>>Good evening, welcome to SAMHSA’s National
Prevention Week in partnership with the University of Texas and the Drug Enforcement Administration.
My name is Wendall Campbell. I’m a special agent with the DEA out of the
Houston field division, also the public information officer.
I’m being joined by Angie Long, the coordinator for this event as well.
And she put a lot of time in behind the scenes to make this event possible.
Guys, tonight we have a fantastic lineup of panelists for you.
Where we’re really going to be doing this evening’s events in two parts.
First, we’ll have our town hall meeting where we’ll open it up for discussion, questions
and so forth and really get interactive from several different angles and then we will
be transitioning to a short candlelight vigil out in the courtyard.
So we definitely want to invite you to that as well.
So to kind of round out where we’re going from here, I’m going to turn it over to Ms.
Angie Long, aka lightning in a bottle.>>Wow.
That’s I echo Wendall’s comments.
We welcome you. We are so happy and excited that you’re here.
This is a conversation that we have been talking about for so long.
This is a this is as you all know, an important epidemic and crisis and we want to hopefully
come up with some suggestions, some recommendations tonight.
You will hear a thoughtful discussion about opioid harm prevention with youth.
So we wanted to kick it off by doing something a little different than we normally do.
We want you to to look around you, meet your neighbor.
And maybe share why you’re here, what you want to learn.
We have two foam boards outside with these little post it notes.
If you would help us be interactive, we’re going to use what you have put on that foam
board as we produce the report for this event. So if you will take a few minutes, meet your
neighbor, discuss what you want to learn, we’ll come back together and and I’ll introduce
the moderator. All right?
[Room chatter].>>All right.
I’m going to try to get your attention back. It’s kind of hard to let you loose and then
corral you back. But I hear good, thoughtful discussion.
I’m excited. That makes me smile.
I have the prestigious honor to introduce our fabulous moderator.
He has done so much work so far in this field and he is an upcoming rising star, in my opinion,
to help us with this issue. So he is Dr. Lucas Hill.
And he’s the director the clinical associate professor, UT college of pharmacy, and he’s
also the director of operation naloxone. And so if you will help me give him a warm
welcome, I’m going to turn it over to him and he’ll explain the rest of the format to
you and he’ll get us kicked off. So thank you again, so much.
>>All right. Let’s see.
The mic magically works, fantastic. Thank you all for taking the time to be here
tonight. We’re very excited to have this astounding
panel of national and regional experts who can synthesize what’s going on in the United
States with what we’re seeing here in Texas. I am honored to get to start things off tonight.
As Angie mentioned, I’m a clinical assistant professor in the UT college of pharmacy, I
am a pharmacist. I’m also the director of operation naloxone,
which is a program that works to increase overdose awareness and overdose response training
throughout Texas, as well as distribution of naloxone, the antidote for an opioid overdose.
We have benefited from some of the federal funding facilitated and now being accentuated
by members of our panel, so we are very excited about sharing some of that progress with you.
We have a few key objectives for you all tonight. In addition to coming out with some key take
aways at the end, we want to make sure that you leave with the ability to do these things.
You are going to be able to describe domestic trends in overdose related to prescription
and illicit opioids. Because those have been changing rapidly and
shifting from one to the other. You are going to be able to discuss the impact
of opioid supply reduction. Law enforcement directed interventions as
well as reduced prescribing, prescription monitoring programs and other misuse prevention
interventions. You will identify the role of opioid overdose
prevention education and naloxone distribution, which is one of our tertiary prevention measures.
And you will consider emerging models for evidence based opioid misuse prevention and
harm reduction. We are doing this all in the context of youth
substance misuse. We know that youth and particularly college
age youth are the most likely to report the use of an illicit in the past year or the
past month. As the illicit market becomes more dangerous,
it’s more important than ever that we have misuse and harm reduction prevention strategies
strategies integrated. So I’m going to set the stage a little bit
here. Give you some perspective for consideration
of what the other panelists will bring up. As you listen to each panelist give their
three to five minute introduction, please write down questions that you might have on
the white pieces of paper that are at your table.
Those will be collected for to facilitate the question and answer session after everyone
has given their introduction. You’ve probably heard that opioids kill more
people every year or drugs kill more people every year than car crashes.
And that’s been true since about 2009. Opioids account for the majority of all drug
overdose deaths. And that was initially driven mostly by prescription
opioids, which is this line that I’m showing you here.
So we’ve got time versus number of overdose deaths, prescription opioids, we had a major
jump that started to level off a little bit around 2010, but it’s continued to rise.
What we’ve seen, though, since 2010 is a massive increase in the number of overdoses that are
due to heroin or to Fentanyl and other Fentanyl analogs.
Fentanyl is an ultra potent opioid. 50 times more than heroin.
Some of the Fentanyl analogs are more potent than Fentanyl, some are less potent.
But they all carry a higher risk of immediate overdose than does heroin. I don’t know about
you, I would be pretty afraid of heroin if one of my family members was using it.
We should be more afraid of Fentanyl and other Fentanyl derivatives.
This is a fix of roughly equivalent dozes of heroin, Fentanyl and Carfentanil, which
is 50 to 100 times more potent than Fentanyl. Increasingly since about 2013 Fentanyl and
Carfentanil have been finding their way into the heroin supply.
People who thought they were purchasing heroin were actually purchasing drugs that had been
adulterateed with amounts of Fentanyl or Carfentanil that might make them higher risk for opioid
overdose. In Ohio, Pennsylvania, rust belts or northeastern
United States the majority are driven by Fentanyls not by heroin.
Along with this rise in the potency and danger of opioids, we have seen a dramatic increase
in the number of teens and emerging adults who are being diagnosed with opioid use disorders.
That’s our new technical terminology for opioid addiction.
So despite this, we’re not seeing the kind of public response that provides the medication
assisted treatment that we know will help these adolescents.
We are not seeing our prevention efforts bend that curve, they continue to increase.
So that’s the context in which we discuss opioids and prevention of youth experiencing
harms related to them. Now, I’m going to go through and introduce
each of our panelists, then I’ll ask them to share their introductions one at a time.
First we’ll have commander Karen Hearod, the Region 6 administrator for the Substance Abuse
& Mental Health Services Administration, or SAMHSA, who are one of our key partners putting
on this town hall, she serves the States of Arkansas, Louisiana, Oklahoma, New Mexico
and Texas. She is a licensed clinical social worker and
she holds a master’s in social work from the University of Oklahoma.
They previously served as the Indian health service Oklahoma area behavioral health consultants
and the behavioral health director for the Choctaw nation of Oaklahoma.
Next Michael Botticelli Executive Director of the Grayken Center for Addiction Medicine,
and Johns Hopkins school of public health. Prior to serving in this role director of
the national drug control policy for the Obama administration.
He was previously the director of the bureau of substance abuse services at the Massachusetts
department of public health where he successfully expanded innovative and nationally recognized
prevention, intervention treatment and recovery services.
He is also in long term recovery from a substance use disorder celebrating more than 28 years
of recovery, and the first person in recovery to serve as director of ONDCP.
Special agent Dante Sorianello is an international law enforcement and intelligence specialist
in organized crime and trafficking expert. 50 counties in Texas, spanning San Antonio
to Waco. Prior to this he supervised the high intensity
drug trafficking area task force and the DEA state and local narcotics task force.
Lisa Ramirez is the director of the Texas Targeted Opioid Response for the Texas Health
and Human Services Commission. She’s an expert on drug user health with a
focus on developing programs that improve public health outcomes associated with substance
misuse. She has led initiatives to provide integrated
care for Texans with co occurring substance abuse and psychiatric disorders as well as
to enhance services for pregnant women with opioid disorder and children experiencing
neonatal [indiscernible] syndrome. Daniel Sledge, dispatched through the nine
system, the mobile outreach time responds to mental health crises called in the field.
He conducts follow up visits for patient who’s receive medical services for opioid overdose.
During follow up he provides them with naloxone kits.
He trains his patients and their loved ones on the medication and promotes recovery.
John Ingram, lead coordinator at university high school, the substance abuse recovery
high school in Central Texas. He has been an advocate, consumer and provider
of substance prevention and treatment services. John is also a students of psychology at Austin
Community College. Please join me in welcoming our panel.
[ Applause ]>>Good evening, first of all, I would like
to thank the University of Texas and the DEA for partnering with SAMHSA for this opioid
town hall. It’s my honor to be here to speak on this
panel with such distinguished panelists joining me.
