Texas addresses opioid epidemic with research and new therapies | Crain's San Antonio

Texas addresses opioid epidemic with research and new therapies

The opioid epidemic has been making headlines as more Americans die each day of overdoses and millions more struggle with use.

According to the U.S. Department of Health and Human Services, that class of powerful drugs — which includes not only illegal substances such as heroin but also deadlier synthetics such as fentanyl and legally available pain relievers such as oxycodone and codeine — accounted for more than 42,000 deaths across the country in 2016, or about 115 per day, the most ever. At least 40 percent of those deaths were attributed to prescription opioids, the Centers for Disease Control and Prevention reports.

Texas hasn’t been immune: In 2015, 2,588 people died in the state from opioid overdose with Houston’s Harris County accounting for 318 deaths. In December, Harris County Attorney Vince Ryan filed suit against drug manufacturers and distributors, doctors and a pharmacist for their roles in promoting the epidemic. “These defendants placed their quest for profits above the public good,” Ryan said at the time. “Unfortunately, Harris County has found itself in a battle against opioids and the crushing financial effect of this epidemic.”

Katharine Neill Harris, an Alfred C. Glassell III fellow in drug policy at Rice University’s Baker Institute in Houston, has studied the issue nationally and in Texas. She spoke with Crain’s about how far-reaching the problem is in the state and what’s being done about it.

How bad is the opioid epidemic in Texas?

It’s as bad in Texas as it’s been in other places. The rate of opioid-related deaths is 4.7 per 100,000, according to the Centers for Disease Control. There’s reason to think that the number is underreported in Texas and other places, as hospitals often undercount drug-related deaths, don’t report them or report them as something else, like cardiac arrest. But in general, we haven’t seen the rate of overdoses in Texas as in other parts of the country. If you look at Houston and Harris County, people still have access to prescription drugs that are opioids, while other parts of the country buy counterfeit on the dark web that may have fentanyl in them. Also, a lot of heroin in Texas is black tar versus white powder in Appalachia, the Midwest and the Northeast. White powder heroin is much easier to mix fentanyl with, while black heroin is black or brown and you can’t mix fentanyl with it.

But opioid use is still a problem in Texas?

Absolutely. Overdose deaths are just one indicator. You also can look at how many are in treatment. In 2015, 15,000 people were admitted to state-funded treatment programs where they said opioids were the primary substance of abuse. That doesn’t count private programs. It’s certainly a problem in Harris County and Texas in general.

Can you give us a sense of the economic impact of the crisis?

There was a study that came out of the Brookings Institution by Alan Krueger in which he looked at trends in the labor force. He estimated that the increase in opioid prescriptions could account for as much as 20 percent of the decline in male labor force participation between 1999 and 2015 and a quarter of the decline in female participation. That’s significant. It’s difficult to tease out the cause. Is it chronic pain or simply more prescriptions that’s led to the abuse?

Is it an urban or rural phenomenon?

Urban areas account for greater numbers of people, but on a percentage basis, rural seems to be more affected. The National Institutes of Health estimated that in 2015 nonmedical uses of pain relievers were more common in the central region of Texas, which includes more rural areas — although San Antonio has had a heroin use problem for a while given that it’s where traffickers travel through from Mexico. The other trend is that the misuse of prescription opioids is more common in white females with a higher education versus those who use heroin.

What are the economic costs?

The Council of Economic Advisers estimates that the epidemic cost the U.S. just over $500 billion in 2015. This estimate is much higher than previous estimates of roughly $80 billion annually, primarily due to the way the CEA now values the cost of a premature fatality from an overdose.

What are governments doing to combat the problem?

President Trump declared it a public health emergency, but it didn’t free up much money — about $57,000, which was the amount in the public health emergency fund. If he had declared it a national public health emergency, there would have been more. His opioid commission had good ideas on how to deal with it after getting input from a lot of stakeholders, who made recommendations for prevention and treatment, but there hasn’t been the funding we need behind it.

The 21st Century Cures Act did free up $1 billion to deal with the epidemic, but that piece of legislation has several different components that aren’t just opioid-related, with a grant the federal government has administrated. Texas got $27 million of that in April for a targeted opioid response and I think they’re going to get another $27 million in 2018. They want to target use among pregnant and postpartum women and in the five major urban areas in Texas where the highest numbers of people are affected. They’re also targeting people who have a history of misuse, including in outlying suburban areas and rural areas, particularly among veterans. They are looking at forming partnerships with community providers and providing them treatments and expanding the number of beds. Cognitive behavior is a big part of what they’re trying to focus on. By summer there should be some initial results.

What are other countries doing that Texas could emulate?

Texas could adopt things other states are doing, like needle exchange programs. Bill Martin [director of the Baker Institute’s drug policy program] has been trying to get legislation for over a decade.

