I'm a Montana reporter who spent 4 months investigating why my state fails to provide adequate care for women who use meth or opioids while pregnant. AMA.

I'm a lawyer who works juvenile and Child Protection cases. The big thing that I see in my state is that resources are available, but the hard thing is to get the women connected with the resources. Most drug users understand that they are breaking the law, and fear that by going to get help they will some how get in trouble. Even if immunity is granted under the law for those who seek help, there's still that issue that the women tend to be uneducated and just don't know what community resources they can go to. These women tend to be poorer, and they tend to be in complete isolation compared to the rest of society. It's not like they are seeing a regular counselor, or are in regular contact with the state's department of health and welfare. It's only after the baby is born, and the drugs are detected that the state can get involved and start working with the women.

How do you propose we overcome this barrier?

You echoed a lot of the women we talked to. It's definitely a complicated issue that will take commitment from a wide variety of Montanans to address. The biggest thing we heard from women is how important it was to have someone help them connect to all those resources. When they sought help, it was overwhelming to navigate the hospital, treatment, social services, safe housing and all the usual challenges of life and pregnancy on their own. They also said it was critical to know they had somewhere to go for help where they wouldn't face trouble or scorn. There are several pilot projects funded by the Montana Healthcare Foundation that are testing different strategies. Wrapped in Hope in Lake County has helped dozens of women, primarily by serving as navigators through those myriad services from pregnancy through a year after birth. (Relapse risk is higher immediately after birth, so it's critical care doesn't stop when the baby is born.) One hospital, mostly through cultural changes and better connections to community groups, reduced CFS removals by 70 percent and cut the length of NICU stay by more than half for infants who experience withdrawals: http://missoulian.com/kalispell-hospital-shifts-to-care-for-mothers-with-addictions-alongside/article_209d0d52-6215-5656-abd6-283e5b7d2fcc.html

What ideas do you have? Or insights you can share from your experiences?

No, I really don't. Not any good ones. I remember a research project I did in undergrad where I was looking at indigenous peoples in central/south america and their political involvement. Indigenous communities were essentially kept out of the political arena, until suddenly in the 90s and 2000s, they exploded onto the scene.

A couple things that showed how this happened included NGOs who got involved, catholic and mormon churches offering services, and the internet which allowed for greater communication. All these things essentially helped these communities learn about available resources and increased the chances of them using the resources when they needed help.

But the big issue is with drug users, they don't really have a community. A community with shared goals and ideas can actually get engaged and make some change, especially once they can utilize the available resources. So creating some kind of drug user community might be one major key.

I think that's why marijuana legalization is actually successful. There's a community effort behind it. But it's much harder to organize a community behind meth and heroin, since it's so ostracized by the vast majority. This is to such an extent, that any appearance of people trying to develop a community around this, they would be immediately targeted.

Maybe this is something that will just take time. As more people get to know the drugs and people who use them, they'll be more accepting and allow for community development. But I wouldn't hold my breath. Those two drugs are so deadly, and too many people have lost loved ones, that it seems almost unlikely. Maybe research should be funded to figure out safer drugs that provide the same effects. That way, people are more accepting, but again that's not something that'll happen for a long while. Maybe a chemist-turned-drug-dealer, with cancer and nothing to lose, could figure something out.

I suppose in the meantime, we could try to figure out resources that target and allow for community development around these drug users. But it would be extremely hard considering that law enforcement and the general community are just so opposed to it.

Interesting. I had not thought about this issue through a social organizing lens, although that makes sense. You sparked some thoughts.

Part of the problem with drug use, or any underground culture, is that there is a community, but it's not necessarily one that reinforces societally desired behaviors. Leave that world behind, and find yourself alone or stigmatized. Stay, and face legal and health consequences. And for some people, that community is all you've ever known. You don't know there is another way to live, cope, etc.

In some ways, I think the current (relative) sympathy for opioid users stems, in part, from the fact painkillers are legal. I see some parallels with marijuana like you mentioned. (Research tidbit: More than 80 percent of today's heroin users became addicted from painkillers, although generally from misuse.) Second sidenote: The effects of pot use during pregnancy are better studied and, to way oversimplify things, are worse on fetal development than crack cocaine or heroin. Alcohol and nicotine are the best studied--easier to study legal substances-- and everyone I talked to said they're terrible, stunting brain or lung development.

