A $30 Million Gift to Build an Addiction Treatment Center. Then Staffers Had to Run It.

Howard Buffett, son of billionaire investor Warren Buffett and chairman of his own charitable foundation, gave $30 million to build an addiction treatment center in the central Illinois community where he farms. But the money was a one-time gift for infrastructure, so the clinic is on its own to keep it running.

DECATUR, Ill. — The question came out of the blue, or so it seemed to Crossing Healthcare CEO Tanya Andricks: If you had $30 million to design an addiction treatment facility, how would you do it?

The interim sheriff of Macon County, Illinois, posed the question in 2018 as he and Andricks discussed the community’s needs. When she responded that she’d have to do some research, she was told not to take too long because the offer wouldn’t be there forever.

“I thought: ‘Oh, my God, he’s serious,’” Andricks said.

That sheriff was Howard Buffett, the philanthropist son of billionaire investor Warren Buffett. The younger Buffett ended up giving Crossing about $30 million from his charitable foundation to build an addiction treatment center in Decatur, a city with a population of just over 69,000 in the heart of Macon County.

There was a caveat, though. The donation to Crossing was a one-time gift to pay only for the buildings. It was up to Andricks and her team to find money to run the programs. And that has proven difficult.

The covid-19 pandemic upended everything mere months after the facilities opened in October 2019. An audited financial statement said the inpatient recovery center had lost $2.5 million by June 2021, and management worried about its ability to continue operating. Even so, the center remained open while other addiction treatment facilities around the country shuttered.

Now communities nationwide are preparing for an unprecedented windfall of their own for addiction treatment from a nearly $26 billion national opioid settlement and a more than $300 million expansion of a federal pilot program for mental health. The experience at Crossing offers them a model but also a warning: It will take more than a single shot of money to build a treatment program that can last.

Drug addiction wasn’t on Howard Buffett’s radar, he told KHN, until he joined the Macon County sheriff’s office as an auxiliary deputy in 2012. While the county has had some treatment resources, like a behavioral health center, it has one of the state’s higher death rates from opioid overdoses.

Buffett moved to the area in 1992 to work for food-processing giant Archer Daniels Midland. He runs a farm nearby and his Decatur-based foundation donates hundreds of millions of dollars for initiatives ranging from helping people kidnapped by Joseph Kony’s Lord’s Resistance Army in central Africa to revitalizing the cacao industry in El Salvador.

Soon after Buffett was appointed interim sheriff in 2017, he toured Crossing to learn more about local social services. The health center offers primary care, including mental health, for all ages and sees roughly 17,500 patients a year. Most Crossing patients are on Medicaid, the public health insurance for people with low incomes.

“He was impressed with what we were able to provide patients,” Andricks recalled. “I don’t think he expected the scope and size of what we do.”

Addiction treatment, though, is notoriously difficult. Evidence supports treating addiction like a chronic illness, meaning even after difficult short-term behavior changes, it requires a lifetime of management. Research suggests relapse rates can be more than 85% in the first year of recovery. So any new treatment program is likely to face headwinds.

Buffett didn’t set Crossing up for failure. In fact, he has helped fund other aspects of the organization’s work. Part of the idea behind paying for the addiction treatment buildings but not the operations, Buffett said, is to keep his foundation “creative.” If it spends all its money on the same programming every year, that means less is available to fund other work around the globe. Buffett said it’s also about sustainability.

“If Tanya can show ‘with this investment I made this work,’” Buffett said, “then other people should be making that investment.”

Crossing’s inpatient recovery center holds eight beds for medication-assisted detox, 48 beds for rehabilitation, and a cafeteria where meals are cooked with input from dietitians working with patients. An outpatient treatment center also has classrooms for continuing education, a gym with a small bowling alley, and a movie theater. Buffett insisted on the last two amenities. (“People have to feel good about getting better,” he said.)

A separate building holds 64 beds of transitional housing, and just across the street are 20 rent-controlled apartments. Buffett spent an additional $25 million on buildings at that campus for other organizations focused on housing, workforce development, and education, among other things.

“There’s a lot to like in this program,” said Dr. Bradley Stein, director of Rand Corp.’s Opioid Policy and Tools Information Center.

As positives, Stein pointed specifically to the spectrum of care offered to patients as they progress in their recovery, the use of medication-assisted treatment to help stave off physical cravings for opioids, the connection to the health center, and even the involvement of law enforcement.

Laura Cogan, a 36-year-old mother who has struggled with addiction since she was 14, is one of the patients working their way through the system.

Cogan said she was the first patient in the doors when the recovery center opened. Less than 24 hours later, she was also the first patient to walk out.

The biggest challenge with Cogan’s previous attempts at recovery, she said, was never being sure about her next steps: What was she supposed to do after getting out of detox and residential treatment?

Crossing’s approach was designed to address that by providing transitional housing, easy access to outpatient services, and educational programming.

On her third attempt, Cogan got a round of applause after completing the first three days in detox. After six days, she joined residential treatment. After a month, she moved over to transitional housing, began outpatient treatment, and started offering peer support at Crossing. She tutored other patients, taught a writing class, and helped them get on computers and fill out job applications.

Then the pandemic hit.

Like other health centers around the nation, Crossing turned its attention to providing covid testing and vaccines. Meanwhile, just about every aspect of addiction treatment became more expensive. Crossing halved the number of residential treatment beds so each room would have only one patient and converted the rooms into negative pressure chambers to reduce the risk of covid transmission.

Staffing grew harder amid a nationwide nursing shortage. The number of patients in residential treatment dropped, Andricks said, because few people wanted to live inside a facility and wear masks. It was common to have as few as 10 beds occupied on a given day. The women’s unit was temporarily closed due to lack of demand and staffing constraints.

Cogan said several other transitional housing residents left once the $1,200 pandemic stimulus checks arrived, with some resuming treatment when that money dried up. But Cogan continued. Eventually she moved into Crossing’s rent-controlled apartments, where she has been one of just a few tenants.

Without the federal Paycheck Protection Program’s $1,375,200 forgivable loan in 2020, Andricks said, the outpatient treatment program might have had to close altogether.

But momentum at the recovery center started to change last spring as covid cases tapered off, Andricks said. Hiring became easier. More patients arrived. In October, the center received a grant to use the apartments for women with a history of substance misuse who are pregnant or who have given birth within the prior year. They’ve placed six women, in addition to Cogan, there already. The inpatient recovery center now averages about 27 occupied beds a day, within striking distance of the 30 that Andricks said the inpatient center needs to survive.

Rand’s Stein suggested another measurement of a treatment program’s success: whether people in the community get into treatment when they need it. National “secret shopper” reports have found significant barriers to service, such as long wait times.

Crossing’s program quadrupled the number of residential treatment beds in Macon County, according to Andricks. In the three years since the inpatient recovery center opened, it has had over 1,300 admissions. While most patients haven’t stayed in recovery, staffers have seen a pattern of success with those like Cogan who stay on campus and become involved with recovery offerings — although Andricks estimated that’s fewer than 10% of the patients.

Cogan said she hopes Crossing doesn’t get discouraged. People are going to mess up, she said, but she’s living proof of the impact the recovery center can have.

“I’m one of the lucky ones and I don’t know why,” Cogan said, sitting on a couch in the apartment on Crossing’s campus that she shares with her 12-year-old son since regaining custody of him. “I just know that today I am. And I hope that more people get the opportunity.”

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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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 https://t.co/87TTYPVE0P

— 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🧵https://t.co/p5dHdbZKou

— 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 https://t.co/PoAduYljXq

— 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 https://t.co/fTfilK4WEX

— 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. https://t.co/qeoXtqKfpo

— 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 www.ncopioidsettlement.org) 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 https://t.co/vRbksffwqP

— 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. https://t.co/vnbHAJYWvY

— 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.https://t.co/sHe0EV1DQG

— 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. https://t.co/UiFiiQ9wre 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.

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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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Fentanilo en la escuela secundaria: una comunidad de Texas se enfrenta al mortal opioide

Desde julio, cuatro estudiantes del Distrito Escolar Independiente Consolidado de Hays, al sur de Austin, han muerto por sobredosis de fentanilo.

KYLE, Texas – Los pasillos de la escuela secundaria Lehman lucían como cualquier otro en un día reciente de otoño. Sus 2,100 estudiantes hablaban y reían mientras se apresuraban a ir a sus clases en medio de paredes cubiertas de afiches que anunciaban eventos del baile de bienvenida, clubes y partidos de fútbol americano. Sin embargo, junto a esos afiches había algunos con un sombrío mensaje que advertía a los estudiantes de que el fentanilo es extremadamente mortal.

Esos carteles no estaban allí el año pasado.

Justo antes de que comenzara el año escolar, el Distrito Escolar Independiente Consolidado de Hays, que incluye a Lehman, anunció que dos estudiantes habían muerto después de tomar pastillas con fentanilo. Fueron las primeras muertes de estudiantes relacionadas con el opioide sintético en este distrito escolar del centro de Texas, que tiene campus de secundaria en Kyle y Buda, una ciudad cercana.

En el primer mes de clases, se confirmaron otras dos muertes.

La reacción de las autoridades escolares, empleados, estudiantes y padres ha sido intensa, una mezcla de angustia y terror con ira y ganas de actuar. La comunidad, al parecer, está dispuesta a contraatacar. El sistema escolar ha dado prioridad a su actual campaña educativa contra las drogas. Los estudiantes hacen frente a sus conductas de riesgo y a la presión de sus compañeros. Y los padres intentan iniciar conversaciones difíciles sobre las drogas con sus hijos.

Están “cogiendo el toro por los cuernos”, dijo Tim Savoy, jefe de comunicaciones del distrito escolar.

Pero también hay dudas sobre si esos esfuerzos serán suficientes.

El problema de sobredosis que afronta el distrito, que está justo al sur de Austin y a una hora al noreste de San Antonio, imita una tendencia nacional.

Según los Centros para el Control y Prevención de Enfermedades, en 2021 murieron más de 107,000 personas por sobredosis, todo un récord. La mayoría de esas muertes —7,238 de ellas— estuvo relacionada con el fentanilo y otros opioides sintéticos. La Administración para el Control de Drogas ha advertido que el fentanilo se encuentra cada vez más en “píldoras de recetas falsas” que son “fácilmente accesibles y a menudo se venden en las redes sociales y plataformas de comercio electrónico”.

El jefe de policía de Kyle, Jeff Barnett, dijo que eso es un problema que afronta en su comunidad. “Probablemente podrías encontrar una píldora con fentanilo en cinco minutos en las redes sociales y probablemente organizar un encuentro en una hora” con un traficante, dijo Barnett.

La amenaza del fentanilo ha hecho que los estudiantes de secundaria sean más propensos a conseguir las píldoras letales. Pueden creer que están consumiendo drogas para fiestas que, aunque son ilegales, no son -por sí solas- tan mortales como el fentanilo.

Los chicos “no están comprando fentanilo intencionadamente”, indicó Jennifer Sharpe Potter, profesora de psiquiatría y ciencias del comportamiento en UT Health San Antonio, en un testimonio durante una audiencia celebrada en septiembre ante la Cámara de Representantes de Texas. No saben qué hay en las pastillas que compran, añadió, y describió el problema como la “tercera ola de la crisis de sobredosis”.

Kevin McConville, de 17 años, un estudiante de Lehman que murió en agosto, parece ser una de las víctimas de esta ola. En un vídeo producido por el distrito, los padres de Kevin explican con una inmensa tristeza en sus ojos que, tras la muerte de su hijo, se enteraron por sus amigos de que tenía dificultades para dormir. Tras tomar pastillas que creía que eran Percocet y Xanax, no se despertó.

Historias como esta han llevado al distrito escolar a emitir la siguiente advertencia en su página web: “El fentanilo está aquí. Tenemos que hablar del fentanilo. Y el fentanilo es mortal”. Es 100 veces más potente que la morfina y 50 veces más potente que la heroína, según la DEA, y dos miligramos son potencialmente letales.

El distrito ha puesto en marcha la campaña “Lucha contra el fentanilo”, que cuenta con la colaboración de la policía municipal y de los servicios médicos de urgencia. Hay un “HopeLine” al que los alumnos pueden enviar anónimamente información sobre compañeros que puedan estar consumiendo drogas ilícitas. A partir de sexto grado, los alumnos deben ver un vídeo de 13 minutos en el que se recalca lo peligroso y mortal que es el fentanilo y se explica cómo identificar si un compañero puede tener una sobredosis.

“Estamos reclutando a los estudiantes para que nos ayuden a ser los ojos y los oídos si están en una fiesta o en casa de un amigo”, dijo Savoy.

El sistema escolar también espera concienciar a los estudiantes de los riesgos que afrontan. No se puede confiar en ninguna píldora, sea cual sea, que no proceda de una farmacia: “Es como jugar a la ruleta rusa”, dijo Savoy.

El mensaje parece que está llegando. Sara Hutson, alumna del último año del instituto Lehman, dice que compartir pastillas que se venden sin receta, como Tylenol y Motrin, solía ser habitual, pero ya no lo considera seguro. Ya no confía.

Pero otros estudiantes no son tan precavidos. Lisa Peralta compartió en un post de Facebook en septiembre que su hija, que está en séptimo grado, admitió haber comido una “gomita para la ansiedad” que le dio su amiga. “Tengo miedo porque mi hija se deja llevar por sus amigos”, escribió la residente de Kyle. “No confío en que no lo vuelva a hacer si se siente presionada”.

Por muy claros que sean los mensajes del distrito y de los padres, a Savoy le preocupa que nunca sean suficientes porque los estudiantes son muy aventureros. “Es simplemente la mentalidad adolescente”, dijo. “Piensan: ‘Somos invencibles; a mí no me va a pasar’. Pero está pasando en nuestra comunidad”.

Aun así, los sentimientos de descontento y dolor son a veces palpables. Los estudiantes se pelean más en la escuela, dijo Jacob Valdez, un estudiante de décimo grado de Lehman que conocía a dos de los estudiantes que murieron. Eso puede estar pasando, añadió, porque “todo el mundo está angustiado”.

La tensión no se limita a los estudiantes de intermedia y secundaria. También se ha vuelto muy real para los padres de los niños de primaria, desde que la DEA advirtió al público en agosto sobre las píldoras con fentanilo que parecen caramelos de colores brillantes. El distrito escolar de Hays también está colgando carteles de advertencia dirigidos a los estudiantes más jóvenes.

Jillien Brown, de Kyle, dijo que está preocupada por sus hijas, Vivian, de 5 años, y Scarlett, de 7. “Les hemos dicho que están ocurriendo cosas aterradoras, que la gente se está poniendo muy enferma y está muriendo por tomar lo que creen que son caramelos o medicamentos”, indicó Brown. “Utilizamos la palabra ‘veneno’, como cuando Blancanieves mordió la manzana”.

Pero la conversación debe ser continua, dijo Brown, porque al día siguiente de hablar con sus hijas, “un niño pequeño en el autobús les dio un caramelo y se lo comieron”.

Del mismo modo, April Munson, residente en Kyle y antigua profesora de primaria, considera que todo es “desgarrador”. Le mostró a su hijo de 9 años, Ethan, fotos de las píldoras multicolores de “fentanilo arco iris”. “Es una conversación difícil de tener, pero las conversaciones difíciles son a menudo las más importantes”, dijo. “Y, realmente, no puedes permitirte dejar de hablar del tema”.

