Strategies to Combat Opioid Use in Rural Communities · Strategies to Combat Opioid Use in Rural...

1/18/18

1

StrategiestoCombatOpioidUseinRuralCommunities

John Gale,MS,SeniorResearchAssociate

Rural Health Research Gateway WebinarJanuary18,2018

Muskie School of Public Service Maine Rural Health Research Center

AcknowledgementsSupportforthisworkwasprovidedbytheFederalOfficeofRuralHealthPolicywithintheHealthServicesandResourcesAdministration.

ResearchTeam:

Strategiesstudy:JohnGale,AnushHansen,MarthaElbaum

Prevalencestudy:JenniferLenardson,JohnGale,ErikaZiller

1/18/18

2


TopicstoBeCovered• Keytakeawaymessages• Opioiduseacrossruralsettings•Whatisdifferentaboutruralareas?• Driversofruralopioiduse• Burdenofopioiduseinruralcommunities• Evidence-basedprevention,treatment,andrecoverystrategiestoaddressruralopioiduse


KeyTakeAwayMessages• Ittakesavillage- Communityengagementandinvolvementarecentraltoaddressingopioiduse• Opioiduseiscommoninruralareasanddrivenbyacomplexmixofsocioeconomicissues• Ruralareasufferdisproportionatelyfromtheseissues• Travelbarriersandisolationexacerbatetheseproblems• Significantgapsexistinsubstanceuseprevention,treatment,andrecoveryinruralcommunities•Modelsmustbeadaptedtothegeographic,resource,andculturalrealitiesofruralareas

1/18/18

3


OpioidUse– AComplexProblem• Thegood:‒ Aclassofprescriptionmedicationsprovidingsignificantbenefitstopatientswithacuteseverepain• Thebad:‒ Undueinfluenceofpharmaceuticalcompanies‒ Earlyfailuretoacknowledgetherisksofprescriptionopioids‒ Slowadoptionofevidence-basedprescribingguidelines‒ Growingpatientdemandforopioids• Complications:‒ Directlinkagebetweenprescriptionopioidandheroinuse‒ Multiple,interrelatedpathwaystoopioidaddiction


RuralOpioidIssues• Opioiduseistheprimarycauseofunintentionaldrugoverdosedeaths• Severalruralstatesareexperiencingthehighestratesofoverdosedeaths- WV,NM,NH,andKY•Misuseofpainrelieversishigheramongruralyouth,womenwhoarepregnantorexperiencingpartnerviolence,personswithco-occurringdisorders,andfelonyprobationers• Heroinusehasbeguntomigrateawayfromurbancommunitiesandnowmoretypicallyoccursinsmallurbanornon-urbanareas• Prescriptionopioidandheroinusearestronglylinked

1/18/18

4



1/18/18

5


FactorsAssociatedwithRuralOpioidUse• Controllingfor:residence,age,sex,race/ethnicity,health,education,maritalstatus,employment,healthinsurance&income,ruralpersons:‒ Were20%lesslikelytohavepastyearopioidusethanurban‒ Ages12-19were70%morelikelytouseopioidsthan30-49‒ Under30hadhigheroddsofopioidusethan30andover‒ Whoweremarriedhad40%reducedoddsofusecomparedtoruralpersonswhowerenotmarried

‒ Maleswere30%morelikelythanfemalestouseopioids‒ Inpoorhealth,withlimitededucation,andnohealthinsurancehadhigheroddsofopioiduse

‒ Whowereuninsuredhad58%higheroddsofopioidusecomparedtothosewithprivatecoverage.


