Readers and Tweeters Diagnose Greed and Chronic Pain Within US Health Care System

KHN gives readers a chance to comment on a recent batch of stories.

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

U.S. Health Care Is Harmful to One’s Health

Thank you for publishing this research (“Hundreds of Hospitals Sue Patients or Threaten Their Credit, a KHN Investigation Finds. Does Yours?” Dec. 21). I am a psychotherapist and have written about this problem in my blog. The mercenary American health care system is hypocritical in the stressful financial demands and threats it imposes on so many patients. Stress due to health care-related bankruptcy, or the threat of bankruptcy, is harmful to one’s health. A health care system that is supposed to treat illness and restore health can, in fact, cause serious illness and/or exacerbate existing medical problems. The higher levels of stress and the threat of bankruptcy that all too frequently follow needed medical care can be harmful to individuals with cardiovascular issues such as high blood pressure and heart arrhythmia, and can trigger panic attacks in those who suffer from anxiety disorders. There may be digestive issues associated with higher levels of stress, and the patient’s sleep may be adversely affected. The individual may have to cut back on essentials such as food and medications because of unpaid medical bills, aggressive calls from collection agencies, and the threat of bankruptcy.

All of this in the name of “health care” delivered by professions and organizations that proclaim the importance of beneficence, justice, and malfeasance within their respective codes of ethics. Curative stress? Therapeutic bankruptcy? The hypocrisy is palpable.

American history is replete with examples of discrimination against certain groups, including racial discrimination, the disenfranchisement of women, child labor, and others. Eventually, political measures were enacted to correct these injustices. It’s only a matter of time until the American health care system, including the pharmaceutical industry, is forced to reform itself for the sake of the men, women, and children in need of essential health care. It’s not a question of if, but when.

— Fred Medinger, Parkton, Maryland

I find this infuriating! Especially the nonprofit organizations. Hundreds of US Hospitals Sue Patients or Threaten Their Credit, a KHN Investigation Finds | Kaiser Health News

— Jan Oldenburg ☮️ (@janoldenburg) December 21, 2022

— Jan Oldenburg, Richmond, Virginia

Thanks for the article about hospitals suing patients. I just switched health plans in New York state. Reasons: My previous insurer raised my premium over 90% last year, paid very little of my claims (leaving Medicare to pay most of the claims), and sent me to collections. This, even though I worked two full-time jobs for most of my 46 years of teaching. How do insurance companies and hospitals get away with this unethical and outrageous behavior?

— George Deshaies, Buffalo, New York

Great story by @KHNews' @NoamLevey, which found that at least 297 hospitals in MN, 56%, sue patients for unpaid medical bills. 90, or 17%, can deny patients nonemergency medical care if they have past-due bills.Mayo is one of those hospitals. See🧵

— Molly Work (@mollycastlework) December 21, 2022

— Molly Work, Rochester, Minnesota

Unhappy New Year of Deductibles and Copays

Listened to a conversation between Noam N. Levey and NPR’s Ari Shapiro, regarding Levey’s article on Germany’s lack of medical debt (“What Germany’s Coal Miners Can Teach America About Medical Debt,” Dec. 14). Levey passed along the tidbit that Affordable Care Act plans purchased through state exchanges would pay a maximum out-of-pocket amount of $9,000 a year. Likely Mr. Levey knows the actual details of the ACA at least as well as I, but I had well over $20,000 in out-of-pocket expenses for my own care last year (in addition to annual premiums of over $15,000). The deductible/copay aspect of health insurance is rigged against folks who actually use their insurance. The in-network and out-of-network provider scheme is likewise designed to benefit providers as opposed to patients.

I’ve had health insurance for about 40 years, since I graduated from college. Always a plan paid for by myself, never through an employer. I’ve had my first year of using a lot of heath care services (colon cancer surgery and chemo follow-up), and the bills are quite astronomical. Still awaiting the final negotiations between Stanford Hospital and Blue Shield of California for the $97,000 bill for services for the surgery and stay in the hospital. Though my surgery was in September, the two had not resolved the bill by year-end. Now all my copays and deductibles have reset, and I’ll be back at the starting gate, dollar-wise.

We need health care payment reform.

— George McCann, Half Moon Bay, California

Tx @NoamLevey for this important comparative piece on how Germany's private healthcare system does not create #medicaldebt. We need to do better. @RIPMedicalDebt

— Allison Sesso (@AllisonSesso) December 14, 2022

— Allison Sesso, president and CEO of RIP Medical Debt, Long Island City, New York

Greedy to the Bone?

In orthopedics, surgery is where the money is (“More Orthopedic Physicians Sell Out to Private Equity Firms, Raising Alarms About Costs and Quality,” Jan. 6). Just as a private equity-controlled ophthalmology group tried to persuade me to have unnecessary cataract surgery (three other eye doctors agreed it wasn’t necessary), too many orthopedic patients can expect to be pushed to unnecessary surgeries.

— Gloria Kohut, Grand Rapids, Michigan

As #private #equity firms acquire #physician practices, the issue of non-competes and #restrictive covenants become even more relevant in #healthcare @AAOS1 @AmerMedicalAssn @JHU_HBHI @linakhanFTC @KHNews

— Amit Jain, MD, MBA (@AmitJainSpine) January 8, 2023

— Dr. Amit Jain, Baltimore

The Painful Truth of the Opioid Epidemic

In a recent article, Aneri Pattani and Rae Ellen Bichell discussed disparities in the distribution of settlement funds from lawsuits against major pharmaceutical companies, especially in rural areas (“In Rural America, Deadly Costs of Opioids Outweigh the Dollars Tagged to Address Them,” Dec. 12).