Y mientras los padres y los funcionarios escolares intentan evitar que el fentanilo vuelva a castigar, llega otro golpe de realidad.

El año pasado, el distrito escolar comenzó a almacenar en cada escuela un suministro de naloxona, el fármaco para revertir sobredosis, también conocido como Narcan. En lo que va de semestre, a pesar de todo lo que ha pasado, lo han tenido que utilizar para salvar a otros cuatro estudiantes, dijo Savoy. En un caso, los socorristas tuvieron que usar tres dosis para reanimar a un estudiante: el fentanilo “era así de fuerte”, agregó.

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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Fentanyl in High School: A Texas Community Grapples With the Reach of the Deadly Opioid

The first fentanyl-related deaths of students in an area south of Austin, Texas, were reported over the summer. The school district, parents, and students are trying to deal with the aftermath.

KYLE, Texas — The hallways of Lehman High School looked like any other on a recent fall day. Its 2,100 students talked and laughed as they hurried to their next classes, moving past walls covered with flyers that advertised homecoming events, clubs, and football games. Next to those flyers, though, were posters with a grim message warning students that fentanyl is extremely deadly.

Those posters weren’t there last school year.

Right before this school year started, the Hays Consolidated Independent School District, which includes Lehman, announced that two students had died after taking fentanyl-laced pills. They were the first recorded student deaths tied to the synthetic opioid in this Central Texas school district, which has high school campuses in Kyle and Buda, a nearby town. Within the first month of school, two more fatalities were confirmed.

The reaction from school officials, employees, students, and parents has been intense, mixing heartbreak and terror with anger and action. The community, it seems, is ready to fight back. The school system has prioritized its existing anti-drug educational campaign. Students are wrestling with their risky behaviors and peer pressure. And parents are trying to start difficult conversations about drugs with their children.

They are “taking the bull by the horns,” said Tim Savoy, the school district’s chief communications officer.

But there are also questions about whether those efforts will be enough.

The overdose problem facing the district, which is just south of Austin and about an hour northeast of San Antonio, mimics a nationwide trend. More than 107,000 people in the U.S. died of drug overdoses in 2021, according to the Centers for Disease Control and Prevention, a record. Most of those deaths — 71,238 of them — involved fentanyl and other synthetic opioids. The Drug Enforcement Administration has warned that fentanyl is increasingly finding its way into “fake prescription pills” that are “easily accessible and often sold on social media and e-commerce platforms.”

The police chief in Kyle, Jeff Barnett, said that’s a problem in his area. “You could probably find a fentanyl-laced pill within five minutes on social media and probably arrange a meeting within the hour” with a dealer, Barnett said.

The fentanyl threat has made high schoolers more susceptible to getting ahold of the lethal pills. They might believe they are using party drugs that, though illegal, are not — on their own — nearly as deadly as fentanyl.

The kids are “not intentionally buying fentanyl,” Jennifer Sharpe Potter, a professor of psychiatry and behavioral sciences at UT Health San Antonio, said in testimony during a September hearing before the Texas House of Representatives. They don’t know that it’s in the pills they buy, she added, describing the problem as the “third wave of the overdose crisis.”

Seventeen-year-old Kevin McConville, a Lehman student who died in August, appears to be one of this wave’s victims. In a video the district produced, Kevin’s parents explain with grief heavy in their eyes that after their son’s death, they learned from his friends that he was struggling to sleep. After taking pills he thought were Percocet and Xanax, he didn’t wake up, his parents said.

Stories like that have led the school district to issue the following warning on its website: “Fentanyl is here. We need to talk about fentanyl. And fentanyl is deadly.” It’s 100 times as potent as morphine and 50 times as potent as heroin, according to the DEA, and 2 milligrams is potentially lethal.

The district launched a “Fighting Fentanyl” campaign — which enlists city police and emergency medical services personnel. There’s a “HopeLine” to which students can anonymously send information about classmates who may be taking illicit drugs. Starting in sixth grade, students are required to watch a 13-minute video that underscores how dangerous and deadly fentanyl is and explains how to identify when a classmate may be overdosing.

“We’re recruiting students to help us be the eyes and ears if they’re at a party or at a friend’s house,” Savoy said.

The school system also hopes to raise students’ awareness of the risks they face. Any pill — no matter what it is — that didn’t come from a pharmacy cannot be trusted: “It’s like playing Russian roulette,” Savoy said.

The message may be resonating. Sara Hutson, a Lehman High senior, said sharing over-the-counter pills such as Tylenol and Motrin used to be common, but she no longer considers it safe. Her trust is gone.

But other students aren’t as cautious. Lisa Peralta shared in a Facebook post in September that her daughter, who is in seventh grade, admitted to eating an “anxiety gummy” her friend gave her. “I’m scared because my daughter is a follower,” the Kyle resident wrote. “I just don’t trust that she won’t do it again if she feels pressured.”

No matter how clear the district and parents make their messages, Savoy worries they may never be enough because students are so adventurous. “It’s just the teenage mindset,” he said. “They think, ‘We’re invincible; it’s not going to happen to me.’ But it is happening to us in our community.”

Still, the feelings of unease and grief are sometimes palpable. Students have been fighting more at school, said Jacob Valdez, a Lehman sophomore who knew two of the students who died. That might be happening, he added, because “everyone is just angsty.”

The tension is not limited to middle and high school students. It’s also become very real for parents of elementary school kids, since the DEA warned the public in August about fentanyl-laced pills that look like brightly colored candies. The Hays school district is also hanging warning posters geared toward younger students.

Jillien Brown of Kyle said she is worried about her daughters, 5-year-old Vivian and 7-year-old Scarlett. “We told them that there’s some scary things going on, that people are getting very sick and they’re dying from taking what they think is candy or medicine,” Brown said. “We use the word ‘poison,’ so like when Snow White bit the apple.”

But the conversation must be ongoing, Brown said, because the day after she talked to her daughters, “some little kid on the bus gave them a candy and they ate it.”

Similarly, Kyle resident April Munson, a former elementary school teacher, considers it all “gut-wrenching.” She showed her 9-year-old son, Ethan, pictures of the multicolored “rainbow fentanyl” pills. “It’s a hard conversation to have, but hard conversations are often the most important ones,” she said. “And, really, you can’t afford to have elephants in the room.”

And even as parents and the school officials attempt to prevent fentanyl from striking again, another reality check comes.

Last year, the school district started stocking in every school a supply of the overdose reversal drug naloxone, also known as Narcan. So far this semester, despite all the community has gone through, it has been used to save four more students, Savoy said. In one case, Savoy said, first responders had to use three doses to revive a student — the fentanyl “was that strong,” he said.

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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Fentanyl in High School: A Texas Community Grapples With the Reach of the Deadly Opioid

The first fentanyl-related deaths of students in an area south of Austin, Texas, were reported over the summer. The school district, parents, and students are trying to deal with the aftermath.

KYLE, Texas — The hallways of Lehman High School looked like any other on a recent fall day. Its 2,100 students talked and laughed as they hurried to their next classes, moving past walls covered with flyers that advertised homecoming events, clubs, and football games. Next to those flyers, though, were posters with a grim message warning students that fentanyl is extremely deadly.

Those posters weren’t there last school year.

Right before this school year started, the Hays Consolidated Independent School District, which includes Lehman, announced that two students had died after taking fentanyl-laced pills. They were the first recorded student deaths tied to the synthetic opioid in this Central Texas school district, which has high school campuses in Kyle and Buda, a nearby town. Within the first month of school, two more fatalities were confirmed.

The reaction from school officials, employees, students, and parents has been intense, mixing heartbreak and terror with anger and action. The community, it seems, is ready to fight back. The school system has prioritized its existing anti-drug educational campaign. Students are wrestling with their risky behaviors and peer pressure. And parents are trying to start difficult conversations about drugs with their children.

They are “taking the bull by the horns,” said Tim Savoy, the school district’s chief communications officer.

But there are also questions about whether those efforts will be enough.

The overdose problem facing the district, which is just south of Austin and about an hour northeast of San Antonio, mimics a nationwide trend. More than 107,000 people in the U.S. died of drug overdoses in 2021, according to the Centers for Disease Control and Prevention, a record. Most of those deaths — 71,238 of them — involved fentanyl and other synthetic opioids. The Drug Enforcement Administration has warned that fentanyl is increasingly finding its way into “fake prescription pills” that are “easily accessible and often sold on social media and e-commerce platforms.”

The police chief in Kyle, Jeff Barnett, said that’s a problem in his area. “You could probably find a fentanyl-laced pill within five minutes on social media and probably arrange a meeting within the hour” with a dealer, Barnett said.

The fentanyl threat has made high schoolers more susceptible to getting ahold of the lethal pills. They might believe they are using party drugs that, though illegal, are not — on their own — nearly as deadly as fentanyl.

The kids are “not intentionally buying fentanyl,” Jennifer Sharpe Potter, a professor of psychiatry and behavioral sciences at UT Health San Antonio, said in testimony during a September hearing before the Texas House of Representatives. They don’t know that it’s in the pills they buy, she added, describing the problem as the “third wave of the overdose crisis.”

Seventeen-year-old Kevin McConville, a Lehman student who died in August, appears to be one of this wave’s victims. In a video the district produced, Kevin’s parents explain with grief heavy in their eyes that after their son’s death, they learned from his friends that he was struggling to sleep. After taking pills he thought were Percocet and Xanax, he didn’t wake up, his parents said.

Stories like that have led the school district to issue the following warning on its website: “Fentanyl is here. We need to talk about fentanyl. And fentanyl is deadly.” It’s 100 times as potent as morphine and 50 times as potent as heroin, according to the DEA, and 2 milligrams is potentially lethal.

The district launched a “Fighting Fentanyl” campaign — which enlists city police and emergency medical services personnel. There’s a “HopeLine” to which students can anonymously send information about classmates who may be taking illicit drugs. Starting in sixth grade, students are required to watch a 13-minute video that underscores how dangerous and deadly fentanyl is and explains how to identify when a classmate may be overdosing.

“We’re recruiting students to help us be the eyes and ears if they’re at a party or at a friend’s house,” Savoy said.

The school system also hopes to raise students’ awareness of the risks they face. Any pill — no matter what it is — that didn’t come from a pharmacy cannot be trusted: “It’s like playing Russian roulette,” Savoy said.

The message may be resonating. Sara Hutson, a Lehman High senior, said sharing over-the-counter pills such as Tylenol and Motrin used to be common, but she no longer considers it safe. Her trust is gone.

But other students aren’t as cautious. Lisa Peralta shared in a Facebook post in September that her daughter, who is in seventh grade, admitted to eating an “anxiety gummy” her friend gave her. “I’m scared because my daughter is a follower,” the Kyle resident wrote. “I just don’t trust that she won’t do it again if she feels pressured.”

No matter how clear the district and parents make their messages, Savoy worries they may never be enough because students are so adventurous. “It’s just the teenage mindset,” he said. “They think, ‘We’re invincible; it’s not going to happen to me.’ But it is happening to us in our community.”

Still, the feelings of unease and grief are sometimes palpable. Students have been fighting more at school, said Jacob Valdez, a Lehman sophomore who knew two of the students who died. That might be happening, he added, because “everyone is just angsty.”

The tension is not limited to middle and high school students. It’s also become very real for parents of elementary school kids, since the DEA warned the public in August about fentanyl-laced pills that look like brightly colored candies. The Hays school district is also hanging warning posters geared toward younger students.

Jillien Brown of Kyle said she is worried about her daughters, 5-year-old Vivian and 7-year-old Scarlett. “We told them that there’s some scary things going on, that people are getting very sick and they’re dying from taking what they think is candy or medicine,” Brown said. “We use the word ‘poison,’ so like when Snow White bit the apple.”

But the conversation must be ongoing, Brown said, because the day after she talked to her daughters, “some little kid on the bus gave them a candy and they ate it.”

Similarly, Kyle resident April Munson, a former elementary school teacher, considers it all “gut-wrenching.” She showed her 9-year-old son, Ethan, pictures of the multicolored “rainbow fentanyl” pills. “It’s a hard conversation to have, but hard conversations are often the most important ones,” she said. “And, really, you can’t afford to have elephants in the room.”

And even as parents and the school officials attempt to prevent fentanyl from striking again, another reality check comes.

Last year, the school district started stocking in every school a supply of the overdose reversal drug naloxone, also known as Narcan. So far this semester, despite all the community has gone through, it has been used to save four more students, Savoy said. In one case, Savoy said, first responders had to use three doses to revive a student — the fentanyl “was that strong,” he said.

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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This story can be republished for free (details).

Overdose Deaths Behind Bars Rise as Drug Crisis Swells

Drug-related mortality rates have increased in prisons and jails even as the number of people incarcerated for drug offenses has dropped. The pandemic lockdowns on visitors didn’t eliminate the problem, showcasing that guards have been a source of the contraband.

Annissa Holland should be excited her son is coming home from prison after four long years of incarceration. Instead, she’s researching rehab centers to send him to as soon as he walks out the gate.

She doesn’t know the person who’s coming home — the person who she said has been doing every drug he can get his hands on inside the Alabama prison system. She can hear it in the 34-year-old’s voice when he calls her on the prison phone.

Her son is one of almost 20,000 inmates in the Alabama prison system living in conditions the U.S. Department of Justice has called inhumane. In two investigations, it found that the rampant use of drugs causes sexual abuse and “severe” violence in the state’s prisons. The department has sued Alabama, alleging conditions in its prisons violate inmates’ civil rights. According to the Alabama Department of Corrections’ own report, almost 60 pounds of illicit drugs were confiscated from its prisons in the first three months of this year.

Even if Alabama’s prisons and jails are especially overrun by drugs, death, and violence, their problems are not unique in the U.S. Within three weeks this spring, incarcerated people died of overdoses in Illinois, Oklahoma, New York, and the District of Columbia.

The alcohol and drug overdose death rate increased fivefold in prisons from 2009 through 2019, according to a recent study from the Pew Research Center — a surge that outpaced the national drug overdose rate, which tripled in the same period.

As the opioid crisis ravages America, overdose deaths are sweeping through every corner of the nation, including jails and prisons. Criminal justice experts suggest that decades of using the legal system instead of community-based addiction treatment to address drug use have not led to a drop in drug use or overdoses. Instead, the rate of drug deaths behind bars in supposedly secure facilities has increased.

This rise comes amid the decriminalization of cannabis in many parts of the country and a drop in the overall number of people incarcerated for drug crimes, according to the Pew report.

“It certainly points to the need for alternative solutions that rely less on the criminal justice system to help people who are struggling with substance use disorders,” said Tracy Velázquez, senior manager for safety and justice programs at the Pew Charitable Trusts.

For decades, drug use in America has mainly been addressed through the penal system — 1 in 5 people behind bars are there for a drug offense. Drug crimes were behind 30% of new admissions to Alabama prisons in March. Nationally, they were the leading cause of arrest, and almost 90% of arrests were for possession of drugs, not sale or manufacturing, according to the Pew study. The researchers also found that fewer than 8% of arrested people with a drug dependency received treatment while incarcerated.

Velázquez said a lot of drug use is spurred by people with mental health issues attempting to self-medicate. Almost 40% of people in prisons and 44% in jails have a history of mental illness, according to the Bureau of Justice Statistics.

