Three decades ago, the treatment Michele Zumwalt received for severe headaches involved a shot of the opioid Demerol. Very quickly Zumwalt says she would get headaches if she didn’t get her shot. Then she began having seizures, and her doctor considered stopping the medication.

“I didn’t know I was addicted but I just knew that it was like you were going to ask me to live in a world without oxygen,” she says. “It was that scary.”

Zumwalt didn’t cut back. In fact, over two decades, the Sacramento, Calif., resident got an ever-increasing number of opioid prescriptions — all while working in corporate sales.

“I could show up at Xerox and put on a presentation, and I was high on Percodan,” she recalls. “I mean, fully out of it. I don’t know how many I had taken but so many that I don’t remember the presentation. And do you know that people didn’t know?”

Her addiction worsened, eventually forcing her to take medical leave. Now sober for a dozen years, Zumwalt wrote a book about recovery called Ruby Shoes.

Her story highlights, among other things, the many challenges employers face in dealing with prescription drug abuse.

According to one study, prescription opioid abuse alone cost employers more than $25 billion in 2007. Other studies show people with addictions are far more likely to be sick, absent or to use workers’ compensation benefits.

When it comes to workers’ comp, opioids are frequently prescribed when pain relievers are called for. How often doctors choose opioids varies by state, with an analysis finding the highest rates in Arkansas and Louisiana.

“The more professional stature you have, the less likely you are going to be forced into recovery, and the longer your addiction is likely to go on unchecked,” says Patrick Krill, who directs a treatment program at the Hazelden Betty Ford Foundation that focuses on lawyers and judges. The legal profession has twice the addiction rate of the normal population, he says.

In December, the advocacy group National Safety Council released a survey showing 4 of 5 employers in Indiana said they’ve confronted painkiller abuse in the workplace.

“Many times they’re showing up late to work because they can’t find pills.” says Dr. Don Teater, medical adviser for the council. “They’re starting to have withdrawal symptoms. They know they can’t work.” He went from family physician in Clyde, N.C., to addiction specialist after seeing prescription opioids and heroin rip through his rural community.

Three-quarters of his patients have lost their jobs. Some manage to hide prescription drug abuse for years, he says, but it does affect brain function and productivity.

“They’re not as sharp. They’re not thinking as quickly,” he says. “For people working in safety-sensitive positions, you know driving the forklift or something, their reactions might not be as fast.”

One of the biggest problems, Teater says, is that many employers aren’t testing for prescription opioids.

“You know, I’ll be talking to 50 or 60 HR people and I’ll say, ‘How many of you test for oxycodone?’ And a third of the hands will go up maybe. And oftentimes I’ll say, ‘How many don’t even know what you’re testing for?’ And a number of hands will go up.”

According to Quest Diagnostics, a testing firm, only 13 percent of the roughly 6.5 million workplace drug tests screen for prescription painkillers.

Even federal government workers in public safety positions who are required to undergo periodic drug testing aren’t currently tested for prescription opioids.

“Within federal agencies we don’t test so we can’t see exactly what the positivity rate would be in prescription drugs,” says Ron Flegel, director of workplace programs for the Substance Abuse and Mental Health Services Administration. “But we know from the private employers the percentage is quite high as far as people that are testing positive.”

Flegel says in coming months, new rules will include prescription painkillers in federal drug testing.

Meanwhile, the tables have turned for Michele Zumwalt, the recovering addict. She now helps manage her husband’s construction firm. “Through the years, we’ve seen lots of people with addictions,” she says. “We can almost recognize it, you know, as employers.”

They urge the workers to get into rehab, she says, and hope they turn around.

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If you fall off a curb, bop your head and go to the ER to make sure you’re OK, there’s a good chance you’ll be trundled off for a CT scan.

That might sound comforting, but people with injuries minor enough that they get sent home are increasingly being given computed tomography scans, a study finds. That’s despite efforts to reduce the unnecessary use of CTs, which use radiation and increase the lifetime risk of cancer.

There’s been a lot of focus on excess use of CTs in children, but much less on adults who go to the emergency department for things that turn out to be no big deal.

So researchers at the University of California, San Francisco looked at data on every single emergency department visit in the state from 2005 through 2013. They looked at people who had relatively minor injuries, focusing only on those who were sent home after being evaluated and treated. That could include people with fractures, sprains, strains and concussions.

Out of those 8,535,831 people with injuries that didn’t appear to be serious, 5.9 percent got at least one CT scan while they were in the emergency department. That number rose over time, from 3.51 percent in 2005 to 7.17 percent in 2013. The study was published Monday in the Journal of Surgical Research.

“There is a lot of awareness about overuse of CTs,” says Renee Hsia, a professor of emergency medicine and health policy at UCSF who was the senior author of the study. But patients and doctors both have reasons for wanting a scan.

“Patients tend to want to be safe, which is not a bad thing,” Hsia says, “but sometimes they want more rather than less. It’s a very American thing. Also doctors don’t want to miss anything.”

