter a person dealing with a substance use problem. The constant, overwhelming need 

to fuel the addiction is often too great for standard deterrents to prevent property crime. As a result, 

law enforcement officers have had to learn how to adjust their approach to law by incorporating MAT 

treatment into jail-based programs while persons with a SUD are in custody.

Over the past few years, MAT programs in jails have rapidly expanded into 30 States. Now sheriffs 

and jail administrators are working to collaborate with support services in the community to ensure 

follow-through treatment after release of inmates in recovery. The upcoming “Jail-Based Medication 

Assisted Treatment: Promising Practices, Guidelines, and Resources” handbook—from The National 

Security Agency, the National Commission on Correctional Healthcare, and the National Institute of 

Corrections—is a valuable new resource for rural, suburban, and urban sheriffs and jail administrators 

“In rural communities, 

jails have become a 

revolving door for 

individuals struggling 

with mental health 

and SUD.”
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seeking innovative evidence-based drug treatment.

Jails are the intersection where public health and public safety crises collide. While a jail sentence 

may seem like rock bottom for those convicted, this time can also serve as a window of opportunity 

to address factors that led to incarceration. Though the corrections environment was not designed for 

addressing substance use problems, law enforcement officials can serve a vital public health need by 

providing incarcerated individuals with treatment and tools. This reduces the risk of fatal overdoses 

and addresses the underlying cause of criminal activity that poses a threat to public safety.

The Massachusetts MATADOR (Medication Assisted Treatment and Directed Opioid Recovery) statewide 

pilot program provides three types of medication-assisted treatment in five county correctional 

facilities. The Middlesex County Sheriff’s Office (MCSO) serves rural, suburban, and urban communities 

and adopted and implemented a successful data-driven model program.

MIDDLESEX COUNTY MATADOR PROGRAM SPOTLIGHT

About 80 percent of individuals sent to the Middlesex County Jail have a SUD, and half of them suffer 

severe addiction requiring immediate medical detoxification. In 2017 the correctional facility’s medical 

unit counted 178,000 contacts with patients, far outpacing the largest hospital emergency room in the 

county. The Massachusetts Department of Public Health’s Section 55 Opioid Overdose Report found 

that individuals released from jails or prisons are 120 times more likely to die of an opioid-related 

overdose than the rest of the adult population.

In response Middlesex launched the MATADOR program to treat substance use with naltrexone. As 

part of the program, they receive health assessments, detox treatment, monitoring, regular medical 

attention, and work with a recovery coach or “navigator” during incarceration. Upon release, the 

MATADOR navigators continue to serve as advocates. They ensure patients have a reentry plan in place, 

are scheduling and attending medical and program appointments, and have support during setbacks.

The navigator also helps ensure clear and timely communication between community healthcare 

providers, support program locations, drug courts, and the sheriff’s office.

MATADOR program participants are deemed successful after six months when they are well into their 

reintegration back into the community, have established routines, are familiar with the network of 

healthcare and other resources available to them, and their continuity of care has been established.

Navigators work closely with research staff at the MCSO to regularly identify and track the progress of 

each enrolled participant, and research staff communicate with each healthcare provider to ensure 

program compliance as well as any interaction with law enforcement.

Three years after inception, research showed that by applying a data-driven public health approach to 

those with OUD within correctional custody, the MATADOR program is both saving lives and reducing 

future incidents of crime. For example, 96.2 percent of MATADOR participants (regardless of their success 

or failure in the program) had not succumbed to a fatal opioid-related overdose post release as of 

June 2018.
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Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

ACTION STEPS TO START A JAIL-BASED MAT PROGRAM

Challenges like slim budgets and limited staff assistance continue to hinder rural 

communities from implementing comprehensive jail-based MAT programs. Most sheriffs, 

particularly those in the western United States, serve vast areas with little or no community 

services that can provide continuity of care after a person is released from a detention 

facility. Incarceration is a window of opportunity for individuals that may have spent years, 

even decades, using opioids, to come clean for the first time. People should not have to 

come to jail to get good treatment, but while there, it should be viewed as an opportunity.

Enforcement professionals in rural communities should consider the following steps:

1. Learn about a variety of jail-based MAT programs. There is no one-size-fits all 

jail-based MAT model. Identifying different options will help law enforcement 

professionals identify a model that could work or tailor one to a specific vision.

2. Identify and recruit like-minded correctional professionals to start. Correctional 

professionals may not be comfortable with this process at first. Initiate a pilot with a 

team of like-minded colleagues, working with a smaller group to start (e.g., juveniles 

or women) for a specified period of time. This will allow time to find, assess, and fix 

any issues before a wider roll out of the program.

3. Determine what resources you have and what resources you need. Take stock 

of the resources needed to introduce a jail-based MAT program. Assess what is readily 

available and what resources need to be acquired before a program can be implemented.

4. Leverage the resources of community partners. A jail treatment program relies 

not just on the services within the system but also on services and programs 

delivered by community partners.

5. Encourage enforcement professional peer-to-peer learning opportunities.

Host workshops and engage with other rural law enforcement and correctional 

professionals dealing with similar situations in other counties or States. Increasing 

opportunities for direct exchanges with peers will help increase the level of 

comfortability with these initiatives and dispel myths.

6. Collect data. Data collection can be daunting for some, but it should not be feared.

Collecting baseline data that includes demographics and basic performance 

measures is essential. Programs like MATADOR may not work for every individual, 

but the potential positive outcomes regarding harm reduction should not be overlooked.
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MAKING DRUG COURTS WORK FOR RURAL AMERICA

By Center for Court Innovation

Drug courts rank among the most successful criminal justice innovations in recent decades, gaining 

widespread support in States across the country. More than 3,000 drug courts exist, including DWI courts, 

mental health courts, and veteran treatment courts.

36 Using a collaborative, team-based approach, 

drug courts combine court-supervised treatment with an array of supportive services, ongoing judicial 

monitoring, and motivational incentives and sanctions. These serve as an alternative to conventional 

case processing and jail.

In addition, large-scale studies like the Federally funded Multi-Site Drug Court Evaluation have helped 

to identify specific, evidence-based practices that promote drug court effectiveness. This research, in 

turn, has been distilled into the Adult Drug Court Best Practice Standards, a detailed set of concrete 

practices that all drug courts should strive to achieve.

RURAL DRUG COURTS FACE SPECIAL CHALLENGES

Drug courts in rural jurisdictions have a few challenges.

Drug courts combine help, in the form of treatment 

and other services, with accountability, such as 

randomized drug testing and utilize principles of 

behavior modification, to help guide participants 

toward long-term success. To promote abstinence and 

detect relapse, it is critically important that drug courts 

engage frequently with participants. Lack of widely 

available public transportation can make it difficult 

for rural drug court participants to attend the frequent 

court hearings, treatment sessions, and probation 

check-ins that drug courts require, putting them at risk 

for program failure.

Rural communities too often lack access to adequate treatment services, including residential treatment 

facilities, intensive outpatient services, medically supervised detoxification, and other evidence-based 

approaches. Many rural communities lack physicians who are licensed to prescribe and monitor these 

life-saving medications. While the National Association of Drug Court Professionals (NADCP) provides 

excellent guidance for vetting providers, rural communities often lack the capacity to monitor unethical 

prescribers of opioids to treat physical pain. Unfortunately, even if rural counties want to develop 

alternatives for drug offenders, they often do not have the resources to establish and maintain a drug 

court independently. Many rural drug courts are significantly underfunded and understaffed.

“Unfortunately, even if 

rural counties want to 

develop alternatives for 

drug offenders, they 

often do not have the 

resources to establish 

and maintain a drug 

court independently.” 
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Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

RURAL DRUG COURT SUCCESS AND STRATEGIES

Innovative strategies are helping rural drug court models become successful. For example, peer 

recovery advocates can supplement formal treatment. These individuals use their own experience of 

substance misuse and recovery to support others, help connect drug court participants with supportive 

services and recovery communities, as well as help transport participants to treatment, court, and

other meetings. In Pennsylvania, the Recovery Specialist Program provides one-on-one recovery 

coaching to individuals in treatment across a five-county area. The program is designed to assist 

individuals to stay in treatment by matching them with seasoned recovery veterans to work together 

and build recovery capital.

Another innovative approach used by rural drug courts 

is teleservices, which is technology that transforms 

how courts deliver remote treatment and facilitates 

remote supervision of participants. Rural drug courts 

throughout the country are experimenting with new 

technologies that allow participants to participate 

in treatment remotely, such as videoconferencing, 

smartphone apps, and portable drug testing devices.

Likewise, technology is helping rural drug court 

participants appear remotely for court hearings and 

probation check-ins, and even providing participants 

with drug tests remotely.

