89TH ANNUAL WEST TEXAS

COUNTY JUDGES AND

COMMISSIONERS ASSOCIATION

CONFERENCE

Wednesday, April 25, 2018

11:05 – 11:55 a.m.

“Opioid Epidemic as it

Relates to Counties”

Ms. Jessica Cance

Agency Analytics Unit Manager

Ms. Kasey Strey

National Prevention Network -

Prevention Coordinator for

Texas, SPF-Rx Project Director

4/11/2018

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Opioids in Texas: The County Perspective

Jessica Duncan Cance, M.P.H., Ph.D.Texas Department of State Health Services

Kasey Strey, A.C.P.S.Texas Health and Human Services Commission

Objectives• Describe the opioid crisis nationally and in Texas

• Understand the Bio-Psycho-Social aspects of substance misuse/substance use disorders

• Define the role of prevention in the opioid crisis

• Discuss evidence-based strategies designed to prevent opioid misuse and associated consequences

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Drug Overdose in Texas

• In 2016, 2,790 Texans died due to drug overdose

• More than the population of a Texas 6A high school

• More than the population of nearly 60 percent of the cities and towns in Texas

Sources: Texas DSHS Provisional counts of drug overdose deaths, 2/15/2018. U.S. Census Bureau (2017). Annual Estimates of the Resident Population in Texas: April 1, 2010 to July 1, 2016. Available at: https://www.census.gov/data/datasets/2016/demo/popest/total-cities-and-towns.html

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What are Opioids?

5Source: National Institute on Drug Abuse

Type of Opioid Examples

Natural opioids (sometimes called opiates) Morphine, Codeine, Thebaine

Semi-synthetic Hydromorphone, Hydrocodone, Oxycodone, Heroin

Fully synthetic Fentanyl, Methadone, Tramadol

The Opioid System

• Controls pain, reward, and addictive behaviors

• Opioids attach to and activate opioid receptor proteins

• Opioids suppress perceptionof pain and calm emotional response to pain

Source: Gutstein H, Akil H. Opioid Analgesics. In: Goodman & Gilman’s the Pharmacological Basis of Therapeutics. 11th ed. McGraw-Hill; 2006:547-590. 6

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Data Trends

Understanding Opioid Misuse and Associated Consequences in Texas

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10.5

0.6

4.2

0.04

12.3

0.6

3.7

0.070

3

6

9

12

15

Marijuana Cocaine Pain RelieverMisuse

Heroin

Past Year Substance Use among Youth Ages 12-17: TX vs. US

Texas U.S.

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2015 and 2016. 8

10.1

1.5

4.5

0.22

13.9

2.0

4.5

0.360

3

6

9

12

15

Marijuana Cocaine PainRelieverMisuse

Heroin

Past Year Substance Use among Adults 18 or Older: TX vs. US

Texas U.S.

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2015 and 2016. 9

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Accidental Poisoning Deaths in Texas: 1999-2015

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Source: Texas Death CertificatesAccidental Poisonings based on County of OccurrencePrepared by Texas Department of State Health Services, Center for Health Statistics 3/6/2018

2,226

1,174

0

500

1,000

1,500

2,000

2,500

1999 2003 2007 2011 2015

Num

ber

of D

eath

s

Total

Opioids

Cocaine

Psychostimulants

Benzodiazepines

Other Drugs

Texas Health Data: Opioid-Related Deaths

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2,594

1,970

862727

305

0

750

1500

2250

3000

Opioids Benzodiazepines Psychostimulants Cocaine Marijuana

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Drug-Related Inpatient Emergency Department Visits: 2016

Source: Texas Hospital Inpatient Discharge Public Use Data Files, Q1 – Q4 2016. Texas Department of State Health Services, Center for Health Statistics, Austin, Texas. 3/7/2018.

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Texas Health Data:Opioid-Related Inpatient ED Visits

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Texas Poison Center Network Drug-Related Exposure Calls: 2000-2017

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5265

0

1500

3000

4500

6000

7500

9000

2000 2002 2004 2006 2008 2010 2012 2014 2016

Antidepressants

Benzodiazepines

All opioids

Stimulants

Source: Texas Poison Center Network, 2000-2017. Analyses include only those calls involving drug exposures; calls asking for information were not included.

Texas Health Data:Opioid-Related Exposure Calls

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Rate of Opioid-Related Poison Center Network Calls, by County: 2011-2015

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Why Do People Use?

