How Texas Is Trying to Stay Ahead of the Opioid Epidemic

By Robyn Ross in Features, Jan | Feb 2018 on January 1, 2018 at 9:10 am | No Comments

“What is an opioid?” clinical assistant professor of health outcomes and pharmacy practice Lucas Hill asks, scanning the faces in the Steve Hicks School of Social Work auditorium and listening for answers.

“Percocet.”

“Fentanyl.”

“Heroin.”

“Vicodin,” Hill adds. “When I got my first ‘explicit lyrics’ album when I was 10 years old, it was the Eminem CD that had a painting of broken Vicodin on it. When I became a pharmacy technician at 19, I couldn’t believe this Vicodin pill I’d seen broken in half on the front of my Eminem CD was in a huge bottle, always within reach of pharmacists, and was the most prescribed medication in the U.S. that year.”

His audience smirks at the Eminem reference and grimaces at the Vicodin statistic. The two-dozen of them, mostly social work master’s students, have dedicated 90 minutes of their Friday afternoon to learning how to recognize and stop opioid overdoses. Hill is leading the training under the auspices of Operation Naloxone, a UT-based program named after the life-saving medication they’ll learn to use.

Since 2009, the national rate of death by drug overdose has outpaced deaths from car crashes, guns, and AIDS. In 2015, more than 52,000 Americans died from an overdose, and opioids were implicated in more than half of the deaths. Add in opioid-related emergency room visits, lost productivity at work, and the strain that drug addiction places on families, and the toll on the country is even higher. In late October, the president declared the opioid crisis a public health emergency, though the announcement was not accompanied by additional funding.

The nation’s opioid epidemic is often perceived as a problem of the Rust Belt and northeastern states—and some experts say that’s a harmful misconception.

“In Texas I get pushback. People tell me we don’t really have a problem, and this would show it,” Hill says, pointing to a Centers for Disease Control and Prevention map that reveals a comparatively low rate of overdoses in the state. “But that doesn’t make sense. We’re surrounded by states we know have a high rate of drug overdose death, and we share a border with a place where illicit drugs come in. Does it all go up I-35 to other states and not here? I’ll tell you in a minute why we probably have a problem across the state—we’re just not catching it.”

***

Operation Naloxone is an effort to catch the problem early. As Hill tells the students at the training, the body naturally makes opioid-like molecules called endorphins and enkephalins, neurotransmitters involved with pain perception, in response to pain and stress. Endorphins bind to opioid receptors in nerve cells in the body and brain, inhibiting pain and sometimes creating euphoria—like the “high” an athlete feels after a long run.

Similar feelings are generated by exogenous opioids, those introduced to the body in medical or recreational settings. Morphine, derived from the opium poppy around 1800, was initially used for anesthesia and pain relief but proved addictive. It was supplanted by heroin, originally marketed by the pharmaceutical company Bayer as a less addictive alternative.

As the addictive properties of opioids increasingly affected society, federal legislation in the early part of the 20th century increased oversight and regulation, and by the middle of the century doctors used them more sparingly.

But in the 1980s and ’90s, pharmaceutical companies and patient advocates began to assert that doctors “undertreat pain and overworry addiction,” says David Ring, associate dean of comprehensive care at Dell Medical School. Doctors began to prescribe more opioids for post-surgery relief and treatment of back pain and arthritis.

In 1995, the American Pain Society advocated for pain to become “the fifth vital sign.” Every time a clinician visited a patient in the hospital and checked her blood pressure, pulse, heart rate, and temperature, the clinician would also ask if she had pain. In fact, Ring says, Medicare and Medicaid hospital reimbursement is partly linked to patient satisfaction with pain relief, which can create an incentive for prescribing more opioids, despite the availability of better alternatives.

This increased attention to pain, combined with marketing by pharmaceutical companies, led to a spike in the number of opioid prescriptions and a new mentality among doctors. “If somebody’s not getting relief from one medication, the first thing we think of is a stronger opioid,” Ring says. In fact, the morphine equivalent for the consumption of opioids per capita increased tenfold in the U.S. between 1990 and 2014.

The unnecessarily large size of some prescriptions meant people were taking them longer than truly needed, or that extra pills sat in medicine cabinets until they were raided for recreational use by someone other than the patient.

Both of those were factors in the experience of a recent UT graduate we’ll call Monica*, who has taken opioid painkillers recreationally. After severe illness and chemotherapy in 2011, she was prescribed both opioids and benzodiazepines (commonly used for anxiety and depression). She realized that when she took slightly more than the recommended dosage—maybe two instead of one, and then three instead of two—or when she took the pain pills and benzos together, she felt a physical and emotional high. “It feels like everything is OK, like you’re wrapped in a warm blanket, and you have no worries in the world,” she says. The experience led her to steal pills from her father, from her boss, and from babysitting clients, although Monica says she’s never become dependent on the pills or had withdrawal symptoms without them.

