In the days that followed, the nurse failed a drug test and was fired, the order states. The nurse later admitted that for months he had pilfered and abused fentanyl left over after surgeries, sometimes daily, according to the order.

Under most circumstances, this would be a routine case of what is known as “drug diversion,” the unlawful taking of controlled substances from healthcare facilities — believed to be so widespread that it occurs at just about every U.S. hospital.

But the Erlanger case stands out because a high-tech watchdog was supposed to be on guard.

The hospital uses the newest line of defense against drug diversion: Sentri7, powered by artificial intelligence and designed to detect missing drugs faster than any human can. But for months at Erlanger, Sentri7 failed to raise alarms, overlooking missing drugs and other “inconsistencies” that “should have been flagged,” the nursing board’s order states.

The Erlanger case, which has not been previously reported, offers a rare glimpse at an apparent failure of AI drug diversion software used in hundreds of U.S. hospitals with little transparency or oversight. Healthcare facilities are not required to disclose their implementation of this kind of software or report malfunctions to anyone, so there is no full account of how widely these programs are used or how often they fail.

Erlanger Baroness, also referred to as Erlanger Medical Center, declined to comment on its use of Sentri7 or on the diverted drugs. André Rebelo, a spokesperson for the health division at Wolters Kluwer, the Dutch technology company behind Sentri7, declined to answer questions about what happened at Erlanger but said the company remained “confident in our software.”

Little Transparency

David Rastall, a Johns Hopkins Medicine neurologist and AI researcher, said that because AI technology is heavily proprietary and hospital officials often don’t understand how it works, this lack of transparency allows for errors to be buried rather than fixed. That means errors could be repeated at other hospitals, he said.

“The ideal for patients, caregivers, and hospital systems would be,” Rastall said, “when an AI is found to be making some type of error, that becomes very transparent and public.”

The Drug Enforcement Administration mandates that hospitals confidentially report lost or stolen drugs. Hospitals can also report stolen drugs to state health agencies, which license medical professionals and investigate wrongdoing.

But these reports are not required to include details about any AI software involved, according to interviews with three drug diversion prevention experts. In interviews, all said they had never seen an AI failure publicly documented like the apparent one at Erlanger.

“I’ve never myself seen these technologies be called out in that specific way,” Jacob Smith, a pharmacist in charge of drug security at Johns Hopkins Medicine, said of the apparent Sentri7 failure. “It doesn’t make sense to me how you could miss it.”

Smith and other experts said the Erlanger case also raises questions because the theft of leftover drugs is one of the most well-known methods of diversion. And fentanyl, a painkiller that can be 50 times as strong as heroin, is one of the most common targets.

Terri Vidals, the founder of , questioned whether the Erlanger case was the result of user error instead of malfunction.

“This is the most basics of basics for this software,” Vidals said. “I find it interesting that they’re saying it wasn’t flagged by the software. I think there’s maybe more to that story.”

The apparent Sentri7 failure at Erlanger was revealed by the Tennessee Department of Health in a routine release of in December. Among those records was the Board of Nursing order, which summarizes a state investigation into nurse anesthetist John Stevenson, who settled the case against him by signing the document in November.

Stevenson declined to comment through his attorney. He has not been charged with any crime related to the Erlanger case. The nursing board put his license on probation while he went to drug counseling.

Bill Christian, a spokesperson for the Department of Health and Board of Nursing, declined to comment on the Erlanger case or Sentri7. In response to public records requests, the Department of Health and the Tennessee Health Facilities Commission each said it possessed no other documents about the apparent Sentri7 failure at Erlanger.

Erlanger spokesperson Charlie Milburn said earlier this year that the hospital had prepared a written statement about its use of Sentri7 in response to questions from ºÚÁϳԹÏÍø News.

That statement was never released.

“Our legal team is debating whether this is something we want to talk about at all,” Milburn said in a March email, before later declining to answer any questions.

Kristy Drollinger, a Wolters Kluwer executive who spoke generally about Sentri7 to ºÚÁϳԹÏÍø News in March, said the software is in high demand because so many hospitals have struggled to secure their drugs.

Sentri7 monitors about 60 “attributions of risk” that identify red flags for further investigation by hospital employees, Drollinger said.

“It’s pretty scary,” Drollinger said of widespread drug theft. “Every health system, every health facility, has had diversion at some point — and probably has it now.”

‘The Way of the Future’

Drug diversion is a widespread challenge in U.S. medical facilities. It can lead to patients not receiving medication or getting drugs that are contaminated with blood-borne diseases. It’s estimated as many as 15% of all healthcare workers divert drugs at least once, according to the nonprofit .

Diversion has been linked to at least — causing more than 200 infections, mostly of hepatitis C — since 1985, according to the Centers for Disease Control and Prevention.

To prevent this, hospitals attempt to track each pill or vial from the moment it is dispensed to the moment it is given to a patient, by comparing data from electronic medication cabinets and patients’ health records.

Hospital staff once performed this painstaking process manually, but in the past decade the task has become largely automated by anti-diversion software. After years of mergers and buyouts, two programs now dominate the industry: Wolters Kluwer’s Sentri7 and Bluesight’s ControlCheck. Both incorporate AI.

“It’s definitely the way of the future,” said Luke Overmire, owner of .

More than 1,500 hospitals use ControlCheck, according to Bluesight. An additional 700 use Sentri7 Clinical Surveillance programs, which can include its drug diversion software, according to Wolters Kluwer.

Neither company publishes the price of its software. Smith, the drug safety official from Johns Hopkins, said hospitals purchase these “expensive technologies” because a disastrous diversion case could result in a multimillion-dollar fine from the DEA.

“They don’t promise a return on investment,” Smith said. “They promise cost avoidance.”

In 2022, a funded by the National Institutes of Health found that Sentri7, then known as Flowlytics, could uncover drug diversion faster than existing methods. The study’s primary author worked for Invistics, the company that previously owned Sentri7.

According to that study, researchers tested the software by having it comb through medication data spanning two years and 10 hospitals in search of 22 nurses who were already known to have diverted drugs.

The program not only found them all, the study states, but found them faster than humans by as little as a week and as much as a year and a half.

At Erlanger, the humans spotted the signs of trouble first.

According to the Board of Nursing order, co-workers reported that Stevenson appeared impaired “while on duty in the surgery center” on or around June 30, 2025.

Stevenson “had slurred speech, appeared extremely tired, was seen standing with his eyes closed and swaying, exhibited head nodding while standing upright and appeared to have difficulty keeping his eyes open,” according to the order.

When questioned by state investigators, Stevenson admitted that he began diverting “unused fentanyl that would otherwise have been wasted after surgical procedures” in March 2025, according to the order. Stevenson said he used the fentanyl waste once or twice a week at first, then “increasing to daily use” by June of that year, the order states.

Erlanger audited Stevenson’s dispensing record over those four months. It found approximately five instances when Sentri7 didn’t flag missing drugs, according to the order.

It adds that the hospital found “additional inconsistencies between drug dispensing and waste documentation that should have been flagged by the automated monitoring system.”

One possible explanation is provided by the Board of Nursing, which said in the order that Sentri7 was in its “initial learning phase” at Erlanger, though the board provided no details.

In an interview, without discussing Erlanger specifically, Drollinger said Sentri7 has no “learning phase,” because it is trained on nine to 12 months of historical data when implemented at a new hospital.

Smith, of Johns Hopkins, had another theory.

In an interview, Smith said his experience with AI drug diversion software had led him to believe that it is effective at monitoring emergency rooms and intensive care units but less so in operating rooms, where drugs are dispensed and charted differently.

These areas can be harder for AI to track, Smith said, and therefore require humans to keep a closer watch.

“We’ve got people whose entire job is to work with this software,” Smith said. “The software is a piece of it, but if you rely on the software to give you all your signals, you’ll miss stuff. It’s just not 100%.”

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The workers, Nathan Jones and Trent Umberger, died in the September 2024 crash, as did a passenger in the Jeep. Tests found that the driver, Patrick Sneddon, then 59, had oxycodone and six times Colorado’s presumed impairment threshold for THC — the psychoactive compound in cannabis — in his blood. He pleaded guilty and is serving on three counts of vehicular homicide and other charges.

“Our four children are completely crushed without their Dad,” wrote Kristine Umberger, the wife of Trent, in a victim impact statement for the local district attorney. “We have lost our ability to live life like we used to.”

