The increasing number of drug overdose deaths in the United States has hit rural areas particularly hard. Between 1999 and 2015, overdose deaths increased 325 percent in rural counties.1 In 2015, they surpassed the death rate in urban areas.2 Additionally, nonfatal prescription opioid overdoses are concentrated in states with large rural populations.3 Helping to drive this trend in rural areas are high opioid prescription rates and challenges accessing medication-assisted treatment (MAT), the gold standard for treating opioid use disorder.4
This fact sheet describes some of the challenges rural communities face in providing access to evidence-based treatment and strategies used by federal and state agencies to enhance treatment capacity, including how one rural community responded to the opioid epidemic by addressing the specific needs of its residents. The policies and programs described are not an exhaustive list but are intended to be illustrative.
Medication-assisted treatment (MAT) combines behavioral therapy with one of three Food and Drug Administration (FDA)-approved medications—buprenorphine, methadone, or naltrexone— for the treatment of opioid use disorder (OUD).5
These medications minimize or block the euphoric effects of opioids, curtail cravings, and significantly increase a patient’s adherence to treatment.6
Rural treatment capacity
Compared with their urban counterparts, rural communities face significant barriers to treatment, such as fewer facilities, which may also offer more limited services, and greater distances to care.7
Opioid treatment programs (OTPs), which dispense methadone and may also offer buprenorphine and naltrexone, are a key component of most current opioid use disorder (OUD) treatment systems. Although a shortage of these programs exists nationally, the gap is widest in rural areas, where 88.6 percent of large rural counties lack a sufficient number of OTPs.8
An opioid treatment program (OTP) is a facility where patients go, usually daily, to take medications to treat their OUD under the supervision of staff and to receive counseling and other care services.
These programs are regulated and certified by the federal Substance Abuse and Mental Health Services Administration and operate in a number of care settings, including intensive outpatient, residential, and hospital locations.9
Another key component of an OUD treatment system is office-based opioid treatment (OBOT), which integrates opioid agonist treatment (i.e., drugs that minimize the effects of opioids) into a patient’s general medical and psychiatric regimen by allowing primary care physicians to provide MAT in their own clinical settings.10 However, OBOT is particularly limited in rural communities: 29.8 percent of rural Americans live in a county without a buprenorphine provider, compared with only 2.2 percent of urban Americans.11
The shortage of treatment options in rural areas places barriers on patients who must travel farther to access MAT and, in some cases, have to rely on friends or family for transportation.12 Numerous studies have found that those who live closer to a health care facility have better health outcomes and can more easily access care.13 Transportation challenges may be particularly acute for patients with OUD; a small survey of OTP patients in Vermont found that 23 percent missed at least one visit due to lack of transportation, 17 percent due to weather, and 8 percent due to costs.14 The rural treatment shortage also places burdens on payers that offer patients transportation services.15 For example, Washington state’s Medicaid program reported in 2011 that it spends $3 million a year to transport rural enrollees of the program to urban OTPs.16
Treatment centers in rural areas are less likely than their urban counterparts to provide buprenorphine and to offer additional services, such as case management, that are shown to improve outcomes.17 Rural facilities also rely more on public funds to care for patients and support innovative programs that may improve treatment quality.18 Such limitations can contribute to decreased availability of evidence-based care, with fewer tailored treatment options and specialized providers to address complex patients.
Closing the treatment gap by expanding the provider workforce
In 2016, Congress passed legislation temporarily allowing nurse practitioners (NPs) and physician assistants (PAs) to prescribe buprenorphine after completing specified training.19 Additional legislation passed in 2018 made this allowance permanent and temporarily authorized other providers, such as clinical nurse specialists, to obtain a waiver to become buprenorphine prescribers.20 This expanded prescribing authority is relevant for rural areas; in 2017, 13.8 percent of rural counties had a waivered NP and 4.6 percent had a waivered PA.21 As a result of this workforce expansion—and a 10.7 percent rise in the number of physicians with a waiver to prescribe buprenorphine—from 2012 to 2017, the number of all waivered providers (e.g., physicians, NPs, and PAs) per 100,000 residents doubled in rural counties.
However, as of 2017, 28 states prohibited NPs from prescribing buprenorphine unless they are working in collaboration with a doctor who also has a federal waiver to prescribe.22 To further increase access to MAT, states may need to change laws and regulations that restrict NPs from prescribing buprenorphine.
Using technology to address physician barriers
For rural physicians, barriers to prescribing buprenorphine include time constraints and a lack of mental health or psychosocial support services for patients, specialty backup for complex problems, and confidence in their ability to manage OUD.23 Treatment models that use technology to address these barriers have been shown to increase access in rural populations.
For example, Project ECHO (Extension for Community Healthcare Outcomes), which was launched in New Mexico, contributed to a nearly tenfold increase in buprenorphine-waivered physicians over a 10-year period.24 In this model, prescribers are recruited to obtain a waiver and are provided regular opportunities for mentoring and education, thereby increasing treatment capacity in rural areas.
