strategies to combat opioid use in rural communities · strategies to combat opioid use in rural...

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StrategiestoCombatOpioidUseinRuralCommunities

John Gale,MS,SeniorResearchAssociate

Rural Health Research Gateway WebinarJanuary18,2018

Muskie School of Public Service Maine Rural Health Research Center

AcknowledgementsSupportforthisworkwasprovidedbytheFederalOfficeofRuralHealthPolicywithintheHealthServicesandResourcesAdministration.

ResearchTeam:

Strategiesstudy:JohnGale,AnushHansen,MarthaElbaum

Prevalencestudy:JenniferLenardson,JohnGale,ErikaZiller

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Muskie School of Public Service Maine Rural Health Research Center

TopicstoBeCovered• Keytakeawaymessages• Opioiduseacrossruralsettings•Whatisdifferentaboutruralareas?• Driversofruralopioiduse• Burdenofopioiduseinruralcommunities• Evidence-basedprevention,treatment,andrecoverystrategiestoaddressruralopioiduse

Muskie School of Public Service Maine Rural Health Research Center

KeyTakeAwayMessages• Ittakesavillage- Communityengagementandinvolvementarecentraltoaddressingopioiduse• Opioiduseiscommoninruralareasanddrivenbyacomplexmixofsocioeconomicissues• Ruralareasufferdisproportionatelyfromtheseissues• Travelbarriersandisolationexacerbatetheseproblems• Significantgapsexistinsubstanceuseprevention,treatment,andrecoveryinruralcommunities•Modelsmustbeadaptedtothegeographic,resource,andculturalrealitiesofruralareas

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Muskie School of Public Service Maine Rural Health Research Center

OpioidUse– AComplexProblem• Thegood:‒ Aclassofprescriptionmedicationsprovidingsignificantbenefitstopatientswithacuteseverepain• Thebad:‒ Undueinfluenceofpharmaceuticalcompanies‒ Earlyfailuretoacknowledgetherisksofprescriptionopioids‒ Slowadoptionofevidence-basedprescribingguidelines‒ Growingpatientdemandforopioids• Complications:‒ Directlinkagebetweenprescriptionopioidandheroinuse‒ Multiple,interrelatedpathwaystoopioidaddiction

Muskie School of Public Service Maine Rural Health Research Center

RuralOpioidIssues• Opioiduseistheprimarycauseofunintentionaldrugoverdosedeaths• Severalruralstatesareexperiencingthehighestratesofoverdosedeaths- WV,NM,NH,andKY•Misuseofpainrelieversishigheramongruralyouth,womenwhoarepregnantorexperiencingpartnerviolence,personswithco-occurringdisorders,andfelonyprobationers• Heroinusehasbeguntomigrateawayfromurbancommunitiesandnowmoretypicallyoccursinsmallurbanornon-urbanareas• Prescriptionopioidandheroinusearestronglylinked

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Muskie School of Public Service Maine Rural Health Research Center

Muskie School of Public Service Maine Rural Health Research Center

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Muskie School of Public Service Maine Rural Health Research Center

FactorsAssociatedwithRuralOpioidUse• Controllingfor:residence,age,sex,race/ethnicity,health,education,maritalstatus,employment,healthinsurance&income,ruralpersons:‒ Were20%lesslikelytohavepastyearopioidusethanurban‒ Ages12-19were70%morelikelytouseopioidsthan30-49‒ Under30hadhigheroddsofopioidusethan30andover‒ Whoweremarriedhad40%reducedoddsofusecomparedtoruralpersonswhowerenotmarried

‒ Maleswere30%morelikelythanfemalestouseopioids‒ Inpoorhealth,withlimitededucation,andnohealthinsurancehadhigheroddsofopioiduse

‒ Whowereuninsuredhad58%higheroddsofopioidusecomparedtothosewithprivatecoverage.

