A patient being treated for opioid addiction in Olympia, Washington, prepares to take a dose of buprenorphine, a medication that prevents opioid withdrawal sickness. The medication was one topic of discussion at a recent hearing of the House Energy and Commerce Committee’s Subcommittee on Oversight and Investigations. (AP Photo/Ted S. Warren)

Battling opioids in rural areas is more than just providing naloxone and reducing opioid prescriptions. It means looking at how addiction services are delivered and how to get patients to treatment, experts said during a U.S. House of Representatives hearing last week.

Witnesses testifying at the House Energy and Commerce Committee’s Subcommittee on Oversight and Investigations on January 14 also said treating the opioid crisis in rural areas in the future will require that states have more flexibility on how they use federal funding. (Testimony and video are available on the web.)

Committee members called the hearing to determine whether federal funding is being used effectively.

In West Virginia, one of the states hardest hit by the opioid crisis, Christina Mullins, commissioner for the West Virginia Bureau of Behavioral Health in the Department of Health and Human Resources, said the state has reduced its opioid prescriptions and opioid doses by half.

“It is no secret that West Virginia is ground zero of the opioid crisis,” she said in her testimony to the subcommittee. “But today, I would like to tell a different story. With your help, West Virginia has reduced overdose deaths for the first time in over 10 years.”

Besides reducing opioid prescriptions and doses, prescriptions for naloxone, which treats opioid overdoses, have more than doubled. The state has also distributed over 10,000 doses of naloxone to local health departments.

Mullins said the state is developing capacity to treat addiction in new ways. Since 2017 the number of waivers to prescribe buprenorphine has doubled.

(To prescribe buprenorphine, used in the treatment of opioid abuse disorder, providers must get a waiver from the U.S. Drug Enforcement Agency. Critics argue that the waiver process is cumbersome and hinders the ability of healthcare providers to treat addicts. To get a waiver, physicians must apply to Substance Abuse and Mental Health Services Administration (SAMSHA), get eight hours of training, learn about addiction treatment, and understand best practices for administering the drug.)

The number of residential treatment beds has more than tripled, from 197 to 740.

“Our records indicate that 85% of these beds are always in use,” Mullins said. “Additionally, nearly all birthing facilities have access to integrated substance use disorder treatment in their community.”

Using data derived from Centers for Disease Control (CDC) and state reports, West Virginia was able to identify “hot spots” and ensure appropriate funding and resources were available to every city and county. West Virginia has received more than $200 million in state and federal funds since July 2016 to address the opioid crisis and establish programs to help local county governments access those funds, she said.

“West Virginia faced several challenges in the deployment of federal resources to its local communities,” Mullins said. These included lack of community infrastructure to administer federal funding appropriately and a lack of a qualified workforce at the local level. The state Department of Health and Human Resources used technical assistance funds from SAMSHA to train communities on state and federal requirements. “These training opportunities will continue in the future as West Virginia works to strengthen and expand the capabilities of local and regional agencies providing services to those most in need,” she said.

The state also uses Quick Response Teams, which work to reach out to individuals who have had an overdose. These teams, made up of law enforcement officers, first responders, health department personnel and substance use treatment providers, are tasked with engaging an overdose survivor within 24-72 hours to discuss treatment options – whether through phone calls, texts or house visits. The goal, Mullins said, is to reduce the possibility of a repeat overdose and to increase the chances the survivor will enter into treatment.

Of fundamental importance, she said, was getting patients to treatment across rural roads.

“As West Virginia is one of the most rural states in the nation, with a lack of mass transit options for many residents, transportation has long been a significant barrier in access to treatment and recovery services,” she said. “Several strategies have been employed to address this barrier.”

The Substance Use Disorder Waiver allows Medicaid-funded transportation to treatment via the non-emergency medical transportation provider. Additionally, West Virginia has partnered with the West Virginia Public Transit Authority to offer after-hours transportation and expanded route access to cover more rural areas specifically to assist individuals in accessing treatment and recovery services.

Similarly North Carolina has addressed the issue of transportation. Building treatment facilities is also important, said Kody Kinsley, deputy secretary of Behavioral Health and Intellectual and Developmental Disabilities for the North Carolina Department of Health and Human Services.

“If we are going to invest heavily in building our treatment capacity, we must also make sure that the people who need it most are connected to that care,” Kinsley testified. “North Carolina’s vision is that no door is the wrong door to getting high quality, evidence-based treatment, and that getting treatment should never be a matter of chance or luck.”

Rep. Greg Walden, R-Oregon, asked witnesses how they were dealing with getting those needing treatment to appropriate facilities. In his state, one woman was forced to travel five hours to a neighboring state for treatment.

Shifting care to doctors’ offices instead of treatment facilities was one way to counter that, Kinsley said, but that shift would require federal removal of the DATA Act DEA waivers. While the federal government requires providers to have a second DEA waiver for the prescription of buprenorphine for treatment of opioid addiction, it doesn’t require a similar waiver for any other use of the drug, or for some other more dangerous drugs. Witnesses said the second waiver was a burden to increasing the number of physicians in their states who can help treat addiction with medicine.

As North Carolina shifts its treatment options to more office-based treatment, it’s necessary for physicians who can provide treatment to get that second DEA waiver. Kinsley said without the second waiver the state could more quickly increase the number of doctors who could provide treatment.

But the crisis is shifting, Kinsley said, and federal funding needs to give states the flexibility to address the coming wave of deaths. In many cases, stipulation on the funding requires it to be linked directly to opioid misuse treatment.

“Already, North Carolina is starting to see rising rates of overdose deaths from methamphetamine and benzodiazepines,” he said. “Those of us who have been in this field long enough know that these epidemics come in waves. Today it is opioids, in the coming years it will be something new: methamphetamine, benzodiazepines, cocaine — just like there were the waves of crack and cocaine in the decades before this one.”

Flexibility in funding will allow states to shift their responses as the drugs at the center of the epidemic change. Jennifer Smith, Pennsylvania’s Secretary for the Department of Drug and Alcohol Programs, said because funding is tied to opioids, using those funds becomes more difficult as the tide shifts.

“We are seeing more poly-substance abuse. And it’s challenging to appropriately tie treatment to opioids while some of the people we’re treating may not identify opioids as their primary substance,” she said.

More flexible funding, she said, would allow states to address the system and not the substance.

And ensuring that funding is stable and sustainable is especially important for rural areas as they build more treatment facilities, Kinsley said. Knowing funding is sustainable, he said, would allow treatment providers the security they need to build and staff treatment facilities.

“Treatment providers in rural and underserved areas need to know that there is sustainable and long-term funding for them to build and expand in the areas that need them the most,” Kinsley said. “I often make the analogy that you wouldn’t build a hardware store if there was only two years of funding for nails.”

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