Treating addiction in a rural area: Small town health center offers big city services
BEULAH, N.D. — During a February 2018 event about rural addiction in Hazen, N.D., Sen. Heidi Heitkamp, D-N.D., tasked attendees with coming up with an integrated plan to address opioid addiction. That would be the most likely way to get future federal funding for the problem, she told them.
Mercer County responded, putting together a group made up of law enforcement, education and health care professionals, says Chastity Dolbec, director of patient care and innovation at Coal Country Community Health Centers. Dolbec chairs the task force which initially was called the "Opioid Use Response Task Force."
But there was a problem: Opioid use was not even considered the No. 1 substance abuse problem in the community by law enforcement.
Rural areas have been hit hard by the opioid epidemic, but addiction is nothing new. Coal Country Community Health Centers have integrated addiction services into their medical care and offer services somewhat unique to rural areas.
Melissa Herman, a licensed addiction counselor at Coal Country, says doing evaluations used to be easy; her patients would identify their drug of choice, and they'd go from there. Now the evaluation form is more "check, check, check," as patients may have one main drug but use multiple substances, she says.
"It's complicated," Herman says. The peaks of different drugs come and go, though there is one constant in what they see in the clinic. "Alcohol is always there."
The task force now is called the "Substance Use Response Task Force," taking into account the fact that addressing opioid addiction alone wouldn't help with addictions to alcohol, methamphetamine, heroin, cannabis and other substances.
A hidden problem
National Farmers Union and the American Farm Bureau Federation teamed up to commission a study by Morning Consult on rural addiction. Of 2,201 rural adults surveyed in October 2017, 75 percent of farmers and farm workers say they had been directly impacted by opioid abuse.
Among farmworkers and farmers who responded to the survey, 27 percent indicated they knew someone who is or has been addicted to opioids or prescription painkillers; 25 percent said they have a family member who is or has been addicted to the substances; 10 percent said they themselves have taken an opioid or prescription painkiller without a prescription; and 16 percent said they themselves have abused or been addicted to the substances.
At Coal Country, the addiction providers don't necessarily see a large percentage of their patients coming from farming and ranching backgrounds. They get plenty of patients out of the oilfields, some who live in area towns, and some who come from larger cities far away because they prefer the care there. Some fit the stereotypes of drug users; others have been high-functioning members of the community who hid their addictions.
Those coming from agricultural backgrounds come to opioid addiction in the same ways as others, they say; for some, it comes from using other substances and moving to opioids while others become addicted while using legally prescribed opioid medications.
"It can affect anybody," says Dr. Michelle Placke, a family medicine provider at Coal Country. Ages range from teens to those on Medicare.
What they do see, Dolbec says, is a reluctance by members of the farming and ranching community to access care. Herman says part of the reluctance often is that care can take them out of their communities. For instance, asking someone to care for crops or cattle is an added hurdle on top of the stigma people already feel when seeking help for addiction, Herman says.
"They're more resistant to come in, from that aspect," Dolbec says. "I think the farmers and ranchers are even more private."
Finding assistance for addiction in a rural area can be a challenge, one of the many problems facing people struggling with addiction outside of major cities. Driving hours for treatment can be a significant deterrent to finding and continuing care.
"In general, the biggest struggle would be to get them in to a licensed addiction counselor," says Leigh Holland, a licensed practical nurse who works on Coal Country's medication-assisted therapy team.
That's what makes Coal Country somewhat unique, both within North Dakota and in the region. The health center, which also offers primary care and works with other providers for some more specialized services, has level one outpatient addiction services, as well as an after-care group, medication-assisted therapy for opioid addiction and a support group for people using the medication-assisted therapy. There are several licensed addiction counselors on staff, as well as two psychiatrists who come from Bismarck to see patients.
The medication-assisted therapy, in particular, is rare for a rural area. This is how that treatment works, according to members of the team administering it: A person addicted to opioids goes through an intake, does an evaluation with a licensed addiction counselor, goes through recommended treatment and then, once in withdrawal, begins taking Suboxone.
Suboxone is the brand name of a medication containing buprenorphine and naloxone. Buprenorphine fills the cravings for opioids without the high produced by other opioid substances, while noloxone, which also is given to patients suffering opioid overdose, helps protect against misuse of the product.
Coal Country offers Suboxone treatment out of Beulah and Killdeer, N.D. Brandi Richter, behavioral health care coordinator, says patients sometimes go from homeless to working full-time jobs and taking care of other health issues thanks to the treatment.
"I think it's changing people's lives," Placke says. "We've seen it work wonders for people."
Task force plans for future
Both Coal Country and Mercer County's new task force are planning for how to better address addiction moving forward.
In the fall, Dolbec says Coal Country hopes to get into the schools more, both to educate students and to screen for problems. Holland explains one of the most surprising aspects of working with people with addictions is how young many of them began using.
On the task force side, Dolbec says the community is working on a needs assessment and a "Strengths, Weaknesses, Opportunities and Threats" analysis.
She sees opportunities in providing more things like sober living facilities often found in larger communities so that people who get through treatment have more support to stay sober once they are back home.
That effort includes writing grants and looking forward to more opportunities for funding. More opportunities may come, depending on what gets included in the in-progress farm bill. The Senate's version of the bill included legislation sponsored by Sen. John Hoeven, R-N.D., and Sen. Joe Donnelly, D-Ind., which would direct the U.S. Department of Agriculture Rural Health and Safety Education Competitive Grants Program to give priority to applicants in rural communities that would use the grants for substance abuse education, treatment and prevention efforts.
The Suboxone team at Coal Country says their rural treatment draws people from larger communities, in part because of the individualized care they provide. Even people who have left the program still call with questions, and evaluators of the program have noted the "family" feeling of the team and its patients, Herman says.
Though the effort to reduce stigma and help people in rural communities continues, Herman offers some advice:
"That person who is struggling with addiction is way harder on themselves than anyone in the community is going to be," she says.