“I really was, at the beginning, very nervous,” Tipton said.

MDMA is the main ingredient in the club drug known as ecstasy or molly. But Tipton wasn’t taking pills sold on the street to get high. She was trying to treat her post-traumatic stress disorder by participating in a clinical trial.

After taking a dose of pure MDMA, Tipton lay in a quiet room with two specially trained psychotherapists. They sat next to her as she recalled some of her deepest traumas, such as discovering her mother’s body after Tipton’s mother killed two people and then herself in a murder-suicide.

“In the embrace of MDMA,” Tipton said, she could revisit that moment without the usual terror and panic. “I was able to find such empathy for myself.”

Scientists are testing how pharmaceutical-grade MDMA can be used in combination with psychotherapy to help patients with a severe form of PTSD that has not responded to other treatments. Unlike street drugs, which may be adulterated and unsafe, researchers use a pure, precisely dosed form of the drug.

MDMA is not yet available as a treatment for PTSD outside of clinical trials. But proponents are aiming for approval by the Food and Drug Administration, which granted status to MDMA-assisted psychotherapy in 2017.

Researchers are conducting Phase 3 clinical trials at more than a dozen sites. Clinicians who treat PTSD are hopeful the next round of trials will show that MDMA treatment is an effective option to relieve patient suffering.

“The problem is we haven’t had a new drug to treat PTSD in over 17 years,” said Dr. Sue Sisley, a physician and president of the , based in Arizona. “There are certain illnesses that are just intractable and not responsive to traditional therapy, and we need to start thinking more broadly.”

But MDMA is a , which means it currently has no accepted medical use and has a “high potential for abuse” (something that MDMA’s therapeutic proponents dispute). Because of that designation, the current research trials are privately funded by the , or MAPS.

‘Anywhere I Would Feel Unsafe’

Tipton struggled for years with PTSD before she was treated with MDMA. She said life with PTSD was like “seeing the world through dirty goggles.”

“Anywhere I would feel unsafe,” the 40-year-old from New Orleans said. “I would feel like I had to always be vigilant because if I didn’t, something bad was going to happen.”

Tipton described her 20s as a catalog of tragedy and trauma. It began when her brother fatally overdosed in her home. After his death, she began caring for her mother, who struggled with mental illness. In 2005, Tipton’s mother killed two people and then herself. Tipton discovered their bodies.

“I completely just disassociated. I couldn’t believe what I was seeing,” Tipton said.

The traumas continued to pile up. The place she lived was destroyed when Hurricane Katrina hit New Orleans, and the following year, she was raped.

As the years went by, Tipton had panic attacks and terrible anxiety. She tried everything to treat her symptoms: talk therapy, antidepressants, hypnotherapy, meditation and yoga. Nothing worked. She went through life exhausted and apathetic, constantly triggered and struggling to be intimate with people close to her.

Then Tipton enrolled in the Phase 2 clinical trials for MDMA-assisted psychotherapy.

MDMA And Therapy Together

MDMA was first synthesized in 1912, and its therapeutic benefits were studied in the 1970s. But those efforts stalled when the U.S. federal government — in light of the growing popularity of ecstasy as a recreational drug — it a Schedule I drug in 1985.

In recent years, research has resumed, funded by private sponsors such as MAPS.

The treatment protocol in the current trial calls for a 12-week course of psychotherapy with specially trained therapists. During that time, there are two or three daylong sessions, which begin with the patient taking a calibrated dose of MDMA in pill form.

A team of two therapists, generally one man and one woman, then guide the patient through the eight-hour MDMA “session.” Later, there’s follow-up talk therapy, without the drug, to help the patient process feelings, thoughts or impressions that came up while under the influence of the drug.

“MDMA allows you to contact feelings and sensations in a much more direct way,” said Saj Razvi, a Colorado-based psychotherapist who was a clinical investigator in the Phase 2 trials.

How MDMA works in the brain is not completely understood. The boosts chemicals like serotonin and oxytocin. It also tamps down activity in the amygdala, a part of the brain that processes fear. This may lead to a state characterized by heightened feelings of safety and social connection.

“Trauma happens in isolation,” Razvi said. “One of the things that MDMA does is, really, lets you know that you are not alone.”

PTSD In Remission

After the Phase 2 trials of MDMA-assisted treatments concluded in 2017, researchers found that 54% of the 72 patients who took MDMA had improved to the point that they the diagnosis for PTSD (compared with 23% in the control group).

And the beneficial effects of the treatment appeared to increase over time. A year later, the number who no longer had PTSD had risen to 68%.

“That was astonishing,” Sisley said. “Even with the best pharmaceutical regimen, you rarely ever see patients go into remission.”

She said she hopes to offer her patients MDMA-assisted psychotherapy as soon as possible, maybe before the drug receives full FDA approval.

Brad Burge, a spokesman for MAPS, said that, beyond sponsoring the MDMA trial, the organization is working to get the FDA to include the drug in its , which can allow individual patients to be approved to use drugs that are still being studied.

Burge said the goal is to make MDMA-assisted psychotherapy available as a prescription treatment in a specialty clinic to anyone with PTSD.

And MAPS is working to persuade public and private insurance plans to cover the treatment, Burge said. He estimates that for patients paying entirely out-of-pocket, a 12-week course of treatment would cost between $5,000 and $10,000.

Most of the cost is for the guided therapy, not the actual drug.

Transformative Treatment

Tipton describes her treatment with MDMA as transformative.

She was able to let go of the troubling feelings surrounding her mother’s death. And, she unearthed other memories, too, feelings of joy that had been sealed away.

By her last MDMA session, Tipton was even able to talk about her sexual assault.

A year later, she was reassessed and no longer qualified as having PTSD. Tipton said she believes the treatment saved her life.

“Everything is at my fingertips for me in a way that it never was before,” she said. “I want that for everybody.”

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Sin embargo, todos los reportes indican que no hay suficientes médicos que se especialicen en el tratamiento de la adicción, médicos con amplia capacitación clínica que cuenten con una certificación oficial en esta especialidad.

La epidemia de opioides ha puesto en evidencia este déficit profesional. Y está obligando a las instituciones médicas del país a crear becas para estudiantes de medicina que deseen tratar estos trastornos con la misma precisión científica que otras enfermedades.

Estas becas, que ya suman más de 60, ofrecen a los médicos un año o dos de capacitación de posgrado en clínicas y hospitales donde aprenden enfoques basados en la evidencia para el tratamiento de la adicción.

Estos programas están atrayendo a una nueva y talentosa generación de médicos idealistas, tan idealistas como la doctora Hillary Tamar.

En busca de pacientes necesitados

Tamar, ahora en su segundo año de residencia en medicina de familia en Phoenix, asegura que no pensó en la especialidad en adicciones cuando empezó a estudiar en Chicago.

“La verdad es que, como estudiante de medicina, una hace su rotación en Urgencias, nos distanciamos de los pacientes llamándoles ‘los que buscan el dolor’, y no está bien”, señaló Tamar.

Pero en su cuarto año en la facultad de medicina, le asignaron una rotación en un centro de rehabilitación en el sur de Arizona.

“Pude conectar con las personas de una manera que no lo había hecho en otra especialidad”, recordó la joven de 28 años.

