Anna Stelter, LMSW, MPH

A national epidemic of opioid use has ignited the deadliest drug crisis in American history. Today, opioid overdoses kill an average of 115 Americans daily. Fatal overdoses are on the rise in nearly every state, and the impact has been nothing short of catastrophic in Appalachia and the Midwest. But how is the opioid epidemic playing out in Texas? And will the crisis continue to escalate?

1. Texas has the third-lowest drug overdose death rate in the country.
While the opioid crisis is driving increases in drug overdose mortality nationwide, rates in Texas have not trended upward as sharply as other states. As a result, Texas ranks 48th of all states in drug overdose mortality, with a rate of 10.1 deaths per 100,000 population in 2016. Texas’ rate is about half the national average (19.8) and less than one-fifth that of the highest ranked state, West Virginia (52.0). Opioids account for about half of all drug overdose deaths in Texas, whereas they account for two-thirds of drug overdose deaths nationally.

2. Opioid use appears most prevalent in parts of north and east Texas. 
Though Texas’ opioid overdose mortality rate is relatively low overall, county-level data reveal areas of the state where opioid use is a major concern. Opioid-related hospital admissions and accidental poisoning deaths are concentrated in North and East Texas, including many rural counties. Drug overdose mortality in some southeast Texas counties exceeded 24 deaths per 100,000 in 2016. Several counties along the Red River also have high rates of drug overdose deaths, including Baylor County (near Wichita Falls) with over 30 deaths per 100,000, highest of any county in the state.  

3. Legally prescribed opioid painkillers are involved in about half of opioid overdose deaths in Texas.
Many people with opioid use disorders first become addicted to opioid pain medication prescribed legally by a doctor. Emergency physicians, primary care physicians, dentists, and surgeons are leading sources of opioid prescriptions. Drug overdose mortality rates tend to be highest in areas where opioid prescribing rates are also highest.

As prescription painkillers become harder to obtain, some people with opioid use disorders transition to heroin use. Heroin has a similar effect on the body, and can be acquired illicitly for a fraction of the cost. Perhaps most concerning, the illicit drug supply is becoming tainted with dangerous synthetic opioids such as fentanyl. Approximately 50 times stronger than morphine, traffickers may mix fentanyl into heroin and cocaine to enhance its potency, dramatically increasing the potential for overdose. Nationally, fentanyl-related deaths nearly doubled from 2015 to 2016.
 
In 2017, roughly two-thirds of opioid related drug exposure calls to the Texas Poison Center Network were made for commonly prescribed opioids, while most of the remaining one-third were for synthetic opioids. Of 1,174 deaths in Texas involving opioids in 2015, 517 involved commonly prescribed opioids, 516 involved heroin, and 153 involved synthetic opioids. 

4. Texas’ opioid problem could be about to worsen.
​While illicit drugs laced with fentanyl are driving a recent wave of overdose deaths nationally, fentanyl was involved in only 4% of heroin deaths in Texas in 2017. Texas has been insulated from the lethal impact of fentanyl primarily because the most commonly used type of heroin in Texas, black tar, is harder to mix with fentanyl than the white powder heroin most prevalent in the Midwest and Appalachia.
 
But that could soon change. According to experts, white powder heroin use is increasing in Texas, drug suppliers are developing new ways to mix fentanyl with black tar heroin, and fentanyl is increasingly being mixed with drugs other than heroin. An uptick in opioid overdoses and deaths in Texas becomes more likely under these conditions.

5. Opioids are only one piece of the substance use crisis in Texas.
The current opioid epidemic has alarmed public health leaders and captured substantial media attention. But by several measures, opioids are hardly the leading addictive substance threatening the health of Texans.
 
Methamphetamine has long been the state’s top illicit drug threat, and currently more methamphetamine deaths occur annually than opioid deaths in Texas. Deaths involving prescription benzodiazepines (sedatives like Valium and Xanax) have quadrupled nationally from 2002 to 2016, and since they are often prescribed with opioids, have been described as an “epidemic within an epidemic.” And for many decades, alcohol has been the most frequently misused substance in Texas and the nation, responsible for 88,000 premature deaths per year nationwide and shortening the lives of those who die by an average of 30 years. People with an opioid use disorder are 8.4 times more likely to have alcohol use disorders than those without.
 
The common thread uniting these challenges is addiction, which has long been stigmatized as a behavioral illness or personal failing rather than a chronic, relapsing, and treatable disease. The emerging opioid threat is not the first substance use crisis Texas has faced, nor will it be the last. However, with the current urgency surrounding opioids, public health leaders in Texas have an opportunity to take a thoughtful approach to preventing and treating substance use, staying ahead of a problem that – at least for now – shows few signs of slowing.

