As overdoses soar in rural America, more clinicians are prescribing addiction medications

The number of U.S. health care providers certified to prescribe buprenorphine more than doubled in the past four years. Treatment advocates hope to see that trend continue.

Iowa — Andrea Storjohann is glad to see that she’s becoming less of a rarity in rural America.

The nurse practitioner prescribes medication to dozens of patients trying to recover from addiction to heroin or opioid painkillers.

The general-practice clinic where she works, housed in a repurposed supermarket building, has no signs designating it as a place for people to seek treatment for drug addiction, which is how Storjohann wants it.

“You could be coming here for OB-GYN care. You could be coming here for a sore throat. You could be coming here for any number of reasons,” and no one in the waiting room would know the difference, she said.

Privacy is an important part of the treatment. And so is the medication Storjohann prescribes: buprenorphine, which staves off cravings and prevents withdrawal symptoms for people who have stopped misusing opioid drugs. The central Iowa clinic, owned the nonprofit agency Primary Health Care, has offered buprenorphine since 2016. “We were kind of a unicorn in this part of the state,” Storjohann said, but that’s changing.

Unlike methadone, the traditional medication to wean people off heroin or other opioids, buprenorphine can be prescribed at primary care clinics and dispensed at neighborhood pharmacies. Federal and state authorities have encouraged more front-line health care professionals to prescribe Suboxone and other medications containing buprenorphine for patients trying to overcome opioid addiction. Federal regulators have made it easier for doctors, nurse practitioners, and physician assistants to become certified to offer the service.

The opioid crisis has deepened in the past decade with the illicit distribution of fentanyl, a powerful, extremely addictive opioid. Its prevalence has complicated the use of medication to treat opioid addiction. Patients who have been misusing fentanyl can suffer severe withdrawal symptoms when they begin taking buprenorphine, so health practitioners must be careful when starting the treatment.

In Iowa, officials designated $3.8 million from the state’s initial share of opioid lawsuit settlement money for a University of Iowa program that helps health care providers understand how to use the medications.

Federal agencies are spending millions to expand access to medication to treat addictions, including in rural areas. The Health Resources and Services Administration, which aims to improve health care for underserved people, offers many of these grants.

Carole Johnson, the agency’s top administrator, said she hopes increased training on treating opioid addiction encourages health care providers to learn the latest ways to treat other kinds of addiction, including methamphetamine dependence and alcoholism, which plague many rural states. “We’re sensitizing people to substance use disorder writ large,” she told KHN.

In 2016, just 40% of rural counties nationwide had at least one health care provider certified to prescribe buprenorphine, according to a University of Washington study. That figure climbed to 63% 2020, the study found.
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The study credited the rise to changes in federal rules that allow nurse practitioners, physician assistants, and other midlevel health care providers to prescribe buprenorphine. In the past, only physicians could do so, and many rural counties lacked doctors.

Buprenorphine is an opioid that pharmacies most often sell as a tablet or a film that both dissolve under the tongue. It does not cause the same kind of high as other opioid drugs do, but it can prevent the debilitating withdrawal effects experienced with those drugs. Without that help, many people relapse into risky drug use.

The idea of opioid “maintenance treatment” has been around for more than 50 years, mainly in the form of methadone. That drug is also an opioid that can reduce the chance of relapse into misusing heroin or painkillers. But the use of methadone for addiction treatment is tightly regulated, due to concerns that it can be abused.

Only specialized clinics offer methadone maintenance treatment, and most of them are in cities. Many patients starting methadone treatment are required to travel daily to the clinics, where staffers watch them swallow their medicine.

Federal regulators approved Suboxone in 2002, opening an avenue for addiction treatment in towns without methadone clinics.

Storjohann said buprenorphine offers a practical alternative for Marshalltown, a town of 27,000 people surrounded rural areas.

The nurse practitioner spends about half her time working with patients who are taking medications to prevent relapse into drug abuse. The other half of her practice is mental health care. A recent appointment with patient Bonnie Purk included a bit of both.

Purk, 43, sat in a small exam room with the nurse practitioner, who asked about her life. Purk described family struggles and other stressors she faces while trying to abstain from abusing painkillers.