SocioeconomicDriversofRuralOpioidUse

1/18/18

6


RoleofRuralPlaceasaDriverofOpioidUse• Ruralplacessufferfromavarietyofhealthandsocio-economicdisparities‒ Greatersenseofstigma‒ Highersenseofisolationandhopelessness‒ Lowereducationrates‒ Higherratesofpoverty‒ Feweropportunitiesforemployment‒ Higherratesofchronicillnesses• Influenceofcultural,ethnic,religiousdifferences


RiskFactorsforOU• Familyhistoryofsubstanceabuse• Personalhistoryofsubstanceabuse• Youngage• Historyofcriminalactivityand/orlegalproblems• Regularcontactwithhigh-riskpeopleorenvironments•Mentaldisorders• Risktakingorthrillseekingbehavior.• Heavytobaccouse.• Historyofseveredepressionoranxiety.• Psychosocialstressors.• Priordrugand/oralcoholrehabilitation

1/18/18

7


InteractionbetweenOpioidUseandRiskFactors• Opioiduseisdrivenbysocioeconomicfactors• Italsocontributestoaself-perpetuatingcyclethatisdifficulttobreak• Individualswithopioidusedisordershavelowerlevelsofacademicachievement,arrestrecords,greaterratesofpoverty,etc.• Intergenerationalsubstanceuse• Intergenerationaltrauma• Stigmaplaysacrucialrole


OtherRuralIssues• Longstandingissueinruralcommunities• Non-medicaluseofprescriptionopiatesinruralareas• Heroinasasubstituteforprescriptionopioidsbythosewithouthealthinsurance– Maine•Majorinitiatives– Vermont,Ohio,otherruralstates• Heroinischeap,accessible,andstronger• Limitedtreatment&lawenforcementresources• Substantialvariationsinopioidprescribingrates

1/18/18

8


PolicyImplications• Despitesocialvulnerabilities,ruralopioidusershaveslightlylowerprevalenceratesthanurbanopioidusers‒ Socialties,support,andotherbuffersmayprotectruralresidentsfromevenhigherprevalencerates

• Preventioneffortshavenoteffectivelyreachedruralresidents– especiallyyoungpeopleandmen– whodonotperceiverisksfromheroinuse• Harmreductionandsyringeexchangeprogramsarealsoimportant,thoughfarlesscommon,inruralareas• Significanteffortstomanageopioidprescribingratesareneeded


APublicHealthModelforOU• Systematicdatacollectiononscope,characteristics,andconsequencesofsubstancemisuse• IdentifyriskandprotectivefactorsforOUandfactorsthatcouldbemodifiedthroughinterventions• Collaborativeeffortstoaddresssocial,environmental,oreconomicdriversofOU• Effectivepreventionandtreatmentinterventionsandrecoverysupportsinawiderangeofsettings•MonitortheimpactofinterventionsonOU,relatedproblems,andriskandprotectivefactors• CommunityleadershipthatmobilizescommunityorganizationsandresourcestoaddressOU

1/18/18

9


CommunityStrategies• Keytoaddressingtheproblematthelocallevel• Importantcomponents‒ Broad-basedsupportandengagement‒ Stigmareduction‒ Prevention‒ Harmreduction– naloxoneandneedleexchanges‒ Engagedlawenforcementthatavoidscriminalizingusers‒ Engagedprovidersusingevidence-basedprescribingguidelinesandofferingmedicationassistedtherapy

‒ Accesstoevidence-basedtreatmentservices,integratedwithmainstreamhealthcare

‒ Peersupportandrecoveryservices


EngagingHospitalsandPrimaryCareProviders• Problemsarenotlimitedtoopioiduseonly,butincludemanyotherhealthandsafetyproblems• Hospitals,emergencydepartments,andprimarycarecontributetotheopioidproblemthroughprescribingpractices• Tax-exemptandpubliclyownedhospitalshaveanobligationtoaddressunmetcommunityneeds• Ruralhospitalsandprimarycareproviderscanplayaneffectiveroleinaddressingopioidusebyfillinggapsinspecialtycaresystem• Itprovidesanopportunityforcollaborativeactionbyhospitals,medical,andcommunitystakeholders

