Stilwell, an accountant in Placerville, California, tried to quit a second time, but she couldn’t tolerate the sickening withdrawal symptoms. She resisted going to the emergency room because “I thought they’d treat me like a drug addict and not a patient in pain,” she said.

Instead, she kept smoking heroin to keep the agony at bay. Then, in February, a county mental health worker told her about a new program that promised stigma-free treatment for her addiction.

She went to the ER at in Placerville, where a doctor put her on buprenorphine, one of approved by the Food and Drug Administration for medication-assisted treatment (MAT) of people with opioid dependency.

Her ongoing treatment includes intensive counseling and social support, providing what is known in the recovery field as “whole person” therapy.

“It’s still early in my battle,” Stilwell said. “But my withdrawals are gone. Now I can concentrate on being a mother.”

Marshall is one of a growing number of health care institutions across California that offer medication-assisted treatment with funding and support from the state’s , which started in 2018 and is financed by $265 million in federal grants.

Numerous studies have shown that relapse and overdose rates are than those who don’t. From 2016 to 2018, for example, the overdose death rate in Humboldt County — one of California’s highest ― dropped by , which officials attributed in large part to the MAT Expansion Project.

In February, California’s Department of Health Care Services, which administers the project, touted its success, reporting that it has provided care for 22,000 previously untreated Californians with opioid addictions and created 650 new locations where patients can receive MAT.

But the number of new people brought into treatment is only a small fraction of those who need it. In 2019, more than half a million Californians with an opioid use disorder lacked access to treatment, according to a by the Urban Institute.

The state effort faces many of the same obstacles that have hindered wider acceptance of MAT for years: the stigma of addiction, federal regulations that depress the number of MAT providers, and hostility in some corners of the treatment community to the very notion of using drugs to combat drug addiction.

Moreover, the addiction treatment industry has become a magnet in recent years for who aggressively recruit clients, eyes fixed on the dollar signs rather than on evidence-based treatments such as MAT.

Now there’s another, hopefully temporary, challenge. The COVID-19 crisis and related social-distancing measures are forcing MAT practitioners to scramble for new ways to accommodate patients, said Eric Hill, a “substance navigator” at Marshall Medical Center who helps guide patients through their MAT treatment.

Hill said MAT patients entering the program through emergency rooms are now given prescriptions for up to a month, rather than a week. He said he is following up with clients by phone rather than in person, and he and others are trying to arrange video calls between doctors and patients for prescription renewals.

The state program seeks to broaden access to MAT by launching or enhancing treatment programs at ERs, hospitals, primary care clinics, residential treatment programs, county mental health centers, jails and drug courts. Training more doctors to provide MAT is also a pillar of the campaign.

But patients who take anti-addiction drugs can have difficulty finding housing and recovery therapy, which are integral to their treatment. They are often shunned by groups adhering to traditional 12-step theories of sobriety that require participants to be free of drugs — including MAT drugs.

“MAT patients will say that the treatment was working. They were just starting to feel better, going to support groups, back at their jobs, but they had a hard time finding a place to live,” said Hill.

Many patients who stop taking their MAT drugs in order to get a roof over their heads have relapsed, Hill said.

Marlies Perez, a division chief at the state health care department, said the agency “is taking a strong stand against such stigma that prevents patients from their continued recovery.” Through its media campaign, , it seeks to alter perceptions within the recovery community and persuade more doctors and patients to embrace MAT.

The state expansion project puts a strong emphasis on building MAT capacity in emergency rooms, where opioid users often face suspicion.

Of the 320 acute care hospitals with emergency rooms statewide, 52 currently offer MAT. In those hospitals, staff members like Hill help patients get the care they need, including the psychological and social dimensions. Health care department officials say they plan to quadruple the number of participating hospitals to more than 200 over the next few years.

Opioid misuse is not nearly as deadly in California as in the rest of the U.S., even though the rise of fentanyl has begun to cause bigger problems in the Golden State.

In 2018, the in California stood at 5.8 per 100,000 residents, far below the national average of 14.6 per 100,000. In some rural counties of California, however, opioid death rates exceed the national average. The two states with the highest rates were West Virginia, at 42.4 per 100,000, and Delaware at 39.3.

Another obstacle to MAT expansion, one squarely in the sights of California health authorities, is that many doctors are hesitant to participate because they must undergo federally mandated training for a waiver that allows them to prescribe buprenorphine.

“Doctors can prescribe OxyContin with abandon but not buprenorphine, which has been shown to be helpful to opioid addicts,” said Dr. Aimee Moulin, a director at the , which helps administer the state’s MAT program.

Buprenorphine is less powerful and than methadone, another drug commonly used to fight opioid addiction. And doctors who get the waiver for buprenorphine can prescribe it in their offices, while methadone must be administered in treatment programs.

The state’s health care department said the expansion project has thus far trained 395 new MAT prescribers. But as of July 2019, just 3.2% of prescribers in the state were authorized to prescribe buprenorphine, according to the Urban Institute study.

Dr. Peter Liepmann, a Pasadena-based family physician with an interest in addiction medicine, said it can be difficult to find a buprenorphine prescriber. Not long ago, when he was thinking about opening a practice in Glendale, California, he consulted the Substance Abuse and Mental Health Services Administration’s (SAMHSA) listings of physicians who offer MAT.

“If you were looking for somebody to dispense buprenorphine and you called people on that list, you would have come up with one doctor who ran a cash-only, no-insurance practice, and he was very expensive,” Liepmann said.

