POSITION STATEMENT: Support policies to address opioid use disorder among rural communities

The opioid crisis is an ongoing public health emergency (PHE). In the United States, opioids are involved in nearly three-quarters of drug overdose deaths,1 and up to 7.6 million adults in the United States are living with opioid use disorder (OUD; a chronic condition characterized by frequent opioid use, withdrawal/tolerance, unsuccessful attempts to quit or reduce use, and/or failure to fulfill role obligation due to use). Consequently, significant bipartisan efforts to end the opioid crisis in the United States are underway and important legislation has been introduced (eg, the Comprehensive Addiction Resources Emergency [CARE] Act, which would provide $125 billion over 10 years to fight the opioid crisis). Notably, certain subgroups of the U.S. population, including those who reside in rural communities,2-11 are disproportionately affected by the opioid epidemic and thus warrant specific legislative attention. Indeed, communities with a higher degree of rurality have higher opioid prescribing rates,4, 5 higher rates of overdose deaths involving natural and semisynthetic opioids,11 and more rapidly accelerating rates of opioid overdose deaths.3 Clearly, there is an urgent need to (1) reduce opioid overprescribing by increasing access to nonopioid pain treatments, and (2) increase access to treatment for OUD in rural communities. Opioid overprescribing is a major contributor to the persistence of the opioid epidemic in the United States.12, 13 Integrated pain management models (ie, care models that involve interdisciplinary, evidence-based multimodal treatment) and evidence-based psychotherapies, such as Cognitive Behavioral Therapy, Acceptance and Commitment Therapy, and mind-body treatments, have been shown to improve patient-important outcomes (eg, pain severity, pain-related interference, opioid use/misuse),14-17 and are viable alternatives to opioids. However, limited access to these nonpharmacological pain management strategies perpetuates high rates of opioid prescribing in rural communities.2, 4, 5, 18 For individuals who go on to develop OUD, opioid agonists (buprenorphine or methadone) should be offered as the first-line treatment.19, 20 However, a recent study of Medicare beneficiaries found that less than 16% of those diagnosed with OUD received medication to treat it,21 and additional work has found that individuals who live in rural areas are even less likely to receive OUD medications.22 The Consolidated Appropriations Act, 2023 removed the federal requirement for practitioners to have a waiver to prescribe opioid agonists, which was a major barrier to accessing medications for OUD in rural areas.23 However, several barriers continue to contribute to the comparatively low rates of OUD treatment initiation and engagement among individuals living in rural communities,24 including further travel distances to access treatment providers.25, 26 Moreover, despite the importance of offering concurrent psychosocial treatment alongside medications for OUD,27 rural residents are less likely to receive such services, given the shortage of addiction medicine specialists, psychiatrists, and nonprescribing mental health clinicians practicing in rural (vs urban) areas.28-30 Telehealth offers a cost-effective solution to improving the availability and accessibility of OUD prevention and treatment programs in rural areas. Critical legislation, including the American Rescue Plan Act of 2021, has highlighted the need to increase the telehealth capabilities of U.S. health care systems and provided funding to support telehealth service delivery (eg, by making improvements in telehealth infrastructure, providing broadband installation and equipment, providing computer tablets, and incentivizing new telehealth service delivery models). Telehealth has been shown to increase rural residents’ access to nonopioid and nonpharmacological pain treatment,31, 32 with 1 recent study demonstrating that establishing a virtual interdisciplinary pain team increased the use of specialty pain services among this population.31 Telehealth-delivered pain interventions have also been shown to result in clinically significant improvements in pain severity and pain-related functioning,33, 34 and noninferiority trials have demonstrated that video teleconferencing is just as effective as in-person delivery of nonpharmacological pain interventions (eg, psychotherapy, physical therapy).35-38 Similarly, telehealth-delivered medication treatment for OUD has been identified as a promising approach to addressing the opioid epidemic, given its potential to mitigate barriers to treatment such as the provider shortage and geographic barriers to care.39 Converging evidence indicates that telehealth-delivered OUD treatments improve treatment retention and abstinence rates, and are associated with high patient satisfaction.39 During the COVID-19 PHE, the federal government authorized Medicare telehealth flexibilities that increased access to OUD treatment and prevention services for individuals in rural communities. Data collected during that time provided support for telehealth as an effective approach for expanding access to pain treatment40, 41 and medication for OUD in rural populations.42-44 For example, the total number of visits for medication for OUD increased among rural populations during COVID-19, despite the number of new patient visits remaining constant.42 Among rural patients who attended an initial telemedicine visit and received a diagnosis of OUD, more than half were retained in care and 49% were adherent to buprenorphine (assessed by urine drug screens) 6 months later.43 Moreover, similar buprenorphine treatment retention rates were observed pre-COVID and during COVID.44 Collectively, these findings suggest that telehealth is no less effective in retaining patients who reside in rural communities, and may, instead, lead to increased treatment engagement. However, since the expiration of the COVID-19 PHE on May 11, 2023, only temporary extensions of telehealth flexibilities have been granted. The end of such telehealth flexibilities is likely to exacerbate OUD-related disparities for rural residents. Therefore, there is an urgent need to ensure continued access to telehealth services in rural communities. Policymakers need to be informed that extending telehealth flexibilities and payment parity is essential for reducing gaps in rural health service delivery and ensuring that individuals residing in rural counties have access to OUD prevention and treatment programs. Making the telehealth flexibilities permanent would have an everlasting effect on the clinical practice landscape for OUD prevention and treatment, as well as the delivery of nonopioid and nonpharmacological pain management interventions. Such a change would also provide a foundation for the development and implementation of additional technology-based solutions to address rural-urban health disparities, and thus influence future rural health policy and research. Recommendation #1: Permanent extensions of all Medicare telehealth flexibilities granted during the COVID-19 PHE should be enforced, including the ability to prescribe buprenorphine to patients with OUD based on a telephone evaluation. Recommendation #2: Permanent extensions of payment parity of Medicare telehealth services should be enforced. Recommendation #3: To further address OUD in rural communities, federal and state governments should pass legislation to increase funding to support the expansion of programs designed to address OUD and chronic pain in rural areas (eg, the Comprehensive Addiction Resources Emergency Act). In summary, people who live in rural areas face substantial barriers to receiving treatment for OUD. Policy changes are sorely needed to ensure that rural residents can access OUD treatment. Specifically, legislation that (1) permanently extends providers’ ability to prescribe buprenorphine to patients with OUD based on a telephone evaluation, (2) ensures payment parity of telehealth services, and (3) supports the expansion of programs designed to address OUD and chronic pain in rural areas would likely increase access to OUD treatment for rural residents and mitigate rural-urban disparities in OUD prevalence and outcomes. Although the importance of making changes to Medicare policy, specifically, is underscored by evidence that Medicare beneficiaries have a higher prevalence of prescription opioid use (28.2%) than those with private coverage (19.9%)45 and rates of OUD are increasing in this population,46 it will also be important to consider state-level policies that ensure rural residents with private health insurance coverage can access OUD treatment. In addition, future research is needed to identify the best practices for telehealth-delivered (including audio-only) OUD prevention and treatment programs to ensure that rural residents can access high-quality care. The authors declare no conflicts of interest. This is a position statement. Therefore, it was not formally registered. There are no data, analysis plans, analytic code, or materials associated with this study.