We suggest that the merit of many of the lawsuits that led to these large settlements remains unproven. While Purdue Pharma clearly overstated the safety of prescription opioids in treating chronic pain, judges in two high-profile cases ruled in favor of the pharmaceutical companies stating that prosecutors falsely inflated the danger of opioids and noted that opioids used per FDA guidelines are safe and effective, remaining a vital means to treat chronic pain. Also, many cases involving Purdue Pharma, Johnson & Johnson, and others were settled based on expediency, rather than merit. This may have been due to the reasoning that continuing their defense against prosecutors having access to limitless public funds would lead to bankruptcy.

The primary cause of America’s overdose crisis is not physicians’ “overprescribing” opioids. Dr. Thomas Frieden, former head of the Centers for Disease Control and Prevention, noted that the rise in prescription opioids paralleled the increase in opioid deaths up to 2010, leading the CDC to create guidelines in 2016 limiting opioid use to treat chronic pain. However, cause-and-effect relationships between the legitimate use of prescription opioids and opioid deaths remain unclear. For example, the National Institute on Drug Abuse noted in 2015 that since 2000, misuse of prescription drugs preceded the use of heroin in most cases. But legitimate prescriptions by physicians to patients with chronic pain constituted only 20% of the cases leading to heroin addiction. Prescription drugs used by heroin addicts were from family members or friends in 80% of the cases leading to heroin use.

Since at least 2010, the volume of prescription opioids dropped by over 60% — yet overdose deaths have skyrocketed to over 100,000 cases in 2021. The opioid overdose death crisis is now driven mainly by illegally imported fentanyl and in part by a misguided crackdown of the Drug Enforcement Administration against physicians who legitimately prescribe opioids to chronic pain patients, forcing them to seek out street drugs.

Statistics from Michigan indicate that nearly 40% of primary care clinics will no longer see new patients for pain management. The CDC, in its 2022 updated guidelines, attempted to clarify misunderstandings, including inappropriate rapid tapering and individualizing care. However, the public health crisis of undertreated pain remains. Some states have passed intractable pain laws to restore access to opioids to chronic pain patients with a legitimate need, indicating the shortfalls of the CDC guidelines to treat pain.

— Richard A. Lawhern, Fort Mill, South Carolina, and Dr. Keith Shulman, Skokie, Illinois

Important reporting from @aneripattani and @raelnb in @KHNews: National settlements are being paid out by #opioids manufacturers, but #rural communities are often getting less funds to address the #OpioidCrisis than their urban and suburban counterparts.

— Joanne Conroy (@JoanneConroyMD) December 15, 2022

— Dr. Joanne Conroy, Lebanon, New Hampshire

We’re fighting to hold accountable the companies that helped create and fuel the opioid crisis so we can help people struggling with opioid use disorder across North Carolina and the country get resources for treatment and recovery. We need this money now to save lives.

To that end, I wanted to flag one concern about the article on rural counties and opioid funding. It looks as if the comparison and the maps about North Carolina funding by county and overdose deaths may not correlate. The reporting seems to reflect overdose deaths on a per capita basis, but funding is indicated by total dollars received.

This spreadsheet might be helpful. It ranks each North Carolina county by the amount of funds they will receive from the distributor and Johnson & Johnson settlements (as posted on per capita, using 2019 population figures. In per capita rankings, rural and/or less populous counties are typically receiving more funding per capita than larger counties. For example, the 10 counties receiving the most per capita funding are all rural and/or less populous counties (Wilkes, Cherokee, Burke, Columbus, Graham, Yancey, Mitchell, Clay, Swain, and Surry). Wake County, our most populous county, is ranked 80th.

It’s also important to note that the formula was developed by experts for counsel to local governments in the national opioid litigation, who represent and have duties of loyalty to both large urban and small rural local governments. It takes into account opioid use disorder in the county (the number of people with opioid use disorder divided by the total number of people nationwide with opioid use disorder), overdose deaths as a percentage of the nation’s opioid overdose deaths, and the number of opioids in the county. Click here for more information.

Indeed, one of the special masters appointed by U.S. District Judge Dan Polster in the national opioid litigation found that the national allocation model “reflects a serious effort on the part of the litigating entities that devised it to distribute the class’s recovery according to the driving force at the heart of the lawsuit — the devastation caused by this horrific epidemic.” (See Page 5 of this report of Special Master Yanni.)

You’re absolutely right that rural counties were often the earliest and hardest hit by the opioid epidemic, and it’s critical that they receive funds to help get residents the treatment and recovery resources they need. We’re hopeful that these funds, whose allocation was determined in partnership by local government counsel, will help deliver those resources.

— Nazneen Ahmed, North Carolina Attorney General’s Office, Raleigh, North Carolina

This article is a great example of equality ≠ equity regarding opioid settlement funds disbursement. Really thoughtful article by @aneripattani & @raelnb

— Kate Roberts, LCSW (@KateandOlive_) December 14, 2022

— Kate Roberts, Durham, North Carolina

A Holistic Approach to Strengthening the Nursing Workforce Pipeline

As we face the nation’s worst nursing shortage in decades, some regions are adopting creative solutions to fill in the gaps (“Rural Colorado Tries to Fill Health Worker Gaps With Apprenticeships,” Nov. 29). To truly solve the root of this crisis, we must look earlier in the workforce pipeline.

