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Substance Use Disorders Treatment and Recovery Support Services in Rural and Remote Areas of the United States: A Three Part Series on the State of the Art

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There is not one model for the delivery of quality and effective substance use disorders treatment and recovery support services in rural areas. However, there are themes emerging from the scientific literature as well as from rural treatment providers implementing new services. These themes/strategies include: use of technology and web-based services; offering recovery support services by telephone or web-based portal systems without initial substance abuse treatment services; and providing flexible service delivery, integrated care, and Project ECHO-like models. Most importantly, a successful substance abuse treatment model for rural areas does not include just one intervention, but rather a combination of the interventions that fit the community and the patient population. Join the NFAR ATTC in this podcast series that includes: exploring rural/remote issues regarding SUDs; highlighting the use of technology in recovery support services both informal and formal strategies; and an update on technology-based interventions for individuals with SUDs or at risk for these conditions.

Presenter: Nancy A. Roget, MS, MFT, LADC

PI/Project Director NFAR ATTC

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Substance Use Disorders Treatment and Recovery Support Services in Rural and Remote Areas of the United States: A Three Part Series on the State of the Art

  1. 1. Nancy A. Roget, MS
  2. 2. develop and strengthen the workforce that provides addictions treatment and recovery support services to those in need Purpose of the Addiction Technology Transfer Centers (ATTCs) (SAMHSA FUNDED)
  3. 3. ATTC Network Coordinating Office 10 Regional Centers 2012 – 2017
  4. 4. National Frontier & Rural ATTC National American Indian & Alaska Native ATTC National SBIRT ATTC National Hispanic & Latino ATTC 4 ATTC National Focus Centers
  5. 5. Servesas the national subject expert and key to PROMOTE the awareness and implementation of telehealth technologies in order to expand access and enhance treatment and recovery services especially in rural and frontier areas
  6. 6. Of the 30 leading diseases and injuries in the United States, drug use disorders have accounted for the greatest increase in deaths and years of life lost between 1990 and 2010 (US Burden of Disease Collaborators, 2013) The largest portion of these deaths results from the ingestion of prescription and illicit opioids (CDC, 2011) exceeding the number of people dying in car accidents (Paulozzi, 2012) Rosenblatt, Andrilla, Catlin, and Larson, 2015
  7. 7. Substance use is a public health crisis in the rural United States and has been identified as one of the top 10 priorities Rural Healthy People 2020
  8. 8. Higher rates of substance use in rural communities compared to urban areas have been well-documented. (Martino et al., 2008; Small et al.,2010; Shannon et al., 2010; Gamm et al., 2003; Jackson et al., 2006; Lamberts et al., 2008; Blazer et al., 1987; Jackson, 2012)
  9. 9. The prevalence of substance misuse in rural communities is also concerning, particularly given that detoxification and intensive recovery centers tend to be located elsewhere (Lenardson, Hartley, Gale, & Pearson, 2014)
  10. 10. More than 1in 5Americans live within a rural area (U.S. Census Bureau, 2010) where economic, religious, historical, and geographic factors combine to create a unique culture that influences mental health outcomes, physical health conditions, and health behaviors Hunt, et al., 2012
  11. 11. There are actually more rural residents than any racial, ethnic, or sexual orientation minority group in the US…. It is surprising, then, that rurality has traditionally not been viewed as a diversity issue worthy of inclusion with other recognized multicultural groups (Harowski, Turnder, LeVine, Schank, & Leichter, 2006)
  12. 12. Individuals in rural communities have unique barriers to treatment and recovery services (Fortney & Booth, 2001; Fortney, 2011 Browne, et al., 2015)
  13. 13. Geographic proximity to substance use services and transportation to access such services are particularly significant barriers in rural communities. (Browne, et al., 2016 Beardsley, et al., 2003; Fortney, 1995; Booth, Ross, and Rost, 1999)
  14. 14. Clients who must travel more than 1 mile to outpatient substance use services have been found approximately 50% less likely to complete recommended treatment…. (Beardsley, et al., 2003 Browne, et al., 2015)
  15. 15. Barriers Include • Travel Costs and Burden (Rheuban, 2012) • Time Away From Work (Berwick, 2008) • Child Care (Berwick, 2008) • Service Provider Shortages (Perle et al., 2011; Swinton et al., 2009)
  16. 16. • lower utilization and treatment completion rates (Fortney & Booth, 2001; Metsch & McCoy, 1999; Staton & Tindall, 2007) limited behavioral health services availability (Pullman &Heflinger, 2009 and Gordon, et al., 2001) • higher financial burden to pay for services (Fortney et al., 2004; Robertson& Donnermeyer, 1997) • exacerbated stigma (Robertson & Donnermeyer, 1997 & Notley et al., 2012) • privacy concerns (Fortney et al., 2004; Hargrove, 1986; Hutchinson & Blakely, 2003) Barriers contiued Browne, et al., 2015
  17. 17. Poverty also diminishes clients’ ability to self-manage their substance use treatment regimes. Browne, et al., 2015
