Addiction Treatment Services - Improving Access for Rural Ohio

Addiction Treatment Services:

Improving Access for Rural Ohio

Melissa Gray, Barb Hillard, Michele Richoux

Executive Summary

        During the past 10 years, Ohio has shown a 431% increase in the number of accidental deaths due to opioid overdose, the second highest drug overdose rate in the United States. Just from 2016 to 2017, drug overdoses increased by more than 35%. Indeed, young Ohio residents between 25-45 years old have been reported to have an disproportionally high risk for drug addiction and premature deaths due to opioid overdoses. This public health crisis has been most notable in rural, non-metropolitan counties counties in Ohio, where nine of the top 10 counties have the highest rate of overdose deaths and offer limited access to addiction treatment clinics compared to urban areas.  

        Despite Ohio’s State Health Assessment and State Health Improvement Plan establishing initiatives to combat the opioid epidemic, for which it spends over 1 billion dollars annually, more money than any other state for this matter, the number of accidental deaths due to drug overdoses is continuing to increase among rural Ohioans. Currently, among its 26 Opioid Treatment Programs and 377 Office Based Opioid Treatment providers certified for administering Medication Assisted Therapy (MAT) – demonstrated to be both cost effective and clinically significant for treating opioid abuse – by the Substance Abuse and Mental Health Services Administration (SAMHSA), Ohio has the capacity to treat 20 to 40 percent of the population of Ohio at risk for opioid abuse. The state’s 26 certified treatment centers are primarily located in urban areas. Seventeen rural counties have no authorized treatment provider at all, and eight of these 17 counties have the highest death rates from opioid overdose.

        To reduce opioid abuse and addiction rates as well as resulting deaths rates, in particular, among rural Ohioans, we propose to implement pilot program in the southwestern Ohio, with the centralized hub in Hillsboro, Ohio.  This hub will be a certified MAT treatment center, that will provide expanded access to trained 10 to 20 healthcare providers, including nurse practitioners, physician assistants, and nurses, who will travel to the rural southwestern counties of Ohio to treat drug addiction among 1,000 to 2,000 patients. With adequate funding from government agencies and private stakeholders, this pilot program is anticipated to last three years to allow feasibility assessment of replicating program to other parts of the state. The impact of the pilot program will be measured to assessment changes in access to providers, distribution of opioid treatment, and opioid related overdose deaths.

Executive Summary

Graphic: state access to clinics, counties with highest overdose death rate

Graph showing overdose deaths going up despite SHIP, GCOAT actions

 strengths:

Ohio can fix this problem:  devotes more spending to opioid epidemic than any other state

Ohio per capita spending on mental health,

Cooperation b/w state local health

Stakeholders SAMHSA,

Lessons learned (need treatment centers)

How expansion of Medicaid/medicare adds to funding

MH and Drug addiction are priority are in SHIP

Challenges:

Drug overdoses going up

Number one reason for not seeking treatment: no access to care

Identified 9 counties with high rate of overdose death, poorly served by MAT

Best option: MAT clinics and providers

Test increased use of Methadone/buprenorphine clinics in populous areas (hub) and increased authorized buprenorphine prescribing physicians (spokes) in rural areas.  Also educate on Naltrexone

Goal:  To increase capacity to treat people with opioid addiction disorder from current rate of 20-40% of people with addiction, to 80-100%.  Make buprenorphine treatment available at primary care level.  Evidence based approach, with success in New Hampshire, other similar rural areas.

Recommendation:  approve additional spending similar to Vermont/NH plans

-Drug turn in days?  Any other program to increase jobs/improve schools in impacted areas:  current addiction rates closely tied to unemployment, education level, and high opioid prescription rates prior to 2012.

(executive summary?): Ohio in 2013 spent $100.29 per capita on mental health and drug addiction care for its citizens, as compared to $119.62 on average in the US, with Ohio ranked 25th out of 50 states in per capita mental health spending, and annual per capita spending increasing annually in Ohio from 2004 to 2013, as compared to largely level spending during the same time frame in the US.

Executive summary: Ohio’s overdose death rate during this period is more than double the national rate during the same time, with Ohio’s non-Hispanic white and black adult males most at risk of accidental overdose death (CDC, NVSS, 2017).  Rural populations disproportionately affected by overdose deaths.  

Magnitude of problem.  Deaths, death rate, comparison to US, rank among other states.  

