If a person experiences an opioid overdose in rural Maine, it can take up to 30 minutes for emergency medical responders to arrive—and that may be too late. That's why MaineGeneral Medical Center in Augusta works to identify individuals at risk of an overdose and provide them with the opioid antidote and information that might keep them alive if it occurs.
The strategy, designed to keep addicted individuals alive until America's opioid epidemic subsides, is one of hundreds developed by rural healthcare providers to address the specific needs of their communities.
MaineGeneral serves two rural counties with a combined population of about 175,000; Kennebec County saw 43 opioid deaths in 2017, and Somerset County had 16 during that time. Health educator Shane Gallagher works at MaineGeneral giving overdose-prevention classes at homeless shelters and addiction-recovery centers and serving high-risk individuals through a needle-exchange program, referrals for treatment, HIV and hepatitis C testing and other services.
“Both within my department but also other departments across the system—primary care, emergency rooms, specialties—we're all actively participating in various initiatives that are local and regional and at the state level,” Gallagher said.
Urban populations have higher rates of opioid abuse in the past 12 months than rural communities, but more rural people die as a result of opioid-induced overdose. The reasons are many—among them an inadequate supply of emergency naloxone devices, longer response times of first responders and a lack of substance-abuse treatment options in rural communities.
Cultural factors may also be at play. Rural opioid users are more likely to be uninsured and to have limited education, low income and poor health status, factors that may affect their ability to seek treatment and maintain recovery.
In Maury County, Tenn. (population 81,000), 15 people died of opioid overdoses in 2016, up from nine in 2015 and just one in 2014. Heroin-overdose deaths didn't show up there until 2016, when two occurred. Earlier this year, three people died from heroin in one day.
“That was a difficult 24 hours for us,” said Dr. Christopher Edwards, chief medical officer at Maury General Health, a three-hospital system based in Columbia, Tenn.
Despite the disturbing trend, Edwards finds hope in systemic efforts to address the root causes of the opioid crisis. He serves on the Commission on Pain and Addiction Medicine Education, which is part of Tennessee's statewide multipronged plan to tackle the opioid epidemic. The commission is developing curricula for medical and nursing schools so students learn the proper use of opioids, he said.
The statewide plan also calls for educating current healthcare providers. Although opioid prescription rates have dropped by about 25% in Tennessee in the past five years, it ranks among the highest-prescribing states in the nation. “We've all been brought up prescribing opioids, and we were taught years ago that the long-acting opioids were not addictive,” Edwards said. “Now we're having to unteach those things.”
Part of the education is that “opioid naive” patients can become addicted with the first dose; another part is that alternatives to opioids can actually treat pain more effectively. “I'm very encouraged that (opioids) won't be introduced as much to the post-operative patients, dental-pain patients and obstetrical patients,” Edwards said.
Maury General Medical Center and MaineGeneral both received federal grants in 2015 to foster a community approach to address the opioid crisis. An evaluation of the Rural Opioid Overdose Reversal Grant program found that developing a partnership among various stakeholders is essential but not necessarily easy. Often, law enforcement agencies, first responders and advocacy organizations have no experience in collaborating with healthcare providers.
“A major piece (of the grant-funded work) was to get the conversation started on a broader level,” Gallagher said.