1/18/18

10


BarrierstoTreatmentAccessinRuralAreas

CHAPTER 5. EVIDENCE-BASED DRUG TREATMENT STRATEGIES FOR RURAL SETTINGS 67

Rural substance use disorder treatment services are less likely to provide more intensive, specialized services or services tailored to the needs of vul-nerable populations, or those with unique cultural needs.185,186

The development and operation of rural substance use treatment programmes are hindered by numerous challenges including:

¹⁸⁵ Gamm, L.D. “Mental Health and Substance Abuse Services Among Rural Minorities”, The Journal of Rural Health. 2004; 20:206-210.¹⁸⁶ Sung, H.E., Mahoney, A.M. and Mellow, J. “Substance abuse treatment gap among adult parolees: prevalence, correlates, and barriers”,

Criminal Justice Review. 2011; 36:40-57.

• Difficulty recruiting appropriately trained and credentialed clinical staff

• Population densities that are insufficient to support viable services

• Limited access to referral and specialty services • Poor economic conditions, lower rates of health

insurance coverage and financing, and higher rates of poverty that further hamper the ability to develop a self-sustaining practice

FIGURE 5.1 ELEMENTS CONTRIBUTING TO A LOWER LEVEL OF ACCESS TO SUBSTANCE USE TREATMENT SERVICES FOR THE RURAL POPULATIONa, b

FEWER FACILITES

GEOGRAPHIC BARRIERS

LESS ANONYMITY

FEWER TREATMENT

PROFESSIONALS

LIMITED PUBLIC

TRANSPORTATION

LOWER TREATMENT ACCESS IN

RURAL AREAS

STIGMATIZATION AND

CRIMINALIZATION

aOser, C., Leukefeld, C., Tindal,l. M., Garrity, T., Carlson, R., Falck, R., Wang, J., and Booth, B. “Rural drug users: factors associ-ated with substance abuse treatment utilization”, International Journal of Offender Therapy and Comparative Criminology. 20.11;55:567–586.

bSexton, R.L., Carlson, R.G., Leukefeld, C.G., and Booth B.M. “Barriers to formal drug abuse treatment in the rural south: a preliminary ethnographic assessment”, Journal of Psychoactive Drugs. 2008; 40:121–129.


BarrierstoOUTreatment• PoorcoverageforMATservices– OTPsarecashonlyservicesinsomestates• Servicesareoftenclusteredaroundurbancenters–requiringlongtraveldistancesforruralresidents•Manybuprenorphineprovidersoperatebelowcapacity•MATservicesarenotenough– substanceuse,mentalhealth,carecoordinationareneeded• Greaterattentionisneededonwhathappensaftertreatment– peersupportandrecoveryservicesareneededtoreducelikelihoodofrelapse

1/18/18

11



ImportantStrategyArea#1- Prevention• Opioidharmsnotrestrictedsolelytothoseusingheroinormisusingprescriptionmedications• Discourage/delayonsetofOU•Minimizerelatedhighriskbehaviors• Focusonchildren,adolescents,andyoungadults• Communityfocusedstrategies‒ Communityorganizingandeducation• Providerfocusedstrategies‒ Reducingsupplyofopioidsprescribed‒ Useofprescriptiondrugmonitoringprograms‒ Offeralternativepain-managementstrategies‒ Provideopportunitiestodisposeofunneededmedications

1/18/18

12


Prevention• Aprimarycomponentofahealth-centeredsystemtoaddressOUuse• Evidence-based(EB)preventionprogramseffectivelypreventinitiation,harmfuluse,andrelatedproblems• Preventioniscost-effectiveatdifferentstagesoflife•Mustbeadaptedtotheuniquecontextofeachcommunitywithfidelitytotheinterventiononwhichtheevidenceisbased• Communitiesareanorganizingforcetobringeffectivepreventionprogramstoscale• Key:Crosssectorcommunitycoalitionstoassesslocalriskandprotectivefactors,OUproblems,andimplementinterventionstomatchlocalpriorities


