In the 25 years since she snorted her first line of methamphetamine at a club in San Francisco, Kim has redefined “normal” many times. At first, she says, it seemed like meth brought her back to her true self — the person she was before her parents divorced, and before her stepfather moved in.

“I felt normal when I first did it, like, ‘Oh! There I am,’ ” she says.

Kim is 47 now and has been chasing “normal” her entire adult life. That chase has brought her to some dark places, so we agreed not to use her last name, at her request. For a long time, meth, known commonly as speed, was Kim’s drug of choice.

Then she added heroin to the mix. She tried it for the first time while she was in treatment for meth.

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After struggling with addiction to both heroin and meth for decades, Kim got care at a residential treatment program for women — Epiphany Center, in San Francisco. She’s now working and plans to go back to college in the fall.

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“That put me on a nine-year run of using heroin,” Kim says. “And I thought, ‘Oh, heroin’s great. I don’t do speed anymore.’ To me, it saved me from the tweaker-ness,” she says, referring to the agitation and paranoia many meth users experience, and how heroin, an opiate, calmed that.

Now, Kim has just finished addiction treatment for both drugs.

She was part of the last meth wave of the ’90s, and now she’s part of a new meth epidemic sweeping through parts of the United States, especially the West. Deaths involving methamphetamine are up. Hospitalizations are up.

Taking meth and opioids for a “synergistic high”

Researchers who have tracked drug use for decades believe the new meth crisis got a kick-start from the opioid epidemic.

“There is absolutely an association,” says Dr. Phillip Coffin, director of substance use research at the San Francisco Department of Public Health.

Across the U.S., more and more opioid users say they use methamphetamine as well, up from 19% in 2011 to 34% in 2017, according to a study published in the journal Drug and Alcohol Dependence last year. The greatest increases were in the western United States.

That research suggests that efforts to get doctors to cut down on writing opioid prescriptions may have driven some users to buy meth on the street instead.

“Methamphetamine served as an opioid substitute, provided a synergistic high, and balanced out the effects of opioids so one could function ‘normally,’ ” the researchers write.

It’s kind of like having a cup of coffee in the morning to wake up and a glass of wine in the evening to wind down — or using meth on Monday to get to work and heroin on Friday to ease into the weekend.

Amelia says that’s how her drug use evolved to include meth.

At first, drugs were just a fun thing she would do on the weekend — ecstasy and cocaine with her friends. Then, on Monday, Amelia would just go about her workweek.

“I’m a horse trainer, so I worked really hard, but I also partied really hard,” she says.

Then one weekend, when Amelia was feeling kind of hungover from the night before, a friend passed her a pipe and said it was opium.

“I thought it was like smoking weed or hash, you know?,” Amelia says now. “I just thought it was like that.”

She says she grew to like the opium stuff and eventually contacted the friend’s dealer.

“The woman said, ‘How long have you been doing heroin for?’ and my jaw nearly hit the ground,” Amelia says. “I was just really, honestly, shocked. I was like, ‘What? I’ve been doing heroin this whole time?’ I felt really naive, really stupid for not even putting the two together.”

Pretty soon, Amelia started feeling sick around the same time every day. It was withdrawal symptoms — a clear sign she was becoming dependent on the drug. Her weekend smoke became her daily morning smoke. Then it was part of her lunchtime routine.

“I just kind of surrendered to that and decided, ‘Screw it,’ ” she says. “I’ll just keep doing it. I’m obviously still working, I’m fine.’ “

A heroin habit is expensive. Amelia was working six days a week to pay for it. Any horses that needed to be ridden, any lessons that needed to be taught, she said yes to because she wanted the money.

But bankrolling her heroin use was exhausting. One day, one of the women she worked with at the horse barn offered her some meth as a pick-me-up.

Meth is comparatively cheap these days. It became the thing that kept Amelia going so she could earn enough money to buy heroin.

“The heroin was the most expensive part,” she says. “That was $200 a day at one point. And the meth was $150 a week.”

This pattern lasted for three years, until Amelia discovered she was pregnant. As soon as her daughter was born, she entered a residential treatment program in San Francisco — the Epiphany Center — that would accept her and her baby.

“I was OK with being a drug addict,” Amelia says. “I was OK with that being my life.” she says. “But I wasn’t OK with having kids and letting that be part of my life.”

