MINOT, N.D.-A clinic aimed at treating opioid addiction will come to North Dakota for the first time.

When Community Medical Services, an Arizona-based company, opens Aug. 10 in Minot, it brings methadone, an established medication for treating opioid dependency to patients struggling with addiction.

There are three drugs approved by the Food and Drug Administration to treat opioid addiction, and medication-based options are considered vital to the comprehensive treatment of opioid dependency by the National Institute on Drug Abuse, the Institute of Medicine, the Substance Abuse and Mental Health Services Administration and the Office of National Drug Control Policy.

"The treatment needs to keep up with the epidemic," said Nick Stavros, CEO of Community Medical Services, which also has centers in Montana and Alaska. "With big city growth comes big city problems."

More than 2 million Americans are dependent on or abusing prescription drugs. Deaths from prescription opioids such as hydrocodone, oxycodone, morphine and codeine have quadrupled in the U.S. since 1999, paralleling the increase in prescription opioid sales, according to the Center for Disease Control.

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North Dakota has not been immune to this growing epidemic that cuts across age, race, geography and economic status. In 2014, 43 people in North Dakota died of drug overdoses, up from 20 people in 2013. It was the largest percent increase in drug overdose death rate in all 50 states, according to the CDC.

Opioids have made headlines in North Dakota after several people died from fentanyl overdoses in Grand Forks and Fargo. Two deaths in Grand Forks prompted federal, state and local investigators to collaborate on an international investigation that netted multiple convictions for drug trafficking, and local leaders are working to prevent future overdoses.

Despite the need for comprehensive treatments, medication-assisted treatments in North Dakota remain few and far between. Reasons include outdated philosophies toward treating addiction, stigmas surrounding methadone clinics, community concerns and the legal and financial challenges of running such a facility, experts said.

Treating the whole person

North Dakota and Wyoming are the last two states without an opioid treatment program, and access to prescription medications for treating opioid addiction is also limited.

Such options are new for North Dakota, said Pamela Sagness, director of the behavioral health division at the state Department of Human Services, which oversees licensing of addiction treatment programs and opioid treatment programs.

"In general, our substance abuse treatment programs do not provide medication-assisted treatment," she said.

Historically, most facilities adhere to a philosophy adapted from treating alcoholism, which focuses on abstinence-based counseling, she said.

Of the 58 facilities in North Dakota that responded to the 2014 National Survey of Substance Abuse Treatment Services, over 75 percent did not offer any form of medication-based treatment as a type of care.

However, research suggests patients in abstinence-only programs do worse. According to a Cochrane review of 11 studies that took place in several countries, patients receiving medication were more likely to continue treatment and had fewer opioid-positive drug tests during treatment.

Even so, the stigma around taking a drug to treat a drug addiction is hard to dispel.

"A lot of people think you're replacing heroin with just another drug because methadone is an opiate," Stavros said. "But it doesn't get you high. It just helps with the withdrawal and cravings."

By managing these symptoms through medication, he said, patients focus on holding down jobs, being available to their families, getting counseling and regaining some normalcy in their lives.

"What we know today is that we need to integrate behavioral health and physical health," Sagness said, likening opioid addiction medication to taking pills for managing diabetes. "It's really difficult to treat someone and not the whole person."

In addition to methadone, which was used to treat heroin addiction in the 1960s and has the longest track record, two other drugs are approved by the FDA for opioid addiction treatment.

Buprenorphine, approved in 2002, acts similarly to methadone, while naltrexone blocks opioid receptors so that patients cannot get high should they relapse.

To date, 18 physicians in North Dakota are certified to prescribe buprenorphine, according to the Substance Abuse and Mental Health Services Administration directory. Fargo and Bismarck have 10 buprenorphine physicians, and the rest are stationed in Beulah, Fort Yates, Dickinson, Minot and Williston.

While Heartview Foundation has buprenorphine-certified physicians on staff, other providers might refer patients to doctors when medication-assisted treatment is part of their treatment philosophy.

This means that patients who want buprenorphine integrated into their treatment program have to seek out addiction treatment providers and doctors separately, Sagness said.

"It absolutely is a lot of work for the client," she said, adding it was important for those seeking help for their addiction to know all of the choices available to them.

Opioid treatment programs would streamline addiction treatment for patients, as programs are required to offer "appropriate, comprehensive behavioral therapy from a licensed clinical professional" along with medications.

"Seeing how opioid addiction is impacting our state, our families, our communities and individuals, we need to increase our ability to provide effective substance abuse treatment," Sagness said. "And the most effective treatment for substance abuse, especially for opioids, is a combination of therapy and medications."

Treatment providers meet roadblocks

In 2011, North Dakota's behavioral health division received legislative approval to write administrative rules for opioid treatment programs that went into effect in 2014, yet few addiction treatment providers in North Dakota have applied for opioid treatment program licenses.

One reason is cost.

Perry Smith, president and CEO of ADAPT Inc., which offers drug and alcohol services across North Dakota, said he believes there's a huge need for methadone clinics, but the startup costs would be prohibitive.

His outpatient facility provides assessments and low-intensity treatments, but opioids are not low-intensity drugs, Smith said.

"We're a private, for-profit industry," he said. "And we wouldn't make any money."

To meet regulatory standards, Smith said he would have to hire physicians, licensed addiction counselors and administrative personnel, as well as upgrade the phones, computers and internet systems.

Stavros acknowledged that methadone clinics are expensive to open and nonprofits often can't bear the financial risks, but he said it was less expensive for patients to go through outpatient methadone maintenance than a residential program.

A daily dose for methadone maintenance costs about $4,000 per patient per year, whereas the cost of a residential program could average $4,000 each month, he said.

Then there is the matter of meeting regulatory standards.

Because there is legitimate concern that methadone and buprenorphine, which are opiates and opioid derivatives, could be abused or end up on the streets, both medications are highly regulated. By law, methadone must be given at licensed opioid treatment programs, while physicians must be certified to prescribe buprenorphine.

To get approval for Community Medical Services, Stavros said they had to pass a series of on-site inspections from state and federal agencies such as SAMHSA and the Drug Enforcement Administration and make sure the drug inventory stayed accounted for on a daily basis.

Sagness said four facilities submitted applications to open methadone clinics in Bismarck, Minot, Mandan and West Fargo, respectively.

In three of the four cases, the cities in which the clinics would be located responded by passing a one-year moratorium preventing the programs from opening.

Bismarck, the only city that didn't impose a ban, is working with Heartview Foundation to open a clinic as early as this fall, Sagness said.

In Minot, Police Chief Jason Olson was directed to gather information on what a methadone clinic would mean for the city.

Olson started by researching opioid treatment clinics in Minnesota, including one in Duluth that had mismanaged medications and racked up dozens of violations. It has since shut down.

He also contacted police departments in cities where Community Medical Services operate before making the trek out to Billings, Mont., unannounced to observe one of the clinics.

Olson said he didn't see people hanging around outside. When he talked to neighboring businesses, half weren't aware that there was a methadone clinic next door, he said, and the ones that were aware told him they hadn't had any issues with crime or loitering.

In the meantime, Stavros said he used the moratorium in Minot to address community concerns, such as fears that a methadone clinic would attract addicts to the area or increase crime rates. When it came time for the Minot City Council to vote, Community Medical Services unanimously received the OK to open.

"The people who come into our clinics are not drug addicts, per se," Stavros said. "They're actually people who want to turn their lives around."