(executive summary): We feel that there is agreement that the problem is very grave and requires immediate attention. There is involvement from the state through their multiple agencies agreeing that this problem is very serious. However, the problem is still rising.

the results of the State Health Assessment and SHIP because regional forums, reviews of local health assessments, and stakeholder review of the evidence and strategies were completed as part of the SHIP process, and these agreed with the priority areas selected.

1.  Community Assessment

Our team recommends Ohio as a site for a pilot project to increase the capacity of Medication-Assisted Therapy opioid addiction treatment programs in order to reduce overdose deaths rates and decrease abuse and addiction rates, in accordance with Ohio’s State Health Improvement Plan (SHIP).  We selected Ohio because we noticed it has a very thorough State Health Assessment (SHA) and SHIP, compared to other states’ SHIPs which our group studied.  We observed substantial stakeholder involvement in the Ohio SHIP, and good coordination between the state and local health departments, as evidenced by the state’s “bottom up” review of health issues impacting Ohio, beginning with data at local and regional levels (SHIP).  The Ohio Department of Health (ODH) also benefits from universities such as Ohio State, which provide public health research and guidance.  Also, there seems to be good agreement between data in the SHA and the results of Ohio’s health improvement planning process, since the priority areas closely match gaps identified in the SHA. We felt that these observations indicated the strength of Ohio’s public health infrastructure, as well as the state’s commitment to improving public health.

The SHIP identifies three main priority areas, on which the state will focus funding and health improvement efforts. The areas are: Mental Health and Addiction, Chronic Disease, and Maternal and Infant Health (Reem, 2017). Of the ten priority outcomes identified in the SHIP, four addressed the area of Mental Health and Addiction. Since almost half of the Ohio SHIP’s priority outcomes address mental health and addiction, this sets the stage for one of the major health issues that the state is committed to improving. In fact, overdose deaths, along with premature deaths due to cancer, were the two most serious health concerns identified in the state’s 2016 health assessment (Aly et al., 2016).  For these reasons, we believe that Ohio is a good setting for a pilot project to increase capacity at addiction treatment centers across the state, with a focus in rural areas, which have reduced access to treatment (Rembert, 2017).

The two Outcome Objective Indicators in the SHIP, which relate to Addiction, are:  Unintentional Drug Overdose Deaths per 100,000 residents, and Drug Dependence or Abuse, measured in percent of population age 12 and up with past-year dependence or abuse.  The goals, or targets, set in the SHIP for these indicators are an almost 3% reduction in both the death rate and addiction rate by 2018-2019 (Reem et al, 2017).  However, the number of overdose deaths statewide have increased by over 30% annually since 2015, the baseline year. Based on these early results and federal guidance on overcoming addiction and overdose deaths, an additional public health approach is necessary in order for overdose deaths to decrease. We feel that the pilot program we propose, if approved, will receive support and funding from both government agencies and stakeholders and will have a good possibility of success.

Between 2007 and 2016, the state of Ohio saw a 431% increase in the number of accidental drug overdose deaths per year (CDC, 2016).  Ohio’s drug addiction and overdose problems may be tied to greater losses of manufacturing jobs in the state as compared to the rest of the nation from 2000 to 2009 (Fee, 2009), and from a much slower recovery in employment levels than most other states, after the Great Recession of 2007 to 2009 (Chapman, Mantell and Hamman, 2018).  Ohio’s unemployment rate is still 2.3% above its pre-2007 rate, and the state is one of only ten states whose unemployment rates have not returned to pre-recession levels.  A nationwide 2017 National Bureau of Economic Research (NBER) study demonstrated that county-level opioid death rates are closely related to county unemployment rates (Hollingsworth et al, 2017).  The NBER study demonstrated that, for every one percent increase in unemployment in a county, there is typically a corresponding 3.6% increase in opioid overdose deaths.  Other factors found to be correlated to increased overdose death rates in Ohio counties are: increased rates of poverty, low levels of education, increased unemployment, and high rates of opioid prescriptions or addiction prior to 2011 (Rembert, 2017). Further statistical study revealed that Ohioans who are married, white, male, aged 25-34, or who had an prescription opioid use disorder before 2011 are more at risk of opioid overdose death  (Rembert, 2017).  This group is included in the priority populations listed in the SHIP: non-Hispanic white and black males aged 25-64, and non-Hispanic white females aged 25-54 (Reem et al., 2017).