Marcia G. Ory, PhD, MPH, and Joy Alonzo, M. Engineering, PharmD, share their insights on the opioid crisis and why its impacts may be underreported. They also offer some reasons to be hopeful that we can make a difference, including the efforts of the Texas A&M Opioid Task Force.
Lindsey Hendrix: Hey there. Welcome to The Vantage Point. I’m Lindsey Hendrix. Today on the show, we’ll be discussing the opioid epidemic in America. This is an issue that affects just about everyone. For decades, and some would argue centuries, a certain type of pain medication has turned, for many, from a life saver to a current that has pulled them into the darkest depths of addiction. There are numerous reasons why opioids have become one of the biggest drug problems in America. Today, we’re joined by two experts who will discuss some of these issues. Dr. Marcia Ory is a public health researcher and professor and chair of the Texas A&M Health Science Center Opioid Task Force. Dr. Joy Alonzo is a clinical pharmacist, researcher and professor and is a member of the Opioid Task Force. Welcome to the show.
Joy Alonzo: Thank you.
Marcia Ory: We’re delighted to be here.
Lindsey Hendrix: Well thank you so much for coming. For people who don’t know you, Dr. Ory, do you want to talk a little bit about your role in the Opioid Task Force?
Marcia Ory: Yes, I’d like to. The Opioid Task Force was actually established in February of 2018, so it’s just a little bit more than a year. And how we started was really a vision of Dr. Carrie Byington, who’s the Vice Chancellor for Health Services at the Texas A&M Health Science Center. It was really her vision of bringing people together from all of the health science components. So we have representation on the task force from public health, from medicine, from pharmacy, from dentistry and nursing. It’s an all HSC-wide task force.
Lindsey Hendrix: It sounds like we’ve got people involved from all different disciplines so they’re actually approaching this from many different angles and perspectives.
Marcia Ory: Exactly. And so not only do we have faculty in the different components, but one of the things that I think is incredibly special is we’ve appointed student ambassadors. When we first started we thought maybe we’d get five to 10 ambassadors. At last count, we have 60 ambassadors from each of the Health Science Center components. Not only in College Station, but we have ambassadors in Dallas, in Round Rock, in Houston, in Kingsville, every single place where we have Health Science Center students.
Lindsey Hendrix: And what are the students’ role in the task force?
Joy Alonzo: Some of the students have been assisting in an intervention that we’ve developed where we’re doing community distribution of naloxone rescue kits. It’s a strategy to decrease the number of deaths associated with opioid overdoses. The students are actually able to participate in the training as expert leaders and subject matter experts and they actually have been training to lead small groups of folks. And we’ve developed the Texas A&M Opioid Overdose Action Plan and the students will lead participants through the action plan just like you would lead somebody through demonstrating their capability to perform CPR.
Marcia Ory: One of the things about the task force, another thing is, that it has a research focus, an education focus and a practice or community focus. So in addition to what we just heard about training, the ambassadors have helped us in community engagement. One of the first things we did was to have an episode of The Trade which really explained how it is that the epidemic started and its sort of movement through Mexico through the U.S. And the ambassadors were there staffing the tables, helping introduce with information for people in the community. We also had a reflection wall, and I think that was very powerful. We had a wall where people could see the sort of statistics—and I know we’re going to be talking about that—the statistics about the opioid epidemic, but also it gave them an opportunity to indicate what they thought, what their own reflections were, what this epidemic meant to them personally. And I think what moved me as I was sitting there while people were writing, somebody would come up and say I never said this, but my cousin, my neighbor, and I think this shows that the epidemic is everywhere. And people who are impacted really don’t tell people, and that’s one of the things that we want to do as the task force is to de-stigmatize opioid epidemic, substance abuse, because with stigma, people don’t get treatment.
Lindsey Hendrix: Right. So let’s take a step back a little bit for people who may not be paying attention to the news. What is the opioid epidemic? And we say that there’s an epidemic happening in America. Describe what that is. What are opioids and how did we get to this point that we’re calling it an epidemic?
