The latest data from the Centers for Disease Control and Prevention on opioid misuse in America are encouraging. In 2018, the drug overdose death rate was lower in 14 states than in 2017. Four of those states—Kentucky, West Virginia, Maine and Iowa—are predominantly rural, meaning more than 50% of their residents live in rural areas. The death rate rose in only five states, none of which are considered rural. For the rest of America, the death rate from drug overdoses stayed relatively flat. While these numbers are still far above what would be required to end the opioid epidemic in America, they highlight an important shift that Rebecca Morgan, CEO and founder of Missoula, Montana-based Spark Creative, has witnessed firsthand as a family practice team trainer for opioid use disorder (OUD). She specializes in working with providers, including physician practices, hospitals and community health centers, in rural areas, getting them up to speed on treating OUD in their communities.
“What happens, especially in rural communities, is you have these solo practitioners who understand that there’s such a need for this type of treatment but at the same time they feel so isolated and alone, because oftentimes they physically are, which can make trying to work with this patient population scary and intimidating,” she says.
One response from many rural providers seeking to “do no harm” is to stop prescribing opioids to patients with OUD. On paper, it makes sense. But reality can play out much differently than intended.
“When we go into a community, we try to talk to as many stakeholders as possible,” she shares. “One thing we heard from a prosecutor was that about half of the defendants on unlawful possession of prescription drug charges don’t make it to their trial date because they’ve overdosed on heroin in the meantime. These street drugs are easier to get and they’re cheaper, but they can be far more dangerous.”
While Morgan is encouraged by the overall decrease in the rate of deaths caused by prescription opioids, she points to an increase in deaths from street drugs like heroin and the synthetic opioid fentanyl, which is cheap to produce and 50 times stronger than heroin.
This is where medication-assisted treatment (MAT) can play a big role. Providers can apply for a waiver that allows them to prescribe or dispense buprenorphine under the Drug Addiction Treatment Act of 2000. They’re required to take an 8-hour class (24 hours if they’re an advanced practice registered nurse) and provide MAT in a “qualified practice setting” that meets the following conditions:
- provides professional coverage for patient medical emergencies during hours when the practitioner’s practice is closed;
- provides access to case-management services for patients including referral and follow-up services for programs that provide, or financially support, the provision of services such as medical, behavioral, social, housing, employment, educational, or other related services;
- uses health information technology systems such as electronic health records;
- is registered for their State prescription drug monitoring program (PDMP) where operational and in accordance with Federal and State law; and
- accepts third-party payment for costs in providing health services, including written billing, credit, and collection policies and procedures, or federal health benefits.
“A lot of times, doctors might say, ‘We don’t want all these people coming into our clinic,’ but chances are they already have them in their clinic,” Morgan says. “They’re already your patients, this is your chance to help give them the treatment they need.”
While telehealth was already helping rural providers connect MAT patients with the needed behavioral health support on a limited basis, the COVID-19 pandemic that has forced many Americans to stay closer to home has actually helped to strengthen its case, Morgan says.
“Telehealth allows patients who feel very vulnerable to have these provider visits in the comfort of their homes,” she says. “Anecdotally, at least, we have heard that telehealth has reduced some of that friction that sometimes is present in a provider-patient relationship.”
Another strategy that is proving effective is the team-based approach to treating OUD. So often, the nurse or doctor may be the compassionate one, but the patient is treated inappropriately or not understood by front office or billing staff, which can worsen patient outcomes. Taking a team-based approach ensures everyone the patient encounters understands what OUD is and what it isn’t, and how best to treat it. Not only can this improve patient outcomes, Morgan says, it can also prevent provider burnout when the burden is shared. In a future post on this blog and in an upcoming webinar, we’ll take a closer look at how the team-based approach to OUD care works, and how it benefits both patients and practices.
Another common question is, how can rural providers, already facing low margins, fund these programs? Morgan points to a range of federal initiatives, among them the Rural Communities Opioid Response Program from the Health Resources & Services Administration (HRSA) and various opportunities with the U.S. Department of Agriculture.