Health Consequences of Rural Illicit
Drug Use: Questions Without
Answers
Dennis G. Fisher, Henry H. Cagle, Dawn C. Davis, Andrea M.
Fenaughty, Theresa Kuhrt-Hunstiger, and Susan R. Fison
Previous chapters in this monograph have noted a general lack of
epidemiological data concerning illicit drug use in rural America, a
lack that extends to the health consequences of substance misuse
behaviors among rural dwellers. Urban population studies indicate
that the major health risks associated with illicit drug use are hepatitis
(users are 12 times as likely as nonusers to contract hepatitis C),
tuberculosis, sexually transmitted diseases, various other bacterial
infections, and human immunodeficiency virus (HIV) infection.
Suppression of the immune system, inadequate nutrition, and other
lifestyle factors are typically cited as the reasons for these health
outcomes. However, characteristics of the individual’s environment
may also play a role. For example, health care facilities and
personnel are typically less available in rural than in urban areas.
Rates of substance misuse-related health conditions may vary with
both availability of health care and with the rate of substance misuse
in the community. What few rural data are available indicate that
geographic region may also influence disease rates, although the
reasons for this variation are unclear.
This chapter presents an overview of health problems related to illicit
drug use in rural areas. Findings from research conducted in the
Anchorage, Alaska area are compared with national data and, where
possible, with U.S. rural data. The relationships between drug abuse
and HIV infection, hepatitis, and pulmonary problems, and evidence
of a possible network of disease transmission are discussed with special
emphasis being placed on the implications for rural dwellers. Method-
ological problems and recommendations for future research are also
presented.
175
,ANCHORAGE, ALASKA
Alaska presents special problems for the study of drug use. Alaska has
the reputation of high rates of alcohol use, but many people are
unaware of the very high rates of drug use (Fisher and Booker 1990).
One reason for the lack of information about drug use in Alaska is
that Alaska is excluded from the major national surveys of drug use
such as the National Household Survey on Drug Abuse (Research
Triangle Institute 1991). Moreover, the State is not listed in the
National Drug Abuse Treatment Unit Survey (NDATUS). This dearth
of information exists even though Alaska spends more per capita on
narcotic law enforcement than any other State in the Nation.
Anchorage, the major city in Alaska, has a combined city-borough
form of government known as the Municipality of Anchorage
(MOA), an area of 1,958 square miles with a population density of
132 persons per square mile. The 1995 population of Alaska is
615,900; 41.9 percent of the State’s population (257,780) lives in
Anchorage (MOA 1995).
Despite its urban characteristics, Anchorage differs from other
seemingly similar cities in the contiguous United States in several
respects. First, it is the major city in a State that is 2.18 times larger
than Texas. The next largest city in Alaska is Fairbanks, with a
population of 84,380. Thus, Anchorage is, by far, the largest city in
a State characterized by vast unpopulated areas. Nonetheless,
compared to the major cities of other States, Anchorage is relatively
small in population. Second, Anchorage has grown rapidly in the past
20 years. Census data for 1970, 1980, and 1990 put the population
of Anchorage at 126,385, 174,431, and 226,338, respectively.
While much of this growth can be attributed to in-migration from
other States and countries, a substantial amount is migration from
rural areas of Alaska. Third, the Matanuska-Susitna Borough, which is
the next population center near Anchorage, has a population of
50,601, making Anchorage the focus of retail, health care, and other
human services for a huge rural area. Finally, for Native Alaskans and
others who have been disenfranchised by their home communities due
to substance abuse, the availability of free shelter and food in
Anchorage makes it a desirable site for relocation. Thus, although the
population of Anchorage is not rural, it does include many individuals
who come from rural areas.
176
, ANCHORAGE, ALASKA SAMPLE
The data presented in this chapter come from research funded by the
National Institute on Drug Abuse (NIDA) under a cooperative
agreement for acquired immunodeficiency syndrome (AIDS)
community-based outreach/intervention research. The grant, titled
"IVDUs (intravenous drug users) Not in Treatment in Alaska," is the
first NIDA research grant in Alaskan history. Data collection began
in 1991. To be eligible for inclusion, a subject had to: (a) be 18 years
of age or older, (b) have not been in substance abuse treatment for at
least 30 days before intake, (c) test positive for cocaine metabolites,
morphine, or amphetamine on a urine test, and/or have visible track
marks.
The Risk Behavior Assessment (RBA) was the data-collection
instrument used at intake. The RBA has been demonstrated to have
good test-retest reliability (Dowling-Guyer et al. 1994; Fisher et al.
1993b; Needle et al., in press; Weatherby et al. 1994). Phlebotomy
for HIV testing and other lab tests were also performed.
Sampling was conducted according to a targeted sampling plan guided
by the Watters and Biernacki (1989) model. Approximately 30 to 35
new subjects were recruited each month, starting in November 1991.
New subject recruitment is ongoing. Not all analyses used all subjects.
The sample design provided for an overrepresentation of blacks and
Alaska Natives and an underrepresentation of whites and Asians (see
figure 1).
Men comprise 68.6 percent of the sample and the median age is 34
years. This compares with 51.4 percent male and a median age of
29.8 years for the MOA. Figure 2 compares the educational
attainment of the sample with that of the MOA population and
indicates that a higher proportion of the sample falls into the less
than high school, general equivalency diploma (GED), and high school
graduate categories, whereas lower proportions fall into the some
college and college graduate categories.
HIV INFECTION
Several reports on HIV infection and risk behaviors among rural
residents have appeared in the recent research literature. A synthesis
of these
177