Rehab admissions on the rise for mixers of heroin and meth

Admissions to drug rehabilitation for heroin have remained steady in recent years in San Francisco. But the number of heroin addicts reporting methamphetamine as a secondary substance problem has been rising. In 2014, 14% of heroin users entering rehab in San Francisco said meth was also a problem. Three years later, 22% said meth was also a problem.

“That is very high,” says Dr. DanCiccarone, a professor of family community medicine at the University of California, San Francisco, who has been studying heroin for almost 20 years. “That’s alarming and new and intriguing and needs to be explored.”

The speedball — heroin plus cocaine — is a classic combination, he says.

“It’s like peanut butter cups, right — chocolate and peanut butter together,” he says. “Methamphetamine and heroin are an unusual combination.”

The meth and heroin combo is colloquially referred to as a goofball, Ciccarone adds, because it makes the user feel “a little bit silly and a little bit blissful.”

For Kim, the methamphetamine use came first. Then she added heroin.

“I ended up doing both at the same time every day, both of them,” she says.

For Kim, it was always about finding the recipe to what felt normal. Start with meth. Add some heroin. Touch up the speed.

“You’re like a chemist with your own body,” she says. “You’re balancing, trying to figure out your own prescription to how to make you feel good.”

Now Kim is trying to find that balance without drugs. She’s been sober for a year. So has Amelia, the horse trainer. Her sober anniversary is the same as her daughter’s birthday.

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

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Spinal surgery made it possible for Liv Cannon to plant her first vegetable garden.

“It’s a lot of bending over and lifting the wheelbarrow and putting stakes in the ground,” the 26-year-old says as she surveys the tomatillos, cherry tomatoes and eggplants growing in raised beds behind her house in Austin, Texas. “And none of that I could ever do before.”

For the first 24 years of her life, Cannon’s activities were limited by chronic pain and muscle weakness.

“There was a lot of pain in my legs, which I can now recognize as nerve pain,” she says. “There was a lot of pain in my back, which I thought was, you know, just something everybody lived with.”

Cannon saw lots of doctors over the years. But they couldn’t explain what was going on. She’d pretty much given up on finding an answer for her pain until her fiancé, Cole Chiumento, pushed her to try one more time.

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Liv Cannon and her fiancé, Cole Chiumento, considered calling off their wedding because of uncertainty over medical debt from her surgery. “I think about it every time I go to the mailbox,” Cannon says.

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“It never improved. It never got better,” Chiumento says. “That just didn’t sound right to me.”

So Cannon went to a specialist who ordered a scan of her spine. A few days later, her phone rang.

“We found something on your MRI,” a voice said.

The images showed that Cannon had been born with diastematomyelia, a rare disorder related to spina bifida. It causes the spinal cord to split in two.

In Cannon’s case, the disorder also led to a tumor that trapped her spinal cord, causing it to stretch as she grew.

In December 2017, a neurosurgeon opened up her spinal column and operated for several hours, freeing the cord.

“I think it was Day 3 after my surgery I could feel the difference,” Cannon says. “There was just a pain that wasn’t there anymore.”

As she recovered, Cannon saw lots of huge medical bills go by. They were all covered by her insurance plan. Almost a year went by after the operation.

Then a new bill came.

Patient: Liv Cannon, 26, of Austin, Texas. At the time of her surgery, she was a graduate student insured with Blue Cross and Blue Shield of Texas through her job at the University of Texas.

Total bill: $94,031 for neuromonitoring services. The bill was submitted to Blue Cross and Blue Shield of Texas, which covered $815.69 of the amount and informed her she was responsible for the balance. The insurer covered all of Cannon’s other medical bills, which came to more than $100,000, including those from the hospital, surgeon and anesthesiologist.

Service provider: Traxx Medical Holdings LLC, an Austin company that provides neuromonitoring during spinal surgery. Neuromonitoring uses electrical signals to detect when a surgeon is causing damage to nerves.

Medical service: Cannon was born with a rare spinal condition that had caused chronic pain and muscle weakness since she was a child. In December 2017, she had successful spinal surgery to correct the problem. Her surgeon requested neuromonitoring during the operation.

What gives: Neuromonitoring made sense for the type of surgery Cannon had. The bill did not. Cannon should have been warned long before her surgery that the neuromonitoring company would be an out-of-network provider whose fees might not be covered by her insurer.

Liv Cannon was diagnosed with diastematomyelia, a rare disorder related to spina bifida, and had surgery in December 2017 to correct the problem. Most of the cost of the surgery was covered by her insurance, but more than $93,000 for out-of-network neuromonitoring services was not.

