Structural vulnerability and rural–urban differences in high-risk substance use among Washington State adolescents

Background High-risk substance use during adolescence is associated with an increased risk of substance use disorders in adulthood. However, patterns of substance use and associated risk factors may differ between rural and urban populations. Socioeconomic disadvantages and community-level factors may further contribute to these disparities.Objectives To compare the prevalence of high-risk substance use among rural and urban high school students in Washington State and examine associated risk and protective factors.Methods Data from the 2021 Washington Healthy Youth Survey were used to examine 10th- and 12th-grade students. Outcomes included methamphetamine use, using painkillers to get high, and non-prescribed prescription drug use. Associations with sociodemographic, socioeconomic, and behavioral factors were assessed. Results All three forms of high-risk substance use were more prevalent among rural students. Food insecurity was strongly associated with methamphetamine use (OR 3.43), painkiller misuse (OR 3.87), and non-prescribed prescription drug use (OR 3.34; all p < 0.001). Housing instability was also significantly associated with all three outcomes. Protective factors included male sex, school commitment, and prosocial behaviors.Conclusions Rural adolescents experience a disproportionate burden of high-risk substance use, highlighting the need for targeted prevention strategies that address socioeconomic disadvantage and strengthen protective factors in rural communities.