Holland said her son was diagnosed with schizophrenia and PTSD six years ago after struggling with drug use since his teens. The son, who asked that his name not be published for fear his comments could jeopardize his release from prison or subsequent parole, said a schizophrenic episode in 2017 led him to break into a house during a hurricane. He said he didn’t realize people were in the house until after he ate a sandwich, got a Coke from the fridge, and looked for dry clothes. They called the police. He was sent to prison on a charge of burglary.

“They don’t put the mental health patients where they should be; they put them in prison,” Holland said.

She’s not only frustrated by the lack of medical care and treatment her son has received, but also horrified at the access to drugs and the abuse she said her son has suffered in the overcrowded, understaffed Alabama prison system.

He told KHN he’s been raped and beaten because of drug debts and put on suicide watch more than a dozen times. He said he turned back to using heroin, meth, and the synthetic drug flakka while incarcerated.

“We need to really focus on not assuming that putting someone in jail or prison is going to make them abstinent from drug use,” Velázquez said. “We really need to provide treatment that not only addresses the chemical, substance use disorder, but also addresses some of the underlying issues.”

Beth Shelburne, who works with the American Civil Liberties Union, logged 19 drug-related deaths in Alabama prisons in 2021, the most she has seen since she started tracking them in 2018.

She said those numbers are just a snapshot of what is going on inside Alabama’s prisons. The Justice Department found the state corrections department failed to accurately report deaths in its facilities.

“A lot of the people that are dying, I would argue, don’t belong in prison,” Shelburne said. “What’s so disgusting about all this is we are sentencing people who are drug-addicted to time in these ‘correctional facilities,’ when we’re really just throwing them into drug dens.”

The corrections department’s reports reveal at least seven overdose deaths in 2021, three of which officials classified as natural deaths. It reported 97 deaths in the first three months of this year that have yet to be fully classified.

Though Republican Gov. Kay Ivey recently announced a grant of more than $500,000 for a program to help incarcerated people address drug use disorders, the number of graduates of drug treatment programs in the state’s prison system has plummeted in the past decade to record lows. About 3% of prisoners completed a treatment program in 2021, down from 14% in 2009.

In contrast, California reported a 60% reduction in overdose deaths in its prisons in 2020, which state officials attributed to the start of a substance use treatment program and the widespread availability of medication-assisted therapy.

Alabama’s system is developing a medication-assisted treatment plan with its health contractor, said Alabama Department of Corrections spokesperson Kelly Betts. Before 2019, medications that curb drug cravings or mute highs were given only to those who could be separated from the general prison population, according to Deborah Crook, the department’s health services deputy commissioner.

“The science has changed considerably and there are more medication options that are safer to prescribe — even in general population,” she wrote in a statement.

Though prison officials have long blamed visitors for bringing in drugs, the ban on visitation during the pandemic did not lead to a drop in drug use inside. Multiple officers were arrested in Alabama last year and accused of bringing drugs into jails and prisons, and the Department of Justice’s 2019 report found dozens of officers arrested in the previous two years on charges related to drug trafficking and other misconduct.

Illegal drugs are “a challenge faced by correctional systems across the country,” Betts wrote in an email. “The ADOC is committed to enforcing our zero-tolerance policy on contraband and works very hard to eradicate it from our facilities.”

Betts did not specify how these policies are enforced. The department also refused to respond to a detailed list of questions about drug use and overdoses in its prisons, citing the litigation with the Justice Department.

Holland doesn’t know what will happen when her son gets out. He said he hopes he can restart his business as an electrician and provide for his family. But the four years of his so-called rehabilitation have been a nightmare for both of them.

“They’re released messed-up, hurt, and deeply dysfunctional. What do you do with someone that’s been through all that?” Holland said. “That’s not rehabilitation. It’s not.”

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 Blackfeet Nation’s Plight Underscores the Fentanyl Crisis on Reservations

The deadly synthetic opioid has spread across the nation during the pandemic, and the problem is disproportionately affecting Native Americans.

BROWNING, Mont. — As the pandemic was setting in during summer 2020, Justin Lee Littledog called his mom to tell her he was moving from Texas back home to the Blackfeet Indian Reservation in Montana with his girlfriend, stepson, and son.

They moved in with his mom, Marla Ollinger, on a 300-acre ranch on the rolling prairie outside Browning and had what Ollinger remembers as the best summer of her life. “That was the first time I’ve gotten to meet Arlin, my first grandson,” Ollinger said. Another grandson was soon born, and Littledog found maintenance work at the casino in Browning to support his growing family.

But things began to unravel over the next year and a half. Friends and relatives saw Littledog’s 6-year-old stepson walking around town alone. One day, Ollinger received a call from her youngest son as one of Littledog’s children cried in the background. He was briefly unable to wake Littledog’s girlfriend.

Ollinger asked Littledog whether he and his girlfriend were using drugs. Littledog denied it. He explained to his mom that people were using a drug she had never heard about: fentanyl, a synthetic opioid that is up to 100 times as potent as morphine. He said he would never use something so dangerous.

Then, in early March, Ollinger woke up to screams. She left her grandchildren sleeping in her bed and went into the next room. “My son was laying on the floor,” she said. He wasn’t breathing.

She followed the ambulance into Browning, hoping that Littledog had just forgotten to take his heart medication and would recover. He was pronounced dead shortly after the ambulance arrived at the local hospital.

Littledog was among four people to die from fentanyl overdoses on the reservation that week in March, according to Blackfeet health officials. An additional 13 people who live on the reservation survived overdoses, making a startling total for an Indigenous population of about 10,000 people.

Fentanyl has taken root in Montana and in communities across the Mountain West during the pandemic, after formerly being prevalent mostly east of the Mississippi River, said Keith Humphreys of the Stanford-Lancet Commission on the North American Opioid Crisis.

Montana law enforcement officials have intercepted record numbers of pale-blue pills made to look like prescription opioids such as OxyContin. In the first three months of 2022, the Montana Highway Patrol seized over 12,000 fentanyl pills, more than three times the number from all of 2021.

Nationwide, at least 103,000 people died from drug overdoses in 2021, a 45% increase from 2019, according to data from the Centers for Disease Control and Prevention. About 7 of every 10 of those deaths were from synthetic opioids, primarily fentanyl.

Overdose deaths are disproportionately affecting Native Americans. The overdose death rate among Indigenous people was the highest of all racial groups in the first year of the pandemic and was about 30% higher than the rate among white people, according to a study co-authored by UCLA graduate student and researcher Joe Friedman.

In Montana, the opioid overdose death rate for Indigenous people was twice that of white people from 2019 to 2021, according to the state Department of Public Health and Human Services.

The reason, in part, is that Native Americans have relatively less access to health care resources, Friedman said. “With the drug supply becoming so dangerous and so toxic, it requires resources and knowledge and skills and funds to stay safe,” he said. “It requires access to harm reduction. It requires access to health care, access to medications.”

The Indian Health Service, which is responsible for providing health care to many Indigenous people, has been chronically underfunded. According to a 2018 report from the U.S. Commission on Civil Rights, IHS per patient expenditures are significantly less than those of other federal health programs.

“I think what we’re seeing now is deep-seated disparities and social determinants of health are kind of bearing out,” Friedman said, referring to the disproportionate overdose deaths among Native Americans.

Blackfeet Tribal Business Council member Stacey Keller said she has experienced the lack of resources firsthand while trying to get a family member into treatment. She said just finding a facility for detoxing was difficult, let alone finding one for treatment.

“Our treatment facility here, they’re not equipped to deal with opioid addiction, so they’re usually referred out,” she said. “Some of the struggles we’ve seen throughout the state and even the western part of the United States is a lot of the treatment centers are at capacity.”

The local treatment center doesn’t have the medical expertise to supervise someone going through opioid withdrawal. Only two detox beds are available at the local IHS hospital, Keller said, and are often occupied by other patients. The health care system on the reservation also doesn’t offer medication-assisted treatment. The nearest locations to get buprenorphine or methadone — drugs used to treat opioid addictions — are 30 to 100 miles away. That can be a burden to patients who are required by federal rules to show up each day at the approved dispensaries to receive methadone or must make weekly treks for buprenorphine.

Keller said tribal leaders have requested assistance from IHS to build out treatment and other substance use resources in the community, with no results.

The IHS’ Alcohol and Substance Abuse Program consultant, JB Kinlacheeny, said the agency has largely shifted to appropriating funds directly to tribes to run their own programs.

The Rocky Mountain Tribal Leaders Council, a consortium of Montana and Wyoming tribes, is working with the Montana Healthcare Foundation on a feasibility study for a treatment center operated by tribes to build capacity specifically for tribal members. Tribes across both states, including the Blackfeet, have passed resolutions supporting the effort.

Blackfeet political leaders declared a state of emergency in March after the fentanyl overdoses. A short time later, some of the tribal council chairman’s children were arrested on suspicion of selling fentanyl out of his home. The council removed Chairman Timothy Davis from his position as tribal leader in early April.

The tribe has created a task force to identify both the short- and long-term needs to respond to the opioid crisis. Blackfeet tribal police investigator Misty LaPlant is helping lead that effort.

Driving around Browning, LaPlant said she plans to train more people on the reservation to administer naloxone, a medication that reverses opioid overdoses. She also wants the tribe to host needle exchanges to reduce infections and the spread of diseases like HIV. There’s also hope, she said, that a reorganization of the tribal health department will result in a one-stop shop for Blackfeet Nation residents to find drug addiction resources on and off the reservation.

However, she said resolving some of the underlying issues — such as poverty, housing, and food insecurity — that make communities like the Blackfeet Nation vulnerable to the ongoing fentanyl crisis is a massive undertaking that won’t be completed anytime soon.

“You could connect historical trauma, unresolved traumas in general, and grief into what makes our community vulnerable,” she said. “If you look at the impact of colonialism and Indigenous communities and people, there’s a correlation there.”

Marla Ollinger is happy to see momentum building to fight opioid and fentanyl addiction in the wake of her son’s death and other people’s. As a mother who struggled to find the resources to save her son, she hopes no one else has to live through that experience.

“It’s heartbreaking to watch your children die unnecessarily,” she said.

This story is part of a partnership that includes Montana Public RadioNPR and KHN.

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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¿Puede una inyección mensual frenar la adicción a opioides? Expertos dicen que sí

Una opción inyectable mensual para el tratamiento de la adicción a opioides no logra llegar a todos los que la necesitan por las trabas burocráticas para obtener el medicamento.

Oakland, California.- El doctor Andrew Herring tiene un objetivo claro con los pacientes que buscan medicamentos para tratar la adicción a opioides: persuadirlos de que reciban una inyección de buprenorfina de liberación prolongada.

En su clínica de adicciones en el Hospital Highland, un centro público en el corazón de Oakland, Herring promueve la administración de una inyección de buprenorfina en la barriga para proporcionar un mes de tratamiento, en lugar de recetar versiones orales que deben tomarse a diario.

Asegura que esta opción es un “cambio de juego” y que puede ser su única oportunidad de ayudar a un paciente vulnerable en riesgo de sobredosis.

En California, donde las muertes por sobredosis han estado aumentado, expertos en adicciones dicen que administrar un mes de medicamento tiene un gran potencial, particularmente para las personas sin vivienda o que luchan contra otras formas de inestabilidad.

Sin embargo, el uso de buprenorfina inyectable sigue siendo bastante limitado, especialmente en comparación con otras formas de medicación para la adicción. Los investigadores aún tienen que publicar estudios que comparen diferentes formas de administrar buprenorfina.

La buprenorfina, uno de los tres medicamentos aprobados en los Estados Unidos para tratar el trastorno por uso de opioides, funciona uniéndose a los receptores de opioides en el cerebro y reduciendo las ansias y los síntomas de abstinencia.

Así, si un paciente toma una dosis alta de una droga como la heroína o el fentanilo, es menos probable que sufra una sobredosis. Los pacientes a menudo usan buprenorfina durante años.

Si Herring receta un suministro de buprenorfina en forma de tableta o de una tira que se coloca debajo de la lengua, el paciente debe comprometerse a tomar el medicamento al menos una vez al día, y muchos dejan de hacerlo.

“Es como algo religioso: tienes que levantarte cada mañana y repetir tus votos”, dijo Herring. “En realidad, hay muchas personas que merecen un tratamiento y que no pueden cumplir con ese requisito”.

Las formas orales de buprenorfina han estado disponibles para tratar la adicción desde 2002 y se pueden comprar como genéricos por menos de $100 al mes.

La buprenorfina inyectable, vendida bajo la marca Sublocade, recibió la aprobación de la FDA en 2017. Tiene un precio de lista alto, de $1,829.05 por una inyección mensual. El fabricante Indivior reportó ganancias de $244 millones por la venta de la droga, solo el año pasado, y pronostica alcanzar los $1,000 millones. No hay disponible una versión genérica o competidora del medicamento.

La mayoría de los pacientes no pagarán el precio completo, dice Indivior, su fabricante, porque la mayoría de los planes de salud cubren el medicamento. Los médicos, sin embargo, dicen que el alto costo puede ser una barrera para los pacientes con planes privados, que a veces se resisten a cubrir el medicamento.

Medi-Cal, el programa de seguro médico de California para personas de bajos ingresos, cubre Sublocade sin autorización previa, lo que hace que el tratamiento sea accesible para la mayoría de los pacientes de Herring.

Aún así, expertos en adicciones dicen que el uso de Sublocade sigue siendo limitado debido a los obstáculos normativos necesarios para administrarlo.

Los proveedores deben registrarse en la Administración de Control de Drogas (DEA) y obtener una exención para recetar buprenorfina porque se considera una sustancia controlada. Además, las clínicas deben completar un programa de certificación de seguridad de la FDA para dispensar el medicamento. Y solo puede pedirse a través de una farmacia especializada, aprobada por la FDA.

“En muchos hospitales, eso significará un retraso en la obtención de este medicamento o simplemente optar por no recibirlo”, dijo el doctor Rais Vohra, director regional de California Bridge Network, un programa financiado por el estado que apoya a los hospitales para que ofrezcan tratamiento para adicciones, incluida la clínica de Herring.

Vohra dijo que el Centro Médico Regional Comunitario en Fresno, donde trabaja como médico de emergencia, todavía está revisando los requisitos para ver si la farmacia del hospital puede distribuir el medicamento, lo que lo convertiría en uno de los pocos proveedores del Valle Central.

La buprenorfina oral, por el contrario, es una receta simple que la mayoría de las farmacias locales tienen en stock.

“Todos los obstáculos que los médicos y los pacientes tienen que superar para obtener este medicamento son una locura. No hacemos eso para ninguna otra enfermedad”, dijo la doctora Hannah Snyder, quien dirige la clínica de adicciones en el Hospital General Zuckerberg de San Francisco.

Varios médicos señalaron que el acceso sigue siendo un problema incluso con formas orales de buprenorfina. A pesar de una cascada de estudios que prueban la eficacia del tratamiento asistido por medicamentos, muchos médicos se resisten a recetarlo, especialmente en comunidades de color.

“La pregunta más importante no es si la bupre inyectable de acción prolongada es una mejor solución”, dijo el doctor Michael Ostacher, profesor de la Escuela de Medicina de la Universidad de Stanford, que compara las versiones inyectables y orales de buprenorfina a través de Veteran Affairs. “La pregunta más importante es cómo aumentamos el acceso al tratamiento para todas las personas que lo necesitan”.

Angela Griffiths se encuentra entre los pacientes que dicen que Sublocade ha cambiado sus vidas. Griffiths, de 41 años, de San Francisco, usó heroína durante 18 años. Cuando estaba embarazada de su hija en 2016, los médicos le recetaron metadona, lo que la hizo sentir “miserable”. Hace tres años cambió a tiras de buprenorfina, pero llevar las tiras a todas partes todavía la hacía sentir atada a su adicción.