Lacking consistently available treatment providers, Montana’s Ninth Judicial District Treatment 

Court, which serves four rural counties and an Indian reservation, has paid treatment providers from 

a neighboring district to travel there and hold treatment groups. This practice was discontinued due to 

high costs, and now the court uses videoconferencing technology to provide remote treatment services.

The outside treatment providers provide weekly therapy groups, including a Moral Reconation Therapy 

group. All drug court participants are required to attend these remote sessions. Additionally, the court 

offers remote anger management sessions and a women’s group.

Similarly, the Klamath County Veterans Treatment Court in Oregon, which serves a population of 68,000 

in a land area larger than the State of Connecticut, has scarce access to local treatment services. Court 

participants use a telehealth link, which is located at a local Veterans Administration community-based 

outpatient clinic, to access providers across the State and the Pacific Northwest. Available telehealth 

services include treatment for substance use problems and post-traumatic stress disorder.

“Rural drug courts 

throughout the country 

are experimenting 

with new technologies 

that allow participants 

to participate in 

treatment remotely.” 
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ACTION STEPS TO HELP BUILD EFFECTIVE RURAL DRUG COURTS

Building an effective drug court is no longer a process of trial and error. There is an 

abundance of resources available to provide guidance. The National Drug Court Resource 

Center provides access to research, publications, and fact sheets that can be utilized for 

training along with the video lessons housed on the Treatment Courts Online platform.

Building an effective drug court in rural communities requires a few essential building 

blocks to help them succeed. These steps include:

1. Identify a willing and engaged judge. An important key to success is the special role 

of the judge. Serving as a drug court judge introduces a dramatically new role, that 

of engaging people in treatment, motivating them in treatment, and being willing 

to reengage them when they slip and fall and fail without blame. This requires a 

judge who is committed to learning about substance misuse and is prepared for 

meaningful engagement with drug court participants to steer them toward success.

In rural communities, judges preside over the drug court alongside many other 

functions. One way to convince a sitting judge to become involved is to have him 

or her visit an existing drug court, observe the process, and interact with the team.

2. Build a strong dedicated team. Drug courts employ a collaborative, multidisciplinary 

team approach. Drug courts are most successful when all key stakeholders—

judge, prosecutor, defense counsel, case managers, treatment providers, court 

coordinators, probation officers, and law enforcement— participate actively and 

consistently in the program.

3. Provide ample access to training. Drug courts require team members to acquire 

specialized knowledge and skills to work effectively. The team should receive basic 

training in the psychopharmacology of addiction, substance misuse treatment, 

behavior modification, and drug court policies and procedures. A few national 

nonprofit organizations like the National Drug Court Institute, Center for Court 

Innovation, and Tribal Law & Policy Institute offer no-cost training and technical 

assistance.

4. Establish relationships with quality providers. Drug courts need communitybased treatment partners to provide participants with reliable, high-quality 

treatment and recovery support services, and access to evidence-based treatment 

including behavioral and psychosocial support. Participants are not positioned for 

success when they lack necessities, such as housing, food, and transportation, or 

because they are not allowed to use the best treatment for their specific disorder.

Engage the local treatment community and identify all the treatment resources 

available and build strong partnerships with treatment providers who can provide 

a range of evidence-based treatment services.
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5. Identify creative ways to fill resource gaps. When gaps exist in the continuum of 

services, find ways to pursue creative strategies and work with community partners 

to identify potential resources. If only one professional is available to serve a large 

geographic area, one solution could be “circuit-riding” where the professional travels 

to each community on a regular basis. A contracted treatment provider (treatment 

counselor) from a larger community could drive to a rural location and hold group 

sessions both before and after the drug court docket. Coalitions, places of worship, 

and civic groups could provide resources as well. Counseling space (office space) 

could be available through a local faith-based organization. Also, consider sharing 

resources between rural courts, utilizing peer recovery advocates, and teleservices 

to help overcome resource limitations.

6. Encourage community engagement and community buy-in. Find ways to integrate 

the community to help them to see the benefit. For example, hold a community 

partners meeting and include individuals from law enforcement, community 

groups, hospitals, churches, and mental health services. Make community service 

an important aspect of the program or have drug court participants volunteer at 

community events to earn community service hours. Efforts to enlist and maintain 

community support through public presentations by the judge and other team 

members, as well as media coverage of graduations and other positive events 

are important.
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TN ROCS DOCKET: AN ALTERNATIVE STRATEGY TO MANAGE LOW-RISK, HIGH NEED 

DRUG OFFENDERS.

Tennessee’s Recovery Oriented Compliance Strategy (TN ROCS) is an intervention strategy for working with drug 

offenders who have an urgent need for treatment but may not qualify for drug court programs. The program’s founder 

Judge Duane Slone based the unique strategy, which helps reduce State jail populations and confronts the opioiddriven addiction crisis, on three components—adequate assessment of treatment, frequent accountability, and “a big 

stick.” Paths to TN ROCS include: those not accepted or ineligible for Drug Recovery Courts (DRC), Pre-trial release, 

Probation Violations, either by committing new crimes or “technical” violations, or as part of an Original Sentence.

Placement on the TN ROCs docket is at a judge’s discretion; it may be voluntary or involuntary. TN ROCs have fewer 

steps, allowing individuals to more quickly be integrated into treatment. In contrast, drug recovery court programs are 

resource-intensive, often requiring many volunteers to operate, and participants must complete a highly-structured, 

four-phased recovery process. TN ROCS draws inspiration from this model but offers a less resource intensive approach.

For example, TN ROCs does not require the same extensive staff or drug court team involvement, and only requires a 

judge to begin handling this portfolio of cases within their docket. Still, the program requires buy-in and hard work from 

participants who want to succeed.

Drug Recovery Courts vs. TN ROCS

Drug 

Recovery 

Courts

TN ROCS

Treats High Risks 

for Recidivism X X

Treats High Needs for 

Behavioral Health & 

Other Services

X

Application Required 

(Voluntary 

Participation)

X

Utilize Three Essential 

Components of DRCs X X

No Eligibility 

Restrictions for 

Sentences Permitting 

Probation

X

Highly Dependent 

on Justice System 

Volunteers

X

TN ROCS participants are usually non-violent offenders 

with demonstrated, persistent substance abuse problems 

who cannot seem to break the cycle of their own 

addiction. The participants are partnered with criminal 

Justice liaisons who perform health assessments, draw 

up evidence-based behavioral health treatment plans, 

which often consist of intensive outpatient therapy and 

medication-assisted treatment; and arrange for the 

acceptance of the offender with all treatment and recovery 

support providers. The behavioral health treatment plan 

continues to be a condition of probation and therefore the 

sentence. Once added to the TN ROCS docket, members 

meet regularly with corrections officers, who monitor their 

adherence to the behavioral health treatment plan. Docket 

members also make regular appearances before a judge to 

provide progress updates. The more progress completed 

and the longer participants adhere to the requirements of 

their treatment plans, the less frequent these appearances.

Eventually, participants can complete the program with 

approval from a judge. The length of time on the Docket 

is open ended, however, it typically takes two years before 

the person no longer has to report to the judge.
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Three Necessary Requirements For TN ROCS

CRIMINAL JUSTICE LIAISON

Trusted Person or Organization Provides Accurate Screening, Assessments, and 

Referrals to Appropriate or Best Available Level of Treatment.

COMMUNITY CORRECTIONS OR CASEWORKER

Trusted Person or Organization Provides Appropriate Level of Supervision.

JUDICIARY

First, Affirmation by the Judge is Critical to the Success of the Individual. Second, the Individual 

Appears Before the Court to Review Compliance with the Behavioral Health Treatment Plan and 

to Make Adjustments to Terms and Conditions of Supervision Where Necessary.

One of the docket’s biggest successes is the high rate of healthy babies born to young mothers participating 

in the TN ROCS program. All 34 babies born during the first three years of the program were healthy, and 

30 of the mothers were able to retain custody of their children. That rate far exceeds the average for women with 

behavioral health issues who are involved in the criminal justice system.
70 SECTION 5: Recovery

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

Section 5

Recovery

PARTNER INSIGHT AND RECOMMENDED ACTION STEPS

Once people get treatment, there are many services needed to ensure they stay 

healthy in long-term recovery. From housing to transportation and employment 

training, there is a significant gap in recovery supports in rural communities. Yet, 

there are also strong assets in rural America for local leaders to tap in building these 

supports. For example, in most small towns, the faith community is a prominent 

piece of the local support network that comes together around any other challenge 

the community may face.

Recovery is a lifelong process that is most successful when carried out in community. 

