(gentle music) - [Anna] Opioid addiction is worsening across the nation, and one particular drug, fentanyl, is making overdoses far more fatal.

Now the crisis is hitting close to home.

- People are dying all over the state.

- My brother didn't think that that would ever happen to him, and it's happening to people left and right.

- [Anna] We'll examine the efforts underway to save overdose victims and find solutions.

And nearly a dozen Montana nursing homes have closed, and the rest are at their breaking point.

- You've got to come to the table with something for us because we will be shutting down.

- [Anna] What can be done to save the homes that are left?

That's coming up on "Impact."

(gentle upbeat music) - [Announcer] Production of "Impact" is made possible with support from the Otto Bremer Trust, investing in people, places, and opportunities in our region, online at ottobremer.org; the Greater Montana Foundation, encouraging communication on issues, trends, and values of importance to Montanans; and viewers like you, who are friends of Montana PBS.

Thank you.

(logo swooshes) - Welcome to "Impact," our continuing series covering issues important to Montanans.

I'm Anna Rau.

Overdoses are now the leading cause of accidental death in the US, and one drug is involved in the majority of those deaths: fentanyl.

Fentanyl is meant to be used in very small doses for pain management, but illicitly manufactured drugs offer a much larger and much more dangerous dose.

As Montana PBS's Breanna McCabe reports, the fast-moving epidemic is destroying lives across the state.

(logo swooshes) - What is being done proactively- - [Breanna] If this recent public meeting in Great Falls is any indication, - Next question.

- [Breanna] Montana has more questions than answers about fentanyl.

- It can affect any one of us in this room.

- [Breanna] Fentanyl has affected 36-year-old Courtney, who's marking one year without the substance that scarred her.

(haunting music) - We were all shooting up.

That was our main route, I guess you could say.

That's what these are.

- [Breanna] She started meth as a teenager, tried heroin in her late 20s, and before long, she was hooked.

- That was my only focus in life.

(bars clinking) - [Breanna] Courtney's addiction took her on a tour of county jails, and eventually, to an encampment under a freeway in Oakland.

That's where fentanyl found her.

- It was cheaper than heroin.

It lasted, it didn't last longer, but it got you higher faster, less got you higher.

So that was very appealing to the whole community.

- [Breanna] Less to get high and less to die.

It takes just granules of fentanyl smaller than the point of a pencil to be fatal.

Users melt down the pills or powder and often smoke it off of foil.

Courtney mixed hers with meth and heroin, and shot up the blend between eight and 10 times a day.

- Most people couldn't do a fraction of my shots without dying.

And they did, people did die off my shots more than once.

- [Reporter] Over two pounds of fentanyl- - [Breanna] Courtney knows she's just one relapse away from the same fate.

- I honestly would be scared to go back into it.

I mean, I had the tolerance then, I could handle it then.

Now that I've been clean for a year, pshh, it would kill me, guaranteed, first time, no matter how little it was.

- [Breanna] As Courtney works every day to avoid becoming a statistic, many more Montanans aren't as lucky.

Last year, someone in the state died of fentanyl poisoning every five days.

- My brother didn't think that that would ever happen to him, and it's happening to people left and right.

- [Breanna] 29-year-old Charlie Pluff's sisters say he had so much to live for: a family who loved him and a daughter who needed him.

(somber music) - He wanted to do better, but I think it was just addiction had a strong hold on his life.

- [Breanna] Last Memorial Day, Charlie got high for the last time.

- Just two days before, he was talking about going to get treatment, like my family was gonna help him pay to get into treatment.

- [Breanna] Toxicology revealed meth and lethal amounts of fentanyl in his system.

- [Kia] It's just unfortunate that he didn't get the help he needed in time before this horrible drug got to him.

(traffic whooshes) - It's everywhere in our community.

We can't get away from fentanyl.

(sirens wailing) People are dying all over the state.

- [Breanna] First responders see overdoses firsthand.

- They are dead so quick.

They're still sitting in the chair, and the syringe is still in their hand that they used to shoot the fentanyl up.

That's how quick it's killing these folks.

(mechanism whirs) - [Breanna] But in the instances someone witnesses an overdose, one medication could save them.

Naloxone, commonly known by its brand name Narcan, acts to reverse the effects.