Muskie School of Public Service Maine Rural Health Research Center

SocioeconomicDriversofRuralOpioidUse

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Muskie School of Public Service Maine Rural Health Research Center

RoleofRuralPlaceasaDriverofOpioidUse• Ruralplacessufferfromavarietyofhealthandsocio-economicdisparities‒ Greatersenseofstigma‒ Highersenseofisolationandhopelessness‒ Lowereducationrates‒ Higherratesofpoverty‒ Feweropportunitiesforemployment‒ Higherratesofchronicillnesses• Influenceofcultural,ethnic,religiousdifferences

Muskie School of Public Service Maine Rural Health Research Center

RiskFactorsforOU• Familyhistoryofsubstanceabuse• Personalhistoryofsubstanceabuse• Youngage• Historyofcriminalactivityand/orlegalproblems• Regularcontactwithhigh-riskpeopleorenvironments•Mentaldisorders• Risktakingorthrillseekingbehavior.• Heavytobaccouse.• Historyofseveredepressionoranxiety.• Psychosocialstressors.• Priordrugand/oralcoholrehabilitation

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Muskie School of Public Service Maine Rural Health Research Center

InteractionbetweenOpioidUseandRiskFactors• Opioiduseisdrivenbysocioeconomicfactors• Italsocontributestoaself-perpetuatingcyclethatisdifficulttobreak• Individualswithopioidusedisordershavelowerlevelsofacademicachievement,arrestrecords,greaterratesofpoverty,etc.• Intergenerationalsubstanceuse• Intergenerationaltrauma• Stigmaplaysacrucialrole

Muskie School of Public Service Maine Rural Health Research Center

OtherRuralIssues• Longstandingissueinruralcommunities• Non-medicaluseofprescriptionopiatesinruralareas• Heroinasasubstituteforprescriptionopioidsbythosewithouthealthinsurance– Maine•Majorinitiatives– Vermont,Ohio,otherruralstates• Heroinischeap,accessible,andstronger• Limitedtreatment&lawenforcementresources• Substantialvariationsinopioidprescribingrates

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Muskie School of Public Service Maine Rural Health Research Center

PolicyImplications• Despitesocialvulnerabilities,ruralopioidusershaveslightlylowerprevalenceratesthanurbanopioidusers‒ Socialties,support,andotherbuffersmayprotectruralresidentsfromevenhigherprevalencerates

• Preventioneffortshavenoteffectivelyreachedruralresidents– especiallyyoungpeopleandmen– whodonotperceiverisksfromheroinuse• Harmreductionandsyringeexchangeprogramsarealsoimportant,thoughfarlesscommon,inruralareas• Significanteffortstomanageopioidprescribingratesareneeded

Muskie School of Public Service Maine Rural Health Research Center

APublicHealthModelforOU• Systematicdatacollectiononscope,characteristics,andconsequencesofsubstancemisuse• IdentifyriskandprotectivefactorsforOUandfactorsthatcouldbemodifiedthroughinterventions• Collaborativeeffortstoaddresssocial,environmental,oreconomicdriversofOU• Effectivepreventionandtreatmentinterventionsandrecoverysupportsinawiderangeofsettings•MonitortheimpactofinterventionsonOU,relatedproblems,andriskandprotectivefactors• CommunityleadershipthatmobilizescommunityorganizationsandresourcestoaddressOU

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Muskie School of Public Service Maine Rural Health Research Center

CommunityStrategies• Keytoaddressingtheproblematthelocallevel• Importantcomponents‒ Broad-basedsupportandengagement‒ Stigmareduction‒ Prevention‒ Harmreduction– naloxoneandneedleexchanges‒ Engagedlawenforcementthatavoidscriminalizingusers‒ Engagedprovidersusingevidence-basedprescribingguidelinesandofferingmedicationassistedtherapy

‒ Accesstoevidence-basedtreatmentservices,integratedwithmainstreamhealthcare

‒ Peersupportandrecoveryservices

Muskie School of Public Service Maine Rural Health Research Center

EngagingHospitalsandPrimaryCareProviders• Problemsarenotlimitedtoopioiduseonly,butincludemanyotherhealthandsafetyproblems• Hospitals,emergencydepartments,andprimarycarecontributetotheopioidproblemthroughprescribingpractices• Tax-exemptandpubliclyownedhospitalshaveanobligationtoaddressunmetcommunityneeds• Ruralhospitalsandprimarycareproviderscanplayaneffectiveroleinaddressingopioidusebyfillinggapsinspecialtycaresystem• Itprovidesanopportunityforcollaborativeactionbyhospitals,medical,andcommunitystakeholders