To build a recovery-friendly community, rural leaders must be proactive and take 

action to learn about the needs of a person in recovery, take inventory of community 

assets and gaps, and foster a network of stakeholders to create an environment in 

which people in recovery can live substance-free.
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HOW FAITH COMMUNITIES CAN HELP RURAL COMMUNITIES 

ADDRESS SUBSTANCE USE DISORDER

By USDA, Center for Faith-Based and Neighborhood Partnerships

ROLE OF FAITH-BASED COMMUNITIES

The American people are key drivers of fundamental change in our country, and few institutions are 

closer to the people than faith-based and community-based organizations. Faith leaders play an integral 

role in bringing communities together, advancing a culture of compassion, and partnering meaningfully 

to leverage the vast array of resources and deliver critical services in our communities.

Faith communities play a vital role in education, prevention, and treatment related to the opioid crisis 

at a very local level. These groups have been a caring and driving force in assisting local communities 

to weather many storms in our country’s history, including helping to heal people from the negative 

effects of war, pandemics, natural disaster, economic downturn, and social upheaval.

Since 2002, the USDA Center for Faith-Based and Neighborhood Partnerships has recognized the 

need and supported efforts to engage a broad and inclusive array of faith-based community-based 

organizations to deliver vital services in our communities. Currently, the center works to empower faith 

communities and leaders to navigate USDA programs and resources to support those who are struggling 

with SUD, including opioids misuse and its dangerous consequences.

FAITH COMMUNITIES ARE LEADING LOCAL EFFORTS TO TACKLE SUBSTANCE USE PROBLEMS

Today many faith leaders are leading the charge to serve their communities in response to the opioid 

crisis. These leaders have highlighted the many ways that faith communities are opening their doors 

to those in need during the height of the opioid crisis. Their work shows how faith-centered recovery 

models can help combat addiction.

Faith communities provide many types of support for opioids use disorder. Informal methods can range 

from rallying around community members or offering a moral uplift, to assisting in fulfilling unmet 

needs. Formal services can include counseling, transportation support, and serving as a drop-off site 

for unused medications. They can encourage congregations to focus on educating and reaching their 

members to connect them to recovery and addiction programs.

As the opioid crisis persists, houses of worship can increase their commitment to reduce the devastating 

effects of this crisis on its victims and their families. This includes supporting a judgment-free and 

compassion-centered approach, promoting and supporting healing through direct care, forgiveness, 

hospitality, and friendship, and actively participating in community-wide strategies.
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INCLUSION OF FAITH-BASED LEADERSHIP 

Faith communities constitute a prominent segment of society and often have a front-row view of the 

opioid crisis and its devastating impacts. They bring both theological and social resources to respond to 

these challenges. By their very nature, faith-based organizations are embedded in neighborhoods and 

serve as trusted pillars among community members. Additionally, many of these interfaith organizations 

provide a wide variety of social service programs to help their communities.

Accordingly, faith leaders should be included and supported as a member of any local task force or 

working group formed to address the crisis right alongside political leadership, law enforcement, 

healthcare providers, as well as educational institutions. Active inclusion and participation will 

strategically leverage best practices, models, existing resources, and programs to empower and assist 

communities in addressing opioids misuse.

Given the assets and untapped potential of faith communities, it is essential that their leadership be 

included along with secular service providers, public and private funding agencies, support systems, and 

consumers of behavioral health services in crafting an effective behavioral health service delivery system.

Faith Based Provider Organizations Secular Provider Organizations

Public/Private Funding 

and Regulatory Agencies

Support Service Agencies 

(e.g., Housing Employment)

Persons with 

Behavioral Health Disorders

Faith leaders’ institutional role as trusted community leaders is essential to building bridges within 

and in between communities. They function as critical information conduits, which are necessary for 

communicating constituent needs to local, State, and national leaders and ensuring that the community 

receives relevant and much-needed information and resources.

While the challenges appear to be many, there are a variety of practical strategies faith communities can 

undertake to serve their respective communities. These activities seek to address concerns primarily 

through the growth and development of social capital and social networks in the community. By 

working with others to identify needs and gaps, faith communities can also leverage their other assets 

to assist families with transportation, housing, family and youth mentoring, and job coaching. These 

support networks will enable faith communities, in partnership with local authorities and partners, to 

assist both prevention and response efforts.
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ACTION STEPS FOR FAITH-BASED COMMUNITIES TO ADDRESS SUBSTANCE 

USE PROBLEMS

To break the cycle of addiction, faith communities should work together with community 

partners, families, and one another. Together, this effort offers an opportunity to make a 

lasting change and save lives. These practical activities can assist faith-based communities 

in addressing the opioid crisis.

1. Form an interfaith group to avoid working in silos. Appoint representatives to 

interact with the community taskforce or working group to gain an understanding of 

the community vision for change and how the interfaith community can help maximize 

resources and increase the impact.

2. Educate the interfaith community about the breadth and scope of the challenge 

and the local level of substance use and behavioral health issues. Host meetings 

with interfaith partners and take steps to better understand what is most and least 

helpful for bringing healing to those who are affected by opioid use.

3. Partner with local health organizations and service providers to stay up to date 

on the latest information, statistics, and educational resources. Maintaining a 

close relationship with local health providers will ensure that the community is up 

to date on valuable trends and treatment options and can assist with the education 

of lay members and congregants.

4. Assess the interfaith community assets. Determine which partners have a high 

number of available volunteers, consistent access to vehicles to supplement 

transportation need, or available meeting space for counseling.

5. Work with partners to educate and train lay people and pastors to deal with 

addiction. Providing congregants and faith leaders with formal training in convening 

and partnering, facilitating, breaking down the barriers of stigma, and addressing 

substance misuse in communities, will create enabling environments for successful 

interventions. Educating the community around critical issues or topics in behavioral 

health will build consensus and identify the most suitable local response.
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BUILDING A STRONG RECOVERY COMMUNITY IN RURAL AREAS

By National Alliance for Recovery Residences

Recovery is a person-driven process with many pathways to health. The process is more successful 

when implemented within a supportive structure, such as a recovery community. These are networks 

of individuals who share the common goal of lifelong sobriety and offer support and fellowship to 

their peers. Due to high rates of SUD, many types of recovery communities have sprung up across the 

country to support persons in recovery. These range from sober living facilities and recovery residences 

to twelve-step support groups such as Alcoholics Anonymous (AA), Heroin Anonymous (HA), Cocaine 

Anonymous (CA), and Narcotics Anonymous (NA). Recovery community organizations (RCO) are 

independent, nonprofit organizations led and governed by local representatives. They focus on the 

needs of individuals, families, and communities seeking or in recovery from SUD.

FACTORS THAT DRIVE RECOVERY CARE

Recovery services include the provision of continuing care following treatment, education regarding 

self-care, regular check-ups, and linkage to community resources and support resources such as 

recovery mutual aid meetings and recovery homes. SUDs typically require long-term involvement 

with the healthcare system. In rural communities there are fewer health practitioners and both mental 

health and SUDs services are harder to obtain. The barriers to recovery in rural areas typically include:

• Limited funding for recovery residences

• Transportation challenges

• Limited access to a continuum of care/

recovery-oriented systems of care

• Lack of detoxification facilities

• Lack of mental, dental, and health services

• Limited access to transition and 

long-term housing

• Lack of anonymity

• Limited access to mutual-aid meetings

• Limited access to employment

Four factors impact rural behavioral healthcare and drive the delivery of SUD recovery support services 

to the community. These variables determine when and if rural residents with behavioral healthcare 

needs will seek care.

• Availability includes basic and specialized recovery support services and staffing that can 

deliver services.

• Accessibility is when and where services can be received and the coordination of services across 

the behavioral health and social service system. This also includes transportation issues that 

may be involved.

• Affordability includes the costs of receiving care and availability of benefits, insurance, and 

alternative revenue streams to underwrite services.

• Acceptability addresses the consistent issues around stigma for those who need services. In 

addition, rural residents may be more likely to make use of informal supports, such as neighbors, 

family, churches, and other community groups.
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Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

FOCUS ON BUILDING RECOVERY ORIENTED SYSTEMS OF CARE IN RURAL COMMUNITIES

Traditional service systems are not sufficient to handle recovery-oriented services. Instead it is necessary 

to change the service system structure to bring about a truly recovery-oriented service system. A 

ROSC (Recovery Oriented Systems of Care) is a coordinated network of community-based services 

that support person-centered, self-directed approaches by building on the strength and resilience of 

individuals, families, and communities to take responsibility for their own sustained health, wellness, 

and recovery. The central focus of a ROSC is to create an infrastructure or‚ system of care, with the 

resources to effectively address the full range of substance use problems within communities. A ROSC 

should provide a network of services and supports that addresses the totality of substance use problems.

