Thirty-three-year-old Whitefish resident Melanie Seefeldt has decided to stop drinking before. But, like many Montanans, Seefeldt knows a core truth about alcohol addiction. Wanting to stop is the easy part.
For many, the excruciation comes later. When she prepares to extricate alcohol from her body, Seefeldt ticks through a very short list of strategies.
She can taper her alcohol intake on her own, with the hope of avoiding the deliriousness, tremors and blackouts that can accompany withdrawal. She can find a doctor willing to prescribe take-home medications to manage her symptoms, or an inpatient rehab facility that takes her insurance.
If those options don’t pan out, she could also turn to the nearest hospital emergency department. But past experience has taught her a painful lesson: If her symptoms aren’t severe enough, she might be turned away.
Seefeldt, a mother and small-business owner, has tried most of those avenues before, over years of trying to control her addiction. She’s achieved long stretches of sobriety that improved her health, stabilized her life and helped her parent her young son. But, too often, Seefeldt has found Montana’s alcohol detox landscape deeply inadequate for the disease she lives with, amounting to an obstacle course full of trap doors, holding patterns and dead-ends.
“I’ve personally dealt with that struggle — needing to stop and not knowing where to go,” Seefeldt recalled. “You can feel so fucking stuck, and also ashamed.”
By now, Seefeldt knows which parts of the health care system might help her bridge the daunting initial gap between drinking and sobriety. But she has also continued drinking when the hurdles to detox and treatment have felt too high — especially the prospect of enduring hours and days of physical distress sparked by the absence of alcohol.
In an October interview, Seefeldt recounted a friend’s recent reaction when facing those withdrawal symptoms — a circumstance that Seefeldt has also experienced firsthand.
“She couldn’t get through it,” Seefeldt said. “So she started drinking again.”
Federal estimates from 2019 put the occurence of alcohol addiction in Montana , affecting almost 8% of the state’s population over 12 years old. That figure is similar to the regional average for states in the Rocky Mountain West but higher than the national average. Other survey data collected from 2019 to 2020 showed more than alcohol in the last month, a figure about seven percentage points above the national average.
Public health researchers point to chronic and heavy alcohol use as a significant contributor to long-term health consequences, mental health crises, alcohol-fueled injuries and preventable fatalities. Montana state health data from 2023 tabulated that 41 deaths per 100,000 residents were alcohol-related — a category that includes causes ranging from liver disease to alcohol poisoning. That rate was more than twice that for deadly drug overdoses and motor vehicle accidents in the same year.
In a grim twist, medical experts also describe alcohol as one of the most dangerous substances a person can stop using. For people with a history of high-volume use, can cause seizures, severe vomiting, tremors, hallucinations and even death.
While alcohol’s long-term health dangers and withdrawal risks are well-known among medical providers, Montana’s fractured health care landscape makes it exceedingly difficult for people in Seefeldt’s shoes to take the key initial steps toward sobriety.
Only a handful of facilities in the state are licensed to provide medical detoxification, or “withdrawal management,” a designation that allows providers to admit and treat high-risk patients in the first hours and days of withdrawal. Just two of those facilities accept Medicaid, the health insurance program that makes treatment available to tens of thousands of low-income Montanans. And while primary care providers can help some patients monitor alcohol withdrawal at home, stigma and a lack of training among medical practitioners about alcohol addiction often create more barriers than open doors for struggling patients.

“Ideally, everyone who is going through withdrawal should be monitored,” said Jacqueline Towarnicki, a nurse practitioner in Missoula who treats alcohol use disorder. “But that’s just not the reality.”
Some Montana medical providers, including Towarnicki, are working to pave over the pitfalls patients face on the road from alcohol use to sobriety. In November, the Montana Primary Care Association held a two-day training in Bozeman specifically about effective treatments for alcohol use disorder. But without the state increasing financial incentives for providers and intentional coordination between treatment facilities, many experts say the current medical gaps will continue to fail patients in need.
BRICK WALLS OR OPEN DOORS
Looking through the lens of a past relapse, Seefeldt can describe the barriers Montanans might face when they decide to stop drinking.
Inpatient rehab is an option, but it comes with tradeoffs, including putting life at home on hold for weeks and traveling across the state. Can she afford to step away from work for that long? If Seefeldt instead chooses to try to ride out the waves of debilitating nausea, shakes and headaches at home, how sick does she have to become before calling for an ambulance to take her to the hospital?
In some ways, lessons learned from past experiences make the decisions easier to navigate, Seefeldt said. But she is also wary of retreading dead-end routes, including frustrating encounters with medical providers.
More than once, Seefeldt said, outpatient providers have declined to prescribe her a few days’ worth of benzodiazepines, a critical medication for managing alcohol withdrawal. Because of their addictive quality and dangers when used with alcohol, Seefeldt said, she understands why some providers are hesitant to prescribe them.
