Gaps in NC addiction treatment hit some harder

By Clarissa Donnelly-DeRoven

In recent years, illicitly manufactured fentanyl has tainted the supply of street drugs, leading to skyrocketing rates of overdoses and deaths.

Of late, though, there’s growing hope for those who want treatment for their substance use disorder. Two medications — buprenorphine and methadone — can be effectively used to help people break the cycle of addiction. 

But that’s only if the drugs are available. Too often, they’re not, according to a recent analysis from the Centers for Disease Control and Prevention. 

The researchers found that more than 75 percent of counties across the country don’t have opioid treatment programs, which are the only places where people can receive methadone, while about 30 percent of counties don’t have any clinicians who can prescribe buprenorphine, which also gets prescribed under the brand name Suboxone. 

Rural North Carolinians suffer disproportionately from those provider gaps, according to an analysis by NC Health News. 

Across the state, the numbers are slightly better than the national picture: 52 counties don’t have an opioid treatment program, while 14 of the state’s 100 counties don’t have a buprenorphine provider. 

But of the 52 North Carolina counties without opioid treatment programs, 50 are rural — leaving 65 percent of the state’s rural areas without access to methadone, while all 14 of the counties without a buprenorphine prescriber are rural. 

While in recent years the state has seen its population increasingly move from rural areas to urban ones, the Office of State Budget and Management estimates that about 42 percent of residents live outside of municipal areas, and North Carolina has the second largest rural population in the U.S.

Nonetheless, the state’s 22 urban and suburban counties have 75 percent of the state’s nearly 1,600 authorized buprenorphine prescribers. 

Structural barriers — from general clinician shortages across rural areas to unsustainable work loads for those who fill the gaps — prevent health care workers from getting these life-saving medications into their patients’ hands. Many also say the persistent stigma against people who use drugs plays a role. 

Time consuming 

A 2019 analysis by researchers at the CDC found that North Carolina was one of just five states where the rate of deaths from overdoses was higher in rural areas than urban ones. 

The dearth of medical providers in rural areas affects all types of patients, but for those who are taking buprenorphine or methadone, the small provider networks can pose an even greater problem since the medications come with strict federal regulations.

“Most of my patients are on a monthly schedule,” said David Sanders, a physician assistant. He’s the only authorized buprenorphine prescriber in Stokes County, where he works at a family medicine practice, though he sees most of his buprenorphine patients at a clinic in High Point dedicated to substance use disorder. 

“We’d be there two or three days a week, and people would come from the surrounding areas,” he said. “They’d come from Greensboro, it’d attract a lot of people from Eden and Reidsville and a lot of the rural areas.”

A monthly visit to the doctor is pretty standard for patients who are taking buprenorphine and are stable on the medication, but at the beginning of someone’s treatment, they may need to come in every week, or every few days. For patients without a clinician in-county, this means a lot of time driving, a lot of money on gas, and a lot of time off work. 

That’s if they even have a vehicle.

“A lot of the people in the area have actually gone to buying Suboxone or buprenorphine off the street, due to the fact that it’s just very much interfering with their schedule,” said Leslie McPherson, the only buprenorphine prescriber in coastal Currituck County. “And it’s very, very, very expensive and a lot of insurance companies don’t reimburse for it either.” 

Multiple hoops to jump through

In order to prescribe buprenorphine, clinicians must complete a training and receive a waiver from the U.S. Drug Enforcement Administration. For physicians, the training is eight hours. For advanced practice nurses and physician assistants, it’s 24 hours. 

The course can be completed online, but for some rural clinicians who are already overloaded with patients and administrative duties, it can be hard to find time. Once the training is over, caring for patients with substance use disorder requires a big commitment. 

“There was no way — no way — I could handle more than 10 [patients taking buprenorphine] at a time in a small office,” McPherson said. “There are a lot of other factors involved in getting them their medication: they couldn’t make it to their urine drug screen, they couldn’t make it to one of their mental health appointments.” 

To continue receiving buprenorphine, per federal rules, patients need to complete regular drug tests and counseling appointments. When somebody missed one of these components of their care, McPherson did everything she could to help them get back on track. Oftentimes, it was just because life got in the way: a car broke down, a family emergency, chronic pain prevented them.

“There’s so many reasons,” she said. “We’d have to go to a modified monitoring schedule.

“My solution wasn’t to just cut somebody off, because I think that’s stupid. I think it’s a very stupid way to practice medicine. You don’t cut off your hypertension patient and just say, ‘You can’t come here anymore because you stopped taking your blood pressure medicine,’ right?”

Daily dosing

While the barriers to getting buprenorphine are great, the ones for methadone are even greater, as patients often must visit a doctor daily to get their dose.

The two medications work differently. Buprenorphine partially activates the brain’s opioid receptors and blocks other opioids from binding to those receptors. This has the result of reducing drug cravings and use and the possibility of overdose. Methadone activates those same opioid receptors to prevent other opiates, such as heroin, from using them. Both medications reduce withdrawal symptoms. 

A third medication, naltrexone, can also be used to treat addiction. It blocks opioid receptors entirely, but it cannot prevent withdrawal symptoms, meaning it’s designed to be used after a person has detoxed to prevent relapse and overdose. There isn’t a similar registry used to track prescribers of naltrexone as there is for buprenorphine and methadone, and the data on how well it helps people get – and stay – off of substances is less compelling.

Because each medication impacts the brain differently, health professionals say it’s critical that people have access to all three to find their best fit. 

In practice, though, that doesn’t happen. 

Racial and rural disparities 

In 12 counties — Anson, Camden, Chowan, Gates, Graham, Hyde, Jones, Martin, Northampton, Pamlico, Tyrell and Warren — residents don’t have access to an in-county opioid treatment program or a buprenorphine provider. 

In half of these counties, between 100 and 83 percent of people live outside of municipal limits, according to Michael Cline, the state demographer at the NC Office of State Budget and Management. 

The CDC analysis on access to these medications found that nationally, as the percentage of Black and Latino residents increased in a county, so did the availability of both treatment options.