Every morning, the moms would gather in a circle for their daily group meeting, their babies within arm’s reach in bouncy chairs or car seats or cribs.
The significant others of the moms remained in the parking lot, waiting outside — often for hours, since the women were in no rush to leave.
After their group sessions, most of the women would cross the hallway to a spacious kitchen overlooking a play area for the toddlers. There, they chatted and fixed lunch — chili, fry bread, wild rice soup, lasagna — while keeping an eye on the kids.
The single-story, wide-planked building on the White Earth Reservation in northern Minnesota was the first home for a one-of-a-kind addiction treatment program for Native parents. At the time they arrived, many of the 30 or so women were not only struggling with opioids but also legal problems, financial stability and child custody issues.
It was here that Julie Williams, a former substance-abuse case manager, launched the Maternal Outreach and Mitigation Services (MOMS) program in 2015.
But that title suggests a fixed plan, an established program. In fact, Williams developed MOMS through her own observations and innovations. She was unwavering about the mission: to give a second chance to White Earth parents with opioid-use disorder.
Inevitably, during those early group sessions, Williams would end up with at least one of the babies in her arms.
“I think people want to think that these amazing moms don’t love their kids because they can’t stop using,” Williams said. “And there’s nothing further from the truth.”
Today, these women can reminisce from a sleek, new building a few miles north of the program’s original home. They’re many years sober now; so are their partners, who were eventually invited to join the program. The women work as counselors and treatment coordinators, continuing to expand the community they built during their recovery. (Though this story focuses on the moms in MOMS, everyone made a point of emphasizing the program’s success at supporting Native partners as well.)
The women are willing to share their journeys to improve life for their families, although they’re also wary of media that hasn’t always accurately portrayed Native American experiences and history. The disproportionate effects of the current opioid crisis aren’t an expression of bad luck. The disparities reflect almost two centuries of destructive government policies, cultural deracination and forced family disruption.
Over the course of a day in Naytahwaush last summer, the women told me their individual stories. Revisiting the dramatic circumstances of their past lives brings tears, but also laughter and inspiration.
As Dr. Cresta Jones, an addiction-medicine doctor, often tells her University of Minnesota Medical School students, “The best expert in a person’s addiction journey is that person.”
Opioid addiction has wracked many communities in Minnesota — but none more so than the Native community. In 2023, Native Americans in Minnesota were at least 22 times more likely to die from opioid overdoses than white people. That’s the worst such racial disparity in the United States.
Addiction discrepancies are rampant, too: 7% of Native women who gave birth in Minnesota in 2023 had opioid use disorder, compared to less than 1% of the overall state population.
In the past few years, Minnesota has begun to recognize the unique challenges involved in treating pregnant people and new mothers. Recently, the state health department awarded about $24 million to about 20 different organizations, including White Earth.
The state said the grants of $40,000–$300,000 each prioritize “culturally specific interventions and prevention programs with population and community groups in greatest need, including those who are pregnant and their infants.”
But those grants come after years of limited funding and insufficient treatment options. Although Native Americans have a legal right to health care, as part of historical treaties with the federal government, the Indian Health Service has been chronically underfunded and understaffed.
Many factors are to blame for keeping Native parents out of treatment, including a lack of capacity, geographical distance, and a disconnect with the everyday lives and traditions of Native people.
The culturally specific program that grew organically on White Earth treats Native parents — mostly people in their 20s and 30s — who have struggled with opioid use (along with other substances, including alcohol). It serves any pregnant or postpartum parent with substance problems who can get there. Some participants come from 60 miles away. By the time these parents arrive at MOMS, their substance use has often led to significant problems with employment, housing and child custody.
The MOMS program has achieved remarkable results. And, statewide experts say, it may suggest new directions and strategies for other distinct communities seeking to develop successful opioid treatment programs.