Peer recovery groups have been around a long time and, when run right, can provide a kind of community for drug users and those in active recovery. Easier said then done, and they can be problematic in their own ways. One of the women I talked to was denied any recognition of her sobriety because she was prescribed buprenorphine and, in their eyes, "not clean." Montana is following states like Wyoming in expanding and professionalizing these groups, to a degree, allowing Medicaid to pay for peer recovery specialists who might get a little more training than an average NA volunteer.

A few of the women we talked to were lucky enough to get into one of the two licensed residential treatment programs in the state that take women with kids. They talked about how the community of peers kept them accountable but also have them a safe space to open up about challenges. It's tough to get the right balance of structure in those programs. Too much and it feels like prison and people shut down or hide how they're actually doing out of fear. Not enough and addict thinking takes over, finding room for lies and justifications to get back to their habit.

One last one: Look at the history of NAMI, the National Alliance for the Mentally Ill. Essentially, people with mental illness and their families were sick of the status quo and the stigmas so they fought for policy change, offered education and myth busting broadly, and organized support groups for both people with diagnoses and for family or friends trying to figure it out. They've been successful at pushing cultural changes at personal and national levels. I don't know that there's a similar group related to drug use beyond AA and NA. (There probably are, and I just don't know it.) Thinking out loud, I wonder if NAMI might extend its umbrella since the majority of drug users have cooccurring mental health challenges.

Anyway, thanks for sharing your thoughts.

"The effects of pot use during pregnancy are better studied and, to way oversimplify things, are worse on fetal development than crack cocaine or heroin." Do you have any resources for this statement?

Generalized statements like that came up in interviews with OBGYNs and were confirmed by a review of studies in the NIH library and medical guidebooks checked out from a university library. I do stand corrected, a bit, after reviewing my notes. There is not as much research on marijuana as I remembered off the top of my head. For all of these, one of the challenges is sussing out what negative childhood outcomes are the result of the in-utero exposure specifically instead of other factors, like poor nutrition, limited prenatal care or poverty.

Some sources:

Fetal alcohol syndrome is "a devastating constellation of birth defects characterized by craniofacial malformations, neurological and motor deficits, intrauterine growth retardation, learning disabilities, and behavioral and social deficits" and "is now the leading known environmental teratogen (an agent capable of causing physical birth defects)." https://report.nih.gov/NIHfactsheets/ViewFactSheet.aspx?csid=27

Tobacco "smoking during pregnancy caused an estimated 910 infant deaths annually from 1997 through 2001, and neonatal care costs related to smoking are estimated to be more than $350 million per year. The adverse effects of smoking during pregnancy can include fetal growth retardation and decreased birthweight." https://www.drugabuse.gov/publications/research-reports/tobacco/smoking-pregnancy-what-are-risks

"Given the potential of marijuana to negatively impact the developing brain, the American College of Obstetricians and Gynecologists recommends that obstetrician-gynecologists counsel women against using marijuana while trying to get pregnant, during pregnancy, and while they are breastfeeding." https://www.drugabuse.gov/publications/research-reports/marijuana/can-marijuana-use-during-pregnancy-harm-baby

For cocaine, "it is difficult to estimate the full extent of the consequences of maternal drug use and to determine the specific hazard of a particular drug to the unborn child....Dire predictions of reduced intelligence and social skills in babies born to mothers who used crack cocaine while pregnant during the 1980s—so-called "crack babies"—were grossly exaggerated." https://www.drugabuse.gov/publications/research-reports/cocaine/what-are-effects-maternal-cocaine-use

Opioids "Earlier reports have not shown an increase in risks of birth defects after prenatal exposure to oxycodone, propoxyphene, or meperidine...The later observed birth defects remain rare and represent a minute increase in absolute risk. A recent meta-analysis that compared methadone and buprenorphine found no difference between the groups with respect to congenital malformations. In addition, the incidence of anomalies reported were similar to what would be expected in the general population." https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Opioid-Use-and-Opioid-Use-Disorder-in-Pregnancy

Hi!

Just wanted to say thank you for your very good investigative reporting, and your detailed explanations and discussion here.

Thanks! I'll pass that along to the students I worked with. Happy New Year!

Is this problem over-represented in the native community?