Julia Robinson for Kaiser Health News

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Julia Robinson for Kaiser Health News

At first, she was baffled by the billing information that Blue Cross sent her. “It was one of those things from the insurance company that says this is the amount we cover and this is the amount you might owe your provider,” she says.

The statement listed four separate charges from the day of her surgery. Each was described as a “diagnostic medical exam.” Together, they came to $94,031.

Blue Cross said the covered amount was $815.69 — minus a $750 deductible and $26.27 for coinsurance — and informed Cannon she might have to pay the balance — $93,991.58

“I was shocked,” she says. Chiumento was outraged.

“As soon as I saw that, I thought it was a scam,” he says.

The bill had come from an Austin company called Traxx Medical Holdings LLC. Traxx did not respond to emails, phone calls and a fax seeking comment on the charge.

The company’s website shows that Traxx provides a service called intraoperative neurophysiological monitoring, which evaluates the function of nerves during surgery. The goal is to help a surgeon avoid causing permanent damage to the nervous system.

There is an ongoing debate about whether neuromonitoring is needed for all spinal surgery. But it is standard for a complicated operation like the one Cannon had, says Richard Vogel, president of the American Society of Neurophysiological Monitoring.

On the other hand, a $94,000 charge for the service can’t be justified, Vogel says.

“You’re not going to meet anybody who believes that a hundred thousand dollars or more is reasonable for neuromonitoring,” Vogel says.

Most neuromonitoring companies charge reasonable fees for a valuable service and are upfront about their ownership and financial arrangements, he says. But some companies are greedy and submit huge bills to an insurance company, hoping they won’t be challenged, he adds.

Even worse, “some neuromonitoring groups charge excessive fees in order to gain business by paying the money back to surgeons,” Vogel says.

Last year, Vogel’s group published a position statement condemning these “kickback arrangements” and other unethical business practices.

It is unclear whether Traxx, the company that provided neuromonitoring for Cannon, has any financial arrangements with surgeons. Cannon’s surgeon did not respond to requests for comment.

The size of the fee for Cannon’s neuromonitoring was only part of the problem. The other part was that Traxx — unlike her hospital, surgeon and anesthesiologist — had no contract with Blue Cross and Blue Shield of Texas.

As an out-of-network provider, the company could set its own fees and try to collect from Cannon any amount it didn’t get from her insurer.

Blue Cross and Blue Shield of Texas said it doesn’t comment on problems affecting individual members. But the insurer did offer a general statement by email about the problem:

“Unfortunately, non-contracted providers can expose our members to significantly greater out-of-pocket costs. These charges often have no connection to underlying market prices, costs or quality. If given the opportunity, we will try to negotiate with the provider to reduce the cost.”

One thing working against Cannon is that she is pretty sure that just before surgery, she signed a paper that authorized the out-of-network neuromonitoring.

“It was 4:30 in the morning and you’re like, ‘OK, let’s get this over with,’ ” she recalls.

Getting consent in the hospital may be legal, but it’s not reasonable, says Dr. Arthur Garson Jr., who directs the Health Policy Institute at the Texas Medical Center in Houston.

For example, a patient might be having a heart attack, Garson says. “You got chest pain, you’re sweating, sick as you can be, and they hand you a piece of paper and they say, ‘Sign here.’ “

The Texas Legislature passed a bill in May to protect patients from the sky-high bills this practice can produce. And Congress is considering similar legislation.

These are small steps in the right direction, Garson says.

“Asking the individual patient to make that decision even when they’re not sick, I think, is difficult,” he says, “and maybe we ought to think of some better way to do it.”

The Texas legislation is expected to take effect later this year but affects only bills that occur after it becomes law. So that $94,000 figure is never far from Cannon’s mind, even as she and Chiumento plan their wedding.

“Every time I go out and I collect the mail, I’m wondering, ‘Is this the day it’s going to show up and we’re going to have to deal with this?’ ” she says.

The takeaway: Neuromonitoring during complex surgery involving the spine can help prevent inadvertent damage. But monitoring may be unnecessary for lower-risk back operations, like spinal fusion.

It is strange that neuromonitoring is charged as a separate service, rather than part of the spine surgery. Cardiac monitoring is not charged separately during bypass surgery, for example.

When considering spine surgery, ask your doctor whether neuromonitoring will be part of the procedure. If so, will it be billed separately? Try to find out the name of the provider and get an estimate of the cost beforehand.

Check with your insurer to determine if the neuromonitoring provider is within your network and to make sure the estimated charge will be covered.

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