Can This New Research Program Teach Houston How to Tackle Opioid Abuse?

The opioid crisis hasn’t hit Texas as hard as other states. But opioid abuse is still a problem here, one that Dr. James Langabeer believes is more widespread than has been acknowledged.

By Gwendolyn Knapp April 25, 2019 Published in the May 2019 issue of Houstonia Magazine

From the moment Jeremy started using opioids in 2012, he spent most of his time trying to figure out how to quit. He’d ended up addicted in the same way so many others had—after an injury. It’s a sadly familiar story.

The accident happened when he was 33, working as the manager of a popular restaurant on Washington Avenue and newly married. The chef had called him up asking for help. “He was smoking meat outside,” Jeremy recalls, “and had locked himself out of the apartment.”

Jeremy arrived and, after assessing things, decided to climb onto the chef’s roof to try to break into a window. But he slipped, succumbing to gravity, and landed on his back, hard, on the sidewalk’s curb.

Driving home, Jeremy almost blacked out from the pain he felt turning the steering wheel. The next day it felt like an elephant was sitting on his back. He couldn’t stand up straight. He could barely walk. He had no health insurance. He told his staff, Somebody has to cover for me. Somebody has to find me something.

Somebody procured hydrocodone.

He took hydrocodone, then OxyContin, then whatever he could get his hands on, even after the pain subsided. By then what is now known as opioid-use disorder had set in. Opioids were attacking the receptors in his brain, making it extremely difficult to quit—his brain just kept craving that feeling.

By 2013 the pills were harder to come by and more expensive.

“I was definitely addicted,” he says. He got sick when he couldn’t find any. “That’s when it transferred to heroin.”

By 2018 he was spending $200 a day on heroin, and it was destroying his life.

It was in June of that year that his brother Jonathan heard about a research program called Houston Emergency Opioid Engagement System (HEROES) on the Houston Public Media radio show Houston Matters. Dr. James Langabeer, a professor of biomedical informatics, emergency medicine, and public health at UTHealth, was giving an interview on the news program.

On the air Langabeer talked about how he’d established HEROES in April 2018 with the dual goals of tracking the prevalence of opioid-abuse disorder in Houston and keeping patients in treatment long-term by establishing a collaborative network to assist them, composed of physicians, psychiatrists, social workers, drug counselors, peer recovery coaches, and first responders.

Before he knew what he was doing, Jonathan picked up his phone to call up the show. He got through.

“My brother is addicted to heroin,” he blurted. “Now that I’ve found out, I’m struggling to find him treatment. He’s been in and out of treatment centers, including places outside of the state. He keeps relapsing. At this point he’s losing everything. His wife. His child. CPS is involved.”

“First of all, I just want to say I’m very sorry,” Langabeer told Jonathan. “And I’d like to say that although this is tragic, it is common. This is truly what opioids do and why it’s an epidemic.” He urged Jonathan to follow up after the show.

Jeremy developed opioid-use disorder after a serious accident.

The full extent of the opioid problem in the Houston area simply isn’t known. Until recent efforts, no one has been tracking it much beyond tallying the death toll, and even that is disputed. One of Langabeer’s goals is to change that.

On a national level, according to the Centers for Disease Control and Prevention, more than 400,000 people have died from opioid overdoses since 1999, an epidemic that’s played out in three waves. First there was the rise of over-prescribed pharmaceutical pills like OxyContin in the late 1990s; then came a spike in heroin overdoses after 2010; and, finally, the onslaught of deaths from the introduction of synthetic opioids—namely fentanyl, which comes in from China or Mexico and is 50 times more potent than heroin—over the past six years. Americans are now more likely to die from an overdose than in a car accident or a shooting. It’s estimated that nearly 2 million of us are addicted to some form of opioid. It’s a national public health emergency.

