By Yen Duong
While conversations about the national opioid epidemic often focus on hardest-hit states such as Ohio, West Virginia and Kentucky, few people have analyzed county-by-county trends, where those state’s policies can make a difference.
But a new study, published last month in an open-access version of the Journal of the American Medical Association, classified 412 counties as “high-risk” and 1,485 as “not high-risk.” Among those, 41 of North Carolina’s 100 counties qualified as “opioid high-risk” counties.
“That was one of the highest states that we found in terms of the number of counties relative to the total number of counties in the state,” said Rebecca Haffajee, a University of Michigan public health professor who ran the study. “That tells us that North Carolina and these counties in particular need to think about how to get more providers to those areas.”
Counties were deemed high risk if they had higher than the national rate of 12.5 opioid-related deaths per 100,000 people, and lower than the national rate of 9.7 providers of medication-assisted treatment, or MAT, for opioid use disorders.
North Carolina’s Department of Health and Human Services is spending two-thirds of a recent $12 million federal grant to fight the opioid epidemic on direct treatment for uninsured people with the remaining third spent on “linkages to care” or support for housing, case management, employment and other social factors, said Kody Kinsley, who works in behavioral health for DHHS.
“A lot of other states that have expanded Medicaid are able to use their Medicaid program to pay for treatment, and they can pump almost all of their federal grant money into linkages to care,” Kinsley said. “That’s a big reason why we continue to struggle in this fight.”
What ‘high risk’ means
High-risk counties had a few common characteristics: fewer primary care physicians per 100,000 residents, higher unemployment, a higher proportion of whites, fewer people with a high school education and fewer residents under the age of 25.
Of rural counties in the U.S., 71 percent had no publicly listed providers of any of the three medications, versus 46 percent of all counties with no such providers. But urban areas were also likely to be high risk.
“We were a little surprised by that finding,” Haffajee said. “The reason, we think, is because we use more recent death data … We’re picking up the risks of fentanyl and [other] illicits that other studies haven’t yet, because those hadn’t become super prevalent and saturated urban areas in the earlier years.”
41 of 100 N.C. counties were classified as opioid “high risk” counties in a recent JAMA study, with higher than national rates of opioid overdose deaths and lower than national rates of providers of medication assistant treatment. Map: Yen Duong
Although Henderson County, south of Asheville, has a federally qualified health center that offers methadone, it was classified as high risk. Steven Smith, the health director in Henderson County, thinks that may be because, with more education, more deaths have been identified as opioid-related.
“Henderson County overall is a pretty well-off county in terms of their percentage of primary care physicians and relatively low amount of uninsured,” said Smith, who is also the president of the North Carolina Association of Local Health Directors “We have been focused with community partners for years here, doing a lot of work upstream with prevention and harm reduction.”
Many barriers to MAT
People who want to get medication-assisted therapy face multiple barriers before they can access the three forms of MAT: buprenorphine, methadone and naltrexone. To dole out buprenorphine, the most common MAT, doctors complete an eight-hour training and apply for a federal waiver to prescribe to up to 30 patients. They can apply for a waiver to prescribe up to 100 patients, and after a year they can reapply to prescribe to 275 per year.
Methadone can only be given under a physician’s supervision in opioid treatment programs approved by the federal Substance Abuse and Mental Health Services Administration. There are 76 such approved programs in North Carolina listed on the SAMHSA website.
“It’s still crazy that both buprenorphine and methadone are regulated more strictly than opioid analgesics,” Haffajee said. “Any prescriber can prescribe hydrocodone or oxycodone [opioid painkillers] without any hoops they have to jump through.”
For naltrexone, patients need to be entirely free from opioids for seven to 10 days before starting treatment; otherwise, they’ll have serious side effects. For those with opioid use disorder, that means withdrawing from opioids first, a hurdle that can be insurmountable for many. But naltrexone has no waiver requirements for prescribing and can be useful for some patients.
“What might work for one patient might not work for another,” Haffajee said. “Having the full panoply of options available and you try one and then [if] that doesn’t work as well, you try other is the best course of treatment.”
Because of how costly MAT is, DHHS funds have gone toward treating “ten to twelve thousand people,” which is not enough, Kinsley said.
“The truth is, we’re still scratching the surface. We suspect one in 20 people have a substance use disorder in North Carolina,” Kinsley said. “It’s a long-term treatment. It’s a chronic disease like diabetes; people don’t go to one dialysis visit and they’re done. It’s a lifetime thing. We’re really behind the curve in keeping up with that.”
Ideas to address the whole person
The study argues that increasing access to these medications in high-risk opioid counties could reduce deaths by up to 60 percent. Haffajee said states should encourage doctors to prescribe more buprenorphine, help more doctors get the waiver, and also focus on policies that address the other conditions of high-risk counties—the linkages to care mentioned by Kinsley.
“If you don’t have a high school education, if you don’t have a safe place to live, if you don’t have access to transportation, the least of your problems is getting a provider to give you a medication for your substance use disorder,” Smith said. “You have to start addressing that whole person in a meaningful way to give them even a chance of climbing out of that abyss.”
Right now, federally waivered doctors who prescribe buprenorphine must also register with the state. House Bill 325, which was just signed by Governor Cooper, gets rid of that requirement and gives more support to needle exchange programs and people who test drugs for contaminants.
In addition to that legislative change, DHHS is hoping to change rules to build up “satellite” dosing offices. In that case, patients could go to a usual MAT provider for their first few doses, and then the provider could send out a nurse or doctor out to rural satellite offices near the patient a few times a week, Kinsley said.
“Right now, if you live in Rutherford County, and you’re on medication-assisted treatment, you’re probably driving to Buncombe County two to three times a week to receive your dose,” Kinsley said. “I couldn’t drive 60 miles somewhere three times a week and keep a job and maintain a family and that sort of stuff.”
Smith said that even if lawmakers do not expand Medicaid, “the cost of this crisis does not go away.”
“Communities are paying for it every day, in terms of support services, human services, legal intervention, detention facilities, emergency departments,” Smith said. “We’re all paying for this, one way or another, regardless of whether or not it shows up on the balance sheets at the state.”