“In the rural counties, there are very few providers that are prescribing the buprenorphine. Very, very few."
Many people, desperate for addiction treatment, made the journey to larger cities in search of providers. Some resorted to buying addiction-treating drugs off the street.
“It’s a big financial issue to buy it off the streets. It was also illegal,” Humphrey said. “In the area there is no medication-assisted treatment, and in rural areas, those are the areas that need it most.”
Humphrey is a licensed clinical social worker and the behavioral health clinical director at Caring Hands Healthcare Centers. The nonprofit has two clinics in rural Pittsburg County, an area that had one of the highest opioid prescribing rates in the state in 2017.
The organization started a treatment program in McAlester in late August that combined the addiction drug buprenorphine with counseling.
Buprenorphine is often prescribed under the brand-name version Suboxone, a drug that is combined with naloxone. The long-acting opioid is typically used to treat opioid addiction and can help manage withdrawal symptoms, curb opioid cravings and comes with a much lower overdose risk than the drug methadone.
In rural areas, professional treatment with buprenorphine can be hard to come by. Experts and treatment providers say rural areas have been slow to embrace the drug, and some areas do not have prescribers who can treat patients with buprenorphine.
Dr. Jason Beaman is the chair of the Department of Psychiatry and Behavioral Sciences at Oklahoma State University Center for Health Sciences. He gives lectures around Oklahoma and the U.S. on Suboxone and the opioid addiction epidemic.
Beaman said many doctors in rural areas don’t realize the opioid epidemic has hit their counties. It’s one of the biggest challenges to addiction treatment access, and oftentimes those doctors are unwittingly overprescribing opioids.
“When I show them (doctors) my Oklahoma map of overdoses in 2002 and then I show them 2014, their eyes just open up,” Beaman said. “And I can’t believe they haven’t seen the map. So a lot of them say, ‘Wow. I had no idea.’
“I would like to think that if they knew that, they would not continue to prescribe the way that they are.”
Many rural health care providers do not get the training they need to prescribe the drug, Beaman said.
Buprenorphine is one of three federally-approved medications to treat opioid addiction. Prescribers who want to treat patients with the drug must apply for a special federal waiver. The number of patients they can prescribe to is capped, a regulation that’s specific to buprenorphine.
In the first year a prescriber has a waiver, he or she is allowed to treat only up to 30 patients with buprenorphine at a time. After a year the prescriber may apply to treat up to 100 patients, and after another year they can request to increase that limit to 275.
The limit can make the drug hard to access, and meanwhile many rural doctors who have a waiver simply don’t use it, Beaman said.
“In the rural counties, there are very few providers that are prescribing the buprenorphine. Very, very few,” he said. “The problem with medication assisted treatment is not just lack of waivers, it’s a lack of people with waivers who are using it.
“You can’t just get the waiver, you actually have to use it. And it’s kind of complicated.”
Doctors in rural areas with already high caseloads may not want to go through the long process of prescribing the drug and treating someone with an opioid addition, Beaman said. Setting the proper burpenorphine dose for a patient takes time. A patient will often wait in a doctor’s lobby for hours while a prescriber measures withdrawal symptoms.
“Now if you’re a family medicine doctor, you’ve got grandma with diabetes, you’ve got little Jenny with a sore throat, and then you’ve got John who’s addicted to heroin waiting in your lobby for eight hours,” he said. “So there are some functional problems with that.”
Critics of buprenorphine argue the drug simply replaces one addiction for another, as the drug itself is an opioid. However, many providers say the drug doesn’t give the user the same high other opioids, such as oxycodone would and though some people abuse it, that is rare.
Mark Woodward, spokesman for the Oklahoma Bureau of Narcotics and Dangerous Drugs, said the agency has not seen a problem with Suboxone when it comes to drug diversion.
“I’m not aware of any cases where it’s been diverted on, sold on the streets, break in of clinics where it was specifically targeted and stolen,” Woodward said. “So, no, it is not really even on our radar in term of any drug that is seen as something to abuse or move to the black market.”
Providers and experts say there is a glaring demand for buprenorphine in rural areas, some of which have been hit the hardest by the opioid addiction epidemic.
Michael Doyle is the operations director for House of Hope, a men’s-only addiction treatment center in Grove. He said men often come into the organization’s residential program with a prescription for Suboxone.
“Most of our (residents), I can’t think of any so far that have come from a local prescriber,” Doyle said of residents using Suboxone.
The state’s Commission on Opioid Abuse, headed by attorney general Mike Hunter, released its final report in January on ways to combat the opioid epidemic. One of those recommendations was to expand the number of providers who are trained in addiction treatment, as well as those who can prescribe buprenorphine.
“If Oklahoma is not ground zero, it is close,” the report said of the nation’s opioid epidemic.
Carrie Slatton-Hodges is the deputy commissioner of treatment and recovery at the Oklahoma Department of Mental Health and Substance Abuse Services. She said although most areas in the state can meet the demand for buprenorphine, some towns don’t have a prescriber. Patients might have to drive almost an hour into larger cities for treatment.
Beaman said those patients from rural areas can be seen in larger cities’ clinics.
“We see them in our hospitals,” he said. “We see those patients that are not being treated in the overdose numbers.”
For some doctors, there’s a stigma around getting a waiver.
“I’ve heard doctors say things like, ‘I don’t want all those addicted people coming to my practice,’ even though half the time they’re already seeing them,” Slatton-Hodges said. “They’re just not treating addiction.”
Slatton-Hodges said though she believes that stigma has lessened, some doctors who are hesitant to treat addiction overprescribe opioids.
“I’m talking about physicians that in their mind, if someone has some arthritis pain, the thing to do is prescribe them opiates,” she said.
The OSU-Center for Health Sciences helped more than 100 doctors get their waivers in the past year, but Beaman said he sees no evidence the gap in addiction treatment access is closing in rural areas.
“I have no reason for optimism in that,” he said. “We’ve seen more providers, but I haven’t seen anybody, out of those providers, I haven’t seen a large uptake in people using it.”
However, Slatton-Hodges said she believes Oklahoma is on the right track in combating the opioid crisis. Overdose deaths from prescription opioids has gone down (statewide there were 435 in 2016 and 317 in 2016), and the number of doctors prescribing opioids has, too, she said.
Still, the state needs to take advantage of federal funds while the issue of opioid addiction is at the forefront, Slatton-Hodges said. President Donald Trump is expected to sign legislation that would help increase access to the medication, but it’s still unclear how much of an effect that will have in Oklahoma.
Meanwhile, Humphrey, the licensed clinical social worker, said her organization is trying to spread the word about the program, which aims to serve low-income patients.
“The medication-assisted treatment program is just in McAlester for now,” she said.”We need to work through all the kinks. The ones (patients) that we have are all from the area. I’m sure as we put the word out there and let the community know what we offer, I’m sure we’ll see more.”
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