But up to a quarter of patients prescribed opioids for non-cancer pain do become dependent on them, and nearly half of opioid overdose deaths involve prescription medicine. Nationally, opioid prescribing quadrupled between 1999 and 2008—and so did opioid overdose deaths. “It was clearly a prescription-driven epidemic,” Hill says.

***

By 2011, the number of overdose deaths connected to prescription opioids began to plateau. By this time some states had implemented prescription monitoring programs, databases for doctors to check before prescribing an opioid. Texas passed a law in 2009 imposing stiffer requirements on pain clinics in an attempt to shut down “pill mills,” cash-only clinics where, without an exam, patients could obtain prescriptions for painkillers. A crush-resistant OxyContin, developed at UT’s College of Pharmacy, hit the market the next year, making it more difficult to crush and snort the drug.

But populations already dependent on opioids didn’t simply stop using them. As prescription painkillers became harder to obtain, people shifted to the less expensive and more widely available heroin. Since 2010, heroin overdose rates have more than quadrupled nationally. And use of illicitly manufactured opioids—pills manufactured overseas and sold as “OxyContin” or “Vicodin,” but often tainted with other substances, including fentanyl—has increased.

“The net public health impact of reducing the supply of prescription opioids for misuse has probably been negative in the short term,” Hill says. “We have pushed people to an illicit opioid market that is more dangerous than ever.”

Fentanyl, an opioid 50 times stronger than heroin, accounts for a growing number of overdoses. (The musician Prince died in 2016 of an overdose of fentanyl, which had been added to illicitly manufactured opioids found in his home.) Fentanyl is legally administered intravenously or via skin patches to patients with chronic cancer-related pain, but a white-powder form of illicit fentanyl manufactured in Chinese labs is added to counterfeit pills and heroin. The drug’s concentrated strength makes it economical for traffickers, because it’s relatively easy to transport in small amounts.

Last year, fewer than 5 percent of documented heroin deaths in Texas involved fentanyl, according to research by Jane Maxwell, a research scientist in the Addiction Research Institute of the Steve Hicks School of Social Work. Texas may have thus far avoided mass overdoses from fentanyl-adulterated heroin because of the type of heroin that’s dominant in Texas: black tar, which is harder to mix with fentanyl than the white-powder heroin used in the northeast. But street outreach teams say that’s changing rapidly, as more white-powder heroin enters Texas and as the industry finds ways to combine fentanyl with black tar.

Mark Kinzly has been a leader since 1988 in the U.S. harm reduction movement, which educates people who use illicit drugs about safer use, while neither demanding abstinence nor minimizing the risks. He moved to Texas in 2013 and cofounded the Texas Overdose Naloxone Initiative, which provides training and naloxone around the state. He is acting executive director of the Austin Harm Reduction Coalition, which provides clean injection equipment to reduce transmission of hepatitis and HIV. The coalition distributes test strips that detect fentanyl in heroin and other drugs. If a person knows her drugs contain fentanyl, she can decide not to use them, or use more slowly, or not use alone, in case of an overdose.

Kinzly’s group started distributing test strips in November 2016. About a third of the people who used them reported that their heroin tested positive for fentanyl. By April 2017, more than 70 percent of the heroin they tested contained fentanyl.

Fentanyl’s potency doesn’t just make it easier to transport; it sharply increases the risk of overdose. Exogenous opioids in excess attach to the part of the brainstem that manages the intrinsic drive to breathe. People die from overdose when their breathing slows to a stop, and they suffocate. Between 2010 and 2015, deaths involving fentanyl and similar synthetic opioids increased by more than 200 percent nationwide.

Compared with states like Ohio and West Virginia, Texas appears to have dodged the worst of the opioid crisis. Texas had 2,588 drug overdose deaths in 2015, a rate of 9.4 per 100,000 residents, one of the lowest in the country.

But Hill says Texas likely undercounts overdoses. Only 13 of Texas’ 254 counties enlist a medical examiner to determine the cause of death when a person dies outside of a health care setting. Other times, a doctor or a justice of the peace fills out the death certificate. State law does not require a justice of the peace to order an autopsy or toxicology  report, and in their absence an overdose death can be misclassified.