Examples of Recovery-Oriented Activities

Prevention Intervention Treatment Post-Treatment

• Early screening 

before onset

• Collaborate with 

other systems, e.g., 

child welfare, VA

• Stigma reduction 

activities

• Refer to 

intervention 

treatment services

• Screening

• Early intervention

• Pre-treatment

• Recovery support 

services

• Outreach services

• Menu of treatment 

services

• Recovery support 

services

• Alternative services 

and therapies

• Prevention 

for families 

and siblings of 

individuals in 

treatment

• Continuing care

• Recovery support 

services

• Check-ups

• Self-monitoring

Bringing the ROSC approach to rural communities means examining these areas through a recoveryfocused approach to make local addiction recovery support services that are available, accessible, 

affordable, and acceptable. The hub and spoke model consists of a network of recovery support 

providers in metro areas who deliver local services in rural areas through the support of a larger hub 

provider, who has committed resources in a variety of forms in the rural market to address treatment 

and recovery support services quality.

Rural leaders can convene a community task force and develop a plan to address the barriers to a 

thriving recovery community. Rural communities can also reach out to nonprofit organizations that 

specialize in addiction recovery, collaborate with local faith-based and civic groups, and apply for 

Federal grants to help bridge the gap. Another solution is to introduce new and innovative delivery 

models and adapt broader e-connectivity to increase access to web-based health technology resources, 

such as telemedicine, telehealth, health apps on smart phones and tablets, online recovery coaches, 

and other programs. Relationships between health professional schools and Critical Access Hospitals 

can also create rural behavioral health practice training sites.
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INCREASE ACCESS TO COORDINATED CARE IN RECOVERY HOUSING

Recovery homes can be a viable and cost-effective alternative to established recovery-oriented systems 

of care. Often when rural communities offer affordable housing options and addiction treatment 

services, these services are rarely coordinated. This lack of coordination leads many people in early 

recovery to return to environments that foster addictive lifestyles, increasing the likelihood of relapse 

or continued substance use. Recovery homes are a good alternative to ROSC because they provide 

safe and healthy environments that support residents in their recovery. Increasing the availability of 

recovery housing ensures that the system of care is responsive to various needs at different points in 

the recovery process.

Recovery homes offer mutual help-oriented, financially self-sustaining, communal living environments 

where individuals in recovery can live after inpatient treatment or incarceration, during outpatient 

treatment or as an alternative to treatment. When people are newly sober, they are moving from a 

culture of addiction to a culture of recovery. Recovery housing gives them the time and support needed 

to change those behaviors that were required for life and death survival in the culture of addiction.

Individuals build resources while living in a recovery residence that will continue to support their 

recovery as they transition to living independently and productively in the community. There is a greater 

concentration of recovery homes in urban and suburban areas. Where they exist, rural residences tend 

to provide higher or a more comprehensive mix of support because there are fewer support resources in 

the surrounding area. They also tend to be more closely linked with a faith-based community, treatment 

center, or other supplemental support community.

There are four levels of recovery residences as certified by the National Alliance for Recovery Residences 

(NARR). The services range from peer-to-peer recovery support (all recovery residences) to medical 

and counseling services (recovery residences offering higher levels of support). One level of support 

is not considered better than another. They simply differ in the kind and intensity of services and 

supports provided. For example, at a minimum, a Level 2 recovery residence provides a sober, safe 

living environment coupled with peer recovery support through a social model recovery philosophy 

and structure. In contrast to a Level 1 residence, a Level 2 residence has an owner/operator appointed 

house manager.

Recovery Residence Levels

Recovery support services

Alcohol and drug free living environments

Social model recovery support

Life skills development

Clinical
SECTION 5: Recovery 77

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

ACTION STEPS TO FOSTER STRONG RECOVERY SYSTEMS

Maintaining a safe, stable recovery community in the earliest stages of sobriety as a 

foundation for lifelong recovery in rural places with limited resources is key. In the early 

stages, it is critical to connect people with SUD to mutual-aid groups, either faith-based or 

12-step fellowships. A few ways to foster stronger recovery systems or recovery residences 

in rural communities include:

1. Survey available recovery housing capacity. Increasing the availability of recovery 

housing ensures that the system of care is responsive to various needs at different 

points in the recovery process.

2. Seek out creative resources for funding. High start-up, operating, and capital 

expenses can be a significant barrier to creating and sustaining quality recovery 

residences. Revenue streams will vary by type of residence; there may be programs 

for certain targeted populations such as criminal justice clients or voucher programs 

and insurance benefit packages that can be tapped.

3. Identify supporting roles for community members. Everyone can play a part in 

the fight against SUDs. In a rural community there is a higher reliance on family, 

extended family, social networks, and local institutions to solve problems.

4. Integrate recovery housing more fully into healthcare and other systems.

Consider delivering addiction treatment services through rural satellites, colocating with existing health and social service resources and assertive outreach 

programs.

5. Engage in regional collaborations. Planning on a regional basis allows geographically 

contiguous rural areas to create and sustain recovery supports jointly.

6. Consider innovative treatment delivery models. Individuals need various types 

and levels of support at different stages of recovery. Matching an individual with the 

appropriate level of support is both recovery supportive and cost effective.

7. Support peer-based recovery support services. During recovery coaching a 

peer mentors an individual seeking recovery by helping set goals, develop a plan, 

and serve as a role model during recovery. This style of coaching includes helping 

connect the individual to recovery support resources needed to restructure life, such 

as professional and non-professional services including housing and employment.

The coach also serves as an advocate and liaison to formal and informal community 

supports, resources, and recovery supporting activities.
78 SECTION 5: Recovery

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

MOBILIZING THE RECOVERY COMMUNITY IN RURAL AREAS

By Faces & Voices of Recovery

THE ADVANTAGES OF PEER SUPPORT SERVICES

Peer Recovery Support is a social support service designed to fill the needs of people in or seeking 

recovery. People who have similar experiences with SUDs give others encouragement, hope, assistance, 

guidance, and understanding, all which aids in lifelong recovery. Peer recovery support specialists, often 

called recovery coaches, serve as a bridge between individuals and resources in the community. They 

offer wide-ranging nonclinical services that assist individuals and families working toward recovery from 

substance use conditions. These include social supports and services such as employment services, 

housing, peer coaching, and substance-free social and recreational activities.

Despite bringing high value, recovery support services are often insufficiently funded throughout the 

prevention, treatment, and recovery continuum of care, largely due to funding constraints and a lack 

of information, capacity, and infrastructure. Yet studies on peer recovery supports have demonstrated 

reduced relapse rates, increased treatment retention, improved relationships with treatment providers 

and social supports, increased satisfaction with the overall treatment experience and increases in 

quality of life factors.

 Key Advantages of Peer Support Services

• Reduces relapse

• Reduces homelessness

• Engages people into care

• Helps individuals and families initiate and 

stabilize early recovery and sustain 

long-term recovery

• Improves continuity of care

• Provides meaningful cost savings

• Reduces the use of acute care services 

such as emergency rooms and 

detoxification centers

• Helps people move beyond treatment settings 

and find support in the communities where they 

live, work, and play

PEER SUPPORT SERVICES IN RURAL COMMUNITIES

Not surprisingly, providing recovery supports in rural communities is challenged by physical, emotional, 

and social isolation, as well as multiple vulnerabilities that coexist with addiction (e.g., trauma, health, 

problems, homelessness) coupled with fewer opportunities for individual self-sufficiency. Two common 

barriers that place rural residents at a distinct disadvantage for initiating or maintaining SUD recovery 

are the limited availability of services and the cost of care. Yet rural communities have their own rich 

internal assets that can be mobilized to expand recovery supports and a strong history of resilience.

RCOs are community-based nonprofits that typically facilitate the placement of peer recovery support 

workers in outreach positions. RCOs advocate for the meaningful representation and voice for people 

in recovery and their families at local, State, and Federal policy levels on issues that affect their lives.

Strategic placement of peer-based community support embedded within frontline services offers a 

timely opportunity for intervention.
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Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

Many rural communities are starting to organize strong grassroots RCOs and linking them into a national 

movement led by the Association of Recovery Community Organizations (ARCO) at Faces & Voices of 

Recovery. These RCOs are developing recovery leaders and offering opportunities for the recovery 

community—people in recovery, family members, friends, and allies—to express their collective voice 

on issues of common concern, respond to community-identified recovery support needs, and provide 

a forum for recovery-focused community service. However, the expansion of RCOs into many rural 

communities is still limited, mainly because of insufficient financial resources.

In recent years, the number of RCOs has risen dramatically to meet the high demand for peer-based 

recovery support services. An RCO is an independent, nonprofit organization led and governed by the 

recovery community, providing advocacy, education, and/or peer-based recovery support services.