Joy Alonzo: Opioids are a class of medication that people associate with pain management. Historically, they’ve been used very effectively to—in the United States and throughout the world—very, very frequently for pain management. Also used for constipation. Also used as cough suppressants. These are medications that most people are probably pretty familiar with and most people, if you’re an adult, you’ve probably had an opioid at some point in your life prescribed to you by a medical professional. What happened here is that there’s several driving factors that have precipitated the opioid crisis. One of the big drivers is pharmaceutical companies marketed physicians in such a way that they implied that there were certain types of opioids that wouldn’t cause tolerance and dependence. That turned out not to be true. All opioids cause tolerance and dependence and that means that over time, your body gets used to the medication and you need it—not for the original medical purpose, but now in a way that your body actually, at the cellular level, is craving this medication—just like the way you would develop tolerance and dependence on alcohol or other types of substances, nicotine, other types of substances.
Marcia Ory: I think we should tell some of the names because when people see opioids, they know the common names.
Joy Alonzo: Sure, so some of the common names that are very frequently prescribed are Vicodin. That particular medication, if you’re a House fan, Dr. House very famously had an opioid use disorder. His substance was Vicodin. It’s also known as hydrocodone and acetaminophen. Other trade names for it are Norco or Lortab. These were all very, very commonly given after very minor surgical procedures and dental procedures. Another one, morphine, is certainly an opioid. Oxycontin, or oxycodone, Percocet, Percodan—these are all opioids that a person could be exposed to. Illicit opioids would be heroin. That’s one that I’m sure a lot of people have heard about. And also illicit fentanyl. Now, fentanyl’s a little tricky because there’s also medical fentanyl. Fentanyl can have legitimate medical uses, but there’s a type of fentanyl that comes here illegally from other countries, like China or Mexico, is illicit fentanyl and it’s not made in a lab by a pharmaceutical company. It’s made in somebody’s garage.
Marcia Ory: When we talk about the epidemic, there’ve always been opioids. We’re talking about morphine.
Joy Alonzo: Always. Thousands of years.
Marcia Ory: Thousands of years. But I think when we’re talking about the current opioid epidemic, we really start in about 1999. The epidemic has three different waves. The initial wave is what we’ve just been talking about and that is prescription drugs. And part of the reason we are where we are is that there was the concept of pain being a fifth vital sign. Doctors felt as though quality care involved reducing people’s pain. At the same time, what we just heard is pharmaceutical companies were saying yes, pain is something we can treat. The original proposition was that it wasn’t going to be addictive. We know that’s not true now. The first epidemic is probably 1990s ’til about 2013. The second wave happens to be heroin. Well that usage goes up. The third wave, which is the most recent wave, is about 2016 and it’s fentanyl. So now when you look at people dying, at first it was more prescription drugs, then it was heroin and now it’s fentanyl. The nature of what people are using and what is most dangerous has changed over the last 20 years.
Lindsey Hendrix: Why has that changed? Why have people gone from prescriptions then to heroin and then to fentanyl?
Joy Alonzo: One of the things that happened was in about 2011, 2012 time frame. The DEA actually recognized that Vicodin, Norco, all the hydrocodone products, were actually being diverted at a very high rate. What they did was they re-scheduled that medication from what’s called a Schedule III to a Schedule II. That might not mean much to most people, but to a physician, that means a lot. Now, if something is a Schedule III, you can write for six month refills. You don’t have a lot of restrictions on it. But now if it’s a Schedule II, you have to write on a special prescription pad, you can only write for one, the original fill. You have to put your DEA number on there. It’s very observable. Re-scheduling Vicodin—on that day, Vicodin had almost no street value up until that point. Opioids are actually really, really cheap to produce. Even the prescription versions, they’re cheap. But on that day, when it was re-scheduled, Vicodin then had a street value because the access is now restricted. And so folks that had tolerance and dependence on Vicodin essentially got cut off. The street value went from almost zero to $20 a tablet. If you’re taking two to three tablets every four to six hours around the clock, all of a sudden, you now have an addiction to a substance that you can no longer afford. This was medically given to you before, but now it’s an observable, and so that physician may not be willing to continue or didn’t want to taper it. So heroin is five bucks a bag.
Lindsey Hendrix: Hm, yep, that’s a big difference.
