Debate about alcohol and other drugs (AODs), particularly those that are illicit and/orsubject to abuse, is pervasive in the community, media and at policy-level alike. While AOD use is commonly linked to the hedonistic social spaces of urban youth, especially with drugs like crystal methamphetamine (‘ice’), it is clear substance misuse is not merely a ‘city problem’. Considerations of place and space, particularly the notion of what it means to be rural, are central to understanding the diverse landscape of AODuse. This paper examines key determinants that shape the experience of rural AOD (mis)use and its influence on crime and criminality. Broad application of Shaw and McKay’s (1942) social disorganisation theory enables examination of rural AOD use and related crime in Australia through a lens of social organisation. Using this lens, the article employs a narrative review methodology to explore three key elements of the rural landscape: (i) accessibility of services; (ii) social and cultural pressures; and (iii) the structural and/or physical constraints of rural geography. Critical examination of these elements and associated narratives reveals the need for recognition of the human struggle linked to AOD use and related crimes as a dimension of both rural life andcriminality. The article argues that the appropriate response to rural AOD use requires a paradigmatic shift from traditional law enforcement approaches to principles of harm reduction and public health. However, greater work is needed to produce evidence-based policy, address the causes of rural AOD use and provide meaningful support to this growing cohort of vulnerable members of the community.