ActivitiestoEngageCommunities• CommunityOrganizationandEngagement• Prescribereducationandbehavior• Supplyreductionanddiversioncontrol• Painpatientservicesanddrugsafety• Drugtreatmentanddemandreduction• Harmreduction• Community-basedpreventioneducation

1/18/18

13


Keyelementsofeffectivecommunitycoalitions• Understandingthecommunity’sneedsandresources•Widelysharedandcomprehensivevision• Clearandfocusedstrategicplan• Diversemembership:keycommunityleaders,localgovernmentofficials,andvolunteers• Strongleadershipandcommittedpartners• Diversifiedfunding•Well-managedstructure:organizedadministration,effectivecommunicationamongparticipants,andacomprehensiveevaluationplan


Evidence-basedcommunityorganizingmodels• ProjectLazarus-‒ InallNorthCarolinaCounties‒ Inruralcommunitiesacrossthecountry- ProjectBaldEagle,Williamsport,PA.WinnebagoCountyHeroinTaskForceinWisconsin,ClarkCountyCollaborativeinOhio,andWashtenawHealthInitiativeOpioidProjectinMichigan

• ProjectVision,Rutland,VT‒ UsesaDrugMarketInterventionmodelandcommunitycollaboration/engagementtoreducethesupplyofopioids

• SAMHSA’SRecoveryOrientedSystemsofCare• CommunitiesThatCare

1/18/18

14


ProjectLazarus– HubActivities• Hubactivitiesarecentralcomponentssupportingallotheractivitiesandreflectacommunity-based,bottom-uppublichealthapproach‒ Buildpublicawarenessofsubstanceusethroughbroad-basededucationaleffortsandtheuseoflocaldatatodriveawareness

‒ Coalitionbuildingandactiontoengageabroadrangeofcommunityproviders,agencies,andorganizations

‒ Identifydataneedsforplanningandevaluationtobuildawareness,tailorprogramstolocalneeds,trackprogress,andsustainsupportandfunding


ProjectLazarus– SpokeActivities• Spokeactivitiesareoptionalareasofevidence-basedpreventioninitiativesthatcommunitiescanselectandreflectamedicalandlawenforcement-based,top-downpublichealthapproach₋ Communityeducation₋ Providereducation₋ Hospitalemergencydepartmentpolicies₋ Diversioncontrol₋ Painpatientsupport₋ Addressingtheconsequencesofuse₋ Addictiontreatment

1/18/18

15


ProjectVision– AddressingSupplyIssues• ProjectVision,Rutland,VT‒ Goals:empowercommunities,strengthenneighborhoods,helppeople,changethefuture

‒ Committees:Crime/Safety,SubstanceAbuse,Community/Neighborhoods/Housing

‒ UseaDrugMarketInterventionmodelandcommunitycollaboration/engagementtoreducethesupplyofopioids(heroinandillicitlydistributedprescriptionopioids)inruralRutlandVT

1/18/18

16


PrescriberEducationandBehaviour• One-on-oneprescribereducationonpainmanagement• Continuingmedicaleducationonpainmanagement• Licensingactionsagainstcriminalprescribing• Implementandmonitorevidence-basedprescribingguidelinesamongallproviders‒ CDCguidelines,stateprogramssuchasWashingtonstate• Strongly encourageuseofprescriptiondrugmonitoringprograms• Thinkaboutan“oxyfree”emergencydepartment• HarmReduction- NaloxoneandOpioidusereducationonoverdosepreventionandresponse


HospitalPreventionStrategies• Participateincommunity-basedpreventionprogramsaspartofhospital’scommunitybenefitand/orcommunity/populationhealthinitiatives• Qualityimprovement:Focusonsupplyreduction‒ Prescribingguidelines‒ Encouragegreateruseofprescriptiondrugmonitoringprograms

