Six Tips to Effectively Treat Opioid Use Disorder in Rural Areas
Overcome barriers to care by using telehealth, supporting home-based treatment, and partnering with local and state services.
Fam Pract Manag. 2021 May-June;28(3):23-28.
Author disclosures: no relevant financial affiliations disclosed.
The opioid crisis has been devastating for many rural communities. According to the Centers for Disease Control and Prevention (CDC), drug overdose deaths increased fourfold from 1999 to 2018,1 and in 2018 nearly 70% of these deaths involved an opioid.2 More than half — 62% — of the U.S. counties with the highest rates of opioid use disorder (OUD) are located in rural areas.3 Unfortunately, these high-need, rural communities are much less likely to have access to OUD treatment services.3,4
In response to the alarming rate of opioid-related overdoses in rural communities, our practice successfully transitioned to offering medications for opioid use disorder (MOUD) to our patients. Lessons learned through our experience may be useful for other practices starting to offer MOUD.
Approximately 60% of the U.S. counties with the highest rates of opioid use disorder (OUD) are located in rural areas.
Rural practices face barriers to implementing OUD treatment programs that their urban counterparts do not.
To overcome these barriers, rural practices may benefit from utilizing telehealth services and establishing community partnerships.
BARRIERS TO TREATMENT
The Food and Drug Administration has approved methadone, buprenorphine, and naltrexone for the treatment of opioid use disorder.5 MOUD are proven to reduce OUD-related morbidity and mortality, with a recent meta-analysis indicating that treatment with the mu opioid receptor agonists methadone and buprenorphine is more beneficial than treatment with the mu opioid receptor antagonist naltrexone.6
Methadone is only available for treatment of OUD through federally licensed opioid treatment programs (OTPs), limiting its availability in rural areas. Buprenorphine can be prescribed by any waivered prescriber, including primary care physicians, and is currently the most accessible effective option.7 However, 60% of rural areas lack waivered buprenorphine prescribers.3 Even among those with a waiver, only a subgroup actively uses the waiver to prescribe buprenorphine and treat OUD.4
Urban practices typically have better access to services necessary for effective OUD care — including mental and behavioral health treatment, social workers, pharmacists, consults with psychiatrists and pain specialists, and specialized addiction medicine services across the spectrum of treatment settings (e.g., intensive outpatient programs, OTPs, and residential treatment). However, many of these options simply do not exist in most rural areas.8 Rural primary care physicians are often responsible for comprehensive management of higher-risk, more complex patients, with little, if any, assistance. Many feel underprepared to effectively address the needs of patients with OUD, particularly those with complex, active addiction.
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1. Centers for Disease Control and Prevention. Wide-ranging online data for epidemiologic research (WONDER). Updated Dec. 22, 2020. Accessed April 5, 2021. https://wonder.cdc.gov...
2. Wilson N, Kariisa M, Seth P, Smith H, Davis NL. Drug and opioid-involved overdose deaths — United States, 2017–2018. MMWR Morb Mortal Wkly Rep. 2020;69(11): 290–297.
3. Grimm CA. Geographic disparities affect access to buprenorphine services for opioid use disorder. U.S. Department of Health and Human Services Office of the Inspector General. January 2020. Accessed April 16, 2021. https://oig.hhs.gov/oei/reports/oei-12-17-00240.asp
4. Andrilla CHA, Coulthard C, Larson EH. Barriers rural physicians face prescribing buprenorphine for opioid use disorder. Ann Fam Med. 2017;15(4):359–362.
5. American Society of Addiction Medicine. The ASAM national practice guideline for the treatment of opioid use disorder: 2020 focused update. J Addict Med. 2020; 14(2S Suppl 1):1–91.
6. Wakeman SE, Larochelle MR, Ameli O, et al. Comparative effectiveness of different treatment pathways for opioid use disorder. JAMA Netw Open. 2020;3(2):e1920622.
7. Thomas CP, Fullerton CA, Kim M, et al. Medication-assisted treatment with buprenorphine: assessing the evidence. Psychiatr Serv. 2014;65(2):158–170.
8. Peterson LE, Morgan ZJ, Borders TF. Practice predictors of buprenorphine prescribing by family physicians. J Am Board Fam Med. 2020;33(1):118–123.
9. Substance Abuse and Mental Health Services Administration (SAMHSA). Statutes, regulations, and guidelines. Updated Oct. 7, 2020. Accessed April 16, 2021. https://www.samhsa.gov/medication-assisted-treatment/statutes-regulations-guidelines
10. Cunningham CO, Giovanniello A, Li X, Kunins HV, Roose RJ, Sohler NL. A comparison of buprenorphine induction strategies: patient-centered home-based inductions versus standard-of-care office-based inductions. J Subst Abuse Treat. 2011;40(4):349–356.
11. Lee JD, Grossman E, DiRocco D, Gourevitch MN. Home buprenorphine/naloxone induction in primary care. J Gen Intern Med. 2009;24(2):226–232.
12. Handelsman L, Cochrane KJ, Aronson MJ, Ness R, Rubinstein KJ, Kanof PD. Two new rating scales for opiate withdrawal. Am J Drug Alcohol Abuse. 1987;13(3):293–308.
13. Lee JD, Vocci F, Fiellin DA. Unobserved “home” induction onto buprenorphine. J Addict Med. 2014;8(5): 299–308.
14. Sokol R, LaVertu AE, Morrill D, Albanese C, Schuman-Olivier Z. Group-based treatment of opioid use disorder with buprenorphine: a systematic review. J Subst Abuse Treat. 2018;84:78–87.
15. Brooklyn JR, Sigmon SC. Vermont hub-and-spoke model of care for opioid use disorder: development, implementation, and impact. J Addict Med. 2017;11(4):286–292.
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