But safety comes with a price. The 72 million CT scans that Americans got in 2007 will cause 29,000 excess cancers, according to a 2009 study from the National Cancer Institute. Nearly 15,000 of those cancers could be fatal.

Efforts to get doctors to cut back on use of CTs may have caused the little downward blip in Hsia’s data from 2009 to 2011, but the numbers then continued to rise. CTs of the head were most popular. The pelvis and abdomen was the only body area that got scanned less often.

People who went to Level I and II trauma centers were more likely to get CTs, the authors found, which may reflect the culture of institutions used to dealing with severely injured patients.

As a practicing ED doctor, Hsia says there’s a lot pressure to scan patients and get them out the door rather than keep them in the hospital overnight for observation, as they would have done in the past. “There’s a lot of pressure for earlier and earlier diagnosis,” she says. “And there are consequences.”

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As the third open enrollment period winds down on the health insurance marketplaces, one thing hasn’t changed much since the online exchanges opened: It’s still often hard to find out whether a plan covers abortion services.

The health law requires insurers to say one way or the other, and they have gotten better about reporting abortion coverage details this year, advocates on both sides agree.

But the federal government has yet to put out final instructions on how insurers should handle the issue on their Summary of Benefits and Coverage overview. Lacking specific instructions about what to say and where to say it, many insurers have simply left the information out of the summary, advocates say.

That leaves consumers in a bind. “It’s not easy to figure out whether a plan covers abortion and if it does, to what extent,” said Kinsey Hasstedt, a public policy associate at the Guttmacher Institute, a reproductive health research organization that supports abortion rights.

The health law lets states decide whether marketplace plans can cover abortion services. Half of states ban abortion coverage to some extent, often limiting it to cases of rape, incest or if the mother’s life is endangered, the standard the federal government uses for coverage in its employees’ plans and for health care programs, such as Medicaid.

However, even in states that permit insurers to cover abortion beyond the limited exceptions, marketplace plans may not have that benefit.

The lack of easily accessible information makes it hard to know whether the number of plans that provide abortion services on the exchanges is increasing or decreasing.

Advocates on both sides of the issue have their eyes on multistate plans. To encourage competition, the health law called for at least two multistate plans to be offered on every state marketplace by 2017, at least one of which excluded abortion services. In subsequent guidance, the Office of Personnel Management, which administers the multistate program, said that multistate insurers had to offer at least one silver- and one gold-level plan that exclude abortion coverage starting this year.

But the number of states offering multistate plans dropped to 32 plus the District of Columbia in 2016, down from 35 last year.

In those states, most multistate plans don’t cover abortion, and the coverage information is easy to find, said Genevieve Plaster, a researcher at the Charlotte Lozier Institute, which opposes abortion rights. Of the 261 multistate plans available in 2016, just four plans in two states — Connecticut and Alaska — cover abortion services, according to OPM.

However, abortion opponents said that because multistate plans aren’t yet available in every state, there’s no guarantee consumers can find a plan that doesn’t cover abortion, if that is their priority. In two states, Hawaii and Vermont, for example, all plans available cover abortion. Neither state has multistate plans.

Abortion rights supporters have a different beef with the multistate plan program. They say it’s not fair to require the marketplace to offer plans that exclude abortion without also requiring plans that include abortion coverage. They also take issue with OPM’s decision that insurers must offer two multistate plans that exclude abortion coverage, instead of the single one that the law requires.

OPM isn’t considering any changes to the program at this time, a spokesman said.

In the meantime, advocates on both sides hope that the final instructions for the coverage summaries will make it easier for consumers to learn whether plans cover abortion.

Questions remain about where in the eight-page summary of benefits and coverage the information appears: Some advocates want it near the section that describes covered services “if you are pregnant,” rather than under “excluded services and other covered services,” as the federal government has proposed.

And advocates on all sides agree that the language describing abortion services needs to be clear and consistent rather than the mishmash of descriptions that appear in current documents, where it may be called “interruption of pregnancy” or “elective termination of a normal pregnancy,” among other terms.

In a final regulation released in June (see page 34297-8), federal regulators said they would clarify requirements for the language and placement of abortion services in the coverage summary in the final template, which is scheduled to be finished in January.

“We’re still waiting for that,” said Gretchen Borchelt, vice president for health and reproductive rights at the National Women’s Law Center.

The Centers for Medicare and Medicaid Services didn’t respond to a request for information about when the new template would be released. The 2016 enrollment ends Jan. 31.

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Michelle Andrews is on Twitter: @mandrews110.

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Butte is an old mining town, tucked away in the southwest corner of Montana with a population of about 34,000. Locals enjoy many things you can’t find elsewhere — campgrounds a quick drive from downtown and gorgeous mountain ranges nearby. But in Butte, as in much of rural America, advanced medical care is absent.

People in Butte who experience serious trauma or need specialty care rely on air ambulance flights to get them the help they need.

