This story was originally published by North Carolina Health News.
In recent years, illicitly manufactured fentanyl has tainted the supply of street drugs, leading to skyrocketing rates of overdoses and deaths.
Of late, though, there’s growing hope for those who want treatment for their substance use disorder. Two medications — buprenorphine and methadone — can be effectively used to help people break the cycle of addiction.
But that’s only if the drugs are available. Too often, they’re not, according to a recent analysis from the Centers for Disease Control and Prevention.
But of the 52 North Carolina counties without opioid treatment programs, 50 are rural — leaving 65% of the state’s rural areas without access to methadone, while all 14 of the counties without a buprenorphine prescriber are rural.
While in recent years the state has seen its population increasingly move from rural areas to urban ones, the Office of State Budget and Management estimates that about 42% of residents live outside of municipal areas, and North Carolina has the second largest rural population in the U.S.
Nonetheless, the state’s 22 urban and suburban counties have 75% of the state’s nearly 1,600 authorized buprenorphine prescribers.
Structural barriers — from general clinician shortages across rural areas to unsustainable work loads for those who fill the gaps — prevent health care workers from getting these life-saving medications into their patients’ hands. Many also say the persistent stigma against people who use drugs plays a role.
A 2019 analysis by researchers at the CDC found that North Carolina was one of just five states where the rate of deaths from overdoses was higher in rural areas than urban ones.
The dearth of medical providers in rural areas affects all types of patients, but for those who are taking buprenorphine or methadone, the small provider networks can pose an even greater problem since the medications come with strict federal regulations.
“Most of my patients are on a monthly schedule,” said David Sanders, a physician assistant. He’s the only authorized buprenorphine prescriber in Stokes County, where he works at a family medicine practice, though he sees most of his buprenorphine patients at a clinic in High Point dedicated to substance use disorder.
“We’d be there two or three days a week, and people would come from the surrounding areas,” he said. “They’d come from Greensboro, it’d attract a lot of people from Eden and Reidsville and a lot of the rural areas.”
A monthly visit to the doctor is pretty standard for patients who are taking buprenorphine and are stable on the medication, but at the beginning of someone’s treatment, they may need to come in every week, or every few days. For patients without a clinician in-county, this means a lot of time driving, a lot of money on gas, and a lot of time off work.
That’s if they even have a vehicle.
“A lot of the people in the area have actually gone to buying Suboxone or buprenorphine off the street, due to the fact that it’s just very much interfering with their schedule,” said Leslie McPherson, the only buprenorphine prescriber in coastal Currituck County. “And it’s very, very, very expensive and a lot of insurance companies don’t reimburse for it either.”
Multiple Hoops to Jump Through
In order to prescribe buprenorphine, clinicians must complete a training and receive a waiver from the U.S. Drug Enforcement Administration. For physicians, the training is eight hours. For advanced practice nurses and physician assistants, it’s 24 hours.
The course can be completed online, but for some rural clinicians who are already overloaded with patients and administrative duties, it can be hard to find time. Once the training is over, caring for patients with substance use disorder requires a big commitment.
“There was no way — no way — I could handle more than 10 [patients taking buprenorphine] at a time in a small office,” McPherson said. “There are a lot of other factors involved in getting them their medication: they couldn’t make it to their urine drug screen, they couldn’t make it to one of their mental health appointments.”
To continue receiving buprenorphine, per federal rules, patients need to complete regular drug tests and counseling appointments. When somebody missed one of these components of their care, McPherson did everything she could to help them get back on track. Oftentimes, it was just because life got in the way: a car broke down, a family emergency, chronic pain prevented them.
“There’s so many reasons,” she said. “We’d have to go to a modified monitoring schedule.
“My solution wasn’t to just cut somebody off, because I think that’s stupid. I think it’s a very stupid way to practice medicine. You don’t cut off your hypertension patient and just say, ‘You can’t come here anymore because you stopped taking your blood pressure medicine,’ right?”
While the barriers to getting buprenorphine are great, the ones for methadone are even greater, as patients often must visit a doctor daily to get their dose.
The two medications work differently. Buprenorphine partially activates the brain’s opioid receptors and blocks other opioids from binding to those receptors. This has the result of reducing drug cravings and use and the possibility of overdose. Methadone activates those same opioid receptors to prevent other opiates, such as heroin, from using them. Both medications reduce withdrawal symptoms.
A third medication, naltrexone, can also be used to treat addiction. It blocks opioid receptors entirely, but it cannot prevent withdrawal symptoms, meaning it’s designed to be used after a person has detoxed to prevent relapse and overdose. There isn’t a similar registry used to track prescribers of naltrexone as there is for buprenorphine and methadone, and the data on how well it helps people get – and stay – off of substances is less compelling.
Because each medication impacts the brain differently, health professionals say it’s critical that people have access to all three to find their best fit.
In practice, though, that doesn’t happen.
Racial and Rural Disparities
In 12 counties — Anson, Camden, Chowan, Gates, Graham, Hyde, Jones, Martin, Northampton, Pamlico, Tyrell and Warren — residents don’t have access to an in-county opioid treatment program or a buprenorphine provider.