It's tough to know. Because hospitals do not universally test the umbilical cord for drug use, we don't really have good data that would allow for an ethnic comparison. We do know the challenges are not limited to Native communities, urban or on reservations. About two-thirds of all child removals by the state involve parental drug use and the majority of those cases involve white families. And we know that Native women can face unique risks for drug use and extra barriers to care. For instance, historical trauma and the multigenerational poverty seen in some Native families can mean some people are more likely to experiences the kinds of terrible things that trigger many drug users to numb their emotions. Limited access to health care also makes it difficult to recover. Some of that is the result of federal policies and Congressional funding decisions that creates a different norm of care for some Native families. It is known that some Native women were sterilized without their consent by federal doctors decades ago, so there is particular mistrust of the health system for some families. Some of the Native women we talked to blamed the Indian Health Service for prescribing painkillers too easily and doing so instead of surgeries they couldn't offer because funding was too short, although that's difficult to track or prove. (A little unrelated, but a guy I interviewed last year needed knee surgery but it wasn't life threatening so he was prescribed painkillers for years until there was the money available to pay for it, a result of Congressional funding decisions. He had worked in construction his whole life and couldn't afford to pay the surgery out of pocket. He had to stop because of the damage to his knees and only years after that was able to get surgery.)

Medicaid expansion and special tribal provisions of the ACA have started to alleviate some of those issues by giving Native families more options for where to access care and how to pay for it. Tribes have increasingly taken on a greater role in delivering health services. For instance, the Confederated Salish and Kootenai Tribes here operates one of the state's few medication-assisted treatment programs, something that is rare in the state as a whole. In Montana, reservations also face the same challenges as other rural communities: isolation from services and job opportunities, hospitals have difficulty recruiting specialists, long drives to basic services, etc.

More here: http://missoulian.com/pregnant-women-on-montana-reservations-find-few-options-for-drug/article_c5f4f34a-bc18-5bed-aceb-b3b7b71a81d0.html

What usually happens to babies born to addicted mothers? Thanks for doing this AMA!

It depends a little on the drug and other aspects of the family's life. Really, there's not a lot of research about how particular drugs affect fetal development and longterm childhood outcomes. That said, the research that has been done shows legal substances like alcohol can have worse effects than illegal ones, like cocaine. About 3/4 of infants exposed to opioids, boys more likely than girls, will be diagnosed with neonatal abstinence syndrome, a fancy term for withdrawal. Babies can be fussy and have trouble feeding, which can make it difficult for them to gain weight. In extreme causes, they might also experience seizures or die. Luckily, trained doctors can ease infants through these withdrawal and send them home healthy.

It's particularly difficult to study the effects on infants because women dose differently depending on money and access day-to-day, and it's difficult to distinguish between the longterm effects caused by a drug in the uterus from those that result from "social determinants" like poverty, nutrition, etc.

Montana, like many states, requires doctors to report to Child and Family Services if the mom's umbilical cord tests positive for drugs. Some hospitals screen all births. Some leave it up to the doctors, which can leave room for bias in who gets tested. So, many of these families end up interacting with child protection workers. Montana removes more kids because of drugs in the home than most.

More here: http://missoulian.com/children-bear-consequences-of-montana-s-failure-to-treat-mothers/article_6b981233-5002-5a3a-836b-41374742cfe0.html

What is the best approach to drug addiction treatment with women who are pregnant? What do other states do that you would like to see Montana do?

For opioids, the American Society of Addiction Medicine recommends medication-assisted treatment. The strategy combines therapy with a prescription for buprenorphine, which satisfies cravings and prevents withdrawals. In effect, it helps people manage the ups and downs of cravings much like insulin helps diabetics, letting them live normally and profess with therapy with much less risk of relapse. The American Congress of Obstetricians and Gynecologists recommend this for pregnant women especially because withdrawals can be dangerous for a fetus. It's best, doctors say, to create a stable uterine environment with buprenorphine.

More about it here: http://missoulian.com/doctors-know-how-to-treat-opioid-crisis-but-not-enough/article_bafbdd13-d00b-5c1b-9f6a-80d9dda96d4b.html

There are other things hospitals and states can do to decrease the severity of infant withdrawals -- such as skin-to-skin contact between mom and baby -- which we detail in the series.