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Muskie School of Public Service Maine Rural Health Research Center

BarrierstoTreatmentAccessinRuralAreas

CHAPTER 5. EVIDENCE-BASED DRUG TREATMENT STRATEGIES FOR RURAL SETTINGS 67

Rural substance use disorder treatment services are  less likely to provide more intensive, specialized services or services tailored to the needs of vul-nerable  populations, or those with unique cultural needs.185,186

The development and operation of rural substance use treatment programmes are hindered by numerous challenges including:

¹⁸⁵ Gamm, L.D. “Mental Health and Substance Abuse Services Among Rural Minorities”, The Journal of Rural Health. 2004; 20:206-210.¹⁸⁶ Sung, H.E., Mahoney, A.M. and Mellow, J. “Substance abuse treatment gap among adult parolees: prevalence, correlates, and barriers”,

Criminal Justice Review. 2011; 36:40-57.

• Difficulty recruiting appropriately trained and credentialed clinical staff

• Population densities that are insufficient to support viable services

• Limited access to referral and specialty services • Poor economic conditions, lower rates of health

insurance coverage and financing, and higher rates of poverty that further hamper the ability to develop a self-sustaining practice

FIGURE 5.1 ELEMENTS CONTRIBUTING TO A LOWER LEVEL OF ACCESS TO SUBSTANCE USE TREATMENT SERVICES FOR THE RURAL POPULATIONa, b

FEWER FACILITES

GEOGRAPHIC BARRIERS

LESS ANONYMITY

FEWER TREATMENT

PROFESSIONALS

LIMITED PUBLIC

TRANSPORTATION

LOWER TREATMENT ACCESS IN

RURAL AREAS

STIGMATIZATION AND

CRIMINALIZATION

aOser, C., Leukefeld, C., Tindal,l. M., Garrity, T., Carlson, R., Falck, R., Wang, J., and Booth, B. “Rural drug users: factors associ-ated with substance abuse treatment utilization”, International Journal of Offender Therapy and Comparative Criminology. 20.11;55:567–586.

bSexton, R.L., Carlson, R.G., Leukefeld, C.G., and Booth B.M. “Barriers to formal drug abuse treatment in the rural south: a preliminary ethnographic assessment”, Journal of Psychoactive Drugs. 2008; 40:121–129.

Muskie School of Public Service Maine Rural Health Research Center

BarrierstoOUTreatment• PoorcoverageforMATservices– OTPsarecashonlyservicesinsomestates• Servicesareoftenclusteredaroundurbancenters–requiringlongtraveldistancesforruralresidents•Manybuprenorphineprovidersoperatebelowcapacity•MATservicesarenotenough– substanceuse,mentalhealth,carecoordinationareneeded• Greaterattentionisneededonwhathappensaftertreatment– peersupportandrecoveryservicesareneededtoreducelikelihoodofrelapse

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Muskie School of Public Service Maine Rural Health Research Center

Muskie School of Public Service Maine Rural Health Research Center

ImportantStrategyArea#1- Prevention• Opioidharmsnotrestrictedsolelytothoseusingheroinormisusingprescriptionmedications• Discourage/delayonsetofOU•Minimizerelatedhighriskbehaviors• Focusonchildren,adolescents,andyoungadults• Communityfocusedstrategies‒ Communityorganizingandeducation• Providerfocusedstrategies‒ Reducingsupplyofopioidsprescribed‒ Useofprescriptiondrugmonitoringprograms‒ Offeralternativepain-managementstrategies‒ Provideopportunitiestodisposeofunneededmedications

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Muskie School of Public Service Maine Rural Health Research Center

Prevention• Aprimarycomponentofahealth-centeredsystemtoaddressOUuse• Evidence-based(EB)preventionprogramseffectivelypreventinitiation,harmfuluse,andrelatedproblems• Preventioniscost-effectiveatdifferentstagesoflife•Mustbeadaptedtotheuniquecontextofeachcommunitywithfidelitytotheinterventiononwhichtheevidenceisbased• Communitiesareanorganizingforcetobringeffectivepreventionprogramstoscale• Key:Crosssectorcommunitycoalitionstoassesslocalriskandprotectivefactors,OUproblems,andimplementinterventionstomatchlocalpriorities