The entire nation currently sits in a dire situation when it comes to having an adequate number of nurses — especially rural communities. With the tripledemic of covid-19, influenza, and RSV tearing through hospitals, it’s never been more evident how vital nurses are to the functioning of our health care system. A recent McKinsey report found that we need to double the number of nurses entering the workforce every year for the next three years to meet anticipated demand. Without support from policymakers and health care leaders, we cannot meet that.

As a health care executive myself, I’ve seen firsthand how impactful apprenticeships can be because they help sustain the health care workforce pipeline. From high school students to working adults, these “earn while you learn” apprenticeships allow students to make a living while working toward their degree, and my system’s apprenticeship program has even reduced our turnover by up to 50%. It provides a framework to support a competency-based education rooted in real-life skills and hands-on training for key nursing support roles, all while team members earn an income.

Education is key to developing competent, practice-ready nurses. Not just through apprenticeships but early on in students’ educational journey, too. According to the newest data from the nation’s report card, students in most states and most demographic groups experienced the steepest declines in math and reading ever recorded. As we continue to see the devastating impact the pandemic had on young learners, it’s crucial we invest more in remediation and support, so students graduate from secondary school with a deep understanding of these core competencies and are ready to pursue nursing. A recent survey of nearly 4,000 prospective nursing students from ATI Nursing Education found that a lack of academic preparedness was the top reason for delaying or forgoing nursing school.

Without intervention now, our nursing workforce shortage will only worsen in the future. We need our leaders to face these challenges head-on and invest in a holistic approach to strengthen our nursing pipeline. There’s no time to waste.

— Natalie Jones, executive director of workforce development at WellStar Health System, Atlanta

1 solution to the staffing crisis: Apprenticeship programs put students directly into long-term care professions. Rural areas benefit the most since they have more residents who are 65 or older & fewer direct care workers to help people w/ disabilities.

— OK Health Action (@ok_action) November 30, 2022

— Oklahoma Health Action Network, Oklahoma City

Planning Major Surgery? Plan Ahead

I read Judith Graham’s good article “Weighing Risks of a Major Surgery: 7 Questions Older Americans Should Ask Their Surgeon” (Jan. 3) on CNN. Thought I should add some personal experience. At age 78, my mother had back surgery in 2016. When she was getting prepped, she was given multiple documents to sign. Once signed, she was immediately taken to surgery. There was not enough time to read any of them. In hindsight, we are certain the documents were mostly for release of liability if something goes wrong. After surgery, she had “drop foot” — total loss of use of her left foot. Never heard of it. She was told she would regain use in about six months. Never happened. She had to use a walker and still had numerous falls in which her head had hit the ground multiple times. She slowly slid into long-term “confusion” that was attributed to her falls and passed away at age 84.

My story is about my abdominal aorta aneurysm surgery in 2022 at age 62. I did not have an overnight recovery — tube taken out of my throat, catheter removed, and was immediately transferred to a room. An IV pump of saline was left on and my arm swelled up — I thought my arm was going to burst. Five days later, I was discharged. Everything seemed rushed. The only postsurgical “instructions” I received were to keep the incision clean and not to play golf, and I don’t even play golf. I recuperated at home, and after five months I still have abdominal pain that I’ll always have.

Both of our surgeries were done on a Friday. I’m certain our experiences were due to hospital staff wanting to leave early on Friday, and weekend staffers are mostly the “B” team. So, my advice is to suggest to the elderly not to have surgery scheduled on a Friday unless there is absolute urgency in choosing the date.

— Paul Lyon, Chesapeake, Virginia

Reality bites, doesn’t it.

— suzette sommer (@suzette_sommer) December 28, 2022

— Suzette Sommer, Seattle

I am writing to express my concerns over the significant misinformation in the article about what older Americans should ask their surgeon before major surgery.

Most abdominal aortic aneurysms are treated with endovascular methods. These minimally invasive procedures still require general anesthesia (with a breathing tube), but most patients have the tube removed before leaving the operating room, and many patients leave the hospital the next day with minimal functional limitations due to surgery being performed through half-inch incisions in each groin.

The “best case” surgical scenario described in your article describes open abdominal aortic aneurysm repair, which is recommended for fewer than 20% of patients requiring aortic aneurysm repairs.

In essence, you’re threatening everyone who comes in for a tuneup with an engine rebuild.

Abdominal aortic aneurysms are still undertreated in the U.S., with many patients not receiving screening recommended by Medicare since 2006. Your article misrepresents the “best case” scenario and may dissuade patients from receiving lifesaving care.

— Dr. David Nabi, Newport Beach, California

I read, with interest, Judith Graham’s article about older Americans preparing for major surgery. But you failed to mention the life-altering effects of anesthesia. My independent 82-year-old mother had a minor fall in July and broke her hip. After undergoing anesthesia, she is required to have 24/7 care as her short-term memory has been forever altered. Was there a choice not to have hip surgery? I didn’t hear one. Did anyone explain the issues that could (and often do) occur with an elderly brain due to anesthesia? No. And now we are dealing with this consequence. And what happens when you don’t have money (like most people in the U.S.) for 24/7 care? I hope you’ll consider writing about this.

