Category: Rural Health

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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In Rural America, Deadly Costs of Opioids Outweigh the Dollars Tagged to Address Them

Some people say it’s reasonable for densely populated areas to receive more settlement funds, since they serve more of those affected. But others worry this overlooks rural communities disproportionately harmed by opioid addiction.

Tim Buck knows by heart how many people died from drug overdoses in his North Carolina county last year: 10. The year before it was 12 — an all-time high.

Those losses reverberate deeply in rural Pamlico County, a tightknit community of 12,000 on the state’s eastern shore. Over the past decade, it’s had the highest rate of opioid overdose deaths in North Carolina.

“Most folks know these individuals or know somebody who knows them,” said Buck, the county manager and a lifelong resident, who will proudly tell anyone that four generations of his family have called the area home. “We all feel it and we hate it when our folks hurt.”

Now, the county is receiving money from national settlements with opioid manufacturers and distributors to address the crisis. But by the time those billions of dollars are divided among states and localities, using formulas partially based on population, what trickles down to hard-hit places like Pamlico County can be a trifling sum.

Out of one multibillion-dollar national settlement, Pamlico County is set to receive about $773,000 over nearly two decades. By contrast, Wake County, home to the capital city of Raleigh, is set to receive $36 million during the same period, even though its opioid overdose death rate for the past decade ranked 87th in the state.

Buck said his county’s share “is not a lot of funds per year. But I’m glad we have something to try to reduce that overdose number.”

Rural communities across America were harbingers of the opioid crisis. In the 1990s, misleading marketing by opioid companies helped drive up prescription rates, particularly in coal, lumber, and manufacturing towns across Appalachia and Maine. As painkillers flooded communities, some residents became addicted. Over time, they started using heroin and fentanyl, and the deadly epidemic spilled into suburbs and cities across the nation.

State and local governments filed thousands of lawsuits against drug companies and wholesalers accused of fueling the crisis, resulting in a plethora of settlement deals. The largest to date is a $26 billion settlement that began paying out this year.

As the funds arrive, some people say it’s reasonable for densely populated cities and counties to receive more, as they serve a greater number of residents. But others worry such an approach misses an opportunity to use that money to make a difference in rural communities that have been disproportionately affected for decades.

“You could really diminish what is effectively generational, more than 20 years of harm in rural areas,” said Robert Pack, co-director of East Tennessee State University’s Addiction Science Center.

Just because rural areas are less populated doesn’t mean it’s cheaper to provide health services there. Research suggests the per-person cost can be greater when counties can’t capitalize on economies of scale.

In West Virginia, Attorney General Patrick Morrisey has rejected several national opioid settlements because of their distribution methods and pursued separate lawsuits instead, saying the state needs a deal that reflects the severity of its crisis, not the size of its population.

Allocations from the $26 billion national settlement were determined by each state's population and the portion of overdose deaths, residents with opioid use disorders, and prescription painkillers it contributed to the nation’s total. Many states used similar formulas to distribute funds among their cities and counties.

Although the goal was to reflect the severity of each area’s crisis, those statistics tend to scale up by population. Further, some experts say wealthier communities with higher rates of prescription drug use may benefit while poorer communities affected by heroin and fentanyl may lose out.

Pennsylvania took a different route, devising its own formula to distribute funds among 67 counties — taking into account opioid-related hospitalizations and first responders’ administration of naloxone, an overdose reversal medication. When that formula left 11 rural counties without “enough money to make an impact,” the state decided each county would receive a minimum of $1 million over the 18-year settlement period, said Glenn Sterner, an assistant professor at Penn State who helped develop the state formula and co-authored a paper on it.

In other parts of the country without guaranteed minimums, some local officials say their share of the settlement funds won’t cover one psychologist’s salary, let alone the creation of treatment facilities.

But medical treatment — among the most expensive interventions — is just one piece of the puzzle, said Nidhi Sachdeva, who leads health and opioid initiatives for the North Carolina Association of County Commissioners. She recommends that rural counties explore lower-cost, evidence-based options like distributing naloxone, funding syringe service programs, or connecting people to housing or employment.

Another option is to pool resources among counties. In eastern North Carolina, Martin, Tyrrell, and Washington counties plan to funnel their settlement dollars into a long-standing regional health department, said David Clegg, manager and attorney for Tyrrell County. With a combined population of 36,000, the three counties have used a similar approach in combating covid-19 and sexually transmitted infections.

When it comes to funding, “we’re always the caboose of the train,” Clegg said of his county. “We couldn’t function if we didn’t partner for lots of different services.”

In Colorado, pooling funds is built into the state’s model for managing opioid settlement money. The lion’s share of funds is going to 19 newly formed regions, about half of which comprise multiple counties.

Regions 18 and 19 together have a population of less than 300,000 spread across an area in southeastern Colorado bigger than Connecticut, New Jersey, and Vermont combined. Since 2016, residents of those regions have landed in the emergency room for opioid overdoses at rates higher than those elsewhere in the state. And in the past decade, people in Regions 18 and 19 have died of opioid overdoses at rates rivaled only by Denver. But combined they are receiving only about 9% of all funds being distributed to the regions.

