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Rural Response to the Opioid Crisis

This guide will help you learn about activities underway to address the opioid crisis in rural communities at the national, state, and local levels across the country. It identifies:

  • Initiatives and funding opportunities
  • Rural program examples
  • Tools and resources focused on prevention, harm reduction, and treatment

For a more comprehensive review of how substance abuse, including opioid misuse, affects rural communities, please see the Substance Abuse in Rural Areas topic guide, and in particular What is opioid abuse, and what effect has it had in rural communities?


Federal & Other National Initiatives Targeting Rural Communities

The federal government has committed significant resources to understanding and responding to the opioid crisis, and other national organizations serving rural areas are also taking an interest. Here are some of the initiatives specifically focused on rural areas:

Rural Communities Opioid Response Program
Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA)
This multi-year initiative will support treatment for and prevention of substance use disorder, beginning with awards of up to 75 one-year planning grants to rural communities through the Rural Communities Opioid Response Program – Planning (RCORP) funding opportunity. $19 million has been awarded to 95 rural health organizations for these planning grants. JBS International has been awarded a cooperative agreement to provide technical assistance to the RCORP grantees. In addition, over $6 million was awarded to 26 rural health organizations through the Rural Health Opioid Program (RHOP).

Rural Opioid Federal Interagency Working Group (IWG)
Office of National Drug Control Policy (ONDCP), U.S. Department of Agriculture (USDA)
Works to address the opioid crisis in rural communities by improving coordination of and reducing potential overlap among federal responses. Established in May 2018 and co-chaired by the Office of National Drug Control Policy (ONDCP) and U.S. Department of Agriculture (USDA). In October 2018, the IWG issued Federal Resources for Rural Communities to Help Address Substance Use Disorder and Opioid Misuse, a directory of federal funding programs, service providers, technical assistance, training, and more.

Opioid Misuse in Rural America
U.S. Department of Agriculture (USDA)
View USDA funding programs available to support projects addressing rural opioid misuse, read about successful programs, and find a wide range of resources from throughout the federal government.

Drug Overdose in Rural America
Centers for Disease Control and Prevention (CDC)
Learn about overdose deaths in rural areas, policy options to address the opioid crisis, and CDC resources related to preventing drug overdose.

NHSC Substance Use Disorder/Opioid Expansion Site Initiative
National Health Service Corps
Expands and improves access to quality opioid and substance use disorder treatment in rural and underserved areas by making new categories of outpatient services and sites eligible to hire NHSC providers.

Farm Town Strong
American Farm Bureau Federation and National Farmers Union
A campaign to help bring attention to the rural opioid crisis and help rural communities and individuals find resources for treatment and prevention.

Pain and Opioid Use Disorder
Indian Health Service (IHS)
A central resource for sharing information and increasing communication related to opioids with tribal stakeholders. Addresses pain management, prevention strategies, treatment, and crisis response. Also includes information on the IHS National Committee on Heroin Opioids and Pain Efforts (HOPE).


Additional Opioid Resources Relevant to Rural Communities

In addition to the rural-focused efforts highlighted above, the federal government is also responding to the opioid crisis with resources relevant to all types of communities, including rural areas:

HHS.gov/Opioids: The Prescription Drug & Heroin Overdose Epidemic
U.S. Department of Health & Human Services (HHS)
Resources to help locate treatment, an overview of the opioid epidemic, and the HHS 5-point strategy to address it. Includes resources and information for prevention, treatment, and recovery.

HRSA's Response to the Opioid Crisis
Health Resources and Services Administration (HRSA)
Highlights efforts underway at HRSA to address the opioid crisis, including expanding access, use of telehealth, primary care training, and more. Also identifies HRSA-supported resources and technical assistance centers.

Drug Overdose Deaths in the United States
NORC at the University of Chicago, U.S. Department of Agriculture
Interactive map providing access to county-level drug overdose deaths, including deaths due to opioid overdose. Includes the option to overlay socioeconomic data, limit to rural or urban counties, and view by timeframe for 2007-2011 and 2012-2016.

CMS Roadmap to Address the Opioid Epidemic
Centers for Medicare and Medicaid Services
Highlights the efforts underway at CMS to address the opioid epidemic focused on prevention, treatment, and data utilization to target prevention and treatment activities. Includes some information specific to rural areas.

CDC Opioid Overdose
Centers for Disease Control and Prevention (CDC)
Information to help patients, providers, and the public understand opioids and learn how to prevent opioid overdose. Provides access to data and CDC reports on the opioid crisis.