Federal highway safety officials have long tracked the role of alcohol in fatal crashes, but they don’t track deaths that involve a driver under the influence of drugs or a combination of drugs and alcohol.

That discrepancy is partly due to the challenges of proving impairment, since some drugs remain detectable for weeks after use. Sneddon’s attorney, Jennifer Gregory, said a driver can be presumed impaired under Colorado law if their blood contains 5 nanograms of THC or higher per liter. But that “permissible inference” threshold is different from a legal limit — such as the 0.08% blood alcohol content limit — and the level set by Colorado is not supported by published scientific studies, Gregory said.

Such information could prove useful as the nation struggles with , the on marijuana, and more than 40 states have legalized or decriminalized some forms of cannabis and .

“Impaired driving is a top public safety issue that extends beyond alcohol,” said Sean Rushton, a spokesperson for the federal highway safety agency, which is tackling the issue collaboratively, with resources to ensure a “comprehensive and coordinated approach.”

But President Donald Trump’s cuts to the federal workforce since he returned to office in 2025, along with dwindling federal investments, mean that efforts to expand and improve the tracking of impaired-driving deaths nationwide have slowed.

The gap in data can be significant. In Mesa County, Colorado, where Jones and Umberger were killed, the coroner’s office tracks various forms of impaired-driving fatalities. From 2017 through 2024, a third of traffic deaths involved alcohol alone, according to data from the county coroner’s office.

When drugs are factored in, nearly half of Mesa County’s traffic deaths over the same period involved a driver intoxicated with alcohol, drugs, or a combination, according to the coroner’s reports.

“If you want to solve a problem, you need to understand the problem,” National Transportation Safety Board researcher Jana Price said. “If you only know that alcohol is present, then it limits your ability to fully understand what might have been impairing a person or a population of people. It trickles into the countermeasures that we use as a society to address the problem.”

Identifying a Hidden Issue

NTSB researchers that, across four geographical samples of roughly 26,000 drivers, about half of those arrested for impaired driving and more than a quarter of drivers killed in crashes tested positive for more than one substance, such as cocaine, sedatives, and antidepressants. The analysis also found that only four states and the District of Columbia drug-tested more than 60% of fatally injured drivers in 2020.

Those findings led the NTSB, an independent federal agency that investigates major incidents, to make a series of recommendations to the and states to establish a comprehensive, nationwide dataset on impaired driving.

But hurdles remain to creating such a system. Fatality and injury reports submitted to the NHTSA database often feature missing or erroneous data, according to a .

Varying state laws around testing arrestees and decedents for drugs make getting uniform data difficult, according to , a former employee of NHTSA’s impaired-driving division, as does a lack of proven metrics like blood alcohol content to measure drug impairment, not just the presence of a drug.

“It’s a slow process, which is incredibly difficult when you know that each day that passes is risking a lack of safety for however many people facing the potential of a drug-impaired-driving crash,” Cash said. “But some progress is better than no progress.”

Acknowledging how long those efforts will take, the NTSB also recommended that NHTSA build an interim surveillance system that would use data from trauma centers to create a national sample of crash-involved impaired drivers.

The agency made some headway, reporting in 2023 that it was conducting its own study with the help of 11 trauma centers and medical examiner offices. It also helped California establish a 19-month statewide surveillance system, which NHTSA will use to evaluate the feasibility of a nationally representative system.

Such programs are useful for public awareness and for improving the ability of police to understand drugged driving patterns that can help them tailor enforcement, said , a University of California-Davis associate professor who researches toxicology and was involved in the California program. But some trauma centers, especially in rural areas, often lack the research infrastructure necessary for round-the-clock drug testing and participation.

Still, it’s possible, and he said the benefit is apparent in the findings from California’s surveillance system.

“If you go out there and tell people that 44% of drivers who ended up in the ER from a car accident had at least one potentially impairing substance in their blood at the time of the accident, that gets people’s attention,” Chenoweth said.

Shrinking Research Teams

Since NHTSA’s update to the NTSB three years ago, however, the agency has yet to follow up on the recommendation. Staff cuts and departures at NHTSA last year paint a poor outlook for change.

From 2021 to 2024, the agency . At the end of Trump’s first year in office, NHTSA had dropped to about 550 people due to government-wide cuts and people leaving on their own.

Cash, who now works for the nonprofit Governors Highway Safety Association, was one of five employees who left NHTSA’s last year. That leaves just two staff members in the division, she said.

Ian O’Dowd, a former employee in NHTSA’s , said he was part of a team of 16 people who studied, in part, impaired driving. Only three or four team members are still with the agency, he said.

“At some point, it becomes unwieldy for a handful of people to be managing all of the research work going on,” O’Dowd said.

NHTSA communications director Sean Rushton said the agency has “both the financial and personnel resources necessary to support its programs with multiple offices carrying out this work collaboratively, ensuring a comprehensive and coordinated approach.”

The 2021 infrastructure law, passed under the Biden administration, increased funding for NHTSA’s state highway safety program from about $667 million in 2021 to nearly $953 million this year.

The law included $750 million to modernize crash-data programs, but as of January over $475 million was unused. The funds expired in September unless they were obligated through a signed agreement.

A report by the U.S. Government Accountability Office found that nearly a quarter of entities awarded grants in 2022 had not received a signed agreement when surveyed between December 2024 and March 2025. It also found that over 1 in 5 grantees reported that obtaining timely replies from Department of Transportation staff was moderately or very challenging.

With the Biden-era infrastructure law expiring later this year, Congress could extend the unused crash-data fund or implement a new approach to impaired driving.

In mid-April, House Transportation and Infrastructure Committee Chairman Sam Graves (R-Mo.) said proposed legislation — less than half of the current bill’s $1.2 trillion — with a more “traditional” focus on roads and bridges.

The bill has amid negotiations for more funding, leaving future support uncertain.

“Certainly, we are always hoping that there will be an increase in the amount of money available to do this work,” Cash said. “Whether or not that will happen this year, I don’t know.”

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The sweeping 195-page , published May 4, advocates for making access to treatment easier than getting drugs, preventing young people from developing addictions in the first place, increasing support for people in recovery, and reducing overdose deaths.

Those broad goals are widely supported by public health researchers, addiction treatment clinicians, and recovery advocates.

But accomplishing such goals will be difficult in the face of the administration’s , and community grants, that serve people who use drugs, and , the state-federal health insurance program for low-income people that is the largest payer for addiction and mental health care nationwide.

Many components of the National Drug Control Strategy are “things that we would agree with and that we fully support,” said , who leads overdose prevention efforts at the Global Health Advocacy Incubator, a public health advocacy group.

But there are “disconnects in what the strategy says is important and then what they’re actually going to fund,” she said of the Trump administration. “Those inconsistencies feel particularly loud in this strategy.”

The White House’s National Drug Control Strategy, released , is a touchstone document meant to lay out the federal government’s coordinated approach to what in recent decades has been one of the country’s defining problems.

Since 2000, have died of drug overdoses. Although deaths have , the numbers remain elevated compared with earlier decades, and overdose death rates among Black Americans and Native Americans are disproportionately high.

The strategy document published this week is the first of President Donald Trump’s current term. In keeping with the administration’s approach to addiction issues, it places heavy emphasis on law enforcement efforts to reduce the supply of illicit drugs. The document repeatedly refers to the ongoing “war” against “foreign terrorist organizations” — the Trump administration’s term for drug cartels — and touts increased enforcement at U.S. borders.

It also to implement artificial intelligence technologies to screen for illicit drugs brought into the country and wastewater testing to detect illegal drug use nationwide.

The second half of the strategy focuses on reducing the demand for drugs through public health prevention efforts, addiction treatment, and support for people in recovery. It promotes the role of religion in recovery and calls for the widespread use of overdose reversal medications, such as naloxone.

In a news release, the White House’s Office of National Drug Control Policy called the document a “roadmap” that will “continue dismantling the drug supply and defeating the scourge of illicit drugs in our country.”

The Trump administration did not respond to requests for comment about how the strategy aligns with its other actions.

In December, Trump signed a , which continues several grants related to treatment and recovery and the requirement for Medicaid to cover all FDA-approved medications for opioid use disorder. In January, he announced the , including a to address homelessness, opioid addiction, and public safety.

However, few details have been provided about the initiative, and in January, about a month after the SUPPORT Act passed, billions of dollars in addiction-related grants were abruptly within a frantic 24-hour period.

