OPIOIDS IN AMERICA:

The State of Texas

Texas Legislative Council

Part 4:

The State of Texas

Opioids in America

The opioid epidemic that has ravaged many communities across America has not left Texas unscathed.

In this fourth and final installment of TLC's Opioids in America series, we will examine in detail the nature and scope of the epidemic within the Lone Star State. We will also examine how inconsistent data collection may be masking the severity of the problem in Texas.

Opioids in America

News reports and state-by-state studies of the epidemic have depicted Texas as one of the states least impacted. For example:

The Kaiser Family Foundation reports that Texas had an age-adjusted opioid overdose death rate of 4.9 per 100,000 population in 2016 versus the national average of 13.3 per 100,000.

Further, Healthcare Cost and Utilization Project (HCUP) data indicate that Texas had a rate of 108.1 opioid-related inpatient hospital stays per 100,000 population in 2015, the fourth-lowest rate in the country and well below the national average of 251.3 per 100,000.

Opioids in America

Though Texas seems to have fared far better than many other states, opioid overdose deaths in the state did rise from a reported 298 in 1999 to 1,420 in 2016―an increase of more than 375 percent.

Prescription opioids have historically accounted for the vast majority of overdose deaths in Texas. In recent years, however, overdose deaths attributable to prescription opioids have been decreasing, even as those attributable to heroin have risen considerably.

Even so, the heroin death rate in Texas, 1.9 per 100,000 deaths in 2016, has remained lower than the national rate, 4.6 per 100,000, in part because the Mexican black tar heroin that predominates in Texas is impure and difficult to mix with more potent drugs such as fentanyl, exposure to which is responsible for many of the nation's heroin overdose deaths in recent years.

Opioids in America

Although on the whole Texas seems to have been less affected by the opioid epidemic than most other states, indicators point to a severe effect in certain pockets of the state.

Based on calls into the Texas Poison Center Network reporting opioid-related drug exposures, opioid abuse is most serious in public health regions (PHR) 2 and 5.

The rate of opioid-related inpatient admissions through emergency room visits are far higher in PHRs 1 and 4 than anywhere else in the state.

The death rates for accidental opioid overdose deaths are highest in PHRs 8 and 5.

Opioids in America

Certain regions of the state stand out when viewing the problem on a national scale as well. For instance:

• 1 Texas county (Foard) was among the 220 counties that the Centers for Disease Control (CDC) identified across the country as being at high risk of an HIV or hepatitis C outbreak due to opioid abuse.

• 3 of the top 25 cities nationwide for prescription drug abuse are in Texas: #10--Amarillo; #19--Texarkana; and #23--Killeen. In each of these cities, more than 40 percent of all opioid prescriptions are abused, with Amarillo leading the cities in Texas at 47 percent.

• 9 counties in Texas are in the highest nationwide quartile of counties by opioid prescribing rates (Bowie, Brown, Childress, Gregg, Hood, Lamar, Nolan, Orange, and Wilbarger).

• 4 of the top 25 cities nationwide for opioid abuse are located in Texas: #10--Texarkana; #13--Amarillo; #15--Odessa; and #17-- Longview. In each of these cities, the rate of opioid abuse is at least 8 percent of city residents.

Opioids in America

Many observers have pointed to the lack of medical examiners in most Texas counties as a flaw in data collection. Only 12 of the state's 254 counties have a medical examiner's office with a licensed medical examiner on staff to perform autopsies as part of the death certification process. In the counties not served by a medical examiner, that process is overseen by a justice of the peace, a position that does not require medical training.

Another source of information, the Texas Poison Center Network, is an entirely voluntary system. Most calls to the network are placed by hospitals around the state during patient intake. Consequently, counties without hospitals are underrepresented in its data, which may mask the severity of the crisis in many of the state's rural counties.

The Houston Chronicle found discrepancies between county-level death records and tallies kept by the Department of State Health Services (DSHS). For 2013, DSHS reported 622 opioid-related deaths across the entire state, while the local medical examiners for just 17 of the state's 254 counties recorded nearly 800 deaths related to prescription drugs.  

Experts have raised concerns that available statistics obscure the true severity of the crisis in Texas.

Opioids in America

Even though Texas' rates of opioid abuse and overdose deaths appear to be far lower than the national average, a 2015 study found that the opioid epidemic cost the state nearly $2 billion in related healthcare costs, the second highest nationwide.

A key factor in that calculation is the number of opioid-related hospital charges. Between 2010 and 2014, Texas saw nearly 19,000 opioid-related inpatient admissions through ER visits, accounting for charges of $761.6 million.

Though ranking second in the nation for total opioid-related health expenditures, Texas fares better per capita than many other states. The state's total opioid cost per capita is an estimated $760, far lower than in such states as West Virginia ($4,793) and Ohio ($2,807).

Moreover, estimated non-fatal opioid health care costs in Texas are slightly more than $200 per capita, which places the state in the fourth quintile nationwide.

Opioids in America

To help recover some of these costs, the Texas attorney general joined a number of other states in filing a lawsuit in state court in May 2018 seeking civil penalties and injunctive relief against Purdue Pharma, the manufacturer of OxyContin and other opioids. The suit alleges that Purdue engaged in deceptive marketing of prescription opioids and misrepresented the risk of addiction and the potential benefits, effectiveness, and side effects of the company's opioids.

