Approximately 14% of British Columbians live in rural areas of the province.446 Notably, 30.3% of Indigenous people in BC live in rural areas and another 40.1% of Indigenous people live on-reserve.447  While data on the prevalence of OUD in rural and remote populations is lacking, 2015–2016 data from BC’s Provincial Overdose Cohort indicates a non-fatal overdose rate of 53.1 per 100,000 people and a fatal overdose rate of 8.7 per 100,000 people in rural areas  and a non-fatal overdose rate of 18.1 per 100,000 people and a fatal overdose rate of 4.8 per 100,000 people in remote areas .448 These rates are substantially lower than urban areas, where the non-fatal overdose rate is 182.9 per 100,000 people and the fatal overdose rate is 20.5 per 100,000 people. 

Several environmental and social factors are thought to predominantly influence opioid use in rural areas of the United States, but there is a lack of comparable research in Canada. In rural areas, widespread use of prescription opioids is partially attributable to the normalization of prescription opioids in heavy-labour occupations, which, in part, results from heightened rates of occupational injury.449,450 In addition, an older population that is more likely to experience increased chronic pain is also thought to contribute to the normalization of opioid use in rural areas.450 There are extensive social and family networks present in rural and remote settings that are associated with protective factors for substance use as well as negative influences that may faciliate initiation into opioid use and diversion of prescription opioids.449 A lack of economic opportunity that results in unemployment and financial hardships further contributes to opioid use in rural and remote communities.450

There are unique barriers to both accessing and providing OUD care in rural and remote areas. The most commonly reported barrier to substance use care is the lack of medication treatment services, followed by increased travel times, stigma, and general lack of resources (e.g., internet access) and local services.451,452 The shortage of health care providers, including those trained to provide OAT, leads to lengthy wait-times for entry into care. Rural and remote area are less likely to have clinics or pharmacies within their communities, necessitating patients travel long distances to access OUD care, which can be costly and time-consuming for patients. Moreover, individuals who live in rural and remote communities are more likely to be undiagnosed and untreated for substance use disorders, and more likely to report unmet substance use care needs.453,454 Individuals who must travel from rural and remote settings to urban settings to receive substance use care are more likely to experience a relapse and more likely to become incarcerated.449 At the provider level, health care providers in rural and remote areas are also less likely to have received training in OUD care and, as a result, are less likely to offer their patients evidence-based treatments, particularly opioid agonist treatment.455  Limited availability and support from other rural health care providers, specialists, and support staff further hinder the delivery of OUD care. 

Several strategies have been identified for providing effective OUD care to patients in rural and remote settings. Care providers can determine how to adapt the recommendations in this guideline in order to reduce barriers for patients. For example, flexible and early take-home dosing can be considered in situations where daily visits to pharmacy are not feasible due to distance or other limitations. All adaptations to the recommendations should have a clear rationale, take patient and community safety into consideration, and be documented. Additionally, nurses can play a key role in increasing access to and retention in OUD care in rural and remote settings, as they are often the primary care providers in these communities. In the United States, where nurse practitioners have had authority to prescribe buprenorphine since 2016, there has been a marked increase in the number of buprenorphine providers in both urban and rural counties.456 More than 50% of the new buprenorphine providers in rural areas were nurse practitioneres and physician assistants. In BC, as part of the provincial response to the overdose crisis, temporary regulatory exceptions were granted in 2020, permitting an expanded scope of practice for registered nurses (RNs) and registered psychiatric nurses (RPNs). In 2023, a new designation of certified practice for opioid use disorder for RNs and RPNs was approved by the BC College of Nurses & Midwives. Certified Practice Opioid Use Disorder RNs and RPNs can diagnose OUD and prescribe buprenorphine/naloxone, methadone, and slow-release oral morphine. This expansion of scope will likely facilitate greater access to evidence-based treatment, particularly in rural and remote areas. 

Another strategy is the wider adoption of virtual care (often called telehealth) in delivering OUD care (see below for further detail). Virutal care enables providers to consult with patients from a distance, eliminating the need for—and additional costs of—patient travel to other communities. While telehealth has demonstrated effectiveness in rural populations, few studies have been conducted examining OUD care specifically.450 However, a 2017 cohort study in rural Ontario found retention rates of participants who received remotely delivered OAT to be significantly higher (50%) compared to those who received opioid agonist treatment through in-person visits (39%), at 1 year (aOR: 1.27, 95% CI: 1.14–1.41, p<0.001). The authors suggest the higher retention rates are attributable to increased acceptability and convenience to patients as they can remain in their communities to initiate and be maintained on opioid agonist treatment.457 A virtual OUD care program in Alberta had a retention rate of 90% at 6 months and 58% at 12 months and was able to reduce wait-times from 6 days to 0 days, highlighting the significant potential to increase access to care in rural and underserved areas.458

4.8.i Virtual Care

Virtual care may be used, when appropriate, along with in-person appointments, collaboration with pharmacists, nurses, and specialists, to reduce travel time for patients, facilitate referrals without onerous travel, increase access to care, facilitate physical distancing (e.g., during pandemic-related restrictions), and support retention in care. Virtual care for substance use care may help engage patients by improving access and convenience and has been shown to be at least as effective as in-person treatment in terms of retention, therapeutic alliance and substance use, during the COVID-19 pandemic.459 However, some individuals may not be able to utilize virtual services due to barriers such as inability to access a telephone, computer, or high-speed internet. These barriers may be particularly challenging in certain groups, including racial minorities, the elderly, and those with low levels of education.460

Clinical judgment and patient circumstances should guide when and if virtual care is appropriate. Virtual care can be used to provide OAT prescriptions as well as follow-up and ongoing care. The current practice standard indicates that physicians can prescribe OAT if they have:

• a longitudinal treating relationship with the patient, or
• performed and documented a comprehensive assessment themselves (either by virtual care or in-person) and will be available to the patient for follow-up and are able to provide ongoing care that includes comprehensive management of the OUD. 

Nurses may also provide OUD care through virtual technology. More information can be found on the BCCNM website.