That “whiplash” left “a sense of instability and uncertainty in the field,” said , a national adviser with the Manatt Health consultancy. She led substance use treatment policy at the Substance Abuse and Mental Health Services Administration, or SAMHSA, under the Biden administration and left about six months into Trump’s second term.

That insecurity was exacerbated by the , which proposes cuts to several addiction and mental health programs and the consolidation of key federal agencies working on those matters. Jones’ group and nearly 100 others in the field have asking Congress to reject the proposals, as it did with similar requests last year.

The national drug strategy adds new, potentially contradictory information to this confusing landscape.

Increasing Access to Treatment

One of the most significant public health goals in the strategy, mentioned at least half a dozen times, is to make it easier to get treatment than it is to buy illegal drugs.

National data underscores the necessity: More than who need substance use treatment don’t receive it.

The administration’s actions on health insurance may make it difficult to improve that statistic.

Medicaid is the for adults with opioid use disorder. When implemented, the Medicaid work requirements in Trump’s One Big Beautiful Bill Act are projected to strip that coverage from with substance use disorders.

The last time Medicaid rolls were purged — after — many people who had been receiving medication treatment for opioid addiction stopped it and fewer people started treatment, according to a .

Olsen, who is also an addiction medicine doctor, said she loves the strategy’s emphasis on making treatment readily available to anyone who wants it. But she said that’s “hard to really imagine when now people may have to pay for it themselves because they may be losing their Medicaid insurance coverage.”

the upcoming Medicaid changes could lead 156,000 people to lose access to medications for opioid use disorder and result in more than 1,000 additional fatal overdoses per year.

People with private insurance may be affected, too.

The Trump administration has Biden-era regulations aimed at bolstering mental health parity, the idea that insurers must cover mental illness and addiction treatment comparably to physical treatments. And recently, the administration said it would altogether, raising fears that addiction treatment could become increasingly unaffordable.

The administration did not respond to specific questions about how it reconciles its actions on Medicaid and parity with the goal of increasing treatment.

Prioritizing Prevention

The strategy highlights preventing addictions before they begin as one of the keys to reducing demand for drugs. It calls for “promoting a drug-free America as the social norm” and implementing school and community-based programs that are backed by science.

“Investing in primary prevention, before drug use starts, saves lives and resources,” it says, citing about of such programs.

Yet, the president’s budget proposes cuts to these types of programs, and federal layoffs have decimated the agencies that would implement such work.

The White House’s proposes cutting roughly $220 million from SAMHSA’s and nearly $40 million from the program.

Since the new administration started, SAMHSA has , and the Centers for Disease Control and Prevention is . 

“It’s not clear to me that they’re really going to be able to have the funds or the people to be able to carry that out,” Olsen said of the strategy’s prevention goals.

Another wrinkle appears in the strategy’s discussion of marijuana. The document points to marijuana use as one of the drivers of increasing drug use disorders and reports that “convergent evidence from multiple sources” suggests cannabis use increases the risk of psychosis. It calls for developing new tools to treat marijuana withdrawal and addiction.

However, just two weeks ago, the White House medical marijuana to a lower tier of scheduled substances and is moving to to do the same for marijuana broadly.

“The administration, on the one hand, is moving in a direction of liberalizing access to cannabis,” Jones said, “but at the same time, in the strategy, it talks about the dangers of doing so.”

“There’s a disconnect there that just makes you question: Which one do you believe?” she added.

The administration did not respond to specific questions about its marijuana policies.

Stopping Overdose Deaths

One of the more surprising elements of the National Drug Control Strategy comes in the last paragraph of the final chapter. It focuses on public drug-checking programs, which often involve using test strips to help people who use drugs determine whether there are more-dangerous substances, such as fentanyl or xylazine, in the batch they bought. That helps them determine whether or how to safely use those drugs.

“Rapid test strips and similar technologies that detect fentanyl and other drugs are an important tool that should be legal,” the strategy document says.

However, SAMHSA announced in that it would no longer pay for test strips, as part of the Trump administration’s “clear shift away from harm reduction and practices that facilitate illicit drug use.”

The administration has similarly attacked harm reduction programs in an and its budget . It did not respond to specific questions about how this position interacts with the drug control strategy.

, a Georgetown University professor who served as acting director of the Office of National Drug Control Policy during the Biden administration, wrote about the contradiction in : “It is the height of rhetoric over reality to champion a tool while simultaneously cutting off the funding used to acquire it.”

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If you or someone you know is seeking help for addiction recovery, contact the free and confidential treatment referral hotline, 1-800-662-HELP, or visit findtreatment.gov.

A day after Hurricane Helene ripped through western North Carolina in late September 2024, Toni Brewer had no power or water. The storm had strewn fallen trees across most roads, wiped out phone and internet communications, and put some neighborhoods near her Asheville home underwater.

Brewer cleared out the food in her refrigerator, grabbed some clothes, and drove more than an hour southwest with her partner to Franklin, to stay with relatives.

When she arrived, she opened the center console of her car, where she kept medication, and discovered another crisis. She had only three days’ worth of Suboxone, a brand of buprenorphine, a prescription drug that eases opioid cravings. Without it, she risked relapsing into a life she described as miserable.

She recalled what it felt like to have those cravings and panicked.

“It’s terrifying just to have that feeling again of, ‘I need this, and I’ll do whatever it takes to get this,’” said Brewer, who had been in recovery from opioid addiction for 18 months at the time. She needed a new prescription but knew communication lines at her doctor’s office were down.

Now, a group of doctors is using the example of Hurricane Helene to urge federal lawmakers to help improve access to substance use medications in severe weather emergencies. Four physicians working in addiction medicine that outlines strategies for getting medication to people in recovery during natural disasters.

As climate change  in the U.S., the group of doctors urged state and federal governments to act soon or risk allowing more disasters to aggravate overdoses, relapses, and deaths caused by opioid use disorder, an ongoing epidemic that has  people in the U.S. since 1999.

that after Superstorm Sandy in 2012, 70% of New Yorkers who relied on recovery medications couldn’t get enough of them. In the two years following Hurricane Maria’s devastation in Puerto Rico in 2017, , another study found. The Tubbs and Camp fires in Northern California in patients’ access to opioid addiction medications, found a study published in 2022.

A combination of factors aggravates the opioid crisis in the U.S., the AJPH editorial authors noted. Mental health stressors, treatment disruptions, drug market volatility, and economic decline all create conditions in which climate-related disasters heighten the risk of overdose deaths.

“We make it so challenging for them to access treatment medications in the first place,” said , the climate health director at Rowan University’s Cooper Medical School and a co-author of the editorial. “When people are displaced or unable to get to their usual clinics or pharmacies, those challenges just become insurmountable.”

Their push comes as President Donald Trump has had a markedly different approach to substance use policy in the past year than in his first term. Trump in 2017 declared the nation’s opioid crisis a national public health emergency and, in 2018, signed a law, known as the , to expand access to treatments.

But his administration has also reduced federal resources for mental health and substance use services, cutting staffers last year at the Substance Abuse and Mental Health Services Administration and ending numerous grants to advance research on prevention efforts.

Disasters Threaten Treatment

SAMHSA works with states to ensure that access to opioid use disorder medication isn’t disrupted, Health and Human Services spokesperson Emily Hilliard said. States can approve emergency measures to allow people more flexibility to obtain their treatments, she added, .

, another co-author of the editorial, saw these access issues play out in the wake of Hurricane Helene.

Stearns, the chief medical officer at High Country Community Health in North Carolina’s Blue Ridge Mountains, said the first calls to her clinics were for buprenorphine. She said people who needed the medication traveled over mountains and crossed rivers to get to her clinics.

“The things that my patients did to be able to access their bupe,” Stearns said, “it was astonishing.”

The that the federal government work with pharmacies to allow patients to take home more medication during emergencies. They suggest keeping a registry of patients with recovery medication prescriptions who can get treatment when evacuating across state lines.

And they propose factoring the need for such medications into disaster response plans, whether that means stocking rescue vehicles with buprenorphine, adding backup generators to opioid treatment clinics, or training volunteer responders.

People with substance use disorders already must often navigate strict, complex regulations to get the medications. For example, methadone can be obtained only through an in-person visit to federally controlled opioid treatment centers, many of which closed for days or weeks after Hurricane Helene.

Buprenorphine is controlled by the Drug Enforcement Administration’s , which restricts supply when pharmacies order more than allowed under specified thresholds. The system is meant to catch potential overuse of recovery medication in a region.