NIDA Opioid Overdose Crisis
National Institute on Drug Abuse (NIDA)
Provides background information on how the opioid crisis developed, as well as an overview of what the National Institutes of Health (NIH) is doing to address it. Includes related NIDA/NIH resources, as well as resources from other federal sources.

Evidence-Based Practices Resource Center
Substance Abuse and Mental Health Services Administration (SAMHSA)
A collection of resources to help incorporate evidence-based practices into communities and clinical settings. Includes opioid-specific resources (select under Topic Area).

SAMHSA Grantee Stories, Tools, and Resources: Prescription Drugs/Opioids
Substance Abuse and Mental Health Services Administration (SAMHSA)
Highlights videos, online courses, tools, and SAMHSA grantee stories related to addressing the opioid crisis.

SAMHSA-HRSA Center for Integrated Health Solutions
Substance Abuse and Mental Health Services Administration (SAMHSA)
Health Resources and Services Administration (HRSA)

Resources, models, training, and technical assistance for developing integrated primary and behavioral health services to better address the needs of individuals with mental health and substance use conditions.

Facing Addiction in America
U.S. Surgeon General
Reports and information related to addiction, with a special focus on resources to address the opioid crisis.

Combatting the Opioid Epidemic
Office of the Inspector General (OIG), U.S. Department of Health & Human Services (HHS)
Describes efforts underway at the OIG to address the opioid crisis by identifying opportunities to improve HHS programs, detecting and addressing fraud, and sharing data and methods with partners. Includes related reports and resources.

Action Collaborative on Countering the U.S. Opioid Epidemic
National Academy of Medicine, Aspen Institute, 30+ Additional Organizations
A public-private partnership focused on sharing knowledge related to the opioid crisis, aligning initiatives, and advancing shared solutions.

CDC TRAIN: Opioid Training
Public Health Foundation
A wide range of public health training opportunities related to the opioids, including recorded webcasts and self-study. Includes training from the federal agencies and national organizations.


Funding

The Funding & Opportunities section of this guide identifies grants aimed at addressing the opioid crisis, with a focus on national opportunities available to rural and tribal communities.

For additional state and regional funding, see the Online Library: Funding & Opportunities lists for Illicit drug use and Prescription drug abuse. For national programs that more broadly address substance abuse, including national and state opportunities, see Substance abuse.


Key Rural Resources

The Rural Prevention and Treatment of Substance Use Disorders Toolkit presents resources, models, and program examples to guide the development and implementation of successful substance abuse prevention and treatment programs for rural communities. In the sections below, you’ll find program models from this toolkit that can be used to address specific aspects of opioid treatment and prevention.

Federal Resources for Rural Communities to Help Address Substance Use Disorder and Opioid Misuse
A directory of federal funding programs, service providers, technical assistance, training, and more to address the opioid crisis in rural communities. Issued by the Rural Opioid Federal Interagency Working Group (IWG).

Strategies to Combat Opioid Use in Rural Communities
A January 2018 Rural Health Research Gateway webinar featuring John Gale of the Maine Rural Health Research Center. Learn about cost-effective, evidence-based prevention, treatment, and recovery programs that have been successfully implemented in rural communities.

Rural Opioid Abuse Prevention and Treatment Strategies: The Experience in Four States
Also from the Maine Rural Health Research Center, an April 2017 paper examining strategies for dealing with the rural opioid crisis, including prevention, treatment, and recovery services. Uses data from interviews with key stakeholders in Indiana, North Carolina, Vermont, and Washington.

Rural Opioid Educational Resources
A comprehensive list of National Organization of State Offices of Rural Health resources addressing the opioid crisis. Includes reports, webinar recordings, promising practices, training materials, and medication-assisted treatment (MAT) resources. Also offers customizable posters, flyers, brochures, and more.

Rural Opioid Overdose Reversal Program
A toolkit from the National Organization of State Offices of Rural Health based on a 2015 Federal Office of Rural Health Policy (FORHP) pilot, the Rural Opioid Overdose Reversal (ROOR) Program. Includes a report documenting lessons learned from the ROOR grant recipients, as well as a webinar recording, training materials, marketing and outreach materials, and data sources.

Indian Health Services: Opioid Dependence Management
Resources on management of opioid use in pregnancy, reducing opioid overdose and overdose-related deaths, decreasing opioid dependence, and treatment strategies for opioid dependence.


