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The House Committee on Opioids & Substance Abuse met on June 26 to hear invited testimony on interim charges regarding “Good Samaritan” laws and the impact of opioids and substance abuse on law enforcement, first responders, and hospital emergency departments.

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.

 

Examine the impact of overdose reporting defense laws known as “Good Samaritan” laws.

Lara Lamprecht, Department of State Health Services

  • Drug overdose Good Samaritan laws provide protections for bystanders wanting to help and those experiencing overdose who seek assistance; goal is to reduce overdose death
  • Implementation must by coupled with education & buy-in
  • 40 states have some form of overdose Good Samaritan law
  • Commonly these laws require good faith & include protections for possession, some laws address paraphernalia & some address stages within prosecution process
  • Common baseline protection is immunity from prosecution for possession prosecution
  • Early adopters have been amending laws to include these types of protections
  • Existing Texas Protections
    • 911 Lifeline Law – Specific to minors who observe & act to possible alcohol overdose
    • Texas Naloxone Access – Incentivize possession and administration of opioid antagonists; can possess antagonist regardless of prescription, but does not address emergency care
  • Chair Price – Regarding the Naloxone Access Law, there has been some confusion; as it reads anyone can possess, but not everyone will have a prescription for it
  • Chair Price – If I have a prescription I can transfer to another and they can possess, but not every interested person will be able to obtain these agents
    • Correct
  • DSHS reviewed studies from 2013-2018 regarding these laws, these tend to go hand-in-hand with other harm reduction laws like PMP and Naloxone Access Laws
  • Also tend to be coupled with EMS laws as many situations can not be resolved without emergency care
  • Access laws are associated with a reduction with overdose deaths, despite overall increase nationally
  • Study also looked at if Good Samaritan Laws also were coupled with increased use, numbers of those reporting past usage did not increase
  • Chair Price – What is generally the limitation on dosage and amount with these laws? Do they distinguish between users and dealers?
    • Studies we looked at didn’t go into this detail
  • Chair Price – If you were reporting an overdose and found an excessive amount of drugs, there was no distinction with lower amounts?
    • This area was not looked at, studies looked at did not focus on this
  • Chair Price – So data indicates number of users may have not increased given these laws?
    • Right, we don’t have larger numbers of users due to these laws, but we do not know if current users are taking drugs more frequently or in larger doses
  • Accurate knowledge of law’s extent by affected individuals is important, education in calls could be an important part of successful use of these laws
  • Relationship of bystander & person overdosing influences whether 911 is called, family & friends are less likely due possibly to stigma, federal housing eligibility, available of naloxone on site etc.
  • Very recent research generally suggests these types of laws are effective in reducing opioid deaths
  • White – Could you elaborate on the federal housing situation? Are you saying that if these tools are used it could potentially disqualify individuals?
    • Might be hesitant to call 911 for fear they will lose their housing
  • White – So there nothing expressed in these housing program rules that you cannot use these tools, it’s just that people may have the perception?
    • There are various rules involved in federal housing looking at tenant behavior, can look more closely at this
  • Chair Price – So would it be accurate to be concerned that even though a state has a Good Samaritan law, this could affect an individual’s housing unless the federal government would also recognize limited immunity in these situations?
    • This would need to be explored
  • Moody – Did we look at how these laws were being injected into the criminal justice system? In 2015, we set it up as a defense to prosecution, but this was vetoed by the Governor
    • We looked at things like sentence reduction, but was not present in 2015 so cannot speak to this
    • Studies and other literature is coming out in an increased rate, info is being added to frequently
  • Moody – Bottom line seems to be that’s it has helped in some states; legally, it allows someone to go through the criminal justice system & have this factor considered
  • Moody – Didn’t understand the vote in 2015, data now seems to be even more in favor
  • Roberts – Of the states that have these laws, are you aware of provisions that would dictate treatment programs?
    • Can’t recall, but can get back to you on that

 

Identify how opioids and substance abuse have impacted the normal scope of work for law enforcement, first responders, and hospital emergency department personnel.