First, when I talk about this subject, though, I always like to pause for a minute and acknowledge
that many of us in this room and also on the live stream have personal experience either
for ourselves or for someone that we love with opioid use disorder or other substance
use disorder. I want to acknowledge that because sometimes
I think we talk about this as an academic exercise and I really want to acknowledge
this is really impacting many of us here. I was asked, as part of this opening introduction,
to talk about what I thought was one of the most important things kind of facing us with
prevention of opioid misuse or prescription drug misuse for adolescents.
It struck me, as I go out and speak to people out in community, oftentimes I give a really
research kind of science based presentation. When we come to questions and answers, somebody
will say what is an opioid, what are prescription medication opioids?
And so I think it’s really important, as a very bottom line, to encourage people to educate
themselves about opioids, about prescription opioids and then, also, about opioid alternative
pain management. So that they can have that information before
they are faced with the situation that they need pain management.
Also, I think it’s so important, especially with adolescents, for parents to have an understanding
about this. When when in Dallas, they have an organization
called challenge Tarrant County. They have really implemented a very effective
prevention campaign targeted at student athletes in particular, because student athletes are
often vulnerable to injury and then require pain management.
Their slogan is decide before you prescribe. It encourages parents to make good decisions
for their children. In addition, I think a lot of parents are
also faced with having to help their their parents or grandparents make decisions.
And that brings me to my second point about safe storage and disposal of prescription
medications. We know that about two thirds of the 12 and
older, their last misuse, the pills came from a friend or family member.
And oftentimes for adolescents, it’s the family’s medicine cabinet.
So really educating folks to to safely secure and store prescription medications and then
dispose of them in a safe way when they are no longer needed or expired.
At a drug take back box or using a medication pouch that is specially made with chemicals
to deactivate the medication to make it safe for the environment for disposal.
So so in closing, and I really look forward to sharing with you a lot of the information
that SAMHSA has during our interaction, but I just want to put forward a special resource
that SAMHSA has just launched, the SAMHSA evidence based practices resource center.
You can get it through it through the SAMHSA.gov site.
This is tools for recovery, treatment, community, evidence based.
To be able to help guide your interventions. Additionally, I just wanted to give a plug
for HHS.gov/opioid. This is kind of a landing pad for all things
HHS and even some other governmental agencies for you to use as resources.
So thank you and I look forward to our discussion tonight.
>>Great. So my name is Michael Botticelli, Karen, thank
you for that segue. That’s actually where I want to pick up here
because um I’ve been doing this work at the state and national level for a very long time.
And I’ve got to tell you like I’m getting opioid summit fatigue.
And by that I mean another organization that feels like it’s got to bring everybody together
and diagnose the issue and figure out what to do.
And the way that I say this we diagnosed this issue ad nauseam.
We know what to do here. We know to monitor and innovate, but by and
large we know what to do, what works. Our collective job, whether it’s at the local
level, state level, national level, are to implement all of those programs we know to
be effective and bring them to scale. Let me just give you, I think, just a quick
run down of from my perspective of the areas where we need to focus on.
One is primary prevention, it’s National Prevention Week, and I think in a lot of our discussion
around opioids and heroin and Fentanyl, we forget about the fact that early use is a
significant predictor of people developing problems later in life.
Early use is often alcohol, tobacco and/or marijuana, often in combination.
So I think we have to continue to focus on early and primary prevention, as we talk about
the opioid issue. Certainly harm reduction plays a key role.
Fentanyl has key role. Fentanyl has challenged us to think beyond
naloxone distribution. Particularly for young adults.
We also know that we are seeing astounding increases in viral hepatitis and beginning
to see increases in HIV associated with needle sharing, particularly among young adults.
Again, I like not being a govern official because I can say things.
Syringe return programs have to be a part of any continuum of care and a glide path
for people to come in for treatment. Many municipalities and states are considering
overdose prevention sites and safe injection facilities as a part of that response.
Treatment is tremendously important. We have a huge treatment gap.
Three highly effective medications, too few people are on them because we don’t have enough
physicians able to prescribe. We have treatment programs in the 21st Century
that don’t offer the best evidence of care that we have.
And I also will say this is probably a not maybe something that I shouldn’t talk about
in Texas. But I think we have to examine the role that
Medicaid and Medicaid expansion plays in getting people access to care.
I’m in Austin, so I can say that here, right? [Laughter].
A couple of other quick things. Recovery and recovery support services are
crucial. Like stopping is the easy part.
Staying stopped is the hard part. And particularly for youth and young adults
need a wide variety of recovery support services in their life to restore their you know, to
give them like a happy, healthy life on the other side of addiction.
I will also talk about the importance of local data, right?
So the data that Lucas just pointed to is 2016 data.
As a federal official, relying on two year old data in an epidemic is challenging.
So how do you come together as a community and share data across law enforcement, EMS,
substance use providers. Two other quick things, one of the bright
spots of this epidemic is the way that law enforcement, public safety and public health
have come together. Not gone beyond naloxone distribution, doing
post overdose intervention programs, encouraging people to get into treatment and, you know,
having the DEA co sponsor this I think is a good indication of what we tried to do at
the local level at the national level of say this is a public health issue and we’ve got
to have everybody working together. The last thing that I’ll say, having done
this work for a long time, we’ve got to get to root cause issues here, right?
Because this epidemic is not happening in isolation.
Life expectancy in the United States has gone down for the second straight year, largely
as a result of drug overdoses, suicides and diseases related to alcoholism.
Why is that? Well, one of the things is how do we get to
community based and root cause issues, racism, trauma, early use, lack of education and vocational
opportunity, if we’re going to solve any drug issue for the long term, focusing on those
social determinants of health and root cause issues is something that we’ve got to focus
on. So thank you.
[ Applause ]>>Good evening.
Thank you, Michael. My name is Dante Sorianello.
I’m with the drug enforcement administration, I’m the regional supervisor here for the area
that encompasses Austin. I will give you a few facts about what the
DEA does here and a little bit about the opioid crisis as we see it.
The DEA as many of you may or may not know. We’re a single mission agency.
With the Department of Justice and focused on enforcing the federal narcotics laws through
the controlled substance act here in the United States.
Our entire focus is on narcotics, that is what we do.
By doing that we ensure the safety and security of the citizens of the United States.
Right now our country is facing the opioid crisis that, frankly, it’s been given with
a lot of lip service, a lot of stuff is moving forward.
But this is a crisis I think your microphone is not working this is a crisis that fully
is affecting our citizens here in the United States.
In 2016, again, two year old data, almost 64,000 people died in the United States from
drug overdoses. If you put that in perspective, that breaks
down to about 174 people per day and in total in that one year, that’s more people that
US servicemen who died in the Vietnam war. That is a terrible number.
And we need to look strongly at that. As we move on, towards this, why and what
is the opioid crisis? What is going on here?
What are opioids? The one everyone knows, that’s heroin.
Everyone has heard the buzz word of Fentanyl floating around the country.
And then you have prescription opioids, such as hydrocodone and oxycodone.
Let’s look at those individually. Heroin been around a long time, people overdose
and they do die from heroin. However, we have never seen a surge of deaths
and overdoses that we have seen of late. Why is that?
Part of that equation is Fentanyl. Fentanyl is a synthetic opioid that comes
from foreign countries, manufactured, easy to make, cheap to make, and the profit margin
is huge. Drug traffickers are in this line of work
to make money. They don’t care about anybody else.
When they see a profit margin, they will go after it.
Fentanyl increases the profit margin. Fentanyl more or less for a kilogram of Fentanyl
being bought is about $5,000. The profit margin on that is anywhere from
five to $10 million of that one kilo of Fentanyl, so what do you think people are going to do
if they are engaged in this business? The other opioids that we’re seeing are hydrocodone
and oxycodone. They are prescription painkillers that are
commonly used in the United States. But I would add this: Approximately 78% of
the produced oxycodone in the world is used in the United States.
Approximately 99% of the world’s produced hydrocodone is used in the United States and
the United States only makes up 5% of the world’s population.
That’s an interesting figure. If you look at that.
There’s something that needs to be looked at and studied.
People are becoming addicted to these pills, not by choice.
They are a lot of these people receive these pills from a doctor, it is prescribed for
medical treatment. However, they develop addictions.