Cuando los médicos de la clínica general de SF la cambiaron a inyecciones mensuales de Sublocade, describió el cambio como “extraordinario”.

En los estados donde los planes de Medicaid aún pueden requerir autorización previa, las esperas para Sublocade pueden extenderse a meses. Al otro lado de la frontera, en la clínica Northern Nevada Hopes en Reno, Nevada, por ejemplo, la doctora Taylor Tomlinson dijo que les dice a los pacientes que, entre las batallas por la cobertura y los retrasos en las farmacias, es posible que tengan que esperar dos meses para recibir una inyección.

“El tiempo de espera crea una barrera para la atención”, opinó Tomlinson

El programa de Medicaid de California no requiere autorización previa, pero proporcionar Sublocade sigue siendo un desafío. Herring ha podido reducir parte de la burocracia en su clínica de Oakland trabajando con la farmacia de Highland para almacenar y distribuir Sublocade.

Tan pronto como un paciente acepta una inyección, Herring simplemente llama a la farmacia al final del pasillo y se la administra en el acto.

Herring ve la urgencia de aumentar el uso de buprenorfina inyectable a medida que aumenta el uso de fentanilo en California. Durante años, el mortal opioide sintético se concentró principalmente en la costa este; en 2018, el 88% de estas muertes ocurrieron en los 28 estados al este del río Mississippi.

Pero más recientemente, el fentanilo ha comenzado a infiltrarse en los estados occidentales. De 2018 a 2020, las muertes por sobredosis de fentanilo en California se quintuplicaron, según datos estatales.

“Nadie entiende a lo que se enfrenta”, dijo Herring sobre la potencia del fentanilo. “Este es el momento en el que ocurrirán un mayor número de muertes”.

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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Can a Monthly Injection Be the Key to Curbing Addiction? These Experts Say Yes

In California, where overdose deaths are on the rise, physicians say administering anti-addiction medication as a monthly injection holds tremendous potential. So, why aren’t more patients getting it?

OAKLAND, Calif. — Dr. Andrew Herring has a clear goal walking into every appointment with patients seeking medication to treat an opioid use disorder: persuade them to get an injection of extended-release buprenorphine.

At his addiction clinic at Highland Hospital, a bustling public facility in the heart of Oakland, Herring promotes administering a shot of buprenorphine in the belly to provide a month of addiction treatment rather than prescribing oral versions that must be taken daily. For him, the shots’ longer-acting protection is a “game changer” and may be his only chance to help a vulnerable patient at risk of overdose.

“At any point in time, they’re just a balloon that’s going to go,” Herring said. “You might only have this one interaction. And the question is, how powerful can you make it?”

In California, where overdose deaths have been rising for years, addiction experts say administering a month’s worth of anti-addiction medication holds great potential, particularly for people without housing or who struggle with other forms of instability. Yet despite its promise, the use of injectable buprenorphine remains fairly limited, especially compared with other forms of addiction medication. Researchers have yet to publish studies comparing different ways to administer buprenorphine.

Buprenorphine, one of three medications approved in the U.S. to treat opioid use disorder, works by binding to opioid receptors in the brain and reducing cravings and withdrawal symptoms. And because it occupies those receptor sites, buprenorphine keeps other opioids from binding and ensures that if a patient takes a high dose of a drug like heroin or fentanyl, they are less likely to overdose. Patients often stay on buprenorphine for years.

If Herring prescribes a supply of buprenorphine as a tablet or film that is placed under the tongue, the patient must commit to taking the medication at least once a day, and many fall out of treatment. He said this is especially true for his patients experiencing homelessness and those who also use methamphetamine.

“It’s like a religious thing — you have to wake up every morning and repeat your vows,” said Herring. “In reality, there are a lot of people who deserve treatment who can’t meet that requirement.”

Oral forms of buprenorphine have been available to treat addiction since 2002 and can be purchased as a generic for less than $100 a month. Injectable buprenorphine, sold under the brand name Sublocade, received FDA approval in 2017. It has a hefty list price of $1,829.05 for a monthly injection. The drugmaker Indivior reported $244 million in revenue from Sublocade last year alone, with a company goal to eventually make $1 billion in annual sales. No generic or competing version of the drug is available.

Most patients won’t pay full price, Indivior says, because most health plans cover the drug. Physicians, however, say the high cost can be a barrier for patients with private health plans, which sometimes resist covering the medication. Medi-Cal, California’s health insurance program for low-income people, covers Sublocade without prior authorization, making the treatment accessible to the majority of Herring’s patients.

Still, addiction experts say, Sublocade use remains limited because of the regulatory hurdles required to dispense it.

Providers must register with the U.S. Drug Enforcement Administration and obtain a waiver to prescribe buprenorphine because it’s considered a controlled substance. In addition, clinics must complete an FDA safety certification program to dispense the medication. And Sublocade can be ordered only by a specialty pharmacy, which must also pass the FDA program.

“At many hospitals, that will mean either a delay in getting this medication on our shelves or just opting out,” said Dr. Rais Vohra, regional director for the California Bridge Network, a state-funded program that supports hospitals in offering treatment for substance use disorders, including Herring’s clinic.

Vohra said Community Regional Medical Center in Fresno, where he works as an emergency physician, is still looking through the documentation requirements to see if the hospital’s pharmacy can distribute the medication — which would make it one of the few Central Valley providers to do so.

Oral buprenorphine, by contrast, is a simple prescription that most local drugstores keep in stock.

“All the hoops that clinicians and patients have to jump through to get this medication is crazy. We don’t do that for any other disease,” said Dr. Hannah Snyder, who runs the addiction clinic at Zuckerberg San Francisco General Hospital across the bay.

Several clinicians noted that access remains a problem even with oral forms of buprenorphine. Despite a cascade of studies proving the effectiveness of medication-assisted treatment, many patients across the country struggle to find a provider willing to prescribe buprenorphine in any form — especially in communities of color.

“The most important question isn’t whether long-acting injectable bupe is a better solution than sublingual buprenorphine for opioid use disorder,” said Dr. Michael Ostacher, a professor at Stanford University School of Medicine, who is comparing injectable and oral versions of buprenorphine through Veterans Affairs. “The bigger question is how we increase access to treatment for all people who need [the medication].”

Angela Griffiths is among the patients who say Sublocade has changed their lives. Griffiths, 41, of San Francisco, used heroin for 18 years. When she was pregnant with her daughter in 2016, doctors put her on methadone, which made her feel “miserable.” Three years ago, she said, she switched to buprenorphine films, but carrying the strips with her everywhere still made her feel tied to her addiction.

“The ritual of taking something every day plays something in your mind,” Griffiths said.

When doctors at the SF General clinic switched her to monthly Sublocade injections, she described the change as “extraordinary.”

“I’m not reaching for my drawer anymore for a fix,” she said. “I have the freedom to wake up and start my day however I want, whether it’s to go to the patio and drink a cup of coffee or to snuggle with my daughter in bed a little longer. It’s there; I don’t have to take anything.”

In states where Medicaid plans may still require prior authorization, waits for Sublocade can stretch into months. Across the border at the Northern Nevada Hopes clinic in Reno, Nevada, for example, Dr. Taylor Tomlinson said she tells patients that between battles for coverage and pharmacy delays, they might have to wait two months for an injection.

“I’m always going to offer it to a patient who I think would be a good candidate, but in the time they have to wait, they get interested in other things,” said Tomlinson. “It creates a barrier to care.”

California’s Medicaid program does not require prior authorization but providing Sublocade is still a challenge. At the Placerville clinic supported by the California Bridge Network, Dr. Juliet La Mers, the director, said a quarter of her buprenorphine patients get injections. Still, they often wait two weeks before Sublocade arrives from the specialty pharmacy.

Herring has been able to cut through some of that red tape at his Oakland clinic by working with the Highland pharmacy to stock and distribute Sublocade. As soon as a patient agrees to an injection, Herring simply calls the pharmacy down the hall and administers it on the spot.

Herring sees urgency — and opportunity — to increase the use of injectable buprenorphine as fentanyl use rises across California. For years, the deadly synthetic opioid was concentrated mostly on the East Coast; in 2018, 88% of deaths from synthetic opioids occurred in the 28 states east of the Mississippi River. But more recently, fentanyl has begun to infiltrate Western states. From 2018 to 2020, deaths from fentanyl overdoses in California quintupled, according to state data.

“No one understands what they’re dealing with,” Herring said of fentanyl’s potency. “This is the time where our greatest deaths are going to occur.”

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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KHN’s ‘What the Health?’: Why Health Care Is So Expensive, Chapter $22K

Congress is making slow progress toward completing its ambitious social spending bill, although its Thanksgiving deadline looks optimistic. Meanwhile, a new survey finds the average cost of an employer-provided family plan has risen to more than $22,000. That’s about the cost of a new Toyota Corolla. Alice Miranda Ollstein of Politico, Anna Edney of Bloomberg News and Rebecca Adams of CQ Roll Call join KHN’s Julie Rovner to discuss these issues and more. Also this week, Rovner interviews Rebecca Love, a nurse academic and entrepreneur, about the impending crisis in nursing.

Can’t see the audio player? Click here to listen on Acast. You can also listen on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

Congress appears to be making progress on its huge social spending bill, but even if it passes the House as planned the week of Nov. 15, it’s unlikely it can get through the Senate before the Thanksgiving deadline that Democrats set for themselves.

Meanwhile, the cost of employer-provided health insurance continues to rise, even with so many people forgoing care during the pandemic. The annual KFF survey of employers reported that the average cost of a job-based family plan has risen to more than $22,000. To provide what their workers most need, however, this year many employers added additional coverage of mental health care and telehealth.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Anna Edney of Bloomberg News and Rebecca Adams of CQ Roll Call.

Among the takeaways from this week’s episode:

  • Moderate Democrats who were worried about the price tag of the social spending bill said during negotiations last week that they wanted to see the full analysis of spending and costs from the Congressional Budget Office. But members of the House probably won’t get that score before voting on the bill. CBO instead is releasing its assessments piecemeal as analysts go through specific sections of the huge bill.
  • If the House passes the bill next week, which leadership is pledging, the legislation could still undergo major revisions in the Senate. Some provisions will be subject to the Byrd Rule, which says items in this type of bill must be related to the budget. Republicans are expected to challenge parts of the bill, and the parliamentarian will have to rule on whether their objections are valid.
  • Among the provisions that some moderate Democratic senators might object to are the paid family leave and the mechanism for lowering Medicare drug prices.
  • Congress is looking at a very busy end of the year, which could complicate passage of the social spending bill. Leaders already postponed a bill to raise the debt ceiling and the annual federal spending bills until early December.
  • A federal judge has blocked Texas Republican Gov. Greg Abbott’s order prohibiting mask mandates in schools. But a final resolution is likely some time away as the case is appealed. Disability rights groups, which had sued to stop the governor’s order, argued that the ban was keeping children with health problems who are at high risk from covid from coming to school.
  • Despite opposition from conservative leaders to vaccine mandates, the vast majority of workers have had their shots, either because they wanted them or their employer mandated it. Lawsuits brought against those workplace requirements may not signal a broad opposition among the population.
  • In its survey of employers’ health plans, KFF found that premiums are still increasing faster than wages as health costs continue to rise. Leaders of both political parties say they would like to reduce the cost of care, but no magic pill appears likely. Instead, lawmakers generally are more inclined to have the government pick up a bigger portion of the country’s health care costs when not finding a way to cut that spending.
  • One key challenge in addressing rising health care spending in Congress is the power of the health care industry. With the close political party margins on Capitol Hill, it is fairly easy for the industries to use their contributions to pick off a couple of members and keep major reform from passing.
  • The KFF survey also documented the wide expansion of telehealth coverage during the pandemic. Although employers and the government have been concerned that telehealth adds to spending because it duplicates services or allows doctors to charge for services they once performed over the phone without billing, it will be hard to put this genie back in the bottle. Consumers like the convenience. And some services, such as mental health therapy or medical consultations for rural residents, are much easier.

Also this week, Rovner interviews Rebecca Love, a nurse, academic and entrepreneur who has thought a lot about the future of the nursing profession and where it fits into the U.S. health care system

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: Washington Monthly’s “The Doctor Will Not See You Now,” by Merrill Goozner.

Alice Miranda Ollstein: NPR’s “Despite Calls to Improve, Air Travel Is Still a Nightmare for Many With Disabilities,” by Joseph Shapiro and Allison Mollenkamp.

Rebecca Adams: KHN’s “Patients Went Into the Hospital for Care. After Testing Positive There for Covid, Some Never Came Out,” by Christina Jewett.

Anna Edney: Bloomberg News’ “All Those 23andMe Spit Tests Were Part of a Bigger Plan,” by Kristen V Brown.

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

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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As Holdout Missouri Joins Nation in Monitoring Opioid Prescriptions, Experts Worry

Missouri is the last state to create a monitoring program to help spot the misuse of prescription drugs. But some public health experts warn that the nation’s programs are forcing people addicted to opioids to seek deadlier street options.

Kathi Arbini said she felt elated when Missouri finally caught up to the other 49 states and approved a statewide prescription drug monitoring program this June in an attempt to curb opioid addiction.

The hairstylist turned activist estimated she made 75 two-hour trips in the past decade from her home in Fenton, a St. Louis suburb, to the state capital, Jefferson City, to convince Republican lawmakers that monitoring how doctors and pharmacists prescribe and dispense controlled substances could help save people like her son, Kevin Mullane.

He was a poet and skateboarder who she said turned to drugs after she and his dad divorced. He started “doctor-shopping” at about age 17 and was able to obtain multiple prescriptions for the pain medication OxyContin. He died in 2009 at 21 from a heroin overdose.

If the state had had a monitoring program, doctors might have detected Mullane’s addiction and, Arbini thinks, her son might still be alive. She said it’s been embarrassing that it’s taken Missouri so long to agree to add one.

“As a parent, you would stand in front of a train; you would protect your child forever — and if this helps, it helps,” said Arbini, 61. “It can’t kill more people, I don’t think.”

But even though Missouri was the lone outlier, it had not been among the states with the highest opioid overdose death rates. Missouri had an average annual rank of 16th among states from 2010 through 2019, as the country descended into an opioid epidemic, according to a KHN analysis of Centers for Disease Control and Prevention data compiled by KFF.

Some in public health now argue that when providers use such monitoring programs to cut off prescription opiate misuse, people who have an addiction instead turn to heroin and fentanyl. That means Missouri’s new toll could cause more people to overdose and leave the state with buyer’s remorse.

“If we can take any benefit from being last in the country to do this, my hope would be that we have had ample opportunity to learn from others’ mistakes and not repeat them,” said Rachel Winograd, a psychologist who leads NoMODeaths, a state program aimed at reducing harm from opioid misuse.

Before Missouri’s monitoring program was approved, lawmakers and health and law enforcement officials warned that the absence made it easier for Missouri patients to doctor-shop to obtain a particular drug, or for providers to overprescribe opiates in what are known as pill mills.

State Sen. Holly Rehder, a Republican with family members who have struggled with opioid addiction, spent almost a decade pushing legislation to establish a monitoring program but ran into opposition from state Sen. Rob Schaaf, a family physician and fellow Republican who expressed concerns about patient privacy and fears about hacking.