Here's the story of one hospital: http://missoulian.com/kalispell-hospital-shifts-to-care-for-mothers-with-addictions-alongside/article_209d0d52-6215-5656-abd6-283e5b7d2fcc.html

Some other states have formed task forces, working groups or the like to bring a variety of experts together (recovery professionals, social workers, doctors, policy makers, etc) to work on local solutions. Some also encourage the formation of treatment programs or medical homes specifically for mothers and mothers to be.

Hospitals can provide training about addiction to their staff, most of whom learned little to nothing about it in medical school because of the way our country has long siloed drug and mental health treatment outside hospitals. Some also are looking to Canada, where NICUs offer private rooms for moms and their babies. Vancouver's Fir Square, in particular, has shown this to be an effective way to help women with addictions bond with their newborns and commit to treatment.

Mostly, we found few folks in Montana have talked about the issue, so we hoped this would spark conversation.

Do you have personal experience with hard drugs?

No. When writing, I have to rely on asking thoughtful questions and listening closely to people who do use them or who are medical experts.

That said, there is a history of alcoholism in my family and two of my closest friends did use hard drugs. One died at age 27 after being sober a year and was so close to finishing his electrician's apprenticeship. Another still uses, mostly heroine these days, and continues to be my favorite person with whom to talk politics and books.

You talk with a heroine addict about politics? I guess he isn't a fan of duterte.

Yeah, safe to assume she wouldn't be.

Why is this the state's problem. If the mother's were locked up for their illegal activities, did health care improve while under the state's supervision?

Generally not. And especially not for pregnant women. A 2013 ACLU report found that Montana jails lack adequate healthcare for women, especially pregnant ones. Our more recent reporting found that the vast majority of jails force people to detox from legal and illegal substances even though doing so is dangerous for a fetus.

More about the justice system interactions here: http://missoulian.com/mothers-to-be-avoid-doctors-hoping-to-keep-drugs-kids/article_69edea02-62b2-59e9-b25e-b2078a4a8f16.html

Some also debate the cost aspect of this. Medication-assisted treatment is cheaper than inpatient therapy and much cheaper than incarceration. It's also more than 3x more likely to lead to longterm recovery than abstinence and counseling. Add in that babies born experiencing withdrawals cost 3x more than an average birth and that the majority of those are paid by Medicaid. There are pretty strong incentives for taxpayers and lawmakers to consider how they should balance cost-saving treatment with the need for criminal punishment.

What leaders in our state think: http://missoulian.com/montana-leaders-fight-drug-crisis-spike-in-foster-care-but/article_487c5371-0113-534a-82d6-2f681a83c3cf.html

Why were you compelled to write about this topic, and especially at such great length? Do you have a personal connection with the issue?

This kind of work is what I enjoy most about my job. I am lucky to get to spend time, in this case months, asking people questions about interesting or important topics and then synthesizing the information for other people to use to make decisions or understand their world a little better. I especially like to write about policy issues and how culture/politics influences the way our world works. In short, I'm a nerd who loves the excuse to learn everyday. This was unique in that I worked with a professor at the University of Montana to lead a group of student journalists to help me report out the story.

I am not personally close to anyone who used drugs before giving birth. I do have family with a history of alcoholism and some close friends who use drugs, including heroine. One died at 27 after being sober for a year just because of how hard his life was before that, homeless or couch surfing since he was 12 years old. So I've been on both sides of the emotional spectrum on this issue: Angry and frustrated by abuse from addicts and their destructive behaviors, and also sad to see smart, wonderful people struggle so mightily to overcome an invisible foe and finding so few people willing to help them do so.

So what would you say to those people who argue that addiction is a choice and an addict pregnant woman should just choose to stop doing drugs for the sake of their baby?

For many people, science clearly shows it's not simple choice to stop using like we might stop buying black socks instead of white. Drug use can literally rewire the brain and depending on the person might never go back to normal. Medication-assisted treatment is similar to insulin for diabetics. It's a way to manage a longterm health condition and no amount of will can change that biology.

