A State of Addiction: Rural v. Urban

Dec 5, 2017

It’s a cold, November morning and I’m outside a free detox center in South Salt Lake. It stands out because it’s a modern-looking building in an industrial part of town. Two tired-looking men are pacing under a heater just outside the center’s doors waiting for a woman to call their names so they can begin detoxing from either alcohol or drugs.

This detox program is run by Volunteers Of America. Currently there’s 80 beds inside this center. There used to be 60 but since opioid-related deaths have spiked around the country, the center has worked with the state of Utah to reduce the number of square footage required per person so they could add more beds and accommodate more people.  

“Detox is often the first step in treatment and recovery," said Kathy Bray, president and CEO of the VOA in Utah. "For many people, they are so intoxicated at the time when they come to us that they really need some days worth of not using. And increase of water and healthy foods before they can go into a treatment setting where they’ll be expected to participate in a group where they might be discussing coping strategies for relapse prevention, things like that so they’re ready for the cognitive work and they need to feel physically better.”

This center sees a lot of alcohol-related issues, and that kind of detox usually takes 3-5 days. But to safetly detox from heroin, it takes two or more weeks. Bray says the center has recently introduced medication-assisted treatment for heroin and opioid detox. Before MAT, most opioid users left detox after only three days since opioid detox is among the hardest to go through.  

“At Volunteers of America Detox Center in Salt Lake County, we see about 1,500 different people a year," Bray said. "Typically, 10 admissions and 10 discharges a day. Of those people, I would think that seven or eight out of 10 do not have the ability to pay. Some of them pitch in a bit towards their stay and then it’s kind of subsidized, if you will, by the government.”

When dealing with drug addiction, detox and rehab, money is always an issue. But Bray says they can always accommodate people, regardless if they are able to pay or not. 

“We use a sliding-fee scale," she said. "So when somebody comes into the facility, we will be asking them, ‘Are you working? Do you have a job? What about insurance?’ We do have substantial contracts, or a substantial percentage of our funding is Salt Lake County Behavioral Health. It is for people who need support in paying for recovery services. So they pay their percentage and then the county government essentially pays the remainder. For people who don’t have any income or any insurance, we can still serve them and we serve them under the county contract.”

Salt Lake County has the resources and manpower to make this happen. But what about rural Utah? What are they doing in say, Green River? Green River has one medical center, no hospital. There’s no doctor and only one physical assistant, who is always on call.

“The biggest barriers here, is the distance we have to nothing," said Shlisa Hughes, operations director at Green River Medical Center. "The closest help to us, is like I said, 65 miles to Price, that’s Castleview Hospital. 45 miles south to Moab, that’s Moab Regional. And 110 miles to Grand Junction, and that’s St. Mary’s or community hospital. That’s one of the biggest barriers here, and then we have, of course, the truly underserved.”

The center is one of the smallest FQHC, or Federally Qualified Health Centers, in the nation. About 35% of their patients are insured, leaving the majority of who they see on a sliding-fee payment scale with some completely unable to pay anything. This is a major issue with opioid addiction because treatment requires a team of people for safe recovery.

“Well opioids and addiction requires a full array of treatment. It’s not just the medical, it’s also mental. You have to have both parts,” Hughes said.

Another barrier for Green River Medical is not being able to contract with all insurance providers because they don’t have a medical doctor, only an PA.

“So we take as much insurance as we possibly can," Hughes said. "We try to contract with any insurance that will contract with us. We get the major ones here in Green River, but there are those barriers of not having a true M.D. on site.”

With the lack of manpower, resources and the distance issue, those seeking help for addiction treatment can seem impossible for many of Utah’s rural community members. Once when a person who struggles with addiction decides they want help, where do they go? Utah’s attorney general is trying to help.

“It’s great that across the front, that there are a number of resources. But in our rural counties, they’re being impacted disproportionately more than even. Maybe not in pure numbers, but on the recovery side, which is a key component,” said Utah Attorney General Sean Reyes.

Reyes recently co-authored a letter, along with 37 other AGs in the nation, “urging health insurance companies to examine financial incentives that contribute to the opioid epidemic.”

The letter, sent out in September, was addressed to the president of American’s Health Insurance Plans asking for a review of healthcare provider’s coverage policies by putting a priority on non-opioid pain management options. This includes non-opioid medications, physical therapy, acupuncture, massage and chiropractic care. 

“If we can get insurance companies, if we can get them incentivize to cover the recovery side, but also to cover and not put up so many barriers to people who want to get less addictive, but more costly, alternatives to opioid prescription drugs," said Reyes. "I, as the Utah Attorney General, have been trying to put a lot of pressure to work with insurance companies. To reexamine their, comprehensively, their coverage, protocols and programs.”

In October, he sent out another letter to national leaders, including Speaker Paul Ryan and Nancy Pelosi, about the need for federal laws to change “to make treatment for drug addiction more affordable and accessible for Americans who need it most.”

“One of the letters that I signed recently to Congress," Reyes said, "along with my colleagues for the Attorney General's to do away with some of the restrictions that exist today because of some arcane rules that we passed 50 years ago, to try to curb abuses in the mental health arena. But right now are limiting a number of people, particularly in the rural communities from being able to get into treatment, residential treatment facilities.”

Whether it’s in rural Utah or downtown in the state capital, opioids are a complex problem.

“As overwhelming as the epidemic may seem, that’s not to diminish in any way the severity of what we are all facing, but I don’t want people to give up hope and feel like there’s just too much and we are never going to be able to get a handle on this. I think we can see how attitudes change.”

And since we started this opioid project a year ago, things are changing.

In September, federal health authorities granted 11 health centers in Utah $1.8 million to help increase the amount of substance abuse and mental health services. The Department of Health and Human Services gave some of this funding to the Green River Medical Center. 

This series is brought to you in part by the Association for Utah Community Health, providing training and technical assistance to health centers and affiliates across Utah. More information available here.