In 2017, Schaaf agreed to stop filibustering the legislation and support it if it required that doctors check the database for other prescriptions before writing new ones for a patient. That, though, sparked fresh opposition from the Missouri State Medical Association, concerned the requirement could expose physicians to malpractice lawsuits if patients overdosed.

The new law does not include such a requirement for prescribers. Pharmacists who dispense controlled substances will be required to enter prescriptions into the database.

Dr. Silvia Martins, an epidemiologist at Columbia University who has studied monitoring programs, said it’s important to mandate that prescribers review a patient’s information in the database. “We know that the ones that are most effective are the ones where they check it regularly, on a weekly basis, not just on a monthly basis,” she said.

But Stephen Wood, a nurse practitioner and visiting substance abuse bioethics researcher at Harvard Law School, said the tool is often punitive because it cuts off access to opioids without offering viable treatment options.

He and his colleagues in the intensive care unit at Carney Hospital in Boston don’t use the Massachusetts monitoring program nearly as often as they once did. Instead, he said, they rely on toxicology screens, signs such as injection marks or the patients themselves, who often admit they are addicted.

“Rather than pulling out a piece of paper and being accusatory, I find it’s much better to present myself as a caring provider and sit down and have an honest discussion,” Wood said.

When Kentucky in 2012 became the first state to require prescribers and dispensers to use the system, the number of opioid prescriptions and overdoses from prescription opioids initially decreased slightly, according to a state study.

But the number of opioid overdose deaths — with the exception of a slight dip in 2018 and 2019 — has since consistently ticked upward, according to a KFF analysis of CDC data. In 2020, Kentucky was estimated to have had the nation’s second-largest increase in drug overdose deaths.

When efforts to establish Missouri’s statewide monitoring program stalled, St. Louis County established one in 2017 that 75 local jurisdictions agreed to participate in, covering 85% of the state, according to the county health department. The county now plans to move its program into the state one, which is scheduled to launch in 2023.

Dr. Faisal Khan, director of the county department, said he has no doubt that the St. Louis program has “saved lives across the state.” Opioid prescriptions decreased dramatically once the county established the monitoring program. In 2016, Missouri averaged 80.4 opioid prescriptions per 100 people; in 2019, it was down to 58.3 prescriptions, according to the CDC.

The overall drug overdose death rate in Missouri has steadily increased since 2016, though, with the CDC reporting an initial count of 1,921 people dying from overdoses of all kinds of drugs in 2020.

Khan acknowledged that a monitoring program can lead to an increase in overdose deaths in the years immediately following its establishment because people addicted to prescription opioids suddenly can’t obtain them and instead buy street drugs that are more potent and contain impurities.

But he said a monitoring program can also help a physician intervene before someone becomes addicted. Doctors who flag a patient using the monitoring program must then also be able to easily refer them to treatment, Khan and others said.

“We absolutely are not prepared for that in Missouri,” said Winograd, of NoMODeaths. “Substance use treatment providers will frequently tell you that they are at max capacity.”

Uninsured people in rural areas may have to wait five weeks for inpatient or outpatient treatment at state-funded centers, according to PreventEd, a St. Louis-based nonprofit that aims to reduce harm from alcohol and drug use.

For example, the waiting list for residential treatment at the Preferred Family Healthcare clinic in Trenton is typically two weeks during the summer and one month in winter, according to Melanie Tipton, who directs clinical services at the center, which mostly serves uninsured clients in rural northern Missouri.

Tipton, who has worked at the clinic for 17 years, said that before the covid-19 pandemic, people struggling with opioid addiction mainly used prescription pills; now it’s mostly heroin and fentanyl, because they are cheaper. Fentanyl is a synthetic opioid that is 50 to 100 times more potent than morphine, according to the National Institute on Drug Abuse.

Still, Tipton said her clients continue to find providers who overprescribe opiates, so she thinks a statewide monitoring program could help.

Inez Davis, diversion program manager for the Drug Enforcement Administration’s St. Louis division, also said in an email that the program will benefit Missouri and neighboring states because “doctor shoppers and those who commit prescription fraud now have one less avenue.”

Winograd said it’s possible that if the state had more opioid prescription pill mills, it would have a lower overdose death rate. “I don’t think that’s the answer,” she said. “We need to move in the direction of decriminalization and a regulated drug supply.” Specifically, she’d rather Missouri decriminalize possession of small amounts of hard drugs, even heroin, and institute regulations to ensure the drugs are safe.

State Rep. Justin Hill, a Republican from St. Charles and former narcotics detective, opposed the monitoring program legislation because of his concerns over patient privacy and evidence that the lack of a program has not made Missouri’s opioid problem any worse than many other states’. He also worries the monitoring program will lead to an increase in overdose deaths.

“I would love the people that passed this bill to stand by the numbers,” Hill said. “And if we see more deaths from overdose, scrap the monitoring program and go back to the drawing board.”

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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KHN’s ‘What the Health?’: Delta Changes the Covid Conversation

With covid cases on the upswing again around the country, partisan division remains over how to address the pandemic. Meanwhile, the Biden administration proposes bigger penalties for hospitals that fail to make their prices public as required. Stephanie Armour of The Wall Street Journal, Alice Miranda Ollstein of Politico and Tami Luhby of CNN join KHN’s Julie Rovner to discuss these issues and more. Also, for “extra credit,” the panelists suggest their favorite stories of the week they think you should read, too.

Can’t see the audio player? Click here to listen on SoundCloud. You can also listen on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

The resurgence of covid cases in the U.S. — largely attributable to the much more contagious delta variant — has given policymakers the jitters. The Biden administration is redoubling efforts to get people vaccinated, and even some Republicans who had been silent or skeptical of the vaccines are encouraging the unvaccinated to change their status.

Meanwhile, it’s not just covid that’s shortening U.S. life expectancy. Nearly 100,000 people died of drug overdoses in 2020, according to the Centers for Disease Control and Prevention. This week a multibillion-dollar settlement among states, drugmakers and distributors could funnel funding to fight the opioid scourge.

This week’s panelists are Julie Rovner of KHN, Stephanie Armour of The Wall Street Journal, Alice Miranda Ollstein of Politico and Tami Luhby of CNN.

Among the takeaways from this week’s episode:

  • If lawmakers fail to craft a bipartisan deal on Capitol Hill on traditional infrastructure spending, Democrats’ plans for a second bill that incorporates significant health care programs may need to be scaled back. That’s because the Democrats have pledged to fund major improvements in infrastructure and they would need to add that to the second bill, which is being moved through a special procedure that keeps it from being stalled in the Senate by a Republican filibuster. Some Democrats are nervous about making that second bill too broad.
  • The momentum toward vaccinating the public has stalled abruptly in the past month or so, and reports of rising cases is causing concern among conservatives. Some high-profile Republicans — including Senate Minority Leader Mitch McConnell, Rep. Steve Scalise (La.) and Florida Gov. Ron DeSantis — have been out during the past week touting the vaccines’ successes.
  • The agreement reached this week between state officials and companies that made or distributed opioids will send billions of dollars to the states to fund prevention and treatment programs for people with addiction problems. Some advocates worry, however, that the funding — much like the landmark tobacco settlement of past years — will instead be absorbed by cash-strapped states for other uses.
  • The Biden administration proposed significantly increasing the fines for hospitals that do not make their prices easily seen online and understood for patients. Despite the widespread eagerness to establish transparency, there is little indication consumers are using such tools.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: NPR’s “The Life Cycle of a COVID-19 Vaccine Lie,” by Geoff Brumfiel

Stephanie Armour: The Washington Post’s “Biden Administration, Workers Grapple With Health Threats Posed by Climate Change and Heat,” by Eli Rosenberg and Abha Bhattarai

Tami Luhby: The Los Angeles Times’ “Same Hospitals but Worse Outcomes for Black Patients Than White Ones,” by Emily Alpert Reyes

Alice Miranda Ollstein: The 19th’s “Courts Block Laws Targeting Transgender Children in Arkansas and West Virginia,” by Orion Rummler

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

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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How ERs Fail Patients With Addiction: One Patient’s Tragic Death

Two intractable failings of the U.S. health care system — addiction treatment and medical costs — come to a head in the ER, where patients desperate for addiction treatment arrive, only to find the facility may not be equipped to deal with substance use or, if they are, treatment is prohibitively expensive.

Jameson Rybak tried to quit using opioids nearly a dozen times within five years. Each time, he’d wait out the vomiting, sweating and chills from withdrawal in his bedroom.

It was difficult to watch, said his mother, Suzanne Rybak, but she admired his persistence.

On March 11, 2020, though, Suzanne grew worried. Jameson, 30 at the time, was slipping in and out of consciousness and saying he couldn’t move his hands.

By 11 p.m., she decided to take him to the emergency room at McLeod Regional Medical Center in Florence, South Carolina. The staff there gave Jameson fluids through an IV to rehydrate, medication to decrease his nausea and potassium supplements to stop his muscle spasms, according to Suzanne and a letter the hospital’s administrator later sent her.

But when they recommended admitting him to monitor and manage the withdrawal symptoms, Jameson said no. He’d lost his job the previous month and, with it, his health insurance.

“He kept saying, ‘I can’t afford this,’” Suzanne recalled, and “not one person [at the hospital] indicated that my son would have had some financial options.”

Suzanne doesn’t remember any mention of the hospital’s financial assistance policy or payment plans, she said. Nor does she remember any discussions of providing Jameson medication to treat opioid use disorder or connecting him to addiction-specialty providers, she said.

“No referrals, no phone numbers, no follow-up information,” she later wrote in a complaint letter to the hospital.

Instead, ER staff provided a form saying Jameson was leaving against medical advice. He signed and Suzanne witnessed.

Three months later, Jameson Rybak died of an overdose in his childhood bedroom.

Missed Opportunities

That March night in the emergency room, Jameson Rybak had fallen victim to two huge gaps in the U.S. health care system: a paucity of addiction treatment and high medical costs. The two issues — distinct but often intertwined — can come to a head in the ER, where patients and families desperate for addiction treatment often arrive, only to find the facility may not be equipped to deal with substance use. Or, even if they are, the treatment is prohibitively expensive.

Academic and medical experts say patients like Jameson represent a series of missed opportunities — both medical and financial.

“The emergency department is like a door, a really important door patients are walking through for identification of those who might need help,” said Marla Oros, a registered nurse and president of the Mosaic Group, a Maryland-based consulting firm that has worked with more than 50 hospitals nationwide to increase addiction treatment services. “We’re losing so many patients that could be identified and helped,” she said, speaking generally.

A spokesperson for McLeod Regional Medical Center, where Jameson went for care, said they would not comment on an individual’s case and declined to answer a detailed list of questions about the hospital’s ER and financial assistance policies. But in a statement, the hospital’s parent company, McLeod Health, noted that the hospital adhered to federal laws requiring that hospital ERs provide “immediate stabilizing care” for all patients, regardless of their ability to pay.

“Our hospitals attempt to manage the acute symptoms, but we do not treat chronic, underlying addiction,” the statement added.

Suzanne said her son needed more than stabilization. He needed immediate help breaking the cycle of addiction.

Jameson had been in and out of treatment for five years, ever since a friend suggested he try opioids to manage his anxiety and insomnia. He had insurance through his jobs in the hotel industry and later as an electrical technician, Suzanne said. But the high-deductible plans often left him paying out-of-pocket: $3,000 for a seven-day rehab stay, $400 for a brief counseling session and a prescription of Suboxone, a medication to treat opioid use disorder.

After he lost his job in February 2020, Jameson tried again to detox at home, Suzanne said. That’s what led to the ER trip.

Treating Addiction in the ER

Hospital ERs across the nation have become ground zero for patients struggling with addiction.

A seminal study published in 2015 by researchers at Yale School of Medicine found that giving patients medication to treat opioid use disorder in the ER doubled their chances of being in treatment a month later, compared with those who were given only referrals to addiction treatment.

Yet providing that medication is still not standard practice. A 2017 survey found just 5% of emergency medicine physicians said their department provided medications for opioid use disorder. Instead, many ERs continue to discharge these patients, often with a list of phone numbers for addiction clinics.

Jameson didn’t even get that, Suzanne said. At McLeod Regional, he was not seen by a psychiatrist or addiction specialist and did not get a prescription for Suboxone or even a referral, she said.

After Jameson’s death, Suzanne wrote to the hospital: “Can you explain to me, especially with the drug crisis in this country, how the ER was not equipped with personnel and/or any follow-up for treatment?”

Hospital administrator Will McLeod responded to Suzanne, in a letter she shared with KHN, that per Jameson’s medical record he’d been evaluated appropriately and that his withdrawal symptoms had been treated. Jameson declined to be admitted to the hospital, the letter said, and could not be involuntarily committed, as he “was not an imminent danger to himself or others.”

“Had he been admitted to our hospital that day, he would have been assigned to social workers and case managers who could have assisted with referrals, support, and follow-up treatment,” McLeod wrote.

Nationwide, hospitals are working to ramp up the availability of addiction services in the ER. In South Carolina, a state-funded program through the Medical University of South Carolina and the consulting firm Mosaic Group aims to help hospitals create a standardized system to screen patients for addiction, employ individuals who are in recovery to work with those patients and offer medication for opioid use disorder in the ER.

The initiative had worked with seven ERs as of June. It was in discussions to work with McLeod Regional hospital too, program staffers said. However, the hospital backed out.

The hospital declined to comment on its decision.

ER staffs around the country often lack the personnel to launch initiatives or learn about initiating addiction treatment. Sometimes affordable referral options are limited in the area. Even when the initial prescribing does occur, cost can be a problem, since Suboxone and its generic equivalent range in price from $50 to over $500 per prescription, without insurance.

In South Carolina, which has not expanded Medicaid, nearly 11% of the population is uninsured. Among patients in the state’s program who have been started on medications for opioid use disorder in ERs, about 75% are uninsured, said Dr. Lindsey Jennings, an emergency medicine physician at MUSC who works on the statewide initiative.

Other parts of the country face similar concerns, said Dr. Alister Martin, an emergency medicine physician who heads a national campaign to encourage the use of these medications in the ER. In Texas, for example, hundreds of doctors have gotten certified to provide the medications, he said, but many patients are uninsured and can’t pay for their prescriptions.

“You can’t make it effective if people can’t afford it,” Martin said.

Too Late for Charity Care

Throughout the night at McLeod Regional hospital’s ER, Jameson worried about cost, Suzanne said.

She wanted to help, but Jameson’s father and younger brother had recently lost their jobs, and the household was running on her salary as a public school librarian.

Suzanne didn’t know that nonprofit hospitals, like McLeod, are required by the federal government to have financial assistance policies, which lower or eliminate bills for people without the resources to pay. Often called charity care, this assistance is a condition for nonprofit hospitals to maintain their tax-exempt status.

But “nonprofits are actually doing less charity care than for-profits,” said Ge Bai, an associate professor at Johns Hopkins University who published a study this year on the level of charity care provided by different hospitals.

That’s in part because they have wide leeway to determine who qualifies and often don’t tell patients they may be eligible, despite federal requirements that nonprofit hospitals “widely publicize” their financial assistance policies, including on billing statements and in “conspicuous public displays” in the hospital. One study found that only 50% of hospitals regularly notified patients about eligibility for charity care before initiating debt collection.

McLeod Regional’s most recent publicly available tax return states that “uninsured patients are screened at the time of registration” and if they’re unable to pay and ineligible for governmental insurance, they’re given an application.