While opioids haven’t hit Texas as hard as they have many other states, they still account for almost half of the recorded fatal drug overdoses here, according to the Department of State Health Services. In 2018 there were 314 deaths, including suicides, attributed to opioid overdoses in Harris County, and in 2017 there were 310, according to toxicity death reports from the Harris County Institute of Forensic Sciences. Those numbers don’t show much of a jump over that period, but they do represent an increase from previous years—2012 saw 235 opioid deaths in Harris County; 2015, 260. And while the majority of these deaths were heroin-related, fentanyl is on the rise. Of those 2018 deaths, 95 involved fentanyl, up from 56 the previous year, according to the same reports.

The opioid-related death rate already has state public health officials concerned, but Langabeer is certain the real numbers are higher. “I believe, firmly, we are not getting really good data on who is dying of opioids,” he says. “A lot of people die, and we don’t know why they die.”

Our state has 13 medical-examiner offices for 254 counties, and autopsies are done on only a small number of people. It’s different in rural counties in opioid hotbeds like Ohio or West Virginia, which are far ahead of cities at tracking overdose deaths because they have more federal funding for more toxicology tests and examiners who, when suspicious that opioids might be at play, investigate, interviewing relatives or people who knew the deceased. That isn’t feasible for a city as large as Houston, which hasn’t historically had an opioid crisis.

Still, Langabeer believes there is a way to get a better picture of the problem. HEROES is working to centralize data systems to track overdoses both fatal and non-fatal in close to real time so that the prevalence of opioid use here is better understood. The program is also collecting data from first responders so that researchers can begin to see who is repeatedly overdosing, identify zip codes that appear to be hotbeds for opioids (especially fentanyl), and use this data to take preventative measures and offer treatment, making the program compliant with privacy laws.

Langabeer has spent his career researching the best ways to use data to improve health care. He’s into the big picture, wants to rethink entire systems. And to talk to him is to realize just how much room for improvement there is in Houston when it comes to treating addiction.

When he first started studying the drug epidemic here in 2016, he says, “There just were inadequate ways of treating patients with any type of substance-abuse disorder, whether it’s alcohol, cocaine, or opioids.”

A few years later, things aren’t much better. The problems remain manifold, particularly when it comes to opioids.

It’s widely believed that medication-assisted treatment is the best way to address opioid-use disorder, and the FDA has approved three drugs for that purpose: methadone, naltrexone, and buprenorphine. All have their merits, but, depending on the patient’s history, Langabeer typically prefers buprenorphine—an affordable synthetic opioid that, like methadone, safely replicates its effects enough to prevent withdrawal symptoms and cravings while patients taper off over time. It’s easier to prescribe than the others, he says.

Methadone is stronger than buprenorphine and can be legally obtained only through specially licensed treatment programs or methadone clinics, many of which operate on odd hours and can be difficult to get to without a car. Naltrexone, which prevents the brain from registering any opioid effects, isn’t addictive, but if a patient relapses while taking it, the drug can trigger withdrawal symptoms.

Buprenorphine is seen as less addictive than methadone, and the government allows physicians with the required certification to prescribe it directly, making it easier for patients to access. But despite its advantages, buprenorphine remains highly regulated because of the ease with which people can sell the pills on the street—fewer than 7 percent of physicians in America have a license to write such a script. 

In general, medication-assisted treatment isn’t easily come by in Houston. In a report last year, researchers at Rice’s Baker Institute found that roughly 200 facilities offer drug treatment in Harris County—state-licensed inpatient and outpatient programs, detox and residential facilities, medication-assisted treatment centers, and more—but, as Katharine Neill Harris, a criminal justice and drug reform expert with the institute, explains, “Most just offer abstinence-only treatment.” 

Harris points to the 2016 National Survey of Substance Abuse Treatment Services, which tallies just 26 clinics in Harris County that offer any of the three main medications shown to curb opioid-use disorder. “I only know of one facility that offers all three medication-assisted treatments,” says Harris, “which is what federal guidelines recommend as best practices.” Meanwhile it’s hard to identify the ones that do, since federal, state, and local government websites don’t clearly list them. 