‒ UseProjectECHOtosupportprescribingandpainmanagementcapacityoflocalproviders

‒ Implementan“oxy-free”emergencydepartment‒ Engageinharmreductionstrategies

1/18/18

17


MidcoastMainePrescriptionOpioidReductionProgram

• ImplementedopioidprescribingguidelinesfordentalpainintworuralEDsinMaine

• DrivenbyEDchairmanwithinputfromphysiciangroup• EDpatientswhorequestrefillsofcontrolledprescriptions,havemultiplecontrolledsubstanceprescriptions,orhavemultiplepreviousEDvisitsforpainfulconditions

• Guidelinesrecommendtheuseofanalgesicalternativessuchasnerveblocksandimmobilization

• Resultsafter12months- reductionsinratesofopioidprescriptionsandvisitsfordentalpain


Oxy-FreeEmergencyDepartments(EDs)• EDsareasignificantsourceofopioidprescriptionsandafrequenttargetforthoseseekingopioids• EDprescribingdevelopedbytheWashingtonStateDepartmentofHealth,theWACollegeofEmergencyPhysiciansandtheWAHospitalAssociation• IncludedlimitationsontheprescriptionofopioidsinEDsandtheconceptofan“oxy-freezone”• LowerratesofEDvisitsby“frequentusers”withlowacuitydiagnosesseekingopioids• WAMedicaidestimated$33.6millioninEDsavings• Hospitalsarepleasedwiththestrategybutsomeexperiencedearlyreductionsinpatientsatisfactionscoresrelatedtopainmanagement

1/18/18

18


“Oxy-Free”EDs–McKenzieHealthSystem

• InFebruary2013,McKenzieHealthSystem'sEDdiscontinueddispensingnarcoticandsedativemedicationsforcomplaintsofchronicpain

• Results– 60%reductioninopioidprescriptionabusewithina12monthperiodandreducedutilizationofunnecessaryandcostlydiagnosticwork-ups

• Staffmetwithcommunitymentalhealthofficials,countyhealthofficials,localprimarycareproviders,lawenforcement,pharmaciestoexplaintheinitiative

• Engagedinpatienteducation


“Oxy-Free”EDs–McKenzieHealthSystem(con’t)• Process:

– Thoroughmedicalexamtoruleoutmedicalemergencies– Reviewofpatient'scompletefile,includinginternalhealthrecords,outsidehealthrecords,drugscreeningtests

– Ifpatientpresentswithachronicpainconditionorsuspectednarcoticsabuses,physicianwillinformpatientofthedangersofnarcoticdrugabuseandmaynotprescribeanarcoticpainmedication

– Mayreceiveanon-narcoticpainmedicationandinformationaboutO/SUprogramsand/orpainmanagementspecialists

– Ifanarcoticpainmedicationisprescribedaftercarefulreviewbythephysician,itisonlyforaverylimitedamountofpills,untilthepatientcanbeseenbyhisorherphysician

1/18/18

19


ReducingOpioidPrescribingbyProvidingPainManagementServices

• Duetothelimitedavailabilityofpainmanagementservicesinruralcommunities,manyprovidersrelyonprescriptionopioidsasaprimarytreatmentmodality

• Ruralprimarycareprovidersoftenhavelimitedexperiencewiththemanagementofchronicpain

• Strategies– Expandaccesstopainmanagementservicesthroughcontractsand/ortelehealth

– ImprovethecapacityoflocalproviderstomanagepainthroughuseofprogramsuchasProjectECHO


ExpandingLocalPainManagementServices:SalemTownshipHospital

• SalemTownshiprecruitedapainspecialisttotravelanhourfromMarion,Ill.,twiceamonthtotreatpatients.– Consideringexpansiontothreetofourtimesamonth.