Trabajar con estos pacientes transformó su manera de entender la adicción, contó Tamar, y le mostró el potencial que tenían los médicos para cambiar vidas.

“Pueden pasar de ocupar todo su tiempo en busca de una droga a ser hermanos, hermanas, hijas y padres que preparan de nuevo el desayuno para sus hijos”, explicó. “Es realmente poderoso”.

Cuando Tamar termine su residencia, piensa solicitar una beca en medicina de la adicción. Para ella, la medicina de la adicción es como la atención primaria, una manera de construir relaciones duraderas con los pacientes. Y una forma de enfocarse en algo más que en un diagnóstico único.

“Me encanta cuando veo pacientes de adicción en mi turno, incluso si están embarazadas y consumen metanfetaminas”, comentó. “Siento que tengo la oportunidad de hacer el bien, es emocionante”.

Si hay un programa, habrá pacientes

Se necesitan muchos médicos con el entusiasmo de Tamar, señaló la doctora Anna Lembke, directora de medicina de la adicción en la Facultad de Medicina de la Universidad de Stanford e investigadora de larga experiencia en este campo.

“Hace sólo 10 años me resultaba imposible encontrar a un estudiante de medicina o residente interesado en aprender sobre la medicina de la adicción. Simplemente no había”, contó Lembke.

Pero Lembke ve un cambio en esta nueva generación de médicos que se sienten atraídos por esta especialidad porque les preocupa la justicia social.

“Ahora vienen a verme estudiantes de medicina y residentes, me envían correos electrónicos; y todos quieren aprender más sobre la adicción”, señaló Lembke.

Históricamente, el camino hacia la medicina de la adicción pasaba por la psiquiatría. Ese modelo comenzó a cambiar en 2015 cuando la American Board of Medical Specialties, considerada el modelo de referencia en la certificación de médicos en los Estados Unidos, reconoció la medicina de la adicción como una subespecialidad genuina y abrió la capacitación a médicos de otras especialidades.

Lembke explicó que, hasta entonces, no había manera de conseguir que se aprobaran becas para el campo de la adicción a través del Accreditation Council for Graduate Medical Education (ACGME), reconocido a nivel nacional. Y eso dificultaba el reclutamiento de jóvenes talentos y la obtención de fondos para sus becas.

El año pasado, ACGME comenzó a acreditar su primer grupo de programas de becas en medicina de la adicción.

“Existe una enorme brecha entre la necesidad y los médicos disponibles para proporcionar ese tratamiento”, dijo Lembke.

“Al menos la comunidad médica ha comenzado a despertar y a considerar no sólo su papel en el desencadenamiento de la epidemia de opioides, sino también la manera en que se deben tomar medidas para resolver el problema”, agregó.

Poniendo los cimientos

Cuando el doctor Luke Peterson terminó su residencia en medicina de familia en Phoenix en 2016, no había becas en medicina de adicción en Arizona.

Así que se mudó a Seattle con una beca de un año en la . Allí aprendió, entre otras cosas, a tratar a las embarazadas que se recuperan del consumo de drogas.

“Necesitaba este tipo de beca si quería tener un impacto y poder enseñar a otros a tener el mismo impacto”, dijo Peterson, quien ayudó a fundar un programa de becas para medicina de la adicción en Arizona. El programa tiene su sede en Phoenix, en la Facultad de Medicina de la Universidad de Arizona y en su hospital universitario, operado por Banner Health y Phoenix VA.

Las dos becas de Arizona para medicina de la adicción recibieron la acreditación de ACGME el año pasado, un sello de aprobación que convirtió a los programas en opciones deseables para los nuevos médicos, señaló Peterson.

No todos los médicos que quieren tratar el trastorno por abuso de sustancias necesitan acceder a una beca, dijo. De hecho, su objetivo es integrar la medicina de la adicción en la atención primaria.

Pero un especialista puede servir como centro de referencia y recursos para los médicos de la comunidad.

Por ejemplo, los médicos pueden aprender de un especialista como Peterson a proporcionar como la buprenorfina.

Líderes de salud pública han presionado para que más médicos se capaciten en tratamientos basados en la evidencia, como la buprenorfina, que ha demostrado entre las personas que se han recuperado de una sobredosis de opioides.

“A medida que proporcionemos más educación y más apoyo a los médicos de atención primaria, se sentirán más cómodos evaluando y tratando la adicción”, explicó Peterson.

La llegada de Peterson a la medicina de la adicción comenzó durante una rotación con un médico de familia en una zona rural de Illinois.

“Cuando muchos médicos se sienten incómodos —quizás un paciente viene a pedir analgésicos y uno ve los efectos secundarios negativos—, él no evitó la situación”, aseguró Peterson. “La afrontó con claridad”.

Fue una experiencia formativa para Peterson, y quiere que la tengan otros jóvenes médicos. Porque dice que es urgente.

“Dentro de 20 o 30 años”, explicó Peterson, “esos estudiantes de medicina van a mirar hacia atrás, a mi generación, y nos juzgarán por cómo hemos respondido a esta epidemia”, de la misma manera que él y sus colegas miran ahora la forma en que los médicos manejaron la epidemia del VIH.

Uno de los primeros pasos para detener la epidemia, dijo, es asegurarnos que tenemos suficientes médicos en los consultorios y hospitales que sepan cómo responder.

Hoy, muchos estudiantes de medicina como Michelle Peterson (sin parentesco con Luke), dicen que también sienten el llamado.

Ella está en su primer año en la Facultad de Medicina de la Universidad de Arizona y se interesó en la adicción después de trabajar en un centro de tratamiento ambulatorio.

Contó que ya les enseñan sobre la adicción en clase, que escucha a médicos especialistas y que ve el compromiso de muchos de sus compañeros.

“Definitivamente no soy yo sola”, dijo. “Hay mucha gente realmente interesada en la adicción”.

Es una tendencia que ella y sus mentores esperan que continúe.

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Yet, by all accounts, there aren’t nearly enough physicians who specialize in treating addiction — doctors with extensive clinical training who are board-certified in addiction medicine.

The opioid epidemic has made this doctor deficit painfully apparent. And it’s spurring medical institutions around the country to create fellowships for aspiring doctors who want to treat substance use disorder with the same precision and science as other diseases.

Now numbering more than 60, these fellowship programs offer physicians a year or two of postgraduate training in clinics and hospitals where they learn evidence-based approaches for treating addiction.

Such programs are drawing a new, talented generation of idealistic doctors — idealists like Dr. Hillary Tamar.

Driven To Connect With Patients In Need

Tamar, now in the second year of a family medicine residency in Phoenix, wasn’t thinking about addiction medicine when she first started medical school in Chicago.

“As a medical student, honestly, you do your ER rotation, people label a patient as ‘pain-seeking,’ and it’s bad,” Tamar said. “And that’s all you do about it.”

But in her fourth year of med school, she happened to be assigned to a rotation at a rehab facility in southern Arizona.

“I was able to connect with people in a way that I haven’t been able to connect with them in another specialty,” the 28-year-old recalled.

Working with patients there transformed Tamar’s understanding of addiction, she said, and showed her the potential for doctors to change lives.

