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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
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TopicstoBeCovered• Keytakeawaymessages• Opioiduseacrossruralsettings•Whatisdifferentaboutruralareas?• Driversofruralopioiduse• Burdenofopioiduseinruralcommunities• Evidence-basedprevention,treatment,andrecoverystrategiestoaddressruralopioiduse
Muskie School of Public Service Maine Rural Health Research Center
KeyTakeAwayMessages• Ittakesavillage- Communityengagementandinvolvementarecentraltoaddressingopioiduse• Opioiduseiscommoninruralareasanddrivenbyacomplexmixofsocioeconomicissues• Ruralareasufferdisproportionatelyfromtheseissues• Travelbarriersandisolationexacerbatetheseproblems• Significantgapsexistinsubstanceuseprevention,treatment,andrecoveryinruralcommunities•Modelsmustbeadaptedtothegeographic,resource,andculturalrealitiesofruralareas
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OpioidUse– AComplexProblem• Thegood:‒ Aclassofprescriptionmedicationsprovidingsignificantbenefitstopatientswithacuteseverepain• Thebad:‒ Undueinfluenceofpharmaceuticalcompanies‒ Earlyfailuretoacknowledgetherisksofprescriptionopioids‒ Slowadoptionofevidence-basedprescribingguidelines‒ Growingpatientdemandforopioids• Complications:‒ Directlinkagebetweenprescriptionopioidandheroinuse‒ Multiple,interrelatedpathwaystoopioidaddiction
Muskie School of Public Service Maine Rural Health Research Center
RuralOpioidIssues• Opioiduseistheprimarycauseofunintentionaldrugoverdosedeaths• Severalruralstatesareexperiencingthehighestratesofoverdosedeaths- WV,NM,NH,andKY•Misuseofpainrelieversishigheramongruralyouth,womenwhoarepregnantorexperiencingpartnerviolence,personswithco-occurringdisorders,andfelonyprobationers• Heroinusehasbeguntomigrateawayfromurbancommunitiesandnowmoretypicallyoccursinsmallurbanornon-urbanareas• Prescriptionopioidandheroinusearestronglylinked
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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.
Muskie School of Public Service Maine Rural Health Research Center
SocioeconomicDriversofRuralOpioidUse
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RoleofRuralPlaceasaDriverofOpioidUse• Ruralplacessufferfromavarietyofhealthandsocio-economicdisparities‒ Greatersenseofstigma‒ Highersenseofisolationandhopelessness‒ Lowereducationrates‒ Higherratesofpoverty‒ Feweropportunitiesforemployment‒ Higherratesofchronicillnesses• Influenceofcultural,ethnic,religiousdifferences
Muskie School of Public Service Maine Rural Health Research Center
RiskFactorsforOU• Familyhistoryofsubstanceabuse• Personalhistoryofsubstanceabuse• Youngage• Historyofcriminalactivityand/orlegalproblems• Regularcontactwithhigh-riskpeopleorenvironments•Mentaldisorders• Risktakingorthrillseekingbehavior.• Heavytobaccouse.• Historyofseveredepressionoranxiety.• Psychosocialstressors.• Priordrugand/oralcoholrehabilitation
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InteractionbetweenOpioidUseandRiskFactors• Opioiduseisdrivenbysocioeconomicfactors• Italsocontributestoaself-perpetuatingcyclethatisdifficulttobreak• Individualswithopioidusedisordershavelowerlevelsofacademicachievement,arrestrecords,greaterratesofpoverty,etc.• Intergenerationalsubstanceuse• Intergenerationaltrauma• Stigmaplaysacrucialrole
Muskie School of Public Service Maine Rural Health Research Center
OtherRuralIssues• Longstandingissueinruralcommunities• Non-medicaluseofprescriptionopiatesinruralareas• Heroinasasubstituteforprescriptionopioidsbythosewithouthealthinsurance– Maine•Majorinitiatives– Vermont,Ohio,otherruralstates• Heroinischeap,accessible,andstronger• Limitedtreatment&lawenforcementresources• Substantialvariationsinopioidprescribingrates