And I don’t think, personally, that we are doing a good enough job of addressing those
addiction problems and looking at these people and trying to help them out when they become
addicted to prescribed pain pills. So that has created a vicious circle in this
country. It’s created a black market on oxycodone and
hydrocodone. Along with that black market, it’s created
a market for counter fit oxycodone and hydrocodone pills.
That are made with things such as Fentanyl or other unknown substances.
That black market, though, increases the value of the oxycodone and hydrocodone so this horrible
phenomena has developed where basically someone who may have become hooked on prescription
pills becomes a heroin addict. And why does that happen?
Because heroin is cheaper on the streets than those prescription pills.
How does that lead to our deaths and overdoses here in the country?
I mentioned earlier about Fentanyl being placed. Now, many of your drug traffickers are selling
Fentanyl as heroin or cutting heroin with Fentanyl for the profit margin.
So the addict who is going to get their fix of heroin has never used Fentanyl before,
and the long and short of it, Fentanyl which is 40 to 50 times more potent than heroin
is placed into their system and they overdose. And it’s a one time thing.
Because unless someone is there to revive you or get you to the hospital, you’re going
to die. I’m not attributing blame to the medical industry
in this. It’s a phenomenon that’s developed.
We as a community need to look at it and see what we can do to make things better.
And as far as social use of these things, another phenomenon that people don’t see the
connections. It was alluded to earlier.
Starting with marijuana use, on college campuses. Let me give you a case study here in Texas,
briefly. We were led to some information down at the
University of Texas San Antonio that individuals were engaged in distributing marijuana, then
they give people Adderall to help them study a little bit, then maybe an oxycodone or hydrocodone
to calm down. Those were all counterfeit.
We started looking into the individuals engaged in this and what we discovered was an international
drug organization trafficking in fake oxycodone pills, made with Fentanyl, distributed them
throughout the United States and making millions and millions of dollars, being sold on the
black web. This all came from just a lead on a college
campus. So it is here.
And I I would like to close my opening just with we at DEA, we know that we cannot arrest
ourselves out of this problem. We know this is not just a law enforcement
situation. I can arrest all of the bad guys that are
out there, but as long as there’s a demand or we’re in a situation, we cannot stop it.
The only solution is going to be all of us coming together as we are here tonight as
partners, drug coalition members, educators, treatment specialists, doctors, nurses, and
law enforcement, to come together, formulate a strategic plan, on how to help the sense
of the United States. They demand it.
We’ve got to stop people from dying. Thank you.
[ Applause ]>>Please excuse me voice, I’m losing my voice,
please bear with me. I’m here to provide a brief overview of Texas’
response to the opioid crisis. Thankfully we received a grant from at the
federal level to address the opioid crisis and Texas actually received the second highest
award in the nation due to unmet treatment need and overdose deaths.
We know that our overdose death data could use some increased clarity.
It’s probably under reported. So in terms of treatment need, our approach
is integrated. We want to make sure that we are increasing
access to treatment and in Texas there are large expanses in which there’s a lack of
geographic access to medication assisted treatment. Medication assisted treatment can reduce all
cause death related to substance use disorders. We really need to ensure that individuals
are receiving appropriate treatment, which is medication assisted treatment for opioid
use disorders. In our current system, only 14% of our opioid
use disorder admissions were entering into medication assisted treatment.
So I know that I hear some rumblings around the state that we’re not experiencing an opioid
crisis. Even if we weren’t, just to get people to
just to get our admissions to 23%, this is we need more funding because this grant only
gets us to 23% admitted to a medication assisted treatment.
So as we get more people impacted by the opioid crisis, there’s going to be increased need
for additional funding to support medication assisted treatment in Texas because we’re
already at a disadvantage. I was so happy that the that this funding
included an approach across the full continuum of care, including prevention.
And I know it’s prevention week, so I’ll talk a little bit about our prevention programs
under the Texas Targeted Opioid Response. We want to make sure that prescribers understand
all of the details involved in terms of safe prescribing.
That they have the most current information about prescribing limits and prescribing practices.
That’s crucial. And in addition we’re supporting efforts to
increase safe disposal and medications and, of course, overdose prevention education and
access to both naloxone, the overdose reversal medication and Fentanyl test strips.
Our integrated approaches to care for medication assisted treatment and medication assisted
recovery in folks medication assisted recovery is a real thing.
I know that I hear a lot in Texas, there’s some division in the recovery community about
medication assisted recovery and recovery support services.
So we’re really wanting to increase education and access to medication assisted recovery.
And integrated care also includes ensuring that we have access to treatment for co morbid
conditions like Hepatitis C. With our under 30 population, we’re seeing
a national trend of a huge increase in Hepatitis C transmission.
So when you think about it, people receiving treatment for medication assisted treatment
have to go to an often long term, daily outpatient treatment.
It’s really difficult to get them to also get the treatment they need for Hepatitis
C. So we want to make sure that they have that
treatment available to them, where they’re going every day to receive care by a physician
for their opioid use disorders. Excuse me.
In addition, we’re also ensuring that we have integrated and innovative approaches to care.
We have partners with our partners in the community, our EMS initiative includes integrating
community paramedicine support with medication assisted recovery support with emergency department
induction on to [indiscernible] one of the medications used to treat opioid use disorders.
We have about 20 initiatives under this grant. We’re really focused on not just addressing
opioid use disorders in this state, but providing innovative approaches to care that can span
all types of substance use disorders. In your community we can really create an
infrastructure of care for this whole epidemic and other subsequent epidemics that could
be a result. [ Applause ]
>>Well, first of all, I’m really honored to be part of this panel of experts and to
help carry this message. I want to talk a little bit about naloxone
outreach. Naloxone is also known by the trade name Narcam.
It’s a medication that’s an antidote to an opioid overdose and when I say opioid, drugs
like heroin, prescription pain medications and Fentanyl, illicit Fentanyl.
So we’re in the throes of an unprecedented deadly opioid crisis which claims the lives
of over 115 people in the US each and every day.
This is the leading cause of death for people under the age of 50 and the majority of those
deaths are the age bracket of 18 to 25 years old.
And experts tell us that this is going to get a lot worse before it gets better.
Naloxone is a rescue drug. It’s used to resuscitate people who weren’t
breathing enough or breathing at all because of an opioid overdose.
I think naloxone should be everywhere, everybody should know how to use it.
It’s safe and it’s legal for anyone to carry and administer to somebody in an opioid overdose
situation. So I want us to think about naloxone the way
we think about AEDs or automated external defibrillators.
AEDs are safe and they are legal for anybody to use.
And if there are more out there, then our communities become safer.
And the incidence of surviving an adverse event increase drastically.
Now, naloxone is a crucial life saving medication, but I want to be clear on this.
It is not a treatment for opioid use disorder. If we say that we’re going to treat opioid
use disorder with naloxone, that would be like saying that we can treat heart disease
with CPR and AEDs. All this stuff is for resuscitation only.
If you have heart disease your doctor can put you on medications take can help manage
the disease and help reduce the risk of death. Similarly, we have medications for treating
opioid use disorder that help to manage the disease and also reduce risk of death.
These medications, along with psychosocial modalities and interventions are considered
the gold standard for treating opioid use disorder.
Like Lisa said, only 14% of patients have access to these gold standard medications.
It’s because of barriers to care like long wait lists for starting treatment, limited
geographic coverage, limited insurance coverage, stall tactics by insurance like prior authorization
appeals, limits to numbers of patient who can receive the medication from one prescriber
when there are no limits to the amount of patients who can receive hydrocodone or continuous
release oxycodone from one prescriber. So we know that these medications can decrease
all causes of mortality by over 50%, there are robust data that prove efficacy of MAT
or medication assisted treatment medications but we’re not getting them to patients who
need them. This is not a knowledge problem.
This is a stigma problem. Continuing to stigmatize substance use disorders
will cause the continuation of poor outcomes. We cannot afford to continue to ignore the
data in evidence. People’s lives depend on it.
Knowledge and compassion will be the drivers of change needed to shift directions on this
lethal crisis. So that we can bury fewer bodies and save
more lives. Thank you.
[ Applause ]>>Hi, first of all I want to say thank you
to the panel thank you for everyone for being here today.
It’s fantastic to have the opportunity to be on this panel.
First of all, I’m John Ingham, a person in recovery from substance abuse, bipolar and
HIV. I have refrained from using drugs and alcohol
since August 3rd of 2014, for that I am also grateful.
I’m still nervous every time I see the DEA coming around.
[Laughter]. Bear with me.
Also the lead student coordinator at university high school.