“They can go from spending all their time pursuing the acquisition of a substance to being brothers, sisters, daughters [and] fathers making breakfast for their kids again,” she said. “It’s really powerful.”

When Tamar finishes her residency, she plans to pursue a fellowship in addiction medicine. She sees addiction medicine, like primary care, as a way to build lasting relationships with patients — and a way to focus on more than a single diagnosis.

“I love when I see addiction patients on my schedule, even if they’re pregnant and on meth,” she said. “More room to do good — it’s exciting.”

Build A Program And They Will Come

Doctors with Tamar’s enthusiasm are sorely needed, said Dr. Anna Lembke, medical director of Addiction Medicine at Stanford University School of Medicine and a longtime researcher in the field.

“Even 10 years ago,” Lembke said, “I couldn’t find a medical student or resident interested in learning about addiction medicine if I looked under a rock. They were just not out there.”

But Lembke sees a change in the upcoming generation of doctors drawn to the field because they care about social justice.

“I now have medical students and residents knocking on my door, emailing me; they all want to learn more about addiction,” Lembke said.

Historically, the path to addiction medicine was through psychiatry. That model started to change in 2015, when the American Board of Medical Specialties — considered the gold standard in physician certification in the U.S. — recognized addiction medicine as a bona fide subspecialty and opened up the training to physicians from other medical fields.

Until then, Lembke said, there had been no way to get addiction fellowships approved through the nationally recognized Accreditation Council for Graduate Medical Education. And that made recruiting young talent — and securing funding for their fellowships — difficult.

Last year, ACGME began accrediting its first batch of addiction medicine fellowship programs.

“We have got an enormous gap between the need and the doctors available to provide that treatment,” Lembke said.

“At least the medical community has begun to wake up to consider not only their role in triggering this opioid epidemic, but also the ways they need to step up to solve the problem,” she said.

Laying The Foundation

When Dr. Luke Peterson finished his residency in family medicine in Phoenix in 2016, there were no addiction medicine fellowships in Arizona.

So he moved to Seattle to complete a year-long fellowship atÌý. There he learned, among other things, how to treat pregnant women who are in recovery from drug use.

“I really needed to do a fellowship if I was going to make an impact and be able to teach others to make the same impact,” said Peterson, who went on to help found an addiction medicine fellowship program in Arizona. His program is based in Phoenix at the University of Arizona’s medical school and its teaching hospital, run by Banner Health and the Phoenix VA.

Arizona’s two addiction medicine fellowships received ACGME accreditation last year — a stamp of approval that made the programs desirable choices for up-and-coming physicians, Peterson said.

Not every doctor who plans to treat substance use disorder needs to do a fellowship, he said. In fact, his goal is to integrate addiction medicine into primary care settings.

But a specialist can serve as a referral center and resource hub for community doctors.

For example, physicians can learn from a specialist such as Peterson how to provideÌýbuprenorphine.

Public health leaders have been pushing to get more physicians trained in evidence-based treatment like buprenorphine, which has been shown toÌýamong people who have recovered from an opioid overdose.

“As we provide more education and more support to primary care physicians, they will feel more comfortable screening and treating for addiction,” Peterson said.

Peterson’s own journey into addiction medicine began during a rotation with a family doctor in rural Illinois.

“In moments that most doctors find uncomfortable — maybe a patient comes in to request pain medication and you’re seeing the negative side effects — he did not shy away from that situation,” Peterson said. “He addressed it head-on.”

It was a formative experience for Peterson — one he wants other young doctors to have. And he recognizes the urgency.

“In 20 or 30 years from now,” Peterson said, “those medical students are going to look back at my current generation of doctors, and we will be judged by how we responded to this epidemic,” in the same way he and his peers now look back at how doctors handled the HIV epidemic.

One of the first steps in stopping the epidemic, he said, is making sure there are enough doctors on the ground who know how to respond.

Many of today’s medical students, people like Michelle Peterson (no relation to Luke), say they feel the calling, too.

She’s in her first year at the University of Arizona College of Medicine and became interested in addiction after working at an outpatient treatment center.

She said she’s already learning about addiction in her classes, hearing from doctors in the field and seeing others classmates equally engaged.

“It’s definitely not just me,” she said. “There are quite a few people here really interested in addiction.”

It’s a trend she and her mentors hope will continue.

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

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La condición hace que el , creando un dolor que no se corresponde con la lesión real. También puede afectar cómo el cuerpo regula la temperatura y el flujo sanguíneo.

En el caso de Hubbard se manifestó hace años, después de la cirugía en el pie, la manera más común que ese dolor se arraigue.

“Mi pierna parece que está ardiendo casi todo el tiempo. Es una sensación que se propaga a diferentes partes del cuerpo”, dijo esta veterana del Ejército, de 47 años.

Hubbard acomoda su pierna, con cuidado de no rozarla contra la mesa de la cocina en su casa al este de Phoenix, Arizona. Está roja e hinchada, todavía con las cicatrices de una úlcera que la llevó al hospital hace unos meses.

“Comenzó como una pequeña ampolla y cuatro días después era del tamaño de una pelota de béisbol”, explicó. “Tuvieron que abrirla y luego se infectó, y como tengo problemas de flujo sanguíneo, no sana”.

La mujer sabe que es probable que esto vuelva a suceder.

“Durante los últimos tres años, me han recetado más de 60 medicamentos y combinaciones diferentes; nada me libró del dolor “, señaló.

Hubbard dijo que recibió inyecciones e incluso viajó por todo el país para tomar infusiones de ketamina, un anestésico que puede usarse para el dolor en casos extremos. Sus médicos han considerado amputarle la pierna debido a la frecuencia de las infecciones.

“Todo lo que puedo hacer es controlar el dolor”, dijo. “Y los opioides se han convertido en la mejor solución”.

Durante unos nueve meses, Hubbard tomó una combinación de opioides de acción corta y larga. Esto le dio suficiente alivio, dijo, para comenzar a salir de la casa y hacer fisioterapia.

Pero en abril todo cambió. En su cita mensual, el médico le informó que tenía que reducir la dosis. “Me quitaron una de las píldoras”, dijo.

Hubbard supo que la causa era la , que impone restricciones a las recetas, y limita la dosis máxima para la mayoría de los pacientes. Pero también sabía que la ley a ella, una paciente que ya padecía de dolor crónico.

Ella discutió con su médico, sin éxito. “Nadie dijo que hubiera alguna razón médica para interrumpir mi tratamiento. Se debió simplemente a la presión de las reglas sobre opioides”.

Su dosis se redujo de 100 miligramos equivalentes de morfina por día (MME) a ​​90, la dosis más alta permitida para muchos nuevos pacientes en Arizona. Dijo que su dolor ha sido “terrible” desde entonces.

“Simplemente duele”, expresó. “No quiero caminar, prácticamente no quiero hacer nada”.

La condición de Hubbard puede ser extrema, pero su situación no es única. Para enfrentar la crisis por sobredosis de drogas, los estados están tomando fuertes medidas contra la prescripción de opioides. Cada vez más, algunos pacientes con dolor crónico como Hubbard dicen que se están convirtiendo en víctimas colaterales.

han implementado algún tipo de ley o política que limita las recetas de opioides. Lo más común es restringir la primera receta de un paciente a varias píldoras que deberían durar una semana o menos. Pero algunos estados, como Arizona, han ido más allá al poner un tope a la dosis máxima para la mayoría de los pacientes.