 

Texas Department of Public Safety Panel

John Bateman, Texas Department of Public Safety

John Jones, Texas Department of Public Safety

  • Speaking directly to fentanyl, has rapid effect and easy exposure, very lethal; inadvertent exposure or regular use can lead to easy overdose
  • Training has to be developed to handle this, also on use of Narcan
  • Changed policy regarding field testing as well, danger of fentanyl has meant testing is only done through labs; delays prosecutions in some areas of the state
  • Have also had to distribute Narcan to personnel across the state, all CID squads, criminal interdiction, and K-9 teams, etc.
  • Main impact has been lac of field testing
  • Chair Price – What is the most common risk associated with fentanyl contact? How does it generally manifest and what are the issues involved?
    • Two main ways, investigations and highway interdiction/searching vehicles
  • Chair Price – Is this most commonly encountered through other drugs laced with fentanyl?
    • Yes, cannot know when other drugs are laced with fentanyl, but we have seized large quantities of fentanyl transported through the state
  • Chair Price – What happens if you touch it or breath it?
    • John Jones, DPS – Fentanyl can be powdered or pill, only takes 2 mg of powder for a lethal dosage; roughly size of 2 grains of salt, very easy to overdose
    • Had a State Trooper find 22 lbs of fentanyl, large quantities are very dangerous
    • Troopers have been put into critical condition or died due to exposure in other states
    • Bateman, DPS – Fentanyl can be absorbed through skin as well, very easy to expose yourself
  • White – Is fentanyl more prevalent in some areas of the state or methamphetamine
    • Jones, DPS – While there is fentanyl, etc. here, Texas is mostly a passthrough; Texas has large increases in meth and heroin
    • Can be challenging to separate heroin overdoses from fentanyl, especially with frequency of lacing
  • White – I was led to believe that meth was manufactured within counties at one time, is this true or is it being shipped in?
    • Heroin is shipped in more, meth is typically home-made
    • More lucrative for cartels to work with pills and easier to manufacture substances like heroin
    • One of the challenges is categorizing overdoses and deaths, fentanyl is related to other opioids data-wise & cannot distinguish between overdose or clinical use, etc.
    • When we are seeing an increase of overdose in a small population, usually indicative of fentanyl issue in that area
  • Roberts – Regarding fentanyl trafficking, had heard that many of these shipments were coming from China through the USPS & USPS is unable to detect fentanyl through scanning
    • Bateman, DPS – I do know there is an increase of fentanyl coming through post office, but cannot speak to capability of the USPS to detect
    • Postmasters are working with federal partners
    • Seeing individuals order these substances currently, more challenging to stop than large shipments
  • Roberts – Some are huge shipments, where are you seeing the majority coming from?
    • Jones, DPS – Other countries, China is one; China has passed law, but still gets through in black market
  • Roberts – Have agencies participated in data-sharing, collaboration, etc.?
    • Yes, Jones is in charge of State Fusion Center which brings many different enforcement authorities together; collaboration is ongoing
    • In national policy, DPS can be part of some national committees with ICE, FBI, etc.
  • Roberts – How do we reduce points of entry?
    • Need to get with federal partners, international transport has intersections with USPS, customs, etc.
  • Roberts – Is it fair to say it is currently hit and miss or are you finding big operations?
    • Bateman, DPS – 2 different prongs, interdiction of fentanyl transporting through state & investigations of dealing of fentanyl in certain areas
    • Other investigations target meth, cocaine, etc. as these are much larger issues
    • Mostly find dealer amounts, not large transport amounts
  • Murr – Regarding delayed prosecution and lack of field tests, do you still field test for substances not necessarily powdered?
    • Policy is if it is a powder, it is not field tested
  • Murr – How many labs do you have?
    • Austin, Laredo, Houston, Garland, several throughout state
  • Murr – Are they being fully utilized?
    • They are able to handle the load, but there is a delay in shipping, etc., also no priorities for fentanyl testing; other enforcement partners use these labs too
  • Murr – We are adding more tests, what delay are we experiencing?
    • Jones, DPS – Do not have this number, can get with lab personnel to get numbers to you
  • Murr – Important to have, may need to anticipate this in future budgets
  • Murr – Currently, level of felony is determined by weight, minus adulterants; is fentanyl considered an adulterant?
    • If it’s tested as heroin is it considered heroin
  • Murr – Should consider separate charges for fentanyl present in other drugs due to danger; we don’t know if substances may contain fentanyl, and could inform policy decisions
  • Chair Price – Goes back to DPS point that data is only as good as what we are testing for or collecting; difficult to know how much of issue is due to fentanyl
  • Murr – Given lethal dose of fentanyl, weight is irrelevant regarding state policy

 

Law Enforcement Panel

Jim Sevey, Nacogdoches Police Department

  • Nacogdoches is about 34k population
  • Investigate and make arrest for narcotics every day, mostly for opioids, takes a lot of resources
  • Hydrocodone, OxyContin, etc. are the most common
  • Estimate that 80% of crime is related to narcotics, almost all homeless individuals have substance abuse issues
  • Need to take a more comprehensive look at this, drug issues are all related
  • Drug issues impact many aspects of society, leads to property damage, community deaths, etc.
  • Can’t speak to counseling, medical treatment, etc.; law enforcement interested in record tracking through pharmacy; can’t find out if an individual has been to 3 or 4 different doctors or pharmacies
  • Prosecution is part of the solution, substance abuse is a choice, prescriptions are choices, have models like DWI response and underage drinking that can inform our approach