• Patientsareseeninonehourincrements• Providestrigger-pointinjectionsforlong-termpainandpromotesphysicaltherapyandalternativetreatments

• Patientscontinuingwithopioidsmustagreetoregulardrugtestsandnotaskforearlyrefills

• Over3to4months,only3outof56patientshavechosentostickwithopioids

• Minimalinvestment- $25,000forcapitalequipment

1/18/18

20


Telehealth-BasedPainManagementProgram:Martha’sVineyardHospital(MVH)

• DuetoitsislandlocationoffCapeCod,MVHworkedwithMassachusettsGeneralHospital’sCenterforPainManagementtoofferapainserviceviatelehealth

• MGHprovidersseepatientsinatelepainclinic3dayspermonthandconducton-sitevisitstwicepermonth

• Servicesincludeinitialconsultsandfollow-upvisits• Vitalsigns/patientsnotesarerecordedinasharedEHR• AnRN,trainedinphysicalexaminationofpainandmedicalmanagement,performspatientexamsunderdirectphysiciansupervisionvialivevideoconferenceandalsoverballyannouncedallfindings


Telehealth-BasedPainManagementProgram:Martha’sVineyardHospital(con’t)

• Physicalexaminationsarerepeatedbythephysicianduringon-sitevisitspriortopatientintervention

• LaboratorydataandimagingstudiesarereviewedinthesharedHER

• Over13months,49patientsparticipatedin238telepainvideoclinicsand121on-siteinterventions

• Patientsreportreducedtravelcosts,improvedaccesstocare,andgeneralsatisfactionwiththeservice

• Patientsratedtheirsatisfactionwithcarereceivedbytelepainlowerthanin-personvisitsandthoughtithardertodeveloparelationshipwiththedoctor

• Thishighlightsthechallengeofbuildingapatient-physicianrelationshipremotely

1/18/18

21



ImportantStrategyArea#2- Treatment• ImplementconsistentOUscreeningforallpatients• DevelopreferralrelationshipswithSU/MHproviders• Explorelocaltreatmentopportunities‒ Medicationassistedtreatment– buprenorphine‒ Integratedbehavioralhealth/SU/primarycareservices‒ Specialtysubstanceuseservices• Collaborativetreatmentprograms– hubandspoke• Exploreuseoftechnologytoexpandaccesstocare• Overdosereversalprograms• Alternativepainmanagementprograms•Workwithlawenforcementtoprovideatreatmentalternativetoincarceration

1/18/18

22


ProviderStrategiesandTreatmentServices• Ruralresidentsdeservethesamelevelofaccesstothefullrangeofsubstanceusetreatmentservicesasurbanresidents• Substanceuseisachronic,relapsingdisease‒ Requiresongoinglevelofservices‒ Reflectsaprimarycare-basedsystemofcareframework‒ Conservesresourcesbymatchingservicestopatientneedsusingalevelofcarecriteria

‒ Professionally-directed,post-dischargecarecanenhancerecovery,butrelativelyfewreceivesuchcare

‒ Distancetoservicesiscorrelatedwithtreatmentcompletion(longertraveldistancesareassociatedwithlowerratesofcompletion)

DefinitionofaSystemofCare

• Anintegratedspectrumofeffective,community-basedservicesandsupportsforruralpeopleandtheirfamiliesatriskfororstrugglingwithOUchallenges‒ Organizedintoacoordinatednetwork‒ Buildsmeaningfulpartnershipswithindividualsandtheirfamilies‒ Addressestheirculturalandlinguisticneeds,tohelpthemfunctionbetterathome,inschool,inthecommunity,andthroughoutlife.

