A new report from the University of Vermont highlights how the challenges faced by providers and their patients undercut access to medication-assisted treatment for opioid use disorders in Maine’s rural areas.
UVM’s Center on Rural Addiction worked with University of Southern Maine’s Cutler Institute to survey more than 300 practitioners and community stakeholders from all 16 Maine counties between April and June of last year. All respondents worked in at least one federally designated rural area.
The universities’ assessment, published in May of this year, shows how, in particular, staffing and time constraints, barriers to access for patients — transportation, paid time off, childcare, for example — and increasingly lethal drugs taken in combination with other substances, are major concerns for this group when it comes to providing care to rural patients.
“Transportation is a huge issue. We have no reliable transport,” said one practitioner who is currently treating with medications for opioid use disorder.
Long drives to the nearest clinic, no childcare or insurance and not enough providers and other community-based supports are also unique barriers to rural patients, several other practitioners said.
When it comes to providing medication-assisted treatment, nearly half of practitioners said that staffing constraints and concerns about diversion — that medication would end up in the hands of someone other than the patient — were their top barriers to providing treatment.
An overwhelming majority of practitioners and more than half of community stakeholders said that transportation stopped patients from receiving and remaining in treatment.
The majority of practitioners also said that the lack of social supports, lack of stable housing and lack of paid time off or childcare were contributing factors.
Some community stakeholders — about a third each of whom work in first responder, school and other settings, such as recovery centers or community health organizations — also said that lack of social supports and care coordination, not enough capacity to treat patients and difficulties in getting patients to adhere to the requirements of treatment, were barriers.
When asked what single most important improvement is needed, one community stakeholder said Maine needs to “get boots on the ground and do outreach in the areas we know are hardest hit.”
Another said Maine needs more facilities, especially in northern Maine.
“The wait lists are long, and we lose many people during the short window after they decide to enter recovery,” one said.
All respondents, but especially practitioners and people who worked in other community settings, said that stigma is one of their primary concerns for why individuals do not seek out or remain in treatment for opioid use disorder.
One practitioner said providers need to learn more about how their attitudes toward patients, especially shaming them, can affect outcomes.
“Shame should never be used to change a patient’s poor health behaviors. However, I too often see this in clinical practice,” the practitioner said. “Many patients experience tremendous shame around their OUD. We, as health care providers, should not heap more shame on top of the patient’s shame. Instead, we should create open, honest, transparent and nonjudgmental practice cultures and learn how to skill up for difficult, vulnerable conversations with our patients with OUD.”
In terms of which substances are of greatest concern, practitioners on average named opioids in combination with benzodiazepines, opioids in combination with alcohol, and fentanyl as their top three, respectively.
Community stakeholders on average named fentanyl, heroin and prescription opioids as what concerns them most.
Those are well-placed concerns, according to the latest monthly overdose report from the University of Maine and the Office of the Attorney General.
The latest report, which was published at the end of last month, shows that nonpharmaceutical fentanyl, a type of synthetic opioid, continues to be the most frequent cause of fatal overdoses.
From January to March, there were 230 confirmed drug-overdose related deaths. Nonpharmaceutical fentanyl was present in three-quarters of those.
Continuing trends from 2021, while deaths due to heroin, either alone or in combination with other drugs, are declining, deaths involving stimulants are on the rise.
Whereas in 2020, heroin was present in 11% of fatal overdoses, the opioid was found in 4% of deaths last year and only 2% of deaths through May of this year.
On the other hand, the percentage of fatal overdoses that involved the stimulants methamphetamine and cocaine recorded during the first five months of this year was higher than they were last year and in 2020.
And for the first time last year, xylazine and nonpharmaceutical tramadol were identified as co-intoxicants with fentanyl. Xylazine, a veterinary tranquilizer, and tramadol, an opioid painkiller, are increasingly appearing mixed with fentanyl in pills and powders, the report said.
All three drugs are sedating and slow breathing. When combined, they can be extremely lethal.