Research has consistently shown that alcohol use is a problem in rural communities and access to substance abuse treatment, particularly evidence-based treatment is limited. Because telemedicine has been shown to be effective in delivering services, this article presents a novel and innovative way of using telemedicine technology in the form of videoconferencing to deliver an evidence-based alcohol intervention (motivational enhancement therapy) with at-risk alcohol users in real-world settings (rural probation and parole offices). This article focuses on: (a) creating a profile of an at-risk group of rural alcohol users; (b) describing the evidence-based intervention; and (c) describing the innovative telemedicine-based service delivery approach.

A semistructured interview was administered to a purposive sample of 12 rural women early in substance misuser treatment in a gender specific, intensive outpatient treatment program from March 2001 through March 2003. The interview used open-ended questions about the women's state of mind before entering treatment, the experiences that helped them feel more comfortable with treatment, the experiences that caused them some discomfort in treatment, and any changes they would recommend to the program content or process in an attempt to gain understanding about factors that might facilitate a subjective comfort and engagement with the treatment experience. In approaching treatment, the women almost uniformly expressed a mixture of anxiety about the requirements of treatment and cynicism about its effectiveness. Although aware of the content and structure of the treatment program, the women focused on interpersonal experiences as the critical factors in their level of comfort once in treatment. The most frequently mentioned factors adding to comfort with the treatment experience were the welcoming, accepting, and non-judgmental attitudes of the staff; having their perceptions of their problems taken seriously by the treatment staff; being with other women who shared much of their experiences; and a respectful and generally positive attitude on the part of both the staff and the patients. The only factor that consistently caused some of the women discomfort in treatment was a difficulty in trusting that some of the other women in treatment would keep the matters discussed in group sessions confidential. The women were not completely satisfied with the program content and structure, but this seemed of very little importance to them in relation to their experience of comfort with their treatment experience.

The use of tobacco by Native Americans in North America seems to have ancient origins and significant spiritual meaning. This article reviews archeological and anthropological data about the use of tobacco and its sacred significance.

Substance abuse is a significant social and public health problem facing rural Americans. However, most treatment protocols have been developed in urban areas. This article describes the development, implementation, and evaluation of an innovative substance abuse treatment designed with the collaboration of rural professionals and consumers specifically for rural clients and delivered by rural clinicians. Results of the process evaluation of Structured Behavioral Outpatient Rural Therapy (SBORT) produced findings about the experiences of participating clients, clinicians, and program directors. Most clients perceived SBORT as a helpful learning process that used multiple treatment strategies and presented an alternative to 12-step programs. Clients also reported that treatment was stressful even when beneficial, and that clinician support was critical for remaining in treatment. Most clinicians found that SBORT challenged their "old" treatment frameworks, was demanding to learn and adopt, and that the training and supervision involved in the project implementation helped remedy rural isolation from the treatment community. Interestingly, agency approach to program implementation strongly influenced clinician responses to the innovation. Agency program directors' appraisals of SBORT included observations that the therapy was viable because of its rural-specific design and that most staff were able to adapt to the changes demanded by the manualized protocol. All three groups reported that they saw the emphasis and acceptance of motivation as an emergent process as important to the treatment. This project highlighted the challenge and importance of testing rural substance abuse treatment protocols in naturalistic settings.

Several national evaluations have been conducted since the late 1960s that have assessed the effectiveness of publicly-funded substance abuse treatment in the United States. These studies, however, have focused principally on urban-based treatment programs, and it is unclear whether findings from urban programs can be replicated in outcome studies of programs in rural areas. The current study, therefore, examined the treatment outcomes of clients admitted to one of several short-term inpatient or outpatient drug-free treatment agencies in rural Kentucky. Findings showed that treatment was associated with reductions in drug use and criminality during a six-month follow-up interval. Employment status also improved significantly, and health services utilization was reduced. The similarity between the current findings and findings from national outcome studies of urban-based treatment programs is discussed.