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PolicyImplications• Despitesocialvulnerabilities,ruralopioidusershaveslightlylowerprevalenceratesthanurbanopioidusers‒ Socialties,support,andotherbuffersmayprotectruralresidentsfromevenhigherprevalencerates
• Preventioneffortshavenoteffectivelyreachedruralresidents– especiallyyoungpeopleandmen– whodonotperceiverisksfromheroinuse• Harmreductionandsyringeexchangeprogramsarealsoimportant,thoughfarlesscommon,inruralareas• Significanteffortstomanageopioidprescribingratesareneeded
Muskie School of Public Service Maine Rural Health Research Center
APublicHealthModelforOU• Systematicdatacollectiononscope,characteristics,andconsequencesofsubstancemisuse• IdentifyriskandprotectivefactorsforOUandfactorsthatcouldbemodifiedthroughinterventions• Collaborativeeffortstoaddresssocial,environmental,oreconomicdriversofOU• Effectivepreventionandtreatmentinterventionsandrecoverysupportsinawiderangeofsettings•MonitortheimpactofinterventionsonOU,relatedproblems,andriskandprotectivefactors• CommunityleadershipthatmobilizescommunityorganizationsandresourcestoaddressOU
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CommunityStrategies• Keytoaddressingtheproblematthelocallevel• Importantcomponents‒ Broad-basedsupportandengagement‒ Stigmareduction‒ Prevention‒ Harmreduction– naloxoneandneedleexchanges‒ Engagedlawenforcementthatavoidscriminalizingusers‒ Engagedprovidersusingevidence-basedprescribingguidelinesandofferingmedicationassistedtherapy
‒ Accesstoevidence-basedtreatmentservices,integratedwithmainstreamhealthcare
‒ Peersupportandrecoveryservices
Muskie School of Public Service Maine Rural Health Research Center
EngagingHospitalsandPrimaryCareProviders• Problemsarenotlimitedtoopioiduseonly,butincludemanyotherhealthandsafetyproblems• Hospitals,emergencydepartments,andprimarycarecontributetotheopioidproblemthroughprescribingpractices• Tax-exemptandpubliclyownedhospitalshaveanobligationtoaddressunmetcommunityneeds• Ruralhospitalsandprimarycareproviderscanplayaneffectiveroleinaddressingopioidusebyfillinggapsinspecialtycaresystem• Itprovidesanopportunityforcollaborativeactionbyhospitals,medical,andcommunitystakeholders
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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.
Muskie School of Public Service Maine Rural Health Research Center
BarrierstoOUTreatment• PoorcoverageforMATservices– OTPsarecashonlyservicesinsomestates• Servicesareoftenclusteredaroundurbancenters–requiringlongtraveldistancesforruralresidents•Manybuprenorphineprovidersoperatebelowcapacity•MATservicesarenotenough– substanceuse,mentalhealth,carecoordinationareneeded• Greaterattentionisneededonwhathappensaftertreatment– peersupportandrecoveryservicesareneededtoreducelikelihoodofrelapse
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ImportantStrategyArea#1- Prevention• Opioidharmsnotrestrictedsolelytothoseusingheroinormisusingprescriptionmedications• Discourage/delayonsetofOU•Minimizerelatedhighriskbehaviors• Focusonchildren,adolescents,andyoungadults• Communityfocusedstrategies‒ Communityorganizingandeducation• Providerfocusedstrategies‒ Reducingsupplyofopioidsprescribed‒ Useofprescriptiondrugmonitoringprograms‒ Offeralternativepain-managementstrategies‒ Provideopportunitiestodisposeofunneededmedications
