Physician Morgan Hungenburg is in the second year of her medical residency program. Since August she's been training in family medicine at Salud Family Health Center in Fort Morgan.
"I really like the continuity of family medicine," Hungenburg said. "We call it 'womb to tomb.' I like that wide age range because I like pediatrics, but I also like geriatrics. I kind of get a little bit of everything."
In Morgan County and the 15 other counties that make up Colorado's Eastern Plains, caregivers like Hungenburg face a difficult problem: Opioid overdose deaths are becoming more common. From 2014 to 2016 these counties had an opioid overdose death rate of 20.6 per 100,000 residents, higher than the state rate of 15.8.
One way to combat the growing crisis is through medication-assisted treatment, or MAT.
"I think it's definitely needed, especially in rural areas," said Hungenburg. "If, as primary care physicians, we can provide that, we should be doing that."
Young, bright-eyed and energetic, Hungenburg has taken the required course for her waiver that allows her to prescribe MAT like buprenorphine, but there's an issue: She's the only provider where she works with it.
"Because I'm a resident, it means I'm still in training, so I have several supervising physicians," she said. "I'm waiting for one of them to be able to prescribe it with me before I can start."
For now, that means there's no one at this Fort Morgan facility who can write the prescription, despite having a provider who meets the requirements.
An issue of people power
The lack of medical providers who can prescribe MAT is a problem not only in eastern Colorado but throughout the state - and the country. There is a nationwide push to get more medical providers waivered to write buprenorphine prescriptions, and a new study is taking the training a step further.
The three-year study is called Implementing Technology and Medication Assisted Treatment Team Training in Rural Colorado, or IT MATTTRs, and it is designed to address the needs of residents in eastern Colorado and the San Luis Valley.
"We recognize there are many different ways to approach the problem of opioid use disorder, this focuses on treatment and how to increase the capacity in rural practices and communities to be able to provide treatment because it's like a barren, barren, landscape right now," said Linda Zittleman, co-director of the High Plains Research Network.
HPRN, based at the University of Colorado Department of Family Medicine, created the study. It is funded by the Agency for Healthcare Research and Quality.
Before the study began, HPRN identified only two providers with the required DEA waiver in the two regions. Their first goal is to help providers get trained and get the waiver to increase that number to 10.
IT MATTTRs started in October 2016. Since then, 30 providers - at least 22 of them in eastern Colorado - have completed the prescribing waiver training. Another 17 have requested their waiver from the DEA.
But Zittleman found that getting providers trained is not enough.
"A provider goes through training, (goes) back to the practice and the rest of the team may not know how to support that," she said. "They don't know the other components of medication-assisted treatment."
Enter the second part of the IT MATTTRs program: a curriculum to teach medical practices about opioids, addiction and MAT.
The Primary Care Practice Team Training aims to better equip practices with the information and resources needed to better serve patients with opioid use disorder. The training is for the whole staff, from the front desk and medical assistants to doctors.
"It's vital to train the entire practice team," said Lori Jarrell, practice facilitator and trainer with the High Plains Research Network. "This is an issue that's complex and we all have personal and professional bias, thoughts, ideas, experiences with that."
The study wanted to recruit 40 health care practices to take the team training. Thus far, 42 have been recruited and 40 have completed the training. Thirty of these practices are in eastern Colorado, including Salud Family Health Center in Fort Morgan. All 50 staff members participated in the four, hour-long, sessions.
"It takes the stigma away," said Sandi Garcia, center director of Salud in Fort Morgan. "One of the main things we learned is that you have no idea what an opioid-dependent or opioid-addicted person looks like."
Getting the community involved
The High Plains Research Network was established 20 years ago and covers the 16 counties in eastern Colorado. The group works with primary care practices, hospitals, public health agencies and communities in rural eastern Colorado on a variety of research studies and programs that are relevant to and contribute to the health of people living there.
About 15 years ago they formed a community advisory council to help guide its work. The council has worked on a variety of health issues like asthma, colon cancer, high blood pressure - and now opioid addiction and treatment.
Council members live in the various Eastern Plains counties and are farmers, ranchers, teachers, large and small business managers, students and retirees.
"Folks who are not medically trained, they're not public health professionals but they live in eastern Colorado," Zittleman said. "So they know what it's like to live there, they know how people communicate, they know what's going on in the community."
That community understanding is essential to the third part of IT MATTTRs, where the council developed a community-based component. They created the awareness campaign "Have You Met MAT?" aimed at changing the conversation around opioid addiction.
"Our work follows a pretty specific process," said Maret Felzien, a fourth-generation rancher and director of academic support services at Northeastern Junior College in Sterling.
She and husband, Ned Norman are members of the community advisory council.
"The first process is really beginning to understand what is the situation and what do we need to know about this health issue?" she said.
At first the council met quarterly to get an in-depth education about opioids, addiction and treatment. Then they translated the medical information and jargon around opioid use disorder and MAT into concepts, messages and materials that are meaningful and actionable to community members.
"While there's this curriculum going on in the clinics and this education process in the clinics," Felzien said, "our desire was to start to get people to see and think and hear about (medication)-assisted treatment and to talk about opioid use and abuse."
The "Have You Met MAT?" campaign launched last spring. It includes movie theater ads, newspaper articles and informational letters sent to law enforcement workers.
There are also handouts like coasters, inserts, posters and placemats. The materials are printed with images representative of the Eastern Plains - such as barns and the Pawnee Buttes.
"It's really important to our community that when we put out publications into our community that it reflects our personalities," Felzien said.
One of the posters features a black and white photo of a player in uniform holding a football in front of his face. In bold green and white letters it reads, "Deaths from opioid drug overdose increase 300 percent in eastern Colorado over the past decade."
"Sports are really important to us," Felzien said. "We're small towns, we're small communities, we revolve around our schools and our school's athletics. And so this is the image that looks like us. It could be one of our kids, likely is."
Members of the community advisory council have distributed tens of thousands of the handouts to many local establishments including churches, restaurants, bars, banks, libraries and liquor stores.
Ben Brunner has a poster and some inserts on display at his pharmacy in the town of Brush in Morgan County.
"I've had a lot of patients really in the last few months saying they want to get off opioids," he said. "I think it's helping. It's kind of drawing attention, saying, you know, there's a problem out there and a lot of people probably shouldn't be taking these on a daily basis."
To determine the effectiveness of the IT MATTTRs program, researchers will conduct pre- and post-surveys with community members, patients and primary care practice teams.
But the study has already made an impact. The Colorado Office of Behavioral Health has included the prescribing waiver training and Primary Care Practice Team Training in the state targeted response to the opioid crisis grant program.
Through the IT MATTTRs statewide dissemination efforts over 115 primary and behavioral health care practices have or will receive the team training. Also 480 providers have completed the training and about 375 have requested their waiver from the DEA.
"So what we want to do with the IT MATTTRs program," Jarrell said, "(is) for people to find options and treatment available within their local communities to get whatever is that they need for care to be able to be successful in their life."