 

David Knight, Kerrville Police Department

  • Major impact has been loss of life, group home proliferation and increase in police calls as a result
  • Local impact from overdose and unattended death has been less serious in our area than other areas of the state, 25 instances of overdose in last 5 years, 15 as a result of opioid, 2 suicides
  • ~Half of remaining 13 were related to heroin, but overall use is not significant
  • Kerrville has a unique situation, 10 residential treatment centers that have led to drastically increased number of calls for service, many of the individuals most frequently involved in opioid issues are involved in recovery
  • Many cases are due to diversion of legitimate prescription pills into private market; many will travel to major population centers and travel to Kerrville to resell
  • White – Are any of the group homes associated with DPS?
    • No, all affiliated with sober living environments

 

Mark Davis, Hardin County Sheriff

  • We’re still struggling to overcome impact from methamphetamine, also compounding opioid issues on top of this
  • County jails are being filled with drug offenders from local communities
  • Officers are being occupied with this for extended period of time, tremendous resources, seeing more injuries & worker’s comp claims stemming from arrests, etc.
  • Deaths are often unattended, hard to investigate & require a lot of resources and manpower; in rural areas without a medical examiner, Justice of the Peace has to handle the investigation
  • Methamphetamine labs have largely been eliminated from our areas, local labs largely gone; much of this is due to increased enforcement, but also due to decreased cost of manufacture in other areas
  • Seeing increased issues among teens, much of this due to leftover pills from doctor, dentist prescriptions
  • Have partnered with other authorities in a take back drug program, have installed drop boxes in many areas; numbers coming in are overwhelming
  • Equipping officers with Narcan to help in the critical first response, critical in areas without fast EMS response
  • Seeing issues with withdrawals in jails as well, county must pay for withdrawal treatment that manifest in county jails
  • Assaults on officers, etc. look to be linked to increase in drug issues
  • Chair Price – Does Hardin County have a crisis outreach team?
    • Yes, LMHA is Spindletop out of Beaumont, looking to make relationship closer and placing an officer with the response team
    • These teams can help in instances where there is no legal basis to take individuals into custody
  • White – At what point do we identify addiction calls vs. pure crime calls; from what I’M seeing, it’s the same individuals for you again and again, so which ones are addiction cases mostly and which are crime cases mostly?
    • Our patrols are seeing a clear difference between the addict and the abuser, addicts aren’t the driven criminals like we see with the dealer/distributers
  • White – So from a policy perspective, we probably need to find another venue for the addicts
    • We are all need to use common sense on which are jail offenses and which calls for alternative services
  • Moody – Need a safe harbor for law enforcement on the scene to allow law enforcement to respond properly

 

Joe Frank Martinez, Val Verde County Sheriff

  • Highlights death statistics in areas around the border, major state transport corridors saw a 50%-60% increase in incidents, have also seen increases of seized weights, and decrease in individuals seeking treatment, etc.
  • Fentanyl issues have been increasing in Val Verde, cites instance of 2 children looking to steal cocaine, but being exposed to fentanyl

 

Emergency Services Panel

Ernesto Rodriguez, Austin-Travis County EMS Chief, Texas EMS Alliance

  • Roughly half of EMS staff responded to a survey, 11% of respondents indicated increased opioid use
  • Often difficult to determine which substance is responsible, seeing increased use of other substances like K2
  • Also seeing need for training in opioid antagonists & response

 

David Persse, Houston EMS Physician Director

  • Drug overdoses have begun to eclipse alcohol, opioids are not the majority, but growing
  • Non-alcohol overdoses cost Houston roughly $4 million last year
  • Working with Houston Forensics Center, fentanyl presence is a large problem; abusers are often poor pharmacists & even low doses of fentanyl leads to overdose/death
  • Starting to see increases, lag time in testing will likely mean current numbers will only increase
  • Pill mill regulation and enforcement has led addicts to street dealers, leading to more issues with dosage/fentanyl
  • Have issues with violent patients with Narcan/naloxone use, sometimes patients come to and are violent with first responders
  • Should look to interactions between law enforcement and HIPAA, could be missing opportunities to use info
  • Alvarado – Asks after estimates of cost to city
    • Strictly drawn from transports made and bills collected, at a minimum it is $3.6 million in 2017
  • Alvarado – Imagine that new unit created by Chief Acevedo increases cost
  • Alvarado – Could you go into training for responders?
    • Provide instructions to work with HPD’s annual training
    • Most important aspect is that Narcan will not harm individuals not overdosing, easy to train officers on administration
    • Problem is poor dosage control with nose spray, IV is more accurate
    • Also highlights violence in affected individuals
  • Alvarado – Asks after pill mills, where were they located & who was involved?
    • Most in Houston had been inside the Loop, seem to be fairly well-distributed throughout the region
  • Alvarado – Have you seen an increase?
    • There has been a decrease, HPD has been effective, but has led to increase of street dealer activity
    • Kush use is also increasing
  • Houston is currently a passthrough, but transporters also need infrastructure laid down in our areas, markets can spring up; Kush being low cost has led to less demand