These non-clinical services, designed and delivered by the recovery community, include peer recovery 

support specialists, telephone-based recovery support, mutual aid groups, recovery housing, and 

much more. When an RCO operates a recovery community center, that center becomes the hub of 

recovery activity where individuals can volunteer, seek employment and education, and participate in 

substance-free recreation activities.

THE RURAL PEER SUPPORT MODEL

 Key Features of a Rural Peer Recovery Support Model

• Connects individuals with SUD to communitybased care

• Strong Recovery Community Organization that 

provides advocacy, education, and peer recovery 

support services

• Boots-on-the-ground peer recovery team

• Capitalizes on community bonds and indigenous 

institutions

• Able to break down the stigma that 

prevents people with SUD and OUD from seeking 

services

• Forges community partnerships

• Cultivates volunteerism 

The optimal model for rural peer recovery support is a strong, vibrant recovery community organization 

providing advocacy, education, and peer recovery support services. This should capitalize on rural 

community ties by focusing on indigenous recovery resource development closely aligned with the 

rural reliance on family, extended family, social networks, and indigenous institutions (e.g., churches, 

co-ops) to solve problems rather than relying on service professionals. Many people seeking recovery in 

rural communities find support from family, friends, primary care physicians, clergy, faith communities, 

work, school, and through local and online recovery support groups. There is also great potential for 

cultivating volunteerism within rural communities of recovery. The peer workforce brings their own 

relevant experience to share with those in need, and they are breaking down the stigma that keeps 

many from reaching out for help.

When the recovery community is not at the table, policies and programs risk becoming ineffective and 

inadequately designed or delivered. Rural services may be inaccessible or unattractive to the needs 

and interests of the people they intend to serve. As such, the most critical need in rural communities 

is education of key community leaders and the community at large about recovery and peer-based 

recovery support services. Once buy-in is achieved, mobilization of the local recovery community can 

be rapid, particularly if the people leading the local effort are well-known and trusted community 

members. In rural communities, the speed of this potential mobilization is enhanced because everyone 
80 SECTION 5: Recovery

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

knows each other, rural agencies work well together, and people are likely to wear multiple hats. Trust 

is essential and, when that trust is present, most rural communities are willing to step forward and offer 

their full support of new recovery support initiatives.

Although research is limited on the ideal design, delivery, and evaluation of recovery support services 

specifically for rural communities, several initial examples show promise as model rural programs.

Successful rural RCOs are taking a lead role in educating the public, policymakers, and service providers 

about the prevalence, pathways, and styles of long-term addiction recovery. They are engaging in 

discussions about the multiple pathways of recovery and sharing their stories publicly to eliminate the 

stigma and discrimination often faced by people in recovery.

• The Green Mountain State. The Vermont Recovery Center Network currently operates nine 

independent member centers and three affiliate centers. The Recovery Community Centers 

have been established for the provision of recovery support services in communities throughout 

Vermont. Recovery centers are local, consumer driven, non-residential facilities that provide 

peer supports, sober recreation activities, volunteer opportunities, community education, 

and recovery supporting services. Leadership is provided by an executive council that consists 

of a board member from each recovery center. The council has been tasked by Vermont’s 

legislature with advising the Vermont Department of Health in prioritizing services, considering 

funding needs for recovery centers, reviewing recovery center funding proposals, and providing 

recommendations for disbursement of funds for the support of recovery centers.

• Making Taos a Recovery-Friendly Community. Taos County, New Mexico is a beautiful place to 

live and a wonderful community. The recovery community has come together because they care 

about making Taos a community where recovery is something to be proud of, not ashamed of, 

where there is help available for people and families struggling with SUDs, and where no one is 

ashamed to ask for help. Recovery-Friendly Taos’ mission is dedicated to promoting a recoveryfriendly community through development of supports, opportunities, and access to services, 

education, and information. They are committed to reducing the barriers created by stigma and 

replacing it with hope and well-being.

• Idaho Recovery Community Centers. The Idaho Association of Recovery Community Centers 

(IARCC) is a consortium of nine recovery centers providing a broad spectrum of recovery support 

services across the State’s 44 counties (37 of which are rural or frontier). Each center operates with 

one or two staff members and a larger volunteer workforce (more than 23,000 volunteer hours 

were logged across the centers this past year). Funding for the centers comes from State grants 

and private local donations. The centers provide service coordination with local health and human 

service agencies, jail outreach, recovery support groups, recovery-focused classes, and workshops 

for individuals and families, recovery coaching, telephone-based recovery checkups, and sober 

social events. These centers averaged more than 5,000 visits each in the fiscal year 2016-2017.

• Western Massachusetts. The RECOVER Project in Greenfield is a safe, welcoming community that 

supports recovery by sharing the wisdom of lived experience and strengthens the community 

through full participation. They create resource connections; advocate to overcome barriers and 

promote the reality that recovery is possible for all. The RECOVER Project is committed to serving 

as a resource for information about addiction and recovery.
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ACTION STEPS TO MOBILIZE THE PEER SUPPORT COMMUNITY

The National Recovery Institute provides technical assistance and training for local and 

State entities on the development of peer recovery support services by drawing on the 

expertise of RCO leaders across the nation. National standards for the delivery of peer 

support services have been established by the Council on Accreditation of Peer Recovery 

Support Services. Here are some concrete steps that local leaders in rural communities can 

take to mobilize the peer support community.

1. Bring peer support specialists to the table early to create a shared vision 

of recovery. To ensure that the voices of those with the experience of addiction 

recovery are heard and respected, they should be involved at all levels of decisionmaking, program, policy, and strategic planning.

2. Identify leaders in the recovery community. Use community organizer roles 

(versus clinical roles) to develop and mobilize indigenous recovery support 

resources within rural areas.

3. Identify recovery champions to support the effort and be ambassadors for the 

cause. These can include local leaders in the county government, faith community, 

health department, business leaders, law enforcement, and others.

4. Launch community visioning. Hold stakeholder meetings across the state or 

region to find out what the recovery community wants, what their hopes of the 

future are, who will be involved, and how the RCO will be structured.

5. Assess community needs; identify the needs, gaps, and strengths in your 

community. This will help decide which types of supports, activities, or service to 

provide.

6. Conduct a needs assessment to identify areas where SUD and related harms 

are most prevalent. The number and location of opioid treatment providers in the 

areas, including providers that offer OUD services; all existing activities and their 

funding sources in the State that address opioid use prevention, treatment, and 

recovery activities and remaining gaps in these activities.

7. Get creative. Capitalize on the indigenous recovery capital that exists or that can 

be mobilized within rural areas.

8. Create recovery community centers that make recovery visible on Main Street.

These should provide a setting for the delivery of non-clinical, peer-based recovery 

support services, supports, and activities.

9. Celebrate recovery from addiction. Plan public recovery celebration events (e.g., 

marches, rallies, concerts) that offer living proof of the transformative power of recovery.
82 SECTION 5: Recovery

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INCREASING HOUSING OPTIONS FOR PERSONS IN RECOVERY 

IN RURAL COMMUNITIES

By Housing Assistance Council

SAFE AND STABLE HOUSING

When it strikes, SUD and opioid misuse often negatively impacts every part of a community. Responding 

solutions must then positively address each of those impacted sectors for the region to recover and 

thrive. This includes not just essential medical treatment and greater access to quality healthcare, but 

also long-term elements of recovery such as providing stable, safe, affordable housing options.

The home should be a calm and safe space with a stable, substance-free environment. Unfortunately, 

in rural areas there is a shortage of affordable housing that meet these basic requirements. Those 

who complete treatment for SUD often return to communities and housing situations where they first 

became addicted, creating an unhealty cycle. Safe and stable housing is essential for any addiction 

treatment and recovery services to be effective.

RURAL HOUSING BARRIERS

Common housing circumstances related to SUDs often 

overlap with housing challenges for rural homelessness: 

reentry from the criminal justice system, household 

stress, and access to housing services. People recovering 

from SUDs may need assistance in acquiring the life 

skills required to become law-abiding, sober citizens.

Substance use rehabilitation, vocational training, and 

employment programs can all help achieve these goals.

The limited supply of quality rental and supportive 

housing is a consistent, overriding housing challenge 

in many rural communities, and around the country.

Housing access and affordability is especially 

problematic for low-income households and renters in 

rural areas nationwide. Housing costs tend to be lower in rural areas, but wages are also lower, resulting 

in an increasing number of rural households who struggle to pay monthly housing expenses. These 

affordability constraints are worse for people recovering from addiction and dealing with challenging 

economic circumstances.