West Virginia’s Comprehensive Opioid Addiction Treatment program is a telemedicine model that uses videoconferencing to prescribe buprenorphine and for medication management.25 Patients residing hundreds of miles from the treatment center participate in virtual group-based medication management followed by in-person group therapy. Retrospective analysis of this program found that rates of treatment retention and abstinence from drug use were comparable to the rates observed when MAT is provided in person.
Developing innovative, local responses to the opioid epidemic
Strategies to address the opioid epidemic must address community needs to effectively reach and treat patients with OUD. For example, Indiana’s Scott County Partnership Inc. responded to an HIV outbreak that was linked to the misuse of prescription opioids and sharing of syringes by developing a “one-stop shop” model to provide buprenorphine, mental health counseling, HIV and hepatitis C treatment, primary care, and syringe exchange in an existing mental health clinic.26 Prior to this model, this rural county had no OUD or HIV treatment services.27
Scott County responded to this local public health crisis by comprehensively addressing the barriers to care faced by people with OUD and HIV. In addition to health care services, patients receive clothes and meals if needed, obtain help finding a job, and have care coordinators to help them enroll in health insurance.28 The partnership also transports patients to appointments and conducts outreach and education to increase the number of physicians who can prescribe buprenorphine.29 Evaluations of the one-stop shop model have not been published, although Scott County’s experience provides an example of a targeted response that takes specific community needs into account.
Closing the rural treatment gap
Policymakers and leaders within health care systems can ensure that effective OUD therapy is available in rural communities by implementing emerging and evidence-based practices and studying the effectiveness of these models within their states. These efforts can help close the treatment gap in rural America and save lives.
- Karin A. Mack, Christopher M. Jones, and Michael F. Ballesteros, “Illicit Drug Use, Illicit Drug Use Disorders, and Drug Overdose Deaths in Metropolitan and Nonmetropolitan Areas—United States,” Morbidity and Mortality Weekly Report 66, no. 19 (2017): 1-12, https://www.cdc.gov/mmwr/volumes/66/ss/ss6619a1.htm?s_cid=ss6619a1_w. The 325 percent increase in overdose deaths is an age-adjusted calculation, meaning it allows for the comparison of communities with different age structures.
- Katherine M. Keyes et al., “Understanding the Rural-Urban Differences in Nonmedical Prescription Opioid Use and Abuse in the United States,” American Journal of Public Health 104, no. 2 (2014): e52-59, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3935688.
- Ibid.; Roger Rosenblatt et al., “Geographic and Specialty Distribution of US Physicians Trained to Treat Opioid Use Disorder,” Annals of Family Medicine 13, no. 1 (2015): 23-6, https://dx.doi.org/10.1370%2Fafm.1735; Substance Abuse and Mental Health Services Administration, “Addressing Substance Use and the Opioid Epidemic in Integrated Care Settings” (PowerPoint, Primary and Behavioral Health Care Integration Central Regional Meeting, Denver, March 8-9, 2018), https://integration.samhsa.gov/pbhci-learning-community/regional_clusters/Hamblin.Disselkoen.Mountain_Plains.ATTC_PBHCI_SUD_Presentation.pdf.
- American Society of Addiction Medicine, “The ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use” (2015), http://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement.pdf?sfvrsn=24; U.S. Department of Health and Human Services, “Addressing Prescription Drug Abuse in the United States: Current Activities and Future Opportunities” (2013), https://www.cdc.gov/drugoverdose/pdf/hhs_prescription_drug_abuse_report_09.2013.pdf.
- Richard P. Mattick et al., “Methadone Maintenance Therapy Versus No Opioid Replacement Therapy for Opioid Dependence,” Cochrane Database of Systematic Reviews no. 3 (2009), https://doi.org//10.1002/14651858.CD002209.pub2.
- Ellen Pullen and Carrie Oser, “Barriers to Substance Abuse Treatment in Rural and Urban Communities: A Counselor Perspective,” Substance Use & Misuse 49, no. 7 (2014): 891-901, http://dx.doi.org/10.3109/10826084.2014.891615; Quentin Johnson, Brian Mund, and Paul J. Joudrey, “Improving Rural Access to Opioid Treatment Programs,” Journal of Law, Medicine & Ethics 46, no. 2 (2018): 437-39, https://doi.org/10.1177/1073110518782951.
- Andrew W. Dick et al., “Growth in Buprenorphine Waivers for Physicians Increased Potential Access to Opioid Agonist Treatment, 200211,” Health Affairs 34, no. 6 (2015): 1028-34, https://dx.doi.org/10.1377%2Fhlthaff.2014.1205.
- U.S. Department of Health and Human Services, “Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs: Inservice Training” (2008, reprinted 2009), http://www.woema.org/pdf/WOHC2013PDF/SAMHSA-Med-Assist%20tx%20for%20opioid%20addiction.pdf.