Joy Alonzo: There’s an economic factor there. Initially, that’s when you saw, like Dr. Ory said, the second wave is heroin. Up until that point, we hadn’t really seen a whole lot of heroin deaths in the United States. That was 2011, 2012, 2013. Additionally at that time, 2011, that was the first time we noticed from a public health perspective that the number of traffic accidents and the number of opioid overdose deaths had crossed. In other words, you actually now have, now today, from an actuarial standpoint, everybody—I’m talking about everybody, I’m not talking about just people with substance use—you actually have a higher risk in the United States of dying from an opioid overdose than you do of dying in a fatal traffic accident.
Lindsey Hendrix: That is crazy.
Joy Alonzo: If you think about that, we all drove here. I just drove here. Everybody drives. Even kids get in buses. Everybody drives. Everybody incurs the risk of a fatal traffic accident every day. Yet, I’m hard pressed to remember, maybe when I was having my children in the hospital, the last time I was at risk for an opioid overdose. Yet my relative risk of dying from an opioid overdose in this country is higher than my risk of dying in a traffic accident.
Lindsey Hendrix: And so how many people are dying every day from an opioid?
Marcia Ory: In the U.S., and these figures keep escalating over time, the last statistics are 2017 and they’re not even complete. But people talk about the numbers in the U.S. averaging out to about 130 deaths a day.
Lindsey Hendrix: Wow.
Marcia Ory: But let’s talk about Texas because that’s where we are. Texas statistics would indicate that we’re not a high incident state, that’s there’s not a problem in Texas. However, experts think that the data is not really in. Part of the problem is that we aren’t reporting the deaths that are occurring. If you think about Texas, it’s a huge state. There are 254 counties. But, there’s less than 20 and probably about 15 medical examiners. If you see a death and there’s not a medical examiner, who’s likely to be certifying the death is a JP and that person doesn’t have medical training. One of the things that I just learned from one of our medical directors, it used to be that Medicare would pay for autopsies. Medicare no longer pays for autopsies, so you really have a death and you have somebody who’s not medically trained. It’s absolutely true when they put on the death certificate “respiratory failure.” It’s a true statement, but it may not be the full statement.
Joy Alonzo: Even when Medicare did cover autopsies, you have to be 65, so anybody below 65 that doesn’t encompass any of the rest of the population. Certainly, that is definitely an issue, the lack of medical examiners. Just by counting up death certificates, that’s the way we’re currently reporting. So that doesn’t capture, for instance, if you die in the hospital in the ER and you’re not resuscitated, it’s actually up to the physicians to decide. And there’s a lot of reasons, based on stigma and the wishes of the family, why they may not want the death certificate filled out in such a way that would indicate that the cause of respiratory failure was an overdose. And there’s insurance reasons for that. There’s all kinds of reasons. Just by counting death certificates, we have a very poor view of how to characterize the opioid use disorder in this state.
Marcia Ory: And that’s just the tip of the iceberg. That doesn’t count the people who overdose and are resuscitated.
Joy Alonzo: Non-fatal overdoses.
Marcia Ory: We also have some of the people look at accidental calls to poison control. But again, even though by law you’re supposed to report that, there’s a difference between what’s supposed to happen and what people do do, so we don’t get all of the accidental poisonings reported. The people who are in the state health department are really trying to titrate all the different sources and improve the data. So we have deaths and we have things that happen at the ER and things that happen when you’re hospitalized and poison and outpatient clinics. We really need to take all of that data together to get an idea of—and even what some people are looking at is prescription drug use. If you’re in a county where you know there’s a lot of prescription drug use, that’s an indicator.
Joy Alonzo: Yeah, can you correlate that to the level of opioid use disorder in that particular county. It’s very difficult to characterize. Non-fatal overdoses are extremely problematic. That data stays where it lays. No way to enforce anybody to report it anywhere. And until it’s considered a quality measure where that facility will get rated or their accreditation is based on their capability to report an aggregate—we aggregate that data up—we just don’t have it.
Lindsey Hendrix: How do you define an opioid use disorder?
