The first time Toni Fernandez got high off opioids, the pills were stolen from a little orange bottle in a friend’s parent’s medicine cabinet. She was in the seventh grade, growing up in Alamosa, the region of Colorado flooded with the most prescription opioids during the height of the opioid epidemic.
“One of the kids in our school, I guess his dad was prescribed large amounts of narcotics,” Fernandez said. “And he would just bring them and share them with us.”
Alamosa, in the high-desert basin of the San Luis Valley, was flooded with more than 17 million prescription pain pills between 2006 and 2019, equating to 77 pills per resident per year. Two worlds coexist in the quaint rural town. In one, children play in the park next to the Rio Grande while neighbors wave hello to each other along Main Street. In the other, a mass dumping of opioids has led to life-altering addictions that have broken families, devastated bank accounts and left some without homes.
Fernandez found herself living in the latter world. At 21 years old, she was prescribed Percocet and Valium for a back injury. Once the pain resolved, she continued to chase the euphoric high the pills brought her.
“Living the fast life, doing drugs, selling drugs, all the things — that was just the culture,” Fernandez said.
From there, Fernandez struggled through years of addiction, moving to meth and heroin when pills sold on the street got too expensive.
In 2020, Fernandez sought medical treatment for her addiction, accessing Medicaid, the federal government’s health insurance program for the poor and disabled, to pay for drug treatment that played a central role in her journey of recovery.
“For the first two and a half years of my recovery, I was using a Vivitrol shot, which was like a godsend,” she said, referring to a prescription drug used to treat addiction by blocking opioid receptors and reducing cravings.
But these days, the passage of Medicaid cuts under the Trump administration may make the treatments that helped turn Fernandez’s life around inaccessible to the many still struggling in Alamosa and throughout the valley. Under new work requirements and federal funding cuts, those in need of costly treatments for their addictions may face insurmountable financial barriers.
Without insurance, treatments that help curb withdrawal symptoms like Vivitrol cost around $1,000 to $1,500 per monthly injection. Suboxone, a similar treatment, costs between $150 and $500 for a 30-day supply. For someone in Fernandez’s situation, accessing these treatments without any form of insurance is nearly impossible.
“We have some of the poorest counties in Colorado, and then you add that substance use disorder on top of it (and) the lack of being able to work,” said Melissa Dominguez, a nurse and lifelong resident of the valley. She is a member of the Colorado Opioid Abatement Council who spends her time connecting people struggling with substance use disorder to recovery resources.
“It’s just not really attainable for them to be able to go to the pharmacy and pick up their script and pay a couple hundred dollars every week, or even once a month,” Dominguez said.
Cutting holes in the safety net
The budget reconciliation bill, passed in July 2025, cuts federal funding for Medicaid by 15% over the course of 10 years. Additionally, new Medicaid provisions planned for 2027 will require nondisabled adults under the age of 65 who are childless or the parents of older teenagers to prove that they are working, volunteering or attending school for at least 80 hours a month.
While people with substance use disorder are explicitly excluded from the work requirements, there are no written guidelines within the provisions that define how individuals can prove their exemption.
According to Deborah Steinberg, a senior health policy attorney at the nonprofit Legal Action Center, these cuts will have dramatic consequences for substance use disorder treatment.
“We know that any cuts, whether it’s to eligibility categories or to benefits, are just going to make treatment less affordable and less accessible,” Steinberg said. “For a lot of providers, Medicaid is also their largest revenue source so it means that some providers might close.”
There is also no standardized way states will implement the exemptions or define substance use disorder, Steinberg added. She worries that many people who would qualify for an exemption for their substance use disorder could fall through the cracks and lose coverage without a formal diagnosis.
“We’re going to miss a lot of folks,” Steinberg said. “I fear these exemptions are just not going to be enough to actually protect people as they were theoretically intended.”