Other indicators suggest that Texas has an opioid problem. The state has the country’s highest rate of maternal mortality, which includes deaths during pregnancy and childbirth and in the year following delivery. Maternal mortality nearly doubled between 2010 and 2014, and the latest data show the leading cause is a drug overdose. Additionally, the number of neonatal abstinence syndrome cases, in which babies are born dependent on a drug, has continued to rise.

To experts like Lisa Ramirez, the Texas Targeted Opioid Response project director for the Health and Human Services Commission, these numbers suggest an under-the-radar opioid problem the state would do well to recognize.

“The misconception that Texas does not have an opioid problem is dangerous and a myth we need to address,” Ramirez says. “If we’re not prepared, the problem will definitely get worse in Texas.”

***

“Who here has a fire extinguisher?” Hill asks, watching as almost everyone at naloxone training raises their hand. He nods. “Now, keep your hand up if you’ve had to use it.” All the hands go down but one.

“I think of naloxone in that context,” he tells his students. “It’s something that should be around if you suspect that you or someone you know may be at risk, but it’s probably mostly going to go unused—and that’s a good thing.”

Naloxone reverses an overdose by displacing the opioid from the receptor cells in the body and binding to those receptors without activating them. Someone who has overdosed typically regains consciousness within two or three minutes of being administered naloxone, though Hill emphasizes it’s crucial to call paramedics. If the naloxone wears off before the opioid leaves the person’s system, he or she could go back into an overdose state.

Hill and pharmacy doctoral candidate Lubna Mazin show the group different types of naloxone: a vial and syringe; a prefilled syringe with a nasal adaptor; a nasal spray; and an auto-injector that comes with pre-recorded instructions. Mazin pops open a trainer cartridge, and a robotic voice tells her to place it against the outer thigh for five seconds. When she does, the voice counts down: “five, four,  three, two, one,” followed by a loud beep, and then, “Injection complete.”

Today’s training is one of many organized by Operation Naloxone, a collaborative effort by Hill, Kinzly, professor of social work Lori K. Holleran Steiker, and clinical assistant professor of health outcomes and pharmacy practice J. Nile Barnes. Together, they have trained all resident advisors and UT police officers on naloxone use, stocked naloxone in UT’s residence halls, and trained pharmacy, medical, and social work students to lead overdose-prevention efforts in the community.

The Center for Students in Recovery, which offers programs for students in all stages of recovery from addiction, has also hosted the training. That’s where Monica, the recent UT graduate, took the class. She left with a new awareness that mixing opioids and benzodiazepines was risky behavior she should abandon. And she left with her own auto-injector cartridge, a precaution for a friend who regularly uses heroin.

The Texas Legislature passed a law in 2015 making naloxone available to Texas pharmacy customers over the counter. A physician signs an agreement called a standing order so that the pharmacist can dispense the drug at his or her discretion. Pharmacists also can sell the drug to a third party: a family member or friend of someone who uses opioids. But not all pharmacists are familiar with the rule, and not all pharmacies keep naloxone in stock.

So Operation Naloxone offers online continuing education programs for pharmacists, prescribers and social workers. And Hill and Holleran Steiker are expanding overdose response training and naloxone distribution throughout Texas with a $1.2 million boost from the federal government, part of a $54.7 million grant made to the state last year by the Substance Abuse and Mental Health Services Administration. That grant, called the Texas Targeted Opioid Response, is an attempt to curb the opioid epidemic by expanding both prevention and treatment services.

For example, Texas has only 85 licensed providers of methadone, considered the gold standard for medication-assisted treatment. For many people with opioid use disorders, counseling and 12-step programs are not sufficient to address the physical symptoms of opioid withdrawal. In a medication-assisted treatment, the patient receives a longer-acting opioid like methadone, which balances the person’s brain chemistry and lets him or her focus on functioning productively. The Texas Targeted Opioid Response grant will expand the sheer number of providers as well as their geographical diversity.

On the prevention side, the TTOR will expand drug takeback programs and distribute carbon pouches, which deactivate the pharmaceutical compounds, to cut down on unused prescription medications falling into the wrong hands. The state will also educate physicians, including dentists and OB-GYNs, on appropriate prescribing guidelines.

“We don’t want people to stop prescribing opioids, we just want to make prescribers aware of how they can do so safely,” says Ramirez, the TTOR project director.

This includes training prescribers on the Texas Prescription Monitoring Program, an online database that shows doctors which drugs have been prescribed for individual patients. The system is designed to reveal whether a patient has been getting multiple opioid prescriptions from different doctors and guard against the prescription of medications that interact, such as an opioid in combination with a benzodiazepine.

When Monica broke her leg last year, her doctor prescribed oxycodone for pain. Monica says the doctor didn’t ask about any past experience with opioids, and she didn’t volunteer it. “The quantity he gave me got me through the pain, but I’m not opiate naïve, so I have a tolerance,” she says. “I feel like the quantity he prescribed could easily have gotten someone dependent.”

