In what would likely become the most restrictive abortion ban in the country, the Alabama House Tuesday passed a bill that would make it a crime for doctors to perform abortions at any stage of a pregnancy, unless a woman’s life is threatened. The legislation is part of a broader anti-abortion strategy to prompt the U.S. Supreme Court to reconsider the right to abortion.

Republican state Rep. Terri Collins of Decatur, Ala. defended her “Human Life Protection Act” during, at times, contentious debate on the House floor.

“This bill is focused on that baby that’s in the womb that is a person,” Collins said. “That baby, I believe, would choose life.”

Democratic lawmakers walked out in protest before the final 74 to 3 vote. During debate, they questioned the motive for an abortion ban in a state that’s refused to expand Medicaid. “I do support life, but there are some people that just support birth they don’t support life,” said Democratic Rep. Merika Coleman of Birmingham, Ala. “Because after a child is born there are some things that need to happen. We need to make sure that child has adequate health care,” Coleman said.

Other states, including neighboring Georgia and Mississippi, have passed laws that prohibit abortion once a fetal heartbeat can be detected. But Alabama’s ban would apply even earlier.

“When a woman is pregnant, an abortion is no longer legal,” says Collins, explaining the bill.

The bill criminalizes abortion, meaning doctors would face felony jail time up to 99 years if convicted. The only exceptions are for a serious health risk to the pregnant woman, or a lethal anomaly of the fetus. There are no exceptions for cases of rape or incest. A woman would not be held criminally liable for having an abortion.

Collins says the bill follows a constitutional amendment approved by Alabama voters last year that recognizes the “rights of unborn children.” It defies the U.S. Supreme Court’s landmark decision that protects a woman’s right to abortion.

“This bill is simply about Roe v. Wade,” says Collins. “The decision that was made back in 1973 would not be the same decision that was decided upon today if you relooked at the issue.”

Her bill cites abolition, the civil rights movement and women’s suffrage as justification for establishing the human rights of a fetus. Alabama is one of more than two dozen states seeking to restrict abortion rights this year, testing federal legal precedent that prevents states from banning abortion before the point at which a fetus could survive outside the womb.

Alabama Pro-Life Coalition President Eric Johnston says there’s a reason there’s so much activity now.”The dynamic has changed,” Johnston says. “The judges have changed, a lot of changes over that time, and so I think we’re at the point where we need to take a bigger and a bolder step.” The bold move to outlaw nearly all abortions is drawing protests from abortion rights advocates.

A coalition called Unite for Reproductive and Gender Equity demonstrated outside the Alabama statehouse last month.

“This bill is an awful piece of grandstanding,” said Amanda Reyes of Tuscaloosa, Ala. She’s president of the Yellowhammer Fund, a group that helps women pay for abortions. “If you make abortion illegal somewhere that doesn’t mean that abortion goes away,” says Reyes. “It just becomes more difficult and more dangerous to access.”

The bill is expected to win final passage in the Republican majority Alabama Senate. The ACLU of Alabama says it will sue if the abortion ban becomes law.

Executive Director Randall Marshall says the bill is unconstitutional. “There is simply nothing that Alabama can do to interfere with the right of access to abortion,” Marshall says. “That is a federal right and the Federal Constitution clearly trumps all state law.” With two Trump appointees now on the U.S. Supreme Court, anti-abortion forces are optimistic that judicial interpretation could be reversed.

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Amelia and her roommate had been awake for two days straight. They decided to spray-paint the bathroom hot pink. After that, they laid into building and rebuilding the pens for the nine pit bull puppies they were raising in their two-bedroom apartment.

Then the itching started. It felt like pin pricks under the skin of her hands. Amelia was convinced she had scabies, skin lice. She spent hours in front of the mirror checking her skin, picking at her face. She even got a health team to come test the apartment. All they found were a few dust mites.

“At first, with meth, I remember thinking, ‘What’s the big deal?’ ” says Amelia, who asked that we not reveal her last name to protect her family’s privacy. “But when you look at how crazy things got, everything was so out of control. Clearly, it is a big deal.”

While public health officials have focused on the opioid epidemic in recent years, another epidemic has been brewing quietly, but vigorously, behind the scenes. Methamphetamine use is surging in parts of the U.S., particularly the West, leaving first responders and addiction treatment providers struggling to handle a rising need.

