Strategies for Addressing Opioid Use Disorder in Rural Areas

November 13, 2019 - The opioid epidemic has affected rural and urban areas alike.

According to research from the American Academy of Family Physicians, those in rural areas had an 87 percent higher chance of receiving an opioid prescription compared to those in metropolitan areas. This might be why, until 2019, opioid-related death rates in rural areas rose faster than in urban areas. Their data also showed that 14 of 15 counties with the highest prescription rates were rural.

Opioid-related death rates are higher in urban areas compared to rural areas. Still, those in urban environments typically have greater access to specialty care providers and more treatment options, including medication-assisted treatment (MAT).

Two programs working in rural areas to combat opioid misuse spoke with HealthPayerIntelligence.com about best practices for implementing successful opioid treatment options in rural areas.

John Brooklyn, MD, medical director of Methadone Clinic at Howard Center for Human Services, helped develop the statewide Hub-and-Spoke intervention model.

READ MORE: How Major Payers Provide Substance Abuse Care for Opioid Misuse

This statewide intervention was created to improve treatment accessibility and promote care coordination. The model replicates treatment models seen in traditional chronic disease management where primary care physicians (spokes) treat patients but refer the latter to more specialized care (hubs) when symptoms escalate.

President and CEO of Project Lazarus Fred Brason discussed how the project provides educational tools to providers and patients to reduce drug supply as well as reduce harm in prescription opioid use.

While both models of opioid treatment differ in their structure, they echo similar sentiments around maximizing small budgets, gaining political will, and working with local communities to improve patient’s lives.

Political Will

Vermont voted to expand Medicaid under the Affordable Care Act (ACA), so Brooklyn and his were able to leverage Medicaid dollars to restructure the system of delivery for opioid treatments. The group drafted an amendment for resources designated to create community health teams for care delivery to create the Hub-and-Spoke system.

Such a significant policy shift required a lot of political buy-in.

READ MORE: Engagement, Data Analytics Cut Opioid Dependency in Managed Care

“We had a lot of support from the governor, the legislature, and the department of health,” Brooklyn said. "We had officials from different areas, all pushing to make treatment happen. We agreed that we were not an abstinence-based state. We strongly believe that the evidence that medication makes a difference in saving lives.”

“The cornerstone of the Hub-and-Spoke model is that we believe medication is efficacious,” he continued. “We can see from our overdose numbers that it has been an effective strategy.”

Since the implementation of the Hub-and-Spoke model, Vermont’s overdose death rates have dropped by nearly 50 percent in several of their counties, and the number of individuals on MAT has risen to over 8,000. 

Governmental buy-in and evidence on the effectiveness of using MAT made the implementation of the model easier.

"Even in tiny communities, you can create a hub and spoke model if they have the political, governmental, and medical community will to do so," Brooklyn stressed.

READ MORE: How Payers Address the Nation’s Opioid Crisis, Patient Safety

With the proper political will, others can easily replicate their model because a funding source already existed in the ACA.

“For the first two years, the Hub-and-Spoke model was funded by ACA dollars. What we found is just after two years the cost savings from treating opiate use disorder and not having our patients end up in the emergency room was $6-7 million,” Brooklyn pointed out. “The state decided that we were going to self-fund. We’ve been self-funding ever since because the cost savings were enormous.”

With political buy-in from the top and funding sources that aligned, the Hub-and-Spoke model was successful not only in starting but in eventually becoming a self-sufficient care model.

Community Health Model

While political will is essential to the success of opioid use treatment programs, the will of the community is also important. Brason emphasized that these community relationships are particularly impactful in rural areas.

“There were almost 69,000 individuals in our community who were very, very spread out. No single source could reach them all,” he noted.

“We can’t reach everybody, but the communities can,” Brason furthered. “We look at it from every perspective. If we want to reach kids, we’re looking at 4-H, Girl Scouts, Boy Scouts, schools, youth groups in churches, athletics. If we want to influence medical care, there’s the medical provider, the hospital, the emergency department, the pharmacists, and the caregiver and families of those individuals.”

Understanding that the health of his community primarily impacts the health of an individual is critical to Project Lazarus' success. To implement this community health model, then, they had to work with organizations across the community.

“We try to be where people go because they’re not going to come to us. We had to determine how we could reach people where they are. That means we looked at every sector,” Brason noted. “It’s engaging law enforcement, faith communities, the medical community, and the general community. Every community has a litany of different agencies and organizations.”