In 2007, Texas legislation allowed for a pilot program in San Antonio, but the district attorney started arresting the workers who were dispensing clean needles on drug paraphernalia charges. The DA now is supportive of these programs, but some elected officials have some logistically impossible stipulations, including requiring everyone to get drug treatment. We don’t have treatment facilities for all of these people and it would give treatment to people who aren’t ready for it and take away opportunities for those who are. Needle exchange programs are relatively inexpensive and a lot of places have them. New Mexico has one. So did Indiana when Vice President Pence was still governor in response to an HIV outbreak in one county. We might see Texas legislation pass in 2019.

Other ideas include safe injection sites. They provide a place to use but under supervision, so if they’re going to overdose, there’s someone there to revive them. They have them in Canada and most European countries. There’s been talk of doing it in Seattle and Portland and counties in New York that have been affected.

Is Texas’ medical community getting involved and if so, how?

I met with Dr. Michael Weaver at UT Health [University of Texas Health Science Center] and they have a program at their Center for Neurobehavioral Research on Addiction. They received a $2.5 million federal grant to provide HIV education and treatment to people with substance use disorders. Initiatives like these are important because people with SUDs often have other co-occurring issues related to their physical or mental health that left untreated can exacerbate the problems of substance use and poor health outcomes, which lead to higher health care costs. The earlier the intervention the better.

The center conducts research on how to treat substance use — opioids but also stimulants, which do not have the same kinds of medical interventions available. And UT Health also has a clinical practice that treats people for SUDs.

Have you seen startups popping up with alternatives to opioid treatments? Are some of them legit?

That’s an interesting debate within the treatment industry, the nonprofit versus the for-profit. There are a lot of methadone clinics, which are difficult to start up with a lot of regulations around them, and a lot of them start out with a profit. That’s not a bad thing at all, but you want to make sure they’re operating in the best interest of patients, providing them with medical treatment along with cognitive behavioral therapy. It costs more money to have licensed counselors on staff. You have many for-profit treatment clinics that offer different kinds of care tailored to different markets, from bare bones, low-cost services to the Cadillac programs for those who can afford to pay $4,000 a week to stay in a plush facility. There’s certainly money to be made in it. But this population is particularly vulnerable and you have to protect patients at the same time.

Has the opioid epidemic seeped into the white collar, executive ranks?

It’s moved into all income levels. Right now, the people most susceptible to use and overdose are the younger population with no insurance. Prescription pills are more popular among slightly older people who have health insurance. You see some of this socioeconomic divide.

Have there been public-private partnerships to address the issue and are they making an impact?

A pilot program with Vivitrol is being run out of the Harris County jail. Vivitrol is not a substitution drug, but an opioid antagonist that blocks receptors. It’s a partnership with Alkermes, which is providing it for eligible offenders upon their release. People are screened and then offered the shot, which lasts for 30 days. They are partnered with Texas health clinics that will administer it monthly. If the person doesn’t get another shot after 30 days, they are more susceptible to overdose because their tolerance is lower. It’s a way to get clean rather than trade one addiction for another.

The other big partnership is with the makers of naloxone. It’s been around since the 1970s and used to be very cheap. But in response to higher demand, the makers have increased the price and there have been partnerships to lower the cost. Kaleo Pharma has created a version called Evzio, which you stick people with it. It doesn’t have to go up the nose, like naloxone. One dose is very expensive, a couple thousand dollars, and they’ve been giving it away for free to groups in Texas. Harris County also has a few partnerships with providers of drug treatment services for criminal justice populations.

So, what can Texas companies do to address opioid addiction in their workforces? Do you know of any who are more progressive?

I don’t know too much about how specific companies are dealing with it, but there are a few things they can do. One involves healthcare coverage. The Mental Health Parity Act requires coverage for substance abuse like any other coverage. That law isn’t always enforced and certainly not in Texas. You have to commit resources to invest in cases where insurance companies aren’t offering coverage. Companies need to ensure that their employees have ample coverage with early intervention screenings. These physically intense jobs, such as in the oilfield, come with a lot of pain, giving people a reason to take prescription drugs. You have to educate the workforce about the misuse of these drugs and have services to help them.

Second, they shouldn’t exclude people with nonviolent drug felonies from employment opportunities. In Texas, possession of less than one gram—the equivalent of a sugar packet—is considered a felony. This is a law that we are hoping to see changed in the near future. People convicted of this aren’t violent or drug dealers. But the fact that they have a felony on their record can make it difficult to find work and unemployment is a factor that can drive a person to continue drug use.

Third, workplaces that drug test should consider not excluding people from employment whose screens show that they use methadone or buprenorphine (Suboxone). Some people may be hesitant to obtain medication-assisted treatment out of concern that it will jeopardize their ability to get a job or keep their job if they have to take a drug test. We have data to indicate that taking these medications is less about getting high and more about satisfying an individual's physical dependency on opioids so he or she is able to function normally in daily life. I understand that in some occupations, where safety is a primary concern, employers don’t want to risk drug use among any employees, even if it is a form of treatment. But where possible, employers should allow employees to take part in this well-established treatment without fear of repercussions.

March 18, 2018 - 3:01pm