Muskie School of Public Service Maine Rural Health Research Center

ActivitiestoEngageCommunities• CommunityOrganizationandEngagement• Prescribereducationandbehavior• Supplyreductionanddiversioncontrol• Painpatientservicesanddrugsafety• Drugtreatmentanddemandreduction• Harmreduction• Community-basedpreventioneducation

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Muskie School of Public Service Maine Rural Health Research Center

Keyelementsofeffectivecommunitycoalitions• Understandingthecommunity’sneedsandresources•Widelysharedandcomprehensivevision• Clearandfocusedstrategicplan• Diversemembership:keycommunityleaders,localgovernmentofficials,andvolunteers• Strongleadershipandcommittedpartners• Diversifiedfunding•Well-managedstructure:organizedadministration,effectivecommunicationamongparticipants,andacomprehensiveevaluationplan

Muskie School of Public Service Maine Rural Health Research Center

Evidence-basedcommunityorganizingmodels• ProjectLazarus-‒ InallNorthCarolinaCounties‒ Inruralcommunitiesacrossthecountry- ProjectBaldEagle,Williamsport,PA.WinnebagoCountyHeroinTaskForceinWisconsin,ClarkCountyCollaborativeinOhio,andWashtenawHealthInitiativeOpioidProjectinMichigan

• ProjectVision,Rutland,VT‒ UsesaDrugMarketInterventionmodelandcommunitycollaboration/engagementtoreducethesupplyofopioids

• SAMHSA’SRecoveryOrientedSystemsofCare• CommunitiesThatCare

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Muskie School of Public Service Maine Rural Health Research Center

ProjectLazarus– HubActivities• Hubactivitiesarecentralcomponentssupportingallotheractivitiesandreflectacommunity-based,bottom-uppublichealthapproach‒ Buildpublicawarenessofsubstanceusethroughbroad-basededucationaleffortsandtheuseoflocaldatatodriveawareness

‒ Coalitionbuildingandactiontoengageabroadrangeofcommunityproviders,agencies,andorganizations

‒ Identifydataneedsforplanningandevaluationtobuildawareness,tailorprogramstolocalneeds,trackprogress,andsustainsupportandfunding

Muskie School of Public Service Maine Rural Health Research Center

ProjectLazarus– SpokeActivities• Spokeactivitiesareoptionalareasofevidence-basedpreventioninitiativesthatcommunitiescanselectandreflectamedicalandlawenforcement-based,top-downpublichealthapproach₋ Communityeducation₋ Providereducation₋ Hospitalemergencydepartmentpolicies₋ Diversioncontrol₋ Painpatientsupport₋ Addressingtheconsequencesofuse₋ Addictiontreatment

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Muskie School of Public Service Maine Rural Health Research Center

ProjectVision– AddressingSupplyIssues• ProjectVision,Rutland,VT‒ Goals:empowercommunities,strengthenneighborhoods,helppeople,changethefuture

‒ Committees:Crime/Safety,SubstanceAbuse,Community/Neighborhoods/Housing

‒ UseaDrugMarketInterventionmodelandcommunitycollaboration/engagementtoreducethesupplyofopioids(heroinandillicitlydistributedprescriptionopioids)inruralRutlandVT

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Muskie School of Public Service Maine Rural Health Research Center

PrescriberEducationandBehaviour• One-on-oneprescribereducationonpainmanagement• Continuingmedicaleducationonpainmanagement• Licensingactionsagainstcriminalprescribing• Implementandmonitorevidence-basedprescribingguidelinesamongallproviders‒ CDCguidelines,stateprogramssuchasWashingtonstate• Strongly encourageuseofprescriptiondrugmonitoringprograms• Thinkaboutan“oxyfree”emergencydepartment• HarmReduction- NaloxoneandOpioidusereducationonoverdosepreventionandresponse