Nevertheless, those denials have closed one avenue for Seefeldt to manage her withdrawal symptoms at home. Fear of another rejection has made Seefeldt wary of asking for help.
“I know exactly what I need when I’m in withdrawal,” Seefeldt said about short-term prescriptions to manage her symptoms. But finding a provider who believes her assessment is a different story, she said. “Sometimes they will and sometimes they won’t.”
Addiction treatment experts agree that finding medically supported avenues from alcohol use to sobriety can be challenging, even though effective treatments exist.
Treating alcoholism as a chronic illness akin to diabetes or heart disease has begun to be normalized only in recent decades, addiction medicine experts say, with attitudes about addiction having long cast the illness as a moral failing rather than a medical condition. Nationwide, only 2.2% of adults with recently reported alcohol use disorder said they received medications to manage the disease, according to the National Institute on Alcohol Abuse and Alcoholism.
“We still treat substance use disorders as just like, ‘other.’ Like just this other thing that’s not part of medicine,” said Dr. Melissa Weimer, an associate professor at the Yale School of Medicine and medical director of , a national project that trains medical providers about alcohol use disorder. “When, in fact, we know that it is a medical condition that needs a medical response as part of the holistic care.”
When someone is struggling with drinking, Weimer’s group advocates for a “no wrong door” approach. But in Montana, most existing addiction treatment settings are designed for people who have already gone through detox, with fewer options for those who are still using but want to stop.
“We still treat substance use disorders as just, like, ‘other.’ Like just this other thing that’s not part of medicine.”
Dr. Melissa Weimer, Yale School of Medicine associate professor and medical director of PCSS-MAUD
Tammera Nauts, a licensed addiction counselor and social worker who’s worked to expand treatment services in Montana for more than 30 years, said many medical providers believe alcohol use disorder requires specialty care in a different corner of the health care system.
“We still have people, providers, that really simply refuse to work with those patients,” Nauts said. “There are still some providers who refuse to operate in a supporting role.”
Another hurdle, experts say, is disillusionment among medical practitioners, a sense of fatigue that comes from watching patients repeatedly relapse.
Towarnicki, who helps treat patients at the homeless shelter in Missoula, tries to be an exception to that industry phenomenon. Her approach includes rooting for a patient’s progress again and again, even when they relapse.
“I call it ‘practicing.’ I tell my patients not to get discouraged,” Towarnicki said. “I never set the expectation that they’re going to fail, because that sucks, but I let people know that eventually, they will succeed.”
Without a dedicated clinic or facility in the area where people can go for supervised management of withdrawal symptoms, Towarnicki said, many patients choose to detox alone or end up in the emergency department when their symptoms escalate.
That leaves outpatient providers to do “the best we can” to support patients who want to stop using, Towarnicki said. Her strategies include prescribing patients small doses of benzodiazepines, plus daily in-person or telehealth check-ins during their first several days of withdrawal.

Towarnicki describes the approach as a calculated weighing of risks and benefits, similar to treatments for other health issues.
“The risk of somebody trying to do this themselves at home is pretty high,” Towarnicki said. “And also, the risk of them just continuing to drink every day is pretty high. So if someone is truly motivated and is sitting in front of me asking for help to stop drinking, we figure out a way to do it.”
Towarnicki and Nauts would like more primary care providers to manage withdrawal in outpatient settings. But they also endorse the importance of physical clinics or facilities where people can go to detox under supervision. More options are better than fewer, they reason.
FEW BEDS, HIGH HURDLES
At least four addiction treatment centers in Montana are licensed to treat withdrawal symptoms. Those facilities, which offer a category of inpatient care in-line with guidance from the American Society of Addiction Medicine, provide roughly two dozen beds for people who need to detox.
Only two of those locations, Rimrock Foundation in Billings and the state-operated Montana Chemical Dependency Center in Butte, accept Medicaid patients. Some providers attribute other facilities’ block on Medicaid to the state’s low reimbursement rates — roughly $300 a day per patient.
The other inpatient settings with similar licensure — Rocky Mountain Treatment Center in Great Falls and Bear Creek Wellness in Stevensville — accept patients only with private insurance or self-pay. State and federal parity laws require that private insurers cover mental health and addiction treatment similarly to medical and surgical services, but information about how much Montana health insurers pay for alcohol detox and treatment is difficult to find. A spokesperson for Blue Cross Blue Shield of Montana, one of the state’s largest private insurers, did not respond to repeated requests for information about their coverage for alcohol withdrawal.