— Nancy Simpson, Scottsdale, Arizona

Shouldn't more people wonder why MA plans are profitable while our own gov't MC is losing money. Only 5% of MA plans are audited yearly. Yet they are getting 8.5% increase in payment & docs (the folks taking care of the pts) are getting cut. via @khnews

— Madelaine Feldman (@MattieRheumMD) December 15, 2022

— Dr. Madelaine Feldman, New Orleans

The High Bar of Medicare Advantage Transparency

Unfortunately, KHN’s article “How Medicare Advantage Plans Dodged Auditors and Overcharged Taxpayers by Millions” (Dec. 13) provided a misleading, incomplete depiction of Medicare Advantage payment.

This story focuses largely on audits that, in some cases, are more than a decade old. While KHN’s focus is on alleged “overpayment,” the same audits show that many plans were underpaid by as much as $773 per patient.

More recent research demonstrates Medicare Advantage’s affordability and responsible stewardship of Medicare dollars. For example, an October 2021 Milliman report concludes “the federal government pays less and gets more for its dollar in MA than in FFS,” while the Department of Health and Human Services’ fiscal year 2021 report shows that the net improper payment rate in Medicare Advantage was roughly half that of fee-for-service Medicare.

KHN’s article is right about one thing: Only a small fraction of Medicare Advantage plans are audited each year — denying policymakers and the public a fuller understanding of the program’s exceptional value to seniors and the health care system. That is why Better Medicare Alliance has called for regulators to conduct Risk Adjustment Data Validation (RADV) audits of every Medicare Advantage plan every year.

There are opportunities, as outlined in our recent policy recommendations, to further strengthen and improve Medicare Advantage’s high bar of transparency and accountability, but that effort is not well served by this misleading article.

— Mary Beth Donahue, president and CEO of the Better Medicare Alliance, Chevy Chase, Maryland

Targeting Gun Violence

I’m curious why KHN neglected to actually get into all the “meat and potatoes” regarding its report on Colorado’s red flag law (“Colorado Considers Changing Its Red Flag Law After Mass Shooting at Nightclub,” Dec. 23). Specifically, it failed to report that the suspect in this case used a “ghost gun” to execute the crime in Colorado Springs, and more importantly what impact any red flag law is going to have on a person who manufactures their own illegal firearm. Lastly, why is it the national conversation regarding the illegal use and possession of firearms curiously avoids any in-depth, substantive conversation of access to firearms by mentally ill people? Quite frankly, this is the underlying cause of illegal firearms use and no one wants to step up to the plate and address the issue at any in-depth level. It’s categorically embarrassing for American journalism.

— Steve Smith, Carbondale, Colorado

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

Los mentores trabajan, sin límites, en la recuperación de adicciones

Los especialistas en apoyo a pares están ellos mismos en recuperación y se los contrata para ayudar a otros. Pueden vincularse con los pacientes de una manera distinta que los profesionales de salud.

CENTENNIAL, Colorado.— Sarah Wright visita a su mentora varias veces al día, en la habitación de hotel transformada en oficina en este suburbio de Denver.

Pero su visita de un miércoles por la mañana a mediados de octubre fue una de las primeras con dientes.

La especialista en ayuda a pares, Donna Norton, había impulsado a Wright a ir al dentista años después de que la falta de vivienda y la adicción afectaran su salud, literalmente hasta la mandíbula.

Wright todavía se estaba acostumbrando a su dentadura postiza. “No he tenido dientes en 12, 13 años”, dijo, y agregó que la hacían sentir como un caballo.

Una nueva sonrisa fue el hito más reciente de Wright mientras trabaja para reconstruir su vida, y Norton ha estado allí en cada paso: al abrir una cuenta bancaria, conseguir un trabajo, desarrollar un sentido de autoestima.

La voz de Wright comenzó a temblar cuando habló sobre el papel de Norton en su vida durante los últimos meses. Norton envolvió a Wright en sus brazos, adornados con tatuajes de llamas, telarañas y un zombi Johnny Cash.

“Oh, muffin”, le dijo. “Estoy tan orgullosa de ti”.

Norton, de 54 años, es una abuela que maneja una Harley, ama a los bulldogs, lleva ocho años sobria y, profesionalmente, “es una persona que anima a los que se ven mal en papel”.

La gente la quiere. “Si me buscaras en un papel, no estarías en esta habitación conmigo”, dijo Norton. “No me dejarías acercarme a tu casa”.

Si fuera terapeuta o trabajadora social, abrazar y compartir sus experiencias con las drogas y la ley podría considerarse cruzar la línea de los límites profesionales. Pero como especialista en apoyo de pares, a menudo eso es parte del trabajo.

“No tengo límites”, dijo Norton. “A la m…”, dijo, “aquí es un término cariñoso”.

Norton trabaja para la Fundación Hornbuckle, que brinda apoyo entre pares a los participantes en la SAFER Opportunities Initiative, que ofrece refugio a corto plazo en el hotel para personas del condado de Arapahoe que no tienen hogar y tienen trastornos de salud mental o adicciones.

Los especialistas en apoyo a pares están ellos mismos en recuperación y se los contrata para ayudar a otros. A medida que se distribuyen miles de millones de dólares en fondos para acuerdos por opioides a los estados y localidades, los líderes locales deciden qué hacer con el dinero.

Entre las opciones están apoyar y capacitar a estos especialistas, cuyos requisitos de certificación varían según el estado.

Los estados, condados, municipios y naciones indígenas presentaron miles de demandas contra las compañías farmacéuticas y los mayoristas acusados ​​de alimentar la crisis de los opioides. Muchos de esos casos se convirtieron en grandes demandas colectivas.