Muskie School of Public Service Maine Rural Health Research Center

HospitalPreventionStrategies• Participateincommunity-basedpreventionprogramsaspartofhospital’scommunitybenefitand/orcommunity/populationhealthinitiatives• Qualityimprovement:Focusonsupplyreduction‒ Prescribingguidelines‒ Encouragegreateruseofprescriptiondrugmonitoringprograms

‒ UseProjectECHOtosupportprescribingandpainmanagementcapacityoflocalproviders

‒ Implementan“oxy-free”emergencydepartment‒ Engageinharmreductionstrategies

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Muskie School of Public Service Maine Rural Health Research Center

MidcoastMainePrescriptionOpioidReductionProgram

• ImplementedopioidprescribingguidelinesfordentalpainintworuralEDsinMaine

• DrivenbyEDchairmanwithinputfromphysiciangroup• EDpatientswhorequestrefillsofcontrolledprescriptions,havemultiplecontrolledsubstanceprescriptions,orhavemultiplepreviousEDvisitsforpainfulconditions

• Guidelinesrecommendtheuseofanalgesicalternativessuchasnerveblocksandimmobilization

• Resultsafter12months- reductionsinratesofopioidprescriptionsandvisitsfordentalpain

Muskie School of Public Service Maine Rural Health Research Center

Oxy-FreeEmergencyDepartments(EDs)• EDsareasignificantsourceofopioidprescriptionsandafrequenttargetforthoseseekingopioids• EDprescribingdevelopedbytheWashingtonStateDepartmentofHealth,theWACollegeofEmergencyPhysiciansandtheWAHospitalAssociation• IncludedlimitationsontheprescriptionofopioidsinEDsandtheconceptofan“oxy-freezone”• LowerratesofEDvisitsby“frequentusers”withlowacuitydiagnosesseekingopioids• WAMedicaidestimated$33.6millioninEDsavings• Hospitalsarepleasedwiththestrategybutsomeexperiencedearlyreductionsinpatientsatisfactionscoresrelatedtopainmanagement

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Muskie School of Public Service Maine Rural Health Research Center

“Oxy-Free”EDs–McKenzieHealthSystem

• InFebruary2013,McKenzieHealthSystem'sEDdiscontinueddispensingnarcoticandsedativemedicationsforcomplaintsofchronicpain

• Results– 60%reductioninopioidprescriptionabusewithina12monthperiodandreducedutilizationofunnecessaryandcostlydiagnosticwork-ups

• Staffmetwithcommunitymentalhealthofficials,countyhealthofficials,localprimarycareproviders,lawenforcement,pharmaciestoexplaintheinitiative

• Engagedinpatienteducation

Muskie School of Public Service Maine Rural Health Research Center

“Oxy-Free”EDs–McKenzieHealthSystem(con’t)• Process:

– Thoroughmedicalexamtoruleoutmedicalemergencies– Reviewofpatient'scompletefile,includinginternalhealthrecords,outsidehealthrecords,drugscreeningtests

– Ifpatientpresentswithachronicpainconditionorsuspectednarcoticsabuses,physicianwillinformpatientofthedangersofnarcoticdrugabuseandmaynotprescribeanarcoticpainmedication

– Mayreceiveanon-narcoticpainmedicationandinformationaboutO/SUprogramsand/orpainmanagementspecialists

– Ifanarcoticpainmedicationisprescribedaftercarefulreviewbythephysician,itisonlyforaverylimitedamountofpills,untilthepatientcanbeseenbyhisorherphysician

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Muskie School of Public Service Maine Rural Health Research Center

ReducingOpioidPrescribingbyProvidingPainManagementServices

• Duetothelimitedavailabilityofpainmanagementservicesinruralcommunities,manyprovidersrelyonprescriptionopioidsasaprimarytreatmentmodality

• Ruralprimarycareprovidersoftenhavelimitedexperiencewiththemanagementofchronicpain

• Strategies– Expandaccesstopainmanagementservicesthroughcontractsand/ortelehealth

– ImprovethecapacityoflocalproviderstomanagepainthroughuseofprogramsuchasProjectECHO

Muskie School of Public Service Maine Rural Health Research Center

ExpandingLocalPainManagementServices:SalemTownshipHospital

• SalemTownshiprecruitedapainspecialisttotravelanhourfromMarion,Ill.,twiceamonthtotreatpatients.– Consideringexpansiontothreetofourtimesamonth.

