Somewhere to Go: Ensuring Access to Medication Assisted Treatment in Rural Maryland

Wicked Problem: Rural communities in America are affected by the opiate epidemic at an alarming rate. From 2010-2015 deaths related to prescription and non-prescription opiate overdose in the State of Maryland has nearly tripled with substantial increases occurring in rural communities in Western Maryland and on the Eastern Shore. Although, buprenorphine treatment can be delivered in a less regulated way than methadone, less than 2% of buprenorphine waivered physicians in the US practice in small and remote rural counties. The wicked problem that confronts us, is how to provide access to evidence based, life-saving treatments such as buprenorphine directly to communities in rural areas that are suffering most from opiate epidemic? On the face of it, this solution may seem clear cut given the long history of success when it comes to using telehealth interventions in rural areas (e.g. SCAN ECHO). Yet, as this is a wicked problem, implementation may be hampered by regulatory and legal hurdles, stigmatization of opioid use, concerns about diversion, as well as historical concerns in the drug treatment community that Medication Assisted Treatment is just substituting one drug for another. Proposed Project: One strategy to overcome this barrier is to use HIPPA compliant technology to provide buprenorphine services directly to rural areas in need. Clinicians at the University of Maryland Medical Center have done just that. Over the last years, over 150 people receiving substance abuse services in a clinic located in Western Maryland have successfully been treated with buprenorphine using this telehealth strategy. A chart review revealed that approximately 60% of these patients were still in treatment at 3 months with 94% of them being free of opioid use. Approach or Strategies: Our approach includes 3 sequential phases that will build on one another. Phase 1 will be a planning phase which will focus on creating materials and enlisting new rural treatment sites. Phase 2 will be an implementation phase which will focus on providing clinician training, ensuring treatment site preparation and evaluating satisfaction with the telehealth services. Phase 3 will be a dissemination and liaison phase which will focus on expanding overall access by training others to provide these services in different locales throughout the State of Maryland and beyond. Anticipated Outcomes: Our primary goal for this project is to increase access to medicated assisted treatment in rural areas using a telehealth approach. To do this we plan to: (1) increase the number of clinicians who are trained to provide medication assisted treatment using a telehealth approach; (2) increase the number of substance use treatment programs in rural areas successfully offering telehealth medication assisted treatment programs and (3) increase the number of patients in rural areas receiving medication assisted treatment. Evaluation Strategies: Our evaluation plan will be cross-walked to our anticipated outcomes and use both chart review and informant interviews of clinicians, patients and their families to provide a complimentary approach to understanding the challenges and success of the proposed project. Teams areas of expertise and partnerships: Tackling a "wicked problem" is a team approach that requires flexible frameworks and an iterative implementation approach. To achieve the goal of increasing access to buprenorphine treatment in rural Maryland, we purposefully created a diverse team of clinical practitioners who have a wealth of experience working in multi-disciplinary substance use settings to lead this project. This clinical team will be assisted by a local advisory board whose complimentary skill sets will assist with creating "outside the box" solutions to challenging problems as they arise.