In her research, Harris has found that not only do the 200 facilities in Harris County vary wildly in regard to quality, services, and personnel, but few cater to low-income patients. Only 10 clinics offer at least one medication approved to treat opioids while also accepting Medicaid, and only 5 of those also accept payment on a sliding-fee scale or offer assistance. And according to Langabeer, many don’t accept Medicaid at all, just cash, which isn’t feasible for people who’ve lost everything to opioids in the first place. On top of that, they often have long waiting lists.

“If you have money, you have a lot of options in terms of treatments that you want,” Harris says. “If you don’t have money to pay for things, you don’t have many options.”

Langabeer says that cost, along with the stigma and shame that often go hand in hand with drug-addiction treatment, is the biggest obstacle to seeking help. 

Part of HEROES’s mission is to demonstrate what happens when these issues are addressed. To that end, it offers affordable, medication-assisted treatment while approaching opioid-use disorder like any other medical problem. Through collaborations with ten community-based clinics, the program offers free or deeply discounted medication to those without insurance.

And through the community network Langabeer has assembled, patients also receive group and one-on-one counseling facilitated by recovery coaches from the Houston Recovery Center, along with a “continuum of care” that gently guides patients through tailored treatment programs for however long they may need them, while offering a safety net in the form of consistent follow-ups and phone chats, until they recover. Each of these services is free.

How much does HEROES cost per patient? All of its partners are formally contracted with UTHealth, but the program’s two costliest elements are physicians’ time and the resources required to seek out new patients, factors that the program mitigates through its state funding. “One of the things we’re looking at is cost-effectiveness,” Langabeer says. “What would it look like on a direct-costing basis to do these kinds of things? And we’d probably be talking about $1,000 initially, just to get a patient going.”

The man behind HEROES: Dr. James Langabeer, a professor of biomedical informatics, emergency medicine, and public health at UTHealth.

Here’s what typically happens when a fire department or EMS responds to an opioid-overdose call: An EMT tries to wake the patient, administers naloxone, commonly known as Narcan—which blocks opioid receptors in the brain, reverses the overdose, and gives the appearance of waking the dead—and rushes the patient to the ER. Then the patient is given fluids and maybe sedatives, depending on the situation, “but not a medication that could start the healing process,” says Langabeer. “It’s a medically supervised form of coming out of overdose.” Some $2,000 to $50,000 in hospital bills later, the patient is released.

The goal of HEROES is to tackle the disorder from the emergency side, identifying and assisting most patients right after they overdose. “Our initial thinking is, there is this critical time where you’re more prone to make changes in your life,” says Langabeer. “New Year’s Day is one. We believe overdoses are one of these critical times.”

As part of that effort, the program has partnered with Memorial Hermann–Texas Medical Center and Harris Health’s LBJ Hospital to ask patients who’ve overdosed if they’d like to be treated with buprenorphine.

“In an ER you can provide a single dose of buprenorphine if it’s stocked in the pharmacy, although it rarely is,” says Langabeer. “You can’t discharge the patient with buprenorphine unless you have this Drug Enforcement Administration/Substance Abuse and Mental Health Services Administration waiver.” To address that issue, he’s enlisted a number of emergency physicians to go through training and get the waiver, so they can administer the drug. “Nobody in emergency departments in Houston was authorized to write the script,” he says, “until we started this program.”

In addition, HEROES reaches out to Houstonians who’ve overdosed on opioids through its partnership with the Houston Fire Department, which provides daily data on any incidents. The fire department sends out a trained team of paramedics, who are partnered with recovery coaches from Houston Recovery Center, to the homes of patients who weren’t approached about HEROES in the hospital, within a day or two of their discharge from an emergency department—sometimes visiting 20 people in a day—to talk about recovery and the program. Is this something that’s happened before? Do you want help? Would you like some options?

While HEROES could prove groundbreaking for Houston, it isn’t entirely revolutionary. When it comes to treatment, its approach has been widely used elsewhere for years. And while there aren’t many programs that are addressing the opioid epidemic by proactively tracking down people with addiction, new ones in San Francisco, Boston, and Austin are making similar attempts to reach out, by finding and writing scripts for opioid users on the streets or in homeless shelters.

