House Select Committee on Opioids and Substance Abuse – March 27, 2018

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The House Select Committee on Opioids and Substance Abuse met on March 27^th, 2018 to take up the following charge: Study the prevalence and impact of substance use and substance use disorders in Texas, including co-occurring mental illness. Study the prevalence and impact of opioids and synthetic drugs in Texas. Review the history of overdoses and deaths due to overdoses. Also review other health-related impacts due to substance abuse. Identify substances that are contributing to overdoses, related deaths and health impacts, and compare the data to other states. During the review, identify effective and efficient prevention and treatment responses by health care systems, including hospital districts and coordination across state and local governments. Recommend solutions to prevent overdoses and related health impacts and deaths in Texas.

This report is intended to give you an overview and highlight of the discussions on the various topics the committee took up. This report is not a verbatim transcript of the hearing; it is based upon what was audible or understandable to the observer and the desire to get details out as quickly as possible with few errors or omissions.

Handouts

Karen Herd, SAMHSA – Substance Abuse and Mental Health Services Administration

I want to make sure that as we look at the crisis we do not lose sight of those individuals on the ground fighting.
Addressing the opioid epidemic has been a top priority of the President and the nation.
The opioid epidemic is tied to two issues. The first is the increase in volume of opioid prescription for pain conditions. The second issue is the lack of healthcare infrastructure.
Some of our data is from as far back as 2015. This highlights the nation’s need for greater study of this epidemic.
National trends show almost 12 million people misusing opioids.
Heroin and synthetic opioid use has increased since the 1990s.
Prescription medication and heroin have a linkage – need multi-pronged framework to address
Prescribing trend is going down – prescription dispensing peaked in 2012.
Geographically there are pockets where there are more prescriptions than people.
Price: Where are those pockets in Texas?
- There are two counties I am particularly concerned with. I will defer to Cynthia to list those in her testimony. (See testimony of Sonja Gaines)
We think that fentanyl is responsible for a great deal of overdose deaths due to its potency. Texas has been relatively safe from fentanyl compared to other states, but it is making its way to Texas.
Price: Can you explain how it is making its way to Texas?
- Interoperability is crucial
Price: How is Fentanyl acquired and its potency?
- Describe various potencies, if it is unknown then the prescriber can overdose
Often fentanyl comes from out of the US via mail order.
About 53% of overdoses happen at home. Therefore, we want to educate caregivers about the use of Naloxone, a counter overdose drug, in case of opioid overdose.
Additional health crisis as a result of these drugs – neonatal implications, etc.
Opioid strategies reviewed – supporting research, advancing the practice of pain management, etc
Price: What do you think the Committee should focus on to have the greatest impact?
- “I am so pleased that Texas has leaned in on this.”
- Focus on opioids will help focus on all people with substance use disorder.

