Lessons About Treating Opioid Use Disorder in Remote Areas

The most sparsely populated regions of the American West often are unable to provide local treatment for opioid use disorder. Long driving distances can be a barrier for people who need treatment, so the issue has ramifications for the health and wellness of many residents across the most rural areas of the country.

A team of researchers from Penn State and JG Research and Evaluation recently examined the effectiveness of a successful model for rural treatment of opioid use disorder in Montana, one of the nation’s most sparsely populated states.

Opioids are highly addictive, and opioid use disorder is difficult to treat. Fortunately, many people who experience opioid use disorder can reach recovery. Most treatment programs, however, are very intensive and require specialized care, highly regulated medication, and daily or weekly clinical visits. Because of this intensive specialization, people in rural areas who experience opioid use disorder often lack access to local treatment.

To address the lack of services for people with opioid use disorder in rural areas, researchers and clinicians in Vermont developed a model of care for opioid treatment. People with opioid use disorders from remote areas are stabilized at addiction care facilities in more populous areas and then receive ongoing care at rural primary care clinics that have established partnerships with these addiction care facilities. Based on this model’s success in Vermont, it has been deployed in many rural areas across the nation.

Danielle Rhubart, assistant professor of biobehavioral health at Penn State, co-authored an article in the journal Substance Abuse: Research and Treatment that evaluated the application of the Vermont model in Montana.

“There are people in Montana who have to drive 100 or even 200 miles one way to reach a physician who can prescribe medical treatments for opioid use disorder,” Rhubart explained. “This is fundamentally very different from Vermont, which is only about 80 miles wide. The model that is used in Vermont has been very successful, and a lot of good science has validated it. We needed to know, however, whether what worked in Vermont was applicable in a state as remote as Montana.”

The researchers found that the Vermont model was not successfully adopted in Montana. Addiction care facilities in Montana were often unsuccessful at forming partnerships with rural primary care offices. The rural providers who were interviewed for this research were concerned about a variety of interrelated issues.

Geographic concerns were one of the reasons that primary care physicians were reluctant to enter into addiction-care partnerships. The total area of Montana is nearly 150,000 square miles, while the area of Vermont is less than 10,000 square miles. Though Montana is home to more people, there are between nine and 10 times as many people per square mile in Vermont as there are in Montana. Prior research has shown that there are important differences between rural areas that are adjacent to urban areas compared with rural areas that are distant from urban areas. People in more remote rural areas, like most of Montana, are much less likely to have access to a variety of services. Physicians were concerned that the lack of trained staff who lived in their area would make implementing the program impractical.

The lack of available staff was cited by some rural primary care physicians as a reason not to participate in opioid use disorder treatment programs. According to the researchers, behavioral health services are more widely available in Vermont than in rural Montana. This lack of medical staff and support services led many rural health care providers in Montana to believe that they would be unable to recruit and retain staff to run an opioid use disorder treatment program.

Some rural providers in Montana reported that they did not want to participate in treatment because they were concerned that the demand would overwhelm their capacity to provide high quality care. Primary care facilities in some of the most rural and remote portions of the state cited the lack of available behavioral health staff in the area as a reason to suspect that, if they started an opioid use disorder program, they would not be able to address their patients’ needs.

In addition, there is a stigma associated with treating people with opioid use disorder in some rural areas, and some physicians expressed fear that they would lose patients if they prescribed these medications.

“The differences between Vermont and Montana go beyond population density,” Rhubart explained. “Cultures differ too. In our study, we found that some rural physicians’ offices in Montana preferred an informal relationship with addiction-treatment facilities to a formal partnership. Rural providers welcomed technical assistance, but were hesitant to formalize long-term partnerships.

One of the most significant barriers to treating opioid use disorder in rural areas is the special license required for prescribing the appropriate medication. There is concern that the medication could be abused as a street drug, so it is highly regulated. In addition, physicians expressed concerns that the Vermont model would not be financially viable for their practices.

This research shows that for treatment of opioid use disorder — and other health issues — there is no one-size-fits-all solution for rural areas.

“When states develop treatment models for opioid use disorder, public health officials must account for local variations in culture, stigma, and access to resources so that rural physicians are not overwhelmed by the prospect of treating people in need,” Rhubart explained. “Program and partnership buy-in from physicians requires attention to the geographic, economic, and cultural norms of a community. These factors are essential for developing care models that effectively support those with opioid use disorder.”

New Policy Brief on Effects of System Affiliation on Rural Hospitals

The Flex Monitoring Team has released a new policy brief, The Association Between System Affiliation and Financial Performance in Critical Access Hospitals.

There is growing evidence to suggest that affiliation with a health system may have important implications for rural hospitals. However, most studies have not investigated the effects of system affiliation on CAHs, specifically, and it is important for hospitals and state Flex programs to anticipate the consequences and potential impact of system affiliation.

The purpose of this study is to examine the association between system affiliation and the financial indicators included in the Critical Access Hospital Measurement and Performance Assessment System (CAHMPAS).