The state’s Perez said some doctors may not fully understand the benefits of MAT because medical schools devote little time to addiction training. Another element of the MAT project, she said, is to fund a substance-use-disorder curriculum at training hospitals.

Perez counseled patience: “We didn’t get into this opioid dependency situation overnight, and we’re not going to find a total solution overnight either.”

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Chisholm calls that cut “the Big One,” and for some of his low-income patients, the consequences were catastrophic. Many of them had diabetes and could no longer afford the foot care so vital for people with the disease, which can constrict blood flow and cause serious nerve damage in the feet. Those patients stopped coming to see him.

He would see them again only when he was called to the emergency room to perform amputations on those whose disease raged unchecked.

“For so many of the working poor, losing this coverage was absolutely devastating,” Chisholm said. “It resulted in people having to choose between the basic necessities of life and going to the doctor. I saw a lot of hurt.”

This month, Medi-Cal restored podiatry and several other adult health benefits eliminated more than a decade ago, including eyeglasses and speech therapy, as well as hearing exams, hearing devices and other related services. The state’s 2019-20 budget provides to pay for the coverage.

About 13 million Californians — including 7 million adults — are covered by Medi-Cal, the state’s version of Medicaid.

“Millions now have access to these types of health care they didn’t have before,” said Anthony Wright, executive director of Sacramento-based Health Access California, a consumer advocacy group. “And we’ve seen that services such as podiatry, audiology and speech therapy are clearly medically necessary.”

Some health activists wonder why it took the state so long to restore the benefits. “A lot of these recession-related cuts came on the backs of the poor. Yet when the economic recovery came, we didn’t see their restoration,” said Linda Nguy, a policy advocate at the Western Center on Law and Poverty. “The low-income people who needed the medical services the most were the first to see them cut and the last to have them returned.”

Anthony Cava, a spokesperson for California’s Department of  Health Care Services, said the recently reinstated benefits are just the latest in an incremental restoration of care for the state’s low-income adult population. Acupuncture was brought back in 2016, and full dental benefits were restored in 2018, he said.

Raquel Serrano, a 67-year-old Fresno farm laborer, will become one of the many to take advantage of Medi-Cal’s resurrected benefits. Serrano learned she had diabetes a decade ago but signed up for Medi-Cal only recently. For years, she drank sugary soda with every meal and hot chocolate with bread at bedtime.

“My parents didn’t have the education about diabetes,” said Serrano’s son, Jose, the eldest of six children. “Soda was something we had on the table for breakfast, lunch and dinner. We drank soda, not water.”  Now, he said, his mother will be able to see a podiatrist, get eyeglasses and fix her damaged teeth. “We think this will add years to her life,” he said.

Proponents of the restored benefits say the state will save money by providing foot care for people with diabetes, such as Serrano. A 2017  by UCLA researchers estimated that the use of preventive podiatric services saved Medi-Cal in 2014, attributable to avoided hospital admissions and amputations.

Lower-limb amputations increased across California by a staggering from 2010 to 2016, according to state hospital data reported by , a San Diego-based nonprofit investigative journalism organization.

Chisholm attributes the rise, in part, to the elimination of podiatric benefits for Medi-Cal patients. “We can’t say for sure,” he said, “but California suffered an avalanche of amputations after these cuts. Those are compelling numbers.”

Chisholm, who runs two podiatry offices in the working-class San Diego suburbs of National City and Chula Vista, said one elderly Latina woman who had been coming to him for years was unable to pay out-of-pocket after Medi-Cal stopped covering her treatments in 2009, so he offered to treat her for free.

But for some reason, whether shame or some bureaucratic confusion, she stopped coming anyway, he said. Chisholm lost track of her, until one day he was summoned to the emergency room to perform a below-the-knee amputation. She was the patient.

Though the benefits are now restored, many activists wonder if patients who need to see podiatrists, audiologists or speech therapists will be able to get appointments.

“Many of these providers have not worked with Medi-Cal for years, so it could be a challenge to accommodate all these patients,” said , associate director of the UCLA Center for Health Policy Research.

Chisholm said California has recently reduced the amount of paperwork required by health care providers to be reimbursed for services they offer to Medi-Cal patients. “It used to be a bureaucratic nightmare, including paperwork and documentation, to get the government to reimburse you for even the simplest procedures,” he said. “But that has improved, along with the rates for reimbursements.”

Many California doctors have long declined to treat patients enrolled in Medi-Cal because of the program’s low payment rates, but the state has — in some cases quite substantially — in each of the past two years.

But the latest restoration of Medi-Cal benefits is so new that many doctors and patients still don’t fully understand it.

Native Spanish speakers face an additional complication, said J. Luis Bautista, who runs two Central Valley clinics that serve primarily Latino patients, many of whom are on Medi-Cal. “What patients hear on the news and read on the internet is different. They’re not sure which services are covered and which aren’t,” Bautista said.

Chisholm said that despite efforts by his office and podiatrist trade groups to spread the word about the reinstated benefits, it has been slow to reach the public — and even some health care workers. Just recently, he overheard a receptionist in one of his offices turn away a Medi-Cal patient who had walked in seeking an appointment.

“I heard her tell the man, ‘No, we don’t take Medi-Cal,’ and I walked out of my office and said, ‘Yes, we do,’” Chisholm recalled. “This woman had been to all the meetings, she’d gotten the memos, it just didn’t click. But we got the patient in.”

This story was produced by , which publishes , an editorially independent service of the .

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).