A Public Health Approach to Substance Use in Rural Settings

The Role of Rural Place in Substance Use, Prevention, and Treatment

John Gale, MS A Public Health Approach to Substance Misuse and Addictions, Region 5 Indianapolis, IN May 12, 2017

Topics to Be Covered

• Key take away messages

• A brief introduction to substance use prevalence in different rural settings

• A discussion of the burden of substance use in rural communities

• Exploring what is different about rural areas

• A review of the factors contributing to rural substance use

• Presentation of a model of rural substance use delivery to provide prevention, treatment, and recovery services

Key Take-Away Messages

• If you have seen one rural community……

• It takes a village - Community engagement and involvement are central to addressing SUDs

• Substance use disorders are common in rural areas and driven by a complex mix of socioeconomic issues

• Rural area suffer disproportionately from these issues

• Travel barriers and isolation exacerbate these problems

• Significant gaps exist in substance use prevention, treatment, and recovery in rural communities

• Models must be adapted to the geographic, resource, and cultural realities of rural areas

Rural Prevalence Rates

Substance Non-metro Small Metro

Large Metro

Underage alcohol use 11.3% 11.4% 11.5%

Binge alcohol use by 12-17 year olds

6.6% 6.2% 6.2%

Illicit drugs 7.8% 9.8% 9.6%

Illicit drug or alcohol dependence

6.4% 8.4% 8.6%

Cigarettes 26.6% 22.4% 19.0%

Smokeless tobacco 6.7% 3.7% 2.1%

Source: 2013 NSDUH

Socioeconomic Characteristics Related to SUDs

Socioeconomic Characteristics (cont’d)

• Socioeconomic: low income, unemployment, manual labor occupations that increase risk of injury, income inequality, lower educational levels, limited opportunities for advancement, and lack of health services

• Social capital: low social support

• Community: inadequate housing, overcrowding, neighborhood violence and high availability of substances

• Environmental: natural disasters, war, conflict, and climate change and degradation

• Social change: changes in income, urbanization, migration and government policies

Treatment and Access Realities

• Treatment access and completion is a problem ▫ Less than 50% admitted to Tx complete

▫ Over 50% discharged use AOD in the first year following discharge (80% of those within the first 90 days)

▫ “Durability” (15% relapse rate) takes 4-5 yrs of remission

▫ Professionally-directed, post-discharge continuing care can enhance recovery outcomes, but only 1 in 5 clients actually receives such care

▫ Distance to services is correlated with treatment completion (longer travel distances are associated with lower rates of completion)

Role of Rural Place as a Driver of SUDs

• Rural places suffer from a variety of health and socio-

economic disparities

▫ Greater sense of stigma

▫ Higher sense of isolation and hopelessness

▫ Lower education rates

▫ Higher rates of poverty

▫ Fewer opportunities for employment

▫ Higher rates of chronic illnesses

• Influence of cultural, ethnic, religious differences

Limited Pathways and Resources

• Roots of rural poverty – Cynthia Duncan 1999 ▫ Chronic poverty represents long term neglect and a lack of

investment in rural people and communities

▫ Deliberate effort to hold people back to control workers and keep them powerless, exclusion from having aspirations of getting beyond their situations Examples – Appalachian coal industry/Southern plantations

▫ Key pathways out of poverty – education, mentoring, examples of pathways out, day to day relationships, Example – Northern New England paper companies

Substance Use in the United States (US)

• Overall rural and urban substance use are comparable

• At the sub-population level, variation in use emerge • Past year use of alcohol, OxyContin, and methamphetamine is

higher among rural youth than urban

• Rural 8th graders are more likely than their urban peers to use amphetamines, crack cocaine, cocaine, marijuana, and alcohol

• Problem alcohol use is also higher in rural communities with rural youth first trying alcohol at a younger age and higher rates of driving under the influence

• Opioid use is higher among rural youth, young adults, women experiencing domestic violence and in states with large rural populations