Cynthia Humphrey, Executive Director of SAMHSA

Defers to Sonja for more details on interoperability but generally, Lubbock has a high rate and believes another area in East Texas but notes someone in the audience may provide further details. (See testimony of Sonja Gaines)
This is not the first opioid crisis our country has faced. Right after the Civil War narcotics were used for veterans with injuries and the proliferation of medical tonics resulted in a significant narcotics addiction problem.
In 1999, overdose deaths were highest in New Mexico. Today they are highest in West Virginia and the numbers have increased significantly.
We are also tracking an increase in alcohol consumption.
When you couple these increases with suicide rate increases, they account for the drop in life expectancy we have just experienced.
Many researchers have referred to this as an addiction epidemic, not just an opioid epidemic.
If you’re an opioid user, you are 8 times more likely to have an alcohol addiction or mental illness.
Price: What are your thoughts on the medically assisted treatment (MAT) regimen?
- There are 3 approved drugs which will treat just opioid disorder, but not alcohol or other addictions. The evidence is clear that when you have an opioid problem and use the MAT it is effective, but it needs to be coupled with counseling.
Price: What are the 3 drugs?
- Buprenorphine, Naltrexone, and Methadone
- Further description of agonist/antagonist
Price: Do you need a DEA license to prescribe one of these?
- SAMHSA manages this. You need to take education and after a year of demonstrating you can prescribe these responsibly, you may increase the number of patients you manage.
Price: How big of an issue is it to have an adequate number of prescribers? Provides personal detail from North Texas.
- It’s a huge issue. The problem is two-pronged; we encourage providers to get the training but even when physicians get the waiver they may not feel confident to prescribe these. For more rural areas, we are looking to expand telemedicine. The Ryan Hade Act made it where you must have a face to face interaction to get this treatment. We want to expand telemedicine to provide for rural areas.
Price: Are any states that you know of doing something to make this more available to those who need it?
- Vermont has a designated MAT provider which the treatment organizations have access to from across the state.
Nevarez: What is the barrier/ unwillingness of doctors to prescribe? Is there oversight which can fix this?
- There are ways to make it more attractive.
- Several programs for emergency departments.
- One of the concerns we hear from prescribers is the reluctance to interact with the DEA and paperwork.
Dean: Some doctors in my area are worried about liability. Can you tell me about the type of training a doctor must go through to be able to administer these drugs?
- For Naltrexone and Buprenorphine, it is an 8-hour waiver training. Some doctors believe that is enough time, some do not.
- That is why I am excited about telemedicine since it can hook these doctors up with experts who can make them more confident in prescribing these.
Dean: So, there’s no training that makes doctors confident? I am hearing that we don’t have the time or don’t want the liability.
- Being able to link these doctors with counselors is very important.
Dean: Is there a specific type of doctor that would qualify to be certified in this? Pediatrics?
Alvarado: What is the likelihood of someone becoming addicted to one of these treatments? I witnessed someone on Methadone and the side effects were very concerning.
- That is one of the drawbacks. The patient may develop an addiction to that drug. At the same time, it does not put the patient in as much danger of an overdose. This is why prescribing these is not easy.
Alvarado: Is the opioid crisis affecting one segment of our population more than others?
- Prescription drugs seem to be affecting the white suburban population more than illicit drugs. The typical heroin user is a white male between 18-35. Older individuals seem to struggle more with prescription drug abuse.
Murr: I would be interested in the Committee exploring why prescribers in rural areas do not prescribe these. My experience is that it is socioeconomics.
Coleman: I don’t know what the numbers are, but the economic impact on a community is huge. The Bauer School of Business did some numbers on this.
Minjarez: Do physicians have to pay for the certification?
- In most cases, they can access that at no cost.
Price: Could you comment on take-back programs and the DEA?
- The next drug takeback day is April 28. It is an opportunity for those with medication they are no longer using to safely dispose of them. There is a high number of adolescents who, the first time they used an opioid, they got it out of their parent’s medicine cabinet.
Sheffield: Can you comment on your understanding of the role of genetics in addiction?
- 50% genetic predisposition makes you vulnerable. We also must look at the role of trauma in addiction. The trauma you experience as a child can have an impact on addiction.
Sheffield: Do you have any statistics on the effectiveness of drug treatment using medication with and without inpatient and outpatient?
- That is a complicated question. There is a large divide in favor of medically assisted treatment vs inpatient treatment.
Sheffield: Can you comment on safe injection sites?
- Several states have needle exchange programs where they go out to where the drug use is and provide a clean needle. Supervised injection sites are where the user goes in and uses the drug under supervision to prevent overdose. Several states are looking at the coming HIV crisis because of the current opioid epidemic.
Price: What type of coverage is in place for MAT through health insurance plans?
- It varies by the insurance plan. Our Medicaid program in Texas covers all three drugs.
White: Your printed testimony states, “amending criminal penalties for drug offenses”. Is that making them stringent?
- If we reduce some of the penalties, we can get people into treatment instead of prison. If you send a low-level offender into prison, they can come out more likely to continue committing crime.
We need to keep an eye on what other drugs may rise in the future. While watching methamphetamines, opioids were able to rise.