El Arizona Opioid Epidemic Act, la culminación de meses de comunicación y planificación por parte de funcionarios de salud estatales, se aprobó a principios de este año con un apoyo unánime.

La psiquiatra Sally Satel, miembro del American Enterprise Institute, dijo que esas directrices estipulaban que la decisión de reducir la dosis de un paciente debería tomarse caso por caso, y no como una política general.

“[Las directrices] han sido gravemente malinterpretadas”, dijo Satel.

Las directrices no estaban destinadas a los especialistas en dolor, sino más bien para los médicos de atención primaria, un sector del que parte administrados entre 2007 y 2012.

“No hay una obligación para reducir las dosis a las personas a las que les ha ido bien”, puntualizó Satel y dijo que, en la premura por abordar la crisis de sobredosis de opioides de la nación, las directrices de los CDC se han convertido en el modelo para muchos reguladores y legislaturas estatales.

“Nos encontramos en un ambiente muy poco saludable, lleno de frialdad, en el que los médicos y los pacientes que sufren dolor crónico ya no pueden trabajar juntos”, expresó.

Satel calificó de “equivocada” la idea de que las nuevas leyes de prescripción reducirán el número de muertes por sobredosis de drogas.

La tasa de prescripción de opioides a nivel nacional , aunque todavía se encuentra por encima de los niveles de los años noventa. Mientras tanto, más personas están que por las recetas de opioides.

Algunos médicos respaldan las nuevas reglas, dijo Pete Wertheim, director ejecutivo de la Arizona Osteopathic Medical Association.

“Para algunos ha sido un alivio”, dijo. “Sienten que se les ha dado una vía, un medio para enfrentar a los pacientes”. Algunos doctores le dicen que es una oportunidad para mantener una conversación difícil con pacientes que podrían estar en riesgo de adicción o sobredosis debido a la medicación.

La organización se esfuerza por educar a sus miembros sobre las reglas de prescripción de Arizona y sus exenciones. Pero, dijo, la mayoría de los médicos ahora sienten que el mensaje es claro: “No queremos que receten opioides”.

Mucho antes que la ley fuera aprobada, Wertheim contó que los médicos ya le decían que habían dejado de recetar, porque “no querían esa responsabilidad”.

Hubbard se considera afortunada que sus médicos no hayan reducido aún más su dosis de analgésicos.

“En realidad tengo suerte de tener un caso tan grave porque al menos no pueden decir que estoy loca o que me imagino cosas”, dijo.

Hubbard sabe muy bien que las personas mueren todos los días por los opioides. Uno de los miembros de su familia lucha contra la adicción a la heroína y ella está ayudando a criar a su hija. Pero insiste en que hay una mejor manera de enfrentar la crisis.

“Lo que están haciendo no está funcionando. No ayuda al que está en la calle consumiendo heroína y está realmente en peligro de sufrir una sobredosis “, expresó. “En cambio, están perjudicando a las personas que realmente se benefician por el uso de estas drogas”.

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The condition causes theÌý, creating pain disproportionate to the actual injury. It can also affect how the body regulates temperature and blood flow.

For Hubbard, it manifested years ago following surgery on her footÌý— a common way for it to take hold.

“My leg feels like it’s on fire pretty much all the time. It spreads to different parts of your body,” the 47-year-old veteran said.

Hubbard props up her leg, careful not to graze it against the kitchen table in her home east of Phoenix. It’s red and swollen, still scarred from an ulcer that landed her in the hospital a few months ago.

“That started as a little blister and four days later it was like the size of a baseball,” she said. “They had to cut it open and then it got infected, and because I have blood flow issues, it doesn’t heal.”

She knows it’s likely to happen again.

“Over the past three years, I’ve been prescribed over 60 different medications and combinations; none have even touched the pain,” she said.

Hubbard said she’s had injections and even traveled across the country for infusions of ketamine, an anesthetic that can be used for pain in extreme cases. Her doctors have discussed amputating her leg because of the frequency of the infections.

“All I can do is manage the pain,” she said. “Opioids have become the best solution.”

For about nine months, Hubbard was on a combination of short- and long-acting opioids. She said it gave her enough relief to start leaving the house again and do physical therapy.

But in April that changed. At her monthly appointment, her pain doctor informed her the dose was being lowered. “They had to take one of the pills away,” she said.

Hubbard knew the rules were part of Arizona’sÌý, which places restrictions on prescribing and limits the maximum dose for most patients. She also knew the lawÌýÌý— anÌý±ð³æ¾±²õ³Ù¾±²Ô²µÌýpatient with chronic pain.

Hubbard argued with the doctor, without success. “They didn’t indicate there was any medical reason for cutting me back. It was simply because of the pressure of the opioid rules.”

Her dose was lowered from 100 morphine milligram equivalents daily (MME) to 90, the highest dose allowed for many new patients in Arizona. She said her pain has been “terrible” ever since.

“It just hurts,” she said. “I don’t want to walk, I pretty much don’t want to do anything.”

Hubbard’s condition may be extreme, but her situation isn’t unique. Faced with skyrocketing drug overdoses, states are cracking down on opioid prescribing. Increasingly, some patients with chronic pain like Hubbard say they are becoming collateral damage.

New Limits On Prescribing

²Ñ´Ç°ù±ðÌýÌýhave implemented laws or policies limiting opioid prescriptions in some way. The most common is to restrict a patient’s first prescription to a number of pills that should last a week or less. But some states like Arizona have gone further by placing a ceiling on the maximum dose for most patients.

The Arizona Opioid Epidemic Act,Ìýthe culmination of months of outreach and planning by state health officials, was passedÌýearlier this year with unanimous support.

It started in June 2017, when Arizona Gov. Doug Ducey, a Republican,Ìý, citing new data, showing that two people were dying every day in the state from opioid overdoses.

He has pledged to come after those responsible for the rising death toll.

“All bad actors will be held accountable — whether they are doctors, manufacturers or just plain drug dealers,” Ducey said in hisÌý, in January 2018.

The governor cited statistics from one rural county where four doctors prescribed 6 million pills in a single year, concluding “something has gone terribly, terribly wrong.”

Later in January, Ducey called a special session of the Arizona legislature and in less than a week he signed the Arizona Opioid Epidemic Act into law. He called it the “most comprehensive and thoughtful package any state has passed to address this issue and crisis to date.”

The law expands access to addiction treatment, ramps up oversight of prescribing and protects drug users who call 911 to report an overdose from prosecution, among other things.

Initially, Arizona’s major medical associationsÌýÌýwhat they saw as too much interference in clinical practice, especially since opioid prescriptions were already on the decline.

Gov. Ducey’s administration offered assurances that the law would “maintain access for chronic pain sufferers and others who rely on these drugs.” Restrictions would apply only to new patients. Cancer, trauma, end-of-life and other serious cases were exempt. Ultimately, the medical establishment came out in favor of the law.

