Min Xian (Narrator) – Being able to access treatment where they live makes a huge difference for people with opioid use disorder. This is especially true for those in rural communities. Without having to travel for medication or counseling, recovery becomes much more realistic.

I’m Min Xian. And you’re listening to “Overcoming an Epidemic: Opioids in Pennsylvania,” a WPSU podcast looking at what researchers, communities and government agencies are doing to try to prevent and treat opioid addiction.

In this episode, we’ll talk about increasing treatment access in rural areas.

Jim Hayden has been a family doctor in Huntingdon County, Pennsylvania, since 1986. For over three decades, he’s treated patients in this rural community with a certain kind of grit.

Jim Hayden: I put up a sign over my desk. The sign said, “We’ve done so much with so little for so long, we are now competent to do anything with nothing.” (Laugh) And, it is what it is, you know?

MX – But as the opioid epidemic sweeps across the country and the state, touching communities large and small, it compounds the shortage of healthcare resources. Primary care providers like Hayden began to see more patients with addiction issues and found themselves on the front lines of treating this epidemic. It’s a task that many family doctors aren’t used to handling.

JH – Being rural doesn’t spare you [from] that taking place. It creates another demand on top of things.

MX – A program he’s taking part in is hoping to address this. Its name is Project ECHO. It stands for Extension for Community Healthcare Outcomes.

JH – They’re trying to take the education and consultation out into the communities, and that’s what project ECHO is trying to accomplish.

MX – One stark contrast between rural and urban parts of Pennsylvania is access to healthcare. On average, rural physicians serve a population three times as big as their urban counterparts. That’s according to 2014 data from the U.S. Health Resources and Services Administration.

Project ECHO is designed to bring resources and knowledge that are traditionally concentrated in urban areas to family doctors across the state.

[door opens]

MX – It’s a Wednesday morning just before 8. I walk into the Huntingdon Family Care Center on Washington Street in Huntingdon. I’m here to sit in on a session of Project ECHO.

It’s quiet. The day’s just beginning, and appointments won’t start until 9. I’m greeted by physician assistant Kylie McNerlin.

Sound: exchanging hello with Kylie McNerlin

MX – She leads me to an office where Hayden is already connected to a video conference call.

[On the conference call, “Good morning everyone, thanks for joining us again. . .”]

[Hi, good morning]

[Good morning, Jim Hayden, Broad Top Medical]

MX – Hayden has been attending conference calls like this every other Wednesday since the end of May. These online video conferences are actually more like case studies. A series of twelve discussions like these are designed to be a crash course on addiction and treating addiction.

On this day, about a dozen people are on the call. About half of them are specialists calling in from Penn State’s Hershey Medical Center, where the project is based. Other participants are family doctors. They are dialing in from their offices all over the state.

The physicians take turns presenting patient cases that they are working on. They describe what’s happening with the patients and what the dilemmas are in treating them. The idea is that these family doctors can learn about treating complex cases of opioid use disorder. It’s just like bedside teaching in med school, but done virtually. That’s the kind of peer support that rural family doctors don’t always find.

Amy Maley, a family medicine doctor in Newville, is getting ready to present a case this morning.

Amy Maley – Um, okay, so I have a 28-year-old female with opiate use disorder. She came to my office over the winter. She was actually a transfer. . .

MX – Maley doesn’t give any identifiable information, which is a rule of these discussions. But she dives into some other specifics.

AM – So a couple things about her - she’s currently separated; she lives in my area, Newville; she drives; she does have Medicaid. . .

MX – Maley says, the patient started using in her early 20s. She attributes a lot of her opioid use to having anxiety. She didn’t use opioids for a couple of years and was on medication-assisted treatment, or MAT, which is standard treatment for opioid use disorder. During that time, she had a baby.

But Maley says, the patient had issues at work and with her then-boyfriend, which led to a relapse. Maley describes it as -

AM – A one-time use that kind of spiraled everything out of control.

MX – It’s not uncommon that people in recovery fall out of treatment when their lives become unstable. Maley’s patient is having trouble staying off opiates, but still doesn’t want to use MAT.

AM – So she still comes back into the office and said, “I have to get off this Suboxone.” One thing that’s really important is she always goes back to the fact that she feels strongly that her opioid use disorder is a moral weakness; she should be able to get over this; she doesn’t know what’s wrong with her.

MX – This is the issue that Maley wants the group to talk about.

The patient wants to get off Suboxone, and it poses a dangerous scenario. People are especially vulnerable to overdose when they lose the level of tolerance they had built up.

The group jumps into discussion.

[one participant says, “Doctor Maley, one of my concerns is this patient. . .”]

One participant says, it concerns him that the patient wants to dictate a treatment plan that’s not good for her condition.

Hayden types a question into the chatbox.

[typing]

MX – The participants explore some more aspects of the patient’s situation. Can she have a full psychiatric evaluation? Does she have family to support her? If she’s moving, will she still have access to treatment? What about her child’s custody? They arrive at a consensus that she needs to stay on suboxone, and give other recommendations that might help stabilize her life at the moment.

[one participant says, “…and reassure her that buprenorphine is not tested in her urine or in the bloodstream if she did not disclose any of this to her employer. That’s pretty much what I have. . .”]

MX – At 9 o’clock, Hayden jumps off the conference call to see patients. His day is packed. So, I come back the next day to talk to him.