, a clinical director of substance use disorder initiatives at the Mountain Area Health Education Center in western North Carolina, said that system delayed medications numerous times in the aftermath of Helene. No exceptions were allowed, .

The agency did not respond to questions about the system.

Individual pharmacies also control who gets medication and who doesn’t. When people try to get medication for opioid use disorder far from home, it can raise alarms.

“We realized there were some pharmacies that would just be like, ‘I don’t know this person. I will only give you three days’ worth, and I’m sure they’ll be back in Asheville soon,’” Fagan said. “They didn’t want to fill a month’s worth. And in our mind, we’re sitting in the disaster, and we’re like, ‘They’re not coming back in a month.’”

Risk of Relapse

When Brewer made it to Franklin, she immediately logged in to the Mountain Area Health Education Center patient portal, dubious about whether she would be able to have her three-month Suboxone prescription refilled.

She didn’t know that her doctors had left the area, too, to get a stable internet connection. They were trying to call and email patients to fill prescriptions.

Trying to be thorough, Brewer messaged several doctors. Two responded, and one filled her prescription.

But when she went to a local Walgreens, it was out of Suboxone. So Brewer took another trip, this time to Clayton, Georgia, where she was finally able to pick up a month’s worth.

The medication that would have been mostly covered by North Carolina Medicaid if she’d stayed in-state was about $130, a high price for Brewer, who had temporarily lost her job when her workplace, a sober living facility, lost power and closed because of the storm.

Despite what little income she had at the time, Brewer said, she paid for her prescription. The thought of relapsing back to her previous life when her addiction was untreated scared her, she said.

“I would wake up every day, and the only thing on my mind was finding my next fix so I could go on about my day, or even just take care of things like feed myself, or bathe, and show up for my daughter,” she said.

Brewer recalled feeling relief after getting her prescription refilled. Her panic washed away.

“Now I can worry about everything else,” she recalled thinking as she drove home to Asheville.

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Who Really Collects in the Wage Garnishment Game?

I was a consumer bankruptcy attorney for years during the global financial crisis of 2008 (pre-Affordable Care Act). Around 40% of the bankruptcies were caused by medical debts uncovered by insurance. With the effectiveness of the ACA, the number of bankruptcies in Colorado plummeted.

My comment on “State Lawmakers Seek Restraints on Wage Garnishment for Medical Debt” (Feb. 20)? BC Services acts as if it is garnishing these wages to keep rural hospitals, medical providers, etc. in business. The likely reality is that BC Services (and other collection operations) takes “90-day-overdue” bills — which may or may not have ever been delivered to the patient; usually disregards whether the hospital has offered the patient a reasonable repayment schedule; and then keeps 50% or more of the debt, along with its attorneys’ fees and costs. The medical provider receives very little of the money sent to collections.

— Bill Myers, Denver

On Work Requirements: Working Out Solutions

Eighty hours a month works out to about 20 hours a week, and I think if people can work or study from home, they should be able to meet the requirements (“New Medicaid Work Rules Likely To Hit Middle-Aged Adults Hard,” Feb. 11). More importantly, though, “navigators” will help people get exemptions if they qualify. I wonder why there is so much moaning about the law and nothing about the means to fix the problems it creates. It seems like a lot of hot air. We know it’s a problem. So how about exploring solutions?

— Therese Shellabarger, North Hollywood, California

The Flip Side of a Drug’s Benefits

I read Phillip Reese’s report on anti-anxiety medications, adults who take them, and their concerns about this administration’s policies regarding them (“As More Americans Embrace Anxiety Treatment, MAHA Derides Medications,” Feb. 23). If the anti-anxiety medications provide solace to adults such as Sadia Zapp — a 40-year-old woman who survived cancer — then she should be able to continue them. Unfortunately, the same is not true for many other people, particularly patients such as myself.

When I was 16, I went through an unnecessarily painful and traumatic year. I was sent away from home three times, sent to a wilderness therapy “troubled teen industry” camp that has now been shut down, sent to a new boarding school that I hated, and was away from my family for many months. Of course, I felt depressed and anxious, so my psychiatrist at Kaiser prescribed citalopram. At first, it caused extreme agitation and violent ideation, stuff that is commonly reported to the point it has an . Thankfully, it calmed down. And when I lowered the dose, my life was calm, stable, and productive.

Unfortunately, that did not last long. Over time, the effects wore out, so I tried to go off. I was not given any safety instructions on how to taper slowly and safely, so I went off multiple times. Each time caused extreme withdrawal symptoms, including self-harm, crying spells, and worse depression than ever before. Also, the sexual “side effects” persisted and even worsened upon cessation to this day. It is a , and it is very rarely covered. While the worst symptoms of withdrawal went away, I still live with a worsened sexuality than a young adult my age is supposed to have.

Back to the article, which seems to focus on adults. Its only named profile is Zapp, and when it cites statistics, it begins at age 18. Solely showing statistics of adults is unethical because it obscures the high and rising prescription rates among minors. Minors are also more likely to suffer permanent developmental damage to their sexualities and experience suicidal ideation. This is a major problem that warrants further conversations.

When covering the downsides of SSRIs, the article mentioned only mild side effects, like upset stomach, decreased libido, and mild discontinuation effects, without covering the major concerns of suicidal ideation, akathisia, PSSD, and severe withdrawal. I believe that framing antidepressants as an unequivocal good is equivalent to framing them as an unequivocal evil; both misguide patients through harm and deception.

Lastly, I want to finish on this by the brilliant psychiatrist Awais Aftab.

— Eli Malakoff, San Francisco

A Rigged System?

Insurers pay these exorbitant amounts because they set them in the first place (Bill of the Month: “Even Patients Are Shocked by the Prices Their Insurers Will Pay — And It Costs All of Us,” March 3). They have been doing this for years. I learned this over 15 years ago, when I dislocated and broke my elbow. I had no insurance and, as a “self-pay” patient, paid the surgeon, hospital, and radiology center myself. They set the prices high enough that people will buy insurance out of fear, ensuring they make a profit.

The first thing I learned was that there is not a set price for all; for the insured, it is a fixed system controlled by contracts and codes. As a self-pay patient, the cost may vary.

It was late in the evening and I tripped over a snow shovel, slammed my arm up against a gate post, and it was hanging like a puppet without a string! I called an ambulance and, at the hospital, they strapped me up and told me that I must see the orthopedic surgeon the next day. He sent me to a radiology facility for an X-ray; I paid for it and took it to the surgeon. When I received a bill from the radiology center, I called to say that I had paid. They said it was for the radiologist (who, as far as I knew, never analyzed it). The contract with the insurance company required that every patient had to be billed, whether or not a radiologist reviewed scans. If not, they would lose their contract.

My elbow was dislocated, with a fracture, and I needed surgery. The surgeon’s office called the hospital for pricing, and he told me it would be about $2,000 for outpatient surgery. I called the hospital to confirm the appointment for outpatient surgery, and they wanted $8,000! When I objected, and told them what the surgeon had quoted, they checked. “Oh, you are a self-pay!” Cost would be $2,000. I gave them my card number and prepaid it before they could change their minds.

I had a friend in New Jersey who had the very same injury and surgery. She had insurance through her employer, and she paid more in copays than I paid when paying directly.

Insurance companies are SHARKS!

— Stephanie Hunt-Crowley, Chamberet, Nouvelle Aquitaine, France (formerly Frederick, Maryland)

US vs. Canada

Re: the article about nurses moving to Canada (“‘You Aren’t Trapped’: Hundreds of US Nurses Choose Canada Over Trump’s America,” Feb. 26). You neglect the “rest of the story” — or maybe you don’t know it? I had my medical office in Los Angeles for about 30 years and had dozens of Canadians come to L.A., where some had to self-pay for care, but chose to because of the superior level of medicine available. One man, a son of a gynecologist in Canada, had a draining abscess from a years-old appendectomy. The reason was, after investigation, that the Canadian practice had used silk suture (organic material), which can harbor microbes and carry a greater risk of infection. The trend has been to discontinue silk in favor of nylon. The Canadians were obliged to “use up” the silk suture they had before switching to nylon. The surgeons at my hospital were astounded.

— Kathryn Sobieski, Jackson, Wyoming

On the NET Recovery Device’s Track Record — And Detractors

I read your piece about the NET Recovery device with interest (Payback: Tracking Opioid Cash: “Maker of Device To Treat Addiction Withdrawal Seeks Counties’ Opioid Settlement Cash,” March 18), and I am grateful to you for pointing to one of our many success stories — the story of Michelle Warfield, whom the NET device helped get off opioids.

