The opioid epidemic has affected communities of all sizes and income levels and in all regions. But one demographic has been hit particularly hard. Among the 2.5 million Americans reportedly addicted to prescription opioids, a disproportionate number live in rural areas.
The rural upsurge of opioid use disorder and overdose deaths arises from multiple factors: geography, socioeconomics, and access to health care. Rural residents have a higher risk of work-related injuries for which opioids may be prescribed. Many have low incomes, limited or no insurance coverage, and live far from addiction treatment clinics. In addition, numerous patients who misuse prescription opioids progress to using heroin and illegally manufactured fentanyl, a synthetic opioid that is much stronger than heroin.
When an overdose occurs in a rural area, “it could be half an hour before [emergency medical services] arrives at the patient’s home,” explained Rachel M. Franklin, MD, professor at the University of Oklahoma (OU) College of Medicine and medical director of the OU Physicians Family Medicine Center.
In response to this growing public health crisis, medical schools and teaching hospitals are reaching out to train small-town and rural physicians and help patients gain access to treatment. In addition, the National Institutes of Health (NIH) has expressed a commitment to work with physicians, researchers, and private partners to develop new treatments for opioid addiction and innovative pain management therapies. In a recent New England Journal of Medicine article describing NIH efforts to address the opioid crisis, Nora D. Volkow, MD, director of the National Institute on Drug Abuse, and NIH Director Francis S. Collins, MD, PhD, wrote that the “scope of the tragedy of addiction and overdose deaths plaguing our country is daunting.”
Most rural communities have few, if any, physicians or other providers with the required training and waivers to prescribe buprenorphine, an opioid used in medication-assisted treatment (MAT) for opioid addiction. Because buprenorphine is prescribed in physicians’ offices and taken at home rather than at daily visits to a clinic, it’s useful in treating rural patients.
“[The academic medicine community] has to be the torch on the hill that sheds some light,” said Jack Westfall, MD, a family medicine physician and associate dean of rural health at the University of Colorado (CU) School of Medicine Anschutz Medical Campus. It needs to serve as a resource for rural communities, he said.
Support for front-line providers
West Virginia has the grievous distinction of placing first among U.S. states in drug overdose deaths, with a rate of 41.5 deaths per 100,000 residents in 2015. Other states with large rural populations also rank near the top of the list, including New Hampshire, Kentucky, and Ohio.
“[The academic medicine community] has to be the torch on the hill that sheds some light.”
Jack Westfall, MD
University of Colorado School of Medicine
A state-conducted preliminary analysis of West Virginia’s 2016 overdose deaths shows a 13% increase, with most deaths involving at least one type of opioid. Rural areas, such as the state’s southern coalfields, have the most severe problem, said James Berry, DO, associate professor of behavioral medicine and psychiatry at the West Virginia University (WVU) School of Medicine.
WVU Medicine treats 550 to 575 patients each month in its MAT program. The outpatient treatment, provided at WVU’s Chestnut Ridge Center in Morgantown in the northern part of the state, has a waiting list of 600.
“The need is so dire that as soon as we get a person off the list and enrolled in our program, another person takes their place on the list,” said Berry, who is medical director of the program. “We’re not even scratching the surface. It seems to be getting worse and worse.”
While MAT patients take buprenorphine at home, they attend weekly group sessions as part of the program, then biweekly and monthly sessions as recovery progresses. Some rural patients must travel four to five hours to participate.
Last year, WVU School of Medicine offered one-day training to help physicians and other providers qualify for waivers to prescribe buprenorphine. Now it conducts biweekly teleconferences to mentor rural primary care providers who already have waivers. Cases are reviewed and providers learn about effective prescribing and how to help patients connect with psychosocial help. The effort is currently expanding to reach providers throughout West Virginia.
WVU Charleston Division and the Joan C. Edwards School of Medicine at Marshall University in Huntington have plans to work on a project to increase treatment in southern West Virginia, Berry said.
Expanding access to addiction treatment
In the 16 counties of rural eastern Colorado, there was only one provider with a waiver to prescribe buprenorphine in 2016. That’s when CU School of Medicine received a $3 million, three-year federal grant to train primary care physicians, nurse practitioners, physician assistants, and office staff about opioid use disorder and MAT. The grant focuses on 24 rural counties in eastern and southern Colorado.
“We’re developing a curriculum for the whole primary care practice, for the front office, nurses, providers, and billing staff. Everybody participates in the care of the patient,” said Westfall, who is principal investigator for the grant. Experts from the CU medical and pharmacy schools formed a team to direct the effort. “We want to change the conversation about who is an opioid addict so everyone understands how common it is,” Westfall said.
Project experts meet regularly with rural residents to talk about the reality of the opioid crisis and how MAT can help. Comparing the current situation with a time when such addiction was chiefly an urban problem, Westfall said, “We now have a group of people with opioid use disorder who are our neighbors—farmers, ranchers, businesspeople, and their kids.” He has a family medicine practice in Ft. Morgan, Colo., and provides MAT at a small clinic in Rocky Ford, a town with about 3,900 residents.
The project will also offer the buprenorphine waiver course required by the U.S. Drug Enforcement Administration, online and free, to physicians, nurse practitioners, and physician assistants in the grant’s 24-county rural region. The course is presented in partnership with the Society of Addiction Medicine. The project already cosponsored a free, in-person, one-day waiver training session for providers from anywhere in Colorado.
Rethinking pain therapy
To help combat the rural opioid crisis, some institutions are seeking to improve pain care. OU College of Medicine has added content on chronic pain management and opioid addiction treatment to its annual primary care continuing education. “We want to help doctors avoid overprescribing” but also assure safe and effective pain management for patients, said Franklin, who leads some of the sessions.
About 250 physicians, many from Oklahoma’s rural areas, take part. Attendees receive education in patient self-assessment surveys on pain and functioning and screening tools to evaluate opioid dependence risk, addiction, diversion, and accidental overdoses. Information gathered can improve doctor-patient discussions about pain.
To broaden understanding of pain care, a program from the University of Washington (UW) Division of Pain Medicine connects providers from rural, tribal, and medically underserved areas with pain medicine specialists. UW TelePain provides weekly audio and videoconferences that include a chronic pain case study and education on topics such as how to take a pain history, nondrug treatment options, safe opioid prescribing, and psychological therapies.
The latest Centers for Disease Control and Prevention (CDC) guidelines for chronic pain care recommend nondrug and nonopioid therapies first before prescribing opioids. “If providers think opioids and nothing else, we have an opioid crisis, and that’s what happened,” said David J. Tauben, MD, medical director of UW TelePain, chief of the Division of Pain Medicine, and professor at UW School of Medicine.
Since UW TelePain began in 2011, more than 1,500 providers have participated from Washington, Wyoming, Montana, Oregon, Idaho, Alaska, and elsewhere. Physicians may receive continuing medical education credit for participating. UW TelePain is a requirement or elective for some medical students and residents. Pain fellows also take part.
Such an approach could reduce rural challenges that include lack of access to pain management resources, Tauben said.