I'd ask them to look at the hard facts showing which types of policies and programs actually help people recover and save the state money. Regardless of what you think addiction is, there is evidence of what works to help people recover, stay out of prison and save taxpayers money. I'd also ask them to listen to the personal stories of these women and try to consider life from their shoes. For most, drug use was not a decision to "have fun," but a coping tool they found to manage with traumas. They were timid to share their experiences because of the stigmas they faced, but ultimately hoped people would take a moment to listen. http://missoulian.com/pregnant-women-who-use-drugs-say-montana-does-little-to/article_16a4f32d-c3f4-5ba1-a4d3-441767f56b4f.html

Found a story I was looking for. This is a pretty good introduction to the brain science behind addiction: https://www.statnews.com/2017/04/19/opioid-addiction-relapse-science/ And other reasons it can be difficult to stop using: https://www.statnews.com/2016/05/25/opioid-addiction-withdrawal-survival/

thank you for doing this AMA. Why would you say there's been such a rise in opioid use in America, especially rural America?

And what do you feel is the best way to prevent it?

This is only a sliver of the good work out there. I couldn't find some of the stories I had saved because they're lost in the mess from being in the middle of a move right now, but here are some good ones to get you started.

ARTICLES A pretty thorough analysis of the stats and the policies from Congressional Quarterly. Wonky, of course, but worth the read: http://library.cqpress.com/cqresearcher/document.php?id=cqresrre2016100700

The Washington Post and 60 minutes investigated how “Congress weakened the DEA’s ability to go after drug distributors, even as opioid-related deaths continue to rise” https://www.washingtonpost.com/graphics/2017/investigations/dea-drug-industry-congress/?hpid=hp_hp-banner-main_deanarrative-hed%3Ahomepage%2Fstory&utm_term=.515090aa249c

Seven Days of Heroin by the Cincinatti Enquirer is an in-depth personal look https://www.cincinnati.com/pages/interactives/seven-days-of-heroin-epidemic-cincinnati/

STAT News, an outfit that does excellent reporting on health issues, collected obituaries from around the country to illustrate the epidemic. https://www.statnews.com/feature/opioid-epidemic/obituaries/ This is a pretty good introduction to the brain science behind addiction: https://www.statnews.com/2017/04/19/opioid-addiction-relapse-science/
And other reasons it can be difficult to stop using: https://www.statnews.com/2016/05/25/opioid-addiction-withdrawal-survival/

Eric Eyre of the Charleston Gazette-Mail, whose reporting on the flood of opioids into economically depressed counties won him a Pulitzer. http://www.pulitzer.org/winners/eric-eyre

The LA Times did an excellent investigation into how OxyContin was marketed and how it shaped our current crisis: http://www.latimes.com/projects/oxycontin-part1/

The New Yorker took a more personal look at the family that got rich off that marketing campaign: https://www.newyorker.com/magazine/2017/10/30/the-family-that-built-an-empire-of-pain

At the Palm Beach Post, Pat Beall’s most recent work includes working with a team to track the true number of overdose deaths in their county and why they’re happening. http://www.mypalmbeachpost.com/generationheroin/

BOOKS Drugging the Poor: Legal and Illegal Drugs and Social Inequality by Merrill Singer. This book was recommended to me by several national addiction recovery experts and it’s stellar at looking at the class issues at play. https://www.waveland.com/browse.php?t=135

Dreamland: The True Tale of America’s Opiate Epidemic by Sam Quinones. This book tracks the rise of cheap Mexican heroin and how and why it reaches America. https://www.goodreads.com/book/show/22529381-dreamland

Substance and Shadow: Women and Addiction the United States by Stephen Kandall. Although the book focuses on women, it provides lots of interesting details about drug culture and policy as a whole in America. http://www.hup.harvard.edu/catalog.php?isbn=9780674853614

addicted.pregnant.poor. by Kelly Ray Knight. A great medical ethnography of drug use by women in San Francisco’s daily rent hotels: https://www.dukeupress.edu/addictedpregnantpoor

Wow, thank you for the amazingly in depth and detailed answers. I will definitely check these out!

Cool. Sorry for the novels. My editors will confirm brevity is not my style. Feel free to post follow up questions here or PM me anytime if anything pops up while you're reading. There are better experts out there, but I'm happy to help when I can.

That’s a tough one and I don’t think there’s a silver-bullet answer. Some folks understand the bigger issue better I do: overprescribing, opioid development and marketing, economics, the rise of pain management, limited rural access to health care, etc. I researched such a narrow slice of how the crisis manifests, but I’ll gather some links to some of the more interesting explanations I’ve read and share those in a bit. Here, I’ll share some of the more interesting things I learned about medical history and rural America that I’ve not often seen mentioned elsewhere.