Homelessness often results from a combination of substance misuse and mental health issues, which 

creates a complex community challenge that demands a tailored approach. Housing and homelessness 

manifest differently in rural environments. Highly effective urban solutions aimed at homelessness too 

“Those who complete 

treatment for SUD 

often return to 

communities and 

housing situations 

where they first 

became addicted, 

creating an unhealthy 

cycle.” 
SECTION 5: Recovery 83

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often falter in rural America. Here nonprofits, not governments, often provide services and those who 

are homeless are often less conspicuous but still need assistance. Rural homelessness recognizes no 

geographic boundaries, and counties with entrenched poverty deal with it regularly. Limited availability 

of rental housing, discrimination against those battling opioid addiction, and lower rates of adequate 

health insurance compound the problem.

Persons in recovery must have the ability to live near a treatment facility or a recovery center to receive 

consistent services for addiction. Since recovery centers or treatment facilities may not be open in every 

area of a rural region, affordable housing absolutely must be available where they do exist. Housing is 

an essential bedrock for day-to-day life in recovery. Once this critical piece is settled, there is more time 

and emotional energy for recovery and treatment efforts. After recovery, a stable environment without 

negative influences can help ensure successful recovery and prevent relapses.

WHERE HOUSING FITS INTO THE SOLUTION

During a recent congressional hearing entitled “The Role of Federal Housing and Community 

Development Programs to Support Opioid and Substance Use Disorder Treatment and Recovery” 

on August 16, 2018, experts testified why housing 

programs are an important solution to the opioid crisis.

The testimony included this statement: “Stable housing 

is a basic human need and one of the primary social 

indicators of public health. Access to stable housing 

is one common factor that is essential for all these 

strategies to produce positive results.”

Tackling the opioid crisis is a multifaceted problem 

that requires a multifaceted approach. Recovery 

from opioid addiction requires treatment, effective 

treatment requires safe and stable housing, safe and 

stable housing requires employment, and employment 

requires effective treatment and staying in recovery. If 

even one element fails, progress will slow to a halt.

Resources may come from many directions, but their 

success will depend on local communities and local 

resources. Educating teachers, parents, healthcare providers, and local government officials is an 

important step towards solving the opioid crisis. Expansion of treatment and addiction support groups 

will not be effective without strong community understanding that addiction is a physical dependency, 

not a moral failing. Addiction must be viewed as a disease, rather than a moral shortcoming. Local 

opinion can help create a sense of acceptance, reduce stigma, and increase the opportunity for recovery.

“Stable housing is a 

basic human need and 

one of the primary 

social indicators of 

public health. Access to 

stable housing is one 

common factor that is 

essential for all these 

strategies to produce 

positive results.”
84 SECTION 5: Recovery

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ACTION STEPS TO PROVIDE COMMUNITIES WITH STABLE HOUSING

1. Get the data. Take steps to find out how affordable housing intersects with the 

opioid crisis in your community and the areas with the greatest need.

2. Bring the housing community to the table. Bring housing representatives from 

the State or local offices and non-for-profits to the table early. People need to be 

in a stable, drug-free environment to complete the recovery process, but there is 

often a shortage of safe and drug-free affordable housing in rural communities.

Invite housing stakeholders to join working groups or the taskforce that is formed 

to address the opioid crisis in the community to get a jump-start on tackling the 

housing issues.

3. Go local. Reach out to your local or community-based housing nonprofit 

organization for advice. Local housing nonprofits understand the unique housing 

needs of the community and the best resources available. Creating a stable and 

consistent home can often lay the groundwork for recovery in the battle against 

addiction. Reaching out to local housing nonprofits can be the first step towards 

finding this stability.

4. Create a local resource guide. Many jurisdictions compile local resource guides for 

those in the treatment and recovery phases of substance misuse. For example, the 

Virginia Department of Health developed a resource guide in response to the opioid 

emergency, which provides links and contact information for shelters, support 

groups, inpatient and outpatient facilities, websites, helplines, and hotlines. Local 

guides like these can simplify the confusing process of identifying resources and 

increase the chance that those in need quickly find the necessary resources.

5. Collaborate with community leaders. The opioid epidemic is a multi-faceted 

problem that requires multifaceted cross-agency coordinated solutions. Help 

local social service providers, criminal justice officials, the medical community, 

and housing providers connect and work together. Cross collaboration across 

key sectors is integral. Serve as the catalyst to help connect these sectors in the 

community.

6. Advocate for rational solutions. Stigmatization and excessive judicial responses 

to addiction can exacerbate the effects of the opioid crisis. Background checks are 

necessary and important, but blanket restrictions for criminal convictions often 

prove counterproductive in this new environment. Individual assessment of tenant 

requirements in both private market and federally funded housing can increase 

access to quality and positive housing arrangements for those recovering from 

substance misuse.
Closing Thoughts 85

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85 Closing Thoughts

Rural Community Action Guide: Building Stronger Healthy, Drug Free Rural Communities

Closing Thoughts

The insight and recommended action steps in this guide are intended to create a roadmap for action in 

rural America. To find illustrations of actions taken, there are numerous examples of promising practices 

on the USDA webpage which are meant to help rural leaders visualize what meaningful action in their 

community could look like. With this information, local leaders are better equipped to shape the future 

of their community.

The magnitude of the addiction crisis and its impact on rural America will take leaders at the Federal, 

State and local level working together and each doing their part to build strong, healthy, and drug-free 

communities. There is no time to waste. The future of rural America is at stake.
86 Rural Community Action Guide Partners

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Rural Community Action Guide Partners 

Addiction Policy Forum Addiction Policy Forum is a nationwide nonprofit organization 

established in 2015 as a diverse partnership of organizations, 

policymakers, and stakeholders committed to working together 

to elevate awareness around addiction, and to improve programs 

and policy through a comprehensive response that includes 

prevention, treatment, recovery, and criminal justice reform.

https://www.addictionpolicy.org/

American Farm Bureau 

Federation

Farm Bureau is an independent, non-governmental, voluntary 

organization governed by and representing farm and ranch 

families united for the purpose of analyzing their problems 

and formulating action to achieve educational improvement, 

economic opportunity, and social advancement and, thereby, to 

promote the national well-being. Farm Bureau is local, county, 

State, national, and international in its scope and influence and 

is non-partisan, non-sectarian, and non-secret in character.

Farm Bureau is the voice of agricultural producers at all levels.

https://www.fb.org/

Appalachian Regional 

Commission

The Appalachian Regional Commission (ARC) is a regional 

economic development agency that represents a partnership 

of Federal, State, and local government. Established by an act 

of Congress in 1965, ARC is composed of the governors of the 

13 Appalachian States and a Federal co-chair, who is appointed 

by the president. Local participation is provided through multicounty local development districts. https://www.arc.gov/

Center for Court 

Innovation

The Center for Court Innovation seeks to help create a more effective 

and humane justice system. Originally founded as a public/private 

partnership between the New York State Unified Court System and 

the Fund for the City of New York, the Center for Court Innovation 

conceives, plans, and operates programs that seek to test new 

ideas, solve difficult problems, and achieve system change.

Center projects include community-based violence prevention 

projects, alternatives to incarceration, reentry initiatives, and 

court-based programs that reduce the use of unnecessary 

incarceration and promote positive individual and family change.

https://www.courtinnovation.org/
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Community Anti-Drug 

Coalitions of America

Community Anti-Drug Coalitions of America (CADCA) is a nonprofit 

organization that is committed to creating safe, healthy, and drugfree communities globally. Since 1992, CADCA has demonstrated 

that when all sectors of a community come together, social change 

happens. CADCA represents over 5,000 community coalitions 

that involve individuals from key sectors including schools, law 

enforcement, youth, parents, healthcare, media, and others. We 

have members in every U.S. State and territory and more than 30 

countries around the world. The CADCA coalition model emphasizes 

the power of community coalitions to prevent substance misuse 

through collaborative community efforts. CADCA believes that 

prevention of substance use and misuse before it starts is the most 

effective and cost-efficient way to reduce substance use and its 

associated costs. https://www.cadca.org/

Faces & Voices of Recovery Faces & Voices of Recovery is dedicated to organizing and mobilizing 

the over 23 million Americans in recovery from addiction to alcohol 

and other drugs. They promote the resources to recover through 

advocacy, education, and by demonstrating the power and proof 

of long-term recovery. https://facesandvoicesofrecovery.org/

Housing Assistance 

Council

The Housing Assistance Council (HAC) is a nonprofit corporation 

located in Washington, DC with regional offices in the Southeast, 

Midwest, and Southwest. HAC has been helping local organizations 

build affordable homes in rural America since 1971. HAC assists 

in the development of both single- and multi-family homes and 

promotes homeownership for working low-income rural families 

through a self-help, “sweat equity” construction method by 

emphasizing local solutions, empowerment of people in poverty, 

reduced dependence, and self-help strategies. HAC offers services 

to public, nonprofit, and private organizations throughout the 

rural United States and maintains a special focus on high-need 

groups and regions, such as Indian country, the Mississippi 

Delta, farmworkers, the Southwest border, and Appalachia.