When sprayed effectively into the nose, it reaches the brain in minutes.

- Your brain, your body has opioid receptors.

So what Narcan will do, it will actually fight off any narcotic or opioid that's bound to those receptors already.

Narcan will come in and kick that drug off the receptor and bind to it, and then it fills up all the other receptors.

(sirens wailing) - [Breanna] Narcan saves lives.

And since it's harmless to those without opioids in their system, responders use it right away.

- Time is tissue in any of those instances.

So it does happen, you know, a fair amount, that we can't intervene soon enough, and the person is gonna pass away from the overdose.

(traffic whooshes) - [Breanna] Police now carry Narcan, too, and reach for it regularly.

- Generally, we're the first ones there.

- [Breanna] Whether it's the effects of an overdose or the ingredients for a future one, officers now anticipate they could come across fentanyl on any call.

(sirens wailing) It's found in powder form, as well as pills mimicking other opioids.

And increasingly, fentanyl is found laced into every other drug.

- [Dispatcher] Overdose.

Used meth and possibly fentanyl.

- [Michael] We're continuously running into it, day after day, after day.

(radio beeps) - 272, 10-4.

- [Breanna] They're even finding fentanyl off duty.

- I was in a restaurant recently, and a individual walked past me, and as he pulled his phone out of his pocket, a bag of fentanyl pills fell to the floor next to me.

- [Breanna] Those pills were added to the growing stack of fentanyl seized in Cascade County.

- We are able to weigh the pills in the package and get a very close estimate of the number of pills so we don't have to handle them.

- [Breanna] Lieutenant Michael Grubb serves as commander of the Russell Country Drug Task Force, which has undercover agents working in the community every day, using confidential informants to buy fentanyl from known dealers.

- The normal person in the community has no idea what's out there.

And to be honest, our drug task force in Great Falls is just barely scratching the surface.

- [Breanna] This surface scratching added up to more than 200,000 doses of fentanyl seized statewide in 2022, triple the amount from 2021, and up 11,000% since 2019.

(train whistle howls) Many of the major busts are the result of months, even years-long investigations, and a careful, coordinated effort between local, tribal, state, and federal agencies.

- Geographically, it doesn't know any boundaries, which means that all different walks of life of people in our community that are being affected by this drug.

Do we have that badge, or?

- [Breanna] Great Falls Police Investigative Services Bureau captain, Robert Moccasin, says it's worth the patience to bring these major players to justice.

- We have to keep going after those individuals that are bringing in large amounts of narcotics into our community, because otherwise, our problems are exacerbated, you know, tenfold or a hundredfold.

- These folks are doing heroic work every day, creative work to try to keep us safe and deal with the drug crisis, the fentanyl crisis here.

- [Breanna] US Attorney Jesse Laslovich says, after it's cheaply manufactured in Mexico, dealers have an incentive to bring it farther north.

- They can get a pill, a fentanyl pill, for 50 cents, 35 cents in San Diego, and as you work your way up to Montana, depending on where you are, it can be $30 a pill, some instances $50 a pill, or even higher in some of our reservations.

So it's simple economics for these folks, where they can get it cheaply, and then they are commuting to Spokane.

And they have their folks there, they're selling it to them, they're making some money.

And then they're marking it up, and they're coming to Montana, and it's big money.

(traffic whooshes) - [Breanna] Slowing the supply is an ongoing challenge, but the other battle is stopping the demand for fentanyl.

- Physiologically, these people get to the point where they can't help it.

They get what's called dope sick.

If they're off the drug for so long, physically they're so sick.

That's why they seek out that drug: It's so addictive.

In that respect, being dope sick is worse than being on the drug.

(somber music) - [Breanna] It's a feeling familiar to Courtney.

When a near-death hospitalization forced her to reconnect with family in Montana, she decided to move away from her addictive environment and get the help she needed to get sober.

But even strong intentions didn't stop her physical withdrawals.

- (sighs) It was just miserable.

Nothing would take that pain away, nothing.

And I would obsess, just obsess on where I could go to get some dope around here.

And thankfully, I never did.

But you know, I was minutes away at some points.

And I knew, if I went looking, I could find it guaranteed.

- The drug has a strong pull, and it's very short-acting, and it wears off quickly.

It's almost perfectly designed to get addicted to.