By Anna Stelter, LMSW, MPH

Last month, Arkansas joined Indiana and Kentucky as the third state to receive approval from the federal Centers for Medicare and Medicaid Services (CMS) to require enrollees in its Medicaid program to work. Beginning in April, non-disabled Arkansas adults under age 50 who are eligible for Medicaid will have to prove they are employed, in school, receiving job skills training, or performing community service at least 20 hours per week to maintain their health insurance coverage. CMS Administrator Seema Verma, explaining her agency’s support of work requirements, remarked “meaningful work is essential to beneficiaries’ economic self-sufficiency, self-esteem, well-being, and health.”
 
Requiring “able-bodied” Medicaid enrollees to work has emerged as a politically appealing option for states wanting to tailor who can enroll in the program and what benefits they receive. Nineteen other states, most with Republican-led governors and legislatures, have asked CMS to allow them to administer a work requirement. However, Texas is one of a handful of such states that has not yet signaled an intent to require its Medicaid enrollees to work, and doesn’t seem likely to do so.
​
Because Texas’ recent approach to Medicaid policy has been in line with several states now forging ahead with work requirements, the state's decision not to join the pack might seem curious at first. Yet it’s precisely because of Texas’ restrictive track record on Medicaid that it’s not in position to pursue a Medicaid work requirement. While Medicaid expansion states like Arkansas and Kentucky have a large share of working-age adult enrollees, Texas’ Medicaid program contains barely any enrollees to whom a work requirement could reasonably apply.

Source: The Commonwealth Fund. Status of Medicaid Expansion and Work Requirement Waivers.

Who are Texas' Medicaid Enrollees?
Of the 4.5 million Texans enrolled in Medicaid, approximately 95% are children, people with disabilities, pregnant women, and seniors, all of whom would be exempt from a work requirement, per CMS guidance. ​The 5% remaining are either low-income parents, young adults under age 26 who have recently exited foster care, mothers in domestic violence shelters, and other small segments of especially vulnerable enrollees. Texas did not expand Medicaid under the Affordable Care Act, and most low-income working-age adults are not  eligible to enroll. 

Proponents of Medicaid work requirements have frequently suggested Medicaid should not be available to those who would rather rely on coverage from the government than work to earn coverage themselves. However, research hardly supports the suggestion people with Medicaid are unwilling to work. Almost all working-age adult Medicaid enrollees are already working (usually in jobs that do not offer health insurance), seeking work, attending school, or taking care of family members. Most of those who are out of work reported facing severe health-related barriers to work, such as chronic mental or physical illness. It is not clear which Texans a Medicaid work requirement would incentivize into work who aren’t legally exempt, currently employed, or have compelling reasons for not working. 

Work Requirements could do More Harm than Good
Conditioning health coverage on work activities risks directly harming the health of out-of-work enrollees and their family members instead of promoting economic self-sufficiency. Under a work requirement, people who are temporarily unable to work for health reasons would lose their access to treatments, prescription drugs, or assistive devices that could facilitate their return to the workforce. People who provide full-time care for very young, ill, or disabled family members would be compelled to balance a job alongside the demands of unpredictable, round-the-clock caretaking, an impossible scenario for many families or employers to accommodate. And at a time when Texas is trying to reverse a statewide trend of rising maternal mortality rates, low-income postpartum women who could not work after delivery would lose access to potentially lifesaving care.
 
Work Requirements are Complex and Costly
If the mismatch between the target population for a work requirement and Texas’ actual enrollee population is not enough to dissuade state leadership, perhaps the complexity and the price tag is. A work requirement would saddle the state with a costly administrative burden (likely at least several million dollars annually) to create, operate, maintain, and staff systems to verify employment for thousands of enrollees. State leaders would also have to invest  time and effort thoughtfully designing how the work requirement will be enforced: What activities qualify as “work”? What do enrollees have to do to prove they are working? How often must someone show proof? 
​
A viable work requirement would also have to be flexible enough to accommodate circumstances characteristic of low-wage work and poverty. For example, many low-income people move frequently, work cash-only jobs, lack control over the number of hours they work per week, have criminal histories, or lack a high school diploma, all of which could impact a person’s ability to seek, keep, and prove their employment.

The bottom line: A work requirement is not well suited to Texas' current Medicaid enrollee  population, and would present a serious administrative and budgetary challenge to the state.