Pressure On Doctors

Since the law’s passage, some doctors in Arizona report feeling pressure to lower patient doses, even for patients who have been on stable regimens of opioids for years without trouble.

Dr. Julian Grove knows the nuances of Arizona’s new law better than most physicians. A pain doctor, Grove worked with the state on the prescribing rules.

“We moved the needle to a degree so that many patients wouldn’t be as severely affected,” said Grove, president of theÌýÌý“But I’ll be the first to say this has certainly caused a lot of patients problems [and] anxiety.”

“Many people who are prescribing medications have moved to a much more conservative stance and, unfortunately, pain patients are being negatively affected.”

Like many states, Arizona has looked to its prescription-monitoring program as a key tool for tracking overprescribing. State law requires prescribers to check the online database. Report cards are sent out comparing each prescriber to the rest of their cohort. Clinicians consider their scores when deciding how to manage patients’ care, Grove said.

“A lot of practitioners are reducing opioid medications, not from a clinical perspective, but more from a legal and regulatory perspective for fear of investigation,” Grove said. “No practitioner wants to be the highest prescriber.”

Arizona’s new prescribing rules don’t apply to board-certified pain specialists like Grove, who are trained to care for patients with complex chronic pain. But, said Grove, the reality is that doctors — even pain specialists — were already facing pressure on many fronts to curtail opioids — from the Drug Enforcement Agency to health insurers down to state medical boards.

The new state law has only made the reduction of opioids “more fast and furious,” he said.

Grove traces the hypervigilance back toÌýput out by the Centers for Disease Control and Prevention in 2016. The CDC spelled out the risks associated with higher doses of opioids and advised clinicians when starting a patient on opioids to prescribe the lowest effective dosage.

Psychiatrist Sally Satel, a fellow at the American Enterprise Institute, said those guidelines stipulated the decision to lower a patient’s dose should be decided on a case-by-case basis, not by means of a blanket policy.

“[The guidelines] have been grossly misinterpreted,” Satel said.

The guidelines were not intended for pain specialists, but rather for primary care physicians, a group that accounted for nearlyÌýÌýdispensed from 2007 to 2012.

“There is no mandate to reduce doses on people who have been doing well,” Satel said.

In the rush to address the nation’s opioid overdose crisis, she said, the CDC’s guidelines have become the model for many regulators and state legislatures. “It’s a very, very unhealthy, deeply chilled environment in which doctors and patients who have chronic pain can no longer work together,” she said.

Satel called the notion that new prescribing laws will reverse the tide of drug overdose deaths “misguided.”

The rate of opioid prescribing nationallyÌýÌýthough it still soars above the levels of the 1990s. Meanwhile, more people areÌýÌýthan prescription opioids.

In Arizona, more than 1,300 people have died from opioid-related overdoses since June 2017,Ìý. Only a third of those deaths involved just a prescription painkiller.

Heroin is now almost as common as oxycodone in overdose cases in Arizona.

A Range Of Views

Some physicians support the new rules, said Pete Wertheim, executive director of the Arizona Osteopathic Medical Association.

“For some, it has been a welcome relief,” he said. “They feel like it has given them an avenue, a means to confront patients.” Some doctors tell him it’s an opportunity to have a tough conversation with patients they believe to be at risk for addiction or overdose because of the medication.

The organization is striving to educate its members about Arizona’s prescribing rules and the exemptions. But, he said, most doctors now feel the message is clear: “We don’t want you prescribing opioids.”

Long before the law passed, Wertheim said, physicians were already telling him that they had stopped prescribing, because they “didn’t want the liability.”

He worries the current climate around prescribing will drive doctors out of pain management,ÌýThere’s also a fear that some patients who can’t get prescription pills will try stronger street drugs, said Dr. Gerald Harris II, an addiction treatment specialist in Glendale, Ariz.

Harris said he has seen an increase in referrals from doctors concerned that their patients with chronic pain are addicted to opioids.ÌýHe receives new patients — almost daily, he said — whose doctors have stopped prescribing altogether.

“Their doctor is afraid and he’s cut them off,” Harris said. “Unfortunately, a great many patients turn to street heroin and other drugs to self-medicate because they couldn’t get the medications they need.”

Arizona’s Department of Health Services is working to reassure providers and dispel the myths, said Dr. Cara Christ, who heads the agency and helped design the state’s opioid response. She pointed to the recently launchedÌýÌýcreated to help health care providers with complex cases. The state has also released a set of detailed prescribing guidelines for doctors.

Christ characterizes this as an “adjustment period” while doctors learn the new rules.

“The intent was never to stop prescribers from utilizing opioids,” she said. “It’s really meant to prevent a future generation from developing opioid use disorder, while not impacting current chronic pain patients.”

Christ said she just hasn’t heard of many patients losing access to medicine.

It’s still too early to gauge the law’s success, she said, but opioid prescriptions continue to decline in Arizona.

Arizona saw a 33 percent reduction in the number of opioid prescriptions in April, compared with the same period last year, state data show. Christ’s agency reports that more people are getting help for addiction: There has been about a 40 percent increase in hospitals referring patients for behavioral health treatment following an overdose.

Shannon Hubbard, the woman living with complex regional pain syndrome, considers herself fortunate that her doctors didn’t cut back her painkiller dose even more.

“I’m actually kind of lucky that I have such a severe case because at least they can’t say I’m crazy or it’s in my head,” she said.

Hubbard is well aware that people are dying every day from opioids. One of her family members struggles with heroin addiction and she’s helping raise his daughter. But she’s adamant that there’s a better way to address the crisis.

“What they are doing is not working. They are having no effect on the guy who is on the street shooting heroin and is really in danger of overdosing.” she said. “Instead they are hurting people that are actually helped by the drugs.”

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Zieman comienza cada nueva consulta con una simple pregunta para la paciente: “¿Cuáles son los síntomas con los que crees que puedo ayudarte?”

Para la mayoría de sus pacientes, es la primera vez que alguien les pregunta cómo se lastimaron. “De hecho, una paciente me dijo que la única persona que le preguntó si alguien la había golpeado fue un paramédico, mientras la trasladaban en ambulancia”, contó Zieman. “Y su marido estaba al pie de su camilla”.

Muchas pacientes van a la clínica por síntomas físicos, como dolores de cabeza, agotamiento, mareos o problemas para dormir, pero la investigación de Zieman muestra que la ansiedad, la depresión y el TEPT (trastorno por estrés postraumático, PTSD en inglés) terminan siendo los problemas más graves.

Los estudios de lesiones cerebrales traumáticas (TBI, por sus siglas en inglés) han revelado vínculos con la demencia y la pérdida de memoria en veteranos y atletas. El TBI también se ha relacionado con

Pero las sobrevivientes de violencia doméstica pueden estar sufriendo en silencio.

Alrededor del 70% de las personas atendidas en la sala de emergencias por estos abusos de esta manera. Es una crisis de salud cubierta por el secreto y la vergüenza, una crisis que Zieman está destapando con su trabajo en el .

Zieman dirige lo que ella califica como el primer programa dedicado a tratar lesiones cerebrales traumáticas en sobrevivientes de violencia doméstica.