Este año, cuatro empresas llegaron a un acuerdo extrajudicial y acordaron pagar $26,000 millones durante 18 años. Los estados participantes deben seguir las pautas sobre cómo se puede gastar el dinero.

En Colorado, cientos de millones de dólares de ese acuerdo (y algunos otros) se destinarán a gobiernos locales y grupos regionales, varios de los cuales presentaron planes para utilizar parte del dinero en servicios de apoyo a pares.

David Eddie, psicólogo clínico y científico investigador del Recovery Research Institute del Hospital General de Massachusetts, dijo que los servicios de apoyo de recuperación entre pares han “ganado mucha fuerza en los últimos años”.

De acuerdo con la Administración de Servicios de Salud Mental y Abuso de Sustancias, la “evidencia creciente” muestra que trabajar con un par especialista puede generar mejores resultados de recuperación, desde una mayor estabilidad en la vivienda hasta tasas más bajas de recaídas y hospitalizaciones.

Un informe de la Oficina de Responsabilidad del Gobierno de EE.UU. identificó los servicios de apoyo entre pares como una práctica prometedora en el tratamiento de adultos con adicciones. En muchos estados, estos especialistas reciben un reembolso a través de Medicaid.

“Pueden llenar un vacío realmente importante”, dijo Eddie. “Pueden hacer cosas que nosotros, como médicos, no podemos hacer”.

Pueden, por ejemplo, ayudar a navegar la burocracia del sistema de servicios de protección infantil, sobre el cual los médicos pueden tener poco conocimiento, o invitar a alguien a tomar un café para construir una relación. Si una persona deja de asistir a la terapia, dijo Eddie, un especialista en apoyo de pares “puede ir físicamente a buscar a alguien y traerlo de vuelta al tratamiento, ayudarlo a volver a participar, reducir su vergüenza, eliminar el estigma de la adicción”.

Norton, por ejemplo, recogió a un cliente que la llamó desde un callejón después de ser dado de alta de un hospital por una sobredosis.

“Algunas personas te dirán: ‘Decidí que me iba a recuperar y nunca más iba a beber, drogarme o consumir’. Esa no es mi experiencia. Me tomó 20 años lograr mi primer año limpia y sobria. Y significó intentarlo todos los días”, dijo Norton desde su oficina. En una canasta debajo de su escritorio tiene tres kits de reversión de sobredosis de opioides surtidos con Narcan.

Su oficina, tibia por la luz del sol que entra por una ventana orientada al sur y la rotación casi constante de personas que se dejan caer en el sofá, tiene un estante con artículos esenciales. Hay tampones, para quien los necesite —Norton “nunca olvidará” la vez que recibió una multa por robar tampones en una tienda de comestibles mientras no tenía hogar— y kits de análisis de orina, para determinar si alguien está drogado o experimentando psicosis.

Norton enseña a “parar, tirarse al piso y rodar” como un mecanismo de afrontamiento cuando las personas se sienten perdidas y piensan en volver a consumir. “Si estás en crisis, ¿qué haces?”, dijo Norton. “Te detienes de inmediato, te recuestas en el suelo, ruedas y sales. Así que digo ‘Vete a la cama. Solo ve a dormir’. La gente dice: ‘Esa no es una herramienta de bienestar’”.

“Lo es”, intervino Audrey Salazar. Una vez, cuando Salazar estaba a punto de recaer, se quedó con Norton un fin de semana. “Literalmente me dormí”, dijo Salazar. Las dos descansaron y comieron Cocoa Puffs y Cheez-Its de la caja.

“Fue tan malo”, dijo Norton sobre el atracón de comida chatarra. Pero el fin de semana volvió a encarrilar a Salazar. Trabajar con un especialista en apoyo de pares que ha “recorrido el mismo camino”, dijo Salazar, “te vuelve responsable de una manera muy amorosa”.

Ese día de octubre, Norton pasó de regañar a una persona para que hiciera una cita con el médico, a conseguir que otra persona creara una despensa de alimentos, a descubrir cómo responder al banco que le dijo a un tercer cliente que no se podía abrir una cuenta sin una dirección residencial. También trabajó en bajar las defensas de un recién llegado, un hombre elegantemente vestido que parecía escéptico del programa.

Algunas personas llegan a Norton después de haber sido liberadas de la cárcel del condado, otras por el boca en boca. Y Norton ha reclutado gente en los parques y en la calle. El recién llegado aplicó después de enterarse del programa en un refugio para personas sin hogar.

Norton decidió que compartir un poco sobre ella misma era el camino a seguir con él.

“‘Mi experiencia son las cárceles, los hospitales y las instituciones. Tengo un número antiguo, es decir, un número de convicto. ‘Y tengo ocho años sin drogas’”, recordó haberle dicho. “‘Mi oficina está al final del pasillo. Hagamos algunos trámites. Hagámoslo'”.

Norton es uno de los siete pares en el personal de la Fundación Hornbuckle, que estima que cuesta alrededor de $24,000 por mes para brindar servicios de pares a este grupo de residentes, y los especialistas que trabajan a tiempo completo ganan alrededor de $3,000 por mes más $25 por hora por cliente.

La oficina de Norton es el centro de actividad de un piso en un hotel donde viven unas 25 personas que participan en la Iniciativa SAFER mientras se recuperan de los trastornos adicciones hasta que se “gradúan” en otro hotel, ubicado al lado. A partir de ahí, se mudarán a su propia vivienda, que los empleados a menudo les ayudan a encontrar.