• Opioid overdose deaths are growing faster in rural counties

Substance Use in a Rural Montana (MT)

• 80% of MT is frontier (<5 people per square mile)

• Rural populations have higher rates of alcohol, methamphetamine, and prescription drug use

• MT’s substance/alcohol use is 1.5 X the national average

• Drug/alcohol use begins on average at age 13

• In north-central Montana, 30% of high-school youth will graduate with or at risk for an SUD

• Alcohol use is ingrained in families and culture

• Rising prescription drug use makes drugs accessible to children not previously able to access illegal drugs

Interaction Between SU and Socioeconomic Issues

• Substance use is driven by socioeconomic factors

• It also contributes to a self-perpetuating cycle that is difficult to break

• Individuals with substance use disorders have lower levels of academic achievement, arrest records, greater rates of poverty, etc.

• Stigma plays a crucial role

Community in Crisis: Austin, IN

• Community of 4,200 people in rural Scott County, IN • Perfect storm-largest outbreak of HIV/HCV in IN history • 169 cases of HIV, 268 cases of HCV, 80% co-infected • Significant escalation of IV use of the drug Opana • High rates of poverty, unemployment, poor health

coverage • Governor declared a public health emergency • Ban on needle exchanges, moratorium on OTPs, no

Medicaid coverage for MAT, no infectious disease care • Limited access to infectious disease services • No recovery and support services for people returning to

the community following treatment • Could happen elsewhere

Rural Place as a Barrier to SUD Treatment and Prevention

• 56% of rural people worldwide have no access to essential health-care services (22% in urban areas)

• Limited supply of specialty SUD providers

• Limited supply of specialty mental health (MH) providers to address co-occurring MH/SUD

• Cultural barriers to seeking treatment

• Stigma/shame are significant barriers to acknowledging problems of SUDs and seeking care

• External and socio-economic influences may limit the “desire” to prevent SUDs

Challenges to Developing Rural Programs

• Programs “imported” from outside the local area are often viewed with suspicion

• Community-based programs are important to create locally developed, culturally appropriate interventions ▫ Must be sensitive to local cultural, religions, and ethnic issues

(cultural humility) and engage local leaders

▫ Limited opportunities after treatment, stigma, restricted social supports frequently leads to relapse – must support sober living

• Continuum of prevention, treatment, and recovery services must be developed simultaneously to address the needs of rural residents “where they are”

Bethel, Alaska

• Located in Yukon-Kuskokwim (Y-K) Delta region ▫ Villages in the Y-K Delta have the highest unemployment rate, the

highest jobless rate and are the poorest in the State of Alaska

▫ High dependency on public assistance for survival

▫ Unavailability of work, dependency on public assistance payments and hopelessness that accompanies such dependency has been linked to a myriad of social problems

▫ High rates of alcohol and substance abuse, suicide, depression, and domestic violence

• Many villages are dry in the Y-K and supply of alcohol is tightly controlled

Huffing as an Alternative Form of SU

• Huffing- most common form of substance abuse in rural Alaska

• Deeply interwoven into the fabric of Alaskan society ▫ Nearly 100% of Alaskan youth report having tried huffing

▫ Long term physiological effects: death, brain damage, vision/ hearing loss, slurred speech, forgetfulness, and organ damage

▫ Psychological effects: emotional volatility, paranoid delusions, passive-aggressive attitude, memory loss, impaired judgment and coordination, severe mood swings, short term and ongoing hallucinations, inhalant psychosis, lowered intelligence, and anti-social personality disorder

Challenges to Developing Rural Programs

• Programs “imported” from outside the local area are often viewed with suspicion

• Community-based programs are important to create locally developed, culturally appropriate interventions ▫ Must be sensitive to local cultural, religions, and ethnic issues

(cultural humility) and engage local leaders

▫ Limited opportunities after treatment, stigma, restricted social supports frequently leads to relapse – must support sober living