University high school is the recovery high school in Central Texas where we serve young
people and their families, domestically and internationally now to gain or to make their
way into long term sobriety and recreate their family systems.
Today we are here to talk about prevention, prevention begins with education.
We all have heard of programs like just say no or dare, what we have found is we have
fought the same empty uphill battle and not everyone can just say no.
One of our UHS students said it best when he was asked what program would you like to
see. His response was what if you don’t say no?
What would that look like. Help the parents, students and educators about
the resources and other means of recovery. How do we educate the parents.
One of the most common stories that I hear from teens, they find a pill bottle inside
of their parents or friend’s parents’ medicine cabinet and use or sell the prescription.
It is essential that as professionals, knowing, prescribing, counseling or distributing prescriptions
that can be abused we inform the client of proper disposal of unused meds.
To our parents we need to create peer based systems inside of our academic setting where
parents can share their experience and offer support to others who may be going through
the same thing. How do we educate the educators?
This is through the trainings to distinguish the difference which is very hard to do.
Between adolescent high risk and addiction substance use behaviors.
It can be very hard to tell the difference, but there are helpful tools if you know where
to look. These differences can be subtle but all telling.
We also need to properly teach academic staff how to best talk about drugs and alcohol with
students through DVT skills, strength based, proper referrals and education of social services
and community resources, last but not least we have our youth.
With our youth we need to learn how to just talk to them.
We need to let them know that what to do if they do start using because it is not just
as simple as saying no. Studies have found that kids who take part
in anti drug campaigns are just as likely to use drugs by the time they are 20 as kids
who do not. The campaign we have created at UHS and everywhere
is a campaign for peer support programs inside of schools where students can talk to their
peers about things they wouldn’t necessarily want to talk to their counselors or teachers
about. They can find commonalty and solution.
We need to be open, honest, communicative with our students to let them know that there
is help for students and their peers. For use of proper language and peer support
programs and the use of naloxone, I love what that’s been shared about tonight, they would
be readily equipped to navigate through preventing use or treating use that may have already
occurred. Services are available to those that know
they exist. We need to let go of fear and honestly talk
to our youth within the education system. With proper education, peer support systems
and peers available in schools to offer support we can make a difference and a lasting impact.
Thank you. [ Applause ]
>>Thank you all for your comments. I want to remind the audience if you have
written any questions that you have for the panelists on those white sheets of paper.
Please pass those on the center of your aisle. As they are being collected I’m going to ask
a few things of the panelists. First, I would like to start with Michael
and Lisa. You mentioned the increasing rates of injection
drug use, particularly among youth. And this study from John Zabell recently showed
this trend. An astronomical increase young people being
admitted to treatment programs with injection use of opioids.
Pretty much perfect correlation of increases in Hepatitis C virus, which can have extremely
negative health consequences and extremely expensive to treat from a state or governmental
standpoint. What do you think is driving this shift?
And how can we address it in Texas, particularly when we consider that we are one of the 15
states where syringe service programs are illegal and anyone who sells or gives away
a sterile stings in Texas is at risk?>>Thank you.
First of all, it’s like the voice of God over your shoulder because we can’t see you.
[Laughter]. So you know I think there’s dual issues here.
The special agent talked about what we have seen in terms of transition from prescription
pain medication to heroin where a significant portion of people left untreated transition
to heroin use. And focus on injection drug use.
You know, one of the things that I think has been challenging is some of the kind of rural
nature of this epidemic. But we also know, I think that part of this
challenge is coupled with the fact that we know that young adults are much less likely
to come into care and to stay in care. So we have this cohort of 18 to 29 year olds,
significant levels of addiction as you saw before, high rates of very risky use.
I have to say here the other issue that we have seen in pockets of the country is dramatic
spikes in H.I.V. in parts of the country where we have in every seen HIV before.
And part of this gets back to needle sharing among this population.
So, again, how do we follow the evidence here? And let me say one of the things that I was
very proud of federally is we actually got congress to rescind the decades old ban on
the use of federal funding to support syringe service programs.
And we see many states and many conservative states like West Virginia, Kentucky, Indiana,
authorizing syringe service programs. But so not only does it reduce infectious
disease, but it creates a glide path into treatment for many people who would otherwise
still be out of treatment. So again this is where I go back to the fact
that we know what works. And we have the evidence.
The other thing that I will say here is, you know, all of the evidence shows it doesn’t
increase drug use, and one of the public safety benefits it actually reduces the amount of
contaminated needles that are on the street. So there’s a public safety value in this that
a law enforcement officer is not going to get stuck by a contaminated needle when you
have syringe service programs. So, you know, it’s one of those areas where
we know it works. I think our challenge has always been political.
And so part of our work has to be around advocacy. You can tell that I’m not a government person
anymore. That we’ve got to work with our our local
leaders, our state leaders, and at the governor’s level to convince states and locals to support
syringe service programs. Because evidence is just too unambiguous and
the magnitude of the disease is just too great for us to thinking about this.
Certainly it’s got to be part of a comprehensive response.
You heard Lisa talk about how the state is really trying to support a continuum of care.
That’s really important. But this has to be part of our response to
this epidemic.>>I’ll just add that it’s really important
to intervene earlier. And I heard someone draw the comparison, if
we treated diabetes the way we treat substance use disorders, we would be intervening at
the point when an amputation is necessary. We are not intervening early enough.
That’s our fault as addiction professionals or recovery support professionals.
We need to make it easier for people to feel comfortable reaching out for help.
Or talking about their substance use disorders. There’s so much stigma surrounding substance
use disorders and opioid use disorders in particular.
But without legal so I just wants to add, we need to really engage our recovery support,
peer support advocates in understanding medication assisted recovery first and foremost.
Without legal syringe programs, we really do wants to avoid a secondary crisis related
to the opioid crisis in Texas by ensuring where people are receiving medication assisted
treatment, they can also receive treatment for other co morbid conditions.
And really make treatment low threshold, easier to access, and long term recovery support
services, the outcomes associated with recovery support services are exponential.
When you have that in combination. Recovery support services aren’t just for
pretreatment or posttreatment, throughout the whole continuum.
>>Next one is for you, Daniel. I got a couple of questions from the audience.
And also think worth considering in the slides, about Fentanyl.
And you may have seen in agent slide there were DEA agents in hazmat suits.
There’s a lot of concern about the risk for passive exposure to Fentanyl and possibly
even overdose from that. Daniel, as a hands on first responder who
gets to the scene, needs to revive someone, it’s unclear what they’ve used, maybe there’s
even a white powder residue around their lip and you are going to be possibly providing
supportive breathing. What are your concerns in that scenario?
How do you respond?>>That’s a great question.
I know in the past couple of years, there’s a lot of concern because we didn’t know very
much. Then what we weren’t sure of, what was driven
by a lot of fear and then I think there were some accounts that were anecdotal and not
necessarily medically accurate that helped fuel those.
So we got to a point of almost panic where we said, you know, we’re not going to respond
to these types of calls until we clear it from a hazmat sort of standpoint and in reality
that’s not practical, nor is it best for the patient.
The risk, as far as getting a toxic exposure, for first responders is exceedingly low.
Unless you’re in some sort of situation where for some reason it’s airborne, you know, it’s
just not going to happen. So the Fentanyl dry powder cannot be absorbed
through the skin. And, in fact, Jansen pharmaceuticals spend
years to figure out how to make a Fentanyl patch that could be absorbed through the skin
like keeping it wet and adhered to the skin and with an engineered matrix of drivers that
make it get absorbed into the skin. So I think that the concern there was kind
of overblown. But my fear was that we were going to be so
worried about this and so kind of caught up in the hysteria that we were going to delay
patient care. So it’s a good question.
It’s sort of similar to the ’80s and ’90s when we didn’t understand very much about
HIV/AIDS and how it was transmitted and you had doctors and dentists saying I’m not going
to treat anybody with HIV/AIDS. That did nothing to curb the spread of HIV/AIDS,
just stigmatized people and reduced their access to care.
So …>>All right.
I’ll just add while we want to be sure that people have realistic understanding of the
risk for a first responder versus certainly the risk for a DEA agent who is going into
a home that may have three or four kilos of Fentanyl around and they may need to take
different precautions. That the first responder street level we are
distributing Fentanyl test strips as part of our naloxone or overdose response kits.
These allow people who are using drugs to test that drug for the presence of an ultra
potent opioid like Fentanyl or some of its derivatives, that is a practice that is being
taken up by more states at this point.>>I might add
>>please do.>>one little bit to that.