In 2022, the state Department of Public Health and Human Services authorized a new license for facilities monitoring withdrawal symptoms — a strategy aimed at increasing services outside of inpatient settings. But the requirements for that license include hiring highly trained providers and supplying round-the-clock staffing, a threshold some addiction specialists say is difficult to achieve with low state Medicaid reimbursements and a sparse and expensive workforce.
So far, the additional license option hasn’t created more access for patients who need to detox. In December, state health department spokesperson Jon Ebelt said no facilities are currently licensed under the new designation. Another department spokesperson, Holly Matkin, said DPHHS “cannot speculate” about why providers “may or may not choose to operate” under the available licensure or don’t accept Medicaid patients.
Nauts connects the lack of services to funding and staffing limitations in a rural state. Many existing addiction treatment providers, already operating on thin budgets, would have to hire more staff to meet the state’s withdrawal management requirements, including a medical director, Nauts said.
The bench of qualified employees to meet those staffing demands, she said, “is just not something that we have here in abundance in Montana.”
FROM HOME TO HOSPITAL
When brick-and-mortar facilities or clinics for monitoring withdrawal symptoms aren’t accessible, some people decide to stop drinking on their own.
Weimer, the PCSS-MAUD director, said patients often pick that avenue after being stymied by hurdles elsewhere, or coming to believe that the medical system can’t help them.
“If you’re constantly not offered services or the way to access them is very opaque or not clear, you’re not going to access them,” Weimer said. “Instead you’re going to potentially rely on your friends or a support [group] which may or may not be medical, or have any sort of medical component.”
That tactic can underestimate the medical risks of detoxing from alcohol, Weimer said. Not everyone will have dangerous medical complications when they stop drinking — milder symptoms include headaches, nausea, sweating and anxiety. But heavier use over a longer period of time can create high-risk withdrawal effects including seizures, hallucinations and disorientation. When those symptoms arise, Weimer said, hospital emergency departments become the “de facto place” for patients to go.

Dr. Marc Mentel, an addiction medicine psychiatrist who treats patients over telehealth and at the Temporary Safe Outdoor Space in Missoula, described the relationship between patients in withdrawal and hospital systems as somewhat illogical.
Many emergency departments won’t admit someone unless their alcohol withdrawal symptoms are severe, or at immediate risk for becoming so, Mentel said. When forced to wait until their symptoms progress, patients often give up and relapse.
“The catch-22 is, ‘Yes, you have alcohol issues, but we can’t do anything until your alcohol withdrawal is so bad that will get you in.’ But typically they won’t come in because before the alcohol withdrawal gets too bad, they’ll start drinking again,” Mentel said.
Many addiction medicine specialists say hospital providers in Montana and elsewhere in the country will stabilize patients in withdrawal but then discharge them quickly. Patients, some of whom leave against medical advice, too often end up exiting care without medication to help manage lingering withdrawal symptoms, curb alcohol cravings and prevent relapse, or without a handoff to inpatient or outpatient treatment programs.
Dr. Nathan Allen, an emergency medicine specialist at Billings Clinic, said his hospital can continue monitoring patients in other parts of the hospital after their withdrawal symptoms are in check. He also prescribes naltrexone, a longer-acting medication to curb alcohol cravings, to patients leaving the emergency department.
“That’s something that I would encourage, both [for] other emergency physicians around the state as well as primary care providers,” Allen said. “To develop the clinical confidence to begin using more medications to assist patients in achieving sobriety.”
But Allen reflected that emergency physicians like himself, while on the front lines of Montana’s addiction crisis, have only so many tools at their disposal. Looking outside the hospital’s walls, Allen sees the need for system-wide improvement.

“The availability of services to assist people with addiction does not meet the scope of the challenge in Montana,” Allen said. “I will hear from patients, ‘I’m trying to get into this inpatient program and I have an appointment — in a month.’ And they’re struggling to try to figure out what to do in that intervening period of time.”
At the Connecticut hospital where Weimer works, the administration and treatment team have tried to fill at least one of those gaps in care. Patients who are in withdrawal but aren’t sick enough for hospital admission can be referred to a separate withdrawal management program “down the street from our hospital,” she said. The partnership between the two facilities lessens the burden on hospitals without letting patients fall through the cracks.
“That, of course, is an intentional thing that we have set up through collaboration,” Weimer said. The protocol also reflects a cultural posture among hospital staff that legitimizes addiction as a disease, she said. “We don’t turn people away for other medical conditions like heart attacks or stroke. So why would we turn people away for alcohol withdrawal?”
“The catch-22 is, ‘Yes, you have alcohol issues, but we can’t do anything until your alcohol withdrawal is so bad that will get you in.’ But typically they won’t come in because before the alcohol withdrawal gets too bad, they’ll start drinking again.”
