"It's always a big dilemma," said Fleming, director of the Salt Lake County Substance Abuse Services. "We've been lucky in Utah in that we haven't had a lot of these for-profit methadone clinics in our state until the last four or five years."

Indeed, the average methadone user pays $4,000 a year for the regular doses.

"That is something we are always concerned about because there is a profit motive in here," Fleming said. "And you can make a lot of money on methadone dosing."

Salt Lake County contracts with Project Reality because, Fleming said, the facility brings people off the drug when it is appropriate to do so.

"Some people will never be able to get off the drug because their receptors in their brain are so messed up from long-term heroin use," Fleming said. "But to not let someone get off that (drug) is unethical."

Discovery House's Walton believes in long-term maintenance over months and years. With that approach, the majority of patients can eventually get off it," he said.

Still, about 25 percent cannot, he said. Prolonged drug abuse changes brain chemistry, and some people cannot get off the medications without severe discomfort, depression, irritability and ultimately relapsing or turning to other substances, he said.

A higher standard

These questions and problems create a complicated task for the state's Delheimer.

"I am concerned about this issue," she said. "We are committed to the very highest standard of care."

And she is not fully convinced methadone users in the state are getting it.

In Utah, if you want to open a methadone clinic, you have to go through strict federal regulations. Her three years on the job have been a study of these federal rules and regulations, which mostly dictate practices over state rules. For example, federal requirements say clinics must be certified by one of four organizations. All in Utah are governed by the Commission on Accreditation of Rehabilitation Facilities.

"As I looked at these regulations, I decided they weren't strict enough," she said. So Delheimer is drafting new state regulations that will be even more strict.

CARF rules say a patient has to be drug tested eight times a year, for example. "That's not frequent enough," she said. "We really need to know what else they are taking."

There are also huge variations on how much counseling patients get on methadone. CARF rules require one visit per month, which is inadequate when counseling and therapy are such a vital part of turning around addictive behavior, Delheimer said. "Most clinics do more, but some don't."

And the federal rules don't require enough time for consultations between patients and physicians, she said. One local clinic had 350 clients with a physician scheduled for five to 10 hours per week. "No way is that enough," Delheimer said.

"This is supposed to be medicated assisted treatment," she said. "It's great to get the medication, but we really have to change people, places and things to make change. "If you aren't giving the counseling, you aren't addressing those components."

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E-mail: lucy@desnews.com