I also wanted to note a couple of instances where I see the facts differently than they were portrayed in your piece. Your piece seemed to imply that the NET device is new, and I wanted to note that the device has been around for decades (it helped Eric Clapton and members of The Who and the Rolling Stones get sober back in their heyday), and is based on a proven technology that stimulates both the brain and the vagus nerve to help patients with their cravings and withdrawal. There are countless studies that prove the power of neurostimulation, including that showed significant reductions in opioid and stimulant use without medication for a polysubstance population receiving at least 24 hours of stimulation.

I also noted you quoted detractors of our device, and I’d simply urge anyone looking at the issue of opioid addiction abatement to consider who those detractors are; organizations that now find themselves competing for grant dollars from counties increasingly choosing to fund innovation. It is not surprising that those with the most to lose financially would prefer the status quo. But the counties and jails leading this charge are doing so because they have seen what works, and their constituents, real patients, are the proof.

The success stories of our patients speak for themselves, and our only motivation at NET Recovery is to help as many people as possible get truly clean and sober by helping to break that initial grip the opioids have on them. When the NET device works, and it works an astounding 98% of the time (producing a clinically meaningful reduction in opioid withdrawal symptom severity in one hour), our patients are experiencing the return of choice and true freedom.

Thank you for your interest in our work and for the coverage you provide.

— Joe Winston, NET Recovery CEO, Costa Mesa, California

Education Is the First Step in Lowering Health Care Prices

After reading this article about making hospital prices more transparent, I realized the information alone could help drive medical prices down (“Trump Required Hospitals To Post Their Prices for Patients. Mostly It’s the Industry Using the Data,” Feb. 17). Your publication shows good use of evidence-based research — it’s timeless and informative.

As a student at Thomas Jefferson University on the path to serving in the health care arena, I understand the struggles and complexities of medical decision-making. In the medical setting, the topic of price is always overshadowed by patient care and clear communication on the part of both professionals and patients, and it does not reflect how patients would navigate comparison-shopping for care. Almost every patient relies on the help of a physician or gets help from an insurance network and not from online price matching.

I believe that many people should engage with this article even if they aren’t entering the health profession; it would benefit everyone. Although price transparency may help insurers and care providers more than patients, if their goal is to lower prices, they must look beyond the simple posting or sharing of prices. I appreciate the effort to try to bring awareness to this major issue and encourage thoughtful policy discussion about lowering medical prices.

— Jan Rodriguez, Philadelphia

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They worked for a bit. But by 2011, Warfield struggled to walk.

And “by that time, I was addicted,” said Warfield, now living in Shelbyville, Kentucky.

After she lost her health insurance, Warfield started buying pills on the street. She tried to quit several times, but the debilitating withdrawal — so bad she couldn’t get out of bed, she said — kept driving her back to drug use.

Until last year.

Through her church, Warfield learned about the NET device. It’s a cellphone-sized pack connected to gel electrodes placed near the ear that deliver low-level electrical pulses to the brain.

“Once I got set up on the device, within 30 minutes, I didn’t have any cravings” for opioids, Warfield said.

After three days on the device in August, she stopped using drugs altogether, she said.

Warfield’s treatment was paid for with her county’s opioid settlement dollars — money from pharmaceutical companies accused of fueling the overdose crisis.

State and local governments nationwide are receiving over nearly two decades and are meant to spend it treating and preventing addiction.

Warfield wants them to allot a good chunk to the NET device, which costs counties about $5,500 a person. The pitch is gaining traction. , which makes the device, said it has signed about $1.2 million in contracts with more than a dozen counties and cities in Kentucky. 

But some researchers and recovery advocates say the company’s rapid consumption of opioid dollars raises red flags. They see the NET device as the latest in a series of products that have been overhyped as the solution to the addiction crisis, preying on people’s desperation and capitalizing on the windfall of opioid settlements. Many of these products — from to body scanners for jails — have little evidence to back their lofty promises. That has not stopped sales representatives from repeatedly pitching elected officials or circulating ready-made templates to request settlement money for the companies’ products.

In fact, a device similar to NET called the Bridge gained popularity several years ago, receiving more than $215,000 in opioid settlement cash nationwide. But about the study backing its effectiveness, and the device is currently off the market.

NET Recovery’s activity “fits the national trends of these industry money grabs,” said , a national expert on opioid settlements based in Tennessee. The device “could be helpful for some,” she said. “But it’s being sold as a silver bullet.”

This year, 237 organizations working to end overdose — including Christensen’s consulting company — to guide officials in charge of opioid settlement money. In it, they called the NET device an example of problematic spending on unproven treatment.

Treating Withdrawal or Addiction

The FDA has for a specific use: reducing drug withdrawal symptoms. It has not approved the device to treat addiction.

That’s a crucial distinction, said , executive director of the Institute for Research, Education and Training in Addictions. He co-authored evaluating the evidence on neuromodulation devices like NET.

“The term ‘treatment’ becomes confusing,” Hulsey said. “These devices were cleared to treat opioid withdrawal symptoms, not to treat an opioid use disorder.”

NET Recovery CEO said the company adheres to FDA rules and advertises the device only for withdrawal management. But “we are finding that physicians are prescribing this to folks for long-term behavior based on the results of our study.”

He’s referring to that he co-authored and the company funded, in which researchers followed two groups of addiction patients in Kentucky for 12 weeks. The first group received the NET device for up to seven days, while the second group received a sham treatment.

The study found no significant difference between the groups’ outcomes. Participants who got the NET device were similarly likely to use illicit drugs after treatment as those who got the fake.

Hulsey, who was not affiliated with the study, said the takeaway is clear: “They didn’t find that was effective.”

A subgroup of participants who chose to use the device for more than 24 hours consecutively, however, went on to use illicit drugs less often than other participants.

As the researchers acknowledged in their paper, that subgroup might simply have been more motivated to engage with any form of treatment. The results don’t necessarily show that the device is making a difference, Hulsey said.

Rapid Growth

Winston had a different take. He said the success of the subgroup is “intriguing and outstanding.”

So outstanding, in fact, that the company this month is opening a brick-and-mortar location in Miami, where the device will be available to anyone who can pay $8,000 out-of-pocket. (The cost is higher for individuals than for county governments.) It has also applied for opioid settlement dollars from the state of Kentucky to conduct a larger research study and aims to bring the NET device into metro areas such as Louisville and Lexington.

Last year, NET Recovery hired a magistrate in Franklin County, Kentucky, to head up its operations in the state. (Magistrates function as county commissioners.) , who is also a mental health clinician, travels to different counties, extolling the benefits of the device and encouraging officials to contract with the company.

Her county to NET Recovery prior to her joining the company. Moving forward, Dycus said, she would recuse herself from any contract votes in her county.

Christensen, the national expert on opioid settlements, called Dycus’ new role “extremely strategic” for the company and “an obvious conflict of interest” for a public official.

Giving People Choice

More options for people to enter recovery is generally good, said Jennifer Twyman, who has a history of opioid addiction and now works with , a nonprofit that advocates to end homelessness and the war on drugs.

But settlement funds are finite, she said, and when counties invest in the NET device, that leaves less money to support options like mental health treatment, housing, and transportation programs — critical for many people who use drugs.

“People slip through these big, huge gaps we have and they die,” Twyman said, pointing to photos of dead friends that line her office wall.

She added that people should have the option of taking medications such as methadone and buprenorphine — for treating opioid addiction. only 1 in 4 people with opioid addiction get them.

Many people can’t afford them, find a doctor willing to prescribe them, or get transportation to appointments, Twyman said. against those who use medications, with detractors saying they’re not truly abstinent or clean.

Companies like NET Recovery sometimes lean into that stigma, Twyman said.

For instance, Scott County, Kentucky, jailer — whom the company considers a key champion for its device — to other county officials that medication treatment is just “swapping one drug for another.” It’s a common refrain from critics that .

Winston told ºÚÁϳԹÏÍø News his company is supportive of all types of recovery but that the NET device can help the “underserved population” of people who don’t want medication.

Longtime addiction researcher has led studies for NET Recovery and consults for , one of the leading producers of medications for opioid use disorder. He said he sees value in both approaches. It just depends on whom you’re trying to treat.