http://www.ruralhome.org/
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National Alliance for 

Recovery Residences

The National Alliance for Recovery Residences (NARR) is a 501-c3 

nonprofit organization dedicated to expanding the availability 

of well-operated, ethical and supportive recovery housing. NARR 

developed the most widely referenced national standard for the 

operation of recovery residences. NARR and these organizations 

collectively support over 25,000 persons in addiction recovery who 

are living in over 2,500 certified recovery residences throughout 

the United States. https://narronline.org

National Association 

of Counties

The National Association of Counties (NACo) strengthens America’s 

counties, including nearly 40,000 county elected officials and 3.6 

million county employees. Founded in 1935, NACo unites county 

officials to: advocate for county government priorities in Federal 

policymaking; promote exemplary county policies and practices; 

nurture leadership skills and expand knowledge networks; 

optimize county and taxpayer resources and cost savings; 

and, enrich the public’s understanding of county government.

https://www.naco.org

National Association 

of Development 

Organizations

The National Association of Development Organizations (NADO) 

provides advocacy, education, research, and training for the 

nation’s regional development organizations. The association 

and its members promote regional strategies, partnerships, and 

solutions to strengthen the economic competitiveness and quality 

of life across America’s local communities. https://www.nado.org/

National Farmers Union The National Farmers Union (NFU) was founded by ten family 

farmers in 1902 as the Farmers Educational Cooperative Union of 

America in Point, Texas. NFU represents family farmers, fishers, and 

ranchers across the country, with formally organized divisions in 

33 States. The key to the success and credibility of the organization 

has been Farmers Union’s grassroots structure in which policy 

positions are initiated locally. The policy process includes the 

presentation of resolutions by individuals, followed by possible 

adoption of the resolutions at the local, State, and national levels.

Members and staff of the Farmers Union advocate these policy 

positions nationwide. NFU believes that good opportunities in 

production agriculture are the foundation of strong farm and ranch 

families, and that strong farm and ranch families are the basis for 

thriving rural communities. Vibrant rural communities, in turn, are 

vital to the health, security, and economic well being of our entire 

national economy. https://nfu.org/
Rural Community Action Guide Partners 89

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

National Rural Health 

Association

The National Rural Health Association (NRHA) is a national 

nonprofit membership organization with more than 21,000 

members. The association’s mission is to provide leadership on 

rural health issues through advocacy, communications, education, 

and research. NRHA membership consists of a diverse collection 

of individuals and organizations, all of whom share the common 

bond of an interest in rural health.https://www.ruralhealthweb.org/

National Sheriffs’ 

Association

Chartered in 1940, the National Sheriffs’ Association is a 

professional association dedicated to serving the Office of 

Sheriff and its affiliates through law enforcement education and 

training and through the provision of general law enforcement 

informational resources. NSA represents thousands of sheriffs, 

deputies and other law enforcement, public safety professionals, 

and concerned citizens nationwide. Through the years, NSA has 

provided programs for sheriffs, their deputies, chiefs of police, and 

others in the field of criminal justice to perform their jobs in the 

best possible manner and to better serve the people of their cities, 

counties, or jurisdictions. https://www.sheriffs.org/

NORC Walsh Center for 

Rural Health Analysis 

The NORC Walsh Center for Rural Health Analysis was established 

in 1996 by Project HOPE and transferred to NORC at the University 

of Chicago in 2003 to study policy issues affecting healthcare and 

health status in rural America. The Walsh Center for Rural Health 

Analysis’ mission is to conduct timely policy analysis, research, and 

evaluation that address the needs of policy makers, the healthcare 

workforce, and the public on issues that affect healthcare and 

public health in rural America.https://www.ruralhealthresearch.

org/centers/walsh

NTCA–The Rural 

Broadband Association

NTCA–The Rural Broadband Association is the premier association 

representing nearly 850 independent, community-based 

telecommunications companies that are leading innovation in 

rural and small-town America. NTCA advocates on behalf of its 

members in the legislative and regulatory arenas, and it provides 

training and development; publications and industry events; and 

an array of employee benefit programs. http://www.ntca.org/

National Rural Transit 

Assistance Program

The National Rural Transit Assistance Program (RTAP) was created 

in 1987. The goals of the RTAP program are to promote the safe and 

effective delivery of public transportation services in rural areas and 

to facilitate more efficient use of public transportation resources. To 

meet those goals, the program focuses on the following objectives: 

Improving the quality of training and technical assistance resources 

available to the rural transit industry; encouraging and assisting 

State, local, and peer networks to address training and technical 

assistance needs; promoting the coordination of transportation 

services; and, building a national database of information about 

the rural transit industry. Since its inception, National RTAP has 

contributed to the achievement of these objectives at the national 

level by developing and distributing training materials, providing 

technical assistance, creating web-based applications, producing 

reports, publishing best practices, conducting research, and 

offering peer assistance for rural and tribal transit providers and 

State RTAP programs. https://nationalrtap.org/
90 Rural Community Action Guide Partners

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

The Pew Charitable Trusts The Pew Charitable Trusts is an independent non-profit, nongovernmental organization, founded in 1948. The mission is to: 

improve public policy by conducting rigorous analysis, linking 

diverse interests to pursue common cause and insisting on tangible 

results; inform the public by providing useful data that illuminate 

the issues and trends shaping our world; and, invigorate civic life 

by encouraging democratic participation and strong communities.

https://www.pewtrusts.org

U.S. Department 

of Agriculture

The U.S. Department of Agriculture (USDA) is made up of 

29 agencies and offices with nearly 100,000 employees who serve 

the American people at more than 4,500 locations across the 

country and abroad. USDA provides leadership on food, agriculture, 

natural resources, rural development, nutrition, and related issues 

based on public policy, the best available science, and effective 

management. USDA has a vision to provide economic opportunity 

through innovation, helping rural America to thrive; to promote 

agriculture production that better nourishes Americans while 

also helping feed others throughout the world; and to preserve 

our Nation’s natural resources through conservation, restored 

forests, improved watersheds, and healthy private working lands.

https://www.usda.gov/

U.S. Department of 

Agriculture, National 

Institute of Food and 

Agriculture

The USDA National Institute of Food and Agriculture (NIFA) was 

established by the Food Conservation and Energy Act of 2008 

(the 2008 Farm Bill) to find innovative solutions to issues related 

to agriculture, food, the environment, and communities. One 

of four agencies that make up USDA’s Research, Education, and 

Economics (REE) mission area, the agency is structured to direct 

Federal funding effectively to programs that address key national 

and global challenges. https://nifa.usda.gov/

U.S. Department of 

Agriculture, Center 

for Faith-Based 

and Neighborhood 

Partnerships 

USDA’s Center for Faith-Based and Neighborhood Partnerships 

reaches out and connects the government with non-profit 

organizations, both secular and faith-based, to help people in 

need. The Center helps communities connect with USDA priorities 

and programs to turn visions more effectively into reality.

https://www.usda.gov/our-agency/staff-offices/center-faithbased-and-neighborhood-partnerships
Endnotes 91

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

Endnotes

1 National Institute on Drug Abuse (NIH) https://www.drugabuse.gov/publications/media-guide/

glossary

2 Mack KA, Jones CM, Ballesteros MF. Illicit Drug Use, Illicit Drug Use Disorders, and Drug Overdose 

Deaths in Metropolitan and Nonmetropolitan Areas — United States. MMWR Surveill Summ 

2017;66(No. SS-19):1–12. DOI: http://dx.doi.org/10.15585/mmwr.ss6619a1

3 NPR/Robert Wood Johnson Foundation/Harvard School of Public Health Publication: Public 

Opinion Poll Series; Harvard T.H. Chan School of Public Health Editor(s): NPR/RWJF/Harvard School 

of Public Health Life in Rural America Experiences and views from rural America on economic and 

health issues and life in rural communities. https://www.rwjf.org/en/library/research/2018/10/

life-in-rural-america.html

4 Morning Consult on behalf of American Farm Bureau Federation and National Farmers Union.

Conducted an online survey of 2,201 rural adults to determine General Attitudes and Perceptions 

of Addiction. October 26-29, 2017. https://farmtownstrong.org/theopioidcrisis/.

5 Center for Behavioral Health Statistics and Quality. (2015). 2014 National Survey on Drug Use and 

Health: Detailed Tables. Substance Abuse and Mental Health Services Administration, Rockville, MD.