Across the country, overdose deaths involving methamphetamine doubled from 2010 to 2014. Admissions to treatment facilities for meth are up 17%. Hospitalizations related to meth jumped by about 245% from 2008 to 2015. And throughout the West and Midwest, 70% of local law enforcement agencies say meth is their biggest drug threat.

But policymakers in Washington, D.C., haven’t kept up, continuing to direct the bulk of funding and attention to opioids, says Steve Shoptaw, an addiction psychologist at UCLA in Los Angeles, where he hears one story after another about meth destroying peoples’ lives.

“But when you’re in D.C., where people are making decisions about how to deploy resources, those stories are very much muffled by the much louder story about the opioid epidemic,” he says.

Even within drug treatment circles, where you’d think everyone would be on the same side, there’s a divide. Opioid addiction advocates are afraid their efforts to gain acceptance for measures like needle exchange programs and safe injection sites will be threatened if meth advocates demand too much.

“The bottom line is, as Americans, we have just so much tolerance to deal with addiction,” Shoptaw says. “And if the opioid users have taken that tolerance then there’s no more.”

So local lawmakers in San Francisco are trying to get a grip on the toll meth is taking on their city’s public health system on their own. Mayor London Breed recently established a task force to combat the new epidemic.

“It’s something we really have to interrupt,” says San Francisco District 8 Supervisor Rafael Mandelman, who will co-chair the task force. “Over time, this does lasting damage to people’s brains. If they do not have an underlying medical condition at the start, by the end, they will.”

Since 2011, emergency room visits related to meth in San Francisco have jumped 600% to 1,965 visits in 2016, the last year for which ER data is available. Admissions to the hospital are up 400% to 193. And at San Francisco General Hospital, of 7,000 annual psychiatric emergency visits last year, 47% were people who were not necessarily mentally ill — they were high on meth.

“They can look so similar to someone that’s experiencing chronic schizophrenia,” says Dr. Anton Nigusse Bland, medical director of psychiatric emergency services, at San Francisco General. “It’s almost indistinguishable in that moment.”

Someone who has methamphetamine-induced psychosis, he says, “they’re often paranoid, they’re thinking someone might be trying to harm them. Their perceptions are all off,” he adds.

For example, someone starts walking into traffic on Sixth Street, shouting, taking off his shirt. A bystander calls 911 and reports a mentally disturbed person, then the police come and deliver him to Nigusse Bland’s department.

If the person is really agitated, doctors might give them a benzodiazepine to calm down, or even an anti-psychotic. Otherwise, the treatment is just waiting 12 to 16 hours for the meth to wear off. No more psychosis.

“Their thoughts are more organized, they’re able to maintain adequate clothing. They’re eating, they’re communicating,” Nigusse Bland says. “The improvement in the person is rather dramatic because it happens so quickly.”

Trends in drug use come in waves

For some people recovering from addiction, the memories of meth-induced psychosis are part of what motivates them to stay sober.

For Amelia, the scabies scare is what alerted her mother to her addiction, forcing an intervention. Even though she did not have scabies, the itchy feeling and the fear are vivid, even a year and a half later.

“I still don’t really want to say it out loud that it wasn’t real,” says Amelia, now 33.

For Kim, another woman in recovery, there was one day last year when she says she went wine tasting with a friend in Sonoma. She was high on Xanax and speed.

“I was crazy,” says Kim, 47, who also asked that we not reveal her last name. “Meth causes people to act completely insane.”

She and her friend got in an argument in the car. Kim thought someone was behind them, following them. She was utterly convinced. And she had to get away.

“I jumped out of the car and started running, and I literally ran a mile. I went through water, went up a tree, and I was literally running for my life,” she says. “I literally thought I was being chased.”

Kim was soaking wet when she walked into a woman’s house, woke her from bed and asked for help. When the woman went to call the police, Kim left and found another woman’s empty guest house to sleep in — Goldilocks-style. Kim says she just wanted to get warm.

“But then I woke up and stole her car,” she says.

That’s how Kim ended up in jail. She’s in a residential treatment program in San Francisco now, part of the steady rise in people seeking help for meth addiction. Rehab admissions in San Francisco for meth are up 25% since 2015.