Mientras están en el programa, los residentes se reúnen al menos una vez a la semana con un administrador de casos, un terapeuta y un especialista en apoyo de pares, además de asistir a reuniones grupales, que se llevan a cabo todos los días excepto los domingos y están dirigidas por compañeros.

Kyle Brewer, con sede en Arkansas, es el administrador del programa de especialistas en pares de NAADAC, la Asociación de Profesionales en Adicción (anteriormente, la Asociación Nacional de Consejeros sobre Alcoholismo y Abuso de Drogas). Brewer, quien dijo que su vida se descarriló después de que comenzó a usar opioides recetados para controlar el dolor de la extracción de una muela de juicio, dijo que los fondos de acuerdos por opioides presentan una oportunidad para apoyar a las personas que trabajan con las personas necesitadas.

“Cuando estamos trabajando y hablando y resolviendo problemas de diferentes enfoques para resolver la crisis de los opioides, deberíamos tener a las personas que se han visto directamente afectadas por esos problemas en la sala, guiando esas conversaciones”, dijo.

Hacia el final del día, Norton volvió a encontrarse con el muchacho nuevo en el pasillo, esta vez cuando regresaba de la máquina de hielo.

“Ocho años limpio. Me quito el sombrero ante ti”, dijo.

“Empecé con un día”, dijo Norton.

“Bueno, comenzaré con una hora”, dijo el muchacho.

Dijo que necesitaba limpiar su auto, donde había estado viviendo. Dijo que tiene problemas para ponerse los jeans por la mañana después de perder un pulgar por haber estado expuesto a temperaturas congelantes. Quería encontrar un trabajo de medio tiempo. Tiene que resolver un trauma con terapia. Su madre murió hace aproximadamente un año y medio.

“El viernes por la noche, iremos al cine”, dijo Norton.

“Oh, genial”, dijo. “Quiero ver la nueva de Top Gun”.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


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The Player-Coaches of Addiction Recovery Work Without Boundaries

States, tribes, and local governments are figuring out how best to spend billions of dollars from an opioid lawsuit settlement. One option they’re considering is funding peer support specialists, who guide people recovering from addiction as they do it themselves.

CENTENNIAL, Colo. — Sarah Wright stops by her peer support specialist’s hotel room-turned-office in this Denver suburb several times a day.

But her visit on a Wednesday morning in mid-October was one of her first with teeth.

The specialist, Donna Norton, had pushed Wright to go to the dentist years after homelessness and addiction had taken a toll on her health, down to the jawbone.

Wright was still getting used to her dentures. “I haven’t had teeth in 12½, 13 years,” she said, adding that they made her feel like a horse.

A new smile was Wright’s latest milestone as she works to rebuild her life, and Norton has been there for each step: opening a bank account, getting a job, developing a sense of her own worth.

Wright’s voice started to waver when she talked about Norton’s role in her life during the past few months. Norton wrapped her arms, adorned with tattoos of flames, spiderwebs, and a zombie Johnny Cash, around Wright.

“Oh, muffin,” she said. “I’m so proud of you.”

Norton, 54, is a Harley-riding, bulldog-loving, eight-years-sober grandmother and, professionally, “a cheerleader for the people that look bad on paper.”

People like her. “If you were to look me up on paper, you wouldn’t be in this room with me,” Norton said. “You would not let me near your house.”

If she were a therapist or social worker, hugging and sharing her experiences with drugs and the law might be considered a breach of professional boundaries. But as a peer support specialist, that’s often part of the job.

“I have no boundaries,” Norton said. “F— off,” she said, “is a term of endearment here.”

Norton works for the Hornbuckle Foundation, which provides peer support to participants in the SAFER Opportunities Initiative. SAFER provides short-term shelter in the hotel for people in Arapahoe County who are homeless and have mental health or substance use disorders.

Peer support specialists are themselves in recovery and are employed to help others. As billions of dollars in opioid settlement funds roll out to states and localities, local leaders are deciding what to do with the money. Supporting and training peer specialists, whose certification requirements vary by state, are among the options.

States, counties, municipalities, and tribes filed thousands of lawsuits against drug companies and wholesalers that are accused of fueling the opioid crisis. Many of those cases were lumped together into one mega-lawsuit. This year, four companies settled out of court, agreeing to pay $26 billion over 18 years. Participating states must follow guidelines for how the money can be spent.

In Colorado, hundreds of millions of dollars from that settlement (and a few others) will go to local governments and regional groups, several of which submitted plans to use some of the money for peer support services.

David Eddie, a clinical psychologist and a research scientist at the Recovery Research Institute at Massachusetts General Hospital, said peer recovery support services have “been gaining a lot of traction in recent years.”

According to the Substance Abuse and Mental Health Services Administration, “mounting evidence” shows that working with a peer specialist can result in better recovery outcomes, from greater housing stability to reduced rates of relapse and hospitalization. A report by the U.S. Government Accountability Office identified peer support services as a promising practice in treating adults with substance use disorders. In many states, peer specialists are reimbursed through Medicaid.

“They can plug a really important gap,” Eddie said. “They can do things that we as clinicians can’t do.”

They can, for example, help navigate the bureaucracy of the child protective services system, about which clinicians might have little knowledge, or take someone out to coffee to build a relationship. If a person stops showing up to therapy, Eddie said, a peer support specialist “can physically go and look for somebody and bring them back to treatment — help them reengage, reduce their shame, destigmatize addiction.”