- [Breanna] Dr. Deborah Rose prescribed Courtney a monthly time-released medicine that provides a replacement simulation to the brain.

- I firmly believe that a period of medication-assisted treatment or medication for opioid use disorder is essential.

I think the drug cravings are too strong.

- You know, I get my shot once a month, and I don't see her or even think about it in between that time.

(gentle music) It just keeps me from feeling that sickness.

- [Breanna] After counseling, group therapy, and a lot of personal strength, Courtney now realizes she can be part of the solution.

She's now a full-time college student, taking classes that will allow her to one day be a counselor, helping others overcome substance abuse.

- I know it's gonna be worth it.

I see it on my counselor's faces with me.

So yeah, that's gonna be amazing.

To change even one person's life is gonna be amazing.

(somber music) - [Breanna] But with fentanyl, second chances are few and far between.

More often, it leaves families, like Charlie's sisters, fractured and forever longing for their loved one.

- This is a really serious problem.

And now we have to live the rest of our lives with a lot of questions, and also just with a lot of sadness.

- We just miss him every single day.

- [Breanna] For "Impact," I'm Breanna McCabe.

- Smugglers bring fentanyl into Montana every day using vehicles and the US mail system.

Attorney General Austin Knudsen says that makes it challenging for law enforcement to cut off the supply.

(logo whooshes) - It's frustrating, right?

I have neither the constitutional power nor the logistical resources to stop every out-of-state car that comes into the state.

We have to have a legal justification to do that.

And then we have to have a legal justification to, you know, run a drug canine around that car and, you know, hopefully get a good search warrant and a good stop.

But we've got hundreds of thousands of miles of road in this state.

We're a very rural state.

It's a very large state.

There's 240 highway patrol troopers, and they're not all working at the same time.

You know, half of 'em are sleeping usually (chuckles), while the other half is working.

So it's a logistical problem from a law enforcement stand standpoint, really.

- When you speak to families who've lost someone, what is your message to them?

- Well, it's incredibly difficult.

You know, I think probably the worst one I had is I talked to a grandmother in Poplar, which is in my home county, she had lost both of her sons to fentanyl in two separate overdose incidents.

And she's now raising her grandchildren.

That's heartbreaking.

I mean, what can I say to someone in that position?

My message to parents, to grandparents, to teachers, to school administrators, and to kids, frankly, I mean, I travel around a lot, and I talk to as many high school and junior high kids as I can, and it's always very well received.

But I mean, my message to those kids is if it didn't come from your pharmacist, out of a bottle with your name on it, don't take it.

You don't know what's in it, you don't know where it came from.

And I mean, even an aspirin from a friend at school, you don't know what that is, and you can't be guaranteed that it hasn't been laced with fentanyl, 'cause we've seen that.

So that, I think, is the biggest thing we can do is try to educate kids, try to educate parents, try to educate families.

I think a lot of people in Montana think this is still a big-city problem and this isn't something that happens in Montana.

It absolutely does happen here.

It is here, and it's here in a very big way.

- The US Food and Drug Administration recently approved over-the-counter sales of Narcan.

Meanwhile, pharmaceutical companies have paid Montana millions to settle lawsuits for their role in the opioid epidemic.

The state is using that money to make Narcan more widely available in schools and public places.

11 Montana nursing homes have shuttered in the last year, and many more are barely scraping by.

A combination of increasing costs, low Medicaid reimbursements, and worker shortages have left some communities with no nursing home at all.

Lawmakers recently approved historic increases in Medicaid reimbursement, but it may be too little too late.

Montana PBS's Joe Lesar reports.

(logo whooshes) (traffic hums) - [Joe] It's 6:00 AM, shift change for the nursing staff at Valley View Home in Glasgow.

(residents chuckle) - Alex was his usual self.

He got up, on and off, every hour.

- [Joe] Each morning, the night crew briefs the day crew on how the previous night went for the skilled nursing facility's 62 residents.

- Getting her involved because she used to teach, and she told me she was one of the best.

- [Joe] And although it's the start of her shift, licensed practical nurse Kayla Young is already most of the way through her morning coffee.

She's driven 80 miles from her home in Malta.

After Hi-Line Retirement Center in Malta closed last October, Valley View is now the closest option she has to work in the field she's always been drawn to.