The trend in rising stimulant use is nationwide: cocaine on the East Coast, meth on the West Coast, says Dr. Daniel Ciccarone, a professor of medicine and substance use researcher at UCSF.

“It is an epidemic wave that’s coming, that’s already here,” he says. “But it hasn’t fully reached our public consciousness.”

Drug preferences are generational, Ciccarone says. They change with the hairstyles and clothing choices, like bell bottoms or leg warmers. It was heroin in the 1970s, cocaine and crack in the ’80s. Then opiate pills. Then methamphetamine. Then heroin. And now meth again.

“The culture creates this notion of let’s go up, let’s not go down,” Ciccarone says. “New people coming into drug use are saying, ‘Whoa, I don’t really want to do that, I hear it’s deadly, people look really doped up and they’re not that fun to be with, I’m going in a different direction.’ “

Kim has been with meth through two waves. When she got into speed in the 1990s, she was hanging out with a lot of bikers, going to clubs in San Francisco.

“Now what I see, in any neighborhood, you can find it. It’s not the same as it used to be where it was kind of taboo,” Kim says. “It’s more socially accepted now.”

Dying from meth

A hint about who is using meth today comes from the data on deaths. Meth is not as lethal as opioids: 47,600 people died of opioid-related overdoses in 2017 compared to 10,333 deaths involving meth. (About half of those involved a mix of meth and opioids.) But the death rate for meth has been rising. Meth-related deaths in San Francisco doubled in since 2011 and more than quadrupled nationally. This is another indication that more people are using meth and that today’s supply is very potent, says UCSF’s Ciccarone.

Another hypothesis that experts have come up with to explain the growth in meth-related overdoses is that meth users are aging. Most meth deaths are from brain hemorrhage or a heart attack, which would be unusual for a 20-year-old.

“Because your tissue is so healthy at that age,” says Phillip Coffin, a physician and the director of substance use research at the San Francisco Department of Public Health. “Whereas when you’re 55 years old and using methamphetamine, you might be at higher risk for bursting a vessel and bleeding and dying from that.”

Older adults have higher blood pressure, maybe heart disease, that makes their heart weaker.

“So stimulant-related death, really, you shouldn’t see it affect so many young people,” Coffin says.

The San Francisco AIDS Foundation runs a 12-week program to help men who have sex with men stop using meth called Positive Reinforcement Opportunity Project (PROP). The project’s program manager Rick Andrews has noticed a trend in older men coming in for help.

“Older gentlemen who grew up in the time of HIV and AIDS initially, maybe they led very safe lifestyles, and now they’re older,” he says.

Now that things are different with HIV — there’s treatment, there’s a prevention pill, PrEP — they’re taking a new approach to the often drug-fueled party scene.

“They feel like they’ve missed out and they want to have a little fun and make up for lost time maybe,” Andrews says.

There are some young people who have died from using meth. Last year, three young people in San Francisco died after smoking meth together — it turns out the meth had fentanyl in it. The synthetic opioid has been causing waves of heroin overdoses across the country, but now it’s showing up mixed in to cocaine and meth.

Most researchers believe the contamination is accidental.

“The whole idea of the evil drug pusher who’s trying to create a market by getting their cocaine users hooked on fentanyl. I would highly doubt that,” says UCSF’s Ciccarone.

Dealers know that people are particular about their drugs, he says. It doesn’t make sense to alienate a customer base like that. He compares it to coffee drinkers preference for a favorite stye of coffee.

“Folks that are doing hardcore illicit drugs can be pretty fussy, too,” he says. “And most meth users really, really, really, really don’t want an unbeknownst fentanyl put into their methamphetamine.”

More likely, Ciccarone says, the same table that was used to cut and bag fentanyl later got used to bag meth.

Deliberate or not, health officials call this poisoning. They started distributing fentanyl test strips to meth users so they can test their drugs. But counselors like Rick Andrews say the strips aren’t refined – even trace amounts will give a positive result.

“I hear guys saying, ‘Oh, there’s test strips and I’m testing. It’s positive, but I do it anyway and everything’s fine,’ ” Andrews says.

That’s why they’re also giving out Narcan, the nasal spray that can reverse an opioid overdose, Andrews says. They’re telling meth users to carry it just in case.