Risk Factors for Opioid Misuse

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BioPsychoSocialFramework

Psychological-Emotions -Thinking

-Attitudes -Beliefs-Stress

Management-Perceptions

Biological-Genetics

-Neurochemistry-Drug Effects

-HPA Axis

Social-Social Support

-Family Background-Interpersonal Relationships

-Cultural traditions-Socioeconomic

Status

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Pain in the United States

• In 2016, nearly one in five adults had chronic pain in the past six months

• Estimated cost of $635 billion

• Late 1990s, pain recognized as “The Fifth Vital Sign”

Sources: QuickStats: Age-Adjusted Percentage of Adults Aged ≥18 Years Who Were Never in Pain, in Pain Some Days, or in Pain Most Days or Every Day in the Past 6 Months, by Employment Status — National Health Interview Survey, United States, 2016. MMWR Morb Mortal Wkly Rep 2017;66:796.Gaskin, D.J., & Richard, P. (2012). The Economic Costs of Pain in the United States. The Journal of Pain, 13 (8), 715. 19

Correlates of Prescription Opioid Misuse

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Community

Organizational

Interpersonal

Intrapersonal

Sources: McLeroy, K. R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological perspective on health promotion programs. Health Education & Behavior, 15(4), 351-377.SAMHSA CAPT (2016). Preventing Prescription Drug Misuse: Understanding Who Is at Risk. Available at: https://www.samhsa.gov/capt/sites/default/files/resources/preventing-prescription-drug-misuse-understanding.pdf

Refusal SkillsRisk Perception

Caregiver MonitoringCommunicationDisapproval

PeerApproval Number of Friends Using

Retail AvailabilityPrescriber Norms

Social AvailabilityCommunity Norms

What Can We Do?

Strategies to Prevent Opioid Misuse and Associated Consequences

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Public Health Approach to Preventing Substance Misuse and Addictions

Source: http://www.astho.org/addictions/ 22

Evidence-Based Prevention Strategies

Risk and Protective

Factors

But why here?

Problems and Related Behaviors

What? And why?

Source: Luciani, N. (2016, September 26). Community-level Strategic Planning to Prevent Non-medical Use of Prescription Drugs in Texas. Lecture presented at CAPT Training - Fall Prevention Provider Meeting, Austin.

Prevention Strategies

What should we do? And how?

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What is Primary Prevention?

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Community Education

• Youth and Young Adults

• Communities

• Health Providers

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Disposal and Storage• Take-Back Events and Drop-Boxes• Individual Medication Disposal Pouches• Lock-Boxes

Source: 2017 Texas College Survey of Substance Use: Main Report. Available at: https://texascollegesurvey.org/wp-content/uploads/2017/08/CDAS_report_final_2017.pdf

55

38

2720

94

0

20

40

60

Someonewith a

Prescription

PersonalPrescription

Someonewithout a

Prescription

HomeMedicineCabinet

Stealing It On-Line

Perc

enta

ge

Sources of Misused Prescription Medication among Texas College Students: 2017

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Workforce Development

• Prevention, Treatment, and Recovery Professionals

• Prescribers and Other Health Care Professionals

Source: Shah, A., Hayes, C.J., & Martin, B.C. (2017). Characteristics of initial prescription episodes and likelihood of long-term opioid use: United States, 2006-2015. MMWR MorbMortal Wkly Rep; 66:265-269. 27

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Prescribing Patterns, by County: 2015

Source: CDC Vital Signs, July 2017Interactive maps: https://www.cdc.gov/drugoverdose/maps/rxrate-maps.html 28

Data Infrastructure• Prescription Monitoring Programs

• High Utilization• Consistent Reporting• Incorporate into Prevention Planning

Source: www.cdc.gov/vitalsigns/opioids 29

Texas Prescription Monitoring Program

• Moved from the Department of Public Safety to the Texas Board of Pharmacy in 2016

• Prescriber mandate passed Spring 2017 (House Bill 2561, 85th Regular Session)• Registration• Requires patient look-up prior to

prescribing opioids, benzodiazepines, barbiturates, or carisoprodol

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What is Secondary Prevention?

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Referrals and Resources

• Outreach, Screening, Assessment, and Referral Centers (OSARs)

• Treatment Centers• Peer Coaches• Recovery

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Outreach, Screening, Assessment, and Referral Centers (OSARs)

Source: https://www.dshs.texas.gov/sa/OSAR/ 33

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Screening & Brief Intervention (SBI)• Designed for use by counselors

and professionals who do not specialize in addiction treatment

• Person-centered methodology that uses motivational techniques based on the person’s readiness to change

• Gives feedback and recommendations respectfully, without judgment or accusations, in the form of useful information

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Treatment and Recovery• Medication Assisted Therapies

• Methadone• Buprenorphine• Naltrexone

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What is Tertiary Prevention?

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Source: San Francisco Department of Public Health. Naloxone for Opioid Safety. San Francisco Health Network Website. http://bit.ly/2t8GaKy

Naloxone

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Resources for academic institutions, community organizations, & healthcare providers

Continuing education for pharmacists, prescribers, & social workers

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Summary and Additional Resources

Texas Health Datahealthdata.dshs.texas.gov/Home

Outreach, Screening, Assessment, and Referral Centers (OSARs)

www.dshs.texas.gov/sa/OSAR/

Operation Naloxonewww.OperationNaloxone.org

CDC Opioid Overdosewww.cdc.gov/drugoverdose/index.html

Opioid Epidemic Practical Toolkit: Helping Faith and Community Leaders Bring Hope and Healing to Our Communities

www.hhs.gov/about/agencies/iea/ partnerships/opioid-toolkit/index.html

U.S. Surgeon General – Opioid Overdose Preventionhttps://www.surgeongeneral.gov/priorities/opioid-overdose-prevention/index.html 39

DEATakeBack.com

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Thank youJessica.Cance@dshs.texas.govKasey.Strey@hhsc.state.tx.us