“Alrededor del recibieron tantos golpes en la cabeza que perdieron la cuenta, lo cual es astronómico comparado con los golpes que reciben los atletas”, expresó Zieman y agregó que no es solo el gran número de lesiones lo que hace que los casos de estos pacientes sean tan complejos.

“Una sola conmoción cerebral sufrida por un atleta ya es muy difícil de tratar, pero estos pacientes son distintos”, dijo. “A diferencia de los atletas, no tienen la suerte, por decirlo de una manera, de recuperarse después de una lesión y antes de volver a lesionarse”.

Se estima que la violencia doméstica afecta a más de cada año. Las lesiones de cabeza y cuello son algunos de los problemas más comunes, y Zieman está sacando a la luz la frecuencia con que aparece la lesión cerebral traumática.

Pero al no reconocerse la gravedad de los problemas relacionados con el abuso se ha dejado a muchas sobrevivientes sin un diagnóstico definitivo. Y a muchas se les hace responsables de su deterioro cognitivo. “Se les ha etiquetado por tanto tiempo con todas estas cosas horribles; pero no es su culpa”, enfatizó Zieman. “Hay una verdadera razón médica detrás de estos problemas y hay algunas cosas que se pueden hacer”.

Los datos sobre la violencia doméstica y la lesión cerebral traumática son escasos porque muchos casos no se denuncian, pero Zieman afirmó que los resultados iniciales de la investigación de su equipo indican que el problema es más frecuente de lo que se pensaba.

Una revisión de 2016 de los archivos médicos de pacientes en el programa, casi todas mujeres, indicó que solo una quinta parte había ido al médico. El 88% había sufrido más de una lesión en la cabeza.

Zieman trabaja con refugios locales de violencia doméstica para identificar a mujeres que pueden estar sufriendo lesiones cerebrales. Los trabajadores sociales de los refugios las envían a la clínica de Zieman, en donde sus síntomas físicos, como dolores de cabeza o mareos, se pueden tratar al mismo tiempo que los efectos cognitivos y emocionales del abuso. Gracias a subvenciones y donaciones privadas, la atención es gratuita, independientemente de si las personas tienen seguro médico, dijo Zieman.

Ashley Bridwell, trabajadora social en Barrow, ayuda a las sobrevivientes a sobrellevar la vida con una lesión cerebral. “Les resulta casi imposible realizar tareas simples, como llenar una solicitud o recordar una cita, o poder contar su historial médico, o social, es casi imposible teniendo en cuenta lo que están experimentando”, dijo.

Bridwell ayudó a iniciar el programa hace seis años después de trabajar con la comunidad sin hogar y darse cuenta que muchos clientes tenían lesiones cerebrales traumáticas debido a la violencia doméstica. Contó que los pacientes a menudo tienen una larga historia de abuso emocional y físico. Y muchos sufren deterioro cognitivo por sufrir de lesiones cerebrales traumáticas leves a repetición.

A veces los pacientes llegan a la clínica con una enorme cantidad de síntomas aparentemente inexplicables. Bridwell dijo que recuerda a una mujer que perdió su trabajo porque se olvidaba de las cosas. La mujer pensó que tenía Alzheimer.

“Acercarse a nosotros para obtener información sobre lesiones en la cabeza, y sobre cómo múltiples golpes pueden afectar tu memoria, tu atención, tu concentración, tu velocidad de procesamiento, resultó ser algo de incalculable valor para ella”, expresó Bridwell.

El diagnóstico le dio una nueva forma de hablar y de entender su sufrimiento más íntimo. “Se dan cuenta que no es su culpa”, dijo Bridwell.

Y Zieman señaló que el TEPT y el trauma afectan profundamente a esta población.

“La importancia de los síntomas del estado de ánimo en esta población supera con creces lo que vemos en nuestros otros pacientes”, dijo.

Zieman apuntó que la ciencia médica aún se encuentra en las primeras etapas para comprender los efectos de las lesiones cerebrales repetitivas y cómo tratarlas mejor. El trauma de la violencia doméstica solo complica el panorama, pero los sobrevivientes que ella trata son sus pacientes favoritos.

“Siento que podemos hacer la mayor diferencia para estos pacientes”, dijo.

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“The domestic violence patients are the next chapter of brain injury,” she said.

Zieman begins every new patient visit with a simple question: “What are the symptoms you hope I can help you with?”

For most, it’s the first time anyone has ever asked how they may have been injured in the first place. “I actually heard one patient tell me the only person who ever asked her if someone did this to her was a paramedic, as she was being wheeled into an ambulance,” Zieman said. “And the husband was at the foot of her stretcher.”

While many patients initially seek out the clinic because of physical symptoms, such as headaches, exhaustion, dizziness or problems sleeping, Zieman’s research shows that anxiety, depression and PTSD usually end up being the most severe problems, she said.

Studies of traumatic brain injury have revealed links to dementia and memory loss in veterans and athletes. And TBI has also beenÌý.

But survivors of domestic violence may be suffering largely in silence.

About 70 percent of people seen in the emergency room for such abuse areÌýÌýas survivors of domestic violence. It’s a health crisis cloaked in secrecy and shame, one that Zieman is uncovering through her work at theÌý.

She runs what she said is the first program dedicated to treating traumatic brain injury for survivors of domestic violence.

“AboutÌýÌýof our patients had so many hits to the head, they lost count, which, you compare that to athletes, is astronomical,” Zieman said.

Zieman said it’s not just the sheer number of injuries that makes these patients’ cases so complex.

“One single athletic concussion is hard enough to treat, but these patients are beyond that,” she said. “Unlike athletes, they do not have the luxury, if you will, of recovering after an injury before they are injured again.”

Domestic violence is estimated to affect more thanÌýÌýeach year. Head and neck injuries are some of the most common issues, and Zieman is uncovering how frequently traumatic brain injury is part of the picture.

Still, she said, the lack of recognition of the severity of the abuse-related problems has left many survivors without a definitive diagnosis. Many get blamed for their cognitive impairment.

“They have been labeled for so long with all these horrible things,” said Zieman. “And in the end, it’s not only not their fault but there is a true medical reason behind these issues and there are some things that can be done.”

Data on domestic violence and traumatic brain injury are sparse because cases are so underreported, but Zieman said her team’s initial findings indicate the issue is more prevalent than previously thought.

A 2016 review of the medical files of patients in the program — almost all women — discovered only one-fifth of them had seen a physician for their injuries. Eighty-eight percent had sustained more than one head injury from abuse.

Zieman works with local domestic violence shelters to identify women who may be suffering from brain injuries. Workers will send them to Zieman’s clinic where their physical symptoms, such as headaches or dizziness, can be treated along with the cognitive and emotional effects of their abuse. Through grants and private donations, Zieman said, the care is free, whether or not people have insurance.

Ashley Bridwell, a social worker at Barrow, works with Zieman to help survivors manage life with a brain injury. “Some of these simple things like filling out an application or remembering an appointment, or being able to give a solid social or medical history — it’s close to impossible considering what they are experiencing,” she said.

Bridwell helped start the program six years ago after doing outreach to the homeless community and realizing many clients had traumatic brain injuries from domestic violence. She said patients often have long histories of emotional and physical abuse. Many have cognitive impairment from repeated mild traumatic brain injury.