There were close to 3,000 air ambulance flights in Montana in 2014, and Amy Thompson was on one of them, curled up among the medical bags in the back of the fixed-wing plane. Her 2-month-old daughter, Isla, had a failing heart, and the hospital that could help her was 600 miles away.

“They did such wonderful care of her, and they tried to take great care of me, but in that moment I couldn’t let go,” Thompson says. “I was so afraid that if I closed my eyes that would be my last vision of her.”

Thompson watched as Isla was placed in a small box strapped to a gurney inside the air ambulance.

Seattle Children’s Hospital saved Isla’s life. Her family’s health insurance took care of the costs beyond her deductible — except for that critical air ambulance ride to Seattle.

The Thompsons read their insurance plan, and interpreted it to mean that any emergency medical transportation was covered.

But it turns out, the air ambulance company was out of their network, and they got a bill for $56,000.

Thompson remembers looking at the bill and thinking, ” ‘You’ve got to be kidding me!’ Here is the flight that ultimately saved Isla’s life by getting her to where she needs to be. And yet is going to put us potentially in financial ruin. Or at least kill our future dreams as a family.”

When a patient needs an air ambulance, the first priority is getting them needed care as fast as possible. Patients don’t always know who is going to pick them up or if the ambulance is an in-network provider.

That can make a huge difference — and lead to huge bills.

“Of all the complaints we have received in our office, not one person was uninsured,” says Jesse Laslovich, legal counsel for Montana’s insurance commissioner. “They’re all insured. And they are frustrated as heck that they’re still getting $50,000 balance bills.”

States can regulate some medical aspects of air ambulances, but federal laws prevent states from limiting aviation rates, routes and services.

The cost of an air ambulance bill is split into two main parts, according to a study completed by the Montana Legislature. First, a liftoff fee, which ranges from $8,500 to $15,200 in Montana, plus a per-mile charge for the flight, which ranges from $26 to $133 a mile.

Some air ambulance companies offer membership programs as protection from big bills. For an annual fee of about $60 to $100, patients who use that company’s services face no cost beyond what their health insurance pays.

But, Laslovich says that doesn’t always work, because a patient can’t always know who is coming to pick them up.

“You want to know what my personal opinion is about what the problem is?” Laslovich asks. “It’s money.”

There is a lack of understanding about the actual costs of running an air ambulance business, says Rick Sherlock, the president of the Association of Air Medical Services. The costs include specialized labor, training, equipment and fuel.

“So those cost-drivers are there, and [it’s necessary] to maintain readiness to respond 24 hours a day, seven days a week, 365 days a year,” Sherlock says.

He says some air ambulance companies remain out of insurance networks because they can’t always reach in-network deals that allow them to stay profitable.

“I think what you also have to look at is that negotiations between [air ambulance] companies and insurance companies take place when there’s good negotiations on both sides,” Sherlock says. “In situations where there may be only one or two insurance options in an area, it’s harder and harder to negotiate on a level playing field.”

There are only three health insurance companies operating in Montana, and at least 14 air ambulance providers. At the time of Isla’s trip to Seattle Children’s Hospital, the Thompsons’ insurer, PacificSource, had no in-network agreements with any air ambulance company in the family’s area. (PacificSource didn’t return calls seeking comment.)

For people who think they are protected from crippling health care bills because they have insurance, the cost of an ambulance ride can be a shock.

A Montana interim legislative committee is now investigating the wide range of pricing by air ambulance companies within the state. The state of Maryland has taken on a similar investigation.

In North Dakota an air ambulance company is suing the state for adding regulations on the industry.

Amy Thompson ended up not having to pay for her flight, but only after repeated appeals. According to Thompson, on the same day they were arranging a time to meet with a lawyer, she was notified by her insurance company that it would pay an additional amount of about $30,000, as well as the $13,000 out-of-network fee to the air ambulance company. The air ambulance firm waived the rest of its fee.

Isla turned 2 in November. She’s a healthy child with big blue eyes, but at times her mom still worries.

“Nobody takes a life flight for a joy ride,” she says. “You’re not going on Kayak.com and booking a life flight.”

Thompson didn’t think the flight should be free, but says the huge bill felt wrong. “I ethically believe this is a part of health care,” she says. “This is not some separate entity. There is something ethically wrong that these companies are profiteering off of people’s worst moments in their lives.”

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

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When Cathy Fields was in her late 50s, she noticed she was having trouble following conversations with friends.

“I could sense something was wrong with me,” she says. “I couldn’t focus. I could not follow.”

Fields was worried she had suffered a stroke or was showing signs of early dementia. Instead she found out she had attention deficit hyperactivity disorder or ADHD.

Fields is now 66 years old and lives in Ponte Vedra Beach, Fla. She’s a former secretary and mother of two grown children. Fields was diagnosed with ADHD about eight years ago. Her doctor ruled out any physical problems and suggested she see a psychiatrist. She went to Dr. David Goodman at Johns Hopkins School of Medicine, who by chance specializes in ADHD.

