PINE RIVER, Minn.-When Dr. David Laposky lost his job at Essentia Health-St. Joseph's Medical Clinic here in November, about 150 patients he treated for opioid dependency faced uncertainty concerning access to a provider.
Laposky, a family medicine doctor with 30 years in the profession, was one of about 50 Essentia Health employees fired for refusing to receive an influenza vaccination.
His departure exposed an unrelated plight: the precariousness of medically assisted treatment for opioid addiction in rural Minnesota.
For some of the patients, Laposky, who began working mid-December for the Cuyuna Regional Medical Center clinic in Longville, said he prescribes Suboxone - the brand name of a mixture of buprenorphine and naloxone used to treat dependence on the dangerous class of pain medications and street drugs - travel hours away from home to receive their monthly doses. The doctor suspects the unmet need is tremendous.
"I wish I could give you numbers, but for everybody that I'm treating, there's 20 times as many people out there needing treatment," Laposky said. "I don't know how much further I'll go in my practice, but I could see as many as I could take."
Suboxone offers a treatment alternative to the more commonly known methadone. Intended for patients with less severe tolerance to opioids, Suboxone can be prescribed in 30-day increments in a film or pill form. Each dose of methadone, however, is administered in a clinic setting-meaning some patients must visit a clinic every day to receive treatment.
"Some people do need that intensive daily exposure," Laposky said. "But it's really hard to hold down a job (or) get your kids to school when life is revolving around getting this drug every day."
However, Laposky said the state needs more providers certified to prescribe Suboxone, a process involving an eight-hour course to receive a prescription waiver.
A decade ago, Laposky did not envision himself as a major provider of addiction-therapy drugs, and said he pursued certification when few of his primary care patients expressed a need.
"Ninety percent of the people in my practice are living normal lives," Laposky said. "They're going to work. They're taking care of their families, and they're enjoying life again. ... It's just a joy for me to see these people. To me, it's a lifesaving therapy that if we could get more providers doing it, I think we could really turn this opioid crisis around."
The barrier to increasing availability stems from a lack of trust in medically assisted treatment-for many, the stigma attached to addiction treatment involving medication lingers, Laposky said.
"I don't think everyone has really bought into the idea of using medication to treat drug addiction," Laposky said. "With this problem, a lot of people don't respond to just rehab by itself. ... We don't consider ourselves a failure if we get a diabetic under control with medication, and I don't really see a difference. ... It's the most rewarding area of medicine that I'm involved with right now."
Provider hesitance may involve more than philosophical differences concerning treatment.
Dr. Brian Konowalchuk, chair of Essentia Health's opioid oversight committee, noted patients receiving drug therapy often need broader support - psychotherapy or counseling, social work support and specialists in addiction to name examples - to accompany their prescriptions. "Suboxone is not being prescribed in the majority of our primary care clinics and I think that's true in Minnesota in general," Konowalchuk said. "Safely managing both Suboxone and patients is not easy."
Konowalchuk said although Essentia Health is focused on opioid addiction prevention through better prescribing practices and patient and doctor education, addiction treatment is part of the health care corporation's multi-pronged approach.
When it comes to medication for opioid addiction, Konowalchuk said the drug likely to have the greatest immediate impact - Narcan - is intended to halt an active overdose.
A leader at the largest distributor of Narcan in the state said the organization is training anyone interested in how to use the drug, most often provided intravenously.
Chuck Hilger, vice president for the medication assisted treatment program at Brainerd's Valhalla Place, said he expects increased access to the drug to cause a slowdown in accidental overdose deaths. The addiction treatment center will likely distribute 25,000 kits over the next year and a half, Hilger said.
Recently, Valhalla Place assumed operation of a methadone clinic in Brainerd, where about 400 patients from across the state receive treatment. The clinic will soon expand its offerings to include Suboxone prescriptions as well, Hilger said, but this is combined with a well-rounded treatment approach providing more structure.
Rural access to any kind of medication assisted treatment, Hilger said, is hampered by numerous problems: availability of skilled labor to run clinics, community resistance to treatment centers and provider reticence to become involved in a seemingly complex doctor-patient relationship.
Valhalla Place worked with both the White Earth and Red Lake reservations to develop Suboxone programs, Hilger said, and is in talks with leaders of the Mille Lacs Band of Ojibwe to coordinate treatment. Deadly opioid overdoses disproportionately impact the Native American populations in the state to a dramatic degree.
"When people understand this disease and the dynamics and all the pieces that play into it, then they walk away understanding the benefits of medically assisted treatment," Hilger said. "But I have no druthers. ... The best treatment is one that works. That's the bottom line."