Despite an opioid epidemic that has reached crisis proportions, nearly half of Minnesota's 87 counties lack clinics that can offer what is now considered state-of-the-art addiction treatment for the dangerous painkillers.

The shortage, which reflects both regulatory barriers and the stigma associated with drug addiction, is one reason Minnesota's opioid scourge has proved so stubborn and so deadly, according to physicians and public health officials.

The number of opioid overdoses has soared in Minnesota in recent years, to more than 2,000 nonfatal cases in 2017. Minnesota doctors issued more than 3 million opioid prescriptions that year, according to the state Department of Health.

The counties without providers are mostly rural, but they represent about 15% of Minnesota's population spread out over 40% of the state's land area. Many other rural counties have only one or two providers, meaning that people who want therapy face long drives to get initial treatment and follow-up care.

"I have had patients come from very far away, like three hours away," said Dr. Emily Brunner, an addiction medicine specialist at St. Joseph's Hospital in St. Paul. "In Minnesota we still have an access problem."

Unlike most prescription drugs, doctors need special clearance from the U.S. Drug Enforcement Agency, including special training, in order to prescribe buprenorphine, a medication that helps reduce opioid cravings and mitigate the severe opioid withdrawal symptoms.

"The doctors, as I see it, are hesitant to ... have to deal with these cases," said Rep. Dave Baker, R-Willmar, who lost a son to an opioid overdose. "It's not that they don't want to help them, but they have to go through many hoops to help them."

And although state health officials have launched several programs to enlist more providers of medication-assisted treatment, some doctors worry that their clinics will attract too many patients with opioid addictions.

"There is so much stigma about people with opioid problems," said Dr. Gavin Bart, director of addiction medicine at Hennepin Healthcare in Minneapolis. "There is maybe this fear that 'I don't want to attract those people into my practice.'‚ÄČ"

One-third of physicians surveyed by rural health researchers said they had concerns about attracting drug users to their clinic, while others cited time constraints, low financial reimbursement and a lack of mental health support services as barriers to prescribing buprenorphine.

Only about 3% of all physicians nationwide have DEA approval, said Holly Andrilla, a rural health research scientist at the University of Washington. "Which is one of the problems in rural places. People have to go a long way to get care."

Using DEA data, Andrilla found that 44 Minnesota counties were without buprenorphine prescribers at the end of 2017.

A federal health agency website currently lists 420 Minnesota providers with prescribing privileges, including 138 nurse practitioners and physicians assistants who became eligible to prescribe buprenorphine in 2016. Two-thirds of the providers are located in the seven county metro area, although the website list is incomplete because providers can opt out of it.

Too late for her daughter

Shelly Elkington of Montevideo didn't learn about buprenorphine until she brought her daughter, who had become addicted to prescription pain pills, to Minneapolis for intestinal surgery in 2012.

At the time, her daughter was trying to taper off the pain pills, but later she agreed to try buprenorphine. But they couldn't find a local doctor in western Minnesota who knew about the drug.

"There was a tremendous lack of understanding," said Elkington. "In meeting with her primary care physician, they didn't have any resources. There were no referrals."

In 2015, her daughter agreed to return to Minneapolis to get treatment, but she died shortly before the trip was scheduled.

Elkington wonders what would have happened if her daughter had received buprenorphine earlier.

"It would have saved her life," Elkington said. "She would undoubtedly be here."

Since that time, more Minnesota providers have obtained DEA approval, including 300 in 2018 alone. But it is unclear what parts of the state are seeing the biggest increase.

'Huge fear'

St. Gabriel's Hospital in Little Falls is one program that is spearheading efforts to increase the number of rural prescribers. The hospital has achieved national recognition for its coordinated approach to reversing the opioid epidemic, including reducing the number of prescriptions and enlisting community partners.

It has also replicated its program in eight other communities and trained 40 providers on best practices for buprenorphine prescribing, stretching from Hibbing to Redwood Falls.

"We like to think that there are not a couple hundred people driving to the Twin Cities" for treatment, said Dr. Kurt DeVine, one of the program's leaders. Through weekly telemedicine conferences and more frequent consultations via phone or text, the initiative is teaching things that most doctors don't learn in medical school or training.

"Everybody has this huge fear that something is going to go wrong," with their patients, DeVine said. "Once they are on buprenorphine, they are actually quite easy to see and take care of. They are very appreciative."

Dr. Paul Kietzmann, a family practitioner in Alexandria, became a certified prescriber last fall after learning about the high rates of opioid use locally.

"Opioid overuse and abuse crosses all economic and social boundaries," he said. "A couple of us just stepped up and said we were willing to learn about this."

Along with another doctor, he is now caring for about 20 patients.

But even as the supply of buprenorphine prescribers increases, federal regulations limit the number of patients prescribers can see. They can care for no more than 30 in their first year of certification, then can apply to increase that to 100. Addiction medicine specialists can have up to 275 patients. Research has also shown that some providers who get certified don't ever write prescriptions, or limit them to existing patients only.

To help increase the supply, the Minnesota Department of Human Services held a "boot camp" this February about buprenorphine prescribing. As a result, 45 providers received initial training and 24 others received additional training, the agency said.

Kietzmann said providing treatment helps him be a better doctor.

"I am learning how fulfilling it is to be able to help patients in this way because you can really change their lives," he said.