But distinguishing it from other efforts nationwide, HEROES has far more moving parts, including data collection, advocacy, and its own built-in recovery program, which is vital, says Langabeer, because he doesn’t believe that medication-assisted treatment alone is enough for most patients to recover long-term.

That built-in program, administered by Houston Recovery Center, is something for which the city deserves credit. “The city created our organization and funds us 100 percent,” says Leonard Kincaid, executive director, referring to its sobering-center arm.

Established in 2012 as a sobering center in response to Houston’s public-intoxication problem, the nonprofit has now expanded into a multifaceted organization that raises money through donations and offers a host of recovery programs, including an 18-month one that’s attempting to address the opioid problem that’s been showing up in our courts and EMS transport and inside Harris County Jail.

The center treats individuals identified by the criminal justice system along with walk-ins but doesn’t advertise to the public. Still, says Kincaid, “the city has created a foundation that we can build upon.” 

Some patients, like Jeremy, come to HEROES on their own. After sending an email, Jonathan was able to get Jeremy an appointment within one week of hearing about the program on the radio.

The brothers arrived at the office on the 16th floor of University Center Tower almost a year ago, on June 25. It wasn’t much to look at by Texas Medical Center standards—just a few cubicles, a small waiting area, and a designated folding table with complimentary coffee set out. But it’s here that a shoestring staff quickly got him on the path to recovery.

Jeremy met the program’s social worker, along with its chemical dependency counselors staffed by UTHealth, and Langabeer, as all patients do. He filled out consent documentation—I agree to be treated and be part of your research program—and a stack of forms, providing his name, age, zip code, living situation, job, and history of drug use.

He told the HEROES team about his failed attempts at recovery through the years, how he tried to go cold turkey in 2013, driving off to his parent’s vacant house in the country for a week, and using again the moment he was back in Houston. How he self-medicated for three years after that, finding Suboxone, a form of buprenorphine that staves off withdrawal while preventing opioids’ high, on the black market. His wife was okay with it—that’s what many people in treatment were getting, anyway—but she always knew when he’d relapsed. His left eye would close a little, his voice would get raspier, weaker, as if he were fighting off a cold. The relationship was strained.

After the couple’s daughter was born in 2015, Jeremy finally told his parents he was battling a heroin addiction, and they paid $10,000 for him to try a rapid-detox treatment center in Michigan. “They put you under anesthetic, shoot you full of Narcan, and rapidly withdraw you from opiates. That’s really bad for you. That was not successful. It took a lot out of me.”

He came back home and used again. He tried Narcotics Anonymous, but people kept glorifying the good old days, and he didn’t like it. 

In April 2017 things went from bad to worse when he got a DWI.

In February of last year Jeremy did a month of outpatient treatment at a center in Houston for around $5,000, attending three times a week, but it didn’t work well for him. They were doing things like macaroni art, and he found the counselors preachy. “I told them I was having a hard time,” he says. “I couldn’t sleep. I started to hallucinate. Toward the third week I started back on heroin.” Staff suggested he try their $35,000 in-patient treatment, but Jeremy couldn’t afford it.

Then, in May of last year, he failed a drug test. At the time, because of delays in his case, he was still out on bond from his DWI—random drug testing is standard pretrial protocol in Harris County. He was briefly jailed and had to post another bond.

Later, because he was in treatment for opioid-use disorder, instead of prosecuting him the court would place him in a pretrial diversion program whose requirements included serving probation, with community service as part of that, in order to get his DWI charges dismissed. Meanwhile, Jeremy moved into a garage apartment across from the bar where he worked. Around that time, CPS stepped in and rehoused his daughter with his in-laws, and he and his wife separated.

The team at HEROES listened, and together they decided supervised doses of methadone would work best for Jeremy, because of his history, and the fact that his schedule (and car) allowed him to pick up his doses six days a week. His time commitment would be about eight to ten hours per week, including peer groups and recovery coaching.

“When this whole disorder started, I wasn’t doing drugs anymore. I had in the past, but I wasn’t even drinking very much. I thought I was past all that,” Jeremy says, recalling the accident that set his nightmare in motion. “I never had to steal or anything, but it was getting to the point where it was kind of coming off the rails, and I could see that was coming.” 