The Colorado Department of Health Care Policy and Financing estimated that the implementation of these work requirements would affect 375,000 Coloradans.
And while crackdowns by the Drug Enforcement Administration have reduced opioid prescriptions, street drugs like heroin and fentanyl are becoming new vices for people formerly dependent on their doctor-approved medications. Dominguez said many of her patients were first prescribed opioids for pain then were abruptly cut off, prompting them to move on to illicit drugs.
When her prescriptions ran out, Fernandez felt she needed to fill the void. She stopped showing up to her job as a certified nursing assistant and began working different jobs — often waitressing — to earn quick money. In 2013 she began using heroin and, that same year, became pregnant with her youngest son. From there, Fernandez was in and out of jail, stealing to support her addiction.
“People think of being a mom and being an addict, that we love the drug more than we love our kids, which is never the case,” Fernandez said. “It’s just all the trauma that’s surrounded our circumstances that keeps us there and we just don’t see a way out.”
As a high schooler, Fernandez had a 4.0 GPA and received multiple acceptance letters from universities. But, she said, substance abuse was normalized by her parents throughout her youth. When she was 17 years old, her father, who struggled with a dependency to alcohol and cocaine, died by suicide. Addiction was always in close proximity, so Fernandez followed the paths carved out by the generations before her.
“I call it valley-minded because we just don’t see outside of it,” Fernandez said. “I had never had anybody in my life show me that there was something bigger than what was here.”
Judy McNeilsmith, the director of operations and program services at La Puente, a nonprofit organization in Alamosa, said that it’s difficult to break habits and escape social groups that encourage substance abuse in the small, rural communities sprawled across the valley.
“You can’t live in a rural area without going to the grocery store and seeing somebody you know so it’s really hard to break those patterns,” McNeilsmith said.
Stopping a destructive cycle
At La Puente’s homeless shelter, on a quiet Saturday afternoon, employees serve bolognese pasta, mashed potatoes and bread. People eat their meals by a box full of Narcan, a nasal spray used to reverse opioid overdose, that is free to take. Many of the people at the shelter, McNeilsmith said, have struggled or are actively struggling with substance use disorder. She said that some people lost their homes after struggling with addiction, while others have stories that reverse that order.
“It’s kind of like the chicken and the egg,” McNeilsmith said. “Poverty begets crisis and crisis — you do what you can do to get money.”
By 2020, Fernandez had enough. She was in jail for drug charges and her kids were nearing the age she was when she tried her first prescription pill. The fear that they might repeat the same cycle that was drowning her was mortifying.
“I know how old I was when I started experimenting, so that kind of hit hard,” Fernandez said. “I just totally started rebuilding my life.”
Once she was released, Fernandez began her journey in sober living and, with Dominguez’s guidance, accessed the medication-assisted treatment that helped lift her from where she’d been stuck. She received Vivitrol shots for the first two and a half years of her recovery.
“It just took away the cravings and the thoughts. I didn’t like the smell of barbecue sauce, vinegar — any of that stuff — because it smelled like the heroin. And when I was taking the Vivitrol, that just wasn’t there,” Fernandez said.
Fernandez accessed these treatments through Medicaid. Without it, she said, she likely would not have been able to receive them and doesn’t know what her alternative treatment paths could have been. She actively works as a recovery coach for Hard Beauty, a nonprofit organization that offers peer support to those struggling with or recovering from addiction. Her clients, Fernandez said, also rely on Medicaid to pay for her coaching services.
McNeilsmith worries that Medicaid cuts will decimate the health care services for those in recovery across the valley. Approximately two in five residents in Alamosa County rely on Medicaid, and, for hospitals and treatment centers in the region, Medicaid makes up a significant portion of the payments they receive. If people lose their Medicaid coverage, these institutions will not get that money. McNeilsmith worries that with some residents losing their Medicaid, local hospitals could face devastating financial strain and be forced to close.