Project Lazarus provides an array of services including in-person training for prescribers of opioids, treatment and recovery resources, harm reduction strategies, education and mentorship for youth, and training for community groups and coalitions.

“We are essentially addressing every community sector and providing them with tools, materials, and resources to appropriately address the problem in the populations that they serve,” Brason said.

With Us, Not About Us

To successfully implement a community health strategy, Brason emphasized the importance of working alongside the community rather than working at them.

“The perception in rural communities is that the state capital doesn’t understand us and what we need. It can quickly become a ‘we and them’ scenario,” he explained.

Outside organizations coming into a community can receive pushback if they implement a project without fully understanding the community. The community might feel that these outsiders are coming in, trying to alter their way of doing things without genuinely caring about the community.

“We work with a community. I emphasize with because we can’t do it for the community,” Brason explained. “We can only come alongside and guide them. We aren’t trying to tell them what to do. We were trying to help them with what they do.”

Rather than tell someone what to do, it is more effective to work with them, helping to promote their goals. In rural communities, Brason noted, this is especially important.

“You have hard-working families and people who want to stay where they are. They are willing to do anything possible to build their lives, overcome social determinants of health, and build resiliency. We need others to come alongside them and help,” he said.

To help a community, an organization must work with them, understanding the needs of the individual community rather than the specific goals of the organization.

“When you realize the population has an issue, look at it from the population’s perspective and how you can intervene,” Brason stated. “It needs to be approached in a way that looks at what appropriate services are necessary for a rural community to function, just like any other community."

Leveraging Telehealth

Rural communities face many unique challenges. They often have a smaller clinical workforce, fewer specialists, and limited transportation to these health services.

Complicating this is the stigma associated with opioid use disorder, which makes many individuals unwilling to seek care for fear of being judged.

Brooklyn noted that telehealth services can help overcome many of these stigmas.

“There could be a hub-like program where you have a clinic that’s 50 miles away that could consult with you about cases through teleconsultation. The key thing is that you’re not going it alone in a rural town with fewer resources,” Brooklyn said.

“The workforce can be the most challenging and then paying for it can be the second greatest challenge. I think there are some solutions like telemedicine and teleprescribing that have been used in some communities,” he continued.

Tele-prescribing is one of the methods Vermont has been using for several years, Brooklyn explained. They have a pilot project where a smartphone app records a patient taking his medication at home. Patients no longer need to come into the clinic every day, but providers can still confirm patients are taking their medication.

The videos are HIPAA compliant and save patients hours of travel time each week.

"It's been employed around the world for monitoring people taking tuberculosis medicines with success. We've used it here for methadone and buprenorphine administration that we're hoping to continue to expand," Brooklyn stated.

Maximize a Small Budget

Budgets are often the limiting factor when it comes to interventions in rural areas. Grant funding eventually runs out, so programs that do not incorporate sustainability into their strategy will leave many individuals who were helped by the program without resources to better their health.

“If you have a grant, you should build something into it that helps the program stay,” Brason argued.

While Brooklyn and the Hub-and-Spoke model were able to integrate sustainability into the program by leveraging federal dollars, they eventually became self-sufficient. He noted that even non-Medicaid expansion states can develop creative ways to leverage budgets and use this model of care.

“You could take some pretty scarce dollars to begin with and allocate them for expanding treatment. There are ways to do that, and it can become self-sustaining because the state ultimately saves a ton of money in healthcare costs,” he said. “It’s an investment up from that you have to be willing to make. We can demonstrate that the cost savings for a little state have been significant enough for us to continue to sustain the program.”

Brason echoed a similar sentiment but furthered that funding should not limit a program’s goals.

“Don’t decide your action plan based on bank accounts. Go into it with the perspective that you have all the money that’s necessary to solve the problem. Then you can determine what needs to be done,” he said. “You either pay now or pay later. You’re already paying for it, so let’s find a better way to spend money to get us to the point where we eventually don’t have to pay for it.”

Scaling these programs requires robust funding, and up-front investments can promote positive long-term health outcomes. The Hub-and-Spoke model and Project Lazarus were both successful in connecting individuals to opioid treatment options because their program managers thought innovatively and sustainably about their budgets.

“Let’s fix the problem rather than build a business,” Brason concluded.