Additionally, at least 55 Texas counties have filed similar lawsuits against various opioid manufacturers, and a number of other counties have taken steps toward retaining counsel and pursuing legal action. 

Several Texas municipalities and hospital districts have taken legal action as well.

Opioids in America

In response to the ongoing epidemic of opioid abuse, the state has adopted a number of policies aimed at curbing abuse and providing treatment to drug abusers.

Texas is one of only 13 states that have enacted legislation providing for the certification and regulation of pain-management clinics and cracking down on so-called pill mills.  

Following implementation of Senate Bill 911 in 2010, more than 200 pain management clinics were required to register with the Texas Medical Board for certification. Studies show that the state has since seen a decrease in average opioid dosage, aggregate opioid volume, and the number of opioid prescriptions and pills dispensed in certain populations that had above-average opioid utilization.

Opioids in America

Texas became a national leader in 1981 when the legislature created a statewide prescription monitoring program, overseen by the Texas State Board of Pharmacy.  Most other states didn't begin to adopt such programs until the early 2000s.

In 2017, the 85th Legislature enacted House Bill 2561 to strengthen the prescription monitoring program by requiring pharmacists to report information to the board on prescriptions for controlled substances within one business day of dispensing a prescription.

Moreover, the legislature mandated that beginning in September 2019 doctors and pharmacists access patient information in the database before prescribing or dispensing opioids and certain other controlled substances.

Opioids in America

Texas has taken steps to expand access to treatment for those suffering opioid addiction and dependency.

The 84th Legislature enacted Senate Bill 1462, which authorized an eligible prescriber to prescribe, directly or by way of a standing order, an opioid antagonist to a person at risk of an opioid-related drug overdose or to someone in a position to help such a person. Opioid antagonists, most notably Naloxone, bind opioid receptors and block the effects of opioids when a person is experiencing an overdose.  

With this authority, the Texas Pharmacy Association in 2016 obtained a physician-signed standing order allowing pharmacists in Texas to dispense Naloxone without a prescription. Since that time, Naloxone has been made available on an over-the-counter basis at each CVS, Kroger, and Walgreens pharmacy across the state. 

Opioids in America

The Texas Medicaid program also provides pharmacy benefit coverage for Buprenorphine and Naltrexone, two drugs used to combat opioid dependency.

The third federally approved medication-assisted treatment (MAT) drug, methadone, is not covered under the pharmacy benefit portion of the state's Medicaid program but is made available as a medical benefit when it is part of treatment received in a state-licensed and federally regulated opioid treatment program.

The state's Medicaid program covers a number of substance abuse treatment options as well, including both inpatient and outpatient detoxification programs. 

Certain other treatment options covered by Medicaid in a number of other states, including psychotherapy, crisis intervention, and case management and care coordination, are currently not covered by Medicaid in Texas.

Opioids in America

The federal Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that nearly 94 percent of Texans deemed to be in need of addiction treatment do not receive it. This places the state among the bottom three in the nation. The scope of this problem is partly explained by the large number of Texans who live in rural areas that lack treatment options.  

Moreover, Texas has only 1,227 physicians statewide who are licensed to administer Buprenorphine to treat opioid dependency. Of the state's 254 counties, 171 do not have a physician licensed to administer that drug.

While the state has 395 facilities that provide substance abuse treatment, 174 counties have no such facility. Of those facilities, only 147 provide MAT drug treatment services, which are widely regarded as one of the most effective and desirable approaches to treating opioid dependency. In Texas, 208 counties lack even a single MAT provider.

Opioids in America

As part of the effort to expand access to treatment and other related services, the Texas Health and Human Services Commission (HHSC) received a $27.4 million grant from SAMHSA in 2017 and an identical grant in 2018 to help fund the state's Texas Targeted Opioid Response (TTOR) program.

According to HHSC, TTOR "expands access to treatment, prevention and early intervention, and provides long-term recovery supports" to those suffering from, or at risk of developing, opioid dependency by funding activities across the state such as:

• Expanding access and capacity for medication-assisted treatment

• Implementing opioid-specialized crisis services to be available 24/7

• Making available long-term recovery support services for those with a history of opioid use

Opioids in America

While Texas has implemented a number of policies and initiatives in an effort to combat opioid abuse, some measures adopted by other states have not been adopted in Texas. These include:

• "Good Samaritan" protections for witnesses who call for help during an overdose event

• Statewide limits on opioid prescriptions

• Participation in the CDC's Overdose Prevention in States (OPIS) grant programs, which direct funds to provide assistance in prevention efforts, improve data collection, and enhance overdose surveillance

• Syringe exchange programs

Opioids in America

While the devastation of the opioid crisis has been more widespread in other states thus far, some corners of Texas have been severely afflicted. 

Local and state leaders have taken meaningful steps to curb abuse and address the factors that heighten the risk of addiction, but given the enormous human and economic costs of the epidemic, future efforts may benefit from the collection of more comprehensive data and will require continued consideration and development of best practices and policies and an examination of their effectiveness.

Opioids in America

For questions, please contact Logan Moore in the TLC Research Division at (512) 463-1155