John, Commissioner Texas Department of Health Services

Humans have very complex brain chemistry that tries to balance between well-being and distress. When someone engages with an addictive substance that action has its root in an attempt to balance these two states.
Opioids, in general, depress the activity of the central nervous system.
The current opioid epidemic led to state and federal declarations of a crisis. This crisis has its roots in the increased prescription of opioids as pain medicine. Access to cheaper and more potent drugs like fentanyl has become easier.
Sheffield: I was in practice when pain was made the fifth vital sign. Can you comment on Press Gainey scores? When a clinic or hospital surveyed patients and asked if the patient’s pain was treated properly, if the patient responded, “No”, the Press-Gainey score for the facility went down. Comment on how the hospital can be scored as ineffective because the patient does not feel their pain was treated properly?
- That is worth noting. I was a physician executive at the time when a lot of that was going on. The premise that if a patient says they need more pain medicine then the prescriber should give it is hopefully going away. I believe pain as a fifth vital sign is going away in inpatient.
Price: Does the Department do any outreach with respect to that issue to the medical community?
- No, we do not. My understanding is that the monetary incentive in an inpatient setting is all gone.
Other drugs, besides opioids, are increasingly present in poison control calls. In 2017 alone, Texas received over 30,000 drug exposure calls.
Antidepressants continue to be the most frequently encountered drugs in Texas.
Increased frequency of drug-related incidents follows up the I-35 corridor.
Drug overdose deaths increased significantly in the early 2000s and often involve the presence of more than one substance in the body making it difficult to tell which drug was most at fault.
Rose: This past session I sponsored SB 584 which required the Texas Medical Board to establish guidelines for Naloxone. Do you know if those guidelines have been established?
Fentanyl has common use in the United States as part of general anesthesia.
Texas Alliance for Innovation in Maternal Health (AIM) Program is part of Texas DHS’ initiative to drive down maternal mortality rates in the state. AIM is a completely voluntary program, but I know that once doctors see the evidence of effective practices then they will be willing to adopt them.
Sheffield: What infectious diseases has your department seen as a result of the crisis?
- HIV, Hep B, and Hep C are very serious threats because of shared needles.

Sharon Brigner, PhRMA

Our industry is committed to working with Texas every step of the way.
In 2016, deaths attributable to opioid usage in the US increased from the previous year.
Older white males are the most prevalent users of opioids.
$78 billion in total loses from the economy is attributed to drug abuse.
We are working with the US Surgeon General, whose own brother is incarcerated due to opioid abuse, to find solutions to the problem.
CDC guidelines have been issued for chronic pain and provided great recommendations.
We ask the Committee to look at script limits, expanded prescriber training requirements, expansion of tools to inform prescribing, enforcing mental health parity, access to non-opioid analgesics, reviewing the DEA manufacturing quota, and expediting new treatments to market.
Price: How can we affect the DEA manufacturing quota?
- Advocacy, primarily.
Nevarez: Can you tell us what the 7-day script limit means?
- We are looking at no refills unless the provider deems necessary.
Nevarez: I want the studies to boil it down to a single area so that I know what type of patient will become addicted to opioids. And I want doctors to say, ‘enough is enough’ and not give any more opioids.
- I appreciate the comment.
40 new meds are in development which will go to drug abuse treatment and an additional 40 new products are in the pipeline for treating those already addicted.
Increased suicide rates among chronic pain patients is worrisome. We are hopeful to see acute pain guidelines from the CDC soon.
Ohio and Kentucky saw a decrease in prescription drug abuse from 85% to 52% in recent years. They have mandated (Prescription Drug Monitoring Program) PDMP reviews by prescribers and implemented many pain clinic regulations.
Florida focused on excessive opioid prescription and we saw a decrease of 80% opioid prescription and a decrease of 50% in opioid related deaths from 2015 to 2016.
Price: We have heard that illicit drug use is growing as prescriptions are going down. Is the relationship as obvious as it seems?
- The media reports that because illicit drugs are cheaper and easier to acquire that users will turn to those.
Moody: Have you seen evidence that good Samaritan laws are being exploited?
- I have not, but I will investigate it.