Joy Alonzo: There’s very specific criteria on that in what’s called the DSM-5. The DSM-5 is a diagnostic manual for psychiatric and behavioral and mental health disorders. There’s a list of criteria that indicate that your tolerance and dependence has reached such a point that you no longer engage in self-care. You can no longer function at school or at work. You don’t engage in satisfying relationships. Essentially, again, at the cellular level, your brain has changed and what it does is it drives you to seek more of this drug, and all the other aspects of your life fall away. The people are very dysfunctional.
Marcia Ory: But I think what’s really important is people used to refer to addicts. But I think now with this concept that opioid use disorder is a disease, it’s an illness. So we really want to get the point across, you’re not a heroin addict. You’re a person with an opioid use disorder that’s taking your life over. And so that’s the other. I think a lot of people think it’s willpower. If somebody just would’ve had more willpower they wouldn’t be addicted. What we know chemically and medically is that’s not true, that this is something that is just like a disease. It’s like having diabetes. It’s not something you can really control.
Joy Alonzo: Right. And certain individuals may be more susceptible to it than others. An aspect of opioids is that they’re psychoactive. I think that that’s an aspect of the pharmacology of opioids that most people aren’t familiar with. Opioids cause what’s called euphoria. Euphoria is that feeling like you got rose colored glasses on. The whole world’s okay. You can hear the ice tinkling in the background. Everything’s great. That phenomenon, that affects some people more than others. Why that is, we don’t exactly know. It’s probably a genetic aberration in certain individuals. We actually here at Texas A&M, we have a research project to establish why some people who are exposed to opioids develop opioid use disorder and that euphoria is very profound for them, and why other folks may be exposed to opioids and they don’t develop opioid use disorder, and what is the difference. The way they metabolize the drug, how fast they metabolize, how the drug actually interacts with their receptors at the cellular level, all those things are pertinent. Just like Dr. Ory said, this is not a character flaw. This is your body working against you. This particular disease state, more than some of the other substance use disorders, is not a white knuckle. It’s very unlikely that without assistance, some kind of very organized medical treatment and mental and behavioral treatment, that you will be able to recover and sustain that recovery meaningfully.
Marcia Ory: Let’s talk for just a moment about who’s impacted. Certainly, I think, initially, people thought of older people who were on prescription drugs. That’s one class. Now we’re seeing people in the workforce, people who have back pain who’ve gotten addicted, adults who might have been in a car accident and get on drugs. But we’re also seeing mothers and children. And so Texas has one of the highest maternal mortality rates. And when you look at infants being born, there’s this concept of neonatal abstinence syndrome. What this really means are babies being born addicted, and that’s when we know that there’s a problem in Texas. Texas has a really high prevalence of this, relative to the rest of the nation.
Lindsey Hendrix: We see if these mothers are carrying babies to full term using opioids and that’s just one population, this probably impacts way more people.
Joy Alonzo: Right, so the mothers have opioid use disorder, then they become pregnant and then the baby is born with tolerance and dependence. These babies are very fragile, medically fragile, very difficult to care for. We’re learning as we go along, but just to give you a perspective, 32% of all U.S. cases of neonatal abstinence syndrome occur in Bexar County.
Marcia Ory: That’s San Antonio.
Joy Alonzo: If you want to study neonatal abstinence syndrome you go to Bexar County. And in fact, right now, we were sharing articles back and forth about how there’s a huge cry for volunteers to come and hold these babies because they do better in the NICU. So there’s a bunch of volunteer people who hold them. They’re extremely agitated, very irritable. It’s an extremely difficult disease state to come up with a protocol for the recovery of this child. And additionally, you have to come up with recovery protocols for the mom, too. If you consider that special population, we have such a prevalence of users in that special population, try to consider what everybody else is like. Additionally, prior to just 2018, December, we kind of looked at this, like Dr. Ory characterized it, as kind of an adult problem. Actually, the CDC just came out with a new report indicating how this has impacted children up to the age of 18 and particularly adolescents. Right now, really for opioids, there is no FDA indication for opioids in children. We use them, but there’s no indication. There’s a lot of off label use of medications in children for all kinds of reasons. But consider this, Texas Children’s Hospital considers it such an issue that they’ve actually stricken codeine, which is actually metabolized to morphine in the body. That is not on the formulary at Texas Children’s. I would say that’s the one opioid that people kind of associate with children is codeine because of cough syrup. That is not on the formulary, it is never used. And in fact, with Texas Medicaid, any codeine-containing product is not a Medicaid covered benefit for Medicaid recipients. In Texas, Medicaid is mostly kids and pregnant women and so they’ve actually stricken codeine from the formulary. Just to give you an idea how bad things are in the adolescent population—we don’t have great statistics, but we do have a lot of anecdotal data that’s given to us—the juvenile justice population in the Brazos: we were told by the juvenile justice officers that have met with us as part of the Opioid Task Force that 60 to 65% of the kids that are in juvenile justice right now have a profound substance use issue. They currently need treatment for substance use disorder. The one juvenile justice officer that we talked to indicated to us that there were four opioid overdoses at intake just last year.