• Continuum of prevention, treatment, and recovery services must be developed simultaneously to address the needs of rural residents “where they are”

McCann Center – Bethel, AK

• Residential Psychiatric Treatment Center for Alaskan youth between the ages of 10 and 18 ▫ Operated by Y-K Health Corporation, a Native Alaskan company

• Offers intensive, culturally competent services ▫ Reinforced by an Elder Counselor who participates in sessions,

serves as a role model, instills pride in the culture

▫ Subsistence Education Program – focuses on traditional subsistence and food gathering activities

▫ Centered around the powerful healing medium of traditional cultural practices blended with evidence-based practices

▫ Other cultural experiences are available, like traditional steam, native dancing, and crafts

Definition of a System of Care

▫ An integrated spectrum of effective, community-based services and supports for rural people and their families at risk for or struggling with drug and substance use challenges Organized into a coordinated network

Builds meaningful partnerships with individuals and their families

Addresses their cultural and linguistic needs, to help them function better at home, in school, in the community, and throughout life.

Prevention

• Prevention is about the healthy and safe development of children and youth to realize their talents and become contributing members of their community and society

• Primary objective - Help people avoid or delay initiation into the use of drugs or to avoid developing disorders if they have already started

• Contributes to the positive engagement of children, young people and adults with their families, schools, workplace and community

Prevention Programs

• One of the main components of a health-centered system to address drugs

• Should be evidence-based

• Must be adapted to the unique the cultural, political, or resource context of each rural community

• Adaptations should maintain fidelity, to the greatest extent possible, to the principles of the intervention on which the evidence is based

Treatment Services

• Rural residents deserve the same level of access to the full range of substance use treatment services as urban residents

• Substance use is a chronic, relapsing disease, rather than an acute, episodic condition • An ongoing level of services

• Reflects a primary care-based system of care framework

• Conserves resources by matching services to patient needs using a level of care criteria

Structure of Treatment Services

• Use of a regional orientation/model

• Reflects the realities of rural resource limitations • Uses technology (e.g., telehealth, mobile phones, etc.) to

address distance barriers and maldistribution of resources across urban and rural areas

• Integration across services systems: • Substance use,

• Mental health, and

• Primary care.

Principals for Treatment

▫ Treatment must be available, accessible, attractive, and appropriate for needs

▫ Ethical standards must be adhered

▫ Requires effective coordination between the criminal justice system and health and social services

▫ SUDs should be viewed as a health problem rather than criminal behavior: users should be treated in the health care rather than the criminal justice system when possible

Principals for Treatment (cont’d)

• Based on scientific evidence and respond to specific needs of individuals with drug use disorders

• Should respond to the needs of special subgroups and conditions

• Should ensure good clinical governance of treatment services and programs for drug use disorders.

• Integrated treatment policies, services, procedures, approaches and linkages must be constantly monitored and evaluated

Recovery Services

• The third essential element of the Rural PTR Model

• Should be provided throughout and following treatment

• Should be evidence-based

Step 1 Assessment

• General health care delivery and drug and substance use delivery system context

• Data needs for development of a rural system of care • Demographic and socioeconomic characteristics of rural areas

• Supply of illicit drugs

• Location of health care services across urban and rural areas;

• Prevalence rates/distribution patterns of major health issues

• Utilization of drug and substance abuse services

• Distribution of services relative to rural areas

• Social and economic consequences

• Gap between service capacity and location and need

Step 1 Assessment –Local Context

• Cultural, religious, and normative beliefs that influence rural substance use and willingness to seek treatment

• Availability of resources • Community leadership

• Provider, treatment resources, acute medical care, prevention, and recovery resources

• Local champions for champion community-based strategies to address substance use

• Community willingness to acknowledge and address rural substance issues

Step 1 Assessment

• Identify community assets and resources

• The impact of stigma on willingness to address drug and substance use disorders