  18. 18.  Poverty • An estimated 17% of adult rural residents live below the  federal poverty line, as compared with 14% of urban residents  (Economic Research Service [ERS], 2011).  • Poverty rates are even higher for minority rural residents: 32% of rural African Americans and 28% of rural Hispanics live  below the poverty line (ERS, 2011).  • Rural residents have been shown to go longer periods of time  without health insurance, and are less likely to seek care when  they cannot pay because of pride and the lack of reduced-price  medical care services in rural areas (Mueller, Patil, & Ullrich,  1997).  • Even if an individual decides to seek care, rural areas are  plagued by shortages in mental health care professionals  (Murray & Keller, 1991).  Bryant-Smalley & Warren, 2012
  19. 19. These cultural, economic, and provider shortage challenges combine to sustain behavioral health problems in rural areas that unfortunately are not easily addressed….. Bryant-Smalley & Warren, 2012
  20. 20. Compared with urban areas, Primary Care providers in rural areas play an even greater role in the de facto behavioral health care system (Geller, 1999; Fox, Merwin, & Blank, 1995 and Hartley, Bird, and & Dempsey, 2005) Yet…. rural PC providers frequently lack the expertise, time, and resources to effectively treat mental health and substance use disorders (Hunt, et al., 2012) Hunt, et al., 2012
  21. 21. Moreover…. the linkages between rural PC practices and distant specialty behavioral health care practices are weak in most rural areas, making referrals infeasible (Reschovsky and Staiti, 2005) and use of off-site mental health specialists unlikely (Hauenstein, et al., 2007) Hunt, et al., 2012
  22. 22. Physicians Approved to Prescribe Buprenorphine 30 million people, or 9.7% of the US population, were  living in counties that had no physician with a waiver, 21.2 million of them in rural counties and 8.8 million  in metropolitan counties.  Of the counties that had no physicians who could prescribe  buprenorphine, 82.1% were in rural areas The relative paucity of these physicians in rural areas is a  major barrier to office-based outpatient treatment for opioid  use disorders. Rosenblatt, Andrilla, Catlin, and Larson, 2015
  23. 23. Perhaps the two most significant obstacles to providing high-quality mental and behavioral health care in rural America are workforce issues and include the persistent shortage of trained specialists and professional/personal isolation. (Deleon, Kenkel, & Shaw, 2012)
  24. 24. Barriers to Treatment Identified by Rural Addiction Counselors included a lack of: • Funding • Public transportation • Case management • Interagency cooperation • Detoxification facilities • Mental health services • Medication assisted treatment (MAT) • Privacy (Pullen & Oser, 2014)
  25. 25. With 20% of the U.S. population being rural, and even more than that coming from a rural background, every clinician will face the influence of rural culture….
  26. 26. Equipping clinicians-in-training with an understanding of rural culture can help them ensure that they deliver the best possible care to their clients. Bryant-Smalley and Warren, 2012
  27. 27. Academic programs should begin to incorporate basic knowledge of rural culture into their curriculum—not only within rural- focused programs, but more importantly outside of such programs where rural competency might not otherwise be acquired. Bryant-Smalley and Warren, 2012
  28. 28. (Bryant-Smalley & Warren, 2012) Remembe r • Not all rural cultures are the same • Be aware of the potential effects of rural living on personality characteristics, including self-reliance and avoidance of help-seeking behaviors • Explore religion as appropriate with rural clients – Do not assume clients are or are not religious, but be mindful of the fact that religious beliefs may enter in the therapeutic discussion • Don’t make assumptions about a patient’s SES just because they live in a rural area and poverty rates are higher • Rural areas have more stigma about receiving mental health services
  29. 29. Resistance to therapeutic techniques and revealing to friends/families the presence of a mental illness will be amplified in rural settings… clinicians must understand that the reasons behind such resistance may well be based in cultural, rather than cognitive decision-making processes. (Smalley & Warren, 2012)
  30. 30. Not all cultural aspects of rural living have negative impacts on mental health. Religiosity, highly prevalent in rural areas, can have a protective and therapeutic effect.
  31. 31. Rural Clients’ Recommendations for Treatment & Recovery Providers… Technology • Increase client engagement by having a Web site that has information about substance use in general, the organization, and its resources • Secure high-speed Internet, interagency-connected phone lines, teleconference capability • Use technology to maximize time spent with clients, as inefficient technology requires significant staff time and decreases staff services (Browne, et al., 2015)
  32. 32. Rural Clients’ Recommendations for Treatment & Recovery Providers-Technology • Ensure Internet access throughout the entire organization as it would greatly enhance patient education and counseling resource options (share with clients and client groups) • Offer services on a flexible operating schedule and include telephone-based services Browne, et al., 2015
  33. 33. (Moore et al., 2011; Muench et al., 2013; Muench, 2015) Current evidence demonstrates that clients use and are interested in using technologies as part of their treatment or continuing support
  34. 34. R Rural is different not less Justin Maxson

