Shayla Archer MS, M. Aryana Bryan MSW CSW, Mitchell Garets BSW, Jacob Baylis MPH, Elizabeth Charron PhD MPH, Alan Taylor Kelley MD MPH MSc, Jacob Foringer CPSS, Amy Kenney MSW LCSW, Danielle Pendergrass DNP APRN WHNP-BC, Maggie Cooper RN, Samantha Costanzo MBA, Bhanu Muniyappa MD, Kristi Carlston BA CCRC, Jade Hill MPH, Lori Begaye BS, Katherine T. Fortenberry PhD, Melissa Cheng MD MOH MHS, Marcela C. Smid MD MA MS, Gerald Cochran MSW PhD – 2021
The Opioid Crisis The opioid crisis is sweeping the United States, with 192 opioid-related overdose deaths occurring daily.1 Rural counties across the U.S. have been heavily impacted, with some rural counties in Utah among the highest rates of opioid prescriptions1 and opioid-related overdose deaths2 in the nation. In 2018, Utah providers prescribed opioids at a higher rate (57.1 prescriptions per 100 persons) than the national average of 51.4 prescriptions per 100 persons.3 While high prescribing rates for the general population are an issue, prescribing to vulnerable populations is a significant concern for the state of Utah. Utah has one of the highest rates in the country of opioid prescriptions filled among pregnant women.4 Opioid use disorder (OUD) among pregnant women delivering at a hospital in the United States has increased 400% from 1999-2014; in Utah, this proportion of women has increased ten-fold.5 Utah has the second highest fertility rate of all 50 states.6 Without treatment, perinatal opioid use disorder (POUD) is associated with increased risk of preterm delivery, low birth weight, difficulty breastfeeding, and neonatal opioid withdrawal syndrome (NOWS).7-11 Costs related to treating NOWS from all substances in Utah reach approximately $10,000,000 per year. 12 Effective treatment is available for POUD – specifically medication for opioid use disorder (MOUD), including methadone or buprenorphine, and psychosocial services.13 POUD treatment is associated with significant benefits to both the mother and infant.13-16 Undertreatment of POUD is associated with adverse outcomes, including maternal relapse and death. 13-15, 23 In Utah, the leading cause of death in pregnant and postpartum women is drug related, and 83% of these deaths involve opioids.17 There is an urgent need for comprehensive, evidence-based addiction treatment services, specifically for pregnant women experiencing POUD. While treatment options exist, few options are accessible in rural communities—which are the communities most impacted by OUD in Utah. 1 Barriers to Treatment Substantial gaps exist for pregnant women with OUD receiving evidence-based addiction care and this is particularly true in rural America. Rates of maternal opioid use and NOWS in rural areas have climbed substantially over the past ten years compared to their urban counterparts,18 yet treatment engagement among this population has failed to keep pace.19 While the efficacy of MOUD in treating OUD is well-established, 14 the limited availability of buprenorphine prescribers and methadone clinics in rural areas has created a substantial barrier to accessing these life-saving treatments for those with OUD—including pregnant women.20,21 Indeed, rural mothers with OUD and their infants frequently require transfer to other hospitals following delivery to receive high level, specialty substance use and neonatal care.22 Perceptions of OUD as a moral failing or a choice to engage in certain behaviors among pregnant women has given rise to punitive approaches rather than evidence-based medical care.23 Rural prescribers also identify stigma from other providers as a major barrier to providing MOUD.24 Lack of specialty support for complex problems, such as perinatal addiction, also creates a significant barrier to rural healthcare providers offering MOUD.25 As of 2017, 60.1% of rural counties did not have a buprenorphine-waivered physician.26 Within rural areas, MOUD prescribers frequently did not treat pregnant patients, particularly among buprenorphine-waivered providers compared to methadone clinics.27 It is therefore critical to identify replicable and sustainable approaches to implement needed OUD care for this vulnerable population. Vulnerable Populations in Carbon and Emery Counties Two adjacent rural counties28 in Utah, Carbon and Emery, were chosen as the site for a needs assessment and intervention, with Eastern Utah Women’s Health LLC (EUWH) as the focal point of care. These counties were selected because of high rates of opioid overdose, limited resources, and a high degree of existing community engagement.29-31 Carbon and Emery counties lead the state in rates of opioid overdose deaths, with collectively 47.7 per 100,000 compared to the state average of 17.4 deaths per 100,000.29 Vulnerable Populations in San Juan County San Juan County was additionally selected as the site for a need’s assessment, due to key risk factors making it likely that opioid misuse and overdose are more prevalent than currently recognized. In the United States, OUD initially 7 appeared to disproportionately impact white non-Hispanic rural communities32, but it has grown to impact a wider, more diverse portion of the country including American Indian and Black/African American individuals.33,32 As an ethnic group, American Indians have one of the highest rates of substance use34 and are second only to whites in the United States in rate of opioid overdose deaths.35 High rates of substance use in American Indian populations34 place American Indians at high risk for opioid medication misuse and addiction.36 San Juan County’s population is comprised primarily of individuals who identify as American Indian (49.0%)37 or individuals who identify as white/Caucasian (44.3%)37. In addition to race/ethnicity, a history of mental illness is another significant risk factor for opioid-related harms.38 Mental health as a risk factor for opioid-related harm is of particular importance for San Juan County, as there is a large disparity in mental health care provider availability for residents, with only 141 providers per 100,000 people.39 OUD in rural communities and vulnerable populations is a particular concern in the state of Utah. The Utah Division of Substance Abuse and Mental Health provided funding for research to be conducted by the Program of Addiction Research, Clinical Care, Knowledge & Advocacy (PARCKA), which is part of the Division of Epidemiology in the University of Utah School of Medicine. This report is the culmination of that research and encompasses two distinct and separate projects that were funded by the Utah Division of Substance Abuse and Mental Health. This report will present findings (in order) from (1) the SUPeRAD Carbon & Emery County project, and (2) the Opioid Use in San Juan County Needs Assessment.