LOUISVILLE, Ky. (WDRB) – When Toya Gatewood began her career as a social worker in the late 1990s, doctors were prescribing pain-relief medication that falsely promised patients they weren’t likely to get hooked.
Since then, she has watched the abuse of opioids spread through rural, urban and suburban parts of Kentucky, where 1,404 people died last year from lethal doses of heroin, fentanyl and other legal and illicit drugs – easily more than were killed in automobile crashes.
“Clients are sicker,” said Gatewood, a clinical therapist for Volunteers of America Mid-States in Louisville. “They need more complex treatment options that will add to their life and add to the likelihood of recovery from addiction.”
Even before a glut of powerful prescription pills and cheap heroin fueled an epidemic in the United States, there were not enough therapists, counselors and other specialists working in addiction fields, national and local experts say. But the opioid crisis has amplified those shortages, particularly in rural areas that historically have struggled to recruit and retain physicians.
In Kentucky, 92 of the state’s 120 counties have too few primary care providers, according to U.S. Department of Health and Human Services data. In Jefferson County, where nearly one person died each day last year from a fatal overdose, most of central and western Louisville is considered “medically underserved.”
Similar deficits exist in 68 of Indiana’s 92 counties. Among them are Clark and Floyd counties near Louisville, and farther north in Scott County, where people sharing contaminated needles to inject liquefied pain pills contributed to an HIV outbreak in 2015.
Both states rank below the national average in another measure: The number of behavioral health professionals for every 1,000 people with a substance abuse problem. Kentucky has 31, while Indiana has 18; the U.S. average is 32, according to federal data analyzed by Jeff Zornitsky of Advocates for Human Potential, a Sudbury, Mass., consulting firm.
And the shortages are only expected to worsen in the years ahead, estimates show, as an aging generation of health care providers leaves the field.
“Our ability to recruit and retain qualified specialists in addiction is already a challenge,” said Jennifer Hancock, president and chief executive officer of Volunteers of America. “This is the type of work that is so gritty and real that a lot of clinicians are not interested in doing it.”
The epidemic has highlighted not only workforce gaps but disparities in where those jobs are needed most.
Kentucky needed more than 1,600 full-time mental health providers, which include social workers and substance abuse counselors, to meet the demand chronicled in a 2013 report by the Deloitte firm for state government.
Among the areas with the starkest need was rural Bell County in southeastern Kentucky, where it would take as many as 39 additional full-time specialists to ease the shortages, Deloitte found. That same year the county had the highest rate of overdose deaths per capita in the state; it was second-highest last year.
There has been no lack of efforts to increase the workforce and find new ways to better use the existing corps of doctors, social workers and other medical staff across the state.
Volunteers of America plans to launch a scholarship program this year with the University of Louisville, allowing students specializing in drug and alcohol treatment studies to do fieldwork and possibly land a job with the organization after they graduate.
U of L and the University of Kentucky now offer addiction treatment fellowships. And Spalding University in Louisville has made a mandatory social work course about addiction worth two credits, instead of one, said Kevin W. Borders, the chair of Spalding’s school of social work.
“So many clients that social workers interact with have substance abuse and/or a co-occurring mental health disorder that we’re negligent if we don’t have students with a well grounding in substance abuse issues,” he said.
State officials acknowledge that more students graduating in substance abuse fields would help. But so would encouraging physicians to work with more people with opioid addictions, said Dr. Allen Brenzel, medical director of the Kentucky Department of Behavioral Health, Developmental and Intellectual Disabilities.
Federal regulations allow a single doctor to prescribe buprenorphine, which is used to treat heroin dependence, to up to 275 patients in his or her care over time. The medication must be administered in an office setting.
But Brenzel said the vast majority of physicians in Kentucky who are qualified to oversee such treatments only work with four or five people.
“What we have is a mismatch of those that are qualified to prescribe and what parts of the state that they are (in),” he said. “So we need to reach out to those physicians, understand why is it they’re choosing not to serve individuals with a substance abuse disorder – particularly an opiate-use disorder – and facilitate coordination there.”
Recognizing the toll that the opioid crisis has had on rural areas, U.S. Sens. Joe Donnelly, D-Ind., and Lisa Murkowski, R-Alaska, introduced a bill in June that would expand a national program targeted areas where there are not enough medical providers.
The measure would add addiction treatment clinics to the National Health Service Corps, which provides loan forgiveness and debt repayment for people who work in underserved communities. If workers agreed to spend two years at eligible facilities, they would get up to $50,000 to help pay back student debt.
During a visit to Jeffersonville earlier this month, Donnelly called the bill “a great incentive.”
Providing debt relief to addiction specialists would be an important tool for clinics, particularly in rural areas, to recruit workers, said Rebecca Farley David, vice president of policy and advocacy for the National Council for Behavioral Health. The organization supports the Senate bill.
“These were areas that had a shortage of professionals before the opioid crisis really started sweeping the nation,” David said. “And now, every single year, with increasing levels of need for addiction treatment the shortages have only become worse.”
The Family Health Centers of Southern Indiana hired a full-time dentist through the National Health Service Corps, and any expansion of the loan forgiveness program would help organizations fill positions, Lori Harris, the centers’ CEO, said in an email.
Being in the service corps “helps us be competitive for the recruitment of providers, which can often be difficult in our area due to having so many quality hospital systems looking to fill the same provider job openings that we are seeking to fill at the same time,” she said.
In Austin, Ind. – the epicenter of the Southern Indiana HIV outbreak – Family Foundations Medicine sometimes struggles getting its patients help with pain management, administrator Jeanni McCarty said.
She didn’t hesitate when asked if the bill, now in a Senate committee, would help alleviate workforce shortages in places like Scott County.
“If somebody knew their college loans were going to be repaid?” she said. “Absolutely.”
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