Norton has, for instance, picked up a client who called her from an alley after being discharged from a hospital stay for an overdose.

“Some people will tell you, ‘I decided I was going to get in recovery, and I never had to drink, drug, or use again.’ That’s not my experience. It took me 20 years to get my first year clean and sober. And that was trying every day,” said Norton from her office, her Vans planted just inches from a basket that lives under her desk: It contains three opioid overdose reversal kits stocked with Narcan.

Her office, warmed by the sunlight coming through a south-facing window and the nearly constant rotation of people plopping onto the couch, contains a shelf of essential items. There are tampons, for whoever needs them — Norton will “never forget” the time she got a ticket for stealing tampons from a grocery store while she was homeless — and urine analysis kits, for determining whether someone is high versus experiencing psychosis.

She teaches “stop, drop, and roll” as a coping mechanism for when people are feeling lost and thinking about using substances again. “If you’re on fire, what do you do?” Norton said. “You stop immediately, you lay on the ground, you roll and get yourself out. So I’m like, ‘Go to bed. Just go to sleep.’ People are like, ‘That’s not a wellness tool.’”

“It is,” Audrey Salazar chimed in. Once, when Salazar was close to relapsing, she stayed with Norton for a weekend. “I literally just slept,” Salazar said. The two rested and ate Cocoa Puffs and Cheez-Its by the box.

“It was so bad,” Norton said of the junk food binge. But the weekend got Salazar back on track. Working with a peer support specialist who has “walked the same walk,” Salazar said, “holds you accountable in a very loving way.”

That October day, Norton pivoted from nagging one person to make a doctor’s appointment, to getting someone else set up with a food pantry, to figuring out how to respond to the bank that told a third client that an account couldn’t be opened without a residential address. She also worked on lowering the defenses of a newcomer, a sharply dressed man who seemed skeptical of the program.

Some people come to Norton after being released from the county jail, others by word of mouth. And Norton has recruited people in parks and the street. The newcomer applied after hearing about the program in a homeless shelter.

Norton decided that sharing a little about herself was the way to go with him.

“‘My experience is jails and hospitals and institutions. I’ve got an old number,’ meaning a convict number. ‘And I have eight years drug-free,’” she recalled telling him. “‘My office is down the hall. Let’s get some paperwork done. Let’s do this.’”

Norton is one of seven peers on staff with the Hornbuckle Foundation, which estimates that it costs about $24,000 a month to provide peer services to this group of residents, with peer specialists working full time make about $3,000 a month plus $25 an hour per client. Norton’s office is the hub of activity for a floor in one hotel where about 25 people participating in the SAFER Opportunities Initiative live while recovering from substance use disorders until they “graduate” to another hotel, located next door. From there, they’ll move on to their own housing, which staffers often help them find.

While in the program, residents meet at least once a week with a case manager, a therapist, and a peer support specialist, in addition to attending group meetings, which take place every day except Sundays and are all run by peers.

Kyle Brewer, based in Arkansas, is the peer specialist program manager for NAADAC, the Association for Addiction Professionals (formerly the National Association for Alcoholism and Drug Abuse Counselors). Brewer, who said his life derailed after he started using prescription opioids to manage the pain from a wisdom tooth removal, said opioid settlement funds present an opportunity to support the people who work on the ground.

“When we’re working and talking and troubleshooting different approaches to solve the opioid crisis, we should have the people that have been directly affected by those issues in the room, guiding those conversations,” he said.

Toward the end of the day, Norton ran into the new guy in the hallway again, this time on his way back from the ice machine.

“Eight years clean. My hat goes off to you,” he said.

“I started with one day,” said Norton.

“Well, I’ll start with one hour,” said the new guy.

He said he needed to clean out his car, where he’d been living. He said he has trouble putting his jeans on in the morning after losing a thumb to frostbite. He wanted to find a part-time job. He has trauma to work through in therapy. His mother died about a year and a half ago.

“Friday night, we’re going to the movies,” said Norton.

“Oh, cool,” he said. “I want to see ‘Top Gun,’ the new one.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


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Calls to Overhaul Methadone Distribution Intensify, but Clinics Resist

The pandemic has shown that loosening the strict regulations on distributing methadone helps people recovering from addiction stay in treatment. But clinics with a financial stake in keeping the status quo don’t want to make permanent changes.

Days typically start early for patients undergoing opioid addiction treatment at Denver Recovery Group’s six methadone clinics in Colorado. They rise before dawn. Some take three buses to get to a clinic by 5 a.m. for a 15-minute conversation with a counselor and their daily dose of methadone, all before they go to work or take their kids to school. Some drive more than an hour each way from Longmont or Steamboat Springs.

“They’re coming from a billion miles away,” said Dr. Andreas Edrich, the clinics’ chief medical officer, noting their strong motivation to get care compared with other patients who struggle to stick to a simple medication regimen. “Most people can’t take their blood pressure to save their life, and that’s in their kitchen cabinet.”

Patients who take methadone, a synthetic narcotic used to treat opioid addiction, must jump through more hoops than perhaps any other patient group in the U.S. due to rules dating back five decades. Proponents for easing the rules say the pandemic has shown certain constraints serve more as barriers to care than protections. And consensus is growing among clinicians, patients, and regulators that it’s time for change.

“There’s probably very few folks who work in the field who feel like we should continue the status quo,” said Dr. Shawn Ryan, a board member for the American Society of Addiction Medicine.

