In the early 2020s, during the COVID-19 pandemic, another public health epidemic was driving up mortality in Wisconsin. By 2021, Wisconsin’s opioid-dose deaths had shot up by 70 percent over three years.
Emergency department visits for opioid overdoses increased by 50 percent, landing Wisconsin in the top five states in the country for increased overdose emergency visits to hospitals. Overdoses were seen as a prime reason that life expectancy in the United States had begun to decline.
Rural Wisconsin residents who struggled with substance abuse lacked access to addiction medicine specialists and to effective treatment such as medication-assisted treatment. Meanwhile, their primary care providers needed more training and support to assist patients in recovery. To bridge this treatment gap, a team that included the peer support group Wisconsin Voices for Recovery, the Wisconsin Hospital Association, and faculty leader Randy Brown, MD, PhD, professor of family medicine and community health at the University of Wisconsin School of Medicine and Public Health, created the Wisconsin Rural Health and Substance Use Clinical Support program, or RHeSUS program.
Supported by a Community Impact Grant from the Wisconsin Partnership Program, RHeSUS has been crossing the state, putting on one- and two-day boot camps to train rural providers in managing substance use disorders and common co-occurring conditions. So far, RHeSUS has trained more than 400 providers in boot camps and held continuing education during monthly lunch-and-learn video sessions. Attendees are also introduced to the UW Addiction Consultation Provider Line and to Project ECHO, which allows providers to bring patient cases related to substance use to a panel of experts and other health care providers statewide. The boot camps also make time for networking and meeting peer recovery experts in their area.
As the grant wraps up, the project team will explore opportunities to keep the momentum going, possibly through private funding or federal grants. For program participants, the knowledge gained at the boot camps has been invaluable and will impact their practices now and into the future.
Brown discusses RHeSUS along with Jill Lindwall, MSN, RN, CPHQ, the quality director for the Wisconsin Hospital Association:
How does RheSUS address barriers to providing care for substance misuse?
Randy Brown: A lot of times general primary care and hospitals can struggle to address substance abuse because it’s been relegated to a siloed system for treatment and there’s a lack of good communication between the systems. For other conditions, primary care providers can rely on specialists for guidance on how best to support patients. There’s a freer exchange of information with other specialists. But due to statutes around confidentiality, information about addiction treatment is blocked in medical records, which can make information exchange a challenge.
The idea was to democratize some of this knowledge; there really is a lot that can be done in primary care to treat substance misuse and related issues as a chronic health condition. There are FDA-approved treatments for alcohol and opioid dependence. If a physician is treating a patient with diabetes, they might collaborate on a management plan with an endocrinologist and nutritionist. For substance use disorders, they can collaborate with addiction medicine specialists and peer recovery resources.
Some of the issues we cover in the boot camps include prescribing buprenorphine products to treat opioid use disorder (OUD) and manage chronic pain; alcohol withdrawal and use disorder; peer support; motivational interviewing skills; harm reduction approaches; and connecting with peer support services. We also work with emergency medical providers on opioid overdose resuscitation, alcohol withdrawal, initiating buprenorphine and naltrexone — a non-addictive medication used to treat opioid and alcohol use disorders — and managing cannabis hyperemesis syndrome, a rare condition affecting long-term, heavy cannabis users.
How do you reach rural providers and communities?
Jill Lindwall: It’s really challenging for rural primary care providers to get away because their practices don’t have a lot of staff, so we bring evidence-based training to them. We have tried to cover different regions of the state, to draw from multiple health systems and critical access hospitals. So far, we have been to La Crosse, Eau Claire, Hayward, Door County, Sheboygan, Madison, Beaver Dam, and Marshfield. We have boot camps coming up in Monroe and Green Bay. Marshfield Clinic reached out and asked us for a one-day boot camp for new employees, then asked for an accelerated course for more experienced providers. The correctional system has been sending people to participate.
We started during COVID, so the first boot camps were virtual, but we realized they were much better in person for networking and relationship building. People would meet and start connecting. Some of the participants have become champions in their own organizations. It’s grown through word-of-mouth from colleagues. We now have a networking consortium in northern Wisconsin that is working on addiction treatment.
A lot of the training focuses on how to have conversations about the issue. We teach about harm reduction if people aren’t ready to quit, and how to let them know that someone is there for them when they are ready.
What does the future look like?
Randy Brown: We really want to express gratitude to the Wisconsin Partnership Program for the opportunity to engage communities and providers on these issues. We are hopeful that this health challenge can be addressed both locally through targeted workforce development, such as the work we’ve been doing with programs like RheSUS, and nationally as well.
In the last two years we’ve seen decreases in overdose mortality from a national peak of 100,000 per year to now about 80,000. And over the last five years we’re seeing more providers prescribing buprenorphine. We’re also collaborating to expand its use in Wisconsin community health centers. It helped that the Federal Drug Administration changed its rules in 2022, so prescribers no longer need a special DEA license to prescribe buprenorphine, and the awareness of its effectiveness continues to grow.
“It was honestly one of the best educational conferences/sessions I have ever attended. I came away with insights that will directly support my work on the medication safety team with Superior Health. Our medication safety team will be meeting with a non-opioid prescribing coalition, and the discussions and education surrounding buprenorphine for pain management will be especially helpful. The education and resources shared will greatly enhance my current part-time nursing work in addiction medicine as well.”
– RheSUS program participant