For people injecting drugs or accustomed to high doses of fentanyl, who are more likely to return to using drugs after residential treatment, “I would hesitate to recommend the device,” he said. Abstinence-based approaches can . But for people who are “highly motivated to stay abstinent,” the NET device may be a good fit.

“Giving people choices is the right thing to do,” he said.

Community as Part of Recovery

Warfield, who has not used opioids since August, credits not just the NET device with her recovery but her community too.

“It’s not a miracle cure,” she said of the device. “You still have to manage your triggers, but it’s easier.”

She regularly attends individual and group therapy to address childhood trauma. She’s found close friends within her church and has reconnected with her daughter. She installed a car seat in her vehicle so she can drive her grandson to preschool.

Warfield explained her hope for opioid settlement money to reach others in her community simply: “I want people to get as much help as they can.”

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Julie Rovner ºÚÁϳԹÏÍø News Read Julie's stories. Julie Rovner is chief Washington correspondent and host of ºÚÁϳԹÏÍø News’ weekly health policy news podcast, "What the Health?" A noted expert on health policy issues, Julie is the author of the critically praised reference book "Health Care Politics and Policy A to Z," now in its third edition.

Millions of Americans are facing dramatically higher health insurance premium payments due to the Jan. 1 expiration of enhanced Affordable Care Act subsidies. But much of Washington appears more interested at the moment in culture war issues, including abortion and gender-affirming care.

Meanwhile, at the Department of Health and Human Services, personnel continue to be fired and rehired, and grants terminated and reinstated, leaving everyone who touches the agency uncertain about what comes next.

This week’s panelists are Julie Rovner of ºÚÁϳԹÏÍø News, Anna Edney of Bloomberg News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Alice Miranda Ollstein of Politico.

Panelists

Anna Edney Bloomberg News

Joanne Kenen Johns Hopkins University and Politico

Alice Miranda Ollstein Politico

Among the takeaways from this week’s episode:

• Congress remains undecided on a deal to renew enhanced ACA premium subsidies, as it is on spending plans to keep the federal government running when the existing, short-term plan expires at the end of the month. While some of the bigger appropriations hang-ups are related to immigration and foreign affairs, there are also hurdles to passing spending for HHS.
• ACA plan enrollment is down about 1.5 million compared with last year, with states reporting that many people are switching to cheaper plans or dropping coverage. Enrollment numbers are likely to drop further in the coming months as more-expensive premium payments come due and some realize they can no longer afford the plans they’re enrolled in.
• A key Senate health committee on Wednesday hosted a hearing on the abortion pill mifepristone, focused on the safety concerns posed by abortion foes — though those concerns are unsupported by scientific research and decades of experience with the drug. Many abortion opponents are frustrated that the Trump administration has not taken aggressive action to restrict access to the abortion pill.
• As the Trump administration moved this week to rehire laid-off employees and abruptly cancel, then restore, addiction-related grants, overall government spending is up, despite the administration’s stated goal of saving money by cutting the federal government’s size and activities. It turns out the churn within the administration is costing taxpayers more. And new data, revealing that more federal workers left on their own than were laid off last year, shows that a lot of institutional memory was also lost.

Also this week, Rovner interviews ºÚÁϳԹÏÍø News’ Elisabeth Rosenthal, who created the “Bill of the Month” series and wrote the latest installment, about a scorpion pepper, an ER visit, and a ghost bill. If you have a baffling, infuriating, or exorbitant bill you’d like to share with us, you can do that here.

Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: The New York Times’ “,” by Maxine Joselow.

Alice Miranda Ollstein: ProPublica’s “,” by Anna Clark.

Joanne Kenen: The New Yorker’s “,” by Dhruv Khullar.

Anna Edney: MedPage Today’s “,” by Joedy McCreary.

Also mentioned in this week’s podcast:

• The Washington Post’s “,” by Paul Kane.
• HealthAffairs’ “,” by Mica Hartman, Anne B. Martin, David Lassman, and Aaron Catlin.
• Politico’s “,” by Alice Miranda Ollstein.
• JAMA’s “,” by Sophie Dilek, Joanne Rosen, Anna Levashkevich, Joshua M. Sharfstein, and G. Caleb Alexander.

Credits

Click here to find all our podcasts.

And subscribe to “What the Health? From ºÚÁϳԹÏÍø News” on , , , , , or wherever you listen to podcasts.

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But inside, the store is a welcoming oasis. Twinkly string lights adorn racks of donated clothing. Shelves and bins overflow with children’s books, allergy medications, and toiletries. Curtains cordon off one side of the room, where there’s a stage for musicians and a neon sign depicting roller skates for weekly free skate nights.

The space is part free thrift store, part over-the-counter pharmacy, part punk show venue — and wholly “a radical community center,” said Dan Bingler, who runs the place.

Bingler is a waiter and bartender in the city who founded a mutual-aid organization called the . He said the building owners allow him to use the space as long as he pays the water, electricity, and trash bills.

On Monday evenings, volunteers from other community organizations show up — some used to set up in the parking lot before Bingler opened the store. They offer free testing for sexually transmitted infections, basic medical care, hot meals, and sterile syringes and other supplies for people who use drugs.

The purpose of the space is simple, Bingler said: “We’re going to make sure we provide for the community.”

Although it’s been open for a few years now, the space has become even more crucial to this community in recent months, with the Trump administration slashing funding for many social service organizations and taking an aggressive approach to homelessness and drug use. In Washington, D.C., the administration has to push people living on the street to . Nationally, it has called for people who use drugs to be . It has — practices that public health experts say keep people who use drugs safe and alive but that critics say promote illegal drug use.

The community space in New Orleans — named the Fred Hampton Free Store after the known for bringing together diverse groups to fight for social reforms — aims to be a haven among this sea of changes.

It doesn’t receive federal funding, state or local grants, or money from foundations, Bingler said. It’s simply neighbors helping neighbors, he said, tearing up and adding, “It’s a really beautiful thing to be able to share all this space.”

All items inside are provided by people or organizations in the community. Bingler said one time a local hotel undergoing renovations donated 50 flat-screen TVs.

On nights the store is open, often more than 100 people visit, Bingler said.

One fall evening, dozens of people browsed for free clothing and over-the-counter medications. Others sat on the grass outside, chatting while keeping an eye on their bicycles or grocery carts full of possessions.

James Beshears stopped by the harm reduction group in the parking lot to get sterile supplies he uses to inject heroin and fentanyl. He said he’d been in treatment for years but relapsed after his doctor moved away and he was referred to a clinic that charged $250 a day. Street drugs were cheaper than treatment, he said.

He wants to stop. But until he can find affordable care, places like the free store keep him going. Without it, he said, he’d have “one foot in the grave.”

Another man in the parking lot was waiting for the arrival of Aquil Bey, a paramedic and former Green Beret well known for helping people overcome obstacles to getting health care. As soon as the man spotted Bey’s black Jeep, he ran up.

“I’ve got stage 4 kidney disease,” the man said, adding that he was scheduled for treatments at a hospital but was struggling to get there.

“Do me a favor,” Bey said as he unloaded folding tables and medical equipment from his car. “When our team gets here, come and see us. Maybe we can get you transportation.”

Bey is the founder of , a volunteer-run organization that provides free basic medical care and referrals for people who are homeless, using drugs, or part of other vulnerable communities. The group has a steady presence at the free store.

That day, Bey and his team connected the man needing kidney disease treatment to reduced-cost transit programs. They also did blood pressure and blood sugar checks for anyone who wanted them, cleaned infected wounds, and called clinics to make appointments for patients without phones.

A man with a leg injury mentioned he was sleeping on the concrete floor of an abandoned naval base. Bey noticed the free store’s furniture section had a mattress. He and another volunteer hauled it out, strapped it to the top of a car, and delivered it to where the man was sleeping.

“We’re just trying to find all these barriers” that people face and “find ways to fix them,” Bey said.

The clinic at the free store helped Stephen Wiltz connect with addiction care. He grew up in the Lower 9th Ward and had been using drugs since he was 10.

Fed up with discrimination from doctors who blamed him for his addiction, Wiltz said, he was reluctant to go to any treatment facility. But after years of knowing the volunteers at the free store, he trusted them to point him in the right direction.

At 56, Wiltz was in sustained recovery for the first time in his life, he said during a phone interview in the fall.

Those volunteers “cared for people who didn’t have nobody to care for them,” he said.