Now officials at the Substance Abuse and Mental Health Services Administration are considering permanent changes to federal methadone rules. A National Academy of Medicine workshop on methadone regulations on March 3 and 4 may signal an inflection point.

Additionally, Sens. Ed Markey (D-Mass.) and Rand Paul (R-Ky.) have introduced a bill that would codify the rules loosened during the pandemic, which allowed flexibility on take-home doses, telehealth, and treatment vans. It would also allow pharmacies to dispense methadone for opioid use treatment.

Any changes to federal rules, however, could face significant resistance from methadone clinics — many of them for-profit — whose financial models are built on daily patient encounters, counseling, and regular drug tests.

“There are some entities who have a financial interest in keeping things the way that they are,” Ryan said. “Change costs money.”

Currently, methadone can be dispensed only through federally regulated opioid treatment centers. Patients, at least initially, have had to show up in person each day to get their dose until they had proven themselves stable, primarily out of concern that they would sell the methadone or take more than their daily dose, risking overdose.

But the covid-19 pandemic prompted federal authorities to loosen methadone regulations, allowing more patients to take doses home and rely on telehealth consultations instead of in-person visits. Studies have found the flexibility didn’t result in any increases in overdoses, illicit sales of methadone doses, or people dropping out of treatment. Instead, patients have reported greater satisfaction and a higher willingness to follow their regimens.

“From that standpoint, the pandemic was an absolute blessing in disguise,” Edrich said.

One study found that the number of methadone take-home doses nearly doubled during the pandemic.

“We really couldn’t see any differences in terms of treatment adherence,” said Ofer Amram, an assistant professor studying health disparities at Washington State University.

That real-world experiment showed that many of the methadone rules might not be needed.

“In most other countries in the West, including Canada, it’s much easier to get access to methadone treatment,” Amram said. “You can get it in most pharmacies.”

But an Oregon Health & Science University survey of 170 methadone clinics found that fewer than half permitted new patients to take home a 14-day supply despite the loosened guidelines, and about two-thirds allowed existing, stable patients to receive the full 28-day allotment allowed.

“At the end of the day, patients with opioid use disorder want to be treated like everybody else,” said Dr. Ximena Levander, an assistant professor of medicine at OHSU and a co-author of the study. “There are a lot of other high-risk medications we dispense in medicine, but it’s only this one medication where it’s required for patients to go to this specific place to get treatment.”

Opioid treatment programs generally get reimbursed on a fee-for-service model: The more services they provide and the more tests they run, the more they get paid. A shift to a model in which a person comes to the clinic only once a month could severely restrict their revenue. According to a federal survey of methadone clinics, 41% were run by private for-profit companies in 2020, up from 30% in 2010.

“Most of these patients pay cash,” said Taleed El-Sabawi, an addiction and public policy professor at Georgetown University. “So if you are requiring urine tests often, if you’re requiring patients come in, if you’re requiring that they go through other hoops, they’re paying for that.”

And with cash payments, she said, no health plans are involved to question whether the services are medically necessary.

Denise Vincioni, regional director for Denver Recovery Group and a former director of Colorado’s State Opioid Treatment Authority, defended the existing regulatory framework.

“The rules and regulations protect our patients, give us parameters to work within, and also keep us safe as providers,” she said. “It’s a very risky business because you’re managing people’s lives with narcotics.”

Many patients, she said, end up appreciating the routine that creates the good habit of taking their methadone at the same time every day. Patients who haven’t put in the time or shown they’re not using illicit substances “haven’t demonstrated some of that entitlement,” Vincioni said. “Loose structure has been to their detriment.”

Vincioni suggested the clinics should have more leeway to decide when somebody is ready for take-home doses and to rely on their clinical judgment rather than strict parameters. Currently, if doses are diverted or the patient overdoses, the clinic could face repercussions.

“If something happens, it’s your butt,” she said. “That’s part of what has prevented us from doing a lot of that loosening up.”

Within the addiction treatment world, methadone patients are treated differently from patients who use other opioid addiction treatments, such as buprenorphine or Suboxone. Generally, buprenorphine is considered safer than methadone, with less risk of overdose, but methadone may be a better option for patients with chronic pain or who have been exposed to high amounts of fentanyl.

There’s also a racial-equity component. It’s often said that Black patients get methadone, which carries a stigma, while their white counterparts get Suboxone, a drug that prevents cravings for opioids. Part of that is because methadone clinics are often located in minority neighborhoods.

Levander said the recent focus on racial justice is driving momentum for changes to methadone rules.

“A lot of the federal regulations have a very racist history and undertone,” she said. “One of the things that is helping to catalyze this change is that motivation to try to right a wrong.”

Christopher Garrett, a SAMHSA spokesperson, said the agency can make some changes to methadone regulations on its own and is currently reviewing the flexibility granted during the pandemic. The agency has indicated that it plans to extend the flexibility for take-home doses another year, regardless of when the public health emergency ends.

Advocates caution that federal and state rules often conflict with each other, and sometimes are poorly aligned with the payment structure from Medicare, Medicaid, and other health plans. A Pew Charitable Trusts analysis, for example, found that in many states fewer than half of the opioid treatment providers accept Medicaid.

The two-day National Academy of Medicine workshop this month is expected to culminate in a report with possible policy change recommendations.

“I’m hoping that the momentum is now finally here,” said Dr. Gavin Bart, director of addiction medicine at Hennepin Healthcare in Minneapolis. “This is now being taken quite seriously.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).