Kicking an opioid habit takes serious commitment.
Methadone, the drug commonly used to curb withdrawal symptoms as a person tapers off heroin, requires supervised daily dosing in a state-licensed opioid treatment program (OTP) for the first month or more. After that, many patients can take a month’s worth of medication home with them, but federal regulations still require that they pick up their doses and check in at the clinic regularly. Most people spend more than two years on methadone, and some continue taking the drug for decades.
Making a daily dosing trip is work for anyone, but if a person lives in the Twin Cities, odds are fairly high that the nearest OTP is relatively accessible — there are 12 such clinics in the seven-county metro area.
People struggling with opioid addiction in rural parts of the state face a much bigger hurdle: There are only four OTPs in Greater Minnesota — in Duluth, Brainerd, St. Cloud and Rochester — meaning that many rural residents seeking medication assisted treatment (MAT) for opioid addiction must travel hundreds of miles each day just to manage their treatment.
In northern Minnesota, for instance, access to methadone or other drugs like buprenorphine that suppress the debilitating symptoms of cravings and withdrawal is limited by geography, population and physician training and support. Advocates around the region and the state are searching for ways to fill this provider gap and make it easier for people to access treatment.
Claire Wilson, Minnesota Department of Human Services deputy commissioner for policy, said that the treatment access problem in Greater Minnesota is acute and needs to be addressed.
“In rural Minnesota,” she said, “we still don’t have the appropriate amount of access to MAT programs. I would preface that statement and underline it by saying that we don’t have access to addiction treatment — period — in rural Minnesota in a way that sufficiently meets the need that’s there.”
Tina Silverness, chief executive officer of the Duluth-based Center for Alcohol & Drug Treatment, said that lack of access to MAT programs for local residents plays a major role in the region’s high rates of opioid addiction.
Because Duluth is the region’s major metropolitan area, residents there have easier access to MAT, Silverness explained. The Center for Alcohol and Drug Treatment employs a staff of 170, providing a full range of addiction treatment services, including the nonprofit ClearPath program, which offers MAT and recovery resources for individuals fighting addiction to heroin or prescription drugs.
But outside of Duluth, OTP options in the region are few and far between — the next closest is two hours away in Brainerd. Because of this issue, Silverness’ program draws clients from far and wide: Some travel hours each day to Duluth for outpatient treatment and methadone dosing.
“We have people coming at least 100-150 miles one way every day to access our services,” Silverness said. “We’ve even got a couple of people traveling from North Dakota.”
While MAT is relatively affordable, the cost of transportation can make addiction treatment inaccessible for many low-income rural residents, said Chuck Hilger, former vice president at Meridian Behavioral Health and member of the Minnesota Association of Resources for Recovery and Chemical Health (MARRCH) board of governors.
“Initially you have to come in for dosing six days a week,” he said. If a person is traveling from Bemidji to Brainerd, for instance, Hilger explained, “that’s six hours a day in the car.” The numbers are skewed, he said. “MAT services are broken down into a daily rate. All of your medications, counseling, nursing, come down to about $13.60 a day. The travel costs are what really add up. There is more money being spent on transportation to services in rural Minnesota than there is on treatment itself.”
Some insurance companies pay for client transportation to and from an OTP, Silverness said, but that benefit is getting more and more rare. “I don’t think many insurance companies are doing that any more. Most of the time clients are having to get their own rides here. It’s a huge barrier for them. They don’t make it easy.”
Debra Wamsley, resident faculty member and director of graduate studies in the master of professional studies in the integrated behavioral health and addictions counseling program at the University of Minnesota’s College of Continuing and Professional Studies (CCAPS), said that physical distance to treatment can be a barrier to successful outcomes.
“Being forced to make long drives to reach a treatment center can lessen motivation to seek help,” Wamsley said. And costs beyond gas and vehicle wear and tear also add up: “If a person experiencing addiction and seeking treatment is employed full time, the travel requirements for treatment have implications on their ability to keep their job and to afford everyday expenses like insurance and child care.”
When a client has to travel hours to get to the clinic for a methadone dose, it takes a huge amount of commitment and sacrifice to complete treatment, Silverness said. She admitted that she’s not all that surprised when some of her clients turn back to heroin after struggling to make the seemingly endless daily trip from home to OPT.
She sighed, and added: “Sometimes buying a drug off the street it is just a lot less hassle.”
While it would be nice to have more programs offering MAT in Greater Minnesota, experts say that opening more may not be the only answer to the access problem.
One possible solution, Silverness said, is buprenorphine. Because it is a partial agonist and does not activate a user’s opioid receptors, the drug, which provides many of the same withdrawal-reduction benefits as morphine, can be distributed outside an OTP. General practice physicians (as well as nurse practitioners and physician assistants) can now apply for a special waiver that allows them to prescribe buprenorphine, thus creating greater access for patients struggling with opioid addiction.