The picture that you did see, those agents at the time were actually going into a Fentanyl
processing location where there was actually a pill press and the individual we were investigating
was making thousands of fake oxycodone pills with Fentanyl and we see these five to 10
we seized five to 10 kilos of pure Fentanyl from that location as well as numerous pills.
So when we go upon a site like that, we have to handle it that way.
>>Let me pick up on this with both Kari and Dante.
We know that disturbances in the opioid supply lead to higher risk environments.
When a drug dealer is busted, it’s a good thing because drugs are coming off the street.
But for a person who is using heroin chronically, it leads to purchasing in a scarce environment
from a supplier with a type or a potency of drug that they are not accustomed to.
When an opportunistic pain clinic that’s opened up in Kentucky is shut down because they have
been just churning out pills to anybody who shows up asking for pain relief, generally
we do not see that those communities are then given a popup medication assisted treatment
facility. Or any increase in availability of buprenorphine
or methadone. Unfortunately I have heard anecdotally that
primary care providers know who those patients were and they don’t want to see those patients
walk through their door because a patient getting high potency opioids is not something
that a prescriber is wanting to be in that position.
Is there anything from DEA or SAMHSA or the health and human services department to try
to expand resources in areas that are experiencing an opioid supply disturbance?
I do know that I have been in some of those discussions.
Where that take down happens, they work together, to connect the known patients from the from
that bad actor that was taken down to a to resources for treatment.
Now, are there the resources for treatment in that area always adequate?
They may or may not be. Definitely we understand that we need to continue
to try to increase the resources for medication assisted treatment in those areas.
But I do know that there is a concerted effort to tie back those patients that have been
displaced because of shutting down that facility back to treatment and connect them.
>>From the DEA perspective, nowadays, in recent history, we’re engaged with many community
coalitions. So we communicate.
Now, obviously during the course of an investigation, because of sensitivities, we cannot engage
a lot of these people into the investigation. But upon the conclusion of the investigation,
we bring the identified problems that we see and try and bring in the people who are the
experts in that field to assist. Now, whether they have the resources to do
it or not, I don’t know because at that point the Drug Enforcement Administration is out
of it. But there is communication between the organizations
now that for many years really did not exist.>>Let me just chime in here.
Because sometimes it’s not just an infusion of resources.
Lisa talked about how like how do we build up this infrastructure?
Particularly in part of the country where we don’t have a bricks and mortar treatment
program, where you don’t have a primary care physician and, you know, I’m at a very large
medical center, not unlike this one, that we’re surrounding.
You know, part of what we talk about is that particularly for medical professionals, treating
people with addiction can’t be an optional healthcare activity anymore.
I think part of this is how do we train every medical resident in issues of addiction, how
do we make sure and make it the expectation that primary care physicians treated can you
imagine if a primary care doc said I’m not going to treat diabetics.
Like it just doesn’t happen. Part of our collective efforts over the year
has been how do we get more physicians and let’s say now we can have nurse practitioners
and PAs be able to do it, to understand that this is part and parcel of their medical care.
They have to be doing this as part of the work that they’re doing.
Even at Boston Medical Center, we are looking at should we set expectations that every primary
care physician who comes to work for us is data waivered to be able to treat people with
addiction. I think we’ve got to move away from seeing
this as an optional activity for primary care. Because, you know,she can have all of the
resources in the world, but if there’s no people to treat people, money doesn’t make
I will add in as well that’s the reason that I am a huge proponent of primary care behavioral
health integration. It’s like a seam loss flow of care.
Talking about early identification of adolescents, when we’re when we have that training and
we’re able to do like screening and brief intervention and referral to treatment in
the setting that that adolescent is seen and have that early identification, that’s where
we’re really I think we can make head way in earlier identification.
>>I think that our medical professionals [indiscernible] blamed for this opioid crisis,
but at the same time we need to be careful about that.
Because they are integral to the solution. They are part of the solution.
So I think in general we all need to do a better job of looking at, Michael you mentioned
earlier, some of the root causes of what’s being called diseases of despair.
And focus and move on from blaming physicians and look towards them as partners in the solution.
>>As we consider this problem in the context of youth, we will flashback to the study that
showed that the majority of youth with an opioid use disorder still do not receive medication
assisted treatment for their disease, do not receive the evidence based medications that
we know prolong and improve their lives. Michael, you mentioned earlier that actually
a majority, the last time that this was surveyed a few years ago, a majority of addiction treatment
centers in the United States do not offer any of the three F.D.A. approved medications
for opioid use disorder. It’s actually true in most addiction treatment
centers, a person with a let’s say a heroin use disorder, will enter, they will be detoxed,
they may receive buprenorphine or methadone for a short period of time, buprenorphine
for a short period of time, for a vast majority they will be discharged with no extremely
high risk for immediate overdose death when as we know the majority will resume use at
some point. It takes multiple treatment episodes.
So what are we doing nationally or specifically in Texas to hold these addiction treatment
centers accountable for providing evidence based care?
>>So this study was actually done by our pediatrician who runs our adolescent and young
adult program. And he does research on the side.
He’s got a young baby. I don’t know what the guy sleeps.
But, you know, the other piece that I want to underscore with these data.
You are absolutely right, you know, this is particularly significant for adolescents who
are not getting on medication. This study also demonstrated that it was particularly
acute for kids of color. Right?
So again this is a health equity issue here in terms of the work that we are doing.
So part of this is I think we have that we have to make a concerted effort to get more
pediatricians trained. As Karen talked about, we’ve got to integrate
this in part a part of mainstream medical care so that we have pediatricians.
So actually our clinic is in pediatric setting in terms of the work that we are doing.
I think it’s really important for us to be able to do that.
As someone who has been doing this work for a very long time, where we’ve tried to educate
providers and get them to be able to do this, we are losing too many people to make this
a voluntary activity anymore. And this is where I go back to, like, we know
what works. So data in Massachusetts show that the biggest
predictor of of death from an overdose is a non fatal overdose.
But if you we can reduce overdose risk by 50% if we can get people on buprenorphine
and methadone. But only five percent of people who are experiencing
non natal overdose are getting on a medication. One of the biggest touch points that we see
in our data in terms of overdose deaths are those folks who have just come out of a detoxification
facility. This is where we need again, it’s not just
about a medication. People need a whole host of other supports in their life to be able
to do this. But it just got to be the expectation now
for a treatment provider in the 21st Century that so I think like if you had cancer and
you went to a treatment facility, that withheld from you the most significant treatment to
cure your cancer, we would have none of it. So part of this has got to be I’ll say this,
because I’m not a fed anymore, that we should not be contracting with a federal with any
facility that doesn’t provide medication assisted treatment.
It doesn’t mean that every patient has to be on it.
But you have to offer it. And we have to do that with our drug courts.
We have got to do that with our criminal justice systems.
I’m sure data here show that the vast majority of people coming out of jails and prisons
are at significantly higher rates of overdose. So our jails and prisons need to start integrated
medication assisted treatment in part of the work that we do.
I’m getting old, I’m really getting impatient. Part of that can’t be voluntary anymore.
There are too many people dying when we know what works.
>>I think there are a lot of misconceptions about the safety of medication assisted treatment
and its place for youth. So I think we really need to work hard at
providing accurate information about the benefits of medication assisted treatment and it’s
really heart breaking to hear parents who have lost their children to overdose get it
too late. And we need to do a better job of getting
that information out there to parents, to about the best treatment for certain substance
use disorders, for opioid use disorders it’s medication assisted treatment.
People need not fear that medication and that treatment.
Parents and loved ones need to understand the benefits of that because when you hear
parents saying, gosh, I just didn’t know and I didn’t know what this treatment provider
I was doing the best that I could in a really difficult situation.
I thought that I was doing the right thing. And then it’s not until later after they have
talked to other parents and done a lot of advocacy work that they say, oh, it was medication
assisted treatment, I didn’t know. This is available for our youth.
We need to send a clear message about that.>>I completely agree with Lisa.
We need to do a better job of educating, particularly parents, who can often be the deciding factor.
And are not getting there is a lot of really bad information on the internet that I’ve
heard too many stories of parents not getting access to really good accurate information
to be able to do that. So I think we need to educate parents and
we need to curate for them a really good set of science and evidence based resources and
have trusted sources of information that they can go to to get that information.