Addiction medicine psychiatrist
Dr. Marc Mentel
Cultural change isn’t easy, but it is possible. Kara Howard, a nurse practitioner in Butte, said local medical groups have built relationships between services for people addicted to opioids, developments that arose from a growing awareness about opioid addiction and treatment.
Hospitalized patients with opioid use disorder are often started on suboxone — a drug that helps counteract cravings — or provided with transportation from the emergency department to a local treatment facility, Howard said. Those protocols are meant to prevent relapses after patients leave the hospital, a high-risk time for fatal overdoses.
But, compared to opioids, alcohol use is “culturally ingrained” in Montana, Howard said. “It’s just what we do. And so people don’t see it as a problem that needs treating.”
Howard described those resources for opioid-addicted patients as “bridges to care.” But when it comes to alcohol addiction treatment, she said, “there is no bridge.”
‘WANTING TO DO IT’
Mentel has rarely met with Melanie Seefeldt face-to-face. But the psychiatrist has been working with Seefeldt for years via telehealth to manage her alcohol use disorder — a relationship she describes as one of the best she’s ever had with an addiction treatment provider.
With Mentel’s help, Seefeldt has stopped using for extended periods of time, sometimes called “remission” by addiction medicine experts. After a relapse in 2024, Seefeldt described Mentel’s response as supportive and pragmatic. He prescribed her small doses of lorazepam, a benzodiazepine, to last her a day or two and scheduled regular check-ins.
“It was the first time I had a detox like this,” Seefeldt said, adding that Mentel talked to her “every single day” during that process. “I’ve never had a doctor who’s done that for me.”
One of the things Mentel told her? “‘I just wish you had told me sooner,’” she recalled.
Mentel’s model of care for treating addiction is something he hopes will become more widespread around Montana in the coming years. Through a nonprofit treatment practice called 406 Recovery, Mentel and other addiction medicine specialists treat patients over telehealth, helping advance their recovery and safely manage withdrawal when necessary.
Mentel and his colleagues see the strength of the strategy as twofold: providing another avenue for patients who need help, and serving as a backup for primary care providers who don’t feel confident treating alcohol use disorder or other addictions.
“Most alcohol withdrawal management can be done as an outpatient,” Mentel said. “But it takes providers wanting to do it.”
That philosophy — diversifying how and where withdrawal management can happen — is in line with the latest guidance from the American Society of Addiction Medicine. The updated clinical advice says that withdrawal can be managed with telehealth consultations, primary care providers or some residential treatment settings “for all but the highest severity withdrawal.”
“The availability of services to assist people with addiction does not meet the scope of the challenge in Montana.”
Dr. Nathan Allen, emergency medicine specialist Billings Clinic
Outpatient settings specifically are often preferable for withdrawal management, the guidance explains, due to the relative affordability and availability of psychological therapy and social supports compared to hospital or inpatient settings.
“Despite these advantages, residential and inpatient settings are often considered the default venue for withdrawal management,” the latest ASAM edition says. “Outpatient settings that provide concurrent withdrawal management and psychosocial services remain uncommon despite their importance in the continuum of care.”
Montana’s state health department has historically adopted licensure rules that mirror ASAM’s treatment scale for substance use disorder. But, as of December, the agency has not updated its standards to align with the latest recommendations. In an emailed statement, Matkin said the department “is currently participating in a state collaborative with ASAM to discuss the adoption and implementation” of the latest guidance in rural states.
Nauts, who serves as part of the leadership team with 406 Recovery, said the updated ASAM guidance “just makes sense” for Montana and other rural states with limited inpatient treatment options.
“There are so many incredibly capable providers out there that can do this work,” Nauts said. “Are we ever going to have enough treatment? I don’t know. But as long as we can keep expanding this work into primary care settings … the better off we’ll be.”
On a Monday in December, Seefeldt was again at a crossroads. She had begun drinking again, a lapse she said was sparked by family challenges and mental health issues. Again, she considered her limited options.
She could temporarily uproot her life for an inpatient rehab bed in another city. Alternatively, she could try to taper her alcohol use, a route she forecasted would leave her “shaking again in a couple hours.”
Her third option, Seefeldt said, is one she doesn’t take for granted. She could again work with Dr. Mentel to ease her way through withdrawal using lorazepam and regular check-ins. She trusts her relationship with him, she said, and knows she can ask for help without judgment.
Seefeldt doesn’t know if that road, or any of the others, will help her reach long-term sobriety. But she knows she wants to try to get better — and that having one good option is better than none, she said.
“It has worked for me in the past,” Seefeldt said. “It has helped me a lot.”
This story was supported in part by a grant from The Carter Center. ԹϺ is part of the , a group of newsrooms that are covering stories on mental health care access and inequities in the U.S. The partners on this project include The Carter Center and newsrooms in select states across the country.
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