Angee Penner felt something was going on with her teenage daughter. When she got a call from one of 17-year-old Ashlyn's friends, her fear was confirmed. But it was far worse than she expected.

The phone rang while she was at work.

"Hey, Momma Ange," the friend began.

When Penner hung up the phone, she was sobbing.

She found out during the call Ashlyn was addicted to heroin. It started after her daughter had her wisdom teeth removed, then spiraled out of control.

The mom sprang into action mode. The family sent Ashlyn to an inpatient rehab center in Louisiana as soon as they could, ultimately shelling out $23,000 to keep her there for two months. Penner tried to have her involuntarily committed to no avail. She thought inpatient care was the gold standard, the best that money could buy. 

It didn't work. Ashlyn died six months ago at the age of 18, about a year-and-a-half after trying heroin for the first time, never having tried an outpatient, medication-based treatment program that experts agree should always be presented as an option to opioid-addicted patients.

The regimen includes a combination of counseling and a drug, such as methadone. Those drugs, which are also opiate-based, stave off withdrawals and cravings and help patients wean off the more dangerous varieties. Outpatient, medication-based treatment is less expensive than inpatient rehab and works for some patients because it allows them to fight their addiction in their own community. 

But Penner said her daughter was never offered the possibility of medication-assisted treatment. 

"I would have baby fed it to her on a spoon," Penner said. "I would have driven her to the methadone clinic every day."

In the debate over how to deal with one of the most severe drug epidemics the country has ever seen, families are left with some of the most difficult choices of all. Private rehab centers can offer an alluring pitch, promising recovery in a safe environment, albeit for a price.

Somewhere in the mix, medication-assisted treatment can be shunted aside despite its positive results, said Sara Goldsby, the director of the state's Department of Alcohol and Other Drug Abuse Services.

It's not that inpatient treatment is never a good option, experts say, but if opioid-use disorders were treated as a disease instead of a moral weakness, all of the options would be laid out for patients to choose.

Having a choice is important, said Julie Cole, executive director of the recovery-focused Courage Center.

That being said, Cole said she has many friends who are alive because of medication-assisted treatment. And as would be the case for patients with diabetes or any other chronic disease, clinicians should suggest the lowest-intensity option first before considering more drastic treatment.

Inpatient vs. outpatient

When it comes to inpatient rehab, it is not only abstaining from drugs far from home that can be intense. The costs of inpatient, abstinence-based treatment are increasingly a burden, too.

Outpatient treatment cost private insurers less than inpatient treatment in 2016, according to a report released April 5 by the Kaiser Family Foundation. 

For people with employer-based health insurance, it broke down like this:

  • For inpatient treatment, the average total cost in 2016 was $16,104. Patients paid an average of $1,628 of that themselves, out-of-pocket. The foundation reported there has been a steep rise in the cost of inpatient care as the epidemic has worsened — it cost $5,809 in 2004.
  • The average total cost of outpatient treatment in 2016 was $4,695. Patients paid an average of $670 out-of-pocket.

Goldsby said many families come to them feeling convinced their loved one requires inpatient treatment.

"A lot of people have this perception they need a bed," she said. 

She sympathizes. Addictions are ugly. Families are maxed out. For Penner, dealing with her daughter's addiction became a full-time job.

Ashlyn was always her princess. The first time her mother had to tell her she needed to leave the house, Ashlyn was at her vanity, putting lotion on her face. Pink fuzzy slippers covered her feet and she was wearing a bubblegum-colored bathrobe. 

Penner thought that would be the worst it would get. She was wrong. 

"I was ready to start talking about prom, graduation, college," Penner said. 

Instead, Penner watched as Ashlyn repeatedly chose heroin over her family and her future.

Ashlyn told her mother she wanted to have the motivation to beat heroin as much as Penner wanted it for her. Her mother said there was always a place for her to come home if she was clean, but Ashlyn has a younger brother she had to worry about, too.

In the months she was able to stop using, Ashlyn admitted she was always thinking about the drug.

'A long journey'

Caitlin Kratz, opioid treatment program administrator with the county-owned Charleston Center, explained how addiction is a disease that hijacks a person's ability to make decisions.

Kratz said stigma still keeps people from opting for methadone or other drugs.

The Charleston Center has inpatient programs, but they are for people with disorders who can't abstain from drugs, and for mothers who are pregnant or who have children.

Even when people finish inpatient treatment, there needs to be outpatient care in place once they return home, Kratz said.

"Just sending people away and thinking it’s going to be fixed is kind of a falsehood," she said. "It's an ongoing process and I don't think (people) see that."

Good outpatient treatment is based on the core idea of building up patients' resistance to the triggers of their daily life. And when people do medication-assisted treatment on an outpatient basis, they can continue to work and be a part of their families.

Kratz said the marketing pitch that some inpatient centers offer is a problem. They may promise a cure to addiction where there isn't one. Kratz said addiction is a lifelong disease and that medication-assisted treatment will be appropriate for about 90 percent of the Charleston Center's opioid use disorder patients.

Jerome Tilghman, executive director of Berkeley County's Ernest Kennedy Center, has to send patients to the Charleston Center or to local doctors if he wants to recommend medication-assisted treatment.

There is a shortage of doctors who will offer it, Tilghman said. So even in cases where the treatment is considered the best option, it is not always easy to coordinate. 

Dr. Shawn Stinson, senior vice president for health care and improvement for BlueCross BlueShield of South Carolina, was careful to say there is no single treatment that is always going to work. It depends on the patient. The insurer will approve reimbursement for both outpatient and inpatient treatment. They don't require patients to try one before green-lighting another.

"Cost would not be the prime consideration," Stinson said. "We would want them to get them the best treatment available."

However, some of the BlueCross BlueShield plans won't cover care that is out-of-state and out-of-network. This is common particularly with plans bought through the Affordable Care Act, he said. Then there are the cash-only outpatient clinics, which are also not in the insurer's network.

"This is a long journey for folks," he said. "The reality is that we end up working with people for a long time."

Part of a club

The journey ended for Penner in October when detectives rang her doorbell. She was packing to move to Ohio. It was Ashlyn’s idea — she thought a new environment might help her make a change.

Ashyln was with the wrong friends at a local motel. After her overdose, they put her on a luggage cart, wheeled her outside and called 911. Penner said police have confirmed this account, though no arrests were made.

She was admitted to the hospital as a Jane Doe, so Penner wasn’t with her when she died Oct. 5. That fact haunts Penner as she tries to work through the grief.

She is in a few Facebook groups for mothers who have lost their kids to the opioid epidemic. It has been comforting to network with other moms, to a degree.

“I’m in that club now,” she said.

One Facebook group has more than 4,000 members. Another 12,000.

She watches as every day hundreds more mothers join.

Reach Mary Katherine Wildeman at 843-937-5594. Follow her on Twitter @mkwildeman.