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Prevention• Aprimarycomponentofahealth-centeredsystemtoaddressOUuse• Evidence-based(EB)preventionprogramseffectivelypreventinitiation,harmfuluse,andrelatedproblems• Preventioniscost-effectiveatdifferentstagesoflife•Mustbeadaptedtotheuniquecontextofeachcommunitywithfidelitytotheinterventiononwhichtheevidenceisbased• Communitiesareanorganizingforcetobringeffectivepreventionprogramstoscale• Key:Crosssectorcommunitycoalitionstoassesslocalriskandprotectivefactors,OUproblems,andimplementinterventionstomatchlocalpriorities
Muskie School of Public Service Maine Rural Health Research Center
ActivitiestoEngageCommunities• CommunityOrganizationandEngagement• Prescribereducationandbehavior• Supplyreductionanddiversioncontrol• Painpatientservicesanddrugsafety• Drugtreatmentanddemandreduction• Harmreduction• Community-basedpreventioneducation
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Keyelementsofeffectivecommunitycoalitions• Understandingthecommunity’sneedsandresources•Widelysharedandcomprehensivevision• Clearandfocusedstrategicplan• Diversemembership:keycommunityleaders,localgovernmentofficials,andvolunteers• Strongleadershipandcommittedpartners• Diversifiedfunding•Well-managedstructure:organizedadministration,effectivecommunicationamongparticipants,andacomprehensiveevaluationplan
Muskie School of Public Service Maine Rural Health Research Center
Evidence-basedcommunityorganizingmodels• ProjectLazarus-‒ InallNorthCarolinaCounties‒ Inruralcommunitiesacrossthecountry- ProjectBaldEagle,Williamsport,PA.WinnebagoCountyHeroinTaskForceinWisconsin,ClarkCountyCollaborativeinOhio,andWashtenawHealthInitiativeOpioidProjectinMichigan
• ProjectVision,Rutland,VT‒ UsesaDrugMarketInterventionmodelandcommunitycollaboration/engagementtoreducethesupplyofopioids
• SAMHSA’SRecoveryOrientedSystemsofCare• CommunitiesThatCare
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ProjectLazarus– HubActivities• Hubactivitiesarecentralcomponentssupportingallotheractivitiesandreflectacommunity-based,bottom-uppublichealthapproach‒ Buildpublicawarenessofsubstanceusethroughbroad-basededucationaleffortsandtheuseoflocaldatatodriveawareness
‒ Coalitionbuildingandactiontoengageabroadrangeofcommunityproviders,agencies,andorganizations
‒ Identifydataneedsforplanningandevaluationtobuildawareness,tailorprogramstolocalneeds,trackprogress,andsustainsupportandfunding
Muskie School of Public Service Maine Rural Health Research Center
ProjectLazarus– SpokeActivities• Spokeactivitiesareoptionalareasofevidence-basedpreventioninitiativesthatcommunitiescanselectandreflectamedicalandlawenforcement-based,top-downpublichealthapproach₋ Communityeducation₋ Providereducation₋ Hospitalemergencydepartmentpolicies₋ Diversioncontrol₋ Painpatientsupport₋ Addressingtheconsequencesofuse₋ Addictiontreatment
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ProjectVision– AddressingSupplyIssues• ProjectVision,Rutland,VT‒ Goals:empowercommunities,strengthenneighborhoods,helppeople,changethefuture
‒ Committees:Crime/Safety,SubstanceAbuse,Community/Neighborhoods/Housing
‒ UseaDrugMarketInterventionmodelandcommunitycollaboration/engagementtoreducethesupplyofopioids(heroinandillicitlydistributedprescriptionopioids)inruralRutlandVT
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PrescriberEducationandBehaviour• One-on-oneprescribereducationonpainmanagement• Continuingmedicaleducationonpainmanagement• Licensingactionsagainstcriminalprescribing• Implementandmonitorevidence-basedprescribingguidelinesamongallproviders‒ CDCguidelines,stateprogramssuchasWashingtonstate• Strongly encourageuseofprescriptiondrugmonitoringprograms• Thinkaboutan“oxyfree”emergencydepartment• HarmReduction- NaloxoneandOpioidusereducationonoverdosepreventionandresponse