“It is what it is,” said Wendy Buxton-Andrade, a Prowers County, Colorado, commissioner and chair of the opioid settlement board for Region 19. “We get what we get, we don’t throw a fit, and you just figure out ways to make it work.”

Region 18 was allocated less than $500,000 for six southern Colorado counties for the first year. Lori Laske, an Alamosa County commissioner and chair of the region’s opioid settlement committee, said its members hope to recruit private entities to fill in gaps the funding won’t cover. For example, as of mid-November, her county was in the process of selling a building behind the sheriff’s office to an organization with plans to turn it into a 30-bed recovery center.

“Nobody has paid any attention to our rural areas and this problem for years,” Laske said. The money “is never enough, but it's more than we had, and it's a start.”

The state has set aside 10% of its opioid settlement dollars for what it’s dubbed “infrastructure,” which can include workforce training, telehealth expansion, and transportation to treatment. Any region can apply for that money. The idea “is to provide additional funds for those areas of the state that are hardest hit,” said Lawrence Pacheco, a spokesperson for the Colorado attorney general.

Pack, the expert from East Tennessee State University, said partnering with private companies can help sustain programs after settlement funds run out. For example, a county could build a treatment facility, then find a local hospital to staff it. Or it could partner with local banks and real estate developers to find unused buildings to renovate as recovery houses.

“We need to be creative and make a good business case for those kinds of partnerships,” Pack said.

For counties that aren’t sure where to start, Samantha Karon, who oversees substance use disorder programs for the National Association of Counties, suggested analyzing data and interviewing community members to identify and prioritize gaps in services.

Surry County in northwestern North Carolina, along the Virginia border, undertook this process last year. County staffers and volunteers conducted 55 in-depth interviews, gathered more than 700 responses to an online survey, and reviewed national, state, and local data. They cross-referenced the results with a list of allowable uses for the $9 million in settlement funds they’ll receive over 18 years to create a priority grid.

“It’s a graphic representation of where we should go first,” said Mark Willis, director of the county’s Office of Substance Abuse Recovery.

To his surprise, residents’ top priority wasn’t simply more treatment facilities, but rather a continuum of services to prevent addiction, treat it, and help people in recovery lead stable and successful lives. As a result, his office is considering creating a community recovery center or funding more peer support specialists. The county also plans to continue the assessment process in coming years and shift efforts accordingly.

Meanwhile, in Pamlico County, Buck said he and other leaders are open to all ideas to decrease the overdose deaths that have racked their community.

Although building a treatment center is unrealistic, they’re looking at low-cost programs that can deliver more bang for the buck. They’re also considering investing other county funds into a project early on and reimbursing themselves with settlement payouts in later years, if the agreement allows that.

“We don’t want anybody to die a tragic death,” Buck said. “Our challenge is figuring out what role we can play in preventing that with the funds we have.”

Methodology

For North Carolina counties, the rates of opioid deaths were calculated by dividing the sum of opioid deaths from 2010 to 2020 by the sum of the annual population estimates from 2010 to 2020. Counts of “illicit opioid deaths” came from the state health department’s Opioid and Substance Use Action Plan Data Dashboard. Deaths involve heroin, fentanyl, fentanyl analogues, or prescription opioids. Data is based on the county of residence, which may differ from where the death occurred. Population estimates came from national Census Bureau data.

Funding estimates for each county come from the North Carolina Opioid Settlements data dashboard and reflect funds from the settlement with Johnson & Johnson and the “Big Three” drug distributors (AmerisourceBergen, Cardinal Health, and McKesson).

For Colorado, regional rates for opioid deaths were calculated by dividing the sum of opioid deaths from 2010 to 2020 by the sum of annual population estimates from 2010 to 2020. Deaths came from Colorado’s Vital Statistics Program, with cause of death listed as “drug overdose involving any opioid (prescription or illicit, including heroin).”

Regional rates for opioid-related emergency department visits were calculated by dividing the sum of such visits from 2016 to 2021 by the sum of annual population estimates from 2016 to 2021. Emergency department visit counts come from the Colorado health department’s drug overdose dashboard and are for drug overdoses with “any opioid (includes prescription sources, fentanyl and heroin).” They are provided by the patient’s county of residence and were originally compiled by the Colorado Hospital Association.

For both the death rate and emergency department visit rate, regional populations were calculated by adding up the Census Bureau’s annual county totals for member counties. The regions are defined in Exhibit C of Colorado’s Memorandum of Understanding. Regional funding estimates come from the Colorado attorney general’s opioid settlement dashboard and reflect funds from settlements with McKinsey & Co., Johnson & Johnson, and the “Big Three” drug distributors (AmerisourceBergen, Cardinal Health, and McKesson).

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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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 Radio, NPR 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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This story can be republished for free (details).