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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Calls to Overhaul Methadone Distribution Intensify, but Clinics Resist

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Watch: Going Beyond the Script of ‘Dopesick’ and America’s Real-Life Opioid Crisis

KHN teamed up with Hulu for a discussion of America’s opioid crisis, following the Oct. 13 premiere of the online streaming service’s new series “Dopesick.”

KHN and policy colleagues at our parent organization KFF teamed up with Hulu for a discussion of America’s opioid crisis, following the Oct. 13 premiere of the online streaming service’s new series “Dopesick.”

The discussion explored how the series’ writers worked with journalist Beth Macy, author of the book “Dopesick: Dealers, Doctors, and the Drug Company That Addicted America,” and showrunner Danny Strong to create and fact-check scripts and develop characters. It quickly moved on to a deeper discussion of how the fictionalized version of the opioid epidemic portrayed in the Hulu series dovetailed with the broader reality KFF’s journalists and analysts have been documenting in their work for the past few years.

Providing perspective on the role of public health and treatment were KHN correspondent Aneri Pattani, who has reported extensively on opioid policy, substance use and mental health, and KFF senior policy analyst Nirmita Panchal, whose analytical work focuses on mental health and substance use.

The forum was moderated by Chaseedaw Giles, audience engagement editor and digital strategist at KHN who has written about hip-hop music’s relationship with opioid abuse. It was filmed in KFF’s Washington, D.C., conference center to an audience of no one (courtesy of covid-19).

You can read a transcript of the forum by clicking here.

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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Opioids like ‘Lean’ Permeate Hip-Hop Culture, but Dangers Are Downplayed

In big cities and small towns, opioid use among some young hip-hop fans is about emulating their favorite rap star’s image — while paying little attention to the serious consequences.

Nykerrius Williams knows about the close relationship between hip-hop and opioid use. Williams, 27, an independent rapper from Gibsland, Louisiana, who goes by the name Young Nyke, took oxycodone pills for the first time when he was 16 and has continued patterns of misuse of those pills, as well as Lortabs, Xanax and codeine cough syrups, until recently. To him, it’s part of the business.

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“If you ain’t rapping about being on no drugs, or you out here in the streets selling some drugs,” he said of his chosen profession, “you ain’t got some of that going on — like, don’t nobody wanna hear what you talking about.”

This snapshot of Williams’ hip-hop life doesn’t seem all that different from that of musicians of other genres for whom the mix of drugs and addiction is a recurring storyline, claiming the lives of artists like Janis Joplin, found dead of a heroin overdose in 1970, and rapper DMX, who died last month.

But drug use in the hip-hop community has an ever increasing presence that is intertwined with the music – and one with dire consequences. The catchy lyrics suggest that opioid misuse is part and parcel with fame and wealth, just a normal, and innocuous, component of that life.  

Coverage on the abuse of hard drugs in the community usually focuses on tragedy surrounding certain popular rappers rather than the lyrics and the culture they create. And while public health experts take great pains, for example, to criticize and curtail the promotion of vaping to young people, little attention is paid to the dangerous effects that hip-hop is having on vulnerable listeners by normalizing popping Percocets or drinking cough syrup.

From big cities like Los Angeles to rural towns like Gibsland — population 878 — opioid misuse among some young, hopeful listeners is about emulating their favorite rap star’s enviable image. For others, it is not all about the high life. It’s self-medication.

“Let’s talk about pain,” said Mikiel Muhammad, 38, aka King Kong Gotcha, a member of the rap trio The Opioid Era in Virginia. “The pain is so deep. They ain’t got money to go see a psychiatrist, but they got money to go get a Perc-10. They got $10, $15 for that,” Gotcha said, referencing the street value of a 10-milligram Percocet tablet.

According to a February KFF report, anxiety, depression and thoughts of suicide have increased for young adults in the past year.

Artists like Young Nyke sometimes confront neighborhood and family violence, as well as a general lack of opportunities and resources in their communities — circumstances amplified by the covid pandemic. The poetic words detailing the rappers’ experience offer some support. But these phrases can also be fraught.

It’s not just the drug use that is worrisome, said Naa-Solo Tettey, an associate professor of public health at William Paterson University in Wayne, New Jersey. Often these songs promote using opioids while engaging in high-risk activities like unprotected sex or speeding and, while she is a hip-hop fan, “from a public health perspective, it’s just dangerous,” she said.

That toxicity reaches into populations already plagued by perpetual cycles of poverty, poor health and lowered life expectancy. There is a need for “culturally relevant interventions” to educate and raise awareness within the hip-hop music audience, which Tettey’s research categorizes as primarily composed of youth from “vulnerable and socially disadvantaged” groups.

It is time to turn a critical eye to how opioid misuse permeates hip-hop’s lyrics, creating an entryway for Black young adults into the American opioid epidemic, said Tettey.

In 2017 that epidemic was declared a national public health emergency, with over 47,000 opioid-related overdose deaths reported. Researchers at the Centers for Disease Control and Prevention say fatal drug overdoses nationwide have surged roughly 20% during the covid pandemic, killing more than 83,000 people in 2020. Within this grim statistic the Substance Abuse and Mental Health Services Administration has found inequities.