• Patientsareseeninonehourincrements• Providestrigger-pointinjectionsforlong-termpainandpromotesphysicaltherapyandalternativetreatments

• Patientscontinuingwithopioidsmustagreetoregulardrugtestsandnotaskforearlyrefills

• Over3to4months,only3outof56patientshavechosentostickwithopioids

• Minimalinvestment- $25,000forcapitalequipment

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Muskie School of Public Service Maine Rural Health Research Center

Telehealth-BasedPainManagementProgram:Martha’sVineyardHospital(MVH)

• DuetoitsislandlocationoffCapeCod,MVHworkedwithMassachusettsGeneralHospital’sCenterforPainManagementtoofferapainserviceviatelehealth

• MGHprovidersseepatientsinatelepainclinic3dayspermonthandconducton-sitevisitstwicepermonth

• Servicesincludeinitialconsultsandfollow-upvisits• Vitalsigns/patientsnotesarerecordedinasharedEHR• AnRN,trainedinphysicalexaminationofpainandmedicalmanagement,performspatientexamsunderdirectphysiciansupervisionvialivevideoconferenceandalsoverballyannouncedallfindings

Muskie School of Public Service Maine Rural Health Research Center

Telehealth-BasedPainManagementProgram:Martha’sVineyardHospital(con’t)

• Physicalexaminationsarerepeatedbythephysicianduringon-sitevisitspriortopatientintervention

• LaboratorydataandimagingstudiesarereviewedinthesharedHER

• Over13months,49patientsparticipatedin238telepainvideoclinicsand121on-siteinterventions

• Patientsreportreducedtravelcosts,improvedaccesstocare,andgeneralsatisfactionwiththeservice

• Patientsratedtheirsatisfactionwithcarereceivedbytelepainlowerthanin-personvisitsandthoughtithardertodeveloparelationshipwiththedoctor

• Thishighlightsthechallengeofbuildingapatient-physicianrelationshipremotely

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Muskie School of Public Service Maine Rural Health Research Center

Muskie School of Public Service Maine Rural Health Research Center

ImportantStrategyArea#2- Treatment• ImplementconsistentOUscreeningforallpatients• DevelopreferralrelationshipswithSU/MHproviders• Explorelocaltreatmentopportunities‒ Medicationassistedtreatment– buprenorphine‒ Integratedbehavioralhealth/SU/primarycareservices‒ Specialtysubstanceuseservices• Collaborativetreatmentprograms– hubandspoke• Exploreuseoftechnologytoexpandaccesstocare• Overdosereversalprograms• Alternativepainmanagementprograms•Workwithlawenforcementtoprovideatreatmentalternativetoincarceration

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Muskie School of Public Service Maine Rural Health Research Center

ProviderStrategiesandTreatmentServices• Ruralresidentsdeservethesamelevelofaccesstothefullrangeofsubstanceusetreatmentservicesasurbanresidents• Substanceuseisachronic,relapsingdisease‒ Requiresongoinglevelofservices‒ Reflectsaprimarycare-basedsystemofcareframework‒ Conservesresourcesbymatchingservicestopatientneedsusingalevelofcarecriteria

‒ Professionally-directed,post-dischargecarecanenhancerecovery,butrelativelyfewreceivesuchcare

‒ Distancetoservicesiscorrelatedwithtreatmentcompletion(longertraveldistancesareassociatedwithlowerratesofcompletion)

DefinitionofaSystemofCare

• Anintegratedspectrumofeffective,community-basedservicesandsupportsforruralpeopleandtheirfamiliesatriskfororstrugglingwithOUchallenges‒ Organizedintoacoordinatednetwork‒ Buildsmeaningfulpartnershipswithindividualsandtheirfamilies‒ Addressestheirculturalandlinguisticneeds,tohelpthemfunctionbetterathome,inschool,inthecommunity,andthroughoutlife.