- I've always just loved the geriatric population.

I feel like you can get along with about anybody.

- [Joe] Stories similar to Young's have been playing out for employees and residents of nursing homes across Montana in the past year.

11 facilities, or 16% of the state's nursing homes, have closed since last April.

The closures impacted 300 residents, and 850 licensed beds were lost.

Bozeman, Missoula, and Helena each lost a facility, but the rest were in smaller rural communities.

- [Kayla] Anything else for you?

Do you want some water?

- [Joe] The closure in Malta impacted Young's career path, but it also impacted her family.

- [Kayla] I know in Malta, when it closed down, I had family in there that had to relocate.

So I know firsthand how hard it is to find that home for them.

- [Joe] Young's relative moved to a facility in Helena.

It's a 4 1/2-hour drive to see her.

- Thanks!

- [Joe] She's fortunate that she has other family in the Helena area.

- So she still has that sense of family, but it's not the case for everybody.

- I'm ready.

- Ready or not.

- Ready or not, here I come.

- That's right.

- [Joe] Leo Woods was one of the 22 residents living at the Malta facility when it closed.

He'd been there for six years.

A native of Harlem, he's called the Hi-Line home for his entire life.

- I'll split the money with ya.

- [Joe] Woods is known around the building for his positive outlook, which helped him take his move to Glasgow in stride.

Having settled in, he's quite pleased with the care he receives at Valley View.

- It's one big family.

(resident chuckles) We couldn't ask for better.

And I mean, if you want something, you ask for it, you got it, just like that.

- [Joe] That being said, the move was not a pleasant process.

- Oh, it hurt like heck because I had a lot of friends there, and I didn't wanna leave.

We had one woman, I believe she was in her 90s, she was crying, she didn't wanna go.

It really hurt her.

And then we had a patient, I'd say he's probably in his 80s, he didn't wanna go.

- [Joe] Involuntary relocation can put residents at high risk for what is called transfer trauma.

The uncertainty about where they'll go next can cause psychological and physical distress that has been shown to lead to increased depression, cognitive decline, and even premature death.

Woods is aware that Valley View is under the same stressors that caused the facility in Malta to close, and that he and his fellow residents are in a similar situation.

- [Leo] Glasgow, you've got a good nursing home, but it's gonna take more than the manager to keep it open, because he's got a lot of bills.

- 01, that's pending still.

- [Joe] Valley View's administrator, Wes Thompson, is the one in charge of making sure those bills get paid.

And since the pandemic, that's become an increasingly difficult task.

The ability for Thompson and other nursing home administrators to cover costs hinges largely on what's been the centerpiece of a years-long conversation being had in Helena.

- The Medicaid rate.

- The Medicaid rates.

- The Medicaid- - Medicaid- - Medicaid- - We're talking about Medicaid here, and I'm curious- - [Joe] The money that nursing homes receive per Medicaid recipient is determined by the state legislature.

Most nursing home residents are on Medicaid, so this rate is critical to daily operations.

Thompson's made efficiency upgrades to the building, he's raised the rate for private-pay individuals, and the Valley County residents have twice voted for mill levies to support the facility.

Even with these steps, Valley View is losing nearly $200,000 a month.

Thompson says the ability to remain open depends on the rate that this legislature decides on.

- And the only way to get there is to make more money.

And the only way to make more money is with Medicaid increase.

- [Joe] The pandemic brought on additional costs, and then inflation raised the cost of everything.

Emergency funding raised rates and helped nursing homes weather the pandemic.

But when that support ended in 2022, the rate went back down, and closures started happening.

Pleas for more short-term funding were denied.

Instead, the state commissioned the Guidehouse consulting firm to conduct a study on post-pandemic costs for several healthcare industries.

The study recommended raising the base rate per Medicaid recipient from the current $211 a day to 278.

Governor Greg Gianforte's budget proposed an increase to 249 next year, then lowering it to 238 the following year.

Legislators have agreed to give $253 for next year and 268 the following year.

Thompson's average daily cost is $360.

- When the Guidehouse study that they spent almost $3 million says this, but the governor's proposal says significantly lower, and we're still saying neither of those are anywhere close to good enough, you've got to come to the table with something for us because we will be shutting down.

- [Joe] Some lawmakers would argue that they already have.

