Addiction Treatment Proponents Urge Rural Clinicians to Pitch In by Prescribing Medication

The number of U.S. health care providers certified to prescribe buprenorphine more than doubled in the past four years, and treatment advocates hope to see that trend continue.

MARSHALLTOWN, Iowa — Andrea Storjohann is glad to see that she’s becoming less of a rarity in rural America.

The nurse practitioner prescribes medication to dozens of patients trying to recover from addiction to heroin or opioid painkillers.

The general-practice clinic where she works, housed in a repurposed supermarket building, has no signs designating it as a place for people to seek treatment for drug addiction, which is how Storjohann wants it.

“You could be coming here for OB-GYN care. You could be coming here for a sore throat. You could be coming here for any number of reasons,” and no one in the waiting room would know the difference, she said.

Privacy is an important part of the treatment. And so is the medication Storjohann prescribes: buprenorphine, which staves off cravings and prevents withdrawal symptoms for people who have stopped misusing opioid drugs. The central Iowa clinic, owned by the nonprofit agency Primary Health Care, has offered buprenorphine since 2016. “We were kind of a unicorn in this part of the state,” Storjohann said, but that’s changing.

Unlike methadone, the traditional medication to wean people off heroin or other opioids, buprenorphine can be prescribed at primary care clinics and dispensed at neighborhood pharmacies. Federal and state authorities have encouraged more front-line health care professionals to prescribe Suboxone and other medications containing buprenorphine for patients trying to overcome opioid addiction. Federal regulators have made it easier for doctors, nurse practitioners, and physician assistants to become certified to offer the service.

The opioid crisis has deepened in the past decade with the illicit distribution of fentanyl, a powerful, extremely addictive opioid. Its prevalence has complicated the use of medication to treat opioid addiction. Patients who have been misusing fentanyl can suffer severe withdrawal symptoms when they begin taking buprenorphine, so health practitioners must be careful when starting the treatment.

In Iowa, officials designated $3.8 million from the state’s initial share of opioid lawsuit settlement money for a University of Iowa program that helps health care providers understand how to use the medications.

Federal agencies are spending millions to expand access to medication to treat addictions, including in rural areas. The Health Resources and Services Administration, which aims to improve health care for underserved people, offers many of these grants.

Carole Johnson, the agency’s top administrator, said she hopes increased training on treating opioid addiction encourages health care providers to learn the latest ways to treat other kinds of addiction, including methamphetamine dependence and alcoholism, which plague many rural states. “We’re sensitizing people to substance use disorder writ large,” she told KHN.

In 2016, just 40% of rural counties nationwide had at least one health care provider certified to prescribe buprenorphine, according to a University of Washington study. That figure climbed to 63% by 2020, the study found.

The study credited the rise to changes in federal rules that allow nurse practitioners, physician assistants, and other midlevel health care providers to prescribe buprenorphine. In the past, only physicians could do so, and many rural counties lacked doctors.

Buprenorphine is an opioid that pharmacies most often sell as a tablet or a film that both dissolve under the tongue. It does not cause the same kind of high as other opioid drugs do, but it can prevent the debilitating withdrawal effects experienced with those drugs. Without that help, many people relapse into risky drug use.

The idea of opioid “maintenance treatment” has been around for more than 50 years, mainly in the form of methadone. That drug is also an opioid that can reduce the chance of relapse into misusing heroin or painkillers. But the use of methadone for addiction treatment is tightly regulated, due to concerns that it can be abused.

Only specialized clinics offer methadone maintenance treatment, and most of them are in cities. Many patients starting methadone treatment are required to travel daily to the clinics, where staffers watch them swallow their medicine.

Federal regulators approved Suboxone in 2002, opening an avenue for addiction treatment in towns without methadone clinics.

Storjohann said buprenorphine offers a practical alternative for Marshalltown, a town of 27,000 people surrounded by rural areas.

The nurse practitioner spends about half her time working with patients who are taking medications to prevent relapse into drug abuse. The other half of her practice is mental health care. A recent appointment with patient Bonnie Purk included a bit of both.

Purk, 43, sat in a small exam room with the nurse practitioner, who asked about her life. Purk described family struggles and other stressors she faces while trying to abstain from abusing painkillers.

Storjohann asked whether Purk felt hopeless. “Or are you just frustrated?”

Purk thought for a moment. “I went through a week where I was just crying,” she said, wiping her eyes with a tissue. But she said she hasn’t been seriously tempted to relapse.

Storjohann praised her persistence. “You’re riding a roller coaster,” she said. “I think you need to give yourself some grace.”

Purk knows Suboxone is not a miracle cure. She has taken the medication for years, and twice relapsed into misusing pain pills. But she has avoided a relapse since spring, and she said the medication helps.