I hope others who find this thread will share their favorite reads and their own insights. tldr note at the bottom.

This is not America’s first opioid crisis. Under pressure in the late 1800s and early 1900s from other countries to control rampant drug use in America, Congress passed the Pure Food and Drug Act to regulate patent medicines (which often contained things like cocaine and opium without labeling) and then the Harrison Narcotic Act, which was intended to control the production/movement of opiates but was used to regulate how doctors prescribed. The mythology of the era today conjures images of a waif, white man lazing in a New York opium den. In reality, the vast majority of opium users were white women who used patent medicines or, as was particularly common in the south, were prescribed opiates for “female complaints” and “neurasthenia,” which Dr. Stephen Kandall described as “a widespread but vague nervous malady attributed to women’s weaker, more sensitive natures” in his excellent book, “Substance and Shadow.” In short order, many women were prescribed more and more to feed the addictions the doctors had created and their continued decline was attributed to weak nerves rather than addiction. With the passage of the Harrison Act, doctors could no longer prescribe opiates to people who were dependent on them, suddenly creating a mass of illegal drug users that never existed before. (There is strong evidence that a push for the Harrison Act stemmed from anti-immigrant sentiments and a shift in who was using what kinds of opiates. Some cities used anti-drug laws as a way to exclude people of color from the workforce, especially factories where operators feared drug-crazed mistakes in the headlong rush to stay ahead in the Industrial Revolution.) More than being interesting, I think it speaks to the broader reasons why America handles addiction so differently from most developed countries and why the stories of drug users are so different here.

All of this resulted in a bifurcated system. Doctors continued to manage health care. Addicts were sent to prison or a limited number of special recovery centers to reform their morality because their condition was not considered a health issue. It wasn’t until the 1960s that medication-assisted treatment, methadone and brain research started to shift the understanding of addiction back toward a recognition of it as a disease that should be managed as a health issue. The 2016 Comprehensive Addiction and Recovery Act is one of the first major policy steps toward recognizing that, creating a mechanism for doctors, nurse practitioners and physicians assistants to prescribe buprenorphine as part of a drug treatment plan integrated with broader medical care. The shift underway parallels similar realizations that HIV/AIDs or mental health issues might be best treated in the medical system rather than isolated from the rest of wellness care.

As for rural America: We’ve always had limited access to healthcare, especially any kind of specialized care. It's pretty normal to travel hours to see a specialist. That's tougher when you're a mom who can't find or afford childcare or don't have the money for the trip. When it comes to drug treatment, the places that have adopted medication-assisted treatment historically were urban centers far from rural America and the rural West in particular. Part of that is because methadone was so tightly regulated and had to be dosed in a certain way, almost always in person, because of the overdose and abuse risks. Buprenorphine is safer and more difficult to abuse, so federal regulators allow it to be prescribed under careful monitoring. That makes it easier for people in rural places to receive that kind of care because you can visit your doctor once a week or once a month instead of daily. Montana, unfortunately, still has the lowest availability of nearly any state, so many people have to drive hours to get to the closest doctor. And they might have a months-long wait list. Also, many recovery groups, like Narcotics Anonymous, ignore the science and argue that MAT is not “true recovery,” so people who do get help are afraid to talk about their prescription or do not feel welcome in the support groups that might otherwise be helpful to their recovery. Peer recovery groups like this are a cheap way to offer drug treatment in areas that lack medical providers, so you see them all over the West and in rural America.

Beyond the usual debates about Medicaid reimbursement rates, physician training, etc., I heard several people repeat one theory about the rural West: We have a can-do attitude, that you can accomplish anything with hard work, determination and faith, Nature be damned. As a result, it is tough for some people to accept that drug use is or can be largely out of a person’s control – so the only reason people use drugs must be because they want to. It shapes the way doctors, lawyers, policymakers, family members, etc. all treat people who use drugs and our willingness to help them.