Langabeer and the HEROES team at a counseling session

A year in, has HEROES proven to be effective? The short answer is yes. As of March, 80 percent of program patients were not using after 30 days. That might not sound like much, but statistically, almost 100 percent of heroin users return to using after seven days, according to Langabeer.

At the time of our interview, Jeremy is nine months into recovery. He credits the low cost of treatment (he pays just $17 a week for his medication) and the peer groups and down-to-earth recovery coaches he sees at the Houston Recovery Center, who have all been through substance-abuse treatment before themselves. “It’s just different,” he says. “They understand what the hurdles are, what’s stopping people.”

If there is a problem, it is one of scope. HEROES is, after all, a research program. It was initially funded with $1.1 million in research grants through another initiative, the Texas Targeted Opioid Response program, which was founded in 2017 with $27.4 million in federal SAMHSA funding. But after an overwhelming response—from patients identified by HEROES as well as people calling and emailing Langabeer in search of help—an additional $2.2 million (from SAMHSA and the U.S. Department of Justice) was secured.

This means that the program definitely will be carried through 2020, and that it will serve 250 patients, rather than its original target of 100 (by March 225 patients already had enrolled). The team intends to keep the program going long-term, too. But to properly address opioid-use disorder in Houston—to establish a permanent program with long-term goals of reaching a much greater percentage of people with opioid-use disorder and partnering with more than just two hospitals, will take far more effort, and not just on the part of HEROES staff.

“It’s important that somebody else can be able to do these programs,” says Langabeer. “There’s a lot of social organizations, recovery centers, and others that can take a leadership role. We do want to make sure the city and social services get involved.”

While numbers are hard to come by, it’s safe to say there are thousands of Houstonians suffering from opioid-use disorder in the shadows. To find and treat them would require millions more in funding, which is why it’s important to make the program scalable and cost-effective for everyone. With the commitment of more partners, that could be possible—Langabeer imagines a network of 100 providers, and he would like to remain involved, doing research.

“I think these [collaborative] programs are really what we need,” adds Harris. “One of the challenges to treating people with an addiction is there’s all these separations between these systems of care—emergency providers, physicians, counselors. None of these silos interact. There’s not a lot of coordination. But HEROES is a good example of how to do that. It’s a practical solution.”

Langabeer and his team have been busy running statistical models for their study, comparing patients, and looking for variables—what pops up that keeps people from staying in recovery? Issues like homelessness, they’ve found, must be addressed at the same time, which is why HEROES is forming more relationships with organizations that are already fighting that problem and others that address medical issues including hepatitis C or HIV.

“Part of our mission, really, is to have an advocacy and a policy role for the city. So convening people to talk about this and saying, Hey, what do we do? How do we affect more people, change more people? That’s what we want to do.”

Langabeer and his colleagues also are finalizing a paper on the relationship between the number of people dying from opioid overdoses and the number of doctors authorized to provide medication-assisted treatment—a national problem. “We want to add to the evidence,” he says. “If we can say, this works and this works, and we can tell cities like San Francisco, and Los Angeles and Raleigh, North Carolina, that’s our goal.”

Opioid abuse, Langabeer says, is an issue that isn’t just important to him professionally. “We all have personal stories. I have personal stories,” he says. “I have family members with addiction issues. It’s something no one was tackling here, and I wanted to make a change.”

As for Jeremy, he says he’s hopeful for the future. He’s just qualified to pick up his medicine once a week, instead of six times—a sign he’s succeeding with treatment—and is still going to peer groups and counseling. His probation will be over soon, and he has just a few hours of community service left. His CPS case is now closed.

Jeremy and his wife have gone to marriage counseling and taken up working out together at the gym. He’s been staying with her and their daughter part-time at a place his in-laws are leasing to them. He plans to move in full time by summer, get the family back together, and, perhaps then, start the long, slow taper off of methadone, but that?

“You don’t want to put a date on it,” he says. “What if you’re not ready?”

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