Relief Routes

Dr. Katherine Keyes sits on the witness stand fielding questions under cross-examination from a lawyer representing Walgreens in Santa Fe late one afternoon last week. Along with Walmart and Kroger, the giant pharmacy chain is defending claims by New Mexico officials that the companies contributed to the state’s devastating opioid crisis by failing to investigate suspicious prescriptions before filling them.

Keyes, a professor of epidemiology at the Columbia University Mailman School of Public Health and key witness in the state’s lawsuit, raises her eyebrows often and asks the lawyer several times to rephrase obtuse questions.

“But have you determined the right level of [opiate] supply?” he presses, “Like, can you give me an estimate…a number?” Keyes is polite, but her answers are almost professorial; her hands wave and her head nods to punctuate key points, as if talking to a grade-schooler rather than a corporate lawyer who is missing the point.

Keyes’ presentation in the preceding hours came during the fourth week of the mega-trial in the First Judicial District Court, which is expected to run until Thanksgiving. It left little doubt that opioid prescribing is far and away the strongest risk factor for opioid use disorder in New Mexico, more so than other important predictors like economic strife or pre-existing mental health problems.

State Attorney General Hector Balderas noted in his opening statement on Sept. 7 that a single Walgreens in Española dispensed over 12.4 million opiate pills from 2006 to 2019, enough to give everyone in the city 841 pills. In other regions of the state, numbers were also alarmingly high. Balderas alleges these companies failed to adequately monitor suspicious opioid prescriptions that may have been written for illegitimate purposes: In short, that they helped cause today’s predicament.

If Balderas prevails in court, it’s not clear how much money would flow into the state for addiction prevention and treatment efforts, but Oklahoma recently obtained a $250 million settlement from opioid distributors in a similar case. Already, Balderas’ office has recovered almost $200 million from a settlement agreement with three large drug manufacturers. The money is earmarked to address the state’s ballooning opioid problem.

Meanwhile, once every 8.5 hours, a New Mexican died from a drug overdose last year for a total of 1,025—with more than half coming at the hands of illicit fentanyl, according to preliminary data from the New Mexico Department of Health. That’s up from 801 deaths in 2020.

Despite the good news about cash coming into the state and more potentially on the way, it’s clear the overdose rates are getting worse, and fast.

Balderas is concerned about whether this money will be appropriated well, and wishes he was seeing more planning and assessment. “This is money coming out of the sky,” he tells SFR, but “elected leaders and health officials are in the dark. I see it as a real game-changer, but we’re underprepared on the delivery side.”

New Mexico has made headlines for opioids for decades, with the state ranking many times in the top 10 nationally for overdose-related deaths. The first wave started in the 1990s with heroin, and the second in the 2000s with prescription pain medications.

Today, the epidemic has a new, more terrifying aspect: illicitly manufactured fentanyl. This third wave started in New Mexico around 2019, and it “has just come raging out of nowhere,” says Dr. Robert Kelly, substance use epidemiology section manager at the health department.

The fentanyl wave began earlier in Northeastern states, around 2014. Fentanyl has been available as a prescription pain medication for decades, but illicitly manufactured fentanyl is different, and it has been spreading like wildfire since.

New Mexico already was a veritable addiction tinderbox when illicit fentanyl arrived here. The state saw an 84% increase in fentanyl-related overdoses from 2020 to 2021, according to DOH preliminary data, whereas the nation saw only a 23% increase.

Fentanyl is far more potent than most prescribed pain medications and heroin, which increases its deadliness.

“With fentanyl it doesn’t take very much. There’s a very small confidence band of getting a safe dose. So it’s very easy to get a little bit more than you need,” says Kelly. “People out there think it’s Oxy and we have an overdose problem,” he continues, explaining that illicit drug manufacturers package fentanyl in capsules that look like prescription pain medications, so users take it unawares. It is also often laced in other illicit drugs such as heroin, cocaine and methamphetamine.

Fentanyl also poses unique challenges to patients and treatment providers when it comes to initiating medication-assisted treatment, which involves taking medications to ease withdrawals and block cravings to avoid relapse. Buprenorphine is considered a first-line treatment for opioid use disorder. During initiation it can trigger withdrawal, but protocols that used to work well with heroin and prescription opioids seem not to be working as well with fentanyl.

Dr. Snehal Bhatt, medical director for Addictions and Substance Abuse Programs and chief of addiction psychiatry at the University of New Mexico, has had to follow word-of-mouth, anecdotal evidence and novel approaches to get people started on buprenorphine over the last few years. So have other providers.

For a while Bhatt and his team knew exactly how to begin buprenorphine treatment smoothly, but when fentanyl arrived, it was like the “Wild West” again, Bhatt laments.

Fentanyl also challenges existing overdose prevention models, according to Kelly. Because it is typically smoked more than heroin, which is often taken intravenously, harm reduction programs that provide clean needles and syringes are serving fewer people.

“What we’re afraid of is we’re losing contact with folks,” he says, and therefore providers have fewer opportunities for essential education about fentanyl and its risks. “People need to know more about [fentanyl]…to reduce the stigma so parents are talking to their kids about it, and kids are talking to their parents about it.”

The public needs to know more about naloxone, which can reverse the effects of an overdose, too, Kelly says.

To make things worse, methamphetamine, which is not an opioid, is rapidly on the rise and is now a major contributor to death rates, too. From 2016-2020, methamphetamine alone was seen almost as often as methamphetamine plus opioids in drug overdoses in New Mexico, and, in 2021, methamphetamine was present in 500 overdoses, only a little less often than fentanyl, DOH numbers show. Neither naloxone nor medication-assisted treatment work for methamphetamine users, who must rely on behavioral therapy for addiction treatment.