In case it's insightful, this details the stories of four Montana women about how and why they started using: http://missoulian.com/pregnant-women-who-use-drugs-say-montana-does-little-to/article_16a4f32d-c3f4-5ba1-a4d3-441767f56b4f.html

tldr; Other folks can better answer this question, but two thoughts: America has long considered addiction a moral issue, not a health one, so it hasn't been integrated into medical care until recently. Rural America always has had limited access to medical care, especially specialists, and drug treatment policies are complicated by the great Western narrative of self-reliance and self-determination.

"In November, Montana had only 80 buprenorphine providers, all but 13 of them limited to 30 patients each by federal rules. That’s just 7.7 providers per 100,000 people, a rate lower than all but seven other states and far short of demand, according to doctors." I think those numbers are super low doctors per citizen ration it is surreal, will you consider researching how these numbers change after Donald Trump announced an emergency situation? The line where Cairns compared how the medical response was like HIV/AIDs really stood out to me because I had never really seen it that way but it all seems to point that there is a stigma to people with opioid and not a lot of generally intrest in doctors to treat them. Do you think the medical community will only act when Opioid becomes an even bigger epidemic?

Montana as a whole has low access to a lot of medical specialties, but this was pretty shocking for us to learn, too. It's definitely on our list to track going forward. On the bright side, a two-year grant from SAMHSA should provide a temporary incentive for doctors to sign up, but the longterm financial viability will depend in large part on whether our state Legislature decides to continue Medicaid expansion. I actually got an email today from a nurse practitioner who just received her waiver because of the grant. And this issue is on the radar of the Montana Healthcare Foundation, which is pretty well respected and might be able to persuade its hospital partners to step up.

Mostly, I think it's just a general lack of awareness. Doctors want to do the best for their patients, but they might not understand how complicated addiction truly is, what it is or what they should be doing. Many medical schools do very little, if any, training on addiction. (Similar to how mental health is only now being incorporated into some training for all.) Doctors often are so focused on the daily challenges in front of them that they don't have time or desire to think outside the box for big picture solutions. They have enough important work to do already. One neonatologist summed it up pretty well. He specializes in caring for infants in the NICU. All of his training was about babies. But his personal bias against addicts made him treat those mothers differently. He was angry with them and he didn't give them opportunities to be involved or help out in ways that actually would improve the child's care. He admitted he was ignorant, if well meaning, until he attended a training about addiction and started to learn about the power of motivational interviewing.

Add in bureaucratic hurdles of paperwork and reimbursement rates that make it difficult to make money, and taking on complicated patients becomes less and less appealing, especially in a market like Montana where there is high demand for everything. Nationally, medical groups like AMA and ACOG have been working more actively to educate their members. (It wasn't too long ago that those groups did not recognize addiction as a brain disease.)

Will the Timbers win a championship under Gio?

Hey there! Now that's a question I don't think I can answer any better than the next person posting a dumb take, but I sure as hell hope so. Here soon, I'll be closer to Portland and able to go to more games.

What do you think?

No idea. It’ll be interesting depending on who he signs. When you get in town, we’ve got to have a Texas reunion!

Yes! See you soon. Hopefully, we'll have good team news to talk about.

How do you feel about the Griz loss to a 4-6 team at the Brawl of The Wild for the second year in a row and missed the playoffs?

Least popular opinion of any Montana resident: I don't care.

I feel for the local folks who saw their team choke against a rival. (Hey, I'm a Timbers fan and am very familiar with unfulfilled promise.) And it stinks that a poor record affects the local economy. But college football just isn't something I've ever invested energy into.

So like James Alexander Malcolm MacKenzie Fraser? 😜 Joking.

I get that so much. And am totally cool with it. I have Scottish roots and am a closeted nerd who plays board games and reads sci-fi or fantasy for fun. (I must confess I haven't read or watched any Outlander.)

I was sort of named after my dad. When my parents scrapped the name "Dimond," they settled on a silly saying: Jay and me made Jayme. So clever.

Why do the politicians of the Democratic Party claim to be for the working class and underprivileged when they are the ones that do things to maintain the under privileged status quo? If they raised people up out of poverty people stop being in poverty and they would have no one left to vote for them.

Asking the tough questions today! I'd ask Democrats.

But in the context of these stories, I should probably note that while poverty is experienced by many of these women it's not the case for all of them and not how many started out. Hospital discharge data also shows that an increasing number of women are legally prescribed opioids during pregnancy, regardless of class, increasing the risk of forming dependence.