Aim To determine the burden and nature of substance use presentations within a defined rural region and provide an estimate of the prevalence and subsequent local needs. Method Anonymised secondary data, based on hospital inpatient enquiry (HiPE) records dated 2010–2021 from three sites, were analysed using descriptive and inferential statistics. Result Despite similar gender distributions across the three hospitals, approximately 3:1 male to female, substance-related admissions varied significantly across hospitals ( p < .001). Hospital C had the highest alcohol-related admissions 3537(98.6%), followed by Hospital A for opiates 369(12.3%) and Hospital B for cannabis 161 (2.2%). Only 1151(8.2%) of patients received substance use treatment. Discharge destinations also differed ( p < .001), with Hospital A having higher patient transfer rates 301(10%) and self-discharge/absconding incidents 415(13.8%) compared to Hospitals B 261(3.6%) and 442(6%) and C 175(4.9%) and 200(5.6%) respectively. Alcohol-related disorders were among the top five non-communicable diseases for men across all sites, and for women in two of the three hospitals, indicating a widespread but gender-variable burden of alcohol-related harm. Discussion The data demonstrates significant disparities in substance-related admissions, discharges, and treatment across the hospitals, highlighting the need for integrated care pathways, personalized services, and targeted professional development to address substance use presentations effectively. The findings underscore that a one-size-fits-all approach is insufficient.