Recovery

Over her two decades of meth use, Kim has been through drug treatment more than a dozen times. Relapse is part of recovery, and among meth users, 60% will start using again within a year of finishing treatment. Unlike opioids, there are no medication treatments for meth addiction, which makes it particularly hard to treat.

Kim finished her last round of treatment in April at a six-month residential program for women in San Francisco, called The Epiphany Center. She came to Epiphany directly from jail, after serving time for her Goldilocks housewarming spree and stealing the car. She says in the first 30 days, all she could do was try to clear the chaos from her mind.

“You have to get used to sitting with yourself, which is essential for life, is to get along with your own self,” she says.

Kim is hopeful that this last time through treatment will stick. She’s living in transitional housing now, she has a job, and she’s been accepted to a program at UC Berkeley to finish her college degree.

“I’ve gone through 12 different programs and it’s been for my children, for my mom, for the courts. I’ve never come to be there for myself,” Kim says. “So it’s like I’ve come to a place where it has to be for me.”

This story is part of NPR’s reporting partnership with KQED and Kaiser Health News.

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It was dusk as Oakley Yoder and the other summer camp kids hiked back to their tents at Illinois’ Jackson Falls last July. As the group approached a mound of boulders blocking the path, Oakley, then 9, didn’t see the lurking snake — until it bit a toe on her right foot.

“I was really scared,” Oakley said. “I thought that I could either get paralyzed or could actually die.”

Her camp counselors suspected it was a copperhead and knew they needed to get her medical attention as soon as they could. They had to keep her as calm and motionless as possible — the venom could circulate more quickly if her heart raced from activity or fear.

One counselor gave her a piggyback ride to a van. Others distracted her with Taylor Swift songs and candy as the van sped from their location in a beautiful but remote part of the Shawnee National Forest toward help.

First responders met them and recommended Oakley be taken by air ambulance to a hospital.

The helicopter flight transported Oakley 80 miles from a school parking lot just outside the forest to St. Vincent Evansville hospital in Indiana, where she received four vials of antivenin. She was then transferred to Riley Hospital for Children in Indianapolis for observation.

Her parents, Josh Perry and Shelli Yoder, were already in bed that night when they got the call about what had happened to Oakley. They jumped in the car and arrived at Riley about two hours before their daughter. Once she made it, doctors closely observed her condition, her toe still oozing and bruised. By lunchtime, Perry said, physicians reassured the parents that Oakley would be OK.

“It was a major comfort for me to realize, OK, we’re getting the best care possible,” said Perry, who is a health care ethics professor at the business school at Indiana University, Bloomington. Less than 24 hours after the bite, Oakley left the hospital with her grateful parents.

Then the bills came.

Patient: Oakley Yoder, now 10, of Bloomington, Ind. Insured through Indiana University, Bloomington, where her father and mother work as faculty.

Total bill: $142,938, including $67,957 for four vials of antivenin ($55,577.64 was charged for air ambulance transport). The balance included a ground ambulance charge and additional hospital and physician charges, according to the family’s insurer, IU Health Plans.

Service providers: St. Vincent Evansville hospital, part of Ascension, a nonprofit, Catholic health system. Riley Hospital for Children, part of Indiana University Health, a nonprofit health system. Air Evac Lifeteam, an air ambulance provider.

Medical service: The essential part of Oakley’s treatment involved giving her four vials of snake antivenin called CroFab.

What gives: When bitten by a venomous snake, there is no time to waste. If left untreated, a venomous bite can cause tissue damage, hemorrhaging and respiratory arrest. Children tend to experience more severe effects because of their small size.

CroFab has dominated the U.S. market for snake antivenin since its approval in 2000. When Oakley was bitten, it was the only drug available to treat venomous bites from pit vipers. (Oakley probably was bitten by a copperhead snake, a type of pit viper, the camp directors told her parents.)

But with only one antivenin available in the U.S. at the time, the drugmaker, London-based BTG Plc, essentially had a monopoly.

The average list price for CroFab is $3,198 per vial, according to the health care information tech company Connecture. Manufacturing costs, product improvements and research all factor into the drug’s price, said Chris Sampson, spokesman for BTG.

A Mexican version of snake antivenin can cost roughly $200. But it couldn’t be sold in the U.S. (More about that in a moment.)

