Opioid addiction disproportionately affects rural communities, with 42% of rural residents reporting they or a family member have experienced opioid addiction, according to KFF Health News. 

Rising overdose death rates in rural areas have been called a cause for concern by the CDC. 

Despite this, opioid use disorder (OUD) treatment remains scarce in rural spaces, with more than half of counties lacking a single buprenorphine prescriber. New research demonstrates that rural Americans are less likely to initiate and continue care for substance use disorders (SUDs).

Addressing the disproportionate need for opioid use disorder (OUD) care in rural areas through holistic treatment approaches presents a valuable business opportunity for substance use disorder (SUD) treatment providers.

“Keeping patients engaged in treatment not only helps with their addiction but also keeps them connected to the healthcare system overall,” Steve Priest, CEO of Spero Health, told Addiction Treatment Business in an email. “This creates opportunities for providers to offer additional services like dental care, mental health support, and more, addressing the holistic needs of rural communities. It’s not just a business opportunity; it’s about making a meaningful difference in people’s lives.”

Nashville, Tennessee-based Spero Health operates more than 95 outpatient clinics throughout Kentucky, Ohio, Indiana, Virginia, Tennessee and West Virginia. The company uses an evidence-based integrated care model that includes medication-assisted treatment, counseling, medication management and family education, among other services.

Spero Health provided care to more than 23,000 people last year. Over 80% of these patients are Medicaid beneficiaries and most live in rural areas, Priest said.

The unmet need for behavioral health services in rural areas may be exacerbated by the recent closure of Walmart’s health centers and virtual care programs, which made behavioral health care more accessible for people lacking access or transportation to specialty centers.

The Walmart closures could signal a potential decline in retail companies’ interest in providing behavioral health services, further limiting access in underserved areas.

A contributing factor to the surge in demand for OUD treatment in rural spaces is the increased use of fentanyl. 

Other illicit drugs are also spiking in use nationwide. A new, “fourth wave” of the opioid epidemic was identified, marked by increases in stimulants including methamphetamine and cocaine. 

“Although we’re seeing spikes in stimulant drug use in rural areas, we should still focus on fentanyl because it is what’s driving most deaths,” Grant Victor, assistant professor at Rutgers University in the School of Social Work and co-author of a study published on overdose deaths in rural Michigan, told ATB. “[It is also] the only drug that we have some really effective interventions for, so that’s the good news. It’s how willing are we to make those [interventions] available and are we willing to make that a priority.”

The skyrocketing rates of fentanyl and opioid-related deaths underscore the urgent need, unmet demand and potential opportunity for providers and investors to expand services in rural areas.

Providers aiming to extend their SUD programs to underserved rural areas must confront the unique challenges persistently impacting those areas, such as fractured care pathways, transportation barriers, stigma and fluctuating telehealth policies.

No pathway to continuous care

In urban areas, patients presenting with OUD symptoms can often enroll in treatment programs immediately after a hospital stay, ensuring continuity of care. However, inconsistent clinician knowledge about these programs can cause snags in the system.

Chronic problems often dealt with in rural settings only exacerbate issues with continuity of care.

“Then you transfer that to a rural area and you have a shortage of providers, you have no clear engine to figure out how [to] get a person from A to B to support treatment, so it becomes more disenfranchised,” Dr. Arun Gopal, national medical director of outpatient care and consultation and liaison psychiatry at Access TeleCare, told ATB.

Access TeleCare provides acute and specialty telehealth services. The Dallas, Texas-based company works with hospitals, outpatient clinics and physician practices to offer various specialties, including behavioral health, neurology and endocrinology.

Rural areas have fewer treatment centers, fewer health care providers who specialize in SUDs and less infrastructure and funding to support specialized medicine.

Few specialty care providers can result in long distances to travel to get an appointment. Still others may not be able to afford a car, and lack of public transportation may mean attending multiple appointments a month can be downright impossible.

People in rural areas may therefore be forced to rely on their primary care provider for much of their care, according to the Bipartisan Policy Center. To mitigate problems associated with a lack of care continuity, Spero offers comprehensive integrated care. 

“Without access to a cohesive treatment program, individuals may struggle to receive the continuous support necessary to remain engaged in treatment, thus heightening the risk of relapse,” Priest said. “Unfortunately, rural areas often lack the resources needed to provide this ongoing support, further exacerbating the issue.”

Partly because of the lack of care continuity, rural hospitals may not even stock medications for opioid use disorder (MOUD), according to Gopal, despite MOUD being considered the gold standard treatment, because there is no further treatment path available to the hospital’s patients once they are discharged. 

Adopting a holistic approach to care, and receiving proper reimbursement, could be one strategy to enhance continuity of care.