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StructureofTreatmentServices• Useofaregionalorientation/model• Reflectstherealitiesofruralresourcelimitations‒ Usestechnology(e.g.,telehealth,mobilephones,etc.)toaddressdistancebarriersandmaldistributionofresourcesacrossurbanandruralareas

• Integrationacrossservicessystems:‒ Substanceuse,‒ Mentalhealth,and‒ Primarycare

PrincipalsforTreatment• Treatmentmustbeavailable,accessible,attractive,andappropriateforneeds

• Ethicalstandardsmustbeobserved• Requireseffectivecoordinationbetweenthecriminaljusticesystemandhealthandsocialservices

• OUDsshouldbeviewedasahealthproblemratherthancriminalbehavior:usersshouldbetreatedinthehealthcareratherthanthecriminaljusticesystemwhenpossible

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PrincipalsforTreatment(cont’d)• Basedonscientificevidenceandrespondtospecificneedsofindividualswithouds

• Shouldrespondtotheneedsofspecialsubgroupsandconditions

• ShouldensuregoodclinicalgovernanceoftreatmentservicesandprogramsforOUDs

• Integratedtreatmentpolicies,services,procedures,approachesandlinkagesmustbeconstantlymonitoredandevaluated

OpioidScreeningTools

• Canbeusedacrossdifferenthealthcaresettings‒ ScreenerandOpioidAssessmentforPatientsinPainRevised(SOAPP-R)

‒ CurrentOpioidMisuseMeasure(COMM)‒ OpioidRiskTool(ORT)‒ Diagnosis,Intractability,Risk,andEfficacy(DIRE)‒ ScreeningInstrumentforSubstanceAbusePotential(SISAP)‒ (vi)ThePainAssessmentandDocumentationTool(PADT)

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BridgtonHospitalBuprenorphineClinic• CoordinatedeffortsbetweenBridgtonHospital,NorthBridgtonFamilyPractice,CrookedRiverCounseling

‒ Programhasenrolled200patientsinaruralMainecommunity‒ Startedin2009‒ Fourphysiciansandtwonursepractitionersprescribebuprenorphineintheirprimarycarepractice(NorthBridgton)

‒ CrookedRiverCounselingprovidesintensiveoutpatientcounselingandgrouptherapyforthepatients

‒ BridgtonHospitalprovidescomprehensivematernitycaretowomenwithOUDduringtheirpregnancy

‒ Servicesareinterconnectedandcoordinatedacrossproviders‒ Keyisthecollaborativeapproachandcommunication

BridgtonHospitalBuprenorphineClinic• Benefits‒ Lowerregulatory/licensurebarriersthanmethadoneprograms‒ SAMHSAprescribingwaiveriscomparativelyeasytoobtain‒ Canbeintegratedintoprimarycaresystem‒ Goldstandardoftreatmentforopioids

• Challenges‒ Buprenorphinealoneisnotsufficienttomeetallpatientneeds‒ Canbedifficulttoincorporateintoabusypracticewithoutadditionalsupport

‒ Linkageswithbiggersystemsofcareareneeded

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Muskie School of Public Service Maine Rural Health Research Center

SupportingMATandOUDServices- Vermont• Vermont’sHubandSpokemodelsupportstheuseofbuprenorphinebyprimarycareandcommunityproviders₋ Comprehensivecaremanagement₋ Carecoordinationandreferraltolocalresources₋ Caretransitions₋ Individualandfamilysupports₋ Healthpromotion₋ Expandsuseofbuprenorphineinprimarycare₋ Recognizesimportanceofmentalhealthandtraditionalsubstanceuseservicesintreatingopioidproblems

₋ Efficientuseofscarceresources₋ Providescareinlessstigmatizingsettings

Muskie School of Public Service Maine Rural Health Research Center

VermontHubandSpoke(cont’d)• Regionalspecialtytreatmentcentersserveasthehubs₋ CoordinatecareofindividualswithcomplexOUDsandco-occurringSUandMHdisorders

₋ ProvidefullrangeofOUDcareandsupportcommunityprovidersbyprovidingconsultativesupporttoprimarycareandotherprovidersprescribingbuprenorphine