Muskie School of Public Service Maine Rural Health Research Center
HospitalPreventionStrategies• Participateincommunity-basedpreventionprogramsaspartofhospital’scommunitybenefitand/orcommunity/populationhealthinitiatives• Qualityimprovement:Focusonsupplyreduction‒ Prescribingguidelines‒ Encouragegreateruseofprescriptiondrugmonitoringprograms
‒ UseProjectECHOtosupportprescribingandpainmanagementcapacityoflocalproviders
‒ Implementan“oxy-free”emergencydepartment‒ Engageinharmreductionstrategies
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MidcoastMainePrescriptionOpioidReductionProgram
• ImplementedopioidprescribingguidelinesfordentalpainintworuralEDsinMaine
• DrivenbyEDchairmanwithinputfromphysiciangroup• EDpatientswhorequestrefillsofcontrolledprescriptions,havemultiplecontrolledsubstanceprescriptions,orhavemultiplepreviousEDvisitsforpainfulconditions
• Guidelinesrecommendtheuseofanalgesicalternativessuchasnerveblocksandimmobilization
• Resultsafter12months- reductionsinratesofopioidprescriptionsandvisitsfordentalpain
Muskie School of Public Service Maine Rural Health Research Center
Oxy-FreeEmergencyDepartments(EDs)• EDsareasignificantsourceofopioidprescriptionsandafrequenttargetforthoseseekingopioids• EDprescribingdevelopedbytheWashingtonStateDepartmentofHealth,theWACollegeofEmergencyPhysiciansandtheWAHospitalAssociation• IncludedlimitationsontheprescriptionofopioidsinEDsandtheconceptofan“oxy-freezone”• LowerratesofEDvisitsby“frequentusers”withlowacuitydiagnosesseekingopioids• WAMedicaidestimated$33.6millioninEDsavings• Hospitalsarepleasedwiththestrategybutsomeexperiencedearlyreductionsinpatientsatisfactionscoresrelatedtopainmanagement
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“Oxy-Free”EDs–McKenzieHealthSystem
• InFebruary2013,McKenzieHealthSystem'sEDdiscontinueddispensingnarcoticandsedativemedicationsforcomplaintsofchronicpain
• Results– 60%reductioninopioidprescriptionabusewithina12monthperiodandreducedutilizationofunnecessaryandcostlydiagnosticwork-ups
• Staffmetwithcommunitymentalhealthofficials,countyhealthofficials,localprimarycareproviders,lawenforcement,pharmaciestoexplaintheinitiative
• Engagedinpatienteducation
Muskie School of Public Service Maine Rural Health Research Center
“Oxy-Free”EDs–McKenzieHealthSystem(con’t)• Process:
– Thoroughmedicalexamtoruleoutmedicalemergencies– Reviewofpatient'scompletefile,includinginternalhealthrecords,outsidehealthrecords,drugscreeningtests
– Ifpatientpresentswithachronicpainconditionorsuspectednarcoticsabuses,physicianwillinformpatientofthedangersofnarcoticdrugabuseandmaynotprescribeanarcoticpainmedication
– Mayreceiveanon-narcoticpainmedicationandinformationaboutO/SUprogramsand/orpainmanagementspecialists
– Ifanarcoticpainmedicationisprescribedaftercarefulreviewbythephysician,itisonlyforaverylimitedamountofpills,untilthepatientcanbeseenbyhisorherphysician
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ReducingOpioidPrescribingbyProvidingPainManagementServices
• Duetothelimitedavailabilityofpainmanagementservicesinruralcommunities,manyprovidersrelyonprescriptionopioidsasaprimarytreatmentmodality
• Ruralprimarycareprovidersoftenhavelimitedexperiencewiththemanagementofchronicpain
• Strategies– Expandaccesstopainmanagementservicesthroughcontractsand/ortelehealth
– ImprovethecapacityoflocalproviderstomanagepainthroughuseofprogramsuchasProjectECHO
Muskie School of Public Service Maine Rural Health Research Center
ExpandingLocalPainManagementServices:SalemTownshipHospital
• SalemTownshiprecruitedapainspecialisttotravelanhourfromMarion,Ill.,twiceamonthtotreatpatients.– Consideringexpansiontothreetofourtimesamonth.
