A new report from Grantmakers in Aging (GIA), “Heartache, Pain, and Hope: Rural Communities, Older People, and the Opioid Crisis,” examines the differential impact of opioid misuse and abuse on older adults living in small towns and rural communities and interventions that provide potential models for scaling up the philanthropic and public response to this crisis. Noting the need for widespread collaboration to address the opioid crisis, the authors write, “Commitment, creativity, ingenuity, and coordination between government, funders, nonprofits, and the medical community will be needed, if we are to make meaningful progress toward meeting the needs, and indeed, saving the lives, of individuals and communities in pain.” For funders and nonprofits, the report profiles a number of best practices that could provide models for successful interventions at the local, regional, or national level.
Extent of the Crisis
In 2015, 52,404 Americans died of drug overdoses. Of these deaths, 63 percent, or just over 33,000, were from opioid use. Nearly half—15,000—were attributed to prescription drugs. (By comparison, 58,000 Americans died fighting in Vietnam.)
Opioid use and misuse has been growing steadily over the last two decades. Since 2000, over 300,000 people have died from overdoses. According to the Centers for Disease Control (CDC), 2 million Americans suffer from opioid use disorder, and another half-million are addicted to heroin. Over four percent of the population over the age of 12—11 million people—report having used prescription painkillers for nonmedical purposes just in the last year.
Rural Communities Hardest Hit
Rural areas of the country have been particularly hard hit by the opioid crisis. Those living in rural communities are twice as likely as urban dwellers to overdose on prescription painkillers. Among the areas experiencing the worst impacts are rural New England, Appalachia, and the Midwest.
The disparate impact of opioid addiction and overdose is due to several factors, according to the GIA report. First, doctors more often prescribe opioids in rural areas. Farmers, miners, and other laborers as they get older often suffer from chronic pain, and have less access to surgery or other medical treatments that might address that pain. “In our area, my dairy farmer has to get up tomorrow morning. He doesn’t have time to go over to Winston-Salem or down to Charlotte for some kind of invasive treatment. So the opioid keeps them going,” explains Fred Wells Brason, founder of Project Lazarus in Wilkes County, North Carolina.
Second, only about 10 percent of opioid addiction treatment resources are located in rural areas. Naloxone (or Narcan), the lifesaving medication that can reverse an overdose, is not only less available but often administered too late as a result of slower emergency response times, as first responders often have to travel long distances. For patients seeking treatment, only 11 percent of those in rural areas receive evidence-based Medication-Assisted Treatment, where a less dangerous opioid, usually buprenorphine, is given to the patient to help them stabilize their life and then eventually end their dependency.
Rural Communities Getting Older
As our country ages, rural communities are aging the most rapidly. One in four adults over the age of 65 lives in a small town or rural area, about 10 million Americans. Many of these older adults suffer from chronic illnesses and pain associated with a lifetime of labor. When opioids are prescribed, insufficient education about dangers associated with these drugs—including overdose and death—can lead to unintended misuse and abuse.
According to the CDC, the Medicare population has among the highest and fastest-growing rates of diagnosed opioid use disorder. There has also been rapid rise in drug overdose deaths among 55- to 64-year-olds, indicating that without intervention, communities will face crisis levels of addiction among older adults in the coming decade.
Nora Volkow, PhD, director of the National Institute on Drug Abuse, explained to GIA, “Baby Boomers’ histories of illicit drug use, and their relatively tolerant attitudes toward it, along with the fact that they now comprise nearly 30 percent of the nation’s population, have raised the stakes on understanding and responding effectively to drug abuse among older adults.”
Impact Goes Beyond Addiction
For older adults, addiction is not the only risk associated with opioid abuse. When younger family members develop addictions, the spillover affect can be profound.
Rising rates of elder abuse and financial exploitation correlate with rising opioid drug addictions. Over the last five years, Massachusetts has seen a 37 percent increase in elder abuse. According to Kay Lazar of the Boston Globe, when addicted children fall on hard times, they move back in with parents, whose “monthly Social Security and pension checks become easy targets for financial, physical, and emotional abuse.” Housing may also be at risk. When addicted children move in with parents in public housing, tenants can face eviction for violating public housing drug-use regulations.
Finally, today 2.6 million grandparents are raising the children of alcohol- and drug-addicted parents. As a result of the opioid epidemic, the number of children in foster care is rising for the first time in decades. According to Generations United, overwhelmed foster care systems are looking to relatives to fill gaps in the system. Moreover, for every child living with a grandparent or other relative through the formal foster care system, 20 children are living with relatives on an informal basis.