• Developing assessment reports and strategic plans

Prevention: Planning, Implementing, and Sustaining

• Good practices and principles for community based prevention in rural settings ▫ Engaging, organizing, and empowering community stakeholders

▫ Assessing & Identifying Readiness, Needs & Resources

▫ Creating an action plan: Selection of prevention strategies, adaptation, and adherence to fidelity

▫ Evaluating and using evaluation results

Prevention

Prevention: Community-Based Engagement Strategies

• Community ownership and mobilization is crucial to effectively target opioid use patterns

• Project Lazarus A broad-based prevention strategy in rural North Carolina

Engage community stakeholders and building local leadership by “starting where the energy is”

• Project Vision, Rutland, VT • Goals: empower communities, strengthen neighborhoods, help

people, change the future

• Committees: Crime/Safety, – Scott Tucker, Substance Abuse, Community/Neighborhoods/Housing

Project Lazarus Hub Activities

• Hub activities are central components supporting all other activities and reflect a community-based, bottom-up public health approach Build public awareness of substance use through broad-based

educational efforts and the use of local data to drive awareness

Coalition building and action to engage a broad range of community providers, agencies, and organizations

Identify data needs for planning and evaluation to build awareness, tailor programs to local needs, track progress, and sustain support and funding

Project Lazarus Spoke Activities

▫ Spoke activities are optional areas of evidence-based prevention initiatives that communities can select and reflect a medical and law enforcement-based, top-down public health approach Community education

Provider education

Hospital emergency department policies

Diversion control

Pain patient support

Addressing the consequences of use

Addiction treatment

Prevention: Community-Based Engagement Strategies

• Project Vision, Rutland, VT • Goals: empower communities, strengthen neighborhoods, help

people, change the future

• Committees: Crime/Safety, – Scott Tucker, Substance Abuse, Community/Neighborhoods/Housing

• SAMHSA’S Recovery Oriented Systems of Care • Developing community and regional systems of care with a

recovery focus

• Communities That Care

Steps to Engage Communities

• Community Organization and Engagement

• Prescriber education and behavior

• Supply reduction and diversion control

• Pain patient services and drug safety

• Drug treatment and demand reduction

• Harm reduction

• Community-based prevention education

Community Organization and Engagement

• Identify formal and informal leaders

• Town hall meetings

• Specialized task forces

• Build community-based leadership

• Coalition building

• Accessing toolkits

Prescriber education and behavior

• One-on-one prescriber education on pain management (“academic detailing”)

• Continuing medical education sessions on pain management

• Licensing actions against criminal prescribing

• Strongly encourage use of prescription drug monitoring programs

• Think about an “oxy free” emergency department

Supply reduction and diversion control

• Hospital ED opioid dispensing policy modified ▫ Oxy free EDs.?

▫ Limits on amount dispensed at once, required check of PDMP

• Unused medication take-back events by sheriff and police departments, with support from DEA and SBI

• Fixed medicine disposal sites at law-enforcement offices

• Hiring and training of drug diversion specialized law-enforcement officers

Pain patient services and drug safety

• Medicaid policy change: mandatory use of patient-prescriber agreements and pharmacy home

• Support groups for pain patients

• ED case manager for Medicaid beneficiaries with chronic pain

• Vetting of local pain clinics and facilitation of specialized pain clinic referrals

• Project Echo models to support providers

Drug treatment and demand reduction

• Improve screening skills of providers

• Drug detox program

• Explore use of buprenorphine in primary care settings

• Link to traditional substance use and mental health services

• Integrate recovery in the treatment model

Harm Reduction

• Naloxone prescription

• Drug user education on overdose prevention and response

Community-based prevention education

• School-based education, including pledge cards

• Red Ribbon campaign - warnings not to share attached to dispensed prescription packages

• Billboard containing message against sharing medications

• Presentations at colleges, community forums, civic organizations, churches, etc.