• Patientsareseeninonehourincrements• Providestrigger-pointinjectionsforlong-termpainandpromotesphysicaltherapyandalternativetreatments
• Patientscontinuingwithopioidsmustagreetoregulardrugtestsandnotaskforearlyrefills
• Over3to4months,only3outof56patientshavechosentostickwithopioids
• Minimalinvestment- $25,000forcapitalequipment
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Telehealth-BasedPainManagementProgram:Martha’sVineyardHospital(MVH)
• DuetoitsislandlocationoffCapeCod,MVHworkedwithMassachusettsGeneralHospital’sCenterforPainManagementtoofferapainserviceviatelehealth
• MGHprovidersseepatientsinatelepainclinic3dayspermonthandconducton-sitevisitstwicepermonth
• Servicesincludeinitialconsultsandfollow-upvisits• Vitalsigns/patientsnotesarerecordedinasharedEHR• AnRN,trainedinphysicalexaminationofpainandmedicalmanagement,performspatientexamsunderdirectphysiciansupervisionvialivevideoconferenceandalsoverballyannouncedallfindings
Muskie School of Public Service Maine Rural Health Research Center
Telehealth-BasedPainManagementProgram:Martha’sVineyardHospital(con’t)
• Physicalexaminationsarerepeatedbythephysicianduringon-sitevisitspriortopatientintervention
• LaboratorydataandimagingstudiesarereviewedinthesharedHER
• Over13months,49patientsparticipatedin238telepainvideoclinicsand121on-siteinterventions
• Patientsreportreducedtravelcosts,improvedaccesstocare,andgeneralsatisfactionwiththeservice
• Patientsratedtheirsatisfactionwithcarereceivedbytelepainlowerthanin-personvisitsandthoughtithardertodeveloparelationshipwiththedoctor
• Thishighlightsthechallengeofbuildingapatient-physicianrelationshipremotely
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ImportantStrategyArea#2- Treatment• ImplementconsistentOUscreeningforallpatients• DevelopreferralrelationshipswithSU/MHproviders• Explorelocaltreatmentopportunities‒ Medicationassistedtreatment– buprenorphine‒ Integratedbehavioralhealth/SU/primarycareservices‒ Specialtysubstanceuseservices• Collaborativetreatmentprograms– hubandspoke• Exploreuseoftechnologytoexpandaccesstocare• Overdosereversalprograms• Alternativepainmanagementprograms•Workwithlawenforcementtoprovideatreatmentalternativetoincarceration
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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.
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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
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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)
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BridgtonHospitalBuprenorphineClinic• CoordinatedeffortsbetweenBridgtonHospital,NorthBridgtonFamilyPractice,CrookedRiverCounseling
‒ Programhasenrolled200patientsinaruralMainecommunity‒ Startedin2009‒ Fourphysiciansandtwonursepractitionersprescribebuprenorphineintheirprimarycarepractice(NorthBridgton)
‒ CrookedRiverCounselingprovidesintensiveoutpatientcounselingandgrouptherapyforthepatients
‒ BridgtonHospitalprovidescomprehensivematernitycaretowomenwithOUDduringtheirpregnancy
‒ Servicesareinterconnectedandcoordinatedacrossproviders‒ Keyisthecollaborativeapproachandcommunication
BridgtonHospitalBuprenorphineClinic• Benefits‒ Lowerregulatory/licensurebarriersthanmethadoneprograms‒ SAMHSAprescribingwaiveriscomparativelyeasytoobtain‒ Canbeintegratedintoprimarycaresystem‒ Goldstandardoftreatmentforopioids
• Challenges‒ Buprenorphinealoneisnotsufficienttomeetallpatientneeds‒ Canbedifficulttoincorporateintoabusypracticewithoutadditionalsupport
‒ Linkageswithbiggersystemsofcareareneeded
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SupportingMATandOUDServices- Vermont• Vermont’sHubandSpokemodelsupportstheuseofbuprenorphinebyprimarycareandcommunityproviders₋ Comprehensivecaremanagement₋ Carecoordinationandreferraltolocalresources₋ Caretransitions₋ Individualandfamilysupports₋ Healthpromotion₋ Expandsuseofbuprenorphineinprimarycare₋ Recognizesimportanceofmentalhealthandtraditionalsubstanceuseservicesintreatingopioidproblems
