Data that reflect a patient’s true risk of substance use disorder or overdose. Technology that alerts physicians of an overdose history. Immediate and affordable access to overdose-reversing medication. Resources that support early intervention.
These types of tools may seem illusory. But the Texas Medical Association’s Committee on Behavioral Health has a clear vision of these and other solutions needed to empower physicians to combat the opioid crisis without compromising their ability to provide the best care possible to all their patients.
“The more time a physician has to spend translating data into clinically actionable information ... the less time they have to connect with their patients and deliver better patient care,” said Michael Sprintz, DO, a pain and addiction specialist in Spring and member of the committee.
“We have a massive population of people that are under-identified and under-treated for a lot of behavioral health issues that increase the probability of developing a substance use problem and or overdose,” he said. At the same time, “when we talk about protecting our patients, it’s not just protecting our patients in identifying a substance use disorder in someone. It’s protecting our patients who don’t have a substance use disorder,” so they can still access needed medications.
Texas continues to take steps to address the opioid problem, with TMA weighing in most recently on potential interim study items by the Texas House Public Health Committee. TMA also helped win reinstatement of state funding to make electronic health record (EHR) integration with the state’s prescription monitoring program (PMP) free for all medical professionals, and the passage of a law requiring certain school campuses to have opioid antagonists on hand.
Gov. Greg Abbott named the fentanyl crisis an emergency item in early 2023. Later in the year, Texas’ Opioid Abatement Fund Council (OAFC) – formed to manage money recovered from statewide opioid lawsuit settlements – announced the first of its responses to the crisis: prevent overdoses with distribution of naloxone, promote drug prevention education in schools and communities, and strengthen the behavioral health workforce.
But state plans still lack what physicians have long called for: more complete and accessible data that can guide clinical decisions and, equally important, early intervention.
“Being able to have these sorts of conversations that then begin to address the use disorders in families becomes so important,” said Leslie Secrest, MD, a Dallas psychiatrist and co-chair of the Committee on Behavioral Health. “That is the area that we’d like to see something begin to change, and processes change, that allow [substance use disorder] to be identified and worked with early on, [as well as] figure out ways to facilitate prevention of those events.”
The data gap
While physicians may not see immediate change, the work and attention on opioids is part of an overall positive trend.
TMA continues to monitor OAFC’s recently proposed rules to guide the distribution of an estimated $166.7 million in opioid settlement funds to more than 150 hospital districts over an estimated 18 years, as directed by state law.
Perhaps acknowledging the data gap, however, the Centers for Disease Control and Prevention (CDC) recently gave states, including Texas, a grant aimed at least in part at improving data collection and analysis and expanding and modernizing data systems.
About $1.6 million of the five-year Overdose Data to Action (OD2A) grant from CDC will go toward expanding and modernizing data systems. The Texas Department of State Health Services (DSHS) will lead the charge on the health information improvements; the Texas Health and Human Services Commission will use the remaining $2.3 million of the grant to implement solutions based on DSHS’ findings.
The OD2A state program provides support for clinician education and training, as well as for health information technology infrastructure improvements, including enhancements to state prescription drug monitoring programs.
In Texas, that means the PMP, which, along with emergency medical services (EMS) data collection, falls short, says Dr. Sprintz.
TMA has long advocated for usability and access improvements to the PMP. The Committee on Behavioral Health would like to see the integration of more helpful enhancements that paint a more complete picture of a patient’s history, for example, by creating an alert when a given patient has a history of overdose and integrating better EMS data that may otherwise not make it to an EHR.
Physicians “need to be able to look at the information and instantly grasp it in a visually usable way that enables them to go, ‘Oh, OK, I see what’s going on,’” Dr. Sprintz said.
He is clear that having the PMP “is absolutely better than not having it.” Throughout much of its tumultuous implementation, however, the overwhelming amount and inaccessibility of PMP data have rendered it not clinically useful.
“The data is not yet in an easily actionable format that physicians or providers without much experience are able to use optimally,” he said.
The PMP presents a patient’s prescription history, along with a “risk score” based on the number of prescriptions, prescribers, and overlap. But Dr. Sprintz says that score is dubious at best, and physicians don’t always have the time or resources to sort through patients’ history.
Nor are physicians informed on “the actual algorithm that calculates that risk score. ... It’s never been peer reviewed, yet clinicians sometimes make life-changing clinical decisions based on those risk scores,” he said.
It does not account for a host of different factors that impact a patient’s risk of a substance use disorder, let alone the risk of an overdose, Dr. Sprintz adds. Additionally, looking at prescription histories from neighboring states requires further legwork by the physician within the PMP. Both factors can obscure the true risk of prescribing to a patient.
Better collection of EMS data also can bridge gaps. In addition to collecting EMS data on overdose-related home visits and emergency department trips, the Committee on Behavioral Health suggests having emergency medical technicians carry additional naloxone to dispense on site, along with educational materials on low- or no-cost treatment options for substance use disorder.
Texas does track overall numbers for opioid-related deaths or disabling events, Dr. Secrest says. But these data leave out a large swath of patients who may overdose and then still be vulnerable to repeat events, or patients at risk of overdose who could be reached with early intervention.
“A person will talk about how [a loved one] overdosed and was given naloxone, and it got them enough time for EMS to get there,” Dr. Secrest said. “Well, where’s the metric? If you talk to the ER docs, [it’s unclear] how much more they’re seeing people come in or not come in by EMS because of an opioid overdose.”
Moreover, patients experiencing an overdose or otherwise struggling with substance use disorder often don’t feel safe going to a hospital or seeing a physician, Dr. Sprintz says.
Along with a general mistrust of the health care system, “there’s a lot of fear. We [physicians] know we’re not calling the cops on [patients]. They don’t.”
Early interventions
Governor Abbott’s emergency declaration also paved the way for greater distribution of naloxone, and the U.S. Food and Drug Administration (FDA) in March approved the first over-the-counter naloxone nasal spray; the second followed in July.
Dr. Sprintz, who serves on the FDA Advisory Committee that made the approval, calls it “fantastic” and “a huge step in the right direction” but recognizes its limitations.
“I don’t want us to create the illusion that just handing out naloxone is going to prevent or decrease the rate of opioid use disorder, the incidence of opioid use disorder, or the prevalence in our communities. We need to do more,” he said.
That includes making antagonists like naloxone more affordable and accessible, whether to individual patients, their communities, or private treatment centers.
At press time, a two-pack of naloxone nasal spray retailed at a pharmacy for about $45 without insurance coverage.
“It’s not inexpensive,” Dr. Secrest said. “How do you get it widely available in all communities in all economic settings? That’s where our opportunity is: beginning to try to have conversations of how to get this in a form that is widely available and readily obtainable.”
TMA’s letter to the Texas House Public Health Committee offered suggestions for supporting private treatment funding and improving payment for screening, brief intervention, and referral to treatment processes. These suggestions could be reformulated as budget requests or catch the eyes of medicine’s allies in the legislature for future bills.
“Being able to provide resources to private community groups to help distribute naloxone and educate their community is the smartest thing we could possibly do,” Dr. Sprintz said. “Bring it back to the community in which the people live.”