The TPMP’s records only go back three years, so the database didn’t include Monica’s 2011 opioid prescriptions. But the system is a step toward helping doctors make more informed decisions about the medications they prescribe. If the doctor had known about Monica’s previous experience with opioids, he could have prescribed a smaller amount or at least discussed the medication’s risk with her.

But while Texas law requires pharmacists to enter the prescription data in the system, the law does not require doctors to consult that data. And right now, only a third of prescribers use the system.

To get more doctors on board, the Texas Health and Human Services Commission awarded a two-year contract to UT’s Center for Health Communication, which tackles problems using the combined expertise of faculty in the Moody College of Communication and Dell Medical School. A team of CHC staff and professors in communication, medicine, pharmacy, nursing, and social work will spend the next two years figuring out why doctors aren’t using the system and devising solutions to increase those numbers.

The team has just started its research, but Center director Michael Mackert suspects one reason doctors aren’t using the PMP is that they’re already pressed for time, and looking up patient data is one more task on a long to-do list. Encouraging doctors to delegate PMP research to a trained medical assistant might be one effective approach.

Talking about the PMP as a tool to improve public health is important, too, Mackert says. “It’s not about catching bad doctors, and it’s not about catching bad patients,” he says. “This is a way to make all of your patients healthier, with an eye toward population health.”

***

Doctors want to address the opioid crisis in part because their over-liberal prescribing practices helped create it, Ring says. His efforts at Dell Medical School focus on improving communication between doctor and patient by reframing the discussion about pain relief. Rather than automatically prescribing opioids, physicians can talk with their patients in a more holistic way both before and after a procedure.

Pre-surgery conversations often focus on making sure patients understand the risks, but Ring suggests surgeons bring up pain relief by asking their patients how they got comfortable after past surgeries. “This question reminds people that surgery will hurt and that we care about their comfort,” he says. In addition to ice, elevation and non-opioid pain relievers (like ibuprofen and acetaminophen), distraction and support have the power to relieve pain. Patients can have a friend come over, stock up on movies or music, or work on a creative project. “Compassion and preparation are great pain relievers,” Ring says. “If we made a greater effort to address the human aspect of pain, or what doctors call the psychosocial aspects of illness—the thoughts, stress, emotions, behaviors and circumstances that create more symptoms and limitations for a given disease—we could get people more comfortable using a lot fewer opioids.”

Helping patients develop resiliency won’t eliminate the need for prescription painkillers. But it’s part of a culture shift in medicine that could reduce their use, Ring says. That shift involves discarding the idea that health is passive: a pill prescribed by an expert that fixes everything.

“In reality the evidence suggests that health is an active process,” he says. “It’s something you do for yourself. The pills just mimic what your body does on its own. You have opioid receptors because your body creates opioids [endorphins and enkephalins].”

Changing cultural attitudes about pain can help curb the opioid crisis. And the initiatives funded by the TTOR grant are an encouraging step forward, the College of Pharmacy’s Hill says.

“Looking at just Texas, I’m enthusiastic,” he says, applauding Ramirez and her colleagues. “There are a number of fantastic, intelligent, and driven people working at the state who are making all the right connections and trying to move the state in a positive direction when it comes to harm reduction and compassionate drug treatment.”

The TTOR funds were authorized under the Obama administration, and Hill is less optimistic about the response from the current White House. President Trump’s October declaration of a public health emergency will expand telemedicine treatment for patients in far-flung rural areas and allow existing public health funds to be directed toward the opioid crisis. The president also emphasized the role of law enforcement and border security in fighting the drug trade.

Addressing the epidemic “will require us to confront the crisis in all of its very real complexity,” Trump said. The president, however, stopped short of declaring it a national emergency by invoking the Stafford Disaster Relief and Emergency Assistance Act. If he had, the federal government could have immediately funded the fight against opioids through FEMA’s Disaster Relief Fund, generally used for natural disasters like earthquakes and hurricanes.

But without additional funding, states will continue to struggle to purchase naloxone, train people to use it, and add treatment facilities for the estimated 2 million people already addicted to opioids, many of whom are also at risk for hepatitis C and HIV. And while the public health emergency can be renewed, it lasts only 90 days—hardly enough time, Hill says, to implement significant change. In that three months, though, an estimated 8,190 Americans will die of opioid overdoses. In the fall, media outlets reported that senior White House officials were working with Congress to increase federal funding for the ongoing opioid crisis. The clock is ticking.

Illustration by Polly Becker