Goodman asked Fields a number of questions about focus, attention and completing tasks. He asked her about her childhood and how she did in school. Since ADHD begins in childhood, it’s important for mental health professionals to understand these childhood experiences in order to make an accurate diagnosis of ADHD in adulthood. Online screening tests are available, too, so you can try it yourself.

Goodman decided that Fields most definitely had ADHD.

She’s not alone. Goodman says he’s seeing more and more adults over the age of 50 newly diagnosed with ADHD. The disorder occurs as the brain is developing and symptoms generally appear around age 7. But symptoms can last a lifetime. For adults, the problem is not disruptive behavior or keeping up in school. It’s an inability to focus, which can mean inconsistency, being late to meetings or just having problems managing day-to-day tasks. Adults with ADHD are more likely than others to lose a job or file for bankruptcy, Goodman says. They may overpay bills, or underpay them. They may pay bills late, or not at all.

For Cathy Fields, the more she thought about it, the more she realized distraction and the inability to focus was the story of her life. It was also the story of her mother’s life. My mother “never got things done,” Fields says.

This is typical, according to Goodman; ADHD often runs in families. According to Children and Adults with Attention-Deficit/Hyperactivity Disorder, or CHADD, an advocacy group, the disorder can be inherited. If a parent has ADHD, the child has more than a 50 percent chance of also having it. If a twin has ADHD, the other twin has up to an 80 percent chance of having the disorder.

But because many of today’s older adults grew up during the 1950s and 60s when there wasn’t much awareness of ADHD, many were never diagnosed. And increasingly, Goodman says, he’s seeing more and more patients who are concerned about dementia but actually have ADHD — just like Cathy Fields.

Goodman also sees patients who are diagnosed after their child or grandchild gets a diagnosis. “That’s the genetic link,” says Goodman, “from grandmom to mom to daughter.”

About 60 percent of children with ADHD go on to become adults with ADHD, says Dr. Lenard Adler, a professor of psychiatry at the NYU School of Medicine. As these older adults weren’t diagnosed, they learned to work around the problem, Adler, says. They developed coping systems to deal with their inability to focus or pay attention.

That was the case with 65-year-old Kathleen Brown, a retired nurse who lives in Maryland. She was never diagnosed as a child but she “knew something was wrong,” she says.

Brown didn’t learn to read until she was 12. And, she says, she had to work a lot harder in school than other kids did for the same grades. When she went to nursing school, Brown made sure she sat in the first row during lectures so she wouldn’t miss anything or be distracted. And when it came to testing, she says, she literally set her desk up in the back of the class, facing a corner.

When she finally got diagnosed and prescribed medication Brown says the change was “stupendous.” She’s not scattered, and can start projects and finish them. “I wish I had it when I went to school 25 years ago,” Brown says. “It would have helped me for sure.”

Like children with the disorder, adults with ADHD are treated with medication, psychotherapy, or a combination of treaments. ADHD medication works just as well for adults as it does for children, but there is a word of caution. Older adults often have other health problems like high blood pressure and heart disease. So doctors need to be careful when prescribing ADHD medications, which are typically stimulants like Adderall or Ritalin.

For older patients, an ADHD diagnosis can be a huge relief. If you’ve spent your whole life with a disorder for which people said you were lazy, stupid, incompetent, says Goodman, “It’s liberating to realize the impairments are the result of a treatable disorder and not a character weakness or intellectual inadequacy.”

So for older people with memory and focus problems, Goodman says, it’s important for doctors to check for ADHD. While it could be cognitive decline, there’s growing awareness that it could also simply be the symptoms of a lifelong childhood disorder.

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For years, Mrs. Sutton came to see me in the office every three months. Visiting the doctor quarterly was “the right thing to do,” she told me, given the fact that she had both diabetes and high blood pressure.

She always set the agenda at our visits. She brought lists of questions and requests that followed the recommendations of her fellow churchgoers and the health materials she had read.

It came as no surprise to me when she asked to undergo a colonoscopy at age 68, in order to be screened for colon cancer. She had read that colon cancer was treatable if caught early, and several friends had told her that undergoing “the scope” was the most comprehensive means of screening.

I agreed that it was a good idea and dutifully made the referral to the gastroenterologist. When the report came back a few weeks later, I was pleased to learn there were no polyps found.

When I mentioned the test to Mrs. Sutton at our next visit, I assumed she’d be as happy with the results as I had been. Instead, her reaction shocked me.

“How on earth could this cost so much?” she demanded of me. “This is an outrageous bill!” she said, referring to both the colonoscopy charges and the facility fee, which totaled more than $5,000.

“Yes, the prices of medical tests can be hard to believe, but you have Medicare” I told her. Because Mrs. Sutton had ‘Medigap coverage,’ she owed nothing.

The fact that her out-of-pocket costs were zero failed to sway her. It was the principle of the thing. She felt gouged by the price of a procedure which she valued at a few hundred dollars at most.