Patients will sometimes arrive at the clinic with a constellation of seemingly unexplainable symptoms. Bridwell said she remembers one who lost her job because of her forgetfulness. The woman thought she had Alzheimer’s.

“And for her to come in and get some information about head injury, and about how multiple hits to the head can impact your memory, your attention, your concentration, your speed of processing, it was incredibly validating for her,” said Bridwell.

The diagnosis gave her a new way to talk about and understand her private struggle. “They realize it’s not their fault,” Bridwell said.

And Zieman said PTSD and trauma affect this population deeply.

“The significance of the mood symptoms in this population far exceeds what we see in our other patients,” she said.

Zieman said medical science is still in the early stages of understanding the effects of repetitive brain injury and how to better treat it. The trauma of domestic violence only complicates the picture, but the survivors she sees remain her favorite patients to treat.

“I feel that we can make the biggest difference for these patients,” she said.

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“It’s really low-barrier the way we are doing it,” Patterson said. “All you have to do is find us.”

Patterson asks for no IDs, no signatures and no questions — all of which might dissuade IV drug users from seeking out clean needles or the overdose reversal drug naloxone, Patterson said. He’s among the volunteers who run Central Arizona’s only syringe exchange program; it’s calledÌý.

“A lot of [the drug users he sees] have trust issues — understandably — with the health care industry, with what’s going to be put on their record,” Patterson said, as he handed out the medical supplies from the trunk of his car.

WhileÌýstates have syringe exchanges, onlyÌý have laws that explicitly permit syringe exchanges — and Arizona isn’t one of them. Shot in the Dark operates quietly, without public funding. The group sets up in different corners of the Phoenix metro area for a few hours at a time, Patterson said, and struggles to keep up with demand.

“There are still a lot of people that don’t know even know about it,” said one man who uses the service. “It shouldn’t be so hidden.” Kaiser Health News and NPR agreed not to use his name because his drug use is illegal.

States across the U.S. are pouring resources into fighting the opioid epidemic. According toÌý, an average of two people died every day in Arizona from opioid-related overdoses. Deaths due to heroin from 2012 to 2016.

“It’s a problem that knows no bounds,” Arizona’s Republican governor, Doug Ducey, said in January during his State of the State address. “It affects men and women, young and old, rich and poor.”

Ducey has declared the opioid epidemic a public health emergency — a move that aÌý of other states have made, too. In Arizona, the designation allowed public health officials to begin tracking overdose data in real time andÌýÌýeffort to combat the epidemic.

But some public health advocates, including Patterson, see the governor’s declaration not necessarily translating into more help for people on the street using drugs.

“Instead of focusing on ways that you can connect with the IV-drug-using population — show them that their health matters, and prevent all the people who are likely never going to stop using IV drugs,” Patterson said, “they, like, leave them out here to pick up dirty needles out of parks and give themselves diseases.”

Needle exchanges are based on a concept known asÌýÌý— they seek to reduce the negative consequences of drug use without forcing abstinence. The U.S. Surgeon General hasÌýsuch programs don’t promote drug use and do improve health outcomes, including lower HIV rates.

But that hasn’t convinced some of Arizona’s most influential law enforcement figures.

“It’s a well-intentioned, misguided program,”ÌýÌýsaid. “We don’t have a free-case-of-beer-a-month program for alcoholics. It sends the wrong message — and it’s not providing the treatment.”

This is a common argument against syringe exchange programs — that they enable drug use. Proponents of harm reduction, however, point toÌýÌýshowing that people who use these programs are actually more likely than others to seek treatment.

Despite his lack of faith in needle exchange programs, Montgomery said he is sympathetic to people who are addicted to opioids — he is not out to prosecute drug users when he doesn’t have to.

“Law enforcement really does look at ‘treatment first’ as an option for those who are addicted,” Montgomery said. He pointed to a pretrialÌýÌýthat is expanding statewide, and theÌý, which lets drug users turn to the police and opt for treatment.

Expanding those kinds of programs is part of the state’s wide-ranging Opioid Action Plan, which treatment specialists helped craft.

Arizona’s 100-pageÌýÌýrecommends improving access to treatment and naloxone, as well as enacting aÌýÌýlaw that gives immunity to those who call 911 to report an overdose.

But the plan also proposes more regulation of doctors and their prescribing practices, including a five-day limit on initial opioid prescriptions for patients who are taking the drug for the first time.

That kind of focus on prescribers is “misguided,” saidÌýDr. Jeffrey Singer, an Arizona surgeon, and senior fellow at the libertarian Cato Institute.

“Our policies right now are aimed at the supply side,” Singer said. “And all they are doing is driving the death rate up. They’re not driving use down.”

Opioid users are increasingly turning to heroin and fentanyl, Singer said. He points toÌýthat shows the rate of opioid prescriptions has fallen in recent years while the deaths associated with illicit drugs continue to rise.

Singer believes even labeling the state’s opioid crisis as a public health emergency could backfire.

“That tends to create a sense of panic,” Singer said. “History has shown us every time we have a panic, we end up passing laws and doing things in haste that are not well thought out.”

Singer thinks Arizona should embrace harm reduction strategies like syringe exchanges, instead of tamping down prescribing.

“My job is to save lives and to ease suffering,” Singer said. “The law enforcement people need to have that same attitude. We’ve got to take personal biases out of it and just focus on the goal, which is less death and less disease.”

Earlier this year, the Arizona Department of Health Services asked a group of treatment providers who were working on the state’s action plan for their top recommendations. Legalizing syringe exchanges was one of the group’s priorities, according to interviews and draft documentsÌý.

But that priority didn’t make the final version of the plan; only a broad reference to using “harm reduction strategies” survived.

A spokesperson for the department said the recommendation was omitted because it “doesn’t directly reduce opioid-related overdoses or deaths.”

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“‘Sorry, we’re not covering that kid,'” Bobbie recalls insurers telling her. “‘She’s a liability.'”

On the day I visited the family at their home in a suburb north of Phoenix, 8-year-old Sophia bounced on a trampoline in the backyard. It’s difficult to tell she has a complex congenital heart condition and has undergone multiple surgeries.

“She’s a kid whose clock is ticking every day,” her mother said, “but she goes to school, she rides horses. She does everything a regular kid can do, with a certain level of limitation.”

In the early years of Sophia’s life, the child’s preexisting condition kept Bobbie and her husband, who runs a sandwich shop, on a constant quest for health coverage for Sophia. Her premiums alone were so expensive that the rest of the family often did without health insurance. The little girl’s medical bills were still huge, and the family racked up debt and lost their car and home.

On one hand, the ACA had finally guaranteed that someone like Sophia Bobbie — with her preexisting medical condition — could apply for insurance and switch policies without risk of being turned down. And yet the plans on the marketplace were unaffordable for the rest of the family.

The Bobbies are the kind of consumers who should be the target audience for Republicans intent on repealing the Affordable Care Act. But, so far, Corinne Bobbie is far from sold on the alternative the GOP is proposing: the American Health Care Act.

“It’s a bunch of garbage,” she said. And about the lawmakers who passed it: “They could be the heroes. And instead it just became this nonsense.”

Opponents of the effort to repeal Obamacare are tapping into this unease, running that accuse Republican moderates like , who represents Tucson, of voting for “a disastrous health care repeal bill.”