Suzanne said she doesn’t remember Jameson or herself receiving an application. The hospital declined to comment on the Rybaks’ case and whether it provides “conspicuous public displays” of financial assistance.

“Not once did anybody tell us, ‘Let’s get a financial person down here,’ or ‘There are grant programs,’” Suzanne said.

Mark Rukavina, with the nonprofit health advocacy group Community Catalyst, said most hospitals comply with the letter of the law in publicizing their assistance policy. But “how effective some of that messaging is may be a question,” he said. Some hospitals may bury the policy in a dense packet of other information or use signs with vague language.

A KHN investigation in 2019 found that, nationwide, 45% of nonprofit hospital organizations were routinely sending medical bills to patients whose incomes were low enough to qualify for charity care. McLeod Regional hospital reported $1.77 million of debt from sending bills to such patients, which ended up going unpaid, for the fiscal year ending in 2019.

Believing they couldn’t afford in-patient admission, the Rybaks left the hospital that night.

After the ER

Afterward, Jameson’s withdrawal symptoms passed, Suzanne said. He spent time golfing with his younger brother. Although his application for unemployment benefits was denied, he managed to defer payments on his car and school loans, she said.

But, inside, he must have been struggling, Suzanne now realizes.

Throughout the pandemic, many people with substance use disorder reported feeling isolated and relapsing. Overdose deaths rose nationwide.

On the morning of June 9, 2020, Suzanne opened the door to Jameson’s room and found him on the floor. The coroner determined he had died of an overdose. The family later scattered his ashes on Myrtle Beach — Jameson’s favorite place, Suzanne said.

In the months following Jameson’s death, hospital bills for his night in the ER arrived at the house. He owed $4,928, they said. Suzanne wrote to the hospital that her son was dead but received yet another bill addressed to him after that.

She shredded it and mailed the pieces to the hospital, along with a copy of Jameson’s death certificate.

Twelve days later, the health system wrote to her that the bill had been resolved under its charity care program.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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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KHN’s ‘What the Health?’: 100 Days of Health Policy

It’s 100 days into Joe Biden’s presidency and a surprisingly large number of health policies have been announced. But health is notably absent from the administration’s $1.8 trillion spending plan for American families, making it unclear how much more will get done this year. Meanwhile, the Centers for Disease Control and Prevention loosens its mask-wearing recommendations for those who have been vaccinated, but the new rules are confusing. Joanne Kenen of Politico, Mary Ellen McIntire of CQ Roll Call and Sarah Karlin-Smith of the Pink Sheet join KHN’s Julie Rovner to discuss these issues and more. Plus, Rovner interviews KHN’s Julie Appleby, who reported the latest KHN-NPR “Bill of the Month” episode.

Can’t see the audio player? Click here to listen on SoundCloud.

It’s been a busy 100 days for the Biden administration on health policy. The promise Joe Biden made as president-elect to get 100 million covid vaccinations in arms was doubled, healthcare.gov reopened to those without insurance, and steps were taken to undo a raft of health policies implemented by President Donald Trump. The covid relief bill passed by Congress in March also boosted subsidies for those who buy their own coverage and provided incentives for the 12 states that have yet to expand their Medicaid programs under the ACA.

But those actions may prove the high point for health policy this year. Administration officials initially promised that health would be a major part of the president’s $1.8 trillion American Families Plan, but major changes, particularly those addressing prescription drug costs, were nowhere to be seen when the plan was unveiled Wednesday.

This week’s panelists are Julie Rovner of KHN, Joanne Kenen of Politico, Mary Ellen McIntire of CQ Roll Call and Sarah Karlin-Smith of the Pink Sheet

Here are some takeaways from this week’s podcast:

  • Among the Trump administration health policies the Biden administration has moved to reverse are those on women’s reproductive health and Medicaid work requirements. Some experts suggest that Democratic officials pushed forward on this with good speed because the past administration’s health policies were easier to disentangle than its rules on environment, where Biden also wants to make changes.
  • Democratic lawmakers had seemed eager to use Biden’s family plan to expand Medicare or drive down prescription drug prices. It likely signals that while health care is a key issue for Democrats on Capitol Hill, it is not as big a priority in the White House. Biden, who did mention those policies favored by progressive lawmakers in his speech to Congress on Wednesday, seems to be putting his emphasis on strengthening the Affordable Care Act.
  • Right now, the pharmaceutical industry is scoring high with voters and politicians because of the successes of the covid vaccines. So, getting Senate approval of a bill to allow Medicare to negotiate drug prices is likely to be difficult. Those odds get even tougher without pressure from the White House.
  • Biden may also have shied away from the drug pricing initiative in his formal plan for helping families because he was concerned that it could divide the Democratic caucus and imperil the overall initiative.
  • The administration is gearing up to provide India with help to fight the pandemic. Public health officials point out that although the vaccination effort in the U.S. is going well, it is imperative to tamp down the virus in other countries so variants that could evade the vaccines don’t develop. However, there is already a debate about how much U.S. vaccine to ship abroad before authorities determine how to vaccinate children here.
  • Federal health officials have lifted the pause on using the Johnson & Johnson covid vaccine, but that decision has been controversial and some scientists question whether there was enough study or it was the right move.
  • The Centers for Disease Control and Prevention loosened its mask-wearing recommendations for people who have been vaccinated, but the new rules are confusing and even sparked some jokes among late-night TV comedians.
  • As the vaccination efforts in the U.S. gain steam, interest is growing among people with long-term cases of covid-19. A hearing on Capitol Hill this week looked at some of the issues, such as what sorts of disabilities these patients face and what workplace accommodations are necessary.
  • The National Institutes of Health is beginning major studies of “long covid” and its myriad symptoms. Although health officials do not yet have a clear definition of long covid, they are generally not dismissing patients’ complaints about the disorder. That differs from some mysterious ailments in the past.
  • The Biden administration has loosened the rules governing who can prescribe the drug buprenorphine, a controversial but effective treatment for opioid addiction. The policy eliminates a training requirement and seeks to allow medical professionals other than doctors to prescribe the drug. But hurdles to its use remain, leading some to question how much more widely the drug will be used as a result of the new policy.

Also this week, Rovner interviews KHN’s Julie Appleby, who reported the latest KHN-NPR “Bill of the Month” feature — about the intersection between car insurance and health insurance. If you have an outrageous medical bill you’d like to share with us, you can do it here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: This American Life’s “The Herd,” by Ira Glass, Anna Maria Barry-Jester and David Kestenbaum. Also, KHN’s “We’re Coming for You’: For Public Health Officials, a Year of Threats and Menace,” by Anna Maria Barry-Jester.

Joanne Kenen: The New Yorker’s “How Vaccine Hesitancy Is Driving Breakthrough Infections in Nursing Homes,” by Masha Gessen.

Mary Ellen McIntire: CQ Roll Call’s “FEMA’s Tasks Pit COVID-19 Vaccinations Against Hurricane Prep,” by Emily Kopp.

Sarah Karlin-Smith: The Pink Sheet’s “Conflicts Galore: Upcoming Accelerated Approval Cancer Panel Includes Many Industry Relationships,” by Sarah Karlin-Smith.

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

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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KHN’s ‘What the Health?’: Open Enrollment, One More Time

Keeping a campaign promise, President Joe Biden has reopened enrollment for health coverage under the Affordable Care Act on healthcare.gov — and states that run their own health insurance marketplaces followed suit. At the same time, the Biden administration is moving to revoke the Trump administration’s permission for states to impose work requirements for some adults on the Medicaid health insurance program. Alice Miranda Ollstein of Politico, Kimberly Leonard of Business Insider and Rachel Cohrs of Stat join KHN’s Julie Rovner to discuss these issues and more. Also, Rovner interviews medical student Inam Sakinah, president of the new group Future Doctors in Politics.

Can’t see the audio player? Click here to listen on SoundCloud.

An estimated 9 million Americans eligible for free or reduced premium health insurance under the Affordable Care Act have a second chance to sign up for 2021 coverage, since the Biden administration reopened enrollment on healthcare.gov and states that run their own marketplaces followed suit.

Meanwhile, Biden officials took the first steps to revoke the permission that states got from the Trump administration to require many adults on Medicaid to work or perform community service in exchange for their health coverage. The Supreme Court is scheduled to hear a case on the work requirements at the end of March.

This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Kimberly Leonard of Business Insider and Rachel Cohrs of Stat.

Among the takeaways from this week’s podcast:

  • The Biden administration said it will promote the special enrollment period, a stark change from the Trump administration, which dramatically limited funding for outreach. But navigator groups, whose workers help individuals find and sign up for coverage, say they haven’t yet heard whether the federal government will be offering to pay them to help people during this three-month sign-up period.
  • The House appears poised to pass a bill next week that would fund the covid relief measures President Joe Biden is seeking, as well as major changes to the ACA. Senate staffers are working with the House to align legislation from both chambers as much as possible. With little or no Republican support and only razor-thin majorities in both the House and Senate, Democrats will need to find common ground among their caucus to push the bill through.
  • Congress has a firm deadline on the covid relief bill since many current programs, such as the expanded unemployment funding, expire March 14.
  • CVS announced this week that its insurance subsidiary, Aetna, will be participating in the ACA marketplaces in the fall, another sign that those exchanges are growing in acceptance.
  • The Biden administration’s effort to walk back Medicaid work requirements appears to be an effort to head off the arguments at the Supreme Court. Democrats fear that even if they stop the program through administrative action now, a high-court ruling saying the effort was legal could open the door for future Republican administrations to restore work requirements.
  • The federal government is pushing hard to get more covid vaccine shots in arms around the country and last week reported that 1.7 million doses had been distributed. But it is a race against the emerging threat of covid virus variants, which are even more contagious than the original coronavirus.
  • Among hurdles in the vaccination effort is hesitancy among certain groups to get the shot. There have been reports that 30% of military personnel refused to accept the vaccine and some high-profile athletes in the NBA don’t want to be in public service announcements promoting it. Groups opposed to vaccines in general are posting misinformation online that may also be a source of concern.
  • The latest controversy over New York Gov. Andrew Cuomo’s policies on counting deaths among nursing home residents with covid-19 has consumed Albany and led to inquiries by legal authorities. It also raises questions about whether politics — Cuomo, a Democrat, and President Donald Trump regularly sparred about covid policies — influenced public health decisions.

Also this week, Rovner interviews medical student Inam Sakinah, president of the new group Future Doctors in Politics.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: Stat’s “Hospitals’ Covid-19 Heroics Have Them Poised for Power in the New Washington,” by Rachel Cohrs

Rachel Cohrs: KHN’s “As Drug Prices Keep Rising, State Lawmakers Propose Tough New Bills to Curb Them,” by Harris Meyer; and Stat’s “States Still Can’t Import Drugs From Canada. Now, Many Are Seeking to Import Canadian Prices,” by Lev Facher

Alice Miranda Ollstein: Politico’s “How Covid-19 Could Make Americans Healthier,” by Joanne Kenen

Kimberly Leonard: The New Republic’s “The Darker Story Just Outside the Lens of Framing Britney Spears,” by Sara Luterman

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Pandemic Presents New Hurdles, And Hope, For People Struggling With Addiction

Relaxed regulations in response to the pandemic means more access to addiction treatment medications. But recovery programs are accepting fewer people, and the danger of overdose remains high.

Before Philadelphia shut down to slow the spread of the coronavirus, Ed had a routine: most mornings he would head to a nearby McDonald’s to brush his teeth, wash his face and — when he had the money — buy a cup of coffee. He would bounce between homeless shelters and try to get a shower. But since businesses closed and many shelters stopped taking new admissions, Ed has been mostly shut off from that routine.

He’s still living on the streets.

“I’ll be honest, I don’t really sleep too much,” said Ed, who’s 51 and struggling with addiction. “Every four or five days I get a couple hours.”

KHN agreed not to use his last name because he uses illegal drugs.

Philadelphia has the highest overdose rate of any big city in America — in 2019, more than three people a day died of drug overdoses there, on average. Before the coronavirus began spreading across the United States, the opioid overdose epidemic was the biggest health crisis on the minds of many city officials and public health experts. The coronavirus pandemic has largely eclipsed the conversation around the opioid crisis. But the crisis still rages on despite business closures, the cancellation of in-person treatment appointments and the strain on many addiction resources in the city.

When his usual shelter wasn’t an option anymore, Ed tried to get into residential drug treatment. He figured that would be a good way to try to get back on his feet and, if nothing else, get a few good nights of rest. But he had contracted pinkeye, a symptom thought to be associated with the virus that leads to COVID-19, so the evaluation center didn’t want to place him in an inpatient facility until he’d gotten the pinkeye checked out. But he couldn’t see a doctor because he didn’t have a phone for a telehealth appointment.

“I got myself stuck, and I’m trying to pull everything back together before it totally blows up,” he said.

Rosalind Pichardo wants to help people in Ed’s situation. Before the pandemic, Pichardo would hit the streets of her neighborhood, Kensington, which has the highest drug overdose rate in Philadelphia. She’d head out with a bag full of snack bars, cookies and Narcan, the opioid overdose reversal drug.

She’d hand Narcan out to people using drugs, and people selling drugs — anyone who wanted it. Pichardo started her own organization, Operation Save Our City, which initially set out to work with survivors of gun violence in the neighborhood. When she realized that overdoses were killing people too, she began getting more involved with the harm reduction movement and started handing out Narcan through the city’s syringe exchange.

When Pennsylvania’s stay-at-home order went into effect, Pichardo and others worried that more people might start using drugs alone, and that fewer first responders would be patrolling the streets or nearby and able to revive them if they overdosed.

So, Pichardo and other harm reduction activists gave out even more Narcan. A representative for Prevention Point Philadelphia, the group that operates a large syringe exchange program in the city, said that during the first month of the city’s stay-at-home order, they handed out almost twice as much Narcan as usual.

After the lockdowns and social distancing began, Pichardo worried that more people would be using drugs alone, leading to more overdoses. But Philadelphia’s fatal overdose rate during the pandemic remains about the same as it was this time last year. Pichardo said she thinks that’s evidence that flooding the streets with Narcan is working — that people are continuing to use drugs, and maybe even using more drugs, but that users are utilizing Narcan more often and administering it to one another.

That is the hope. But Pichardo said users don’t always have a buddy to keep watch, and during the pandemic first responders have seemed much more hesitant to intervene. For example, she recently administered Narcan to three people in Kensington who overdosed near a subway station, while two police officers stood by and watched. Before the pandemic, they would often be right there with her, helping.

To reverse the overdoses, Pichardo crouched over the people who she said had started turning blue as their oxygen levels dropped. She injected the Narcan into their noses, using a disposable plastic applicator. Normally, she would perform rescue breathing, too, but since the pandemic began she has started carrying an Ambu bag, which pumps air into a person’s lungs and avoids mouth-to-mouth resuscitation. Among the three people, she said, it took six doses of Narcan to revive them. The police officers didn’t step in to help but did toss several overdose-reversal doses toward Pichardo as she worked.

“I don’t expect ’em to give ’em rescue breaths if they don’t want to, but at least administer the lifesaving drug,” Pichardo said.

In her work as a volunteer, she has reversed almost 400 overdoses, she estimated.

“There’s social distancing — to a limit,” Pichardo said, “I think when someone’s life is in jeopardy, they’re worth saving. You just can’t watch people die.”