Unfortunately, there was no turning back. The damage had been done. Mrs. Sutton made very clear to me that she’d never undergo a test that pricey again, even if insurance paid for it.

Furthermore, she told me that she expected me to provide better information about what something might cost beforehand.

Without realizing it, I had fallen into the abyss of medical prices— a topic that still puzzles and enrages millions of Americans.

Like many doctors, what little I know about medical pricing comes from a combination of what my patients tell me and what my family and I experience personally. There was no formal training in medical school about health care spending or the cost-effectiveness of various tests and treatments.

Instead, we were taught to ignore costs and focus on the best care and treatment we could provide. This was health care, American-style. No stone should go unturned in the pursuit of a diagnosis. Any and all resources should be brought to bear in treatment. Payment was almost never discussed in polite company.

Fortunately, I think, doctors are warming to the idea that we must be better stewards of the resources we command.

Pharmaceuticals were long an exception to the cost-is-no-concern rule. Orthodox medical teaching has always emphasized the principle that a well-established, low-priced generic drug is as good as a more expensive name-brand alternative. Yet evidence shows that in spite of mutual doctor-patient desire to discuss drug costs, we docs usually shirk the duty.

Diagnostic tests are an entirely different kettle of fish. Despite patient demand to know the cost of a test or procedure, it’s been very hard to get reliable price quotes. New entities have formed to try to solve this perennial puzzle: One company provides an app that links with insurers’ databases to accurately list contracted prices. Another provides incentives to patients to get tests in-network by offering discounts and sending patients a check for a small portion of the accrued savings.

Which brings me back to Mrs. Sutton, who died before smartphones changed the way we live. Back when she confronted me about the cost of her colonoscopy, there was no app to help her shop around. Nor was there any resource for me to guide her to the most cost-effective alternative.

All of my experience to that point had taught me that patients with insurance simply didn’t care about prices. Mrs. Sutton begged to differ. Her reaction taught me never to make that assumption again.

John Henning Schumann is a writer and doctor in Tulsa, Okla. He serves as president of the University of Oklahoma, Tulsa. He also hosts Public Radio Tulsa’s Medical Matters. He’s on Twitter: @GlassHospital

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Childbirth historically involved a support system of women who assisted a woman from her pregnancy through the birth and in the immediate postpartum period afterward.

Today, obstetricians and midwives provide prenatal care and help a woman deliver her baby. Doulas continue to fulfill the historical role of emotionally supporting a pregnant woman through labor and childbirth, helping her advocate for herself and communicate with her caregivers.

A study published online Thursday by the journal Birth suggests that offering women the support of a certified doula could save Medicaid and perhaps private insurers real money — nearly $1,000 a birth — by reducing cesarean and preterm births.

Previous research has showed lower rates of cesarean births, more satisfaction from mothers and better newborn Apgar scores — a measure of a baby’s condition at birth — among mothers who use doula care. In fact, the American Congress of Obstetricians and Gynecologists says in guidelines for safe prevention of cesarean births that doula care is “probably underutilized.”

This is the first study, however, to show a reduction in preterm births and a net savings for public insurance. Cesarean births — about a third of all U.S. births — cost about twice as much as vaginal births, and the 1 in 10 U.S. infants born preterm (before 37 weeks) incur medical costs 10 times greater than those of full-term infants.

“What is coming together now is a research consensus and a professional consensus of the benefits of doula care,” said lead author Katy Kozhimannil, an associate professor in the University of Minnesota School of Public Health. “The barriers to access are financial, cultural and geographic. The financial barrier ought to be the first to fall.”

Her analysis compared 1,935 women in Minnesota who accepted state doula services covered by Medicaid with 67,147 Medicaid-covered women throughout the northern and midwestern U.S. who didn’t get help from doulas.The doulas visited with the mothers four times leading up to the birth, provided support during labor and delivery and made two postpartum visits to the women.

In comparing the groups, 4.7 percent of the women using doulas had preterm births compared with 6.3 percent of the women who didn’t get doula help. Similarly, 20.4 percent of doula-supported women had cesarean deliveries compared with 34.2 percent of the women without doulas All told, an estimated $986 per birth would be saved if all the women received doula services, the analysis found.

How doulas decrease the odds of a cesarean birth isn’t entirely clear. One way might be by reducing cesareans recommended out of convenience, such as during a more slowly progressing labor.

“One of the questions doulas are trained to help women remember to ask is, ‘Is this an emergency or do I have time to think about it?’ ” Kozhimannil said. “If it’s an emergency, it’s outside the doula’s scope of work. If it’s not, that’s an opportunity for the doula to help the woman come to a decision with her clinician.”

However, there is a potential risk if inadequately trained doulas practice outside their scope of care, says Aaron Caughey, chair of the Department of Obstetrics & Gynecology at Oregon Health & Science University in Portland.

“I can’t think of a lot of negatives fundamentally in the routine use of doulas,” he said. “But in my clinical experience, the one possible negative is that a lot of the time the individuals who use doulas have a certain mindset about birth, and the doula can sometimes serve to block the clinician from practicing in the way the clinician might wish.”