Lindsey Hendrix: Oh my goodness.
Joy Alonzo: They overdosed right in front of her while they were in intake being processed.
Marcia Ory: And that’s because they were caught, they swallowed their drugs and then it takes you a little bit of time—
Joy Alonzo: It takes a couple hours.
Marcia Ory: So by the time you get booked. But let’s talk about some solutions. One, I think, the CDC and professional societies are putting in force policies and procedures. And I think these have both good and negative implications. Now physicians are told you need to be really restrictive about prescribing opioids. I think that you can’t have a one-size-fits-all. So in some cases that’s appropriate, when the opioids were terribly over prescribed. But if you’re an 85-year-old lady and you have five crushed vertebrae and you’ve been on opioids for a long time, you’re not going to go from being prescribed and the next time you go to see your doctor your doctor says, sorry, I can’t prescribe. That person may actually be on the street seeking drugs. So I think that if you have these new policies, which actually could be beneficial, you also have to have a strategy to taper people down.
Joy Alonzo: Yeah, I think that’s absolutely true. Here in Texas, as of September 1 of 2019, all physicians, all prescribers—that includes nurse practitioners who prescribe controlled substances and PAs under protocol—they all have to evaluate the Prescription Monitoring Program—it’s called the PMP—prior to prescribing. It doesn’t tell you what criteria to use. You’re supposed to use your clinical judgment on whether or not you want to prescribe a controlled substance or not. But I think the theory is the act of looking will make you think twice and assess the safety and the risk versus benefit for this patient. And additionally, I do agree, that you can’t just cut people off. That’s how we actually got the second wave. That’s how we pushed people to heroin. The other piece of that is that pharmacists also have to look at the PMP prior to dispensing. There’s two kind of stops there, but not a whole lot of training has been rolled out about what the criteria are. Additionally, what happened this year, was another policy that was implemented. The CMS that adjudicates Medicare, as of January 1, 2019, they changed how much they are willing to pay for for Medicare recipients. If you’re opioid naive, which means you haven’t taken opioids before, you’re only allowed a seven-day supply before you’re re-assessed. That’s great if you are just starting on opioids or you just had an acute procedure. I think that that’s a great safety initiative. But what do we do about these folks that are in this position who are in situations where they’re not in palliative care, they’re not in oncology care or cancer care, but they still have some kind of condition that is chronic? They don’t have addiction, but they do have tolerance and dependence. Addiction is a behavioral issue, right? Tolerance and dependence are physiological. We want them to be maintained on these medications, but we have to find a way to implement other procedures where we’re checking in more, making sure it’s as safe as possible.
Marcia Ory: I think there’s certainly pharmacological aspects to pain, but I think what we also want to do is to teach our health care providers and others what alternatives to pain might be. And so instead of just having the first solution be let’s get somebody an opioid, it’s do they have muscular skeletal pain? Would PT, would yoga, would different kinds of alternatives be beneficial? And I think in the past, people didn’t think about that. They thought I’ll just write a script. And so now one of the things we want to teach health care providers is to be aware of and think about alternatives.
Lindsey Hendrix: Are these types of interventions, the alternative pain management interventions, covered by insurance? Are there barriers to that?
Marcia Ory: That’s one of what I think is a huge problem. It’s a huge problem geographically. We talked to family medicine docs here and when they see somebody from a rural area, they are more likely to write a prescription because they know if you go back, there’s not going to be a yoga instructor, there’s not going to be PT, there’s not going to be that. Also, you’re absolutely right. You’re more likely to be reimbursed for a drug than you are for these alternatives.