In an interview after her monthly appointment with Storjohann, Purk said the medicine dulls cravings and blocks withdrawal symptoms. She recalled terrible night sweats, insomnia, diarrhea, and jitters she suffered when trying to stop abusing pills without taking Suboxone.

“You focus on nothing but that next fix. ‘Where am I going to get it? How am I going to take it?’” she said. “You just feel like a train wreck — like you’ll die without it.”

Purk said mental health counseling and frequent drug tests have also helped her remain sober.

Patients can stay on buprenorphine for months or even years. Some skeptics contend it’s swapping one drug dependence for another, and that it should not be seen as a substitute for abstinence. But proponents say such skepticism is easing as more families see how the treatment can help people regain control over their lives.

Dr. Alison Lynch, a University of Iowa addiction medicine specialist, warned about the risks of fentanyl and buprenorphine in a recent lecture to health professionals in training.

Lynch explained that fentanyl remains in the body longer than other opioids, such as heroin. When someone with fentanyl in their system takes buprenorphine, it can cause a particularly harsh round of nausea, muscle pain, and other symptoms, she said. “It’s not dangerous. It’s just miserable,” she said, and it can discourage patients from continuing the medication.

Lynch noted drug dealers are lacing fentanyl into other drugs, so people don’t always realize they’ve taken it. “I just make the assumption that if people are using any drugs they bought on the street, it’s probably got fentanyl,” she said. Because of that, she said, she has been using smaller initial doses of buprenorphine and increasing the dosage more gradually than she used to.

Nationwide, the number of health professionals certified to prescribe buprenorphine has more than doubled in the past four years, to more than 134,000, according to the federal Substance Abuse and Mental Health Services Administration. Efforts to expand access to the treatment come as drug overdose deaths have more than doubled in the U.S. since 2015, led by overdoses of fentanyl and other opioids.

Storjohann would like to see more general clinicians seek training and certification to prescribe buprenorphine at least occasionally. For example, she said, emergency room doctors could prescribe a few days’ worth of the medication for a patient who comes to them in crisis, then refer the patient to a specialist like her. Or a patient’s primary doctor could take over the buprenorphine treatment after an addiction treatment specialist stabilizes a patient.

Dr. Neeraj Gandotra, chief medical officer of the Substance Abuse and Mental Health Services Administration, said he sees potential in expanding such arrangements, known as a “hub and spoke” model of care. Family practice providers who agree to participate would be assured that they could always send a patient back to an addiction treatment specialist if problems arose, he said.

Gandotra said he hopes more primary care providers will seek certification to prescribe buprenorphine.

Johnson, the Health Resources and Services Administration administrator, said states can also increase access to medication-assisted treatment by expanding their Medicaid programs, to offer health insurance coverage to more low-income adults. The federal government pays most of the cost of Medicaid expansion, but 11 states have declined to do so. That leaves more people uninsured, which means clinics are less likely to be reimbursed for treating them, she said.

Health care providers no longer are required to take special classes to obtain federal certification — called a “waiver” — to treat up to 30 patients with buprenorphine. But Lynch said even veteran health care providers could benefit from training on how to properly manage the treatment. “It’s a little daunting to start prescribing a medication that we didn’t get a lot of training about in medical school or PA school or in nursing school,” she said.

Federal officials have set up a public database of health care providers certified to offer buprenorphine treatment for addiction, but the registry lists only providers who agree to include their names. Many do not do so. In Iowa, only about a third of providers with the certification have agreed to be listed on the public registry, according to the Iowa Department of Health and Human Services.

Lynch speculated that some health care professionals want to use the medication to help current patients who need addiction treatment, but they aren’t looking to make it a major part of their practice.

Storjohann said some health care professionals believe addiction treatment would lead to frustration, because patients can repeatedly relapse. She doesn’t see it that way. “This is a field where people really want to get better,” she said. “It’s really rewarding.”

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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A Needle Exchange Project Modeled on Urban Efforts Aims to Save Lives in Rural Nevada

Five years after HIV tore through a rural Indiana town as a result of widespread drug use, a syringe and needle exchange program was set up in rural Nevada to prevent a similar event.

ELKO, Nev. — Richard Cusolito believes he’s saving lives by distributing clean syringes and needles to people who use drugs in this rural area of northeastern Nevada — but he knows some residents disagree.

“I’m hated in this town because of it,” said Cusolito, 60. “I’m accused of ‘enabling the junkies,’ pretty much is the standard term. People don’t get the impact of this whole thing.”

Drugs, including heroin and other opioids, are readily available in Elko, and Cusolito said a program like his has long been needed. Cusolito is a peer recovery support specialist and received training through Trac-B Exchange, a Las Vegas-based organization that provides a range of harm reduction services throughout Nevada.

