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The U.S. Senate floor is ready for a showdown this week as Democratic demands for $600 million in emergency funding is threatening to take down a bipartisan bill (backed by Senators Sheldon Whitehouse (D-RI) and Rob Portman (R-Ohio))  to tackle the nation’s latest public health epidemic – opioid addiction. 

Democrats indicated they are prepared to fight include the emergency funding, which is backed by Senator Jeanne Shaheen (D-NH) who urged separately for her colleagues to help her get the funding included as part of the CARA/Comprehensive Addiction and Recovery Act.  The test vote comes early this week when the Senate votes to end debate on taking up the legislation.  The broader legislation would authorize but not appropriate funding for programs to address opioid and heroin abuse as well as increasing access to naloxone/narcan, a drug that is highly successful in reversing a drug overdose.

While the Hill takes a test vote and fights on the floor, back home constituents in rural communities continue to address best they can as resources allow, directly facing the growing epidemic that has shattered many a family.  It should be no surprise that a string this national epidemic finally reached headline news via presidential primaries, at HHS the White House and the Hill. The epidemic has grown so rapidly that according to the Centers for Disease Control and Prevention (CDC), opioids were involved in 28,648 deaths in 2014 — a 14 percent spike in deaths from the drugs and that the historic levels in 2014 resulted with an individual more likely to die of an overdose than in a car crash. 

People in rural communities are more likely to overdose on prescription pain medications than people in cities, and the rate of opioid-related overdose deaths in rural counties is 45 percent higher than in metro counties. Further reality bears witness that the rise in drug related deaths has gone up most dramatically in rural areas showing that 1999 was the last year drug related deaths (age adjusted) were lower in urban vs. rural and that in 2008-2009 a sharp increase of 394 percent in rural deaths in those years, while metropolitan counties’ rates went up 297 percent. New Hampshire, Arizona, Utah, New Mexico, Alaska, Oklahoma, West Virginia and Kentucky are just a few of the states making headlines with overdose death rates but the reality is no state is immune as increased fears, death and drug addictions are growing even in the quietest of communities.  The staggering human consequences of the opioid abuse include dependence on ED visits, criminal activity, lost work days even unemployment, HIV, hepatitis, premature death and equate to economic costs exceeding $56 billion annually. 

Given the enormity of tragedy and danger, it should be no surprise that on Feb. 2, the Obama administration proposed $1.1 billion in new funding to address the country’s prescription opioid and heroin abuse.

This proposal would expand access to medication-assisted treatment for substance abuse.

  1. The  FY 2017 budget will include $920 million over two years to support cooperative agreements with states to expand the medication-assisted treatment. 
  2. The budget includes a $90 million increase for efforts across the Departments of Justice (DOJ) and Health and Human Services (HHS) to expand drug overdose prevention strategies, make medication-assisted treatment programs more available, improve access to the overdose-reversal drug naloxone and support enforcement activities.
  3. The administration is also seeking $10 million to help distribute the Strategic Prevention Framework for Prescription Drugs to address the risk of the over-prescription of painkillers by primary care doctors.

This is a much needed push from the initial $100 million in funding dispersed to Community Health Centers to expand substance use disorder services, with a focus on medication-assisted treatment for opioid use disorder and the $1.8 million support for rural communities introduced back on Sept. 17, 2015 by the Department of Health and Human Services (HHS) Secretary Sylvia M. Burwell when funding was allocated via the Rural Opioid Overdose Reversal (ROOR) Grant Program to support the purchase and placement of naloxone/narcan and training for its use by licensed healthcare professionals and emergency responders in rural areas.  The pilot program, developed by HHS’ Federal Office of Rural Health Policy at the Health Resources and Services Administration (HRSA), supported partnerships formed at the local level to coordinate care and required that awardees work in rural partnerships with two or more organizations representing law enforcement, fire departments, local emergency responders, health facilities, academic organizations and other non-profit or for-profit organizations involved prevention and treatment of opioid overdoses.  The partnerships will collaborate to increase the availability and use of naloxone in rural communities with emphasis on the importance of referring those with an opioid use disorder to an appropriate substance use disorder treatment center.  Since the announcement, 18 awardees representing 13 states, have received $100,000 over one year.

Additionally, Department of Agriculture (USDA) Secretary Tom Vilsack was recently charged by the President to lead the USDA’s new “Rural America Opioid Initiative, which is intended to address the 76 percent shortage in substance abuse and mental illness in rural areas. 

The USDA already has already shown a commitment via the Shaping Our Appalachian Region (SOAR) initiative through the Rural Development Community Facilities loan program to address heroin and prescription painkillers. Operation UNITE in Eastern Kentucky is also a promising focus to save lives. 

A closer look at the severity of impact of the rural community fabric and how it is threaded in the fiber of the drug epidemic can be attributed to several research findings:

  1. Higher rates of workplace-related injuries (like that seen in high numbers in the Appalachian region of Kentucky and West Virginia).  
    1. Increased chronic diseases and depression resulting in seeking drugs to manage, over compensate or escape as a result these drugs have easily become addictions.
    2. Many of those who abuse prescription painkillers such as oxycodone and codeine have switched to heroin as those prescription pills become more expensive and more difficult to obtain. According to some reports, heroin is stronger, cheaper and more plentiful than ever before.
    3. Greater economic stressors creating mental, physical and emotional vulnerabilities.
    4. Lack of economic opportunities and drug addiction has manifested as circumstances of an economy where there is more automation and a lower need for workers.
    5. Rising suicide rates, declining physical and mental health, and increased financial stress.
    6. Expanded network connections creating market distribution and focus on young adult users.
    7. Increased number of prescriptions written and dispensed.
    8. More social acceptance to use medications for a variety of health related reasons.
    9. Pharmaceutical companies expansive marketing and number of prescription drugs available.

No matter the research, rational or findings, rural prescription and heroin overdose and deaths do differ from those experienced in urban populations suggesting that the rural uniqueness, complexity and multi-dimensional problems will require a collaborative and all-hands on deck approach incorporating all community elements.  This will require even more focus in time, energy and resources to best position and support rural healthcare and healthcare delivery models and partnerships to address via a variety of different short and long-term strategies in prevention, treatment and intervention by clinicians, communication and engagement via community action groups and legislation via policymakers. 

What was a mere blip on the radar less than 10 years ago is now “the radar.”  Back on the Senate floor let’s hope the showdown this week doesn’t produce another test for our rural communities and rural healthcare facilities.  They have taken their own respective test votes and they need expanded support now.   

About the Author 

Janelle Ali-Dinar, PhD,  is the chief operations officer at MedFirst Partners and a senior rural health expert at Healthcare Solutions Connections. She has more than 10 years of experience in rural health policy, legislation, strategy, and operations, having served on the National Rural Health Association’s national rural congress. Dr. Ali-Dinar is also an NRHA Rural Fellow. 

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