 

Health System/Hospital Panel

Kathleen Berg, Dell Children’s, Texas Hospital Association

  • Seeing opioids affect younger and younger children due to spread and availability, seeing overdose in toddlers who get access to medications, also seeing teens present to Emergency Department
  • Adopting ED guidelines for opioid treatment would hopefully combat this
  • Using PMP before prescribing opiates, will often turn down patients & can be difficult as many patients become disruptive/violent
  • Also seeing increase of patients presenting with acute opiate withdrawal
  • We are seeing other substances in addition to opiates, methamphetamine, synthetics, etc.; multi-drug issues are common
  • Chair Price – Appreciates checking PMP as part of the process
    • Would be good to have PMP integrated into EMR
  • Chair Price – This is something we are looking at

 

Celeste Johnson, Parkland, Texas Hospital Association

  • 45% of substance abuse disorder population has cooccurring mental health issues
  • Parkland is currently the only behavioral health emergency room in the Dallas region
  • Opioid use ED visits are around 10% of substance abuse visits, taking a toll on ED
  • Also see substance abuse disorder in medical-surgical and women’s health floors
  • Opioid disorders are likely to be missed in patients requiring trauma care or surgery needing opioids, Parkland runs substance use screenings (SBIRT) to try and identify individuals
  • THA’s ED guidelines supports using SBIRT, Parkland has applied for a SAMHSA grant to implement & expand SBIRT
  • Parkland addiction team is able to carry out detox according to national standards, evidence-based detox management has helped retain patients who would have left against medical advice
  • Referral to treatment is challenging for MAT, expensive & unaffordable for indigent patients
  • Guaranteed referral to addictions clinic or outside provider of MAT, Parkland can provide Suboxone treatment in-facility
  • Other challenges to MAT are lack of workforce, lack of training, & lack of credentials; options for some free training exist, like through the American Psychiatric Nurses Association
  • Legislative recommendations
    • Support hospitals on cost of integrating use of PMP into EMR
    • Support implementation of SBIRT
    • Assistance with cost of MAT for patients
    • Embed mental health and substance abuse education in health curricula
    • Explore reasons MAT providers are not practicing and remove obstacles
    • Increase availability of prescription take back programs
    • Provide funding to educate others about signs of substance abuse
  • Roberts – Has relation in medical school, saw limitation of pharmacology education; would it be beneficial to increase availability? Could this be a transformation?
    • Could be, also refers to Dell Children’s work in increasing knowledge
    • Berg, THA – In the ER we are being pushed for 3-day maximum
  • Chair Price – Many of these recommendations are being considered

 

Doug Jeffrey, Texas College of Emergency Physicians

  • ED is not the typical clinical setting, very fast-paced and chaotic; EMR has helped quite a bit for informational organization
  • See a good number of individuals who are drug-seeking, can have an impact on the ED; patients can become disruptive/aggressive
  • Trying to focus on evidence-based practice, working with physicians and being good stewards of opiates is important, likewise trying to change patient behavior through social work supports, etc.
  • Also working on Alternative to Opioid Programs (ALTO)l can include lidocaine, nerve blocks, etc.; being explored on a federal level and wanting to bring this to the state level

 