The governor's proposal and the increase from the legislature are both historic increases to the Medicaid rate.

Some lawmakers see it as a solid starting point in helping the nursing home industry.

- We have looked at this issue, and we have taken action, and we have made quite an investment.

- [Joe] One argument for not investing more is that nursing home occupancy has been slowly declining for decades, while the use of in-home and community-based services has risen.

Governor Gianforte sees this as signaling a shift towards elderly Montanans preferring to age at home.

An emailed statement from the governor's office said, "With more seniors electing to age in place in their communities, Governor Gianforte believes the state and long-term care industry must adjust to meet aging Montanans where they're at.

To ensure there is not a gap in services as the industry shrinks due to falling demand, DPHHS is working to build up services for Montanans who choose to age at home and not move to a facility."

Matt Knierim is an attorney in Glasgow, who works pro bono with Valley View.

He says occupancy dropped rapidly during the pandemic and is now being driven by the labor shortage.

Many facilities, including Valley View, have more space, but have voluntarily lowered their occupancy because they don't have the staff to provide proper care for more residents.

- So you have to staff to prevent bad things happening to your residents, and that drives the costs through the roof.

You take less residents, that lowers the amount of income, and you get in this vicious spiral.

- [Joe] Nursing staff costs before the pandemic took up 58% of Valley View's budget, and now they take up 90%.

When the staffing crunch hit, the only option was to hire traveling nurses at rates that could be triple what Thompson is able to pay his local staff.

He's worked hard to attract and retain people, but still, 40% of his nursing staff are traveling nurses.

- [Matt] As they see these travel agencies go from, "Hey, you can make $30 an hour," to, "Hey, would you like to make $86 an hour?"

"Yes."

- [Joe] Administrators say that if Medicaid rates were higher, they'd be able to attract and retain more staff, and with more staff, they'd be able to raise their occupancy and make more money.

- And when that occurs- - [Joe] Thompson feels he's done everything the state has suggested he do, yet is still facing a significant risk of having to shut down.

- Valley View's not alone in this.

If you talk to anyone, I can assure you they're broke.

They are all broke.

We are broke.

And we're all just sweating and praying for July, to find out what the number is, because that's when we're gonna have to have the real sit-downs with all of our board of directors and say, "That's the number they gave us.

What do we do?"

- [Joe] Valley County would lose its second-largest employer if Valley View were to close.

Knierim says that in rural communities, these closings affect more than just residents and employees.

- To me, this is rural development, it's rural infrastructure.

And for people that say, "We wanna develop jobs in Montana," well, you don't develop jobs in Montana by gutting the healthcare system next to it, 'cause you can't attract younger workers here.

You can't take care of your mother, you have a family member that needs nursing home care.

To me, that's integral to making this place survive as a community.

- [Joe] Legislators on both sides of the aisle agree that action needs to be taken.

Just how much action is the question.

In the meantime, Thompson is grappling with the thought of Glasgow becoming the next Malta.

- Their continuum of health services is officially broken.

The county has a broken continuum of health services, and that's a very sad thing.

- [Joe] And Woods is grappling with the thought of having to move again, potentially away from the area of the state that he has always called home.

- It's gotta be open because we gotta have some place to go.

- [Joe] For "Impact," I'm Joe Lesar.

- This session, lawmakers stripped nearly all of the funding out of a bipartisan bill that proponents say would've adequately funded nursing homes across the state.

The bill is still working its way through the legislature.

(gentle music) That's it for this edition of "Impact."

On our next episode, (logo swooshes) Jocko Valley residents are fighting a gravel pit in their backyard.

But how much say do citizens and regulators really have when it comes to gravel pits?

And Sidney is losing a landmark.

The sugar beet factory there is closing, leaving the community and farmers retooling for a new future.

Thanks for joining us.

I'm Anna Rau.

We'll see you next time.

(gentle upbeat music) (gentle upbeat music continues) (gentle upbeat music continues) - [Announcer] Production of "Impact" is made possible with support from the Otto Bremer Trust, investing in people, places, and opportunities in our region, online at ottobremer.org; the Greater Montana Foundation, encouraging communication on issues, trends, and values of importance to Montanans; and viewers like you, who are friends of Montana PBS.

Thank you.

(logo swooshes) (bright music)