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.