• Physiciansprescribingbuprenorphineandcollaboratinghealthandaddictionsprofessionalsserveasthespokes₋ Dispensebuprenorphine,monitoradherencetotreatment,coordinateaccesstorecoverysupports,andprovidecounseling,contingencymgt,andcasemgtservices

• FundedthroughMedicaidwaiver

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Muskie School of Public Service Maine Rural Health Research Center

Muskie School of Public Service Maine Rural Health Research Center

ImportantStrategyArea#3- Recovery• ThethirdandoftenoverlookedstrategytoaddressOUdisorders• Providesupportthroughprogramsorastructuredmilieutosupportsobrietyandsubstancefreeliving• Ideally,recoverybeginsbeforetreatment• Addressessocial,rehabilitation,andvocationalissues• Providesacommunitytoreinforcesobriety

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Muskie School of Public Service Maine Rural Health Research Center

Recovery• “Recoveryisaprocessofchangethroughwhichanindividualachievesabstinenceandimprovedhealth,wellnessandqualityoflife.”SAMHSA• Fourdimensionsthatdefineahealthylifeinrecovery:‒ Health- Managingone’sdisease(s)orsymptoms;makinginformedchoicesthatsupportphysical/emotionalwellbeing

‒ Home– Havingasafeandstableplacetolive‒ Purpose– Participatinginmeaningfuldailyactivitiesandhavingtheindependence,income,resourcestoparticipateinsociety

‒ Community– Engaginginrelationshipsandsocialnetworksthatprovidesupport,friendship,love,andhope

• Hospitalscancoordinatewithlocalrecoveryprograms

Muskie School of Public Service Maine Rural Health Research Center

Recovery– CommunityPrograms• Doescommunitycreateasupportiveenvironmentforrecovery?‒ Stigmareduction– opportunitiesforanewstart‒ Employmentopportunities‒ Educationalopportunities‒ Social,recreationaloutlets‒ Connectiontoculturalheritage‒ Twelvestepprograms‒ Peersupport

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Muskie School of Public Service Maine Rural Health Research Center

Evidence-BasedRecoveryPrograms• DepartmentofVeteran’sAffairs– PeerRecovery‒ Recruitveteransinrecoverytosupportthosegoingthroughtheprocess

• Australianmentalhealthpeersupport‒ Goal– avoidanceofunnecessaryhospitalizations

• TurningPointCenter,Rutland,VT‒ PartoftheVermontRecoveryNetwork

• SupportingPeerRecovery:TheRECOVERProject,FranklinCounty,MA

• ProjectAngels,Gloucester,MA‒ Providestreatmentasanalternativetoincarceration

Muskie School of Public Service Maine Rural Health Research Center

ChallengestoDevelopingRuralPrograms• Programs“imported”fromoutsidethelocalareaareoftenviewedwithsuspicion• Community-basedprogramsareimportanttocreatelocallydeveloped,culturallyappropriateinterventions‒ Mustbesensitivetolocalcultural,religions,andethnicissues(culturalhumility)andengagelocalleaders

‒ Limitedopportunitiesaftertreatment,stigma,restrictedsocialsupportsfrequentlyleadstorelapse– mustsupportsoberliving

• Continuumofprevention,treatment,andrecoveryservicesmustbedevelopedsimultaneouslytoaddresstheneedsofruralresidents“wheretheyare”

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Muskie School of Public Service Maine Rural Health Research Center

Recommendations• TheCommunityiskey!!• Supportthedevelopmentandimplementationofcommunitycoalitions- ProjectLazarusorProjectVision• Engageproviders,businesses,schools,residents,lawenforcement• Conductbroad-basededucationonthedangersofopioids• Buildalocalsystemofcarethatintegratesprevention,treatment,andrecoveryandengagesmentalhealth,andsubstanceuseproviders

Muskie School of Public Service Maine Rural Health Research Center

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Muskie School of Public Service Maine Rural Health Research Center

ContactInformationJohnA,Gale,MSSeniorResearchAssociateMaineRuralHealthResearchCenterMuskieSchoolofPublicServiceUniversityofSouthernMainePOBox9300Portland,ME04104-9300

John.gale@maine.edu207.228.8246