MX – Hey Dr. Hayden.

JH – Hi, how you doing?

MX – Good. Nice to see you again. . .

MX – Hayden says, treating patients with opioid use disorder takes a whole person perspective. It’s never just about medication, or just about mental health, or any one thing. In the case Maley presented, he says, the cause is likely the patient’s mental conditions that were not fully assessed.

JH – My suspicion is, is that she has the mood disorder and when the mood disorder goes awry, that triggers her use. So if we get the mood disorders settled and controlled and have somebody watching for changes in that - family member’s support - that would kind of be the approach.

MX – And discussions like this, ones that focus on real cases and complex conditions of a patient’s life, are what he hopes to get from Project ECHO.

To treat patients with opioid use disorder, family doctors like him need to get what’s known as a waiver training. It enables them to prescribe medications like Suboxone or naltrexone. But that alone wouldn’t cut it, Hayden says, actually treating patients with MAT is a lot more complicated than simply getting the waiver training.

Jennifer Kraschnewski: Unfortunately, just having people become waiver trained in the primary care clinic doesn’t necessarily equal into greater care. There’s many people, who are waiver trained, who only provide care to a small number or maybe actually no patients with opioid use disorder.

MX – Jennifer Kraschnewski is the director of Project ECHO and a primary care doctor herself.

She says, Project ECHO is trying to accomplish a couple of things. Family doctors would get education on treating addiction, while training for a waiver to prescribe medication-assisted treatment. They can connect with other family doctors and specialists for peer support in their practice.

And, she believes this could be particularly meaningful for patients in rural Pennsylvania. Traditionally, family doctors refer patients with opioid use disorder to specialists - more often than not, out of the area. Kraschnewski says, instead, Project ECHO would help family doctors treat patients where they live.

JK – The bulk of the folks who have this training are still located within cities. So having ECHO trained physicians who are in rural communities will really help improve access for patients.

MX – That could make a huge difference. If patients don’t have to travel to get treatment, they can be working or taking care of their families.

And, when people go to their family doctors for treatment, it normalizes the process.

JK – One of our family physicians here said, he’d like the physicians he works with to all be able to treat patients with opioid use disorder, and then we could look at this just like we look at patients with diabetes.

MX – And family doctors aren’t just more convenient. They are people you’re familiar with. When it comes to entering and staying in recovery from opioid use disorder, having that bond is incredibly important.

JK – Patients trust their primary care doctor. They’ve, in typical situations, have been seeing them for quite some time. They were more adherent to the medications that were recommended. They were more likely to follow up. And, in the end, they had just as good of outcomes as their fellow patients who were seen by the [substance] specialists. So there is that level of trust there.

MX – Hayden has a lot of faith in Project ECHO, in its idea of empowering family doctors to treat addiction using their strengths in their own communities. He completed his waiver training before he joined Project ECHO. But he can’t prescribe just yet.

JH – I have patients that are in MAT that are already my patients. Yes.

MX – So they’re seeking MAT elsewhere?

JH – They’re getting MAT elsewhere at the moment.

MX – Do they have to, like, travel?

JH – Yes, that’s the issue.

MX – Hayden passed his waiver training at the beginning of May. It was certified by the Substance Abuse and Mental Health Services Administration, or SAMHSA. It’s a federal agency. But since prescribing MAT for opioid use disorder is new for Hayden, he can’t proceed until his clinic’s malpractice insurance covers this new job responsibility. The thing is - the clinic’s malpractice insurance? It’s provided by the Federal Tort Claims Act. Just like SAMHSA, they’re both parts of the federal government.

I tell Hayden that. . . this sounds like red tape.

JH – The problem is nobody pulls everything together when somebody passes a law. Laws are passed addressing an issue in isolation. It’s never simple.

MX – Hayden says, he plans to soak up as much as he can from the ECHO lectures while waiting for the insurance issue to clear up. In October, he will graduate as one of the 24 participants of Project ECHO’s second cohort.

His clinic has been looking to hire a social worker or maybe partner up with a local counseling agency, so that patients with opioid use disorder can access MAT services and psychological counseling under one roof. Hayden will be able to treat up to 30 patients with MAT in the first year, and up to 200 patients by the third year.

Hayden says, step by step, he’d like to see people understand addiction recovery for what it is - chronic illness management.

JH – The idea of something’s mental health, something’s behavioral health versus something is physical health. That’s what I hope disappears as we integrate the two, you know, because it really is superficial titles.

MX – In the next episode, we’ll talk about recovery. It’s that final stage for a lot of people with opioid use disorder, but it’s a kind of new normal that takes a lot of work and some new types of treatment.

Erin Deneke – "This is a disease that costs lives. And you need to give people the best tools available out there so that they can maintain their recovery once they’re out of treatment, where they’re back facing the same pressures they had before coming into treatment."

MX – Recovery… on the next episode of Overcoming an Epidemic: Opioids in Pennsylvania, a production of WPSU.

Thanks for listening. Reporters on the project include Anne Danahy, Emily Reddy, and me, Min Xian. Cheraine Stanford and Frank Christopher edited the episodes.

You can find more resources on the opioid crisis and what to do if you or a loved one need help at wpsu.org/opioids. For WPSU’s Overcoming an Epidemic, I’m Min Xian.