Many Minnesota rural areas lack access to opioid recovery medication

There are nearly twice as many health care providers licensed to prescribe an opioid addiction treatment drug compared to two years ago, as more clinics recognize the need to address the opioid epidemic in their communities.

Yet 32 rural Minnesota counties still lack any providers that have obtained the necessary federal approval to prescribe the drug Suboxone, known as the gold standard for addiction treatment as part of comprehensive recovery effort.

Nearly 560 Minnesota health care professionals can now prescribe the drug, up from 290 in 2018, according to a Star Tribune analysis of federal databases. Those numbers have been buoyed by an increasing number of nurse practitioners and physician assistants who became eligible, joining the ranks of doctors.

"I never thought I would be focusing on addiction medicine in my practice, but I have come to find that I am saving more lives now than I ever did before," said Rachel Pearce, a nurse practitioner at the Altru Clinic in Warroad who got prescribing permission from the U.S. Drug Enforcement Administration (DEA) last year.

"We have not advertised yet and I have already had 21 patients," she said. Most of them came to her unemployed and have since gotten jobs as a result of addiction treatment.

While Minnesota opioid-related deaths have fallen 22% in 2018 to about 330, according to preliminary data from the Minnesota Health Department, there were nearly 2,000 trips to hospital emergency rooms caused by nonfatal overdoses.

The drug, which has the generic name of buprenorphine, is essential to recovery because it reduces the cravings and withdrawal symptoms of opioids, be they pain pills or heroin.

"It felt like my bones were breaking," she said. "My withdrawals were total hell."

Rudolph's path to opioid addiction started when she was prescribed pain medications after a 2009 car accident. Back then it was typical for doctors to write 30-day supplies, and sometimes they routinely granted early refills.

After eight months her insurance company sent a letter questioning her pain pill use. Still in high school, Rudolph hid the letter from her parents but continued her habit by buying pills on the street. Eventually it became easier and cheaper to buy heroin. Amazingly, she completed a nursing degree but narrowed the rest of her life to using opioids along with the evictions, stealing and broken relationships.

She tried to enter treatment programs, but there was often a delay of weeks before she could get a chemical dependency assessment. By the time the appointment came around, she was no longer motivated. Eventually she was caught stealing money from her Little Falls parents. They urged her to get help.

Rudolph knew about Suboxone. She learned that a clinic 10 minutes from her parents' home had recently started prescribing it. She got a same-day appointment.

Rudolph had visited CHI St. Gabriel's Health, which in 2014 began a nationally recognized program to reduce opioid prescribing. It also helped clinics in 16 rural communities set up their own Suboxone prescribing programs. Altogether, 50 providers have gotten training and support under the effort, dubbed Project Echo. They in turn, have provided treatment to at least 460 patients.

"These are all patients who previously did not have access to care in rural Minnesota," said Dr. Kurt DeVine, one of Project Echo's leaders.

The program has also partnered with Hennepin Healthcare to conduct "boot camp" sessions where providers get the training mandated by the DEA.

But some have questioned why providers need to get special DEA permission, known as a waiver, to prescribe Suboxone, especially since waivers are not needed to prescribe pain pills.

The American Medical Association has said that the federal government should rethink its approach to waivers and other requirements so that more patients have access to medication-assisted treatment.

Under DEA rules, providers can have only 30 Suboxone patients in their first year of prescribing. Those limits increase over time. Clinics are also required to keep detailed documentation on all patients that is subject to federal audits.

"Physicians have also said that is something they worry about," said Harris. "You make a simple mistake and then you have a federal agency at your door."

Dr. Heather Bell, a Project Echo co-leader, said there is still resistance among some providers and clinics to providing medication-assisted treatment.

"There is a fear that you will have these belligerent people," she said. But eventually, most providers realize they are already caring for and treating the health problems of those with opioid addictions.

"You are seeing that patient population anyway," said Bell. "They are drug seeking, they are lying. You realize that you are able to help them."

"I have found more meaning in my work now than I ever had before, and I'm busier now than I had ever been before," said Pearce. "I may be working more hours now, but I have never felt so refreshed."

As for Rudolph, she has maintained her recovery and has become a licensed practical nurse, working at the Little Falls clinic where she got help. She still takes Suboxone, but the dose has been decreased as her cravings have abated.

"I definitely lost some good years," she said. "Right now I am just enjoying this."