6 Lipari, R.N. and Van Horn, S.L. Trends in substance use disorders among adults aged 18 or older. The 

CBHSQ Report: June 29, 2017. Center for Behavioral Health Statistics and Quality, Substance Abuse 

and Mental Health Services Administration, Rockville, MD. https://www.samhsa.gov/data/sites/

default/files/report_2790/ShortReport-2790.html.

7 The Associated Press-NORC Center for Public Affairs Research (2018). Americans Recognize the 

Growing Problem of Opioid Addiction http://www.apnorc.org/PDFs/Opioids%202018/APNORC_

Opioids_Report_2018.pdf.

8 NIDA. (2018, July 2). Media Guide. Retrieved from https://www.drugabuse.gov/publications/

media-guide on 2019, June 17.

9 Centers for Disease Control and Prevention (CDC). Opioid Overdose. Data Overview. (2019).

https://www.cdc.gov/drugoverdose/data/index.html

10 Mack K.A., Jones C.M., Ballesteros M.F. Illicit Drug Use, Illicit Drug Use Disorders, and Drug Overdose 

Deaths in Metropolitan and Nonmetropolitan Areas—United States. MMWR Surveill Summer 2017; 

66 (No. SS-19):1-12. DOI: http://dx.doi.org/10.15585/mmwr.ss6619a1.

11 See Opioid Misuse Community Assessment Tool www.opioidmisusetool.norc.org

12 Mercer County Comprehensive Plan, August 2018 http://www.mercercountywv.org/

images/2018.06.28-Final-Plan.pdf
92 Endnotes

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

13 CDC/NCHS, National Vital Statistics System, Mortality. CDC WONDER, Atlanta, GA: US Department 

of Health and Human Services, CDC; 2018. https://wonder.cdc.gov

14 Rural America at a Glance, 2018 Edition (November 1, 2018). USDA-ERS Economic Information 

Bulletin No. 200. Available at: https://www.ers.usda.gov/webdocs/publications/90556/eib200.pdf?v=5899.2

15 U.S. Census Bureau. New Census Data Show Differences Between Urban and Rural Populations.

United States Census Bureau https://www.census.gov/newsroom/press-releases/2016/cb16-

210.html. Published 2016. Accessed November 1, 2019.

16 American Hospital Association, 2019 Rural Report: Challenges Facing Rural Communities and the 

Roadmap to Ensure Local Access to High Quality, Affordable Care. https://www.aha.org/system/

files/2019-02/rural-report-2019.pdf.

17 B. Whitacre, P.S. Hartman, S. Boggs, V. Schott - 2008, Oklahoma State University, Evaluating 

the Economic Impact of Telemedicine in a Rural Community. https://shareok.org/bitstream/

handle/11244/49723/oksd_agec_1007_2013-01.pdf?sequence=1; HRSA 2015 Policy Brief, 

Telehealth in Rural America available at https://www.hrsa.gov/advisorycommittees/rural/

publications/telehealthmarch2015.pdf.

18 Appalachian Diseases of Despair, Prepared for the Appalachian Regional Commission, The Walsh 

Center for Rural Health Analysis, NORC at the University of Chicago (2017) available at https://

www.arc.gov/assets/research_reports/appalachiandiseasesofdespairaugust2017.pdf.

19 Creating a Culture of Health in Appalachia: Disparities and Bright Spots, https://healthinappalachia.

org/

20 Federal Rural Resources Guide https://www.rd.usda.gov/files/RuralResourceGuide.pdf.

21 Hanley, S.M., Ringwalt, C., Ennett, S.T., Vincus, A.A., Bowling, J.M., Haws, S.W., & Rohrbach, L.A. (2010).

The prevalence of evidence-based substance use prevention curricula in the nation’s elementary 

schools. Journal of Drug Education, 40(1), 51-60. doi:10.2190/DE.40.1.d; Griffin, K.W., & Botvin, G.J.

(2010). Evidence-based interventions for preventing substance use disorders in adolescents. Child 

and Adolescent Psychiatric Clinics of North America, 19(3), 505–526. doi:10.1016/j.chc.2010.03.005.

22 Morning Consult on behalf of American Farm Bureau Federation and National Farmers Union.

Conducted an online survey of 2,201 rural adults to determine General Attitudes and Perceptions 

of Addiction. October 26-29, 2017. https://farmtownstrong.org/theopioidcrisis/.

23 The Cecil G. Sheps Center for Health Services Research, available at https://www.shepscenter.

unc.edu/programs-projects/rural-health/rural-hospital-closures/.

24 Siegel, Jessica, National Rural Health Association (Feb. 20, 2019) Rural Hospital Closures Rise 

to Ninety-Eight, available at https://www.ruralhealthweb.org/blogs/ruralhealthvoices/

february-2019/rural-hospital-closures-rise-to-ninety-seven.

25 University of Michigan Behavioral Health Workforce Research Center. Characteristics of the Rural 
Endnotes 93

Rural Community Action Guide: Building Stronger Healthy, Drug-Free Rural Communities

Behavioral Health Workforce: A Survey of Medicaid/Medicare Reimbursed Providers. Ann Arbor, MI: 

UMSPH; 2018.

26 C. Holly A. Andrilla et al., “Geographic Distribution of Providers With a DEA Waiver to Prescribe 

Buprenorphine for the Treatment of Opioid Use Disorder: A 5-Year Update,” The Journal of Rural 

Health (2018), https://doi.org/10.1111/jrh.12307.

27 Richard P. Mattick et. al., “Methadone Maintenance Therapy Versus No Opioid Replacement Therapy 

for Opioid Dependence,” Cochrane Database of Systematic Reviews 3, no. CD002209 (2009), http://

www.ncbi.nlm.nih.gov/pubmed/19588333; Sandra D. Comer et al., “Injectable, SustainedRelease Naltrexone for the Treatment of Opioid Dependence: A Randomized, Placebo-Controlled 

Trial,” Archives of General Psychiatry 63, no. 2 (2006): 210-8, http://archpsyc.jamanetwork.com/

article.aspx?articleid=209312; Paul J. Fudala et al., “Office-Based Treatment of Opiate Addiction 

With a Sublingual-Tablet Formulation of Buprenorphine and Naloxone,” New England Journal of 

Medicine 349, no. 10 (2003): 949-58,

28 Mattick et al., “Methadone Maintenance”; Comer et al., “Injectable, Sustained-Release Naltrexone”; 

Fudala et al., “Office-Based Treatment”; Richard P. Mattick et al., “Buprenorphine Maintenance Versus 

Placebo or Methadone Maintenance for Opioid Dependence,” Cochrane Database of Systematic 

Reviews 2, no. CD002207 (2014), http://dx.doi.org/10.1002/14651858.CD002207.pub4.

29 American Society of Addiction Medicine, “The ASAM National Practice Guideline.”

30 John A. Gale, Anush Y. Hansen, and Martha Elbaum Williamson, “Rural Opioid Prevention and 

Treatment Strategies: The Experience in Four States,” Maine Rural Health Research Center 

(2017), https://muskie.usm.maine.edu/Publications/rural/WP62-Rural-Opioid-PreventionTreatment-Strategies.pdf.

31 Andrew Rosenblum et al., “Distance Traveled and Cross-State Commuting to Opioid Treatment 

Programs in the United States,” Journal of Environmental and Public Health no. 948789 (2011), 

https://doi.org/10.1155/2011/948789.

32 C. Holly A. Andrilla et al., “Geographic Distribution of Providers With a DEA Waiver to Prescribe 

Buprenorphine for the Treatment of Opioid Use Disorder: A 5-Year Update,” The Journal of Rural 

Health (2018), https://doi.org/10.1111/jrh.12307.

33 C. Holly A. Andrilla, Cynthia Coulthard, and Eric H. Larson, “Barriers Rural Physicians Face 

Prescribing Buprenorphine for Opioid Use Disorder,” Annals of Family Medicine 15, no. 4 (2017): 

359-62, http://dx.doi.org/10.1370/afm.2099.

34 Mary Bond Edmond, Lydia Aletraris, and Paul M. Roman, “Rural Substance Use Treatment Centers 

in the United States: An Assessment of Treatment Quality by Location,” American Journal of Drug 

and Alcohol Abuse 41, no. 5 (2015): 449-57, http://dx.doi.org/10.3109/00952990.2015.1059842.

35 P. Todd Korthuis et al., “Primary Care-Based Models for the Treatment of Opioid Use Disorder: A 

Scoping Review,” Annals of Internal Medicine 166, no. 4 (2017): 268-78, http://dx.doi.org/10.7326/

M16-2149.
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