“Addressing both physical and mental healthcare needs under one roof can help prevent overutilization of other services and ensure comprehensive support for individuals battling addiction in rural areas,” Priest said. “From a reimbursement standpoint, there needs to be a better understanding of integrated, comprehensive care for the SUD population and its value to society.”

Telehealth services can also help bridge the gap in access to care for people in rural areas.

Access TeleCare works with many rehabs to advocate for suboxone and other medications for SUDs, Gopal said, bringing evidence-based best practices and a collaborative care model to rural areas.

“We anchor somebody to a hospital [so] we could look as similar to real service as possible,” Gopal said. “We own that patient alongside the primary team which is the hospitalist and emergency room team and we follow that patient.”

This collaborative model allows Access TeleCare to troubleshoot issues along with the in-person care team. For example, an Access TeleCare clinician may suggest a patient try methadone if a hospital does not supply suboxone.

The virtual team works hard to integrate into the care model, utilizing messaging apps and video chat to build a relationship with the patient and care team.

But telehealth services are not panacea solutions, according to Grant Victor, first author of the study published in Drug and Alcohol Dependence Reports.

“I just have the general sense that [telehealth is] just another one of these half-measures that we’ve tried it out in lieu of brick-and-mortar health care centers in rural areas and in some impoverished areas in urban environments as well,” Victor said. “I do think it’s better than nothing. … As long as that helps them stay engaged within some sort of treatment scheme, then that’s great.”

“But I don’t necessarily think that it is going to stem rural overdoses without folks who are on the ground doing harm reduction, street outreach and having buy-in from community members of some prominence,” Victor continued.

 U.S. Health and Human Services Secretary (HHS) Xavier Becerra has touted telehealth as key to connecting rural Americans to care. 

But certain telehealth flexibilities introduced during the COVID-19 pandemic are set to expire unless the federal government takes action by the end of 2024, setting the scene for interruptions in care for people who rely on telehealth, including some rural populations.

Among the flexibilities set to expire on Dec. 31, 2024, is the removal of a requirement for patients to see a clinician in person within six months of an initial behavioral health appointment conducted via telehealth and annual visits moving forward. 

The same barriers that make it difficult for people in rural areas to access care, including shortages of providers and lack of transportation, could prevent patients with OUD from attending these visits.

Other legislation has also focused on increasing access to SUD care in rural areas. Congress members introduced a bipartisan bill called the Home-Based Telemental Health Care Act in 2023. If passed, the bill would direct the HHS to award $10 million in annual grants designed to establish SUD telehealth services for rural Americans, focusing especially on those working in the farming, fishing and forestry industries. 

Heightened stigma

People with OUD are often subject to extensive stigma, which research shows can have detrimental impacts on treatment engagement, greater barriers to care and more negative public attitudes. 

Stigma is even more pervasive in rural areas, Victor said.

“If you’re in a small town, you know people and they know you, and you have a reputation to uphold,” Victor said. “It could be as simple as going into a treatment center that can be off-putting for some folks.”

Stigma in closer-knit communities is often due to a lack of understanding and education around addiction as a disease, Priest said.

Health care workers in both urban and rural settings can also hold biases and perpetuate stigma regarding SUDs.

“The patient with the substance use disorder goes at the bottom of the list,” Gopal said. “Versus someone who’s coming in with a stroke or a heart attack [the clinician] says ‘We can manage this, but [SUD] is emotionally draining, and I don’t have a solution for it.’”

Levels of stigma have improved, Victor said, with more people accepting SUDs as medical disorders that need to be taken seriously. Still, further improvements are required.

One possible solution to combat stigma is mobile syringe vans, Victor said.

Mobile vans, equipped with syringes and naloxone kits, can offer people in overdose hotspots prescriptions to MOUDs, as well as naloxone training, disposal of used syringes and HIV/HCV testing. 

Research demonstrates that mobile strategies employed in rural areas can mitigate barriers associated with lack of transportation and may also reduce stigma. 

Other harm reduction methods, often put in place by boots-on-the-ground workers and volunteers, could also improve the status quo in rural areas.

Distributing naloxone and creating overdose prevention sites can help reduce deaths. For people who are unknowingly ingesting fentanyl through the use of drugs contaminated with fentanyl, fentanyl test strips can reduce risk of overdose.

Unintentionally consuming fentanyl is more of a concern for rural populations than those in urban or suburban settings. Almost half of people in rural areas express concern that someone in their family will unknowingly consume fentanyl, according to KFF, compared to 39% of people in urban areas and 37% of people in suburban areas.

Certain harm reduction policies aimed at curbing the prevalence of fatal drug overdoses receive more widespread support than others, however.

The majority of Americans support having addiction treatment centers in their communities and making the opioid overdose reversal drug Narcan freely available in places including bars, health clinics and fire stations, according to KFF. Safe consumption sites are more controversial, but still 45% are in support.