This report, Substance Abuse in Rural and Small Town America, shows that rural and urban places today have similar rates of substance use and abuse, and, for abuse of some substances, rural Americans are at an even higher risk than their urban counterparts. For instance, rural youth are particularly at risk for substance abuse, and stimulant use among the unemployed is higher in rural America. The report makes it clear that rural America is not immune to "city" problems, but that rural people and places face unique challenges. Despite some dire statistics, this report offers hope for rural communities struggling with an epidemic of drug and alcohol abuse that one person quoted in this report calls "an issue eating us alive." We offer recommendations for programs and policies that can make a real difference -- investments that work -- by drawing on the strengthsalready in place in rural areas. But the problem of substance abuse demands a multi-faceted approach.