In half of these counties, between 100 and 83% of people live outside of municipal limits, according to Michael Cline, the state demographer at the NC Office of State Budget and Management.
The CDC analysis on access to these medications found that nationally, as the percentage of Black and Latino residents increased in a county, so did the availability of both treatment options.
But NC Health News found that of the 12 counties in the state without opioid treatment options, 10 have higher proportions of Black or Indigenous residents — two groups that suffer from overdose deaths at disproportionate rates — than the rural average.
“What we do see in North Carolina is what we see across the country — significant health disparities across the board, and a lot of that is driven by the adverse social determinants of health,” said Ronny Bell at a May webinar hosted by the National Indian Health Board. Bell is a professor at Wake Forest University, the chair of the NC American Indian Health Board, and an enrolled member of the Lumbee tribe.
Mary Beth Cox is a substance use epidemiologist at the state health department who studies disparities in treatment access.
“If we were to just look at the counts, then you might say, ‘Yes this is primarily a non-Hispanic white problem.’ However, when we standardize for population in our state and look at the rates per 100,000,” she explained at the webinar, “we see a much different story unfold.”
American Indians in North Carolina have the highest proportional rate of deaths from overdose. During the pandemic, it got even worse: in 2020, Indigenous people in North Carolina died from drug overdoses at a rate of nearly 84 per 100,000, compared to a white death rate of 36 per 100,000.
Stigma and Lack of Support
Eight counties without access to methadone have just one authorized buprenorphine prescriber.
In southeastern Bladen County, that’s Robert Rich — or, it was.
“I’m not currently prescribing,” he said. He only works part time at Bladen Medical Associates, and he has many administrative duties that keep him from seeing patients.
There are three providers at the site currently in waiver training — one doctor, and two PAs/NPs — but Rich doesn’t think it’s safe to go back to prescribing until there are back-up prescribers for when he’s unavailable. While he’s not prescribing, the clinic arranged to send patients to nearby Robeson County for their medication.
Rich has had his prescriber authorization for about four years, and he’s represented the American Academy of Family Physicians in many different opioid initiatives.
“I’ve been intimately aware of the issue for several years,” he said. “You see and hear about it in the community all the time.”
He, Sanders and McPherson all agree that stigma against people who use drugs is partially to blame for the prescriber shortage.
“Before I got into it, I even had this stigma,” Sanders said. He didn’t recognize the names of the medications, and all of the additional steps needed to become a prescriber fueled his skepticism.
“It’s weird,” he said. “You have to get this waiver, so you have to do extra training whether you’re a doctor or a PA or a nurse practitioner. And even the wording — instead of initiating a medicine, which is what I would do with any other medicine on the planet, when we do this it’s called ‘induction.’”
“It’s just unfamiliarity with the medicine and so people are hesitant and uncertain about it,” he said. “But I’ve grown to have a high comfort level with it, and I think it’s a wonderful, wonderful medicine because it is so relatively safe.”
Building the Needed Workforce
Part of increasing the number of prescribers, especially in rural areas, Rich said, is showing models for how this care can work. New prescribers need to feel like they have a community of other clinicians they can turn to when issues or questions arise.
“The more examples that you have of a prescriber that is doing it, is making it work, and can serve as a mentor to other individuals — you can get those individuals to say ‘I’ll give it a try as long as I have someone else to back me up and help me through the process of learning how,’” Rich said.
A recent bill in Congress, which has rare bipartisan support, would require doctors be trained in treating opioid use disorder. If passed, it could help increase the number of prescribers who feel equipped to care for people experiencing addiction.
The American Medical Association has come out against it.
Even if the bill were to pass, other structural barriers remain, said McPherson, from Currituck. She prescribed buprenorphine from her small, independent family medicine practice. She started after patients she was seeing for primary care asked if she could prescribe it.
Once the word got around she realized how significant the need was.
“It got really complicated at my office because I had to say, ‘Look, I’ve got the max amount of patients. And yes, I do want to help, but I can’t afford it. I can’t afford the resources to do it. I can’t afford the time,’” she remembered.
“This is really something that should be taken up by every, in my opinion, every primary care office,” she said, but it’s hard because “providers don’t have the support they need.”
Lack of insurance reimbursement proved to be one of the most significant barriers.
“Every Suboxone patient I had was negative income,” she said. “A lot of insurance companies will not reimburse primary care providers for certain mental health codes, especially if [the patient] already is seeing a mental health provider.”
She said many patients would make an appointment to see her for their medication and a mental health provider for counseling on the same day. That way, they didn’t have to take extra time off work or spend the extra money on gas.
But, her office soon realized that a patient’s insurance company wouldn’t pay for two mental health visits on the same day.
“They couldn’t see a primary health care provider and a mental health care provider using a mental health care code on the same day,” she said. “I didn’t get paid for a lot of people.”
“I chose to do it because our community needed it, but I could only do as many as I could.”