There is not one model for the delivery of quality and effective substance use disorders treatment and recovery support services in rural areas. However, there are themes emerging from the scientific literature as well as from rural treatment providers implementing new services. These themes/strategies include: use of technology and web-based services; offering recovery support services by telephone or web-based portal systems without initial substance abuse treatment services; and providing flexible service delivery, integrated care, and Project ECHO-like models. Most importantly, a successful substance abuse treatment model for rural areas does not include just one intervention, but rather a combination of the interventions that fit the community and the patient population. Join the NFAR ATTC in this podcast series that includes: exploring rural/remote issues regarding SUDs; highlighting the use of technology in recovery support services both informal and formal strategies; and an update on technology-based interventions for individuals with SUDs or at risk for these conditions. Presenter: Nancy A. Roget, MS, MFT, LADC PI/Project Director NFAR ATTC

1. Nancy A. Roget, MS

2. develop and strengthen the
workforce that provides addictions
treatment and recovery support
services to those in need
Purpose of the
Addiction Technology Transfer Centers (ATTCs)
(SAMHSA FUNDED)

3. ATTC Network
Coordinating Office
10 Regional Centers
2012 – 2017

4. National
Frontier & Rural
ATTC
National
American Indian & Alaska Native
ATTC National
SBIRT
ATTC
National
Hispanic & Latino
ATTC
4 ATTC National Focus Centers

6. Servesas the national subject expert
and key
to PROMOTE the awareness and
implementation of telehealth
technologies in order to expand access
and enhance treatment and recovery
services especially in rural and frontier
areas

7. Of the 30 leading diseases and injuries in
the United States, drug use
disorders have accounted for the greatest
increase in deaths and years of life lost
between 1990 and 2010 (US Burden of Disease Collaborators,
2013)
The largest portion of these deaths results
from the ingestion of prescription and illicit
opioids (CDC, 2011) exceeding the number of people
dying in car accidents (Paulozzi, 2012)
Rosenblatt, Andrilla, Catlin, and Larson, 2015

9. Substance use is a public health crisis
in the rural United States and has
been identified as one of the top 10
priorities
Rural Healthy People 2020

10. Higher rates of substance use in
rural communities compared to urban areas
have been well-documented.
(Martino et al., 2008; Small et al.,2010; Shannon et al., 2010; Gamm et al., 2003; Jackson et al., 2006;
Lamberts et al., 2008; Blazer et al., 1987; Jackson, 2012)

12. The prevalence of substance misuse in
rural communities is also concerning,
particularly given that detoxification
and intensive recovery centers tend to
be located elsewhere
(Lenardson, Hartley, Gale, & Pearson, 2014)

13. More than 1in 5Americans live within
a rural area (U.S. Census Bureau, 2010) where
economic, religious, historical, and
geographic factors combine to create a
unique culture that influences mental
health outcomes, physical health
conditions, and health behaviors
Hunt, et al., 2012

14. There are actually more rural
residents than any racial, ethnic, or
sexual orientation minority group in
the US….
It is surprising, then, that rurality has
traditionally not been viewed as a
diversity issue worthy of inclusion with
other recognized multicultural groups
(Harowski, Turnder, LeVine, Schank, & Leichter, 2006)

15. Individuals in rural communities have
unique barriers to treatment and
recovery services
(Fortney & Booth, 2001; Fortney, 2011
Browne, et al., 2015)

16. Geographic proximity to
substance use services and
transportation to access such
services are particularly
significant barriers in rural
communities.
(Browne, et al., 2016 Beardsley, et al., 2003; Fortney, 1995; Booth, Ross, and
Rost, 1999)

17. Clients who must travel more than 1 mile to
outpatient substance use services have been
found approximately 50% less likely to
complete recommended treatment….
(Beardsley, et al., 2003 Browne, et al., 2015)

18. Barriers Include
• Travel Costs and Burden
(Rheuban, 2012)
• Time Away From Work
(Berwick, 2008)
• Child Care
(Berwick, 2008)
• Service Provider Shortages
(Perle et al., 2011; Swinton et al., 2009)

19. • lower utilization and treatment completion rates
(Fortney & Booth, 2001; Metsch & McCoy, 1999; Staton & Tindall, 2007)
limited behavioral health services availability (Pullman
&Heflinger, 2009 and Gordon, et al., 2001)
• higher financial burden to pay for services
(Fortney et al., 2004; Robertson& Donnermeyer, 1997)
• exacerbated stigma
(Robertson & Donnermeyer, 1997 & Notley et al., 2012)
• privacy concerns
(Fortney et al., 2004; Hargrove, 1986; Hutchinson & Blakely, 2003)
Barriers contiued
Browne, et al., 2015

