Opioid Use Disorder: Rural Policy Brief

Key points

  • Drug overdoses are one of the leading causes of injury death in adults and have risen over the past several decades in the United States.1

Overview

Opioid use disorder is a complex problem that crosses different areas of public health and health care. The rate of opioid overdoses in rural areas is affected by several factors including the number of people exposed to opioids, how many of those people become addicted, and what, if any, treatment is available.1

Addressing these multiple, high-impact factors simultaneously could help prevent new people from becoming addicted, treat those who are already addicted, and prevent overdose deaths.

While there is promising evidence on the effectiveness of these types of polices and strategies in preventing and treating opioid use disorder and opioid overdoses,23 more information is needed to understand how to effectively target rural populations and reduce rural opioid overdose deaths.

Policy and Strategy Options

Increase Adherence to Evidence-Based Prescribing Practices

Data show that despite continued concerns about opioid use disorder, the number of opioid prescriptions in the United States remains high.4 Following prescribing guidelines can improve patient safety and address opioid misuse and overdose.5

In 2016, CDC released the Guideline for Prescribing Opioids for Chronic Pain that covers 12 recommendations for primary care clinicians treating patients with chronic pain (excluding those patients under active cancer treatment, palliative care, and end-of-life care). The CDC Guideline was intended to ensure patients have chronic pain treatment while reducing the risk of opioid use disorder, overdose, and death. 6The recommendations in the Guideline are voluntary, rather than prescriptive standards. Yet, the CDC Guideline provides scientific evidence that could be used to inform local policy changes.

Expand Access to Medication-assisted Treatment (MAT)

Medication-assisted Treatment (MAT) is “a comprehensive way to address the needs of individuals [with opioid use disorder] that combines the use of medication (methadone, buprenorphine, or naltrexone) with counseling and behavioral therapies.”7 MAT plays a crucial role in controlling withdrawal symptoms as people try to manage their recovery.8

In order to treat patients with buprenorphine outside of traditional federally certified opioid treatment programs, doctors, and other qualifying health care providers, must apply for and receive a waiver from Drug Enforcement Administration (DEA), in conjunction with the Substance Abuse and Mental Health Services Administration (SAMHSA).

Increase Availability of Overdose Reversing Medications

Naloxone is a prescription drug that can reverse opioid overdoses. State laws and regulations can limit access to naloxone. Currently, all 50 states and the District of Columbia have changed their laws to increase access to naloxone,9 but there are other legal and regulatory changes that can increase access and availability, such as the following:

  • Providing naloxone to non-medical personnel who may witness an overdose is a cost-effective and safe way to reduce overdose deaths.10
  • Allowing doctors to provide naloxone to a person who could administer the drug to another person who is at risk for an overdose, also known as third-party prescriptions. Research shows that educating family or close friends about the signs of overdose and use of naloxone may help prevent overdoses.11
  • Examining scope of practice laws that determine which emergency personnel may administer naloxone. Only 19 states allow all levels of emergency personnel to administer the drug.12 This means that in rural areas basic EMTs are often not allowed to use naloxone.

State laws and regulations have a direct impact on the availability of overdose reversing medications. State legislators and regulators can consider changes to existing policies in order to increase availability and decrease fatal overdoses in rural areas.

Case Studies

Midcoast Maine Prescription Opioid Reduction

Over 40% of Maine's population lives in a rural area.13 In 2011, two hospitals in rural Maine changed their emergency departments' prescription protocol, with an overall goal of deterring opioid use disorder.14 Physicians and nurses used the guidelines to evaluate patients who came to the emergency departments experiencing dental pain and make decisions about prescribing. After comparing data from the year before and the year after the guidelines were implemented, the emergency departments observed a 17% reduction in the opioid prescription rate for patients discharged with painful dental conditions. In addition, the proportion of emergency department and urgent care visits by patients claiming dental pain decreased by 19%.

Vermont Hub and Spoke Model

Over 65 % of Vermont's population lives in a rural area.14 Vermont developed a comprehensive system to treat opioid use disorder that includes MAT and behavioral support. Six regional specialty treatment centers are the "hubs" coordinating the care of individuals with complex opioid use disorders. Designated clinics and physicians who prescribe buprenorphine are the "spokes."15 These spokes can reach out to hubs for consultations on referrals and screenings.16 The program also created "care connectors" who provide coordination between the hubs and the spokes.17

The state incentivized doctors to begin prescribing buprenorphine/naloxone by funding online training for physicians to obtain DEA waivers. In addition, the state offers technical assistance to physicians who prescribe buprenorphine.17 After implementing this model and putting in place additional support structures, Vermont has increased the number of waivered physicians in the state.