- American Society of Addiction Medicine, “Public Policy Statement on Office-Based Opioid Agonist Treatment (OBOT),” (2010), https://www.asam.org/docs/default-source/public-policy-statements/1obot-treatment-7-04.pdf?sfvrsn=0.
- C. Holly A. Andrilla et al., “Geographic Distribution of Providers With a DEA Waiver to Prescribe Buprenorphine for the Treatment of Opioid Use Disorder: A 5-Year Update,” The Journal of Rural Health 35, no. 1 (2018): 108-12, https://doi.org/10.1111/jrh.12307.
- Andrew Rosenblum et al., “Distance Traveled and Cross-State Commuting to Opioid Treatment Programs in the United States,” Journal of Environmental and Public Health (2011): 1-10, http://dx.doi.org/10.1155/2011/948789; Stacey C. Sigmon, “Access to Treatment for Opioid Dependence in Rural America: Challenges and Future Directions,” JAMA Psychiatry 71, no. 4 (2014): 359-60, http://dx.doi.org/10.1001/jamapsychiatry.2013.4450; Pullen and Oser, “Barriers to Substance Abuse Treatment.”
- Charlotte Kelly et al., “Are Differences in Travel Time or Distance to Healthcare for Adults in Global North Countries Associated With an Impact on Health Outcomes? A Systematic Review,” BMJ Open 6, no. 11 (2016): 1-9, http://dx.doi.org/10.1136/bmjopen-2016-013059.
- Sigmon, “Access to Treatment.”
- Erik Kvamme et al., “Who Prescribes Buprenorphine for Rural Patients? The Impact of Specialty, Location and Practice Type in Washington State,” Journal of Substance Abuse Treatment 44, no. 3 (2013): 355-60, https://dx.doi.org/10.1016%2Fj.jsat.2012.07.006.
- Mary Bond Edmond, Lydia Aletraris, and Paul M. Roman, “Rural Substance Use Treatment Centers in the United States: An Assessment of Treatment Quality by Location,” American Journal of Drug and Alcohol Abuse 41, no. 5 (2015): 449-57, https://dx.doi.org/10.3109%2F00952990.2015.1059842.
- Comprehensive Addiction and Recovery Act, sec. 303: Medication-Assisted Treatment for Recovery From Addiction (2016), https://www.congress.gov/bill/114th-congress/senate-bill/524/text.
- Substance Use Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities Act, sec. 3201: Allowing for More Flexibility With Respect to Medication-Assisted Treatment for Opioid Use Disorders (2018), https://www.congress.gov/115/bills/hr6/BILLS-115hr6enr.pdf.
- Andrilla et al., “Geographic Distribution of Providers.”
- Christine Vestal, “Nurse Licensing Laws Block Treatment for Opioid Addiction,” Stateline (April 21, 2017), accessed Aug. 28, 2018, http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2017/04/21/nurse-licensing-laws-block-treatment-for-opioid-addiction.
- C. Holly A. Andrilla, Cynthia Coulthard, and Eric H. Larson, “Barriers Rural Physicians Face Prescribing Buprenorphine for Opioid Use Disorder,” Annals of Family Medicine 15, no. 4 (2017): 359-62, http://dx.doi.org/10.1370/afm.2099.
- Miriam Komaromy et al., “Project ECHO (Extension for Community Healthcare Outcomes): A New Model for Educating Primary Care Providers About Treatment of Substance Use Disorders,” Substance Abuse 37, no. 1 (2016): 20-4, http://dx.doi.org/10.1080/08897077.2015.1129388.
- Wanhong Zheng et al., “Treatment Outcome Comparison Between Telepsychiatry and Face-to-Face Buprenorphine Medication-Assisted Treatment for Opioid Use Disorder: A 2-Year Retrospective Data Analysis,” Journal of Addiction Medicine 11, no. 2 (2017): 138-44, http://dx.doi.org/10.1097/ADM.0000000000000287.
- Ibid.; P. Todd Korthuis et al., “Primary Care-Based Models for the Treatment of Opioid Use Disorder: A Scoping Review,” Annals of Internal Medicine 166, no. 4 (2017): 268-78, https://dx.doi.org/10.7326%2FM16-2149.
- Michelle Goodin, Scott County Health Department, pers. comm. to The Pew Charitable Trusts, Nov. 20, 2018.
- Elizabeth Beilman, “State-Ordered ‘One-Stop Shop’ for HIV Outbreak Open in Scott County,” News and Tribune, April 1, 2015, https://www.newsandtribune.com/news/state-ordered-one-stop-shop-for-hiv-outbreak-open-in/article_31572476-d8d7-11e4-9aad-33610ed3dbd0.html; Korthuis et al., “Primary Care-Based Models”; Goodin, pers. comm.