20. Poverty also
diminishes clients’
ability to self-manage
their substance
use treatment
regimes.
Browne, et al., 2015

21. Poverty
• An estimated 17% of adult rural residents live below the
federal poverty line, as compared with 14% of urban residents
(Economic Research Service [ERS], 2011).
• Poverty rates are even higher for minority rural residents: 32%
of rural African Americans and 28% of rural Hispanics live
below the poverty line (ERS, 2011).
• Rural residents have been shown to go longer periods of time
without health insurance, and are less likely to seek care when
they cannot pay because of pride and the lack of reduced-price
medical care services in rural areas (Mueller, Patil, & Ullrich,
1997).
• Even if an individual decides to seek care, rural areas are
plagued by shortages in mental health care professionals
(Murray & Keller, 1991).
Bryant-Smalley & Warren, 2012

22. These cultural, economic, and provider
shortage challenges combine to sustain
behavioral health problems in rural areas
that unfortunately are not easily
addressed…..
Bryant-Smalley & Warren, 2012

23. Compared with urban areas, Primary
Care providers in rural areas play an
even greater role in the de facto
behavioral health care system (Geller, 1999; Fox,
Merwin, & Blank, 1995 and Hartley, Bird, and & Dempsey, 2005)
Yet…. rural PC providers frequently
lack the expertise, time, and resources
to effectively treat mental health and
substance use disorders (Hunt, et al., 2012)
Hunt, et al., 2012

24. Moreover…. the linkages between rural
PC practices and distant specialty
behavioral health care practices are
weak in most rural areas, making
referrals infeasible (Reschovsky and Staiti, 2005) and use
of off-site mental health specialists
unlikely (Hauenstein, et al., 2007)
Hunt, et al., 2012

25. Physicians Approved to Prescribe
Buprenorphine
30 million people, or 9.7% of the US population, were
living in counties that had no physician with a
waiver, 21.2 million of them in rural counties and 8.8 million
in metropolitan counties.
Of the counties that had no physicians who could prescribe
buprenorphine, 82.1% were in rural areas
The relative paucity of these physicians in rural areas is a
major barrier to office-based outpatient treatment for opioid
use disorders.
Rosenblatt, Andrilla, Catlin, and Larson, 2015

26. Perhaps the two most significant obstacles to
providing high-quality mental and behavioral health
care in rural America are workforce issues and
include the persistent shortage of trained
specialists and professional/personal
isolation.
(Deleon, Kenkel, & Shaw, 2012)

27. Barriers to Treatment Identified by Rural
Addiction Counselors included a lack of:
• Funding
• Public transportation
• Case management
• Interagency cooperation
• Detoxification facilities
• Mental health services
• Medication assisted treatment (MAT)
• Privacy
(Pullen & Oser, 2014)

28. With 20% of the U.S.
population being rural, and even
more than that coming from a rural
background, every clinician will face the
influence of rural culture….

29. Equipping clinicians-in-training with an
understanding of rural culture can help
them ensure that they deliver the best
possible care to their clients.
Bryant-Smalley and Warren, 2012

30. Academic programs should begin to
incorporate basic knowledge of rural culture
into their curriculum—not only within rural-
focused programs, but more importantly
outside of such programs where rural
competency might not otherwise be acquired.
Bryant-Smalley and Warren, 2012

31. (Bryant-Smalley & Warren, 2012)
Remembe
r
• Not all rural cultures are the same
• Be aware of the potential effects of rural living on
personality characteristics, including self-reliance
and avoidance of help-seeking behaviors
• Explore religion as appropriate with rural clients
– Do not assume clients are or are not religious, but be
mindful of the fact that religious beliefs may enter in the
therapeutic discussion
• Don’t make assumptions about a patient’s SES just
because they live in a rural area and poverty rates
are higher
• Rural areas have more stigma about receiving
mental health services

32. Resistance to therapeutic techniques and revealing to
friends/families the presence of a mental illness will be
amplified in rural settings… clinicians must understand that
the reasons behind such resistance may well be
based in cultural, rather than cognitive decision-making
processes.
(Smalley & Warren, 2012)

33. Not all cultural aspects of rural living have
negative impacts on mental health.
Religiosity, highly
prevalent in rural areas,
can have a protective
and therapeutic effect.

34. Rural Clients’ Recommendations for
Treatment & Recovery Providers…
Technology
• Increase client engagement by having a Web site
that has information about substance use in general,
the organization, and its resources
• Secure high-speed Internet, interagency-connected
phone lines, teleconference capability
• Use technology to maximize time spent with clients,
as inefficient technology requires significant staff time
and decreases staff services
(Browne, et al., 2015)

35. Rural Clients’ Recommendations for
Treatment & Recovery Providers-Technology
• Ensure Internet access throughout the entire
organization as it would greatly enhance
patient education and counseling resource
options (share with clients and client groups)
• Offer services on a flexible operating schedule
and include telephone-based services
Browne, et al., 2015

36. (Moore et al., 2011; Muench et al., 2013; Muench, 2015)
Current evidence demonstrates that clients
use and are interested in using technologies as
part of their treatment or continuing support

37. R
Rural is different not less
Justin Maxson