For grandparents, taking on raising children can be both emotionally and financially stressful. Often living on fixed incomes in small apartments, grandparents may not be prepared to meet the needs of traumatized grandchildren. As Jaia Peterson Lent, deputy executive director of Generations United, explained in Senate testimony, “Relative caregivers are often grieving a host of losses, including that of the treasured traditional grandparent role, control over their future, financial security, or even the ability to go on vacation.”
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In August, President Trump declared the opioid crisis a national emergency, but since then his administration has failed to turn this off-the-cuff remark into a formal declaration that would bring additional federal resources to the table beyond the $40 million in state-based grants recently announced by the CDC. In the meantime, GIA has identified an array of promising interventions that philanthropic organizations could invest in to help rural communities address opioid addictions among people of all ages. These strategies include:
Educating Clinicians to Better Manage Chronic Pain
The opioid crisis is in many ways the outcome of healthcare providers trying to do something good: reduce acute and chronic pain. When they first started prescribing these new medications, there was little understanding of the risks involved. Better educating doctors and other providers in rural areas so they can manage pain, especially for seniors, is an important strategy for reducing opioid use.
The University of Washington Division of Pain Medicine is helping providers in rural communities manage patients with chronic pain through teleconferencing. Since 2011, over 1500 providers across the Northwest have participated.
Expanding Access to Medication-Assisted Therapy
Nationally, only three percent of primary care physicians have the necessary training and “waiver” to administer buprenorphine, the replacement opioid used for Medication-Assisted Treatment (MAT). This treatment is extremely difficult to access in rural areas.
In rural Eastern Colorado, for example, only one healthcare provider could administer MAT until Colorado University School of Medicine began training primary care physicians, nurse practitioners, physician assistants, and office staff about opioid use disorder and MAT. The university now trains clinicians in MAT through a free online “waiver course.”
Building Community Coalitions
Treatment and education programs work best when they are tailored to specific communities. In Wilkes County, Brason, a hospice chaplain, worked with community leaders to create Project Lazarus. By bringing together emergency room physicians, local hospitals, primary care doctors, faith-based programs, and law enforcement, the project reduced overdose deaths by 69 percent. In 2013, the program received a $2.6 million grant from the Kate B. Reynolds Charitable Trust to adapt its work statewide.
Providing Senior-Centered Therapy
For older adults in need of addiction treatment, conventional programs that serve younger addicts can be off-putting or even intimidating. Tailoring programs specifically to the needs of seniors has been proven to be effective. For example, at Senior Hope Counseling in Albany, N.Y., staff are experienced working with older people and are trained to speak slowly and loudly. Group sessions are smaller, with people of similar age, and address issues such as depression, isolation, and grief that impact older people. In addition, the program provides transportation services when needed, along with linkages to other community services.
Training Community Health Educators
Ashley Merritt, a pharmacist in rural Missouri, told GIA, “Opioid misuse by older adults is very common in this region, largely due to poor health literacy and misunderstanding of the medication itself rather than a blatant desire to abuse.” An issue that often comes up among elders, for example, is the sharing of medication: A friend is in pain, so why not give them a few pills?
One underused resource to address the need for more widespread education and support is community health workers and other peer educators. In rural New Mexico, for example, the Community Addictions Recovery Specialist (CARS) program uses telehealth and in-person training to train medical assistants, community health workers, health educators, and peer support specialists to provide culturally appropriate clinical support, health education, and evidence-based behavioral interventions in the community.
Community health workers, making regular home visits, can help ensure that older adults understand the importance of taking their medications as directed and provide much needed social support, thereby reducing the risk of falls, overdose, and abuse and exploitation.
Changes in Public Policy
Interventions that help people address their addictions are essential to the health and well-being of individuals and communities all across the nation. But to stem the tide of opioid use disorder, we need upstream solutions that more fully address the health care needs of older Americans and the overprescribing of addictive substances. According to the CDC, in 2012, health providers wrote 259 million prescriptions for opioids, enough to provide every adult in the country with a bottle of pills. And yet, despite this healthcare emergency, according to a recent ProPublica/New York Times story, insurance companies are blocking access to more expensive nonaddictive painkillers. Clearly, we need a national action plan that gets all the boats rowing in the same direction.
The National Institutes of Health is calling for more research into better medications to reverse overdoses, new medications for addiction treatment, and safe and effective treatments for pain management. Though these are important avenues of research, the bigger problem lies in access to addiction treatment, nonaddictive pain medications, preventive education, and social supports, particularly for older adults impacted by addiction within their families. These are public policy issues that we could address, if our legislators in Washington, D.C., would turn to addressing our nation’s healthcare needs, rather than reviving efforts to repeal the Affordable Care Act.