Even before Philadelphia officially issued its stay-at-home order, city police announced they would stop making low-level arrests, including for narcotics. The idea was to reduce contact overall, help keep the jail population low and reduce the risk of the virus getting passed around inside. But Pichardo and other community activists said the decreased law enforcement emboldened drug dealers in the Kensington neighborhood, where open-air drug sales and use are common.

“You can tell they have everything down pat, from the lookout to the corner boys to the one actually holding the product — the one holding the product’s got some good PPE gear,” said Pichardo.

More dealers working openly on the street has led to more fights over territory, she added, which in turn has meant more violence. While overall crime in Philadelphia and other major cities has declined during the pandemic, gun violence has spiked.

Police resumed arrests at the beginning of May.

Now when she goes out to offer relief and hand out Narcan, Pichardo packs a few extra things in her bag of supplies: face masks, gloves and gun locks.

“It’s like the survival kit of the ’hood,” she said.

For those struggling with addiction who are ready to start recovery, newly relaxed federal restrictions have made it easier to get medications that curb opioid cravings and stem withdrawal. Several efforts are underway among Philadelphia-based public health groups and criminal justice advocacy organizations to give cellphones to people who are homeless or coming out of jail, so they can make a telehealth appointment and get quicker access to a prescription for those medicines.

During the pandemic, people taking medication-assisted treatment can renew their prescription every month instead of every week, which helps decrease trips to the pharmacy. It is too soon to know if more people are taking advantage of the new rules, and accessing medication-assisted treatment via telehealth, but if that turns out to be the case, many addiction medicine specialists argue the new rules should become permanent, even after the pandemic ends.

“If we find that these relaxed restrictions are bringing more people to the table, that presents enormous ethical questions about whether or not the DEA should reinstate these restrictive policies that they had going in the first place,” said Dr. Ben Cocchiaro, a physician who treats people with substance-use disorder.

Cocchiaro said the whole point of addiction treatment is to facilitate help as soon as someone is ready for it. He hopes if access to recovery can be made simpler during a pandemic, it can remain that way afterward.

This story is part of a partnership that includes WHYY, NPR and Kaiser Health News.

Coronavirus Crisis Opens Access To Online Opioid Addiction Treatment

Under the national emergency, the government has waived a law that required patients to have an in-person visit with a physician before they could be prescribed drugs that help quell withdrawal symptoms, such as Suboxone. Now they can get those prescriptions via a phone call or videoconference with a doctor. That may give video addiction therapy a kick-start.

[UPDATED on April 28]

Opioid addiction isn’t taking a break during the coronavirus pandemic.

But the U.S. response to the viral crisis is making addiction treatment easier to get.

Under the national emergency declared by the Trump administration in March, the government has suspended a federal law that required patients to have an in-person visit with a physician before they could be prescribed drugs that help quell withdrawal symptoms, such as Suboxone. Patients can now get those prescriptions via a phone call or videoconference with a doctor.

Addiction experts have been calling for that change for years to help expand access for patients in many parts of country that have shortages of physicians eligible to prescribe these medication-assisted treatments. A federal report in January found that 40% of U.S. counties don’t have a single health care provider approved to prescribe buprenorphine, an active ingredient in Suboxone.

A 2018 law called for the new policy, but regulations were never finalized.

“I wish there was another way to get this done besides a pandemic,” said Dr. David Kan, chief medical officer of Bright Heart Health, a Walnut Creek, California, company. It has recently started working with insurers and health providers to help addicted patients get therapy and medications without having to leave their homes. He said he hopes the administration will make the changes permanent after the national emergency ends.

For years before the emergency regulations, Bright Heart — along with several other telemedicine counseling providers — began offering opioid addiction treatment and counseling via telemedicine, even if they couldn’t prescribe initial medication for addiction. Patients can renew prescriptions for drugs to deal with withdrawal symptoms, get drug-tested and meet with counselors for therapy.

When Nathan Post needed help overcoming a decade-long drug addiction, he went online in 2018 and used Bright Heart Health to connect to a doctor and weekly individual and group counseling sessions. He said the convenience is a big benefit.

“As an addict, it was easy to have excuses not to do stuff, but this was easy because I could just be in my living room and turn on my computer, so I had no reason to blow it off,” he said.

Post, 38, a tattoo artist who recently moved from New Mexico to Iowa City, Iowa, was addicted to Suboxone, the drug he was prescribed in 2009 to deal with an addiction to opioid pills.

Officials with the insurer Anthem said using Bright Heart’s telemedicine option has helped increase medication-assisted treatment for members with opioid drug abuse issues from California and nine other states from 16% to more than 30%. While fewer than 5% of Anthem patients seeking addiction treatment use telemedicine, the company expects the option to become more common.

Bright Heart Health officials say one barometer of the effectiveness of the care is that 90% of patients are still in treatment after 30 days and 65% after 90 days — far higher than with traditional treatment.

Several insurers — including Aetna, and Blue Cross and Blue Shield companies like Anthem across the country — have begun covering the telemedicine addiction service.

Dr. Miriam Komaromy, medical director of Boston Medical Center’s Grayken Center for Addiction, said there are some downsides to virtual care.

“I think therapists and providers do worry whether it provides the same level of engagement with the patient and whether it’s possible to gauge someone’s sincerity and level of motivation as easily over a camera as in person,” she said.

But she predicted telemedicine service will grow because of the tremendous need to broaden access to mental health and addiction counseling. “Too often the default is no counseling for patients,” she said. “This gives us another set of tools.”

Patients can also have trouble finding a doctor who is eligible to prescribe medication to help treat addiction. Physicians are required to get a federal license to prescribe Suboxone and other controlled substances that help patients with opioid addictions and can write only limited numbers of prescriptions each month. Many doctors hesitate to seek that qualification.

A few small studies have found that patients are as likely to stay with telemedicine treatment as with in-person care for drug addiction. But no studies have determined whether one type of therapy is more effective.

Telemedicine does have its limits — and is not right for everyone, particularly patients who require more intensive inpatient care or who lack easy internet access, Komaromy said.

Premera Blue Cross and Blue Shield officials said they are partnering with Boulder Care, a digital recovery program based in Portland, Oregon, to help customers in rural Alaska. “Telemedicine is a unique way for someone to go through treatment in a discreet manner,” said Rick Abbott, a Premera vice president.

Nathan Post, a tattoo artist living in Iowa City, Iowa, used a telemedicine service to help overcome his addiction to Suboxone. “This was easy because I could just be in my living room and turn on my computer, so I had no reason to blow it off,” he says. (Courtesy of Nathan Post)

While telemedicine has been growing in popularity for physical medicine, some people may still be reluctant to use it for drug addiction.

There are also concerns that allowing providers to prescribe controlled substances without meeting patients in person could increase the risks of fraud.

“There is a fear around this that there may be some rogue providers who make a lot of money off addiction and will do it stealthily on the internet,” said Dr. Alyson Smith, an addiction medical specialist with Boulder Care. “While that is a small risk, we have to compare it to the huge benefit of expanding treatment that will save lives.”

Smith said she doesn’t notice a big difference in treating patients for drug addiction in her office compared with on a video screen. She can still see patients’ pupils to make sure they are dilated and ask them about how they are feeling — which can determine whether it’s appropriate to prescribe certain drugs. Dilated pupils are a sign of patients suffering from withdrawal from heroin and other drugs.

Dr. Dawn Abriel, who treated Post and previously directed a methadone clinic in Albuquerque, New Mexico, said she can diagnose patients over video without issue.

“I can pick up an awful lot on the video,” particularly a patient’s body language, she said. “I think people open up to me more because they are sitting in their homes and in their place of comfort.”

In West Virginia, one of the states hardest hit by the opioid addiction epidemic, Highmark, a Blue Cross and Blue Shield company, started offering telehealth addiction coverage with Bright Heart Health in January. Highmark officials say a lack of providers, particularly in rural parts of the state, meant that many of the insurer’s members had difficulty finding the help they need.

Dr. Caesar DeLeo, vice president and executive medical director of strategic initiatives for Highmark, said the insurer was having problems getting customers into care. Only about a third of members with addiction issues were receiving treatment, he said.

“We needed to address the crisis with a new approach,” DeLeo said. “This will give people more options and give primary care doctors who do not want to prescribe Suboxone another place to refer patients.”

DeLeo said patients will also be referred to Bright Heart in hospital emergency rooms.

Dr. Paul Leonard, an emergency doctor and medical director for Workit Health, an Ann Arbor, Michigan, company offering telemedicine treatment and counseling programs, said many patients who turn to ERs for addiction treatment get little help finding counseling. With online therapy, patients can sign up while still in the ER.

“We’ve built a better mousetrap,” Leonard said.

Telemedicine addiction providers said they and their patients are getting more accustomed to virtual care.

“There are always times you wish you could reach out and hold someone’s hand, and you can’t do that,” said Boulder’s Smith. “But we feel like we are more skilled at a virtual hand-holding and really connect with people and they feel well supported in return.”

California’s New Attack On Opioid Addiction Hits Old Roadblocks

State officials in California have achieved some success in promoting the use of medication-assisted treatment for people with opioid addictions, but they are bumping up against familiar resistance and constraints.

Jennifer Stilwell, a 30-year-old mother of two young children, kicked heroin cold turkey five years ago, but she got hooked again last fall.

Stilwell, an accountant in Placerville, California, tried to quit a second time, but she couldn’t tolerate the sickening withdrawal symptoms. She resisted going to the emergency room because “I thought they’d treat me like a drug addict and not a patient in pain,” she said.

Instead, she kept smoking heroin to keep the agony at bay. Then, in February, a county mental health worker told her about a new program that promised stigma-free treatment for her addiction.

She went to the ER at Marshall Medical Center in Placerville, where a doctor put her on buprenorphine, one of three drugs approved by the Food and Drug Administration for medication-assisted treatment (MAT) of people with opioid dependency.

Her ongoing treatment includes intensive counseling and social support, providing what is known in the recovery field as “whole person” therapy.

“It’s still early in my battle,” Stilwell said. “But my withdrawals are gone. Now I can concentrate on being a mother.”

Marshall is one of a growing number of health care institutions across California that offer medication-assisted treatment with funding and support from the state’s MAT Expansion Project, which started in 2018 and is financed by $265 million in federal grants.

Numerous studies have shown that relapse and overdose rates are lower among opioid users who get MAT than those who don’t. From 2016 to 2018, for example, the overdose death rate in Humboldt County — one of California’s highest ― dropped by about half, which officials attributed in large part to the MAT Expansion Project.

In February, California’s Department of Health Care Services, which administers the project, touted its success, reporting that it has provided care for 22,000 previously untreated Californians with opioid addictions and created 650 new locations where patients can receive MAT.

But the number of new people brought into treatment is only a small fraction of those who need it. In 2019, more than half a million Californians with an opioid use disorder lacked access to treatment, according to a study by the Urban Institute.

The state effort faces many of the same obstacles that have hindered wider acceptance of MAT for years: the stigma of addiction, federal regulations that depress the number of MAT providers, and hostility in some corners of the treatment community to the very notion of using drugs to combat drug addiction.

Moreover, the addiction treatment industry has become a magnet in recent years for unscrupulous operators who aggressively recruit clients, eyes fixed on the dollar signs rather than on evidence-based treatments such as MAT.

Now there’s another, hopefully temporary, challenge. The COVID-19 crisis and related social-distancing measures are forcing MAT practitioners to scramble for new ways to accommodate patients, said Eric Hill, a “substance navigator” at Marshall Medical Center who helps guide patients through their MAT treatment.

Hill said MAT patients entering the program through emergency rooms are now given prescriptions for up to a month, rather than a week. He said he is following up with clients by phone rather than in person, and he and others are trying to arrange video calls between doctors and patients for prescription renewals.

The state program seeks to broaden access to MAT by launching or enhancing treatment programs at ERs, hospitals, primary care clinics, residential treatment programs, county mental health centers, jails and drug courts. Training more doctors to provide MAT is also a pillar of the campaign.

But patients who take anti-addiction drugs can have difficulty finding housing and recovery therapy, which are integral to their treatment. They are often shunned by groups adhering to traditional 12-step theories of sobriety that require participants to be free of drugs — including MAT drugs.

“MAT patients will say that the treatment was working. They were just starting to feel better, going to support groups, back at their jobs, but they had a hard time finding a place to live,” said Hill.

Many patients who stop taking their MAT drugs in order to get a roof over their heads have relapsed, Hill said.

Marlies Perez, a division chief at the state health care department, said the agency “is taking a strong stand against such stigma that prevents patients from their continued recovery.” Through its media campaign, Choose Change California, it seeks to alter perceptions within the recovery community and persuade more doctors and patients to embrace MAT.

The state expansion project puts a strong emphasis on building MAT capacity in emergency rooms, where opioid users often face suspicion.

Of the 320 acute care hospitals with emergency rooms statewide, 52 currently offer MAT. In those hospitals, staff members like Hill help patients get the care they need, including the psychological and social dimensions. Health care department officials say they plan to quadruple the number of participating hospitals to more than 200 over the next few years.

(Photo Courtesy of Jennifer Stilwell)

Opioid misuse is not nearly as deadly in California as in the rest of the U.S., even though the rise of fentanyl has begun to cause bigger problems in the Golden State.

In 2018, the rate of opioid overdose deaths in California stood at 5.8 per 100,000 residents, far below the national average of 14.6 per 100,000. In some rural counties of California, however, opioid death rates exceed the national average. The two states with the highest rates were West Virginia, at 42.4 per 100,000, and Delaware at 39.3.

Another obstacle to MAT expansion, one squarely in the sights of California health authorities, is that many doctors are hesitant to participate because they must undergo federally mandated training for a waiver that allows them to prescribe buprenorphine.

“Doctors can prescribe OxyContin with abandon but not buprenorphine, which has been shown to be helpful to opioid addicts,” said Dr. Aimee Moulin, a director at the California Bridge Program, which helps administer the state’s MAT program.

Buprenorphine is less powerful and less likely to cause fatal overdoses than methadone, another drug commonly used to fight opioid addiction. And doctors who get the waiver for buprenorphine can prescribe it in their offices, while methadone must be administered in federally certified treatment programs.

The state’s health care department said the expansion project has thus far trained 395 new MAT prescribers. But as of July 2019, just 3.2% of prescribers in the state were authorized to prescribe buprenorphine, according to the Urban Institute study.

Dr. Peter Liepmann, a Pasadena-based family physician with an interest in addiction medicine, said it can be difficult to find a buprenorphine prescriber. Not long ago, when he was thinking about opening a practice in Glendale, California, he consulted the Substance Abuse and Mental Health Services Administration’s (SAMHSA) listings of physicians who offer MAT.

“If you were looking for somebody to dispense buprenorphine and you called people on that list, you would have come up with one doctor who ran a cash-only, no-insurance practice, and he was very expensive,” Liepmann said.

The state’s Perez said some doctors may not fully understand the benefits of MAT because medical schools devote little time to addiction training. Another element of the MAT project, she said, is to fund a substance-use-disorder curriculum at training hospitals.

Perez counseled patience: “We didn’t get into this opioid dependency situation overnight, and we’re not going to find a total solution overnight either.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

They Fell In Love Helping Drug Users. But Fear Kept Him From Helping Himself.

Sarah and Andy fell in love while working to keep drug users from overdosing. But when his own addiction reemerged, Andy’s fear of returning to prison kept him from the best treatment.

She was in medical school. He was just out of prison.