I hear that exactly what you are saying, I hear that all the time.
>>So this subject, we know even for individuals who go to addiction treatment centers that
do offer that medication, who find one of the small proportion of primary care providers
who do prescribe buprenorphine or an opioid treatment program that offers methadone, that
they often find it hard to integrate into an alternative peer group.
12 step setting. Another recovery setting.
Because they aren’t accepted oftentimes, even by the recovery community that does not consider
being maintained on a medication that to any extent activates opioid receptors as recovery.
How do we push through that resistance in the recovery community so that individuals
with opioid use disorder, who are on evidence based method indications, are entering a supportive
environment? Open to any.
>>I think that’s a great point. Again, I think oftentimes it’s our professionals
in the addiction treatment or services field that are the biggest barriers to people getting
the kind of support and treatment that they need.
There’s a tremendous amount of stigma. One of the states approaches is providing
training on medication assisted recovery. It’s it’s critical that individuals have a
safe place to go and to talk openly about their treatment, their care, their path to
recovery. And to feel safe in doing so.
Because, you know, you would think within our own field that there would be an understanding
of this and I was so confused when I first came into this field and didn’t quite understand
that there’s a separate dichotomy, there are silos between medication assisted treatment
and medication assisted recovery and “Abstinence” based treatment.
I hate that term. Because when people are in medication assisted
recovery, they are that is abstinence based treatment, too.
But we talk about it in very different languages. And so I just think that we need to have more
open dialogue. We need more honestly I think to reduce stigma,
we need more people who are successful in medication assisted recovery to talk about
their success in medication assisted recovery. We need to dispel the myths by having people
who are in medication assisted recovery talk on panels like these so people know that medication
assisted recovery doesn’t mean people nodding off or people sedated or sleepy.
I hear that time and time again. We don’t want these people in our recovery
homes or our recovery groups or in our treatment sessions because they might trigger other
patients because they may seem sedated. And that is just not what medication assisted
treatment and medication assisted recovery is.
If you talk to people and you create a forum for people to have those discussions openly,
and they feel safe doing so, I think we’ll learn a lot from each other about it.
>>At SAMHSA we’ve been doing some work around that recovering housing and doing some convenings.
Usually the most powerful thing is to well, I notice a lot of times people that are in
recovery identify their path to recovery as the path to recovery.
And when you can get in a convening and many people can share how they recover and particularly
using medication assisted treatment, it kind of opens up people’s minds to other paths
of recovery. Because, you know, I believe in many paths
to recovery. But I believe that medication assisted treatment
has to be one of those things on the menu. And so when we look at recovery housing, a
lot of recovery housing historically was abstinence only housing.
When you look to H.U.D., a lot of their housing model is housing first and then moving towards
sobriety. So bringing those together as well has been
a little complicated. And then, also, just working with treatment
centers that have, you know, traditionally just for abstinence based, how do they integrate
that medication assisted treatment. As Lisa shared, really hearing those voices
and getting those people together and trying to bridge that understanding, I think is very
important.>>John, how is this how is this issue handled
at the recovery high school? Or is this an issue at all where some students
might be on medication assisted treatment and is that ever a conflict in your peer groups?
>>So if I’m being entirely honest, it was something that had conflict inside of my own
mind whenever I was first getting into this line of work.
You know, I think that’s part of what it is with with integrating into the system is that
we have to allow it to integrate into the system.
Part of that is the language that we use around it.
It is not a form of treatment. It is a form of recovery.
That’s something that we have to constantly refer to it as.
You know the language is something that I’m a really big proponent of.
In order to meet people where we’re at, we have to meet them in a way that we can tell
them in a strength based way they are in a place that they need to be.
And by doing that, you know, we’ve been able to allow our students at UHS to see that as
long as we’re accepting of it, they can be accepting of it as well because they trust
us. We are their providers, right?
So if we can continue to do that, then the students are going to trust us in the end,
too. That’s what we found that works.
>>Let me pause for a second and let everyone in the audience know if you don’t already
have Sticky Notes, you will soon. We want you to be thinking of what is one
key take away that you have gotten from the panelists or the discussion today that you
can stick on to the board as you’re walking out at the end of the session.
Keep that in mind and those will be passed around soon.
Let me stick with you, John, but open this up to anyone.
I think there are probably many people in the audience who come from come though this
discussion for more of a primary prevention standpoint.
How do we provide education or resources that keep people from developing substance use
disorders or opioid use disorders in the first place.
We have gone in the deep end because we have a crisis and we’re talking about immediate
tertiary prevention and those sorts of things. How do we zoom back and let me ask directly
what the person in the audience said: What is your advice to those in the intervention,
treatment and recovery world that don’t see prevention, primary prevention, as an important
part of the process. How does primary venue factor in and what
insight do we have from the recovery high school or from others?
>>So, you know, the way that recovery was kind of described to me at one point was that
it’s like a set of guard rails. So the guard rails start off very narrowly,
right? And the whole idea is that when you first
get into it, you are bouncing off of both sides of those guard rails.
As you progress through the treatment system, all of a sudden the guard rails start going
further and further out. So the whole idea behind it is that you keep
on going along that narrow set of guard rails and not bouncing back and forth, then you
can move back if you need. That’s what the continuum of care is all about.
As long as we can work together and make a proper referrals that we need to and get people
where they need to go, then proper treatment is able to be instilled and part of that is
prevention at our level as a recovery high school at the APGs with, you know, primary
treatment providers, whatever the case may be.
If we can all work together, we can create those sets of guardrails in order for people
to integrate successful into a recovery setting.>>If they are not talking about [indiscernible]
prevention there will be unintended consequences. I will give you an example.
When we are talking about increased utilization of the prescription monitoring program.
I will give you an example of an experience that I had when we first started this grant,
I was talking to our prevention specialist. She said, great, we can really increase utilization
of the prescription monitoring program. I thought hmmm, well, some of data, you know,
so I thought I wasn’t as excited about that thought because I thought, well, I know that
increased utilization of the postponement MP can result in some decreased prescription
opioid overdose related deaths, but then subsequent increase of illicit opioid overdose deaths.
So I think that that allowed having these discussions allowed us to avoid unintended
consequences by having a comprehensive approach to the utilization of the PMP, meaningful
use of the PMP. You don’t just stop with requiring the utilization
of the PMP, you support meaningful use and Karen mentioned earlier, screening, brief
intervention, referral to treatment. When we are having conversations about primary
prevention and increased utilization of the PMP, we also have to think about from the
harm reduction perspective what that could mean and include the integration of primary
healthcare providers into the system to screen, briefly intervene and provide a referral to
treatment. It’s all of those components in a package.
You can’t do them in silos, that’s just one example.
So we all need to come together. And I was really excited with this STR grant
it really encompasses the full continuum to force us to have discussions like these so
that we are not operating in silos and contributing to some unintended consequences.
>>I think additionally, I’ll just add, too, that that’s one of the things that I love
about the drug free community grants, it allows local communities to come up with local solutions,
right? So identify using the strategic prevention
framework what their needs are for their community and then come up with a plan.
So I think a lot of times we try to do a one size fits all and all communities are really
different. In how things come together.
And so allowing a community to come together and make their strategies and figure out how
to proceed I think is very important as well.>>Lisa, I appreciate your point, Lisa, about
the prescription monitoring program. As a pharmacy professor and pharmacist, I’m
very cautious to teach my students your intervention doesn’t end at searching a person’s name in
the database, finding that they have a problematic pattern of prescriptions and then saying,
no, you can’t fill this prescription today. That is not ultimately serving the patient.
You are acting essentially as almost like a law enforcement type of barrier and maybe
you can’t fill that prescription that day, but how do we switch the conversation to I
can’t fill this today and I want to offer you naloxone.
And I want to connect you with a an evidence based treatment provider in our community.
And I want to talk to you a little bit more about your substance use, if you are injecting
drugs, I want to get you a sterile syringe, which in Texas if you have that conversation
with a patient, that’s a pharmacist, you are legally in jeopardy for selling that syringe.
So thank you for bringing that up. Now, a couple of our panelists, they gave
me a little bit of a hard time about my 2016 data.
[Laughter]. But it was the best that I could do.
There’s not much out there. Unless I’m going to go search the CDC database
and create my own graphs. How do we speed up the access to data maybe
from drug seizures and testing of drugs by police as well as end user testing like these
Fentanyl test strips, how do we get that data feedback from patient?
What can we do so when I go talk in public I’m not giving this old data anymore?
