By Anna Boiko-Weyrauch
The United States is in the midst of an epidemic, and Colorado is no exception. If you live in the rural plains, valleys or mountains of Colorado, your county is likely to face some of the highest rates of drug overdose deaths in the state, but you're unlikely to have counseling—let alone addiction treatment medication—anywhere nearby.
Coloradans are dependent on or abuse illicit drugs at slightly higher rates than the national average, according to survey estimates by the federal Substance Abuse and Mental Health Services Administration.
Opioid overdose deaths in Colorado happen at a rate of 16.3 per 100,000 people, which exceeds the national average of 14.7 per 100,000, according to an analysis by the Colorado Health Institute, a grantee of The Colorado Trust. The analysis also found overdose deaths increased 68 percent between 2002 and 2014, with rural counties seeing the biggest jump.
Research shows that treating addiction with medication, such as buprenorphine, methadone or an injection of the drug naltrexone is more effective than counseling alone. These medications interact with the brain’s opioid receptors in different ways, blocking its ability to get high, or tricking the brain into thinking it’s satisfied while suppressing cravings and withdrawal.
The approach, coupling traditional behavioral health services with specialized medication, is known as medication-assisted treatment. It is a new priority in the U.S. Department of Health and Human Services’ opioid treatment initiative.
The medication is not without potential downsides. Buprenorphine can still be abused or diverted to non-patients. A study in the Journal of Substance Abuse Treatment called buprenorphine abuse “common.”
Non-addicted people can use buprenorphine to get high, and addicted people can supplement their heroin use to smooth out withdrawals in between highs. The New York Times has reported on a “volatile subculture” of buprenorphine abuse and “unscrupulous” prescribers—even as some patients credited the medication with saving their lives.
Geographic disparities in Colorado for opioid treatment services are profound. Only three buprenorphine prescribers serve the eastern plains and San Luis Valley, an area that comprises more than a third of the state geographically. The area also has a small handful of behavioral health organizations offering other forms of substance abuse treatment and counseling.
Most of the more than 200 physicians who are qualified to prescribe buprenorphine in Colorado are located in urban areas along the Front Range.
“We have big access issues,” said Jack Westfall, MD, founder and director of the High Plains Research Network and a professor of family medicine at the University of Colorado.
His group seeks to change that in a new initiative to be rolled out over the next three years.
Starting in January, the High Plains Research Network plans to train 40 primary care physicians and their teams in 24 rural Colorado counties on how buprenorphine can be used along with counseling to help treat opioid use disorders.
Another barrier to treatment comes from stigma and lack of community willingness to discuss the problem, Westfall said, so another goal of the program is to facilitate those conversations.
“We talk about the weather and sports. We don’t talk about our feelings and behavioral health,” said Westfall, who is from rural eastern Colorado.
Primary care has lately gotten more attention from researchers and health care providers as a way to bolster scarce drug-treatment options, especially in rural America.
A 2015 article in Annals of Family Medicine called increasing drug treatment in family medicine practices “a promising strategy to address rising rates of opioid use disorder and unintentional lethal overdoses.”
Physicians have to be trained and federally certified to prescribe buprenorphine to treat addiction.
“You can prescribe OxyContin to your heart’s content, but you’re not allowed to prescribe buprenorphine for addiction (without approval),” Westfall said.
John Fox, MD, a family doctor at Lincoln Community Hospital in Hugo, is looking forward to completing training on buprenorphine and getting certified to gain more tools in his practice.
“It’s like treating blood pressure and only using half the medications out there to treat it,” he said.
Of course, some rural counties face a scarcity of primary care physicians, too. Cheyenne, Elbert, Kit Carson and Lincoln counties have the worst ratios of physicians to patients, with more than 3,000 patients per doctor, according to an analysis by the Colorado Health Institute.
Instead, patients are more likely to see a nurse practitioner or physician assistant. Until recently, those health care providers weren’t eligible to obtain the federal certification needed to prescribe buprenorphine for addiction treatment. In July, federal law changed and expanded the ability to prescribe buprenorphine to nurse practitioners and physician assistants.
Buprenorphine doesn't work for every patient. Kearstein Craycraft took the drug as a patient at Denver Health.
It made her feel like she could “do normal things” without cravings for heroin, like wake up on time and clean the house. When she used heroin while also taking buprenorphine pills, she wouldn’t get high, she said.
But she missed the feeling. So Craycraft stopped taking her medication and started shooting up again.
Recounting her battle with recovery makes her cry as she relights a cigarette that keeps going out. The 20-year-old has been addicted to heroin since she was 16 years old, she said.
“I just hate it so much,” Craycraft said.
Despite the challenges, Craycraft is ready to get her life back.
Her doctor recommended a monthly shot of naltrexone instead, which Craycraft said she's looking forward to trying.
“I don’t want to be 45, on the streets panhandling, or dead,” she said.
Find medication-assisted treatment for opioid use here.