This study has several limitations. For example, it is impossible to recruit a random representative sample from an unknown universe of illicit drug users, but it has been argued that respondent-driven sampling can improve the representativeness of such samples (6
). Second, our findings are based on self-reports, but there is substantial support for the validity of self-reported data from illicit substance abusers (14
). Despite these limitations, to our knowledge this is the largest natural history study of the predictors of treatment entry among rural, illicit stimulant users conducted to date.
Overall, 18.7% (133) of the sample entered treatment over 24 months. As one example of a rural/urban contrast in treatment entry, a longitudinal study of urban crack-cocaine users in Dayton, Ohio, reported 30.5% (131) of participants entered treatment over 24 months (5
Among the predisposing variables considered, residents in Ohio and Kentucky were significantly more likely to enter substance abuse treatment over 24 months (27.8% and 18.7%, respectively), compared to those in Arkansas (9.3%). This finding is somewhat parallel with regard to treatment history at baseline, with 56.9% of the Ohio participants having a history of substance abuse treatment, compared to 41.4% in Arkansas, and 37.3% in Kentucky.
Variation in treatment entry across states may be related to several factors which impact treatment access. Ohio counties ranked somewhat higher than Kentucky’s and much higher than Arkansas’s (15
) in terms of having lower poverty levels, larger county seat populations, closer proximity to urban centers, highest number of treatment centers located within 100 miles, highest number of local inpatient treatment programs, and highest per capita expenditures for drug abuse treatment. These findings are reflected in a recent study that ranked Ohio 18th
, Kentucky 21st
, and Arkansas 44th
in terms of drug abuse treatment utilization relative to local treatment needs (18
The majority of the nation’s rural poor are concentrated in the South. This population has been identified having fewer locally available health services compared to other regions, and facing the greatest number of barriers to accessing health services (19
). As residents of the most rural and “southern” of the three states, Arkansas participants perhaps faced the greatest constellation of barriers to treatment services relative to availability/accessibility.
No other sociodemographic characteristics were associated with entering substance abuse treatment. This finding is consistent with Hser and colleague’s (4
) longitudinal study of polydrug users in California, although age has been associated with substance abuse treatment entry in another longitudinal study (5
In terms of substance use practices, tranquilizer use was independently associated with treatment entry, while non-daily crack use and daily/non-daily marijuana use were negatively associated with entering treatment. The relationship between tranquilizer use and treatment entry may be related to excessive self-medication as tranquilizers are often used by stimulant users to mediate the negative effects of extended binge periods of use (1
Daily/non-daily marijuana use may be negatively associated with treatment entry for a variety of reasons. Marijuana is often viewed as “harmless” and socially acceptable, compared to “hard drugs” (20
). Marijuana is also used to aid in “calming down” and going to sleep after binge use of stimulants. But unlike tranquilizers, marijuana also helps stimulant users, especially MA users, regain their appetites (1
). So, marijuana use by some stimulant users may make it less likely for them to fully experience or recognize stimulant-related physical problems (e.g. drastic weight loss) or mental health problems (e.g. post-binge depression) that might motivate treatment seeking. Finally, participants who use crack cocaine less than daily were less likely to enter treatment. This may reflect belief that their level of use is not problematic enough to require substance abuse treatment services.
variable predicting treatment entry was previous substance abuse treatment history, which is consistent with longitudinal findings among various populations (2
). This suggests that substance abusers with previous knowledge of the substance abuse treatment system may be more cognizant of the need for treatment, have less fear or uncertainty about what it entails, and be more willing and adept at seeking it out (22
Neither the SF-8 physical or mental health status measures used to assess current illness-level factors
were related to substance abuse treatment entry. It is not clear why this is the case. For example, in a study on perceived need for substance abuse treatment among the same sample, it was reported that participants having SF-8 physical and mental health status scores above the lowest quartile were less likely to perceive a need for treatment (23
). Because perceived need for treatment is related to treatment entry, one might suspect a similar finding with regard to the SF-8 health status and treatment entry; however, this was not the case.
Among the enabling/mediating factors
included in the model, ASI legal status was a significant predictor of treatment entry. This finding is consistent with previous studies (4
). Legal problems associated with obtaining and using illicit drugs perhaps motivates perceived need and subsequent linkage with services.
ASI family/social problems were not significantly associated with substance abuse treatment entry. Findings elsewhere regarding this variable have been mixed. For example, Hser and her colleague’s (4
) found that lower levels of ASI family or social problems were associated with substance abuse treatment entry, while participants having higher levels of problems in these areas were less likely to enter treatment. Our finding of a lack of association is consistent with our previous study among urban crack-cocaine users (5
), and suggests that rural stimulant users who do, or do not, enter treatment experience family/social problems at similar levels.
Regardless of predisposing and illness-level variables included in the model, participants who perceived a need for treatment were more likely to enter treatment than participants who did not. This finding is consistent with longitudinal studies among urban crack users (5
) and injection drug users (21
). Perceiving a need for treatment may be motivated by a number of factors, such as deteriorating health, increased frequency of use, costs, and/or legal problems. In another report on this sample, higher ASI composite scores for family/social problems or legal problems, and prior drug treatment experience were associated with perceived need for treatment (23
). Our findings also point to a substantial gap between perceived need and linkage with services in rural areas in general, but especially in Arkansas. Further research is needed to understand why some rural stimulant users who perceive a need for treatment access services while others do not.
Our study, like others (5
) indicates that previous treatment history is one of the most consistent predictors of substance abuse treatment reentry. As such, it is extremely important to link substance abusers with treatment services for the first time. Increasing entry into available services in rural areas may be enhanced through outreach efforts. Finally, the overall low level of treatment entry (18.7%), indicates a general need for increased treatment services in rural areas, a finding reported elsewhere (2
). Increases in funding for local treatment services may help reduce disparities across states.