Methamphetamine use has been characterized as a “rural” drug; however, little is known about rural methamphetamine use disorders (MUD). This study describes and compares characteristics of rural and urban patients with MUD. Rural study participants reported earlier first regular use of methamphetamine, more alcoholism, more intravenous use, and a greater number of cigarettes/day, and were more likely to report methamphetamine-related psychotic symptoms. Rural methamphetamine users report multiple factors that may contribute to medical and psychiatric complications and worsen their prognosis. This is of significant concern given the limited substance abuse, mental health, and specialty care available in most rural Midwestern communities. (Am J Addict 2007;16:79-84)