>>I will start with some examples that I have seen around the country.
I would say that at the community level, so a city like Austin, that you have the opportunity
to bring everybody together as a piece of the data puzzle here.
So EMS runs, drug arrests, treatment admissions, discussions with active users in terms of
the work that they’re doing. So everybody who has got a piece of this puzzle
who can actually look at and the extent to which in Boston we are actually to able to
drill down to the zip code level to look at not only where we’re seeing spikes in overdoses,
what we might be seeing in terms of Fentanyl, Carfentanil and heroin so we are able to deploy
resources to those communities to be able to do it.
Because at the federal level, just because of how long it takes to get the information
to the federal government, is always going to be behind both.
I would say this Lisa, true, probably at the state level and the national level.
So I think it’s really incumbent for cities to come together, bring all of the relevant
stakeholders to the table who has a piece of these data, and try to the largest extent
possible to create and pulse the data on a real time basis so you can really look at
where you are seeing problems at the neighborhood level.
Because I think that’s what ultimately you know, you probably see this all the time in
terms of EMS runs related to emergency department mentions are another great way to bring your
emergency departments together to really look at who’s coming to the I think that has to
happen at the local level.>>I agree.
So creating these real time heat maps that show the hot spots and the pockets of overdoses
with you know, online tools and tools that are applications for smart devices like the
high intensity drug trafficking mapping tool or the Texas overdose and naloxone initiative
that Mark and Charles got out for Samsung and Apple that tracks and records overdoses
that users can put in, and additionally we need to be using this as first responder agencies
so that we can have real time data. A lot happens in a two year time span from
when we get the data from CDC and so forth. So being able to come together and sit at
the same table and talk about what we are seeing trend wise in certain areas.
That way we can deploy resources and really target target our efforts.
>>I also say, will say this is an opportunity for partnership with the law enforcement with
the DEA. And I’ve got to say this, you know, I used
to be frustrated at the federal level that I never knew something was coming until there
was an outbreak in the community. And I’m thinking well, we must have better
intelligence than this. To, you know, wait until we had a spike in
Fentanyl in Charlestown, West Virginia to understand this.
I think we can have a good understanding of what’s happening on a real time basis, but
also what might be coming our way really helps from a prevention standpoint to see around
the corner a little bit, to see what the next thing might be.
And to help to the largest extent possible plan what your actions could be at the local
level.>>That’s actually happening at the local
level, as I mentioned earlier before, with some of the coalition meetings that we’re
a part of. Obviously we don’t share sensitive case information.
But the trends that we can say is, look, we don’t see this happening, but we’re seeing
this happening, and we are sharing that with the wide range of medical professionals, EMS
professionals, all sponsored under the United States attorney’s office.
So that is ongoing. And perhaps that’s a newer phenomenon.
But that is going on. And I think it’s getting better and better
with the engagement at that level.>>I agree with all of those strategies and
a lot of those strategies are supported by the state.
[indiscernible] the tool, the [indiscernible] tool, those are all great tools.
I have learned so much from collaborating with EMS and a proportion of people going
to the emergency department, our prevention programs, our prevention coalitions.
We need to get this information to them so they can send out to the community and key
people in the community to respond efficiently and effectively.
And I think most of all, we need a to have more meetings instead of about people, with
people. And in San Antonio I was really inspired by
one of their groups related to maternal opioid use.
They had physicians and regular meetings with physicians and all kinds of key community
officials and they have people in early recovery and people actively using and their votes
count more when they are decision making, they count twice compared to physicians.
I don’t think we do that often enough. To bring people to the table.
They are the key. We learn so much from our community members
that are in early recovery or actively using and we need to have more conversations with
them involved to get to some really good solutions and timely solutions.
>>We’ve heard a lot of discussion about border security.
As a possible prevention mechanism against illicit opioids in particular.
And I wonder if you could speak at all to how there have been changes in regards to
where these opioids are entering the country. You talked a lot about illicit Fentanyl.
My understanding is most of that is probably being made in China.
How does it find its way to the US? Is heroin really coming mostly across the
southern border or mail across the northern border, what kind of security measures may
actually help?>>There’s a wide variety addressing those
from border security to the interaction through the mail system, through private mail services.
As you said, and it is correct, a majority of that Fentanyl that we are seeing in the
country has originated in China, Asia, some of it actually being manufactured in Mexico
at this time. So the traditional smuggling routes that have
existed for a long, long time continue to be used.
The challenge we face at the federal level is because such a small amount can be utilized
and is so dangerous, it’s a lot easier to conceal that or smuggle that across.
Smugglers, drug traffickers, adapt, unfortunately much faster than law enforcement.
So we are playing a catch up game with them. I think from border security, the effort is
being made there. From the DEA’s standpoint, we look at those
distributors here in the United States who are what are the organizations that are moving
this? And in spite of what you sometimes see in
the press, we do not go after drug addicts, with he do not arrest people for simple possession
of narcotics, we focus on the criminal organizational structures that are throwing that poison into
the communities. Again from the DEA perspective, we look at those organizations.
If we identify an organization here in the Austin area, we would try to identify every
tentacle that they had distributing that, how is it getting on the street, coming into
the country, where is it originating from? We would coordinate with our international
partners in whatever country we may be dealing with to attack it at the roots.
There’s a much bigger thing on the criminal side, the investigation part that is not seen
a great deal, particularly some of the things that happen overseas.
That said, we are challenged by the amount of the narcotics coming into the country.
It’s cliche ish, as long as there’s a demand the narcotics are going to be here.
We can keep it down, one way or another they are going to get here or something as a supplement
to that. Shut down all of the heroin, now you have
the Fentanyl or somebody is going to find something else.
We have to continue to adapt. But that is what we do.
So addressing it on the education side and the treatment side is critical for a solution.
One thing that I did here tonight that was a little troubling, I don’t remember who brought
it up. That was of the youth that are educated, even
though they are educated very well knowing the dangers, they still are engaging in it
and taking that risk. Why and what is the cause of that?
I don’t know. It’s very troubling to me from a law enforcement
perspective. Because even in one of our recent investigations,
we had an individual on the dark web selling counterfeit oxycodone and he specifically
mentioned it had Fentanyl in it. And he was selling a ton of it.
Why are people engaging in that type of behavior? If you just think about this logically, this
is not being made in a lab that that you know that pill is going to have a certain amount,
that’s not going to kill you. A lot of these pills are being made in back
yard setups and there’s no quality control. So people are dying from that.
But why are you playing that Russian roulette. That goes to further root causes, some of
them discussed tonight. We have to get to the bottom of that.
That’s a bigger, broader discussion. Very philosophical here.
You need to look at it from all angles. From a law enforcement perspective, in spite
of what people will saw say about law enforcement, most people in law enforcement are very compassionate
individuals. We would love not to have to go out to scenes
and see a family that’s suffering because someone died from an overdose.
Or because someone is drug so addicted to narcotics or engaging in other types of behavior,
violent crime, theft. We don’t want to see that.
If you could get us out of a job it would be fantastic.
We have to deal with that. And we need to have this total discussion,
as we are having tonight, and continue to enlarge upon this to find a solution.
To make it better.>>Daniel, let me borrow that hand mic real
quick. So if I could, I’m going to go off script
for a second and ask an expert who is in our audience today, Mark Kinslee, the Executive
Director of the Austin harm, co founder of the Texas overdose naloxone initiative, if
he would be willing to give us some insight as a person who works with people who inject
drugs on a daily basis to try to improve their health outcomes, why might an individual use
a drug, even though they know there’s an ultra potent opioid in it.
What is that pattern of use like and why is that person making that choice or being put
in that position.>>I think it’s complex, right?
One of the things that I wanted to start off by saying is first of all Fentanyl is not
new. It’s not new in the drug using community.
China white is three [indiscernible] Fentanyl it’s been around forever.
The analogs that are here are a little different, right?
The reason that there’s a lot of reasons that people use substances.
If you look at the state of Texas, that has the highest rate of uninsured people in the
country, right? It’s not different than anybody else that
goes and gets a medication for a certain issue, right?
I know Nancy was well intended, she was misinformed, right?
Drugs do work. Right?
And oftentimes people that can’t access drugs or medications through the system of doctors
or whatever, go to the street pharmacist to get it.
Right? It’s the same thing.
They use it for the same reason. The other thing is that it’s interesting we
talk about youth education. And, you know, it I just got to say it.
