Building a lifeline for rural addicts

Melissa Kinnaman can only imagine the life she might have led if Suboxone had been an option long ago.

In her hometown of rural Sterling, Colo., however, no doctors were qualified to prescribe the medication until two years ago, even though the Food and Drug Administration in 2002 approved buprenorphine for clinical use. (Suboxone is made with buprenorphine and naloxone, another medication used to treat opioid addicts.) Combined with counseling and behavioral therapy, the medication is a powerful weapon against opioid addiction.

Kinnaman's addiction began around the year 2000 when she spent six months on Percocet, prescribed when doctors were unable to diagnose her mysterious pains. It later turned out she needed gallbladder surgery. By the time doctors arrived at the proper diagnosis, “I was eating them,” Kinnaman said of the painkillers.

For the next 14 years, she rode the roller coaster of drug abuse, selling meth or draining her mother's bank account to fuel her habit. She served several stints in prison and jail and several unsuccessful months in rehab, Kinnaman said.

In 2014, she learned that a local doctor had gained federal clearance to prescribe buprenorphine. She lost no time in seeing him and getting the 4-milligram strips she now tucks beneath her tongue three times a day.

“I felt normal, finally, for the first time,” Kinnaman, 45, said. “Suboxone saved my life.”

Cities and towns all over the U.S. are reeling from the opioid addiction epidemic, which has emerged as a major issue on this year's campaign trail. From 1999 to 2014, more than 165,000 people died from overdoses related to prescription opioids, including more than 14,000 in 2014. Today, at least half of opioid overdose deaths involve prescription opioids, which nearly 2 million Americans abused or depended on in 2014.

A source of hope for saving lives in this ongoing crisis is medication-assisted treatment, or MAT, the combination of buprenorphine and counseling that federal officials increasingly support. The administration recently raised the maximum number of patients that qualified practitioners can treat with buprenorphine from 100 to 275, while the military healthcare program expanded MAT coverage for substance-use disorders.

But in parts of rural America, where the epidemic has struck especially hard, MAT is rarely an option. Practitioners with the expertise and qualifications to help those with addiction are few and far between. And in most small towns, there remains a stigma against confronting the mental health issues that frequently accompany addiction.

“Medication-assisted treatment is fairly new for rural primary-care practices, nationally and certainly in eastern Colorado,” said Dr. Jack Westfall, a family doctor who teaches at the University of Colorado and will lead a three-year project to expand MAT in rural parts of the state. “We're all learning how best to approach this crisis. We don't have all the answers.”

In rural America, “There are shortages in general, in terms of healthcare professionals,” said Susan Heil, a principal researcher at the American Institutes for Research. The Washington, D.C.-based not-for-profit corporation, whose mission is conducting and applying behavioral and social science research, is leading a similar three-year project to expand access to MAT in rural Oklahoma.

Providers who can treat addiction, never mind offer medication-assisted treatment, are even scarcer. “It's a knowledge issue, a training issue,” Heil said. Screening patients for addiction and knowing appropriate levels of care are just the beginning; to prescribe buprenorphine, providers must apply for a waiver from the federal government, a process that requires eight hours of training.

About 3% of primary-care physicians in the U.S. have buprenorphine waivers. Not even half of U.S. counties—1,465 out of 3,143—have a physician who can prescribe the medication, according to an analysis published in the Annals of Family Medicine in 2015. This leaves 30 million Americans, 21.2 million of them in rural areas, living in counties without a physician who can legally prescribe buprenorphine.

To fill in these gaps, the federal Agency for Healthcare Research and Quality is putting $9 million over three years into three initiatives—including Heil's and Westfall's, plus another in Pennsylvania—which are launching this month or already underway. Although the target is to bring MAT to 20,000 people in their specific regions, the broader hope is that their experiences will hone strategies other states can adopt and adapt to make MAT more accessible.

“They are being asked to pretty aggressively share the impact of their solutions,” said Dr. Andy Bindman, AHRQ's director. “We thought that there were some significant barriers in that (rural) context that could be addressed by different possible strategies.”

Bindman, Heil and Westfall are keenly aware of these barriers, but they are hopeful, too. “That'll be part of our documentation of this whole effort: What exactly were the supports and challenges?” Heil said. “Some of the regions will face different challenges than others. It's coming up with ways to adapt the model to the local setting in a way that ensures successful intervention.”

Heil's project, eventually spanning 28 counties in northeast, north central and south central Oklahoma, also involves the state of Oklahoma; the University of New Mexico's remote consultation and telehealth program, Project ECHO; and consultants from the American Society of Addiction Medicine. The multifaceted approach includes training providers on topics such as addiction medicine fundamentals and buprenorphine certification. Through Project ECHO, providers can get support on tough cases by using remote consultations with other physicians and addiction experts.

Although telehealth will alleviate logistical burdens for doctors, it doesn't necessarily remove them for patients.

Oklahoma has 10 community-based addiction recovery centers, a map from its Mental Health and Substance Abuse Services Department shows. Three are clustered in Tulsa and two in Oklahoma City, with two more on its outskirts. Three more are in the southwest region, leaving the state's southeastern and northwestern sections bare of clinics.

“We may find that folks have to go a longer distance or go to an urban area,” Heil said. But, she added, collecting this information will help the state identify where more centers and treatment services are needed.

Besides physical distance, in rural Colorado—where attitudes about mental illness tend to be unforgiving—the stigma prevents people from asking for help or giving it.

“I've seen many, many times, people park two, three blocks away and walk up the alley to the back door of the mental health center, so that no one knows they're seeing a counselor,” said Westfall, who practices part time in eastern rural Colorado. Addiction and substance abuse are viewed as an individual's fault. To overcome them, the prevailing attitude is, “You pull yourself up by your bootstraps,” said Westfall, who is director of the High Plains Research Network, a community-academic partnership.

Softening that attitude—and its repercussions for treating opioid addiction—is one goal of the Colorado project. It will use “boot camp translation,” a process developed by the High Plains Research Network's Community Advisory Council, which takes medical jargon and turns it into relevant, everyday language. The program educates local community leaders and providers to foster medically accurate conversations about addiction that are comprehensible for average people, too.

“We want to de-mystify it, de-stigmatize it, provide the community with an understanding that it's common and that there's treatment, to try to pull people out of the shadows,” Westfall said.

Other challenges permeate clinical settings, where the complexities of treating opioid addiction can prove overwhelming without a team. A doctor might be legally able to prescribe buprenorphine, but do employees at the front desk know what to do when a patient arrives in withdrawal?

Using telemedicine through Project ECHO and in-person training conducted by teams from the High Plains Research Network, the Colorado project will also train entire medical practices—nurses, physician assistants, administrators—to manage opioid addiction and medication-assisted treatment. The goal is to reach 40 out of roughly 75 practices in 23 counties in eastern and south central Colorado.

Ideally, that approach will “lead to the long-term sustainability of medication-assisted treatment and management of patients with opioid use disorder,” Westfall said.

It worked for Kinnaman, for whom Suboxone staved off the demons of addiction. Her experience offers a glimpse into the promise and possibilities of medication-assisted treatment in rural areas.

“The monkey's off my back,” Kinnaman said. “I'm excited to get on with my life.”