For example, a doula might discourage a woman from agreeing to a rupture of membranes recommended by a clinician even if breaking her waters is medically indicated, he said. If physicians, midwives and doulas work together from the start, disputes over care are less likely.

Why doula care might affect preterm birth is also uncertain but might partly result from a reduction in stress because of the support of a doula during prenatal care, Caughey said.

Kozhimannil’s team analyzed preterm births and cesarean births separately, but another analysis that combined them revealed no reduction in cesareans among preterm births. She said that’s a good thing because it means the reduction occurs among healthy deliveries and not the complicated ones more likely to need a C-section.

Although the researchers adjusted the analysis for mothers’ age and race/ethnicity and having high blood pressure or diabetes during pregnancy, the groups may still have been too different for adequate comparison, wrote Adam Powell, a health economist and president of Payer+Provider Syndicate, in an email.

He pointed out that the larger control group may have included some doula-assisted births, albeit a small number, but that the better health of the women in the doula group may not have been fully accounted for in the statistical adjustments.

“It is not surprising that the intervention group was in better health than the control group as the intervention group had to be proactive about their health in order to be included in the group,” he wrote since only 15 to 20 percent of the mothers eligible for Medicaid-covered doula services used them.

The study’s findings would be stronger if the women had been randomized through a lottery to receive doula support or not, Powell said.

Even so, insurers can look through their own claims for answers. “Medicaid programs and healthcare companies generally have the data to conduct these analyses with their own data,” Kozhimannil said. “There is no reason they shouldn’t consider adding doula care or at least exploring that option.”

She pointed out the importance of this study’s findings in terms of the racial disparities in poor birth outcomes in the U.S.

“It’s important in an equity context because preterm birth is so much more frequent among black women compared with white women and preterm birth is the largest contributor to infant death,” Kozhimannil said. “The infant mortality rates and the disparities in infant mortality are something we’ve been reckoning with as a country for 100 years without good progress. Any identification of interventions that can help address issues related to preterm birth and especially disparities in preterm birth is urgently needed.”

Tara Haelle is a freelance health and science writer based in Peoria, Ill. She’s on Twitter: @tarahaelle

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A new method of delivering medication for opioid addicts gained approval from a Food and Drug Administration advisory panel this week. It’s a matchstick-like insert designed to slip under the skin and release a drug over a period of months. Some physicians say the implant will be a useful addition to the currently short lineup of medication-assisted treatment options.

The rod is called Probuphine, developed by the companies Braeburn Pharmaceuticals and Titan Pharmaceuticals. It contains a medication called buprenorphine which the FDA approved for opioid addiction in 2002 and is currently widely in use. The FDA typically follows the advice of its advisory panels on approvals.

This molecule binds to opioid receptors in the body, but doesn’t hit them as hard as something like heroin or morphine would. So it can reduce cravings without giving a full high. It’s often taken in combination with a medication called naloxone, which negates the effect of any additional opiates and acts as an antidote for overdoses. Right now, patients must hold a tablet or a film under their tongue or in their cheek until it dissolves every day.

This gives a long-lasting implant a few advantages over oral daily doses. Probuphine lasts up to six months. So unless patients want to dig underneath their skin to tear the thing out, there’s no deviating from the treatment.

“With the Suboxone [a daily combination of buprenorphine and naloxone], you can go on these drug holidays,” says Patrick Kennedy, a former congressman and former opiate addict who urged the panel to approve Probuphine. “If I knew I had access to another drug, OxyContin, I would just stop taking the Suboxone and — you know.”

And with the oral medications, health providers worry that patients with a prescription might sell the medication illegally. Buprenorphine is commonly confiscated by the Drug Enforcement Agency, says Behshad Sheldon, president and CEO of Braeburn Pharmaceuticals. “And sometimes it’s actually unfortunately accidentally ingested by children.” The Probuphine implant would reduce those incidents, she says.

On top of that, Sheldon says the implant’s long-acting nature will give patients peace of mind. “They won’t have to think about where their medicine is or worry if it gets lost or stolen. One of the first things I’ve read [from patients] is ‘I want the implant because if you go to jail, they can’t take it from you.'”

But it wouldn’t be for everybody. “It’s really for those doing well on buprenorphine and don’t need a high dose,” says Dr. Adam Gordon, a professor of medicine at the University of Pittsburgh and member of the advisory panel who voted in favor of approving Probuphine.

With the insert, it would be difficult to change a patient’s dosing. Sometimes, within a few months patients need to go on a higher dose of buprenorphine, so Probuphine would be best for people who can get along with a low, constant level of medicine. For different people suffering with addiction, other treatments might be more appropriate.

Right now, there are only two other chemicals for treating opioid addiction: methadone and naltrexone. In broad strokes, each is more suited to different patients and situations, but it’s not always clear-cut, Gordon says.