Sarah Ziegenhorn and Andy Beeler’s romance grew out of a shared passion to do more about the country’s drug overdose crisis.

Ziegenhorn moved back to her home state of Iowa when she was 26. She had been working in Washington, D.C., where she also volunteered at a needle exchange — where drug users can get clean needles. She was ambitious and driven to help those in her community who were overdosing and dying, including people she had grown up with.

“Many people were just missing because they were dead,” said Ziegenhorn, now 31. “I couldn’t believe more wasn’t being done.”

She started doing addiction advocacy in Iowa City while in medical school — lobbying local officials and others to support drug users with social services.

Beeler had the same conviction, born from his personal experience.

“He had been a drug user for about half of his life — primarily a longtime opiate user,” Ziegenhorn said.

Beeler spent years in and out of the criminal justice system for a variety of drug-related crimes, such as burglary and possession. In early 2018, he was released from prison. He was on parole and looking for ways to help drug users in his hometown.

He found his way to advocacy work and, through that work, found Ziegenhorn. Soon they were dating.

“He was just this really sweet, no-nonsense person who was committed to justice and equity,” she said. “Even though he was suffering in many ways, he had a very calming presence.”

People close to Beeler describe him as a “blue-collar guy” who liked motorcycles and home carpentry, someone who was gentle and endlessly curious. Those qualities could sometimes hide his struggle with anxiety and depression. Over the next year, Beeler’s other struggle, with opioid addiction, would flicker around the edges of their life together.

Eventually, it killed him.

People on parole and under supervision of the corrections system can face barriers to receiving appropriate treatment for opioid addiction. Ziegenhorn said she believes Beeler’s death is linked to the many obstacles to medical care he experienced while on parole.

About 4.5 million people are on parole or probation in the U.S., and research shows that those under community supervision are much more likely to have a history of substance use disorder than the general population. Yet rules and practices guiding these agencies can preclude parolees and people on probation from getting evidence-based treatment for their addiction.

A Shared Passion For Reducing Harm

From their first meeting, Ziegenhorn said, she and Beeler were in sync, partners and passionate about their work in harm reduction — public health strategies designed to reduce risky behaviors that can hurt health.

After she moved to Iowa, Ziegenhorn founded a small nonprofit called the Iowa Harm Reduction Coalition. The group distributes the opioid-overdose reversal drug naloxone and other free supplies to drug users, with the goal of keeping them safe from illness and overdose. The group also works to reduce the stigma that can dehumanize and isolate drug users. Beeler served as the group’s coordinator of harm reduction services.

“In Iowa, there was a feeling that this kind of work was really radical,” Ziegenhorn said. “Andy was just so excited to find out someone was doing it.”

Meanwhile, Ziegenhorn was busy with medical school. Beeler helped her study. She recalled how they used to take her practice tests together.

“Andy had a really sophisticated knowledge of science and medicine,” she said. “Most of the time he’d been in prison and jails, he’d spent his time reading and learning.”

Beeler was trying to stay away from opioids, but Ziegenhorn said he still used heroin sometimes. Twice she was there to save his life when he overdosed. During one episode, a bystander called the police, which led to his parole officer finding out.

“That was really a period of a lot of terror for him,” Ziegenhorn said.

Beeler was constantly afraid the next slip — another overdose or a failed drug test — would send him back to prison.

An Injury, A Search For Relief

A year into their relationship, a series of events suddenly brought Beeler’s history of opioid use into painful focus.

It began with a fall on the winter ice. Beeler dislocated his shoulder — the same one he’d had surgery on as a teenager.

“At the emergency room, they put his shoulder back into place for him,” Ziegenhorn said. “The next day it came out again.”

She said doctors wouldn’t prescribe him prescription opioids for the pain because Beeler had a history of illegal drug use. His shoulder would dislocate often, sometimes more than once a day.

“He was living with this daily, really severe constant pain — he started using heroin very regularly,” Ziegenhorn said.

Beeler knew what precautions to take when using opioids: Keep naloxone on hand, test the drugs first and never use alone. Still, his use was escalating quickly.

A Painful Dilemma 

The couple discussed the future and their hope of having a baby together, and eventually Ziegenhorn and Beeler agreed: He had to stop using heroin.

They thought his best chance was to start on a Food and Drug Administration-approved medication for opioid addiction, such as methadone or buprenorphine. Methadone is an opioid, and buprenorphine engages many of the same opioid receptors in the brain; both drugs can curb opioid cravings and stabilize patients. Studies show daily maintenance therapy with such treatment reduces the risks of overdose and improves health outcomes.

But Beeler was on parole, and his parole officer drug-tested him for opioids and buprenorphine specifically. Beeler worried that if a test came back positive, the officer might see that as a signal that Beeler had been using drugs illegally.

Ziegenhorn said Beeler felt trapped: “He could go back to prison or continue trying to obtain opioids off the street and slowly detox himself.”

He worried that a failed drug test — even if it was for a medication to treat his addiction — would land him in prison. Beeler decided against the medication.

A few days later, Ziegenhorn woke up early for school. Beeler had worked late and fallen asleep in the living room. Ziegenhorn gave him a kiss and headed out the door. Later that day, she texted him. No reply.

She started to worry and asked a friend to check on him. Not long afterward, Beeler was found dead, slumped in his chair at his desk. He’d overdosed.

“He was my partner in thought, and in life and in love,” Ziegenhorn said.

It’s hard for her not to rewind what happened that day and wonder how it could have been different. But mostly she’s angry that he didn’t have better choices.

“Andy died because he was too afraid to get treatment,” she said.

Beeler was services coordinator for the Iowa Harm Reduction Coalition, a group that works to help keep drug users safe. A tribute in Iowa City after his death began, “He died of an overdose, but he’ll be remembered for helping others avoid a similar fate.”(Courtesy of Sarah Ziegenhorn)

How Does Parole Handle Relapse? It Depends

It’s not clear that Beeler would have gone back to prison for admitting he’d relapsed and was taking treatment. His parole officer did not agree to an interview.

But Ken Kolthoff, who oversees the parole program that supervised Beeler in Iowa’s First Judicial District Department of Correctional Services, said generally he and his colleagues would not punish someone who sought out treatment because of a relapse.

“We would see that that would be an example of somebody actually taking an active role in their treatment and getting the help they needed,” said Kolthoff.

The department doesn’t have rules prohibiting any form of medication for opioid addiction, he said, as long as it’s prescribed by a doctor.

“We have people relapse every single day under our supervision. And are they being sent to prison? No. Are they being sent to jail? No,” Kolthoff said.

But Dr. Andrea Weber, an addiction psychiatrist with the University of Iowa, said Beeler’s reluctance to start treatment is not unusual.

“I think a majority of my patients would tell me they wouldn’t necessarily trust going to their [parole officer],” said Weber, assistant director of addiction medicine at the University of Iowa’s Carver College of Medicine. “The punishment is so high. The consequences can be so great.”

Weber finds probation and parole officers have “inconsistent” attitudes toward her patients who are on medication-assisted treatment.

“Treatment providers, especially in our area, are still very much ingrained in an abstinence-only, 12-step mentality, which traditionally has meant no medications,” Weber said. “That perception then invades the entire system.”

Attitudes And Policies Vary Widely

Experts say it’s difficult to draw any comprehensive picture about the availability of medication for opioid addiction in the parole and probation system. The limited amount of research suggests that medication-assisted treatment is significantly underused.

“It’s hard to quantify because there are such a large number of individuals under community supervision in different jurisdictions,” said Michael Gordon, a senior research scientist at the Friends Research Institute, based in Baltimore.

A national survey published in 2013 found that about half of drug courts did not allow methadone or other evidence-based medications used to treat opioid use disorder.

A more recent study of probation and parole agencies in Illinois reported that about a third had regulations preventing the use of medications for opioid use disorder. Researchers found the most common barrier for those on probation or parole “was lack of experience by medical personnel.”

Faye Taxman, a criminology professor at George Mason University, said decisions about how to handle a client’s treatment often boil down to the individual officer’s judgment.

“We have a long way to go,” she said. “Given that these agencies don’t typically have access to medical care for clients, they are often fumbling in terms of trying to think of the best policies and practices.”

Increasingly, there is a push to make opioid addiction treatment available within prisons and jails. In 2016, the Rhode Island Department of Corrections started allowing all three FDA-approved medications for opioid addiction. That led to a dramatic decrease in fatal opioid overdoses among those who had been recently incarcerated.

Massachusetts has taken similar steps. Such efforts have only indirectly affected parole and probation.

“When you are incarcerated in prison or jail, the institution has a constitutional responsibility to provide medical services,” Taxman said. “In community corrections, that same standard does not exist.”

Taxman said agencies may be reluctant to offer these medications because it’s one more thing to monitor. Those under supervision are often left to figure out on their own what’s allowed.

“They don’t want to raise too many issues because their freedom and liberties are attached to the response,” she said.

Richard Hahn, a researcher at New York University’s Marron Institute of Urban Management who consults on crime and drug policy, said some agencies are shifting their approach.

“There is a lot of pressure on probation and parole agencies not to violate people just on a dirty urine or for an overdose” said Hahn, who is executive director of the institute’s Crime & Justice Program.

The federal government’s Substance Abuse and Mental Health Services Administration calls medication-assisted treatment the “gold standard” for treating opioid addiction when used alongside “other psychosocial support.”

Addiction is considered a disability under the Americans with Disabilities Act, said Sally Friedman, vice president of legal advocacy for the Legal Action Center, a nonprofit law firm based in New York City.

She said disability protections extend to the millions of people on parole or probation. But people under community supervision, Friedman said, often don’t have an attorney who can use this legal argument to advocate for them when they need treatment.

“Prohibiting people with that disability from taking medication that can keep them alive and well violates the ADA,” she said.

This story is part of a partnership between NPR and Kaiser Health News.

No Quick Fix: Missouri Finds Managing Pain Without Opioids Isn’t Fast Or Easy

In the first nine months of an alternative pain management program in Missouri, only a small fraction of the state’s Medicaid recipients have accessed the chiropractic care, acupuncture, physical therapy and cognitive-behavioral therapy meant to combat the overprescription of opioids.

ST. LOUIS — Missouri began offering chiropractic care, acupuncture, physical therapy and cognitive-behavioral therapy for Medicaid patients in April, the latest state to try an alternative to opioids for those battling chronic pain.

Yet only about 500 of the state’s roughly 330,000 adult Medicaid users accessed the program through December, at a cost of $190,000, according to Josh Moore, the Missouri Medicaid pharmacy director. While the numbers may reflect an undercount because of lags in submitting claims, the jointly funded federal-state program known in the state as MO HealthNet is hitting just a fraction of possible patients so far.

Meanwhile, according to the state, opioids were still being doled out: 109,610 Missouri Medicaid patients of all age groups received opioid prescriptions last year.

The going has been slow, health experts said, because of a slew of barriers. Such treatments are more time-consuming and involved than simply getting a prescription. A limited number of providers offer alternative treatment options, especially to Medicaid patients. And perhaps the biggest problem? These therapies don’t seem to work for everyone.

The slow rollout highlights the overall challenges in implementing programs aimed at righting the ship on opioid abuse in Missouri — and nationwide. To be sure, from 2012 to 2019, the number of Missouri Medicaid patients prescribed opioid drugs fell by more than a third — and the quantity of opioids dispensed by Medicaid dropped by more than half.

Still, opioid overdoses killed an estimated 1,132 Missourians in 2018 and 46,802 Americans nationally, according to the latest data available. Progress to change that can be frustratingly slow.

“The opioids crisis we got into wasn’t born in a year,” Moore said. “To expect we’d get perfect results after a year would be incredibly optimistic.”

Despite limited data on the efficacy of alternative pain management plans, such efforts have become more accepted, especially following a summer report of pain management best practices from the U.S. Department of Health and Human Services. States such as Ohio and Oregon see them as one part of a menu of options aimed at curbing the opioid crisis.

St. Louis chiropractor Ross Mattox, an assistant professor at chiropractic school Logan University, sees both uninsured patients and those on Medicaid at the CareSTL clinic. He cheered Missouri’s decision to expand access, despite how long it took to get here.

“One of the most common things I heard from providers,” he said, “is ‘I want to send my patient to a chiropractor, but they don’t have the insurance. I don’t want to prescribe an opioid — I’d rather go a more conservative route — but that’s the only option I have.’”

And that can lead to the same tragic story: Someone gets addicted to opioids, runs out of a prescription and turns to the street before becoming another sad statistic.

“It all starts quite simply with back pain,” Mattox said.

Practical Barriers

While Missouri health care providers now have another tool besides prescribing opioids to patients with Medicaid, the multistep approaches required by alternative treatments create many more hoops than a pharmacy visit.

The physicians who recommend such treatments must support the option, and patients must agree. Then the patient must be able to find a provider who accepts Medicaid, get to the provider’s office even if far away and then undergo multiple, time-consuming therapies.

“After you see the chiropractor’s for one visit, it’s not like you’re cured from using opioids forever — it would take months and months and months,” Moore said.

The effort and cost that go into coordinating a care plan with multiple alternative pain therapies is another barrier.

“Covering a course of cheap opioid pills is different than trying to create a multidisciplinary individualized plan that may or may not work,” said Leo Beletsky, a professor of law and health sciences at Northeastern University in Boston, noting that the scientific evidence of the efficacy of such treatments is mixed.

And then there’s the reimbursement issue for the providers. Corry Meyers, an acupuncturist in suburban St. Louis, does not accept insurance in his practice. But he said other acupuncturists in Missouri debate whether to take advantage of the new Medicaid program, concerned the payment rates to providers will be too low to be worthwhile.

“It runs the gamut, as everyone agrees that these patients need it,” Meyers stressed. But he said many acupuncturists wonder: “Am I going to be able to stay open if I take Medicaid?”

Structural Issues 

While helpful, plans like Missouri’s don’t address the structural problems at the root of the opioid crisis, Beletsky said.

“Opioid overutilization or overprescribing is not just a crisis in and of itself; it’s a symptom of broader structural problems in the U.S. health care system,” he said. “Prescribers reached for opioids in larger and larger numbers not just because they were being fooled into doing so by these pharmaceutical companies, but because they work really well for a broad variety of ailments for which we’re not doing enough in terms of prevention and treatment.”

Fixing some of the core problems leading to opioid dependence — rural health care “deserts” and the impact of manual labor and obesity on chronic pain — requires much more than a treatment alternative, Beletsky said.

And no matter how many alternatives are offered, he said, opioids will remain a crucial medicine for some patients.

Furthermore, while alternative pain management therapies may lessen opioid prescriptions, they do not address exploding methamphetamine addiction or other addiction crises leading to overdoses nationwide — even as a flood of funds pours in from the national and state level to fight these crises.

The Show-Me State’s refusal to expand Medicaid coverage to more people under the Affordable Care Act also hampers overall progress, said Dr. Fred Rottnek, a family and addiction doctor who sits on the St. Louis Regional Health Commission as chair of the Provider Services Advisory Board.

“The problem is we relatively cover so few people in Missouri with Medicaid,” he said. “The denominator is so small that it doesn’t affect the numbers a whole lot.”

But providers like Mattox are happy that such alternative treatments are now an option, even if they’re available only for a limited audience.

He just wishes it had been done sooner.

“A lot of it has to do with politics and the slow gears of government,” he said. “Unfortunately, it’s taken people dying — it’s taken enough of a crisis for people to open their eyes and say, ‘Maybe there’s a better way to do this.’”