Research on methamphetamine use and related issues often uses data from in-treatment and post-treatment populations in urban areas. Rural ethnographic studies are less common, particularly self-assessments by active methamphetamine users that explore use patterns and their adverse consequences. Such work is especially rare in the rural South, where illicit methamphetamine manufacture and use have recently been increasing. This article presents an ethnographic overview of methamphetamine use in rural Kentucky and Arkansas based on qualitative interviews conducted with 34 active, not-in-treatment, primary methamphetamine users. Methamphetamine supply, distribution, and prevalence of methamphetamine use are described. Pathways and motivations for methamphetamine use and use patterns are outlined as well. A discussion of the adverse consequences and potential risks of methamphetamine use follows. The findings indicate that informed drug treatment outreach and reduction of potential adverse consequences among methamphetamine users in rural areas are important issues for public health and for interventions.