In a city the size of Elko, with 20,000 residents, Cusolito’s work has hit close to home. He helped his daughter access rehabilitation services, and earlier this year, she died from an overdose.

“I just keep up hope for the ones that I can help,” he said.

Cusolito has run the exchange program since 2020, when the Elko City Council approved a resolution that gave him permission to hand out needles and syringes at the city’s camp for homeless people. The agreement was originally for one year, but the council recently renewed it for three.

Elko officials’ approval of Cusolito’s work comes as leaders in small, often conservative cities have been asked to adopt policies forged in large, more liberal cities, such as New York and San Francisco. Federal reports show people who use needle exchange programs are five times as likely to start drug treatment programs and three times as likely to stop using drugs as people who do not, but programs in Nevada and other states have faced similar pushback.

Scott Wilkinson, assistant city manager for Elko, said the city’s ability to provide resources to people who use drugs is limited. “We’ve done what we can do to try to help out, but we don’t have a health department,” Wilkinson said.

Trac-B Exchange funds Cusolito’s project, and he provides reports to the city about how many syringes and needles he distributes and collects for disposal.

Needle exchanges are part of efforts known as harm reduction, which focus on minimizing the negative effects of drug use, rather than shaming people. In recent years, harm reduction tactics have begun to spread to rural areas, said Brandon Marshall, an associate professor of epidemiology at the Brown University School of Public Health.

Marshall said a 2015 HIV outbreak fueled by drug use in rural Austin, Indiana, became a “canary in the coal mine,” showing how shared needles could spread the virus. A syringe exchange program could have averted the outbreak or reduced the number of people who were infected, according to a modeling study that Marshall co-authored in 2019.

Cusolito is trying to prevent that kind of disaster in Elko. His small office, in a gray building just off the main street near downtown, isn’t eye-catching from the outside. A “Trac-B Exchange” placard is posted outside, but it doesn’t identify the space as a syringe and needle exchange. Yet Cusolito estimates he sees 100 to 150 people a month, relying on word-of-mouth.

He also visits the jail, helping people booked on drug charges complete assessments required to receive treatment at rehabilitation facilities.

He is adamant that participants turn in their used syringes and needles before getting replacements. The old ones go into a sharps container — a sturdy plastic box — that he sends to Trac-B Exchange in Las Vegas, where they are sterilized and pulverized for safe disposal.

Trac-B Exchange’s harm reduction efforts also reach other areas of rural Nevada: A peer recovery support specialist runs a needle exchange program in Winnemucca, 124 miles from Elko and home to 8,600 people. In Hawthorne, which has fewer than 3,500 residents, leaders approved installing a vending machine that is operated by the organization and contains clean syringes and needles, as well as condoms, tampons, and body soap. In 2019, the organization installed two sharps containers in Ely, a city of fewer than 4,000 residents.

Trac-B Exchange program director Rick Reich said the organization has been offering services in rural areas to help people there use drugs more safely or find resources so they can become and stay sober. The services include assistance in obtaining identification documents, housing, and jobs.

“You’re trying to get a carrot that someone will go after,” he said, referring to the clean needles and syringes. “Then as they come to you, to get that carrot and eat that carrot, they can see that you have other things available and that you aren’t the scary person that they thought you were in the nightmare that they were living.”

In 2020, the overdose death rate in Nevada was 26 per 100,000 people, 27th-highest among states, according to the Centers for Disease Control and Prevention. That year, as the spread of covid-19 spurred stay-at-home orders and shuttered businesses, more than 800 Nevadans died from overdoses.

Seven years since the 2015 HIV outbreak in Indiana, seven states still don’t have any syringe exchange programs, according to a KFF analysis. In some states, harm reduction workers could face criminal penalties for carrying clean syringes or strips that detect the presence of the synthetic opioid fentanyl, which is 50 to 100 times as strong as morphine.

Nevada’s legislature passed a law in 2013 that legalized syringe and needle exchange programs so peer recovery support specialists like Cusolito can do their work.

But that doesn’t mean such efforts are always accepted.

Cusolito said he can put aside nasty comments because he believes in the work he’s doing. He recalled a client who had one of the worst heroin addictions he’d ever seen. “I didn’t think he’d survive,” Cusolito said. After connecting with Cusolito and going through treatment, the client went back to work, bought a house, and got married. He still checks in with Cusolito every couple of months to tell him about his latest achievements.

Clients with stories like those help Cusolito move forward when other challenges of the job weigh on him. The hardest part is losing clients.

“Sometimes I feel really strong and like I can beat the world,” he said, “and other times I think about when I got the knock on the door, you know? I want to lock the door and not let anybody in because I don’t want to deal with anybody else who might 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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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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