As the sun went down that fall evening at the store, a punk band started setting up for a show across the room from the medical clinic. Lights dimmed and music blared — a reminder that this was not your everyday clinic or community center.

Bey continued consulting with a patient who had gout.

“I get used to the sound,” Bey said of the rapid drums and loud power chords. “I like it sometimes.”

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LODGE GRASS, Mont. — Brothers Lonny and Teyon Fritzler walked amid the tall grass and cottonwood trees surrounding their boarded-up childhood home near the Little Bighorn River and daydreamed about ways to rebuild.

The rolling prairie outside the single-story clapboard home is where Lonny learned from their grandfather how to break horses. It’s where Teyon learned from their grandmother how to harvest buffalo berries. It’s also where they watched their father get addicted to meth.

Teyon, now 34, began using the drug at 15 with their dad. Lonny, 41, started after college, which he said was partly due to the stress of caring for their grandfather with dementia. Their own addictions to meth persisted for years, outlasting the lives of both their father and grandfather.

It took leaving their home in Lodge Grass, a town of about 500 people on the Crow Indian Reservation, to recover. Here, methamphetamine use is widespread.

The brothers stayed with an aunt in Oklahoma as they learned to live without meth. Their family property has sat empty for years — the horse corral’s beams are broken and its roof caved in, the garage tilts, and the house needs extensive repairs. Such crumbling structures are common in this Native American community, hammered by the effects of meth addiction. Lonny said some homes in disrepair would cost too much to fix. It’s typical for multiple generations to crowd under one roof, sometimes for cultural reasons but also due to the area’s housing shortage.

“We have broken-down houses, a burnt one over here, a lot of houses that are not livable,” Lonny said as he described the few neighboring homes.

In Lodge Grass, an estimated 60% of the residents age 14 and older struggle with drug or alcohol addictions, according to a local survey contracted by the Mountain Shadow Association, a local, Native-led nonprofit. For many in the community, the buildings in disrepair are symbols of that struggle. But signs of renewal are emerging. In recent years, the town has torn down more than two dozen abandoned buildings. Now, for the first time in decades, new businesses are going up and have become new symbols — those of the town’s effort to recover from the effects of meth.

One of those new buildings, a day care center, arrived in October 2024. A parade of people followed the small, wooden building through town as it was delivered on the back of a truck. It replaced a formerly abandoned home that had tested positive for traces of meth.

“People were crying,” said Megkian Doyle, who heads the Mountain Shadow Association, which opened the center. “It was the first time that you could see new and tangible things that pulled into town.”

The nonprofit is also behind the town’s latest construction project: a place where families together can heal from addiction. The plan is to build an entire campus in town that provides mental health resources, housing for kids whose parents need treatment elsewhere, and housing for families working to live without drugs and alcohol.

Though the project is years away from completion, locals often stop by to watch the progress.

“There is a ground-level swell of hope that’s starting to come up around your ankles,” Doyle said.

Two of the builders on that project are Lonny and Teyon Fritzler. They see the work as a chance to help rebuild their community within the Apsáalooke Nation, also known as the Crow Tribe.

“When I got into construction work, I actually thought God was punishing me,” Lonny said. “But now, coming back, building these walls, I’m like, ‘Wow. This is ours now.’”

Meth ‘Never Left’

Meth use is a throughout the U.S. and a growing contributor to the nation’s . The drug had been devastating in Indian Country, that encompasses tribal jurisdictions and certain areas with Native American populations.

Native Americans face the in the U.S. compared with any other demographic group.

“Meth has never left our communities,” said A.C. Locklear, CEO of the , a nonprofit that works to improve health in Indian Country.

Many reservations are in rural areas, which have of meth use compared with cities. As a group, Native Americans face high rates of poverty, chronic disease, and mental illness — all are . These conditions are rooted in , a byproduct of colonization. Meanwhile, the Indian Health Service, which provides health care to Native Americans, has been . have shrunk health programs nationwide.

LeeAnn Bruised Head, a recently retired public health adviser with the U.S. Public Health Service Commissioned Corps, said that despite the challenges, tribal nations have developed strong survival skills drawing from their traditions. For example, Crow people have held onto their nation’s language; neighbors are often family, or considered such; and many tribal members rely on their clans to mentor children, who eventually become mentors themselves for the next generation.

“The strength here, the support here,” said Bruised Head, who is part of the Crow Tribe. “You can’t get that anywhere else.”

Signs of Rebuilding

On a fall day, Quincy Dabney greeted people arriving for lunch at the Lodge Grass drop-in center. The center recently opened in a former church as a place where people can come for help to stay sober or for a free meal. Dabney volunteers at the center. He’s also the town’s mayor.

Dabney helped organize community cleanup days starting in 2017, during which people picked up trash in yards and alongside roads. The focus eventually shifted to tearing down empty, condemned houses, which Dabney said had become spots to sell, distribute, and use meth, often during the day as children played nearby.

“There was nothing stopping it here,” Dabney said.

The problem hasn’t disappeared, though. In 2024, officials broke up a multistate based on the Crow reservation that distributed drugs to other Montana reservations. It was one example of how drug traffickers as sales and distribution hubs.

A few blocks from where Dabney spoke stood the remains of a stone building where someone had spray-painted “Stop Meth” on its roofless walls. Still, there are signs of change, he said.

Dabney pointed across the street to a field where a trailer had sat empty for years before the town removed it. The town was halfway through tearing down another home in disrepair on the next block. Another house on the same street was being cleaned up for an incoming renter: a new mental health worker at the drop-in center.

Just down the road, work was underway on the new campus for addiction recovery, called Kaala’s Village. Kaala means “grandmother” in Crow.

The site’s first building going up is a therapeutic foster home. Plans include housing to gradually reunite families, a community garden, and a place to hold ceremonies. Doyle said the goal is that, eventually, residents can help build their own small homes, working with experienced builders trained to provide mental health support.

She said one of the most important aspects of this work “is that we finish it.”

Tribal citizens and organizations have said the political chaos of Trump’s first year back in office shows the problem with relying on federal programs. It underscores the need for more grassroots efforts, like what’s unfolding in Lodge Grass. But a reliable system to fund those efforts still doesn’t exist. Last year’s federal grant and program cuts also fueled competition for philanthropic dollars.

Kaala’s Village is expected to cost $5 million. The association is building in phases as money comes in. Doyle said the group hopes to open the foster home by spring, and family housing the following year.

The site is a few minutes’ drive from Lonny and Teyon’s childhood home. In addition to building the new facility’s walls, they’re getting training to offer mental health support. Eventually, they hope to work alongside people who come home to Kaala’s Village.

As for their own home, they hope to restore it — one room at a time.

“Just piece by piece,” Lonny said. “We’ve got to do something. We’ve got these young ones watching.”

This <a target="_blank" href="/mental-health/tribal-health-meth-epidemic-recovery-montana-town-rebuilds-crow-reservation/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

NEW ORLEANS — Elyse Stevens had a reputation for taking on complex medical cases. People who’d been battling addiction for decades. Chronic-pain patients on high doses of opioids. Sex workers and people living on the street.

“Many of my patients are messy, the ones that don’t know if they want to stop using drugs or not,” said Stevens, a primary care and addiction medicine doctor.

While other doctors avoided these patients, Stevens — who was familiar with the city from her time in medical school at Tulane University — sought them out. She regularly attended 6 a.m. breakfasts for homeless people, volunteered at a homeless shelter clinic on Saturdays, and, on Monday evenings, visited an abandoned Family Dollar store where advocates distributed supplies to people who use drugs.

One such evening about four years ago, Charmyra Harrell arrived there limping, her right leg swollen and covered in sores. Emergency room doctors had repeatedly dismissed her, so she eased the pain with street drugs, Harrell said.

Stevens cleaned her sores on Mondays for months until finally persuading Harrell to visit the clinic at University Medical Center New Orleans. There, Stevens discovered Harrell had diabetes and cancer.

She agreed to prescribe Harrell pain medication — an option many doctors would automatically dismiss for fear that a patient with a history of addiction would misuse it.

But Stevens was confident Harrell could hold up her end of the deal.

“She told me, ‘You cannot do drugs and do your pain meds,’” Harrell recounted on a Monday evening in October. So, “I’m no longer on cocaine.”

Stevens’ approach to patient care has won her awards and nominations in , , and . Instead of seeing patients in binaries — addicted or sober, with a positive or negative drug test — she measures progress on a spectrum. Are they showering daily, cooking with their families, using less fentanyl than the day before?