A Call to Action: Address Oral Health for Low-Income Populations

A new commentary in JAMA Network Open underscores the importance of strengthening Medicaid benefits to include dental coverage. In the commentary, authors Tamanna Tiwari, MPH, MDS, BDS, and CareQuest Institute’s Julie Franstve-Hawley, PhD, CAE, write that “it is imperative to have a concerted call to action for federal policy that mandates comprehensive, nationwide adult dental benefits as a permanent part of Medicaid.”

Read the article.

HHS Study Finds COVID-19 Vaccine Linked to Saving Lives for Older Americans

A new report from the U.S. Department of Health and Human Services (HHS) shows that COVID-19 vaccinations may have helped prevent hundreds of thousands of new COVID-19 infections and tens of thousands of deaths among seniors. The study shows that COVID-19 vaccinations were linked to a reduction of approximately 265,000 COVID-19 infections, 107,000 hospitalizations, and 39,000 deaths among Medicare beneficiaries between January and May 2021.

The report reaffirms the importance of COVID-19 vaccinations in saving lives and controlling the pandemic. People 65 years and older are at a higher risk of becoming severely ill or death from COVID-19, which is why it’s so important to be vaccinated.

Learn more about the COVID-19 vaccine and if you have not yet been vaccinated remember it is free and you can find a place near you by visiting vaccines.gov

To read more about the report here.

CMS recognizes that more than 57 million Americans live in rural areas, and face several unique challenges.  And those challenges can differ dramatically among the different kinds of rural areas across the country.  Rural residents tend to be older and in poorer health than their urban counterparts, and rural communities often face challenges with access to care, financial viability, and the important link between health care and economic development.

Pennsylvania Hospital Association Releases Hospital Economic Analysis, Interactive Dashboard

The Hospital and Healthsystem Association of Pennsylvania (HAP) released a new economic impact report based on an analysis of 2020 data.

This analysis examines how, even during the COVID-19 pandemic, the hospital community continued its vital economic role regionally and across the state. It assesses the effects of hospital spending and employment, documenting that hospitals remain among the largest employers across the commonwealth. It also recognizes the role hospitals play in attracting federal research dollars and the broader benefits hospitals provide by training tomorrow’s clinicians, providing charity and unreimbursed care.

Findings from this paper should be used to inform policy discussions surrounding topics that affect long-term hospital sustainability. This includes, but is not limited to, hospital funding, promoting health equity, prior authorization reform, telemedicine service reimbursement, credentialing process streamlining, adequate Quality Care Assessment support, and bolstering Pennsylvania’s health care workforce.

The overview, full report, and interactive dashboard can be accessed here.

CareQuest Addresses Oral Health of Low-Income Populations

The CareQuest Institute for Oral Health published “Addressing Oral Health of Low-Income Populations: A Call to Action” in the Journal of the American Medical Association (JAMA) Network Open. The article underscores the importance of strengthening Medicaid benefits to include dental coverage. The commentary was in response to the article and study that suggested that the combination of Medicaid expansion and addition of Medicaid dental benefits not only improved coverage and access to dental care among low-income adults but also produced significant improvements in clinical indicators of oral health.

Click here to read the article.

Health Workforce Research Centers Release Annual Report

The Health Resources and Services Administration- (HRSA)- sponsored Health Workforce Research Centers (HWRC) released their annual report. The report includes information on a variety of resources for physical, behavioriral, and oral health. See the image below from the report, depicting specific requirements in state laws and regulation that impact the ability of dental hygienists to apply silver diamine fluoride (SDF).

Click here to download the report.

Household Food Security in the U.S. Last Year

The Economic Research Service (ERS) at the U.S. Department of Agriculture released its annual report on access to adequate food for households in the U.S.  The survey data collected in December 2020 showed an estimated 89.5 percent of households had food access throughout the year, a number not significantly different from the same survey taken at the end of 2019.  The prevalence of very low food security for rural areas, 4.5 percent, was slightly higher than the national average of 3.9 percent.

RAND Weighs in on Vaccine Hesitancy

The RAND Corporation is a non-partisan, nonprofit organization that researches and analyzes public policy.  Their recommendations promote the World Health Organization’s “three Cs” model: 1) boosting confidence in the safety and effectiveness of vaccines, 2) combating complacency about the pandemic, and 3) increasing the convenience of getting vaccinated.  Earlier this year, the Centers for Disease Control and Prevention cited data showing lower COVID-19 vaccination coverage in rural areas.

ONC: Challenges to Interoperability

The ability to exchange electronic health data between facilities, known as interoperability, is essential to the long-term goals of the Office of the National Coordinator for Health IT (ONC). This report examines the challenges for acute care hospitals – including rural hospitals and Critical Access Hospitals – exchanging electronic health information with public health agencies.  The report uses data collected in 2019 and identifies ongoing barriers that may have been exacerbated by the pandemic.