When we start to misinform by people that are incredibly influential in the community,
when we start putting out, you know, the DEA does great stuff and I wouldn’t want to have
to have their job for anything in the world. But I’ve got to tell ya, when we put out information
like chasing the dragon, that has a ton of misinformation in it, this is the stuff that
continues to, you know, put out stuff that the community bases it on, right?
That causes harm. It causes harm in our communities.
So people use drugs for untreated trauma, sexual abuse, you know, poverty, racism, all
of these things, right? So we’ve been the most failed war that we’ve
ever fought, right? Here we are, still.
We are really not doing anything different. This looks very similar to a lot of things
that I have experienced in this, right? You know, it’s the new Jim crow, right?
We’ve heard this 100 times, right? And yet we continue to do much of the same
And the officer said, you know, the agent said that we’re not going to, you know, lock
ourselves out of this problem, but we continue to do that.
Even from the highest level of the federal government who says we need to have stiffer
penalties, right, around this stuff. It doesn’t work, it’s never worked.
It will never work. So we need to, you know, it’s interesting,
I’m involved with a thing called the international drug users union.
And so I hear people say we need to invite the experts to the table.
Well, in the meeting today that we were on the conference call with, we’re going to start
inviting you guys to the table. You know what I’m saying?
You need see, drug users need to be a part of this conversation.
At every level. Because if you want to know how to prevent
some of this stuff that’s going on, bring in the people that are in the mix of it, right?
Because I’ve got to tell ya, at 2:00 or 3:00 in the morning, none of you guys are out there.
But you know who is out there? The people that are in that community doing
that behavior. And if they are not a part of this, then the
solution is never going to be met.>>On that point I know that you share often
in your speeches and trainings around the state that we talk about putting naloxone
in the hands of first responders. But the real first responders are friends,
family and other people who use drugs. The people who you are using with.
And those are the people who are most likely to save your life.
So thank you for sharing that insight, Mark, I really appreciate it.
>>I often wonder, with increased potency of opioids, if that’s one of the causes why
we’re seeing youth needing treatment earlier. So with increased potency, there’s an increased
tolerance, right, of opioids. So people may actually become accustomed to
this increased potency and actually seek out a adulterated, you know, heroin with Fentanyl
or seek out Fentanyl purely. Or seek out Fentanyl to overcome, you know,
a blockade associated with certain medication assisted treatments.
So I think it’s just important to note that there’s a difference in this epidemic there’s
been other opioid epidemics. But with this epidemic, we’re dealing with
one different factor and that’s the increased potency of the opioid with Fentanyl, what
are the results of that? Does that mean that people are actually seeking
an increased potency because they’ve become accustomed to it, making the epidemic more
I’ve also heard that because of the relatively short half life of Fentanyl, a person who
has developed say a Fentanyl use disorder and is injecting Fentanyl, may find themselves
needing to inject every one to two hours, which also leads to an increased risk for
reusing syringes and developing Hepatitis C or H.I.V. with this increasing potency,
we have other unexpected consequences. So I have time for just one more question
before I bring Angie back up to give us a little call to action and a summary of how
we’re going to transition to the next piece. With this last question, you know, Michael,
you said earlier that you’re not a fed anymore. I’m going to test ya.
I’m going to see if that’s true. So when you were in at OMDCP, it was in the
Obama administration. They put in place a director who was the first
director who was a person in recovery. They moved in a more compassionate direction
on a number of initiatives and passed some legislation that has now seen its funding
come to fruition. The STR, the 21st Century cures, the CARA.
Donald Trump specifically campaigned on a promise to address the opioid crisis in the
United States, brought it up often and made it a center piece.
When he got into office, he did continue to discuss it and even today has declared a public
health emergency, which unarguably has brought public attention to the issue to an even greater
extent than previously. However that initiative or that announcement
did not bring additional funding. Did not, from my perspective as a healthcare
provider, result in any immediate on the ground regulatory changes in regards to who can access
MAT or other services. The people that were chosen in the administration
to lead various agencies have been concerning. There currently is no director of the office
of national drug control policy and the budget has been cut by 90%.
The previous secretary of health and human services said MAT was just trading one opioid
for another. The leader of the opioid task force is Kelly
Anne Conway. And I’m just going to leave that there.
[Laughter]. So Michael, if Donald Trump were to call you
today and invite you to a meeting in the oval office tomorrow and you had his attention
for five minutes, what would you tell him, what would you recommend that he do?
>>Let me start off by saying that one of the reasons that we got things done during
the Obama administration is that this was one of the few areas that was not a partisan
issue. We were able to work with both Republicans
and democrats on this issue and, you know, if there’s any bright spot, I still think
some of that continues in congress around that.
But trying to be objective and not political about this, I have to say that I share some
of the same concerns. Right?
So, you know, the solution to drugs coming into the United States is not a border wall.
The agent knows that most of the heroin that comes into the United States comes in through
legal ports of entry. It’s not even strategic in terms of those
pieces. But I think we, Republicans and democrats,
have made the pivot to the understanding that it’s got to be this balanced public health
and public safety strategy and that we’re not going to arrest and incarcerate.
So when I hear things like first of all, you know, again, you know, I think that I’m an
eternal optimist. When the president went to New Hampshire to
announce his opioid plan I was really is discouraged because one there was no plan and strategy.
I think there’s got to be a fundamental convener of all of the federal government in terms
of what is our plan going to be. No additional resources to be able to do that
by and large just really talking about the death penalty for drug dealers.
I don’t think we want to model our drug policy in the United States on Singapore and the
Philippines that are just murdering people left and right around this issue.
So the challenge becomes, you know, I think there are lots of really good people still
at the federal level. Who need to be involved in in the conversation.
So in light of I think what I think is challenge at the executive level, I think we need to
continue to work at the congressional level. To make sure that we’re working with our congressional
delegations to really focus on policy based solutions.
I can’t even keep track of the number of bills in congress right now that are focused on
this issue. So I think we’ve got to work with our congressional
delegation, you know, to advocate for more resources.
The last thing that I’ll say here, that does get one of the people mentioned one of the
biggest obstacles of why people don’t get treatment, not just here in Texas but around
the country, is not having access to insurance coverage.
We see that. Right?
So you cannot simultaneously say that I’m pro treatment and call for the repeal of the
Affordable Care Act, which is the very mechanism by which we have seen.
[ Applause ] in Kentucky, Ohio, West Virginia, the way people get treatment.
And Lisa can’t talk about this because she’s a state person.
But I had her job for nine years, right, before healthcare reform in Massachusetts and after
healthcare reform. In Massachusetts we have the lowest uninsurance
rate in the nation and we have a great Medicaid program and a great Medicaid benefit.
And that’s why, you know, I won’t say that we have a treatment on demand system, but
we’re pretty close. And we don’t experience these huge treatment
gaps that places like Texas and other places have because of because of not having wide
spread Medicaid expansion and insurance coverage. So you cannot simultaneously say that you
support treatment and want to eviscerate Medicaid. While we’re seeing all of this activity, simultaneously
we are seeing through the budget that was just released the evisceration of Medicare
and Medicaid. I do get on my high horse because you cannot
create a treatment on demand system without people having access to insurance coverage.
>>And that concludes our panel. Please give them all your thanks.
[ Applause ] No, stay in your seats for just a moment longer
and Angie Long from the DEA is going to give us our next steps as we transition to the
candlelight vigil.>>Thanks so much.
That was amazing. Could we please give them a round of applause.
[ Applause ]>>That was
[ Applause ] The conversation was fantastic.
And I really appreciate every single one of you taking the time out to do this tonight.
I join you in wanting to see more conversations like this.
So thank you very much. Tomorrow, we have a summit, the University
of Texas at Austin popup institute for youth substance abuse misuse and addiction is having
their summit tomorrow. It’s a tongue twister.
But we are having our summit tomorrow from 8:00 to 5:00, breakfast at 8:00.
The first opening remarks are at 9:00. Three panels two in the morning, one in the
afternoon. You get Dr. Hill again, you have Julie and
Lynn moderating a panel, you have sierra, I encourage you to check it out.
Our website is www.>>[Indiscernible].
>>Thank you. So much.
>>All right.>>Yeah, it’s in this room.
Just show up here, just come back for more. And on the way out, we’re going to begin with
our candlelight vigil if you would like to join us, there will be candles and don’t forget
to put your post it notes on our white boards and thank you again so much for coming, this
was fantastic. [ Applause ]