Comprehensive Approaches

The following rural programs take a broad approach to addressing opioid misuse, combining a variety of interventions:

  • Project Lazarus
    To counter the high death rates related to opioid overdoses in Wilkes County, North Carolina, Project Lazarus equips prescribers, patients, and communities with education and tools needed to lessen the drug supply and demand and lower death rates.
  • Project VISION
    Project VISION in Rutland, Vermont, has been working since 2012 to address the underlying issues of crime in its community, such as mental illness, poverty, and substance abuse, particularly with opioids.
  • Winnebago County Heroin Task Force
    Addresses the complex problem of heroin and opiate addiction through a four pillar approach, including prevention, treatment, harm reduction, and law enforcement.

Additional programs focused on particular aspects of the opioid response are identified below.


Understanding and Tracking Opioid Misuse
Federal and state agencies are funding research studies and collecting and sharing a wide range of data to help understand the opioid crisis, so it can be responded to effectively.
Grants Awarded for Rural Projects

Rural-Urban Differences in Opioid-Affected Pregnancies and Births, FORHP-funded study by the University of Minnesota Rural Health Research Center

Impact of the Opioid Crisis on Rural Emergency Departments, FORHP-funded study by the Maine Rural Health Research Center

Illicit Drug and Opioid Use Disorders among Non-Metropolitan Residents, FORHP-funded policy brief by the University of Kentucky’s Rural and Underserved Health Research Center

Resources

Opioid Use and Treatment Availability – Rural Health Research Recap summarizing findings from FORHP-funded rural health research center studies.

Opioid-Related Hospital Use – National data on inpatient stays and emergency department visits by level of rurality.

MMWR Opioid Reports – Lists reports in the Morbidity and Mortality Weekly Report focused on opioid misuse. Many of these reports include data on rural opioid use.

Drug Overdose Deaths in the United States – Interactive map identifying drug overdose deaths by county, along with related sociodemographic and economic information.

Data Sources and Data-Linking Strategies to Support Research to Address the Opioid Crisis – Identifies data sources available to conduct research on the opioid crisis and describes methods for linking or merging these data sources.

Toolkit: Using Data Analysis To Calculate Opioid Levels and Identify Patients At Risk of Misuse or Overdose – HHS Office of the Inspector General guide for using prescription drug claims data to analyze patients' opioid levels and identify those at risk of opioid misuse or overdose.

See the Resources section of this guide for many additional reports and other resources describing the rural opioid crisis.

Prevention

Reducing and Monitoring Opioid Prescribing
Avoiding unnecessary use of opioids is a key method of preventing opioid misuse before it starts. Rural healthcare providers are addressing pain management and opioid prescribing to help protect their patients.
Rural Prevention and Treatment of Substance Use Disorders Toolkit – Program Models

Prescription Drug Monitoring Programs

Proper Drug Disposal Programs

Evidence-Based Rural Programs

Midcoast Maine Prescription Opioid Reduction Program (Effective)
In two midcoast Maine emergency departments, an easy-to-follow, one page protocol was implemented to assist providers in treating patients complaining about pain and also patients presenting opioid or controlled substance abuse behavior.

Integrated Chronic Pain Treatment and Training Project (Promising)
To reduce prescription opioid use, the ICPTTP standardizes and streamlines chronic pain management in North Carolina primary care clinics.

Additional Rural Program Examples

Morrison County Accountable Community for Health
The Morrison County ACH brings together community stakeholders to reduce opioid use and overdose in Minnesota.

Resources

Medicare Part D Opioid Prescribing Mapping Tool – An interactive tool from CMS that shows opioid prescribing at the state, county, and zip code level.

Department of Veterans Affairs Opioid Prescribing Data – A map showing VA facility opioid-dispensing rates.

Opioid Overdose: U.S. Prescribing Rate Maps – County-level prescribing rate maps from the CDC.

Pain Management Best Practices Inter-Agency Task Force – Includes representatives from U.S. Department of Health & Human Services agencies, the Departments of Veterans Affairs and Defense and the Office of National Drug Control Policy.

Indian Health Service: Pain Management – Resources to help address the challenges providers face helping patients with chronic pain while preventing illegal or harmful use of opioids.

Turn the Tide Rx – An initiative of the Surgeon General of the United States focused on opioid prescribing, with resources for both healthcare providers and their patients.

Rx Awareness – A CDC campaign to increase awareness of the danger of prescription opioids.

Six Building Blocks: A Team-Based Approach to Improving Opioid Management in Primary Care – Provides a structured approach for improving management of patients on chronic opioid therapy. Offers a self-assessment and implementation guide.