₋ Efficientuseofscarceresources₋ Providescareinlessstigmatizingsettings
Muskie School of Public Service Maine Rural Health Research Center
VermontHubandSpoke(cont’d)• Regionalspecialtytreatmentcentersserveasthehubs₋ CoordinatecareofindividualswithcomplexOUDsandco-occurringSUandMHdisorders
₋ ProvidefullrangeofOUDcareandsupportcommunityprovidersbyprovidingconsultativesupporttoprimarycareandotherprovidersprescribingbuprenorphine
• Physiciansprescribingbuprenorphineandcollaboratinghealthandaddictionsprofessionalsserveasthespokes₋ Dispensebuprenorphine,monitoradherencetotreatment,coordinateaccesstorecoverysupports,andprovidecounseling,contingencymgt,andcasemgtservices
• FundedthroughMedicaidwaiver
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ImportantStrategyArea#3- Recovery• ThethirdandoftenoverlookedstrategytoaddressOUdisorders• Providesupportthroughprogramsorastructuredmilieutosupportsobrietyandsubstancefreeliving• Ideally,recoverybeginsbeforetreatment• Addressessocial,rehabilitation,andvocationalissues• Providesacommunitytoreinforcesobriety
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Recovery• “Recoveryisaprocessofchangethroughwhichanindividualachievesabstinenceandimprovedhealth,wellnessandqualityoflife.”SAMHSA• Fourdimensionsthatdefineahealthylifeinrecovery:‒ Health- Managingone’sdisease(s)orsymptoms;makinginformedchoicesthatsupportphysical/emotionalwellbeing
‒ Home– Havingasafeandstableplacetolive‒ Purpose– Participatinginmeaningfuldailyactivitiesandhavingtheindependence,income,resourcestoparticipateinsociety
‒ Community– Engaginginrelationshipsandsocialnetworksthatprovidesupport,friendship,love,andhope
• Hospitalscancoordinatewithlocalrecoveryprograms
Muskie School of Public Service Maine Rural Health Research Center
Recovery– CommunityPrograms• Doescommunitycreateasupportiveenvironmentforrecovery?‒ Stigmareduction– opportunitiesforanewstart‒ Employmentopportunities‒ Educationalopportunities‒ Social,recreationaloutlets‒ Connectiontoculturalheritage‒ Twelvestepprograms‒ Peersupport
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Evidence-BasedRecoveryPrograms• DepartmentofVeteran’sAffairs– PeerRecovery‒ Recruitveteransinrecoverytosupportthosegoingthroughtheprocess
• Australianmentalhealthpeersupport‒ Goal– avoidanceofunnecessaryhospitalizations
• TurningPointCenter,Rutland,VT‒ PartoftheVermontRecoveryNetwork
• SupportingPeerRecovery:TheRECOVERProject,FranklinCounty,MA
• ProjectAngels,Gloucester,MA‒ Providestreatmentasanalternativetoincarceration
Muskie School of Public Service Maine Rural Health Research Center
ChallengestoDevelopingRuralPrograms• Programs“imported”fromoutsidethelocalareaareoftenviewedwithsuspicion• Community-basedprogramsareimportanttocreatelocallydeveloped,culturallyappropriateinterventions‒ Mustbesensitivetolocalcultural,religions,andethnicissues(culturalhumility)andengagelocalleaders
‒ Limitedopportunitiesaftertreatment,stigma,restrictedsocialsupportsfrequentlyleadstorelapse– mustsupportsoberliving
• Continuumofprevention,treatment,andrecoveryservicesmustbedevelopedsimultaneouslytoaddresstheneedsofruralresidents“wheretheyare”
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Recommendations• TheCommunityiskey!!• Supportthedevelopmentandimplementationofcommunitycoalitions- ProjectLazarusorProjectVision• Engageproviders,businesses,schools,residents,lawenforcement• Conductbroad-basededucationonthedangersofopioids• Buildalocalsystemofcarethatintegratesprevention,treatment,andrecoveryandengagesmentalhealth,andsubstanceuseproviders
Muskie School of Public Service Maine Rural Health Research Center
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Muskie School of Public Service Maine Rural Health Research Center
ContactInformationJohnA,Gale,MSSeniorResearchAssociateMaineRuralHealthResearchCenterMuskieSchoolofPublicServiceUniversityofSouthernMainePOBox9300Portland,ME04104-9300
[email protected]