• Radio and newspaper spots

Treatment

• Regional, primary-care based system of care • Level of care guidelines to determine appropriate level of

treatment

• Team-based

• Linking community services with regional, higher level specialty services

• Basic services provided at the community level with more specialized services provided at a regional level

• Connect local services with more specialized care through technology

Treatment Pyramid

Levels of Care: Community-Level

• Informal community care • Outreach

• Informal support through friends and family

• Basic primary health care services • Screening, brief intervention, and referral to care (SBIRT)

• Continued support to people in treatment/contact with a specialized treatment service.

• Serve as the base for integrated mental health and/or substance use services through use of specialty providers

Levels of Care-Primary Care

• Serve as a telehealth originating site to connect individuals with drug and substance use disorders to specialty services using technology

• Where allowable, providing medication assisted treatment services (e.g., buprenorphine or naltrexone) for individuals with opioid use disorders.

• Basic primary health care services to individuals with drug and substance use disorders

• Team-based care involving SUD, mental health, and community health workers

Examples of Technology in Primary Care

• Project Echo – Connects specialists with local providers • Flexible program

• Local providers receive training, participate in case conferences to improve capacity and receive consultative support

• Telemedicine – direct services provided by specialists from distant settings to patients in their communities • Madison Outreach and Services through Telehealth (MOST)

brings services to 7 remote Texas counties

• Telephone case monitoring for people with SUDs • Better short term outcomes than those not receiving follow up

Team-Based Services in Primary Care

• Using trained village health workers in Inuit villages in rural Alaska, USA

• Providing opioid treatment in a primary care clinic in rural Maine, USA – primary care providers prescribe buprenorphine to control opioid use and conduct group counseling session, substance use counselors are providing services on site under a contract.

Levels of Care: Basic Social Welfare

• Housing/shelter

• Food

• Social support

• Ensuring access to more specialized health and social services as needed

Specialized Care: Local and Regional

• Psychosocial interventions – Can be offered through primary care or in specialized settings • Cognitive-behavioral therapy

• Relapse prevention

• Contingency management

• Motivational interviewing

• Brief interventions

• Family therapy

• Medication assisted treatment • Methadone, buprenorphine, naltrexone, naloxone

• Recovery management services

Levels of Care – Specialty SU Services

• More often available on a regional level – requires coordination and sharing of information, addressing transportation issues • Treatment centers

• Detoxification

• Intensive outpatient

• Partial hospital

• Inpatient (short term)

• Co-occurring (substance use and mental health)

Levels of Care – Others Specialized Services

• Requires coordination/sharing of information

• Infectious disease care (HIV, Hepatitis-CV)

• Physical health services

• Mental Health Services

• Oral health

Recovery

• “Recovery is a process of change through which an individual achieves abstinence and improved health, wellness and quality of life.” SAMHSA

• Four dimensions that define a healthy life in recovery: • Health - Managing one’s disease(s) or symptoms; making

informed choices that support physical/emotional wellbeing

• Home – Having a safe and stable place to live

• Purpose – Participating in meaningful daily activities and having the independence, income ,resources to participate in society

• Community – Engaging in relationships and social networks that provide support, friendship, love, and hope

Recovery – Community Role

• Does community create a supportive environment for recovery? • Stigma reduction – opportunities for a new start

• Employment opportunities

• Educational opportunities

• Social, recreational outlets

• Connection to cultural heritage

• Twelve step programs

• Peer support

Evidence-Based Recovery Models

• Department of Veteran’s Affairs – Peer Recovery • Recruit veterans in recovery to support those going through the

process

• Australian mental health peer support • Goal – avoidance of unnecessary hospitalizations

• Rural women with substance use disorders • Associated with increases in readiness to change and slightly

increased levels of control

• Twelve step programs

Maine Rural Health Research Center Muskie School of Public Service University of Southern Maine PO Box 9300 Portland, ME 04104-9300 John Gale 207-228-8246 jgale@usm.maine.edu

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