Quality Improvement and Care Coordination: Implementing the CDC Guideline for Prescribing Opioids for Chronic Pain – A guide to help primary care providers, practices, and healthcare systems manage patients who are on long-term opioid therapy.

Harm Reduction

Naloxone/Overdose Prevention

Programs that train rural first responders, community members, friends, and family members to administer naloxone to prevent an opioid overdose.

For an overview of the role of naloxone in rural communities, see these 2016 Rural Monitor features:


The Opioid Epidemic: Testing the Limits of Rural Healthcare

The Opioid Epidemic: Rural Organizations Fight Back

Rural Prevention and Treatment of Substance Use Disorders Toolkit – Program Models Naloxone Expansion Programs
Additional Rural Program Examples

Nevada Rural Opioid Overdose Reversal (NROOR)
NROOR, led by a Critical Access Hospital (CAH), furnished naloxone and provided education on prescription opioid use and overdose.

MaineGeneral Harm Reduction Program
To reduce deaths from opioid overdoses in rural Maine, the MaineGeneral Harm Reduction Program provides community education and naloxone training for healthcare staff and first responders.

Project Renew
Project Renew provides naloxone training and certification to first responders, healthcare staff, and laypeople in West Virginia in order to reduce the number of deaths from opioid overdose.

SLV N.E.E.D.: Naloxone Education Empowerment Distribution Program
The San Luis Valley Area Health Education Center has initiated opioid-related education efforts for health workers and the larger community in addition to establishing a naloxone distribution program.

Opioid Overdose Prevention Outreach Program
A Maryland program educates healthcare providers, EMS staff, and laypeople on the risks of opioids, prevention and treatment options, and Narcan training.

Resources

SAMHSA Opioid Overdose Prevention Toolkit – Guidance for community members, first responders, prescribers, patients, and families in responding to an overdose, including information on administering naloxone.

Rural Opioid Overdose Reversal Program – Toolkit offering training materials, marketing and outreach examples, and lessons learned for developing an opioid overdose reversal program.

HRSA Poison Help Line – Connect to your local poison control center for free advice from medical professionals. 1-800-222-1222

Preventing and Treating Co-Morbidities
Strategies to prevent and treat the consequences of opioid injection, including HIV, hepatitis B and C infections, and other sexually transmitted diseases.
Rural Prevention and Treatment of Substance Use Disorders Toolkit – Program Models Harm Reduction: Syringe Services Programs
Grants Awarded for Rural Projects Nine grant awards co-funded by the CDC, National Institute on Drug Abuse (NIDA), the Appalachian Regional Commission (ARC), and the Substance Abuse and Mental Health Services Administration (SAMHSA) to help communities prevent and treat consequences of opioid injection.
Resources

Integrating Responses at the Intersection of Opioid Use Disorder and Infectious Disease Epidemics – Proceedings from a workshop focused on the link between the opioid crisis and infectious disease such as HIV and HCV. Includes rural information. The workshop presentations are also available.

Infectious Diseases and Opioid Use Disorder (OUD) Policy Issues and Recommendations – A report that highlights policy considerations, including those focused on rural settings, for addressing infectious disease linked to injection drug use.

Managing HIV and Hepatitis C Outbreaks Among People Who Inject Drugs: A Guide for State and Local Health Departments – A guide from the CDC, with information on outbreak preparedness and detection, investigation, and response.

Syringe Services Programs – CDC guidance on how states, tribes, and territories can request a determination of need for SSPs, which would allow use of federal funds to support this service.

Threading the Needle – How to Stop the HIV Outbreak in Rural Indiana – A New England Journal of Medicine perspective piece describing steps taken to address an HIV outbreak tied to injection drug use.

Treatment

Medication-Assisted Treatment (MAT)
MAT is a treatment approach that combines counseling and behavioral therapy with medication to block the impact of opioids on the brain. For insights about the use of MAT in rural areas, as well as background information explaining how MAT works, see these 2018 Rural Monitor articles:


What’s MAT Got to Do with It? Medication-Assisted Treatment for Opioid Use Disorder in Rural America

The “M” of MAT: Medications for Opioid Use Disorder

Understanding the Science of Pain and Opioids

Rural Prevention and Treatment of Substance Use Disorders Toolkit – Program Models Medication-Assisted Treatment Models
Additional Rural Program Examples

New Horizons Substance Use Recovery Network
Medication-assisted treatment for patients with opioid use disorder in rural Northern Michigan.