“They are trying to put her in league with the extreme, hardcore Republicans in Congress,” said GOP consultant , who is a partner at Molera Alvarez.

Democrats think McSally and , R-Ariz. — who are both up for re-election — are vulnerable. The politicians have a fine line to walk.

“It’s a balancing act between being aggressive in wanting to repeal Obamacare,” Molera said, “with the fact that there are a lot of components of it that people like.”

Those components include protections for preexisting conditions and Medicaid expansion, which has covered more than 400,000 people in Arizona alone.

The replacement bill would scale back that expansion, and the proposed curtailment in Arizona, including .

The major cuts to Medicaid, however, probably won’t survive in the Senate version, and Molera says that could actually help Flake.

“He doesn’t have to take that extreme position in order to get out of a Republican primary,” Molera said, “and then that affords him the opportunity to be more of a centrist running against the Democrats.”

Among Republican incumbents in Arizona, Flake is likely in the toughest race, but Democrats are even at Republicans in safer districts like conservative , who represents Scottsdale and is a member of the House’s conservative .

Schweikert says he voted for the GOP health plan in order to give states flexibility to transform Medicaid — through block grants, for example — even though that means less federal money for the state.

He admits his decision makes some in Arizona’s health care industry nervous.

“They are concerned because they are quite comfortable with the current Medicaid model instead of a model that would provide a lot more choices,” Schweikert said.

The state’s health care industry has warned that the GOP bill would result in more people showing up in the emergency room without insurance coverage, leaving hospitals — and, ultimately, consumers — to pick up the tab.

Schweikert also claims the bill will help salvage the state’s marketplace, which, he says, is “imploding.”

“We can lower the price so much for that 50 percent that’s healthy, that they’ll start to participate in the system, because that’s the only way the math works,” Schweikert said, adding that the ACA’s penalty system is not getting enough young people to join.

About 20 percent of people who signed up for Arizona’s marketplace are between , according to the Kaiser Family Foundation.Ìý(Kaiser Health News is an editorially independent program of the foundation.)

The GOP bill is expected to bring down the cost of some premiums, but prices would rise significantly for those who are older or have preexisting conditions, to the Congressional Budget Office.

Schweikert also predicts that, as configured right now, the insurance marketplace will not survive for much longer, given the exodus of insurers in recent years.

“Today, you’re lucky we have one,” he said, “and tomorrow, you may have zero.”

But , who oversees enrollment for the Arizona Alliance for Community Health Centers, disagrees that the state’s insurance exchange is in crisis.

“We believe that the two insurance companies that are covering Arizona will be back next year with the same footprint,” Gjersvig said.

He also doesn’t expect Arizona to see the same dramatic rate hikes it saw last year, calling that an adjustment for underpricing in previous years.

But with the current uncertainty about what is in store for the health care law, insurers are having a tough time planning for the future.

Gjersvig said the biggest unknown is whether the Trump administration will withhold key payments known as ; these payments to insurers help subsidize coverage for low-income people. If insurers lose those, Gjersvig said, the insurance premiums for consumers will go up.

All this uncertainty is also a problem for Corinne Bobbie.

She said the debate over the ACA has become a political game in which her family and others have been forgotten. Her overriding fear: “We are potentially in a position where this time next year, nobody in this house will have insurance,” Bobbie said. “If that happens, it’s going to be ugly. It’s going to be real ugly.”

And the political fortunes of elected officials in Arizona and across the nation may well depend on voters like her family getting the care they need.

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“I like that we can choose our own doctors,” said the 60-year-old resident of Mesa, Ariz. “They also have extensive mental health coverage.”

Dotts isn’t on some pricey plan, either. She’s among the nearly 2 million people enrolled in and one of the more than 400,000 who have signed up since the Republican-led state expanded Medicaid in 2014.

Her eight prescription drugs are cheap, Dotts said, and she has no copays or premiums. The Medicaid benefits have helped her manage her emphysema, depression and osteoarthritis.

But taking care of other problems has to be delayed: “I have torn ligaments in my ankles, and I can’t take the time off work to go to physical therapy or surgery.”

Unlike some states that expanded Medicaid, Arizona saw a rush of people joining the rolls, Reddy says, because it had a “high-need, uninsured” population.

The Republican bill would continue to pay the higher federal rates that the ACA’s Medicaid expansion offered people like Dotts, Reddy said — but only if they’re already enrolled in Medicaid, and their personal income stays about the same.

“What we know about the Medicaid population is that they kind of fall in and out of eligibility on a regular basis,” she said, because the amount of money they earn tends to fluctuate.

“So it has the real potential of eradicating Medicaid expansion over a period of time,” Reddy says.

The states and the federal government share the cost of Medicaid. Instead of an open-ended entitlement, the bill making its way through Congress right now would cap the federal government’s contribution or turn it into a block grant.

Putting a fixed limit on the federal government’s contribution is unlikely to allow Arizona Medicaid to keep up with the growing cost of covering people, Reddy said.

“The states will have to come up with the remaining money to cover these folks,” she said.

The Republican health plan nearly half a billion dollars a year, according to calculations by the state, to keep the adults with the lowest income in the expansion population insured. It’s a group that Arizona voters actually required the state to cover in 2000 through . But during the recession in later years, financial pressure led state lawmakers to for those adults.

Scaling back Medicaid could be a particularly risky proposition for Arizona, according to the state program’s administrators, because Arizona is already one of the most efficient, lean programs in the country.

Getting locked in at the current funding rates would give other states a leg up, saidÌýTom Betlach, who runs Medicaid in Arizona.

“If they are able to achieve improved outcomes and reduced costs, they are able to capture those savings,” Betlach said. “Versus we actually get penalized for being a good steward of taxpayer funds.”

Betlach said Arizona needs more control than it currently has over who and what types of treatments and procedures are covered if the federal government intends to give Arizona only a fixed amount of cash.

The federal fight over health care puts the state’s Republican governor, , in a tricky situation. Ducey has said he would like the ACA repealed, but he has also said he doesn’t want hundreds of thousands of people to lose coverage. He has that the GOP bill doesn’t give the state enough flexibility.

And it wasn’t even on Ducey’s watch that Arizona expanded Medicaid. The expansion happened under Jan Brewer, Arizona’s former governor and an ally of President Donald Trump. To pull that off, Brewer had to band together with Democrats and buck some of her fellow Republicans in the state Legislature, who then sued her over the expansion. In their lawsuit, the legislators claimed that the way the state pays its share — a fee on hospitals — is unconstitutional.

At a recent court hearing for that long-running lawsuit, Brewer defended her controversial decision to accept the ACA’s expansion funding.

“I think it was the right thing to do,” she said in an interview outside the courtroom. “It saved lives. It insured more people. It brought money into the state. It kept rural hospitals from being closed down. And today there are tens of thousands of people that are very, very grateful.”

But some Republicans, like , who was among the Arizona legislators who sued Brewer, figured the day would come when the feds wouldÌýtry to roll back the funding.

“I voted against Medicaid expansion, not because I don’t want people to get health coverage,” Lesko said, “but because I’m a realist and I know how much we can afford in our budget.”

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

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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