Joy Alonzo: We just had a pain management conference at the Coastal Bend Health Education Center and for the first time I thought we actually did the entire continuum. We discussed alternate pain management, but we also had when you do have a patient that you think may be developing an opioid use disorder, what kinds of treatments can you offer? But the whole range of things that can be done, different types of medications, there’s other classes of medications that you can consider. Right now we’re looking at Amitriptyline. We’re looking at duloxetine, which are drugs that have been used traditionally for psychiatric services, but they also have great pain management. We’re also evaluating people for underlying, untreated mental health issues that may contribute to their pain. We find that if we can manage these underlying mental and behavioral health issues like major depressive disorder, that the pain is much less of an impact. We’re able to actually address other types of things that may be effective. Chiropractors. Ketamine. Ketamine was one of the drugs we talked about, the promise of other medications that we’re studying aggressively to find other, different modalities to treat pain.
Marcia Ory: We’ve been talking a lot about medicine and pharmacy, but as a Health Science Center, we also have dentistry. And if you think traditionally, it was dentists with adolescents, when they would come in and get their molars extracted, they used to get lots of heavy doses of opioids. Now, again, the dental societies have said you can only get limited amounts. I think it’s not just physicians, it’s everybody who might be prescribing. If you’re part of the problem, we want you also to be part of the solution.
Lindsey Hendrix: So you mentioned that physicians tend to prescribe people who maybe live in rural or outlying areas more opioid prescriptions because that’s an easier tool for them to use once they’ve left the city or the hospital where they’re seeking care. Are we seeing that there’s a bigger problem with opioid misuse disorders in rural areas?
Marcia Ory: If you look nationally, the places that have been hardest hit, it’s Ohio, it’s West Virginia. There’s a concept that the first wave of opioid use disorder was in rural areas. If you look in Texas, Texas has four of the 25 highest abuse areas and they’re in rural areas. But now, in this new wave, and particularly when we’re talking heroin or fentanyl, you talk to law enforcement in Tarrant County, in Dallas, you talk to people in San Antonio, people in Houston. I think you can’t say that geography determines now where there’s going to be an epidemic. I think it’s everyone, every place and every age.
Joy Alonzo: I think that that’s probably right. I do think the rural areas are particularly hard hit. You might not have the numbers that we have in the more densely populated areas, but consider we live really close to Brenham. Brenham had 368 opioid-related arrests last year and the two officers that we just recently trained for naloxone rescue, they actually just recently reported that they had two overdose deaths in these two rural counties. That probably doesn’t compare to the overdose deaths that Harris County has, but—
Marcia Ory: Per population.
Joy Alonzo: Yeah, by per capita it does. It’s very impactful.
Marcia Ory: Let’s talk about some other solutions. We’ve been doing a lot of training, so we talked about the students and their involvement, but let’s hear about some of the training both for health science students as well as people in the community.
Joy Alonzo: One of the boots on the ground interventions that we’ve developed at the Opioid Task Force is opioid overdose education and naloxone administration training. This program takes about 90 minutes, and it introduces a lot of the topics we’ve talked about—some of the factors driving the opioid crisis, a little bit about the basics of opioid pharmacology—and then it introduces this idea of a reversal agent that anybody, anybody can use to reverse what they think is an opioid overdose. The beauty of this whole solution is that you actually don’t have to know if it’s an opioid overdose or not. If it is an opioid overdose, the person will, after being administered naloxone, they will start to breathe again. The way you die from an opioid overdose is respiratory depression, which leads to coma, which leads to death. So essentially, you get no oxygen to the brain, your brain is starved for oxygen and then you expire. This drug actually, at the receptor level, will reverse the activity of an opioid on respiratory depression and the person will start to breathe again. But if it’s not an opioid overdose, if they’re unconscious due to some other reason, it’ll have no affect at all. We’ve been very, very successful in training law enforcement assets in the nine counties of the Brazos, and we’ve actually trained folks all the way down on the corridor all the way down through Houston and then the Galveston area.