Editor's Notes

  • The ability to be culturally sensitive and aware is so valued within clinical
    training programs and clinical practice that individuals who demonstrate an
    inability to gain cultural competence and sensitivity can be held back or even
    dismissed from training programs (Chronicle of Higher Education, 2010; Inside
    Higher Ed, 2010).
    Despite the abundant evidence pointing to the importance of considering and incorporating cultural themes into mental health treatment, the recognition of rurality as a bona fide multicultural issue has not been embraced by the mental health field. More than one in five Americans live within a rural area (U.S. Census Bureau, 2010), where economic, religious, historical, and geographic factors combine to create a unique culture that has been shown to influence mental health outcomes, physical health conditions, and health behaviors (GeorgiaHealth Equity Initiative, 2008; Pathman, Konrad & Schwartz, 2001; Pearson &
    Lewis, 1998; Tai-Seale & Chandler, 2003). It is surprising, then, that rurality has
    traditionally not been viewed as a diversity issue worthy of inclusion with other
    recognized multicultural groups (Harowski, Turnder, LeVine, Schank, &
    Leichter, 2006). There are actually more rural residents than any racial,
    ethnic, or sexual orientation minority group, representing a large group of individuals
    being strongly influenced by culture, but without professional recognition
    of the importance of that culture in influencing their mental health.
    We posit that rurality should be recognized as its own unique culture that
    merits inclusion into the traditional notions of multiculturalism—in essence, that
    rurality is a diversity issue. While a concise definition of rural is elusive (see
    Chapter 1), and has been debated in the literature since at least the 1930s
    ( Jordan & Hargrove, 1987), this lack of a consistent definition does not mean
    that rurality has any less of an influence on an individual’s cultural heritage.
  • All of the issues listed here were identified as common barriers to individuals entering treatment for mental health or SUDs according to several different studies and articles. Using telehealth technologies to deliver treatment and recovery services may help address these barriers, especially for those living in frontier/rural areas.
    Source
    Berwick, D., Nolan, T., & Whittington, J. (2008). The Triple Aim: Care, Health, and Cost. Health Affairs, 27(3), 759-769.
    Perle, J.G., Langsam, L.C. & Nierenberg, B. (2011). Controversy clarified: An updated review of clinical psychology and telehealth. Clinical Psychology Review, 31(8), 1247-1258.
    Rheuban, K.S. (2012). The Role of Telehealth in an Evolving Health Care Environment: Workshop Summary. Washington, DC: National Academy Press.
    Rheuban, K.S. (2012). Planning committee remarks. In The role of telehealth in an evolving health care environment: Workshop summary (pp. 55-57). Available at http://www.iom.edu/Reports/2012/The-Role-of-Telehealth-in-an-Evolving-Health-Care-Environment.aspx
    Swinton, J.J., Robinson, W.D., and & Bischoff, R.J. (2009). Telehealth and rural depression: Physician and patient perspectives. Families, Systems, & Health, 27(2), 172-182.
  •  
    And transportation . . . is the number one problem for many of the folks we have. They no longer have a driver’s license; they abused that privilege and lost it. They can’t get to 12 step meetings, they can’t get to work, they can’t get an IOP or any kind of counseling session, and they live 20 miles away from wherever. Without public transportation these people are having to rely on rides from other family members who have been enabling or using with them, or friends who have been enabling or using with them.
  • Emerging evidence suggests that incorporating religious themes into therapy with rural populations can be particularly effective It also addresses the high degree of comorbidity between physical and mental
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