MIST: Mothers and Infants Sober Together
Helps mothers who used substances to get treatment, including medication-assisted treatment, and provide safe, drug-free homes for themselves and their newborns.

Grants Awarded for Rural Projects Patient-Centered Outcomes Research Institute announces $10 million to study MAT use in pregnant women:

Increasing Access to Medication Assisted Treatment of Opioid Abuse in Rural Primary Care Practices – The Agency for Healthcare Research and Quality announced 4 awards to provide MAT to 20,000+ people in rural areas using innovative technology.

Predictors of Buprenorphine Prescribing by Family Physicians in Rural Areas Nationally, FORHP-funded study by the Rural and Underserved Health Research Center

What Are Best Practices for Providing Buprenorphine Maintenance Treatment in Rural Primary Care?, FORHP-funded study by the WWAMI Rural Health Research Center

Increasing the Supply of Providers with a Drug Enforcement Agency Waiver to Treat Opioid Addiction in Rural America – Possible Effects of Permitting Physician Assistants and Nurse Practitioners to Prescribe Buprenorphine, FORHP-funded study by the WWAMI Rural Health Research Center

Resources

Implementing Medication-Assisted Treatment for Opioid Use Disorder in Rural Primary Care: Environmental Scan, Volume 1 and Volume 2 (Tools and Resources) – Agency for Healthcare Research and Quality reports that summarize findings from the literature and identify tools to support MAT.

UDS Mapper – The UDS Mapper provides access to Mapping Areas of Priority for Medication-Assisted Treatment (MAP for MAT), a tool to assist in identifying areas of high need and existing services. This mapping tool includes HRSA-funded awardees and health facilities related to the opioid epidemic and population indicators including drug poisoning mortality, opioid prescribing rates, and information on DEA waivered providers, who can prescribe medications used for MAT. Free, but registration is required.

Treatment Access and Recovery Support
Health care providers, law enforcement, community organizations, friends, and family members are working together to make it easier for people to get needed care for opioid addiction.
Rural Prevention and Treatment of Substance Use Disorders Toolkit – Program Models

Peer-based Recovery Support

Screening, Brief Intervention, and Referral to Treatment (SBIRT)

Behavioral Therapy

Additional Rural Program Examples

ASPIN Network: Community Health Worker Program
A Community Health Worker/ Certified Recovery Specialist training program that prepares people who are recovering from substance abuse to provide peer support to others with substance abuse issues.

Addiction Recovery Mobile Outreach Team (ARMOT)
ARMOT provides 1) case management and recovery support services to individuals with substance use disorders and 2) education and support to rural hospital staff, patients, and their loved ones. Read more about ARMOT in the Rural Monitor: Pennsylvania Mobile Team Addresses Substance Use Disorders.

The Dawn Center Intensive Outpatient Program
Treats patients with substance addiction in rural South Carolina with a mixture of counseling services and medication-assisted treatment.

Vermont Hub-and-Spoke Model of Care for Opioid Use Disorder
A statewide treatment access system using a hub-and-spoke approach to provide access to comprehensive opioid use disorder treatment.

Grants Awarded for Rural Projects Perceived Treatment Need and Utilization for Illicit Drug and Opioid Use Disorders in Non-Metropolitan Areas, FORHP-funded policy brief by the University of Kentucky’s Rural and Underserved Health Research Center
Resources

Become an NHSC Site – Information on eligibility and application instructions for becoming a National Health Service Corps site, which allows facilities to recruit and hire NHSC providers, including those specializing in mental and behavioral health. The NHSC has added new categories of outpatient services and sites eligible for NHSC to address the opioid crisis.

Opioid Epidemic Practical Toolkit: Helping Faith and Community Leaders Bring Hope and Healing to Our Communities – Center for Faith-based and Neighborhood Partnerships toolkit providing practical steps that community and faith-based organizations can take to help address the opioid crisis. The Partnership Center also offers a collection of videos.

Telehealth
Rural Prevention and Treatment of Substance Use Disorders Toolkit – Program Models Telehealth Models
Evidence-Based Rural Programs Project ECHO Opioid Addiction Treatment
Project ECHO is an evidence-based approach where primary care providers and specialists work as a team to manage chronic complex conditions of rural patients and to increase the knowledge base through shared case studies. Among other areas of focus, the Project ECHO model is being used to help meet needs related to rural opioid treatment.
Resources Telehealth as Means to Diagnose and Treat Opioid Abuse – Highlights specific ways telehealth could be used for diagnosis and treatment in rural areas.

Last Reviewed: 6/1/2018