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We are thinking about moving to a rural area to avoid the drug and drinking problems that our children are exposed to in the city. Do rural Americans, especially teens, have similar problems with alcohol or drugs?

A move to a rural area will not insure that teenagers will escape the influences of alcohol and drugs. Higher rates of substance abuse, including alcohol, tobacco, and other drugs, actually exist among rural teens. There are also higher rates of traffic violations, such as DWIs, in rural areas. There is speculation as to whether the higher numbers of DWIs in rural areas have to do with the dis- tances traveled or the number of intoxicated drivers. Certain rural areas in the northeast, such as New Hampshire and Vermont, and the west (Nevada and California) have higher rates of alcohol and substance abuse among teenagers than in the south. It is speculated that the number of individuals in the south with strong Christian values has kept the incidence of alcoholism low. Here are some surprising statistics: Eighth graders living in rural America are more likely to do any one of the following than their urban counterparts:

• Smoke marijuana (34.5%)

• Drink alcohol (29.9%)

• Use tobacco (chewing and smoking) (50%)

Factors that may contribute to the higher rates of substance abuse among rural teens are as follows:

• Higher rates of unemployment

• Limited after-school activities because of distance, weather events, and so forth

• More uneducated families living below the poverty line

Not only is the rate of alcoholism and drug abuse higher, but there are barriers to accessing health care resources for a number of reasons, including cultural beliefs and attitudes. Stigma is associated with seeking help for mental illness and substance abuse. Rural Americans believe that individuals should take care of themselves. A "pull-yourself-up-by-the-bootstraps" mentality exists. Maintaining confidentiality in a small town is also difficult because there are no secrets. There is fear that everyone will know, resulting in shame for the entire family. Other barriers to accessing care include a lack of qualified health care and substance-abuse professionals, fewer AA meetings and other substance-abuse treatment programs per square mile, long distances to get to health and mental health programs, and a lack of transportation to those services.

If you are concerned about the influence of the drug culture at your child's school in the city, discuss your concerns with the teachers, the principal, other parents, and your child. Insist that your children attend drug-education programs. Moving to a rural area may be peaceful and quiet and may be beneficial for your family, but it will not make your children any safer from alcohol and drugs. No such thing as a "geographical cure" exists. Where and when you move, troubles will be packed in your luggage along with your clothes and other belongings.

I have heard the term "impaired professional. " Do professionals have similar problems with alcohol or drugs as others? If I suspect that a professional is impaired, what should I do?

During the past few years, a body of literature has been growing on the impaired physician, as well as other health care professionals, because of alcohol or drug abuse; however, the impaired professional may include college professors, lawyers, and even congressmen, besides doctors and nurses. The impaired health care professionals are used as a model for this discussion because physicians and nurses have easier access to drugs and are thus at a greater risk for being impaired. A frequently mentioned rate of alcoholism and drug abuse among physicians is that physicians have a greater risk of addiction by 30 to 100 times that of the general population. Some authors dispute that figure, however, claiming that no sound data are available. Other authors speculate that the rate of addiction among health care professionals is equal to the general population. What is similar to the general population is that men outnumber women in terms of excessive drinking or drugging. Some of the risk factors are the same as the risk factors for the general public, as are the therapeutic interventions. One factor other than an easy access to drugs is the stress that is associated with the work of caring for others, which increases the risk of professional impairment; however, each professional role has its unique stressors associated with the job. All professionals have a greater sense of being invulnerable because of their ability to control their own destinies. Precisely because professionals are independent, however, they are also more vulnerable because of the lack of formal controls or supervision to monitor their job performance.

Since the late 1970s, programs have been developed to assist professionals in becoming drug and/or alcohol free. The American Medical Association has published a number of articles about impaired professionals, including doctors, nurses, social workers, and lawyers. AA has developed groups that specifically target professionals. Both the American Medical Association and the American Nurses Association have established programs that are based on AA principles for the impaired health care professional. The National Nurses Society on Addictions has two goals: advocacy and education. During the 1980s and 1990s and today, many corporations, including hospitals, have established employee assistance programs to promote early identification and intervention for employees, enabling them to receive rehabilitation and still maintain their job status in the future after completion of a substance abuse program.

Impaired professional programs serve as follows:

• Liaisons with hospitals, professional organizations, and licensing boards

• Educators about impairment among professionals

• A registry of programs for recovering professionals

• Investigators related to reports of impairment

• Advisors regarding financial aid during treatment, while away from the job

State licensing boards are available to the general public to respond to concerns of the possibility of an impaired professional. They will conduct an inquiry, and if the concern is valid, they will initiate measures for rehabilitation. The only down side of the investigations that state professional licensing boards conduct is that some boards have become overly zealous, acting like tribunals that accuse a suspect of being impaired and presuming guilt without due process. State boards, however, see their mission as protecting the public and they take that mission very seriously.

The prognosis for recovery of professionals is good, especially if the intervention is started early in the disease process. Treatment entails close monitoring by a peer in the work situation, usually designated by the treatment team or the licensing board, maintenance of health promoting activities by the professional, random urine screens, regular checkups with a designated substance-abuse professional, and attendance at a 12- step program. Finally, nurses may not work nights where there is less supervision, nor can they pass out narcotic medications or have access to the medicine keys, at least during the first year of recovery. Support from fellow employees, family, and a 12-step program is essential for a successful recovery.

The prognosis for recovery of professionals is good, especially if the intervention is started early in the disease process.

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