Samantha Schaeffer, Legislative Budget Board

Estimated Medicaid and chip expenditures for Substance Use Disorders (SUD) services totals $190 million. Overall, total state funding for SUD services is $931 million.
Through the Texas Targeted Opioid Response (TTOR) Grant of $55 million, HHSC adds or expands SUD services.
Price: Does this replace any state dollars or is this truly a supplement?
- I can check and get with you.
Residential and outpatient treatment programs, comprehensive SUD benefits through the Medicaid program
Price: You gave us data on individuals treated, do you have data on individuals successfully treated?
- I can check and get with you.

Sonja Gaines, Health and Human Services Commission

I want to thank everyone on the Committee for their investment into health services.
Substance abuse is defined as a recurring misuse of alcohol or drugs.
When we began working on the statewide strategic plan, we sought input on the most pressing issues in health services.
Substance abuse was ranked as the most pressing challenge.
The estimated need in Texas is 1.6 million adults who have a need for substance abuse services and 1.1 million children.
In 2016, Texarkana, Amarillo, Odessa, and Longview were identified as top cities in the nation which struggle with substance abuse.
Dean: Why does the TTOR grant lists individuals who live in metropolitan areas if these rural areas listed as the most in need?
- I’d be happy to meet with you concerning efforts across rural areas in Texas. You are exactly right, there are gaps there.
There is an array of services provided through counseling agencies. For example, specialty drug courts and diversion programs with the Texas Department of Criminal Justice.
One substantial resource in Texas is the Outreach, Screening, Assessment, and Referral Centers (OSARs). These are centers operated by local mental health authorities to which people can go for aid.
Prevention Resource Centers provide behavioral health resources for the populations which they serve.
Price: These are non-Medicaid programs that you are listing. How many people are accessing these programs and how successfully can you monitor outcomes? What is changing as we learn more and become more aware?
- We have over 500 contracts throughout the state. We have very strong performance measures that we review on a regular basis. In most cases, our people are exceeding the target number of individuals we ask them to serve.
76% of substance abuse health services funding comes from the Federal Government.
Medicaid reimburses for this service. Assessment, detox, residential and outpatient treatment, medically assisted treatment, screening, and referral to treatment are all covered by Medicaid.

Lisa Ramirez, Health and Human Services Commission

80% of the funding goes to treatment and about 5-10% goes toward prevention efforts.
Price: What is the term of the grant?
- The new administration has chosen 2 years, but we are waiting to hear if the grant will be extended.
Through ‘takeback’ programs, the state has been able to take back over 8,000 lbs. of prescriptions.
We have seen on average 7-8 reversals reported per month.
Office-based opioid treatment will increase geographic access to medically assisted treatment throughout the state.
Vandeaver: Are there plans to continue to expand OSAR centers throughout the state?
- Many of these centers have satellite locations.
Vandeaver: Texarkana was listed as an area with a lot of need, however, there is no center close to the area.
- We may not have a satellite site, but we will be outreaching to individuals either at hospitals or emergency sites.
Vandeaver: Would it be beneficial if a provider in the area were to reach out to you?
- If there is a need in the area I would be interested in talking with them.
Recovery support services are offered to individuals highly vulnerable to substance abuse.
White: How do these satellite offices look? Is it an office that says ‘OSAR’?
- They operate out of local mental health facilities and outreach to individuals in the community.
White: People tell me these sites don’t exist.
- We have onsite reviewers who ensure the site aligns with our standards. But it makes sense that you say that because with mental health, there is no need to know about these sites exist unless you have an issue.
Alvarado: What did the CDC recommend concerning testing for chronic pain patients on opioids?
- We can check on this and get back to you.
Sheffield: Can you explain the use of a carbon pouch?
- The carbon pouch deactivates the active components in an opioid so that it can enter back into the ecosystem safely. When you dispose of opioid medication in coffee grounds, it deters someone from using it but does not make the environment safer. The carbon pouch fixes this problem.
Sheffield: Can you explain the use of fentanyl test strips?
- They are another strategy to reduce the risk of overdose death rates. The person using the substance with a fentanyl test strip can use that strip to determine whether fentanyl is present.