Marcia Ory: What I think is really important is there’s this myth that if you have naloxone and you have the ability to bring somebody back from a near death episode, then that person will be more likely to use and abuse opioids, and that’s absolutely untrue. And you want to talk pharmacologically why?
Joy Alonzo: Yeah, for a person who is a user or they have opioid use disorder, the one thing that they don’t want to do is go through withdrawal. You will do anything to avoid withdrawal. Withdrawal for a person who has opioid use disorder is extremely uncomfortable. It’s something you will avoid at all costs. And actually, what happens when you give somebody naloxone, is you are actually putting them in withdrawal immediately. So the notion that somebody who has opioid use disorder would sort of keep naloxone around as a safety net and either give it to themselves or ask their fellow users to give it to them to bring them back, that is actually counterproductive to the entire drug use culture. You absolutely would not do that.
Marcia Ory: And another myth is that if you’re going to be the rescuer that you will be in danger. There’s no problem now if you see somebody and you administer naloxone. You’re not going to be held responsible. But people think that if they do this, they may be in harm’s way, and again, that’s not true.
Joy Alonzo: There’s actually no evidence of that at all. There’s no case reports, there’s not one shred of written evidence that says that that’s true.
Lindsey Hendrix: So how do you get a prescription for naloxone?
Joy Alonzo: It’s a best practice—and we’re actually teaching physicians and our students that are going through the Health Science Center now to become future medical professionals—we’re actually trying to teach them that it’s a best practice to actually co-prescribe naloxone rescue kits along with a prescription for an opioid, especially if the opioid is over a certain level that would indicate risk to that patient. Additionally, the State of Texas implemented what’s called the Standing Order, the Naloxone Standing Order. And what this does is essentially, kind of think of it as a prescription that’s written for all citizens of the State of Texas. You can go to a pharmacy that honors the standing order and request a naloxone rescue kit from the pharmacist and you don’t need a prescription written specifically for you. The third way is through community distribution. And actually, that’s how we’ve been giving out kits. To date, we’ve given out 500 naloxone rescue kits and that number keeps going up. But right now we’ve given out about 500. We actually know that we’ve had five of those 500 kits that were used in opioid overdose reversal. So we’ve had a 1% return. The reason we know they were used is because the individual that used it actually called us and asked for another kit.
Marcia Ory: So that means five lives saved, is what it really means.
Lindsey Hendrix: That’s amazing.
Marcia Ory: Let’s go back and talk about the plan. Again, with Dr. Byington’s blessings, we want to have a plan. What do we do as a Health Science Center? And so we’re doing the training for every single student and residents and that’s really amazing. But we also want not just to stop in the Health Science Center. Eventually, we want to, and we’ve been asked, to work with student government groups, with the resident’s assistants. And so if you think about it, we would really like these harm reduction strategies in all the dorms so that in the same way that you have fire alarms or AEDs, what Joy would say is, let’s have a naloxone box.
Joy Alonzo: Right, the nalox box. We want to have the widest possible access to naloxone rescue kits that we possibly can. Essentially, we want to cocoon the entire community, and surrounding communities, with as much easily accessible naloxone as possible. Exactly that, wherever there’s an AED, wherever there’s a first aid kit, wherever students congregate, we want to have a naloxone rescue kit very, very readily accessible. And additionally, like Dr. Ory just alluded to, that we’re training all the Health Science Center profession students on how to use a naloxone rescue kit. The idea is for it not to stop with them, that they go on and train everyone else or advocate for it. Those casual conversations like, hey, well how’s this work? Every nursing student, every pharmacy student, every medical student, every dental student, every medical resident, every pharmacy resident, every PhD and student in the Public Health Department will be able to say, ‘hey, are you familiar with this? You should know how to use this.’ Just like you would teach somebody to use a fire extinguisher if they came on your boat. Or you would teach them how to do a little bit of CPR if they were in a situation where, hey, you should know a little bit about this.
Marcia Ory: We’re really training the next generation of health care professionals. They’re not going to all stay, and the majority won’t stay in the Brazos Valley, but think about how they’re going to be in every community in Texas and even throughout the state. We’ve been talking about harm reduction, but let’s sort of end up talking about treatment issues. For people who are addicted, there’s a variety of different, both pharmacological and behavioral, aspects. There’s what’s called a new training that we’re going to be doing in May. It’s X-Waiver. So again, these are controlled substances. It’s quite interesting. To be able to prescribe the medication that will treat somebody that’s addicted, you have to have a waiver. And very few people have a waiver, so let’s hear a little bit more about this.
