How one rural California county went from the state’s highest rate of opioid deaths — to zero

Portola, Calif. – The heavily forested valleys and mountains in Plumas County, California are stunning and peaceful. But in recent years, this rural county has also earned the notorious distinction of having the highest rate of opioid-related deaths in the state, one made all the more remarkable considering the county is the eighth least populous.

“Probably no one in this room is untouched by this problem,” Andrew Woodruff, the county’s acting director of public health, told the Plumas County Board of Supervisors in November. “Public Health started looking into what was actually going on, and we quickly saw that our county overdose death rate was higher than we ever expected, and multiple times higher than the state rate.”

The national opioid epidemic has been playing out most markedly in remote, rural areas like Plumas County, which presents a challenge for health care providers already hampered by rising health care costs. Geographical isolation and too few medical professionals and resources in these areas have exacerbated the situation, leaving both law enforcement and small local hospitals struggling to keep up.

But Plumas County has seen a dramatic drop in opioid-related deaths recently, a reversal credited in part to a network of regional coalitions tackling the problem the across the state. 

The California Health Care Foundation started funding Opioid Safety Coalitions four years ago, so counties could combine opioid treatment resources. The nonprofit Center for Health Leadership and Practice, in cooperation with the foundation, has advised public health officials in 32 counties representing 24 coalitions and formed the umbrella group the California Opioid Safety Network.

According to Dr. Carmen Rita Nevarez, director of the Center for Health Leadership and Practice in Oakland, the work of the coalitions varies depending on the problems they are trying to solve. A coalition made up of doctors may focus on getting other doctors to find alternatives to opioids and encourage safer prescribing, or will work on helping those who are addicted get off of the drugs.

“They are like self-organizing task forces,” said Nevarez. “Coalitions are defined by the situation, every single one is different, depending on the community. There’s no mandate, but instead, these are people who band together to work together to solve a problem.”

To that end, she notes, “We’ve seen that where there have been coalitions, the capacity to provide more treatment has been well-documented and more people are getting treatment,” Nevarez said. “We believe this will lead to lower death rates.”

In 2015, health professionals in California’s northern Sierras formed the regional Northern Sierra Opioid Safety Coalition. The group aimed to curb the growing number of opioid-related deaths in four counties — Plumas, Lassen, Sierra and Modoc — and to expand access to treatment for those struggling with addiction. Its objective was three-fold: promote safer prescribing, increase access to naloxone, which can counteract the effects of an opioid overdose, and widen treatment options for addiction.

Geographical isolation and too few medical professionals and resources in these areas have exacerbated the situation, leaving both law enforcement and small local hospitals struggling to keep up.

“We’ve been trying to expand medication-assisted treatment,” said James Wilson, a Coalition health education coordinator in Plumas County referring to the drug buprenorphine, which is used in opioid-replacement treatment. “We have doctors in the area who are prescribing that but there’s not as much access as we would like.”

Prior to the coalition, he said, the only option for people with opioid-use disorders was to attempt to quit cold turkey.

“But we all know how that turns out,” Wilson said. “In general, access to treatment has been one of the main barriers to overcoming addiction.”

The opioid crisis also coincides with the distress in many rural areas across the nation as they continue to lose hospitals. According to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina, which has been tracking rural hospital closures nationwide since 2010, more than 80 have shuttered their doors in that time.

“In general, more rural areas have larger challenges than those that are more urban,” said Nevarez, referring to the opioid crisis. “There’s a lack of concentration of people, higher unemployment and scarcer resources — if you have a job, you’re less likely to engage in substance abuse.”

Since September 2016, the Northern Sierra coalition has distributed 500 naloxone doses in the four counties and has recorded 18 overdose reversals.

Data from the California Department of Public Health show a dramatic decline in opioid deaths in Plumas County. In 2014, the county had 20.52 opioid-related deaths per 100,000 residents, compared to the state’s overall rate of 4.92. In 2015, the county’s opioid death rate was 31.3 per 100,000, compared to the state’s rate of 4.73. By 2016, however, for which the most current records are available, there were no opioid-related deaths in Plumas.

That’s a stunning decline. But problems remain.

The Plumas County Public Health Agency, which heads the Northern Sierra Opioid Safety Coalition, set up a medication-assisted treatment program but was unable to get their local physicians to get licenses which would allow them to prescribe buprenorphine for addiction treatment.

And funding has been uneven, too. “The medication is covered by Medi-Cal but none of our clinical fees are,” Wilson said.

That’s because Plumas County is not Drug Medi-Cal certified, meaning it cannot receive treatment funding from the state.

“Reimbursement is still an issue,” said Wilson. “We’re taking a hit in that regard. And there are some barriers to getting certified directly related to the rural and frontier nature of our county. The clinics, he notes, are not even allowed to dispense buprenorphine at the clinics.

“Instead, our doctors prescribe it, the patient goes and picks it up at the pharmacy, and then comes back to the clinic to have it administered,” Wilson said.

All of this is a big shift for doctors and clinics in the region. “Before all of this, clinics were mostly just offering vaccinations and STD testing,” Wilson said. “Our clientele has totally changed, this is something new for us.”

In Plumas County, meanwhile, the number of opioid prescriptions has declined by nearly a third. In the second quarter of 2011, there were 1,234 opioid prescriptions per 1,000 people. In the fourth quarter of 2017, for which the most current figures are available, the number of prescriptions was 867 per 1,000 people.

“Plumas County went from having the highest rate of overdoses in California to the lowest,” Wilson said, referring to the state data. “This is really significant when you think about the size of the county, which is comparable to the state of Maryland but has just one percent of the population.”

While the 2017 state data are not yet available, Wilson said that based on Plumas County’s own tracking, there were “one, possibly two deaths from prescription overdose.”

“This is still a vast improvement from where we were four years ago,” he said. “Resources here are spread very thin, which is why we hoped it would be a good idea to have the counties come together as a coalition. The numbers show that it has been.”

(Editor's Note: The California Health Care Foundation, which is mentioned in this post, is a funder of the Center for Health Journalism. Dr. Carmen Nevarez, quoted here, serves on the Center for Health Journalism's Advisory Board.)

[Photo by David Prasad via Flickr.]