Abstract: Veterans of the United States Armed Forces are exposed to occupational, environmental, social, economic, and psychological hazards during and after their military service, and are at an increased risk for substance abuse and addiction. Veterans residing in rural areas experience multiple barriers in accessing substance abuse treatment. These stem from the common rural barriers to behavioral health care (travel, social stigma, availability, etc.), as well as the urbanocentric distribution of Department of Veterans Affairs (DVA) substance abuse treatment facilities (SATFs). There is currently no analysis of substance abuse treatment service and setting availability by rurality comparing DVA facilities with other veteran-accessible facilities using a common instrument. Using data from the 2005 National Survey of Substance Abuse Treatment Services linked with data from the 2005 Area Resource File and population estimates from the U.S. Census Bureau, a series of logistic regression analyses were performed. These modeled the relative probability that a rural or urban substance abuse treatment facility offered one of several service types or treatment settings, in both DVA-operated facilities (n=182) and all veteran-accessible facilities in the contiguous United States (n=11,174). Map-based analyses were used to calculate the number of veterans that reside within a certain number of counties away from the nearest SATF that provides a selected service or treatment setting. Rural veteran-accessible SATFs were less likely than urban SATFs to offer all testing and pharmacotherapy services studied, but were more likely to offer family and aftercare counseling modalities. Among DVA-operated facilities, there were no significant differences in service or setting provision between rural and urban facilities except for Buprenorphine and Methadone treatment services, which were almost non-existent in rural DVA-operated facilities. Of all the treatment services examined using the map-based methodology, pharmacotherapies were the most poorly distributed. Potential causes for these differences include variations in workforce and patient population compositions, substance abuse prevalence in client populations, funding sources, travel distance to care, federal and state policies governing substance abuse treatment and licensure, and DVA internal assessment mechanisms.

The following is a summarized presentation of my dissertation, and includes the full set of adjacency maps.