“We are a high-poverty area and adding those additional requirements is going to really impact the safety net and have folks with no resources,” McNeilsmith said.
New hope in the valley
One of these resources is a new detox and rehabilitation center that just celebrated its first anniversary in July.
The center opened with some help from the projected $880 million in opioid settlement funds paid by pharmaceutical companies to the state of Colorado following lawsuits over their role in the opioid crisis.
South of Main Street, nestled between railroad tracks and the Alamosa County Jail, is the aptly named Hope in the Valley. Its staff describes it as the only full-scale treatment center with withdrawal management in the San Luis Valley. Community members say it brought much-needed support to the area. The long one-story brick building is split: one side is a detox with a 10-person capacity and the other is a residential treatment program that houses up to 15 patients.
On the rehabilitation side, residents take part in a ceremony for two individuals who will soon be graduates of the program. David Herrera, the center’s community engagement coordinator, shares his favorite stories of the two residents as the room bursts into chuckles. Herrera expresses excitement that, with one of the graduates gone, he will now be the funniest person at Hope in the Valley again. The room joins hands in prayer for the two and wishes them well in their recovery journeys outside the brick walls.
Herrera himself struggled through addiction. In the backyard of the facility — which for now is just asphalt, a chicken coop, some chairs and a basketball court — Herrera says he wants to build a labyrinth for residents to walk through, a representation of the addiction and recovery process he found himself in. Herrera sought treatment for alcohol addiction in Estes Park and said that when he told his case manager he would be moving on to the valley, she expressed hesitation.
“She just said, ‘David I’m going to be honest with you. There’s not a lot of resources down in the valley,’” Herrera said. “This was only two and a half years ago.”
At that time, Herrera said, there were only about four Alcoholics Anonymous meetings a week in Alamosa. But now there are daily recovery meetings hosted by Hope in the Valley that are open to the public. According to Herrera, this shift has been needed.
“The psychological defeat from the opioids has been devastating to our community. You have people that have lost family members to this addiction — moms and uncles and dads and the whole thing,” Herrera said. “And you hear it all the time, but it’s very real here.”
Fernandez, who helps lead peer support groups at Hope in the Valley, witnessed many of her acquaintances and loved ones from her youth, including her own brother, fall victim to addiction.
“A lot of us are not here anymore,” Fernandez said.
However, Fernandez and Herrera say, because of the opening of the center, there’s more local support for people struggling with addiction.
“The first time I went to treatment, I had to go to Pueblo,” Fernandez said. “And now this treatment center has built more of a community — which I love — for all of us, not just the people that have been here.”
This community is also reliant on Medicaid. Most residents, Herrera said, use Medicaid to access Hope in the Valley’s detox treatment, 30-day residential program, any necessary hospitalizations, intensive outpatient treatment, telehealth services and medically-assisted treatment.
On a brisk Saturday in November, outside Milagros Coffee House, a focal point of downtown Alamosa, a small number of protesters gather, holding signs reading, “Medicaid protects your family” and “Unite and resist” as cars pass through the intersection.
McNeilsmith says, given the impact cuts in government benefits would have for many valley residents, the community has been protesting for health care access and rallying around food drives. This community-based activism and support is not well-recognized by the rest of the state, according to Dominguez.
“A lot of times I feel like up north they don’t see the community that we do have here,” Dominguez said. “Compared to Denver, compared to Greeley, we don’t have half of some of the resources that they have. But the resources we do have, we work really hard to connect with each other and get people connected to the resources that are going to be best for them.”
Fernandez is grateful for this community and with its backing, she’s been able to raise her kids in a healthier environment. Instead of experimenting with prescription drugs, they play basketball at the local recreation center. Still, many of the people and resources in this environment rely on Medicaid, and cuts could make the already precarious and difficult process of recovery more so.
“I think there would be people a lot worse off,” Fernandez said. “To cut somebody off their medication — people are just going to go full blown back into addiction.”