1/18/18

23

StructureofTreatmentServices• Useofaregionalorientation/model• Reflectstherealitiesofruralresourcelimitations‒ Usestechnology(e.g.,telehealth,mobilephones,etc.)toaddressdistancebarriersandmaldistributionofresourcesacrossurbanandruralareas

• Integrationacrossservicessystems:‒ Substanceuse,‒ Mentalhealth,and‒ Primarycare

PrincipalsforTreatment• Treatmentmustbeavailable,accessible,attractive,andappropriateforneeds

• Ethicalstandardsmustbeobserved• Requireseffectivecoordinationbetweenthecriminaljusticesystemandhealthandsocialservices

• OUDsshouldbeviewedasahealthproblemratherthancriminalbehavior:usersshouldbetreatedinthehealthcareratherthanthecriminaljusticesystemwhenpossible

1/18/18

24

PrincipalsforTreatment(cont’d)• Basedonscientificevidenceandrespondtospecificneedsofindividualswithouds

• Shouldrespondtotheneedsofspecialsubgroupsandconditions

• ShouldensuregoodclinicalgovernanceoftreatmentservicesandprogramsforOUDs

• Integratedtreatmentpolicies,services,procedures,approachesandlinkagesmustbeconstantlymonitoredandevaluated

OpioidScreeningTools

• Canbeusedacrossdifferenthealthcaresettings‒ ScreenerandOpioidAssessmentforPatientsinPainRevised(SOAPP-R)

‒ CurrentOpioidMisuseMeasure(COMM)‒ OpioidRiskTool(ORT)‒ Diagnosis,Intractability,Risk,andEfficacy(DIRE)‒ ScreeningInstrumentforSubstanceAbusePotential(SISAP)‒ (vi)ThePainAssessmentandDocumentationTool(PADT)

1/18/18

25

BridgtonHospitalBuprenorphineClinic• CoordinatedeffortsbetweenBridgtonHospital,NorthBridgtonFamilyPractice,CrookedRiverCounseling

‒ Programhasenrolled200patientsinaruralMainecommunity‒ Startedin2009‒ Fourphysiciansandtwonursepractitionersprescribebuprenorphineintheirprimarycarepractice(NorthBridgton)

‒ CrookedRiverCounselingprovidesintensiveoutpatientcounselingandgrouptherapyforthepatients

‒ BridgtonHospitalprovidescomprehensivematernitycaretowomenwithOUDduringtheirpregnancy

‒ Servicesareinterconnectedandcoordinatedacrossproviders‒ Keyisthecollaborativeapproachandcommunication

BridgtonHospitalBuprenorphineClinic• Benefits‒ Lowerregulatory/licensurebarriersthanmethadoneprograms‒ SAMHSAprescribingwaiveriscomparativelyeasytoobtain‒ Canbeintegratedintoprimarycaresystem‒ Goldstandardoftreatmentforopioids

• Challenges‒ Buprenorphinealoneisnotsufficienttomeetallpatientneeds‒ Canbedifficulttoincorporateintoabusypracticewithoutadditionalsupport

‒ Linkageswithbiggersystemsofcareareneeded

1/18/18

26


SupportingMATandOUDServices- Vermont• Vermont’sHubandSpokemodelsupportstheuseofbuprenorphinebyprimarycareandcommunityproviders₋ Comprehensivecaremanagement₋ Carecoordinationandreferraltolocalresources₋ Caretransitions₋ Individualandfamilysupports₋ Healthpromotion₋ Expandsuseofbuprenorphineinprimarycare₋ Recognizesimportanceofmentalhealthandtraditionalsubstanceuseservicesintreatingopioidproblems

₋ Efficientuseofscarceresources₋ Providescareinlessstigmatizingsettings


VermontHubandSpoke(cont’d)• Regionalspecialtytreatmentcentersserveasthehubs₋ CoordinatecareofindividualswithcomplexOUDsandco-occurringSUandMHdisorders

₋ ProvidefullrangeofOUDcareandsupportcommunityprovidersbyprovidingconsultativesupporttoprimarycareandotherprovidersprescribingbuprenorphine

• Physiciansprescribingbuprenorphineandcollaboratinghealthandaddictionsprofessionalsserveasthespokes₋ Dispensebuprenorphine,monitoradherencetotreatment,coordinateaccesstorecoverysupports,andprovidecounseling,contingencymgt,andcasemgtservices