Dr. Leslie Boyer, founding director of the VIPER Institute, a venom research center at the University of Arizona, acknowledges that some of the price in the U.S. can be attributed to strict Food and Drug Administration requirements for testing and monitoring. But more than that, she added: “It’s a profitable drug and everyone wants a piece of it.”

She should know: Funded by government grants and at times working with colleagues over the border in Mexico, her group was instrumental in developing CroFab.

Antivenins were first developed more than a century ago. Although CroFab is safer and purer than antivenins of the past, the process — while labor-intensive — remains fundamentally the same. Snakes, spiders and other creatures are milked for their venom, then a small amount of the toxin is injected into animals like horses or sheep. The animals then make antibodies without falling ill, and the protective molecules are extracted from their blood and processed to make antivenin.

What patients pay for CroFab can widely vary. Treatment may require a few vials or dozens of them — it depends on factors like the size of the patient, the potency of venom in the bite and how quickly the patient is treated. The more antivenin needed, the higher the cost.

But hospitals also jack up the price, even though some of these facilities purchase the drug at a discount, said Dr. Merrit Quarum, chief executive officer of WellRithms, a health care cost containment company.

In Oakley’s case, St. Vincent Evansville hospital charged $16,989.25 for each unit of CroFab, according to the facility’s bill. That’s more than five times higher than the average list price.

WellRithms analyzed Oakley’s bill from St. Vincent Evansville at Kaiser Health News’ request and found providers generally accept $16,159.70 for all four vials of the drug.

In a statement, St. Vincent Evansville noted that the family was not responsible for that full tab and instead was expected to pay less than $3,500. But the facility appears to have since lowered its price for CroFab. According to its price list — posted online to satisfy a recent federal requirement — the drug now costs $5,096.76 per vial.

And the snake antivenin market in the U.S. now has another drug competing for patients: Anavip. The Mexican product — launched in October — has a list price of $1,220 a vial in the U.S., according to Rare Disease Therapeutics, which distributes the drug in the U.S.

Anavip’s arrival was stalled by a lawsuit filed by BTG in 2013, claiming the drug infringed on its patent.

The drug’s true effect on the market remains unclear. CroFab and Anavip are not entirely interchangeable. (The FDA hasn’t approved Anavip for copperhead bites, for instance.) And, as part of the legal settlement, Anavip-makers must pay royalties to BTG until the CroFab patent expires in 2028.

Resolution: The insurer IU Health Plans negotiated down the antivenin and air ambulance charges and ended up paying $44,092.87 and $55,543.20, respectively. After adjustments to additional bills, IU Health Plans paid a total of $107,863.33. Oakley’s family didn’t pay a dime out of pocket for her emergency care, but such high outlays contribute to rising premiums.

Secondary insurance offered through the summer camp covered $7,286.34 in additional costs that otherwise would have come out of Perry and Yoder’s pockets for their deductible and coinsurance. The policy covers up to $25,000 in damages.

Oakley’s foot is healed, but her toe bends slightly downward and is sensitive to pressure. She intends to return to the same summer camp this year.

Perry teaches a course on the ethics of the health care industry, and yet he said the cost of Oakley’s care shocked him. But he is aware of how rare it is that a patient ends up paying nothing for health care. “I know that in this country, in this system,” he said, “that is a miracle.”

Takeaway: Hospitals and insurers can negotiate; snakes don’t. If you’ve been bitten by a snake “take care of your injury,” said Boyer. Don’t wait while you worry about the cost.

When you get a bill, compare what the facility charged with other health care providers’ prices using their public charge lists online. Cost estimation tools like Fair Health Consumer or Healthcare Bluebook allow you to see how your bill compares with the average.

There is momentum growing for potential government action on drug prices. In states and in Congress, different proposals have been floated, which include allowing Medicare to negotiate drug prices, tying the U.S. price of expensive drugs to the average price in other developed countries, and allowing the government to inject competition into a market when there is none — such as speeding generic drug approvals or allowing for imports from other countries.

Consumers should keep an eye on these proposals as they move through the legislative and political process.

NPR produced and edited the interview with Kaiser Health News’ Elisabeth Rosenthal for broadcast. WFYI’s Jake Harper provided audio reporting.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that isn’t affiliated with Kaiser Permanente.

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