According to a 2020 report from the Department of Health and Human Services’ Office of Behavioral Health Equity and SAMHSA, attention to this crisis has focused more on white suburban and rural communities, even though Black communities are experiencing similar dramatic increases in opioid misuse and death. The report also found that synthetic opioids, like fentanyl, are affecting opioid death rates among Black people more severely than other populations.

A 2020 SAGE journal research paper found a large increase in prescription opioid overdose deaths among Black people. The paper also found the rate of death almost tripling between 1999 and 2017. In February 2018 the U.S. surgeon general tweeted a warning that trends in opioid misuse “may be a precursor to even more opioid overdose fatalities in the black community in coming years.”

“The music industry, all it does is perpetuate whatever’s going on outside,” said Jarrell Gilliard, 40, explaining the pharmaceutical drug presence he’s encountered and how it’s reflected in popular lyrics. “How they pump these pills and all these prescribed medicines through the streets. Once the streets got ’em …” said Gilliard, whose hip-hop alias is Grunge Gallardo.

Grunge is also a member of The Opioid Era, named for their gritty, raw imagery and lyrics. Songs such as “Suboxones,” “Sackler Oath” and “Overdose,” which opens with a haunting 911 recording of a woman frantically pleading for help with one, contrast sharply with the pill-laced tunes of hip-hop’s mainstream.

“I think that’s the most dangerous thing about it,” said Richard Buskey, 42, who completes The Opioid Era trio as Ambassador Rick. “It’s a disconnect between the youth and them realizing that they’re in the same category as what they would consider a junkie or a fiend.”

Tettey said that’s partly because mainstream artists represent a lifestyle many young adults want for themselves, which can translate into modeling behaviors like opioid misuse.

Feeling the ‘Lean’

Patrick Williams, 26, an independent rapper from Orange, Texas, with the stage name PatvFoo, is no stranger to addiction.

He was 21 when he first sipped “lean” — a drink made from mixing prescription cough syrup containing the antihistamine promethazine and the opioid codeine with soda, Jolly Rancher candies and ice, served in doubled-up Styrofoam cups. “It’s a variety of colors that you have,” PatvFoo said, referencing the various formulations of codeine cough syrups. Purple syrup ranks as most potent. PatvFoo learned about lean through the Texas rap scene and artists like DJ Screw and then became a user.

“At first, there’s a mellowing high,” said Stevie Jones, 23, also known as Prophet J, an independent rapper in Louisville, Kentucky. He has similar recollections from his first time misusing codeine syrups. He and his friends drizzled some on a blunt — the slang term for a hollowed-out cigar filled with pot. “It just makes it burn slower — like, get you a little bit higher, I guess,” Prophet J said.

Things can take a bad turn quickly. Although lean is one of the weaker opioids, experts say it is highly addictive, and often in a short time. “The day you go without it you get bad, bad stomach cramps. You feel like you got to just throw up all the time. You sweating. It’s like you got a bad flu,” PatvFoo said.

That flu-like feeling is opioid withdrawal, said Dr. Edwin C. Chapman, a Howard University College of Medicine alum who has practiced internal and addiction medicine in Washington, D.C., for more than 40 years. The symptoms range from runny nose and eyes to diarrhea and usually can be stopped with a gulp of cough syrup or lean, he said.

And there’s a harsh reality in that. Whether it’s Percocet pills or lean, “it’s all in the same class as heroin and fentanyl,” Chapman said.

But learning that opioid use is promoted in popular music came as a revelation to Chapman. “That’s not the music that I listened to,” said the 75-year-old doctor. The medical community, he said, has been focused on curbing the overprescribing of pain medication. “But it’s never talked about … that it’s being advertised overtly to young folks through music or through the media.”

Indeed, abuse of lean, also known as “purple drank” and “sizzurp,” has managed to evade the regulatory spotlight while remaining popular and recognizable — so much so that vaping companies distributed nicotine-containing e-liquids resembling the drink and even mimicked the slang term “double cup” in their labeling. These products triggered a 2019 Food and Drug Administration crackdown on the vaping juices. The drugs themselves, however, still pump through the streets, just like the hip-hop lyrics.

And it has altered the market, moving it beyond the street options of heroin and opioids, said hip-hop artist Buskey. “We living in the times where they’re getting it out of the medicine cabinet.”

Phillip Coleman, 34, a rapper in Rochester, New York, who goes by the name GodclouD, started using at age 15 after being prescribed 5-milligram tablets of Percocet following wisdom tooth extraction. That set him on a path to misusing prescription painkillers, which led to cocaine and then a heroin addiction that eventually landed him in prison.

Fortunately, Coleman was able to overcome his addictions in rehab and refocus on family and music. He cautions that people buying Percocet or other prescription pills on the street have no way of knowing if they are legitimate or “just pressed fentanyl.” He said the reward for opioid addiction isn’t the lifestyles of the rich and famous you see portrayed by some hip-hop artists. “You don’t get to trade in your empty bags like the box tops and get, like, a bike or whatever. Like, you don’t get no hat; you don’t get no fentanyl swag,” he chuckled. “Like, you just die.”

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).