Pregnancy poses unique challenges — and opportunities for treatment
The White Earth Reservation spans about 1,000 square miles north of Detroit Lakes and south of Bemidji — a landscape, where corn and soybean fields meet forests and lakes. Since an 1867 treaty, the land has been home to White Earth Nation. The reservation includes the towns of Naytahwaush, Mahnomen, Rice Lake, Elbow Lake, and White Earth: hamlets that range in size from hundreds to about 4,000 people. About half the reservation’s population of 9,726 is Native, primarily Anishinaabe. (In its official history, White Earth uses the designations Chippewa and Ojibwe, depending on the context.)
Forced relocation and compulsory Indian boarding schools stripped Native children here of their language, culture and families. Several generations later, the consequences can be seen in the poverty rate in Mahnomen County, which hovers around 20 percent. The unemployment rate is one of the highest in the state; the median income is the absolute lowest.
Another consequence is the trauma that has been passed down to the current residents of White Earth Nation. Addiction often increases with poverty and trauma, and White Earth is no exception. More people use opioids here than in surrounding counties. The five-year death rate from opioid overdoses in Mahnomen County has been roughly 30 times higher than in the rest of the state.
“Everyone here is affected by addiction in some way, shape or form,” said Teah Lovejoy, one of the moms who went through the White Earth program.
When Julie Williams and nurse Mina Spalla started the MOMS program with the support of the Tribal Council, their goal was simple: to help people. And, as a tribal member and resident of White Earth Reservation, Williams knew the success of any program would hinge on trust, relationships and some practical matters.
Starting with those broad parameters, Williams created a comprehensive, individualized treatment program — what’s now referred to in health-care circles as low-barrier, medication-assisted treatment for opioid-use disorder.
Williams has never struggled with addiction herself, but she understood the challenges faced by new and future parents who are using opiods.
For example, the fear of losing custody often prevents Native pregnant women from seeking prenatal care. In 2019, over a quarter of the children in foster care in Minnesota were Native American, even though fewer than 2 percent of the state’s children were Native — again, the worst such disparity in the United States.
Many believe that the current foster care system is a continuation of the forced assimilation of boarding schools. Child welfare policy in this community has instilled fear in parents of losing more than language and cultural traditions; they fear losing custody of their children.
“That fear gets passed down to new generations; the possibility of foster care triggers that generational trauma,” said one of the mothers, Lacy Armstrong.
Some women hide their pregnancies for months out of shame and fear. Others simply avoid the health-care system during pregnancy, missing important prenatal appointments. Some quit taking opioids in the days immediately preceding birth, so they can check in to the hospital “clean.”
Soon after starting MOMS, Williams decided to try to improve relationships with Child Protective Services, hoping to alleviate some of that fear. She invited county employees to a conversation, and explained that recovery often involves relapses. When parents aren’t scared and ashamed, they often remain committed to the program and recover, she explained.
“It became a pretty good partnership, and I think it’s been super successful,” she said.
MOMS was different in other fundamental ways, too.
Most treatment programs have fixed timelines for recovery. Programs force patients out after just a month or two. Because most people struggle when they return to their previous environments, Williams believed people at White Earth would fare better if they could pursue treatment in the community where they lived and keep going as long as they needed.
“I think people go into treatment and it’s so quick, like, 90 days? 30 days? 60 days? And boom, you’re graduated? Are you kidding me?”
Julie Williams
“I think people go into treatment and it’s so quick, like, 90 days? 30 days? 60 days? And boom, you’re graduated? Are you kidding me?” Williams said.
She also wanted treatment to be convenient, located where people could go home to their own families and beds, with childcare and mental-health services in the same building.
At the request of participants, Williams quickly opened the treatment program to significant others and partners who were also Native. And the meetings were infused with Native culture and context, from smudging to education on the historical context of addiction.
Coming for group therapy on Christmas
It worked: The first MOMS women came seven days a week — even when they had to hitchhike to get there. Even through blizzards, and on Christmas and Thanksgiving.
“They asked for group [therapy] like every single day and that was unheard of,” Williams said. “They thrived on that. And I think that’s what made us successful; that’s what made them successful.”
The MOMS treatment space became such a safe haven that some of the women never left.
