Vermont Gov. Peter Shumlin attracted national attention last January when he devoted his entire State of the State address to Vermont's opiate addiction problem.
For the first time, he said, the number of people seeking drug addiction treatment had surpassed those getting help for alcoholism, and many had nowhere to go.
"Right now, we have hundreds of Vermonters who are addicted and are ready to accept help, but who are condemned to waiting because we don't have the capacity to treat the demand," he said.
Shumlin's speech grabbed the attention of everyone, including lawmakers, who more than doubled the state's budget for addiction treatment and kicked the system into high gear.
But just as building new roads can make traffic worse, the upward trajectory in the number of people seeking treatment got even steeper as more help became available.
Nearly a year later, the state has made good on promises to expand treatment — but the waiting lists remain.
"This has not been an easy year for anybody running any of these programs," says Dana Poverman, outpatient director with HowardCenter in Burlington, which provides addiction treatment. "It's been strenuous."
Poverman's center, despite more openings, has a waiting list of nearly 300 people.
"There's a lot to congratulate ourselves as a state about, but sadly it's just still not enough," she says.
The state's approach to addiction treatment is called a "hub and spokes" system. The Howard Center is one of five regional hubs providing intensive treatment, including regular doses of the maintenance drug methadone.
Once patients leave the hubs, they're treated by doctors and therapists in local communities — the spokes in the system.
The number of treatment openings at the hubs has increased significantly, but the state has had limited success getting doctors to agree to provide the local treatment.
Barbara Cimaglio of the Vermont Department of Health says the state has asked primary care physicians to help by treating addicted patients in their practices, and also has offered to pay for nurses and counselors to work alongside them.
But the state has had a hard time making its case. Only about one in five primary care physicians treat opiate addiction, which involves prescribing a maintenance drug called buprenorphine. Doctors also report a shortage of counselors to treat patients with addiction.
Some doctors are worried about the added work and the complex needs of addicted patients. Will Porter, one of just three doctors now providing treatment in one Vermont county, says in years past that was his concern.
"When I was engaged in family practice, it was hard to imagine doing it in addition to everything else," Porter says. "It was overwhelming."
David Pattison, who has been treating addiction for eight years, says many doctors have been burned by patients who faked needing drugs for pain. They're leery when the same patients come back for addiction treatment.
"It really feels bad to get tricked like that," Pattison says. "They don't want to have anything to do with those people who have been violating their trust."
Pattison says those patients have setbacks and relapses, but once a drug user seeks help, the relationship with a doctor changes.
"My buprenorphine days in clinic are my best days," he says. "It's fun to see these people who are getting better and thankful to us."