The entry of Probuphine as a potential treatment option has revived longstanding disagreement over how these medications should be administered. Some doctors think certain patients need to be on medicine forever. “Will they need to be on it six more months, maybe many times over their entire life? When is a good time to stop treatment?” Gordon says. “These are unanswered questions.”

Some doctors think buprenorphine, including Probuphine, can be a stepping stone on a path to being medication-free. “Buprenorphine is a way to withdraw someone from opiates,” says Dr. David Pickar, a psychiatrist at the Johns Hopkins University School of Medicine on the advisory committee who also voted to approve. “The idea of not having any opiates in your body is very disturbing to some. The buprenorphine will help bridge that. Then you give them naltrexone,” he says.

Naltrexone works by blocking the effects of any opioid someone might try consuming. It prevents the high, potentially stopping a relapse. It’s most often taken as a monthly injection, and is likely best for people who haven’t recently been using heavily. Eventually, once someone has regained much of their normal life, Pickar says they might try going off the naltrexone.

But sometimes naltrexone doesn’t work. Some patients never go back for their next dosage. The other option is methadone, which binds to opioid receptors in a way similar to buprenorphine. It’s good for those who used heavily, but it must be administered daily at methadone clinics. “Let me tell you, that is a tough world,” Pickar says. Not everyone can or wants to go to a clinic every day.

Pharma companies, including Sheldon’s, are looking to develop new medications and treatments. In the pipeline is a monthly or weekly injection of buprenorphine, which could be better for those who might still need to see a physician often but struggle to take a daily pill. Ultimately, Sheldon says, there need to be more treatments that can be better tailored to individual patients.

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Many Republican-led states rejected expanding Medicaid under Obamacare. But some GOP governors are reconsidering. That means more poor Americans could be eligible for coverage in 2016.

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Addicted to prescription painkillers after a high-school sports injury, Cameron Burke moved on to heroin, which was cheaper and more easily accessible. His parents tried everything, more than once sending him out of state for treatment.

“It was never enough,” Jennifer Weiss-Burke of Albuquerque, N.M., told a local TV reporter last year. “Thirty days here, 30 days there, maybe detox for five days. It was never long-term, and that’s what he needed. Recovery from heroin addiction requires long-term treatment.”

During the course of two years, Cameron would seem to recover, only to relapse. In 2011, Weiss-Burke found him dead in his room.

Weiss-Burke turned her grief into action, lobbying for state legislation that would require all medical practitioners to complete a course in addiction and pain management when their licenses are renewed, and pushing for the creation of Serenity Mesa, a long-term treatment center for youths in Albuquerque that opened its doors last year.

Although drug addiction was described as a disease as long ago as the 1700s, addiction medicine has been neglected by the medical system, according to a 2012 study by the National Center on Addiction and Substance Abuse at Columbia University.

“While a wide range of evidence-based screening, intervention, treatment and disease management tools and practices exist, they are rarely employed,” the report found.

Lack of effective treatment in the teen years can blight an entire life. “When substance use disorders occur in adolescence, they affect key developmental and social transitions, and they can interfere with normal brain maturation,” the National Institute on Drug Abuse reported in 2014. “These potentially lifelong consequences make addressing adolescent drug use an urgent matter.”

The first line of defense is primary health care, according to Dr. David E. Smith, an addiction medical specialist who founded the Haight Ashbury Free Clinics in San Francisco. To increase the number of physicians trained to diagnose and treat addiction and to recognize early signs of adolescent substance use disorder, Smith would like to see addiction medicine mandatory in medical school.

“Engaging people earlier in their addiction improves their chances of recovery and overall better health,” Smith said. “Meanwhile, costs for the health care system are dramatically reduced.”

A youth-centered approach

Deaths from heroin overdose in all age groups doubled from 2010 to 2012, according to a 2014 study from the Centers for Disease Control and Prevention.

In response, communities are seeking new strategies to treat addiction and speed access to care. That includes trying to meet the unique needs of youth after years of addiction treatments geared to adults. Serenity Mesa is one of those youth-centered efforts.

Such programs offer evidence-based treatment, types of therapy that have shown scientifically validated results. They include: Screening, Brief Intervention and Referral to Treatment (SBIRT), a preventative protocol for early detection; Motivational Interviewing, a counseling approach that guides individuals to set goals; and Functional Family Therapy (FFT), which treats teens in a family setting.

Addiction treatment requires continuing care, no less than hypertension or diabetes. While public policy and social attitudes have begun to catch up with science, treatment for teens lags far behind. The 2012 National Survey on Drug Use and Health found that 90 percent of drug-addicted youth ages 12 to 17 get no treatment at all.

“Twenty years ago, we were just beginning to focus on evidence-based treatment for drug-involved youth,” says Dr. Holly Waldron, a senior scientist at the Oregon Research Institute who studies adolescent behavior. “Historically, interventions for addictive behaviors have included confrontational approaches, but we’ve learned that confrontation does not produce effective change in substance-abuse behavior.”