Its reputation grew in the community. Soon, people started calling who weren’t pregnant or new moms. Some women pledged to get pregnant in order to be eligible. (Today, there’s an associated program for non-parents.)
Williams declines to discuss the finances of the program, but the MOMS program grew steadily through 2019, a time when fentanyl arrived in Minnesota. As the potent drug started contaminating most of the illicit drug supply, demand for treatment far outpaced supply.
When the COVID-19 pandemic hit, in-person participation levels dropped as treatment options moved online.
Now, with numbers back to pre-pandemic levels, about 50 patients are enrolled in MOMS. They come through referrals by their doctor, a court, a probation officer, or an inpatient treatment facility. Some participants come on their own.
The program operates from its new building with the same principles and a more flexible format: Treatment includes three-hour group sessions, three times a week. Patients also meet weekly with a counselor, one-on-one, and take daily maintenance medication.
Participants can choose from individual therapy and mental-health therapy options, as well. Child care is available in a kid-friendly room outfitted with low tables and chairs, a plastic slide and a basketball hoop. Patients still help determine how long they stay.
Outcomes and lessons learned
Since 2015, about 40 people have gone through the MOMS program; about 70 individuals have participated in a partner program that is not specific to parents. Williams doesn’t like the word “graduate,” because opioid-use disorder is often a lifelong disease and most patients remain on maintenance medication indefinitely.
“It’s a disease I’m living with the rest of my life,” said A.B., one of the moms who went through the MOMS program and who asked to be identified by her initials.
Williams wishes that more people would think about Suboxone and methadone, the two primary maintenance drugs for people with opioid-use disorder, the same way they think about insulin for diabetes. Many long-term diseases require long-term medications.
The women and partners I interviewed are all sober, employed, and taking care of their children: These are typical outcomes for the program, though much less common in the wider world of opioid treatment. In the years before MOMS, about 48 babies born to White Earth moms were taken away from their parents in the hospital and sent to foster care, Williams said. That practice ceased after MOMS launched, she said.
Research supports the benefits of low-barrier treatment like MOMS: More people remain engaged with recovery and fewer return to using street drugs. Program participants make fewer trips to the emergency room, too. Those benefits make the programs cost-effective, according to the Substance Abuse and Mental Health Services Administration.
Flexibility and individualization — hallmarks of low-barrier treatment — can be critical to a patient’s success, said Dr. Jones, the addiction-medicine doctor at M Health Fairview with expertise in tailoring treatment to women. At MOMS, that’s evident from listening to the women who wanted to invite their significant others to the program, she said.
“It makes me so happy that the women are empowered to speak up and the program responded,” Jones said.
Over the years, the MOMS program has shared ideas and advice: A Minneapolis program called UMOMS was modeled after the White Earth effort. But there aren’t nearly enough community-centered programs for pregnant people and new parents, Jones said.
“I wish we had options like this all over the state,” she said.
Public perception increases the challenges in developing such programming. People suffering from opioid use disorder face more stigma than people with other diseases. Pregnancy further escalates negative perceptions.
Lacy Armstrong, one of the moms who went through the program, recalls those critical voices:
"Oh my God, you’re pregnant and you’re using?!”
But pregnancy can actually be a good time to start treatment, Jones said.
Most people don’t understand the best medical practices for pregnant people with opioid-use disorder, Williams said. The American College of Obstetricians and Gynecologists recommends medications — buprenorphine and methadone — for most pregnant moms who are using opioids. Medical experts don’t suggest that mothers try to quit cold turkey. Babies have better health outcomes when their moms are taking maintenance medications.
And since most women come into contact with the health care system during pregnancy, Jones said, providers have the opportunity to encourage treatment. If women feel safe and welcome, many will opt in, she said.
“Honestly, these people, these amazing women and men who come through these doors every day, they work hard,” Williams said. “Granted, it’s not going to work for everybody. They have to want it. And a lot of people relapse as well, but they still come through it.”
Read their individual stories here.
The series is part of a reporting fellowship sponsored by the Association of Health Care Journalists and supported by The Commonwealth Fund.