Kristene Blackstone, Associate Commissioner Child Protective Services

In fiscal year 2017, caregiver substance abuse contributed over 60% in cases involving the removal of children.
The bulk of DFPS appropriation for substance abuse goes to drug testing services.

Bryan Collier, Director Texas Department of Criminal Justice

Within the prison system, over 14% are drug offenders.
Within state jail, over 40% are drug offenders.
We have over 10,000 beds identified for substance abuse treatment.
Recidivism rates are about 21% (offenders who leave from and return to the prison system).
White: Did you cover pre-trial diversion programs?
- In the date I am providing (handout) you have the money and services being provided through the Department.
White: I was told these services are not receiving funding.
- I imagine most of the programs are not funded through probation dollars.
Sheffield: Tell us about faith-based dorms.
- Our goal is to have a faith-based dorm in every facility in Texas. Volunteer groups work with offenders on a pre-determined curriculum in those facilities.

Riley Webb, Executive Director Governor’s Criminal Justice Division

Specialty courts provide mandated treatment to high-risk offenders in a non-adversarial setting.
CJD’s role is to provide verification for the specialty court to operate in the State of Texas.
Specialty courts are funded by program fees from participants. These fees cannot exceed $100.
CJD made a total investment into 71 specialty courts in Texas.
42% of the courts we fund have been funded for over 10 years.
Specialty courts are designed and operated at the local level. This creates differences in the success rate of each court.

John Hawkins, Texas Hospital Association

Academic institutions roughly $93,000 per patient treated with this issue
Should start with hospital emergency units because that’s where most of the costs occur
Despite relatively low prescription percentage, several opioids get distributed for non-medical use there
Encouraging use of prescription monitoring program
Electronic medical records because of 1115 waiver is an attempt to help track
Price: ED are a large piece of the drugs ending up in other individual’s hands, this has had some success in other states, Texas does not have anything like the guidelines?
- Not on a statewide basis

Lee Johnson, Texas Council of Community Directors

Presented written testimony
Mental health systems should be able to better identify, treat, or refer out people with substance abuse disorders.
Price: If you have a local mental health authority who is contracting with a provider, can this occur?
We want to say thank you for the Legislature’s investment.
We’re working with our membership to identify state and national trends in health and substance abuse disorders.
Certified community behavioral health clinics are projects the state should focus on.

Andy Keller, President and CEO of Meadows Mental Health Institute

When we talk about substance use disorders, we mean people who have a medical condition with continued abuse of substances. To treat this, the full suite of medical treatment needs to be at the caretaker’s disposal.
Methamphetamine is an important issue to many communities, in addition to opioid abuse.
Price: Billions of dollars are spent on unnecessary ER and incarceration. Is that something you are paying attention to?
We are.
There are no statistics now on how many people get care in the private system.
Integrated treatment is the way the state needs to go in.
Death trends for Texas have increased since the late 1990s when we began more aggressively treating pain. This was also when the state began cracking down on pill mills.

Jamie Dudensing and Laurie VanHoose, TX Association of Health Plans

There is a dangerous 3 drug combination that is prescribed to patients. There has been a 60% reduction in the number of prescriptions of that combination.
We’re combining education and early intervention to address the opioid crisis.
We’re identifying at-risk members and doing a pharmacy lock-in program where we try and keep members with a single pharmacy or provider.
CDC recommendations are an important part of our health plans.
Medication-assisted therapy is an important therapy that needs to be available in the State of Texas.
We do not control prior authorizations in the drug program.