Instead, Waldron and her colleagues favor evidence-based interventions including functional family therapy and cognitive behavioral treatments for adolescent substance abuse.

“We’re actively involved in taking these treatments to community settings,” she said. “If we can connect kids to treatment, we know they’ll improve.”

Most health insurers now require proof that addiction programs use evidence-based treatment, a sign of efficacy. And since the 2010 Affordable Care Act expanded the Mental Health Parity and Addiction Equity Act, more adolescents have better access to insurance coverage.

Yet, teenagers rarely enter rehab voluntarily. “Clinicians are dependent on systems like juvenile justice and the schools to get teens connected to treatment,” Waldron said.

Making family therapy work

Some treatments for teens with substance use disorder engage the whole family. Functional Family Therapy uses a dozen or more one-hour sessions to defuse negativity, then teach skills training in family communication, parenting, problem solving and conflict management. Later sessions strengthen a family’s capacity to navigate community resources, which can prevent relapse.

Waldron is also testing the effectiveness of delivering therapy to New Mexico’s scattered rural population via videoconference. Privacy is one benefit of videoconferencing, Waldron noted. “If you live in a small town and your car is parked in the lot at the mental health clinic, everybody knows that’s your car. In Native American communities, if you go to a tribal counselor, it’s more likely people will know your business. Talking at home over the Internet offers greater confidentiality. “That’s important to families.”

Videoconference dynamics can be complicated, however. “It’s harder to discern over a video stream how people are responding,” Waldron said. “If they’re quiet, if they’re becoming emotional, we might not see cues.”

To compensate, “the therapist has to do verbal check-ins with each member of the family,” Waldron explained. She posed an example, meant to invite participants to describe their feelings: “I hear you being quiet. Does this topic hit close to home for you all?”

The study ran through November, and Waldron said preliminary data shows the online treatment is as effective as treatment delivered face-to-face at home. If, as Waldron expects, the final data shows measurably improved outcomes such as a decline in drug use and better family dynamics, she hopes that the results can be reproduced elsewhere.

“It will mean that it’s possible to get the best treatment to kids who would never have access otherwise,” she said.

Treating addiction with medication

At HealthRIGHT 360, a nonprofit in San Francisco created in 2011 when the Haight-Ashbury Clinic merged with the local residential center Walden House, treatment can include individual or group therapy, family therapy and mindfulness meditation. All can be used in combination with medications such as methadone.

While methadone can be effective in addiction recovery for adults, it is not well-suited for teens, according to Dr. Ako Jacintho, HealthRIGHT 360’s medical director.

Methadone is highly regulated and can only be administered at methadone clinics. The drug must be taken daily, so trips to and from the clinic, often far from home and work, can be especially difficult for teens. And, Jacintho noted, teens may encounter other addicts at the clinic, as well as opportunities to buy drugs.

The maintenance drug often prescribed for teens is Suboxone, a combination of buprenorphine, an opiate substitute that eliminates craving, and naloxone, which blocks euphoric effects. Suboxone doesn’t cause drowsiness, and, the equilibrium it provides can make it easier to identify and treat co-occurring disorders like depression or anxiety. The dosage is eventually tapered.

A 2014 Yale School of Medicine study showed that ongoing maintenance treatment with Suboxone is more effective than detoxification and abstinence alone.

“There is strong data on Suboxone,” Jacintho said. When combined with behavioral therapy, he says, Suboxone can reduce relapses and promote recovery. And, it can be prescribed and given by a trained and certified primary care physician — in a doctor’s office, rather than a clinic, Jacintho noted. “We get better outcomes when we change from methadone clinics to primary care.”

As education and training around addiction improve, Smith hopes more attention will be paid to the people he calls “role models of recovery.”

Vitka Eisen, CEO of HealthRIGHT 360, is one of them. She was a heroin addict from age 19 to 25, until the Haight Ashbury Free Clinic and Walden House put her back on her feet. Three college degrees later, including a doctorate in education from Harvard University, she’s proud to call herself “a 1987 Walden House graduate.”

Having been homeless during periods of her addiction, Eisen knows the difficulties teenage addicts may face.

“It’s hard for these kids to get off heroin, because they lead such challenging lives. If a kid’s using heroin, there’s a high likelihood of trauma exposure” from school, work or family life, she said. “Drugs may seem like the best thing in their life, the thing that helped them deal with how they experience the circumstances of their lives.”

The most effective treatments for teens, she says, build on the individual’s strengths while empowering them to better handle stressful circumstances.

And these treatments can gain in effectiveness when used in combination with medications such as Suboxone.

Jacintho also says there soon will be greater acceptance of integrated treatment for teens. “The data is going to show positive health outcomes,” he predicted.

Smith is cautiously optimistic, too. “Every interface with a health care professional should give a consistent message,” he said. “We care.”

This story was produced by Youth Today, the national news source for youth-service professionals, including child welfare and juvenile justice, youth development and out-of-school-time programming.

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