“If we can encourage more prescribers in Greater Minnesota to get a [prescription] waiver,” Silverness explained, “a lot of their patients might try buprenorphine from home and not need to travel all the way to our clinic for methadone.”
Because methadone activates the opioid receptors, it is highly regulated in the United States, Hilger said: “In order to provide methadone you have to meet very stringent requirements for storage, the medical practitioners involved, the nurses. You have federal guidelines that tell you how many take home doses a patient can receive based on the length of time in treatment and how well they are doing in their recovery process.”
Access to buprenorphine used to be similarly controlled until regulations were eased and the number of providers who could prescribe the drug was expanded, Wamsley said. The drug is now considered a good alternative for treating patients with opioid addiction, and its safety profile is deemed high.
Silverness thinks that the complicated waiver process, which requires that physicians complete several hours of continuing education before approval, may be a roadblock to access for the people who need this drug the most. “It’s just ridiculous,” she said. “Doctors can prescribe anything else but they are putting up this roadblock for buprenorphine. It is safer than most of the drugs that they can prescribe.”
When the physician waiver option was introduced, advocates thought that would mean that many would line up to prescribe buprenorphine. But that has not been the case, Hilger said.
Some rural physicians have expressed reluctance to work toward qualifying for the waiver, citing a lack of support. To encourage more rural providers to consider prescribing buprenorphine, Minneapolis-based Hennepin Healthcare has developed Project ECHO, which links addiction medicine experts with rural primary care providers via telemedicine.
“They operate as a hub,” Hilger said. This approach helps provide rural physicians with a virtual team of expert colleagues. “Once a week everybody involved in the program will call into a Zoom video conference and they’ll go do some teaching, go over a case study and then a learning tool using technology.” This model is called “hub-and-spoke,” Hilger added: “It helps increase physicians’ comfort and skill set with prescribing buprenorphine.”
Other rural physicians have expressed reluctance to seeking the waiver simply because of the potential landmines involved in opening their practice to patients fighting addiction. This frustrates Wilson, who advocates for viewing addiction as a “chronic and continuing disease” that requires individualized treatment for each patient. “No cancer patient gets the same amount of chemo or radiation,” she said. “It’s individualized to the patient. That’s the way addiction treatment should be handled, too.”
This change in treatment approaches may require a larger cultural change in perspective, Wilson added.
When talking about addiction, she said, “I’ve moved away from talking about ‘stigma.’ Instead, I refer to it as ‘discrimination.’ There is still discrimination in many parts of the medical community around people who struggle with the disease of addiction, and we need to do whatever it takes to change that.”
The idea of opening more OTPs in rural Minnesota hasn’t been completely abandoned, either. Silverness said that staff from the Center for Alcohol and Drug Treatment is collaborating with a local health clinic to open a program in a yet-to-be-named location.
“We’re really excited about the prospect,” she said.
At the state Legislature, lawmakers have introduced the Opioid Stewardship Bill (HF 400 / SF 751). If approved, this legislation would assess an increased license fee on all manufacturers and distributors of opioids who sell their products in the state. The fee’s proceeds would support addiction treatment, prescriber and patient education, and opioid-related costs to county child protective services.
“I’m hoping that the legislation moves forward,” Silverness said. “I don’t know if it will or not.” Maybe what it will take is hearing the stories of people who work on the front lines of the state’s addiction crisis. “All of us in this field have true compassion for human beings. One death is too many. It’s just tragic. I hope that our legislators will listen to us as we move things forward.”
From her office in Duluth, Silverness has a clear view of her region’s opioid crisis.
Her program’s comprehensive services, which include a walk-in assessment clinic; a detox; an opiate withdrawal stabilization unit; a residential program; an OTP that distributes methadone and buprenorphine; a 6-bed Pathfinder unit that helps patients adjust to a dose of buprenorphine; and an outpatient office-based addiction treatment (OBAT) program, has helped thousands of people in its nearly 60-year-history.
But Silverness still doesn’t think that’s enough.
“So many people are dying from overdoses,” she said. “All of these efforts are about saving lives.” Still, the crisis continues: “Opioid-related deaths in Minnesota have risen 430 percent since 2000. St. Louis County ranks third statewide in opioid deaths, right behind Ramsey and Hennepin counties. Our responsibility from a health and safety perspective is to keep people alive.”
Nobody knows these statistics better than Silverness. But she also knows that talking about statistics doesn’t really help the problem.
“You can read off all the statistics you want,” she said, “but in the end, does it really do anything? Every one of these overdoses is a human being. It is one of our children, one of our sisters, our brothers. Even one death is too many. There’s still so much work to be done.”