It is common knowledge that the United States is currently fighting a war on the abuse of Opioids and other narcotic substances. It is not as well known that many of these wars are occurring in rural areas where drugs are plentiful, and access to treatment is challenging. Vermont (a largely rural state), for example, has some of the highest rates of opioid abuse in the country(Sigmon).
The purpose of this article is to explore the challenges facing opioid and substance abuse in rural areas and some of the technologies and techniques available to help in the fight. To properly layout our hypothesis it is appropriate first to define a few terms:
- Telehealth – Telehealth enables healthcare professionals to collaborate on care across a variety of settings (@HIMSS 2014)
- Opioid Abuse – The misuse of Opioids or other substances contrary to a Doctor’s prescription (@NIDAnews 2017)
- Rural – All population centers not within an urban center (2500-50,000 pop)(2017)
Treatment of Opioid and other narcotic abuse often requires significant investments in treatment centers. Many rural areas only have several treatment centers leading to a delay of up to two years to provide treatment (Sigmon). The development of treatment facilities has not kept up with the demand in many rural areas thus requiring “new and creative methods for eliminating barriers to treatment access”(Sigmon).
Impact of Opioid Abuse in Particularly in Rural Communities
A recent study from the CDC demonstrated that the rates of drug overdose deaths are rising in rural areas in the U.S. and surpassing rates in urban areas. Specifically, from 1999-2015, the percentage change increase in age-specific drug overdose deaths was higher for rural areas than urban areas for persons aged ≥ 12 years of age with the largest increase in drug overdose deaths (OD)(411%) among those aged 18-25 years. Rural drug OD death rates in 2015 were higher than urban rates for those aged 26-34 years (Mack, Jones and Ballesteros 2017).
There are many potential explanations for why rural nonmetropolitan areas may be more vulnerable to opioid overdoses and death. Fundamentally, rural counties may be particularly sensitive to substance abuse based on associated social determinants of health including poor housing, poverty, and unemployment. There are a scarcity of addiction treatment/mental health services and emergency care resources in rural areas, challenging the limits of healthcare delivery systems that are more available with faster response times in urban/metropolitan areas. Rural prehospital emergency medical systems have far less highly trained paramedic personnel and often rely heavily on volunteers and lower skilled staff which may not have the education or skill set to provide life-saving airway techniques or medication administration.
New and Creative Ways for Diagnosis and Treatment
Treatment is multifactorial and may include medication-assisted therapy (e.g., methadone or buprenorphine), psychological/psychiatric services, and multiple psychosocial support systems.
Treatment options for acute opioid overdose are quite straightforward and include: administering an antidote that can reverse the toxicity, oxygen, and managing the patient’s airway either through basic first aid (mouth to mouth resuscitation). More advanced techniques including bag-mask ventilation or intubation (e.g., placing a breathing tube into the person’s area and controlling the ventilation). It is important to re-establish a person’s breathing (e.g., ventilation) as well as provide oxygen for crucial, vital organ functioning. The challenge with diagnosis and treatment is that clinical deterioration and death may follow within 3-5 minutes, making “on the scene” treatment imperative for many overdose patients. The time for symptoms to appear depends on the route or type of opioid use with intravenous usage or injecting resulting in a quicker onset of symptoms compared to ingestion or snorting.
Regulatory restrictions and EMS capability and certification to treat drug overdose cases limit the use of naloxone at the scene of overdose events and may also be a factor in higher opioid poisoning-related deaths in rural areas. This is where technologies like telehealth can help to supplement personnel not trained in OD.
Certainly, while it is a vital component to potentially saving lives, the use of Naloxone is a strategy that may only stabilize the increasing rise of opioid-associated death; however, the solution to preventing death is preventing overdose in conjunction with comprehensive treatment programs and services for those suffering from opioid use disorder.
Importance of Telehealth
Collaboration among multiple providers and organizations that address the public health issues associated with Opioid abuse are crucial. When diagnosing and treating opioid abuse, skilled practitioners (located remotely) can provide an array of integrated patient services using telehealth technology to include:
- Patient screening
- Assessments using electronic face-to-face communication, observation, and online questionnaires in real-time – practitioner experience is key for this service (for example, recognizing when someone is in withdrawal)
- Managing and monitoring medications
- Providing individual and group therapy sessions
- Providing ongoing relapse prevention services (for example, 24/7 access to help)
Through telehealth, participants can receive needed treatment by accessing expert help without current barriers, receive needed medications, be taught new skills to prevent relapse, and make important connections with others with healthcare system change. With the use of telehealth technologies providers in rural settings can receive assistance in providing the gold standard for opioid abuse treatment, Medication-Assisted Treatment (MAT). While telehealth is a partial solution to the war on Opioid abuse policy changes could include:
- Improving MAT prescriber’s availability through telehealth
- Improving outpatient mental health, recovery, and peer recovery services available through telehealth
- Lifting legal restrictions for prescribers via telehealth
- Making Naloxone available to every patient suffering from an opiate use disorder through telehealth
Successful opioid crisis intervention (via telehealth) is illustrated in different programs in the United States, such as the New Mexico Echo Project (now expanded nationally and internationally), and the Maryland Hagerstown Project. In each case, a team of professionals works together to meet the needs of participants in crisis. These services provide hope that recovery is not only a possibility but that it can be a reality for all those struggling with addiction. Through policy reform, expanding telehealth access to services to all those suffering from opioid addiction can help end the opioid crisis and is a logical, cost-effective answer to being part of the solution.
2017. What is Rural?
@HIMSS (2014) Introduction to Telehealth.
@NIDAnews (2017) Opioids.
Ciccone, T. G. 2017. Opioid Overdoses Deaths Higher in Rural Than Urban Areas an Interview with Mark Faul, Ph.D., MA. Practical Pain Management.
Mack, K. A., C. M. Jones & M. F. Ballesteros (2017) Illicit drug use, illicit drug use disorders, and drug overdose deaths in metropolitan and nonmetropolitan areas -- United States. 66.
Sigmon, S. C.
About the Contributors
Dr. Erica Liebelt is the Executive Director and Medical Director of the Washington Poison Center and Clinical Professor of Pediatrics and Emergency Medicine at the University of Washington School Of Medicine. In her current position, she leads the management and oversight of medical direction including consultation on management of poisoned patients and development of clinical guidelines as well as collaborating with the Board of Directors and WAPC’s senior leadership in driving strategic planning for the organization.
Stuart Rabinowitz, MBA, MSHI is the Division Director of IT & Data Analysis for Strategic Health Solutions. Stuart holds an undergraduate degree from Temple University, an MBA from Lehigh University, and a Master’s of Science in Health Informatics from the University of Illinois at Chicago.
Ira Nathan, ASA, MAAA is an Analytics Manager for StrategicHealthSolutions. Ira holds an undergraduate degree from the University of Nebraska. He is an Associate in the Society of Actuaries and a member of the American Academy of Actuaries.
Ms. Paula Bruland earned her Master's degree in social work with honors at the University of Nebraska, Omaha. She is a Licensed Independent Mental Health Practitioner and has practiced as a clinician for more than 20 years in local hospitals, in a sub-acute facility for the severely and persistently mentally ill, and as an in-home therapist in private practice. During this time, she served as the Medicaid Primary Care+ Blue Cross Blue Shield of Nebraska Program Administrator, the Executive Administrator of the Region Six Recovery Center, and currently serves as a StrategicHealthSolutions Program Manager of a team that develops provider, beneficiary, and other stakeholder educational materials covering Medicare and Medicaid Programs Federal and State laws, rules, and benefits.