Andrilla isn't your typical expert on the rural opioid
epidemic. She's a Biostatistician and Research Scientist
from the WWAMI Rural Health
Research Center, who in her words, “fell
into the expertise.” Nonetheless, when the
United Nations Office of Drugs and Crime came calling for
experts in the field to present on substance abuse
prevention and treatment in rural settings, Andrilla was
more than excited for the opportunity.
I recently had the chance to speak with Andrilla about
her trip to Vienna, Austria. Through our conversation, I
quickly found out that Andrilla holds an encyclopedia's
worth of knowledge on the issue. We discussed the
similarities countries all over the world have with
substance abuse in general and opioid use in particular.
How did you fall into researching the topic of
opioid use in rural areas?
I'm actually a biostatistician rather than a typical
physician working on the issue. I worked with the late
Dr. Roger Rosenblatt who was a family physician in
Washington. He had a passion for training rural
providers. But, he noticed that when he would take
medical students out in the field, they had a negative
view of dealing with drug seeking patients and found it
off-putting to practicing in rural places. He wanted to
do something to change this and to offer more
physician-assisted help for those struggling with
This was a number of years ago. He was ahead of the
general curve in noticing that this was going to be a
huge problem. He proposed a study that looked at the
distribution of providers who had obtained a waiver to
prescribe buprenorphine to treat opioid use disorder.
What we found was that there weren't providers in rural
places. He saw this natural connection that family
physicians could fulfill this role in rural areas. He
died before we finished that study. I worked with him
through his research and it sort of morphed into my lab.
He would have loved to see this opportunity [to speak at
the UN] come up!
What insights did you share with attendees of the
The point of the meeting was for the UN to develop a
toolkit for providing treatment for substance abuse
disorder in rural areas. I was asked to present on the
challenges of providing treatment in rural areas.
I wanted them to know it's not good enough to have just
one provider. Communities need backups.
I wanted to provide the ideas that were true for all
substance abuse treatment in rural places. Lack of
facilities, lack of providers, and backup providers. Half
of the counties in the United States don't have any
providers waivered to prescribe buprenorphine for the
treatment for opioid use disorder. And, many of the
counties also only have one provider. I wanted them to
know it's not good enough to have just one provider.
Communities need backups.
I also made the point that there's a lack of mental
health specialists to treat comorbidities. We know that a
lot of people struggling with substance abuse also have
other conditions like anxiety and depression. If you
don't have anyone who can treat those conditions, those
people medicate themselves or try to solve their problem
with their drug of choice.
It's hard to be anonymous in small communities.
In small communities across the world and here at home,
there's a problem with anonymity. Whether you're having
trouble with alcohol or opiates, people want their
treatment to be anonymous because there's a social stigma
in many, many cultures. It's hard to be anonymous in
Typically, people in rural areas have a lower
socioeconomic status and on the community level, there
are fewer resources to address the problem. For example,
in the U.S. if you live in a rural county and you're
trying to get treatment for an opioid use disorder,
you'll probably have to travel a long way for treatment.
That takes time and money on a regular basis. That
impacts people's employment. If they lose their job, they
could lose their insurance. It's just an extra barrier
for people in a hard position anyway.
What differences among countries stood out to you
I thought that Iceland was the most promising country.
They have a really strong connection between their
researchers and their policymakers.
It was really interesting to see the voices from all over
the world. I thought that Iceland was the most promising
country. They have a really strong connection between
their researchers and their policymakers. The
policymakers guide their decisions around the evidence.
It would be nice to see that happen in the U.S. They have
shown significant decreases in substance use. When they
do work in schools, they provide data back to the school
within two months. They're very connected with the
research and the communities.
In Afghanistan, they did a survey study of children, and
100 percent of the children in the study were found to
have measurable levels of opium in their system. The UN
is trying to do interventions there but opiates are used
in Afghanistan like aspirin or Tylenol. There's a whole
requirement to change social norms — at least
we don't have that.
There was a guy from Columbia that said, “We
grow the best drugs, but we don't use them.”
Their problems were more with alcohol, which surprised
me. In India and Finland, the primary problem
[represented at the conference] was alcohol. One woman
from India realized the typical models used in her
country wouldn't work for rural, so she set up these
camps where groups of four or five providers are sent to
rural areas to provide treatment right in the town.
I'm not sure if that model will work for opioids, but
they are starting to try it out in Afghanistan to treat
One woman from Spain had touched on their problem in the
Menorca island region with tourism. The substance abuse
problem has blown up for them because of tourists
bringing over drugs and alcohol. It's people bringing the
stuff, but they rely heavily on tourism for their
economy. That's a part of substance use we don't really
deal with here.
We have to prevent people from ever getting to the point
where they would need treatment. We need fewer
prescriptions and more education.
What were some cultural barriers that perhaps
America doesn't have to tackle?
I'm really thankful to be a woman in America. Women are
not allowed to see male physicians in some countries.
Some people talked about using midwives to reach women
who aren't, I'll use the word
“allowed,” to see a doctor because of
their husband. I mean you know this stuff exists out
there, but it was eye-opening to hear how that will
greatly reduce the reach of a single physician in a rural
You realize that the ideas and concepts are the same. The
problems are the same. We have a lot more in common with
people around the world when it comes to this problem
than we have different.
It was really interesting to hear from voices all over
the world. You realize that the ideas and concepts are
the same. The problems are the same. We have a lot more
in common with people around the world when it comes to
this problem than we have different. But when it comes to
the particulars of how programs will be implemented,
that's where the differences begin.
One man was a former Roman Catholic priest who was now
working in Africa. He had this idea to train common
people in the community to be the providers of care
because he saw that as the most realistic solution. He
knew that they would never have enough providers because
they didn't even have enough providers to solve the
problems that don't have a big stigma.
We may complain here in the states that we don't have a
lot of resources, but we have a lot more than other
countries. In some places, substance use disorder just
isn't a top priority or even on the radar. I mean, it's
really only recently on the U.S. radar.
What were you glad to take back home with you
from the conference?
I think the idea of the shared humanity was really
powerful. It was an amazing experience just to be at a
meeting with so many countries at the UN. It was amazing
to hear such similar stories being shared through the
words of others. To me, that was the most unique thing
about this meeting.
It was quite the experience. Going through these giant
doors after numerous stages of security, you walk into
this giant circle plaza with a fountain surrounded by all
the nation-state flags, you realize “Wow! I'm
at the UN” It was a really special experience.
Opinions expressed are those of the interviewee
and do not necessarily reflect the views of the Rural
Health Information Hub.