Joy Alonzo: Yeah, we actually have this program call to action called Get with the Waiver. Get the waiver. This provides training for a physician or a prescriber to be able to give a drug that’s called buprenorphine. Buprenorphine is part of a strategy called medication assisted treatment. What buprenorphine does for a person with opioid abuse disorder is, essentially, instead of the heroin, you’re taking the buprenorphine. It controls your cravings but doesn’t induce euphoria. So a person who’s taken buprenorphine can resume work, can resume school, can get back to their lives and start taking care of themselves. Their cravings are controlled. Maybe eventually, with lots of wrap around care, lots of talk therapy, lots of CBT, lots of—
Marcia Ory: Cognitive behavioral training.
Joy Alonzo: Yes, exactly, yeah. With all those kinds of care, maybe, eventually, you can taper off the buprenorphine and then they can sustain abstinence. Maybe not, everybody’s different. But essentially, the statistics, the outcomes show that this is probably one of the best ways to try to maintain recovery. And that’s the name of the game here, is to get the person into recovery. Recovery means they’re able to go back and resume their lives. They’re not driven by getting that next fix.
Marcia Ory: So let’s sort of also end up by going back to the task force. The task force is involved in education. We’ve talked a lot about the training. It’s involved in community engagement. One of the things that we’re doing is working with the recovery oriented systems of care. That’s every stakeholder in the community, whether it’s prevention, treatment or recovery. We’re not just an ivory tower staying where we are, but we’re actually out in practice. The third thing we want to do, and we alluded to this, is research. One of the things we have is really what we would call a rapid deployment force all across campus, not just the Health Science Center. But there are 30 to 40 academic faculty who want to be researching different aspects, whether it’s the pharmacists that want to look at making sure that drugs can’t be modified or if it’s people looking at brain functioning. Throughout campus, there’re different people interested in research.
Joy Alonzo: We have several disciplines. We have some really novel engineering collaborations to evaluate. We actually are doing a phone app where we’re strategizing contingency management. Contingency management basically means how can you help the person sustain recovery? They’re strategizing their triggers and how not to have the trigger trigger them to use. We’re actually researching that, that’s one of our research projects. We have a project to evaluate how bad the cravings are for a person that’s in recovery and what that means for them long term. Is that something that is genetically modifiable? All these issues, we’re looking at the 360 person. For people in the workforce, does their patterns of absence—do the disease states that they’re being treated for with opioids or their opioid pattern of use, does that contribute to opioid use disorder? Or are there certain professions that actually, not based on access, but more based on what that profession, what they actually do from day to day, does that make them more susceptible to opioid use disorder? We already know that having underlying, untreated mental and behavioral health issues makes you more susceptible. Do these particular professions have higher anxiety? Do they induce depression? Are there interventions that we could put into place that would stave off mental and behavioral health disorders and ergo the person wouldn’t try to self-medicate and then become a user?
Lindsey Hendrix: So really addressing the root cause of the problem.
Marcia Ory: Exactly.
Joy Alonzo: Yeah. So right now, that’s one of the biggest issues in the United States. The average and age of initiation into a mental and behavioral health disorder that causes great dysfunction is 11.
Lindsey Hendrix: Oh my goodness.
Joy Alonzo: Not inconsequentially, the average age of initiation into substance use disorder is 12. I used to go around saying 13 and the DEA agents got all over me and said no, that’s not correct, it’s 12. And that might not seem like a nuance, but if you consider 13 to 12, that’s hundreds of thousands more people.
Lindsey Hendrix. Wow, that is crazy. It sounds like the Opioid Task Force has a lot of work ahead of them. It sounds like a lot of work is being done. Thank y’all both so much for coming down and talking about all of the great work that y’all are doing in the Opioid Task Force, but also enlightening everybody about the crisis that we’re facing here in America.
Joy Alonzo: Thank you.
Marcia Ory: Thank you.
Lindsey Hendrix: Thank you.