But not everyone agrees with this flexible approach that prioritizes working with patients on their goals, even if abstinence isn’t one of them. And it came to a head in the summer of 2024.

“The same things I was high-fived for thousands of times — suddenly that was bad,” Stevens said.

Flexible Care or Slippery Slope?

More than who need substance use treatment don’t receive it, national data shows. Barriers abound: high costs, lack of transportation, clinic hours that are incompatible with jobs, fear of being mistreated.

Some doctors had been trying to ease the process for years. Covid-19 accelerated that trend. Telehealth appointments, fewer urine drug tests, and medication refills that last longer became the norm.

The result?

“Patients did OK and we actually reached more people,” said , immediate past president of the American Society of Addiction Medicine. The organization supports continuing flexible practices, such as helping patients avoid withdrawal symptoms by of addiction medication and focusing on recovery goals .

But some doctors prefer traditional approaches that range from zero tolerance for patients using illegal drugs to setting stiff consequences for those who don’t meet their doctors’ expectations. For example, a patient who tests positive for street drugs while getting outpatient care would be discharged and told to go to residential rehab. Proponents of this method fear loosening restrictions could be a slippery slope that ultimately harms patients. They say continuing to prescribe painkillers, for example, to people using illicit substances long-term could normalize drug use and hamper the goal of getting people off illegal drugs.

Progress should be more than keeping patients in care, said , a Stanford psychologist, who has treated and researched addiction for decades and .

“If you give addicted people lots of drugs, they like it, and they may come back,” he said. “But that doesn’t mean that that is promoting their health over time.”

Flexible practices also tend to align with harm reduction, a divisive approach that proponents say keeps people who use drugs safe and that critics — — say enables illegal drug use.

The debate is not just philosophical. For Stevens and her patients, it came to bear on the streets of New Orleans.

‘Unconventional’ Prescribing

In the summer of 2024, supervisors started questioning Stevens’ approach.

In emails reviewed by ºÚÁϳԹÏÍø News, they expressed concerns about her prescribing too many pain pills, a mix of opioids and other controlled substances to the same patients, and high doses of buprenorphine, a medication considered to treat opioid addiction.

Supervisors worried Stevens wasn’t doing enough urine drug tests and kept treating patients who used illicit drugs instead of referring them to higher levels of care.

“Her prescribing pattern appears unconventional compared to the local standard of care,” the hospital’s chief medical officer at the time wrote to Stevens’ supervisor, . “Note that this is the only standard of care which would likely be considered should a legal concern arise.”

Springgate forwarded that email to Stevens and encouraged her to refer more patients to methadone clinics, intensive outpatient care, and inpatient rehab.

Stevens understood the general practice but couldn’t reconcile it with the reality her patients faced. How would someone living in a tent, fearful of losing their possessions, trek to a methadone clinic daily?

Stevens sent her supervisors of and backing her flexible approach. She explained that if she stopped prescribing the medications of concern, patients might leave the health system, but they wouldn’t disappear.

“They just wouldn’t be getting care and perhaps they’d be dead,” she said in an interview with ºÚÁϳԹÏÍø News.

Both University Medical Center and LSU Health New Orleans, which employs physicians at the hospital, declined repeated requests for interviews. They did not respond to detailed questions about addiction treatment or Stevens’ practices.

Instead, they provided a joint statement from Richard DiCarlo, dean of the LSU Health New Orleans School of Medicine, and Jeffrey Elder, chief medical officer of University Medical Center New Orleans.

“We are not at liberty to comment publicly on internal personnel issues,” they wrote.

“We recognize that addiction is a serious public health problem, and that addiction treatment is a challenge for the healthcare industry,” they said. “We remain dedicated to expanding access to treatment, while upholding the highest standard of care and safety for all patients.”

Not Black-and-White

ºÚÁϳԹÏÍø News shared the complaints against Stevens and the responses she’d written for supervisors with two addiction medicine doctors outside of Louisiana, who had no affiliation with Stevens. Both found her practices to be within the bounds of normal addiction care, especially for complex patients.

, an addiction medicine doctor and the , said doctors running pill mills typically have sparse patient notes that list a chief complaint of pain. But Stevens’ notes detailed patients’ life circumstances and the intricate decisions she was making with them.

“To me, that’s the big difference,” Loyd said.

Some people think the “only good answer is no opioids,” such as oxycodone or hydrocodone, for any patients, said , an addiction medicine doctor and associate professor at Michigan State University. But patients may need them — sometimes for things like cancer pain — or require months to lower their doses safely, she said. “It’s not as black-and-white as people outside our field want it to be.”

Humphreys, the Stanford psychologist, had a different take. He did not review Stevens’ case but said, as a general practice, there are risks to prescribing painkillers long-term, especially for patients using today’s lethal street drugs too.

Overprescribing fueled the opioid crisis, he said. “It’s not going to go away if we do that again.”

‘The Thing That Kills People’

After months of tension, Stevens’ supervisors told her on March 10 to stop coming to work. The hospital was conducting a review of her practices, they said in an email viewed by ºÚÁϳԹÏÍø News.

Overnight, hundreds of her patients were moved to other providers.

Luka Bair had been seeing Stevens for three years and was stable on daily buprenorphine.

After Stevens’ departure, Bair was left without medication for three days. The withdrawal symptoms were severe — headache, nausea, muscle cramps.

“I was just in physical hell,” said Bair, who works for the National Harm Reduction Coalition and uses they/them pronouns.

Although Bair eventually got a refill, Springgate, Stevens’ supervisor, didn’t want to continue the regimen long-term. Instead, Springgate referred Bair to more intensive and residential programs, citing Bair’s intermittent use of other drugs, including benzodiazepines and cocaine, as markers of high risk. Bair “requires a higher level of care than our clinic reasonably can offer,” Springgate wrote in patient portal notes reviewed by ºÚÁϳԹÏÍø News.

But Bair said daily attendance at those programs was incompatible with their full-time job. They left the clinic, with 30 days to find a new doctor or run out of medication again.

“This is the thing that kills people,” said Bair, who eventually found another doctor willing to prescribe.

Springgate did not respond to repeated calls and emails requesting comment.

University Medical Center and LSU Health New Orleans did not answer questions about discharging Stevens’ patients.

‘Reckless Behavior’

About a month after Stevens was told to stay home, Haley Beavers Khoury, a medical student who worked with her, had collected nearly 100 letters from other students, doctors, patients, and homelessness service providers calling for Stevens’ return.

One student wrote, “Make no mistake — some of her patients will die without her.” A nun from the Daughters of Charity, which ran , called Stevens a “lifeline” for vulnerable patients.

Beavers Khoury said she sent the letters to about 10 people in hospital and medical school leadership. Most did not respond.

In May, the hospital’s review committee determined Stevens’ practices fell “outside of the acceptable community standards” and constituted “reckless behavior,” according to a letter sent to Stevens.

The hospital did not answer ºÚÁϳԹÏÍø News’ questions about how it reached this conclusion or if it identified any patient harm.

Meanwhile, Stevens had secured a job at another New Orleans hospital. But because her resignation came amid the ongoing investigation, University Medical Center said it was required to inform the state’s medical licensing board.

The medical board began its own investigation — a development that eventually cost Stevens the other job offer.

In presenting her side to the medical board, Stevens repeated many arguments she’d made before. Yes, she was prescribing powerful medications. No, she wasn’t making clinical decisions based on urine drug tests. But national addiction organizations supported such practices and promoted tailoring care to patients’ circumstances, she said. Her response included a 10-page bibliography with 98 citations.

Liability

The board’s investigation into Stevens is ongoing. shows no action taken against her license as of late December.

The board declined to comment on both Stevens’ case and its definition of appropriate addiction treatment.

In October, Stevens moved to the Virgin Islands to work in internal medicine at a local hospital. She said she’s grateful for the welcoming locals and the financial stability to support herself and her parents.

But it hurts to think of her former patients in New Orleans.

Before leaving, Stevens packed away handwritten letters from several of them — one was 15 pages long, written in alternating green and purple marker — in which they shared childhood traumas and small successes they had while in treatment with her.

Stevens doesn’t know what happened to those patients after she left.

She believes the scrutiny of her practices centers on liability more than patient safety.

But, she said, “liability is in abandoning people too.”

This <a target="_blank" href="/mental-health/addiction-medicine-harm-reduction-opioids-louisiana-doctor-battle/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">