Ken Mitchell, St. David’s HealthCare

  • Operated by HCA and 2 non-profit foundations, proceeds from operations of hospital are reinvested in foundations that are then invested into community health and wellness
  • Impact of opioids has been massive, many patients with these issues require admission to emergency departments/ICUs & is very costly
  • In a 2017 study, average cost of treating opioid patient in ICU is ~$90k
  • Hospitals have a long history of being proactive regarding public health emergencies, industry has stepped up to curtail availability of opioids in healthcare markets, THA guidelines being one measure
  • Asking for flexibility in implementing strategies
  • Hospitals are required to report quality metrics publicly, pain management metrics being a component has led to increase in opioid prescriptions/issues; creating new protocols can take time, especially in working with physicians who many not be employed by the hospital
  • Any effort to integrate PMP into EMR would be greatly appreciated, including associated funding or reduction of user fees
  • Reduction of use, increased PMP use, and patient education/outreach are the basic elements of opioid prescribing guidelines used by hospitals nationally
  • Many hospitals within St. David’s have implemented significant portions of voluntary guidelines, encouraging hospitals to adopt
  • Many are also adopting the CDC guidelines or developing in-house guidelines
  • David’s has implemented reduction strategies in acute care facilities, coupled with multi-modal pain management strategies
  • Also implemented a High Alert Program to identify chronic users, similar systems are in place with Seton, but firewalls and HIPAA prevent interlinking
  • Hospital staff are not immune to opioid epidemic, some estimates say as many as 10%-15% of hospital staff are using opioids; hospitals within our system have been charged with reinvigorating diversion and prevention
  • Need to support education/outreach on patient pain management, patients can be disruptive/aggressive when they have been confronted with PMP data
  • Reiterates ask for flexibility in implementing opioid solutions, different solutions fit different areas of the state; management of pain is not one-size & should avoid overly tight restrictions on prescribing of opioids
  • Have read Congressional material suggesting 3-day limit for acute pain, could be overly restrictive; THA guidelines suggest 3-5 days
  • Chair Price – You mentioned negative impact hospitals can receive if they follow some of these guidelines; what are these impacts & how are you feeling this as a business?
    • We have been mandated by CMS to participate in patient satisfaction surveys, this survey rolled into value-based purchasing and was a part of what could penalize hospitals
    • Fortunately, questions have been slightly reworded to reflect physician communication about pain, but it is still a survey component; was removed from value-based purchasing

 

Bexar County Panel

Colleen Bridger, City of San Antonio

  • Increase in addictions, overdose, and death has led to this being referred to as an epidemic, but opioids have a disproportionate effect on first responders and health departments
  • Data challenges are a large part of the problem, we know there are hundreds of deaths, hundreds of children born addicted, large numbers of overdose responses needed; leads us to believe 10k+ people are addicted, but no data to support
  • Polysubstance abuse & fentanyl additives are also a large problem
  • Would support MAT, but with a caution that there is an inherent tension with traditional abstinence model; need to implement gently and respect abstinence model
  • Need to recognize that many of the opioid problems are also mirrored in other substance abuse problems

 

Kevin Lucius, San Antonio Police Department

  • SAPD must use extreme caution in collection of evidence with rise of fentanyl, fentanyl can look like other substances and complicates collection of all types of drugs
  • Working with Opioid Prevention Taskforce to train and expand number of SAPD personnel carrying Naloxone
  • Financial impact is extra cost for supplies, collection equipment, increased time to collect & process evidence, increased risk, etc.
  • Have seen an increase in volume of calls where substances play a key role

 

TJ Mayes, Chief of Staff for Bexar County Judge Nelson Wolff

  • Run a naloxone initiative in partnership with HHSC, HHSC assisted us in obtaining a federal grant to help distribute doses to first responders
  • Developed a training program with several law enforcement agencies to train those who will train their departments, administered by UT Scholl of Nursing; SAPD joining next month
  • Provider education initiative focuses on hospitals and collaborating on best practices; planning to replicate the symposium bringing these individuals together every year
  • Also working on community education/outreach, operates a mobile medication take back program sponsored by San Antonio Water System and waste Management; collected 47,000 lbs of unused medication
  • Working with SAPD to create permanent safe disposal boxes
  • Working with San Antoni Council on Alcohol and Drug Abuse to create commercial regarding dangers of keeping excess pills in reach of children
  • Regarding Good Samaritan Laws, some districts will cap amount of drugs to receive immunity
  • It costs County $67/day to detain individuals, diversion programs can help offset costs & tend to be revenue neutral; participants have experienced much lower recidivism rates than general population
  • Chair Price – Appreciates what San Antonio has done, collaboration between law enforcement and medical community has been an example for others to follow
  • Chair Price – Evidence shows some of these initiatives not only produce better outcomes, but also save money
  • Minjarez – Can you speak to Neonatal Abstinence Syndrome & Syringe Exchange
    • Bridger, San Antonio – 300 babies are born addicted to substances in Bexar County, 1/3 of cases in TX; convening a group of experts to explore solutions like increased contact with mothers and access to recovery housing
    • Syringe Exchange has been shown to decrease transmission of Hepatitis C and HIV, Bexar is the only county with authority to operate Syringe programs
    • Looking at how to connect underground syringe services programs with community resources; individuals involved are more likely to seek treatment