Project Lazarus 181920

Project Lazarus is a model of community engagement that has been successfully adopted in rural communities throughout North Carolina and in other states. The program is intended to help communities prevent overdoses, promote responsible pain management practices, and support substance abuse treatment. From 2009-2011, unintentional overdoses in Wilkes County, the original site of the Project Lazarus, decreased 69%. The program addresses and prevents drug overdose deaths through a variety of methods, including providing Project Lazarus Rescue Kits for individuals, families, health departments, and law enforcement personnel. The kit contains two doses of nasal naloxone as well as educational information on how to revive someone who has overdosed. Between August 2013 and November 2014, there were reports of over 200 documented overdose reversals in the state.21

Print
Content Source:
Public Health Infrastructure Center
  1. Health Affairs Blog. A Systems Approach is the Only Way to Address the Opioid Crisis. 2016. Available from https://www.healthaffairs.org/content/forefront/systems-approach-only-way-address-opioid-crisis. Accessed May 17, 2017
  2. Centers for Disease Control and Prevention. Promising State Strategies. 2017. Available from Strategies and Partnerships | Drug Overdose | CDC Injury Center. Accessed August 19, 2017.
  3. Centers for Disease Control and Prevention. Expanding Naloxone use could reduce overdose deaths and save lives. 2015. Available from https://www.cdc.gov/media/releases/2015/p0424-naloxone.html.
  4. Centers for Disease Control and Prevention. Vital Signs: Opioid prescribing. 2017. Available from: https://www.cdc.gov/vitalsigns/pdf/2017-07-vitalsigns.pdf [PDF – 4.67 MB]
  5. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1
  6. Centers for Disease Control and Prevention. CDC Guideline for Prescribing Opioids for Chronic Pain. 2017. Available at Prescribing Practices | Drug Overdose | CDC Injury Center. Accessed August 19, 2017.
  7. Centers for Disease Control and Prevention. Treat Opioid Use Disorder. 2017. Available at Overdose Prevention | Drug Overdose | CDC Injury Center. Accessed August 19, 2017.
  8. Pew Charitable Trusts. Medication-Assisted Treatment Improves Outcomes for Patients with Opioid Use. 2016. Available from http://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2016/11/medication-assisted-treatment-improves-outcomes-for-patients-with-opioid-use-disorder. Accessed September 15, 2017.
  9. The Network for Public Health Law. Legal Interventions to Reduce Overdose Mortality: Naloxone Access and Overdose Good Samaritan Laws. 2017. Available from https://www.networkforphl.org/_asset/qz5pvn/network-naloxone-10-4.pdf. Accessed September 14, 2017.
  10. Wheeler, Eliza & Stephen Jones, T & K Gilbert, Michael & J Davidson, Peter. (2015). Opioid Overdose Prevention Programs Providing Naloxone to Laypersons – United States, 2014. MMWR. Morbidity and Mortality Weekly Report. 64. 631-5.
  11. Dasgupta, N., Sanford, C., Albert, S., & Brason, F. W. (2010). Opioid Drug Overdoses: A Prescription for Harm and Potential for Prevention. Pharmacy Review, 4(1), 32-37. doi:10.1177/1559827609348462.
  12. Rural Health Information Hub. Midcoast Maine Prescription Opioid Reduction Program. 2017. Available at https://www.ruralhealthinfo.org/community-health/project-examples/893. Accessed August 19, 2017.
  13. Rural Health Information Hub. Maine. 2016. Available from https://www.ruralhealthinfo.org/states/maine. Accessed October 10, 2017.
  14. Rural Health Information Hub. Vermont. 2017. Available from https://www.ruralhealthinfo.org/states/vermont. Accessed October 10, 2017.
  15. Gale JA, Hansen AY, Elbaum Williamson M. Rural Opioid Abuse Prevention and Treatment Strategies: The Experience in Four States. Portland, ME: University of Southern Maine, Muskie School, Maine Rural Health Research Center; April 2017. Working Paper #62.
  16. Brooklyn, J. R., & Sigmon, S. C. (2017). Vermont Hub-and-Spoke Model of Care For Opioid Use Disorder: Development, Implementation, and Impact. Journal of Addiction Medicine, 11(4), 286–292. http://doi.org/10.1097/ADM.0000000000000310
  17. Chou R, Korthuis PT, Weimer M, et al. Medication-Assisted Treatment Models of Care for Opioid Use Disorder in Primary Care Settings [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016 Dec. (Technical Briefs, No. 28.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK402352
  18. Rural Health Information Hub. Project Lazarus. 2017 Available from https://www.ruralhealthinfo.org/community-health/substance-abuse/3/project-lazarus. Accessed August 7, 2017.
  19. Rural Health Information Hub. Project Lazarus Evidence Summary. 2015 Available from https://www.ruralhealthinfo.org/community-health/project-examples/870. Accessed August 7, 2017.
  20. Project Lazarus. Naloxone: The Overdose Antidote. Available from https://www.projectlazarus.org/naloxone. Accessed August 7, 2017.
  21. Watson, V. (2015). Top-down and bottom-up initiative create a comprehensive prescription drug overdose prevention program in North Carolina. In J.L. Michenar, D. Koo, B.C. Castrucci, and J.B. Sprague (Eds.), The Practical Playbook: Public Health and Primary Care Together. Retrieved from https://academic.oup.com/book/29494/chapter/247492595
  • Spencer MR, Garnett MF, Miniño AM. Drug overdose deaths in the United States, 2002–2022. NCHS Data Brief, no 491. Hyattsville, MD: National Center for Health Statistics. 2024. DOI: https://dx.doi.org/10.15620/cdc:135849