• FundedthroughMedicaidwaiver

1/18/18

27



ImportantStrategyArea#3- Recovery• ThethirdandoftenoverlookedstrategytoaddressOUdisorders• Providesupportthroughprogramsorastructuredmilieutosupportsobrietyandsubstancefreeliving• Ideally,recoverybeginsbeforetreatment• Addressessocial,rehabilitation,andvocationalissues• Providesacommunitytoreinforcesobriety

1/18/18

28


Recovery• “Recoveryisaprocessofchangethroughwhichanindividualachievesabstinenceandimprovedhealth,wellnessandqualityoflife.”SAMHSA• Fourdimensionsthatdefineahealthylifeinrecovery:‒ Health- Managingone’sdisease(s)orsymptoms;makinginformedchoicesthatsupportphysical/emotionalwellbeing

‒ Home– Havingasafeandstableplacetolive‒ Purpose– Participatinginmeaningfuldailyactivitiesandhavingtheindependence,income,resourcestoparticipateinsociety

‒ Community– Engaginginrelationshipsandsocialnetworksthatprovidesupport,friendship,love,andhope

• Hospitalscancoordinatewithlocalrecoveryprograms


Recovery– CommunityPrograms• Doescommunitycreateasupportiveenvironmentforrecovery?‒ Stigmareduction– opportunitiesforanewstart‒ Employmentopportunities‒ Educationalopportunities‒ Social,recreationaloutlets‒ Connectiontoculturalheritage‒ Twelvestepprograms‒ Peersupport

1/18/18

29


Evidence-BasedRecoveryPrograms• DepartmentofVeteran’sAffairs– PeerRecovery‒ Recruitveteransinrecoverytosupportthosegoingthroughtheprocess

• Australianmentalhealthpeersupport‒ Goal– avoidanceofunnecessaryhospitalizations

• TurningPointCenter,Rutland,VT‒ PartoftheVermontRecoveryNetwork

• SupportingPeerRecovery:TheRECOVERProject,FranklinCounty,MA

• ProjectAngels,Gloucester,MA‒ Providestreatmentasanalternativetoincarceration


ChallengestoDevelopingRuralPrograms• Programs“imported”fromoutsidethelocalareaareoftenviewedwithsuspicion• Community-basedprogramsareimportanttocreatelocallydeveloped,culturallyappropriateinterventions‒ Mustbesensitivetolocalcultural,religions,andethnicissues(culturalhumility)andengagelocalleaders

‒ Limitedopportunitiesaftertreatment,stigma,restrictedsocialsupportsfrequentlyleadstorelapse– mustsupportsoberliving

• Continuumofprevention,treatment,andrecoveryservicesmustbedevelopedsimultaneouslytoaddresstheneedsofruralresidents“wheretheyare”

1/18/18

30


Recommendations• TheCommunityiskey!!• Supportthedevelopmentandimplementationofcommunitycoalitions- ProjectLazarusorProjectVision• Engageproviders,businesses,schools,residents,lawenforcement• Conductbroad-basededucationonthedangersofopioids• Buildalocalsystemofcarethatintegratesprevention,treatment,andrecoveryandengagesmentalhealth,andsubstanceuseproviders


TheRuralHealthResearchGatewayprovidesaccesstoallpublicationsandprojectsfromsevenresearchcentersfundedbytheFederalOfficeofRuralHealthPolicy

Visitourwebsiteformoreinformation:http://www.ruralhealthresearch.org/

SignupforemailorRSSalertsat:http://www.ruralhealthresearch.org/alerts

1/18/18

31


ContactInformationJohnA,Gale,MSSeniorResearchAssociateMaineRuralHealthResearchCenterMuskieSchoolofPublicServiceUniversityofSouthernMainePOBox9300Portland,ME04104-9300

[email protected]

Date post:	11-Jun-2020
Category:	Documents
Upload:	others
View:	0 times
Download:	0 times

Strategies to Combat Opioid Use in Rural Communities · Strategies to Combat Opioid Use in Rural...

Documents