If you have watched a nightly news program or opened a newspaper in recent years, I’m sure you’ve been confronted by coverage of our country’s opioid epidemic. In your mind’s eye, tap in to those media images you have seen. What does this epidemic look like? Who do you see?
Perhaps you envision people in the rugged mountains of Appalachia, near the rundown coal mines of West Virginia or on the vast farmlands of Ohio. Indeed, it is the case that people in poor, rural communities are often left with few or no resources to protect themselves from harms associated with substance use.
Of all the states, however, Maine has the highest percentage of citizens living in rural communities. This leaves many Mainers geographically isolated from key resources they need, including amenities like grocery stores, schools and libraries. In these rural areas, many children are living in poverty, adults struggle to gain sufficient employment and people must drive for miles just to get to the nearest hospital. In sum, they are inadequately equipped to respond to the ill effects of substance use. Rural Maine doesn’t just exist within the confines of a postcard’s hand-picked blueberries or snowy rolling hills.
Addressing substance use disorders in rural areas is a pressing issue for our state. Just last year, it is estimated that 627 people died from fatal drug overdoses in Maine. Even then, that number of overdose deaths drastically underestimates how many people have substance use disorders. In fact, it’s estimated that 8.64% of Mainers above age 12 have a substance-use disorder.
There are also many negative health outcomes correlated with substance use, which further increases the burden on rural areas. For instance, many people who have substance use disorders have an untreated mental health disorder, such as depression or anxiety. There is also an increased risk of infection complications among those who use substances – HIV, hepatitis B and C, endocarditis, fungal sepsis – especially among people who inject drugs. Other leading health impacts include impaired decision-making, kidney damage, lung disease and more. With such a wide number of health issues caused by substance use disorders, where do we begin to help?
Maine’s government is taking steps in the right direction to help those dealing with substance use disorders in rural areas around the state. Substantial federal money has supplemented expanded state funding. If more significant progress is to be made, however, that funding needs to be directed primarily to the most promising evidence-based approaches. I’ll outline some of them here.
• We need to expand access to evidence-based treatment for substance use disorders in rural areas using medication-assisted treatment for opioid and alcohol use disorders (such as access to methadone or buprenorphine). Efforts to expand treatment for substance use disorders should be matched with efforts to expand treatment for mental health disorders. In rural areas, treatment options that employ mobilized services or telehealth will increase access to care for those who are geographically isolated. Imagine, if you can, a system that addresses mental problems before they are compounded by problematic drug use.
• In rural Maine, people who inject drugs are struggling with wounds and infections due to their lack of access to sterile supplies. This issue is being addressed by researchers and local community organizations, where outreach specialists provide those with substance use disorders in rural areas with wound care kits. Imagine having the tools to prevent infections that, if untreated, can become life-threatening.
• In Maine, most overdose deaths in the last year were attributed in part to fentanyl, a synthetic opioid that can be up to 50 times stronger than heroin. Although fentanyl can be prescribed by doctors to treat serious pain, people working toward harm reduction are primarily concerned with fentanyl that is made and marketed illicitly by the people selling other illicit drugs. Programs focused on reducing harm related to substance use can empower people by providing fentanyl test strips – which detect fentanyl and fentanyl-analogs in someone’s drug supply. Imagine having access to an inexpensive means of preventing overdoses.
• Syringe service programs also provide naloxone (also known as Narcan), an opioid antagonist that can reverse an opioid overdose. Did you know that in less than five minutes, you can learn the signs of an opioid overdose and learn how to administer naloxone? In Maine right now, anyone can carry naloxone, acquire it without a prescription and administer it without penalty in case of a suspected overdose. Learn where you can obtain it in your community, be it at a local pharmacy or from a local syringe services program. Imagine that you have the opportunity to save a life.
• Finally, Maine urgently needs to part ways with its outdated one-for-one syringe exchange policy. This unnecessarily restrictive policy is shockingly inefficient and has no proven benefits. A one-for-one exchange prioritizes false beliefs that more syringe access enables more drug use. In reality, we have significant scientific evidence that broader distribution decreases disease transmission without increasing drug use. Picture yourself as a person who injects drugs in a rural area. You must travel for miles just to get to the nearest syringe exchange program. Realistically, are you going to drive to that program daily just to get one sterile needle? Or are you going to reuse your needles that you already have and just visit the program when convenient to you? How do we eliminate the need for people to have to make this choice? Imagine avoiding harm related to substance use by providing people with the resources they need to use substances safely.
To be sure, many people stand in opposition to these ideas and believe that providing resources to people who use substances is controversial. Nonetheless, I believe we must support efforts that are backed by both science and compassion.
One last time: Imagine a Maine where all people have access to opportunities and resources that allow them to thrive.
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