On a recent afternoon, Bhatt sits unobtrusively on a squeaky desk chair in a typical university-style office: A desk takes up most of the room, the walls are bare, and the bookshelf is filled with medical tomes. Although his CV highlights years of work as a dedicated practitioner, teacher and leader, he seems unaware of how badly his office needs an upgrade. There are more important battles.

When asked what the state needs most to heal from the opioid problem, he has a lot to say. “Huge wait times” plague patients, both urban and rural, for example. And programming for adolescents with addictions is inadequate to meet the state’s needs.

Bhatt also wishes that medication-assisted treatment were available in all of the state’s jails and prisons. Although it is offered at the Metropolitan Detention Center in Bernalillo County, many other county lockups, including the Santa Fe County Adult Detention Center, do not use it.

Finally, he feels New Mexico offers inadequate resources for patients who need higher levels of care than typical outpatient treatment, such as partial hospitalization and residential treatment programs, especially those that “someone with public funding or who isn’t independently rich can access.”

At the outpatient program he directs, which provides medication-assisted treatment, individual and group therapy to people with opioid and other addictions, he says he often ends up seeing patients who are not “outpatient appropriate…which is scary at times.”

The opioid settlement cash should help pay for additional access to treatment, Balderas says.

New Mexico will soon receive almost $200 million to combat the opioid epidemic as a result of the settlement agreement with Johnson & Johnson and drug distributors McKesson, AmerisourceBergen and Cardinal Health. Additional funds from the ongoing trial and another pending lawsuit against CVS, Albertsons and Allergan may bring even more money, says Balderas. But how those funds would be distributed throughout the state is not yet established.

For the money that’s already slated to come in, there are clear rules. According to the “New Mexico Opioid Allocation Agreement,” which state and local governments and tribal officials developed in consultation with public health experts, all of that money must be spent on opioid abatement and treatment, or “strategies that directly mitigate harms of opioid addiction,” Balderas notes.

Examples of such strategies might include, but are not limited to, investing more in overdose reversal drugs; treating expecting mothers with addictions; building new treatment programs to target areas of need; supplementing pre-existing successful programs to increase the numbers of patients being served; community education; and harm-reduction programs.

Furthermore, 45% will go to the state, to be appropriated by the Legislature, and 55% heads directly to individual municipalities and counties, based on metrics that measure the degree of opioid-related harm and rates of use and overdoses.

“I wanted to empower professionals and get as many politicians and money managers out of the equation, and benefit those impacted by addiction,” Balderas says. “One size doesn’t fit all local governments in the state.” The money will be paid out over 18 years so “communities can plan sustainable programming.”

Kyra Ochoa, director of the Santa Fe Community Services Department, says the city does not have any details about when it will see settlement money, but she plans to propose using it for housing for people with substance use disorders, in particular transitional and permanent supportive housing. The idea is to get people off the streets and into behavioral health services if they are interested.

At the state level, there have been successes and failures to accomplish those goals.

State Rep. Miguel Garcia, D-Albuquerque, has toiled over two opioid bills during the last five years—House Bill 46 (last introduced in 2021) and House Bill 112 (last introduced during this year’s session)—neither of which came to a vote in the Senate despite bipartisan support in the House. “They just died without any action [which was] demoralizing and depressing,” says Garcia, who has served in the House since 1997.

HB46 was for a $150,000 feasibility study of an injectable opioid treatment program that researchers in Vancouver, Canada found to significantly reduce street opioid use and illegal activities. If passed, the program would have provided injectable hydromorphone, a prescription opioid, to people who were not interested in entirely stopping use of opioids, or who had treatment-resistant opioid use disorder. Bhatt, who had been planning to collaborate on this project, says it would have been the first program of its kind in the country. Safe drug use sites, which allow people to use their drug of choice in a safe environment, are still controversial, but Garcia’s proposed program would be different and “so much more” by offering a clinical setting where the injectable opioid would be given by licensed providers, as well as access to housing, food stamps and Medicaid services. Removing the substance user from street life would reduce their need to commit crimes and save lives, he says.

HB112 proposed to appropriate $917,800 from an account set up at the AG’s Office to supplement an existing treatment program operating out of El Centro Family Health Clinic, which has its hub in Las Vegas, New Mexico. The money would have gone toward renovating an existing facility and expanding the numbers served from 1,000 to 1,500. El Centro operates clinics in many remote, rural, predominantly Hispanic areas in Northeastern New Mexico.

Both bills died in the Senate Finance Committee, which puzzled Garcia. With HB112, he posits that state Sen. George Muñoz, D-Gallup and the committee chair, had a “distorted view” of the plan for funding the bill.

Muñoz tells SFR that proposals to build infrastructure for health care must also explain how the operational costs will be covered—even if the money is to come from the settlement fund—and he’s not sure whether the rules for the soon-to-arrive opioid settlement money will allow for brick and mortar infrastructure as well as operational costs. He believes HB46 didn’t get the green light because UNM, which was to conduct the study, did not submit a request for those funds.

Garcia will likely reintroduce at least the hub plan in 2023.

Balderas has also been frustrated with the Legislature’s tendency to overlook promising opioid legislation. “Every legislator’s against the opiate crisis, but there’s been very little movement. And as far as I can tell, Miguel wanted to study it. And I was disappointed that a lot of these ideas have not emerged into the rule of law, and the rule of law is important.”

Legislators and community officials should be thinking ahead about how they will spend the settlement money, Balderas adds: “I’m concerned that the Legislature and local governments are behind in planning…I would argue: Let’s start establishing best practices or create a deployment mechanism so that when the money arrives, we’re ready to go.”

On the other hand, there have been some notable recent successes in opioid legislation, backing Kelly’s impression that, as a state, “we are ahead on these things” compared to other states, in part because we’ve been dealing with an opioid problem for so long.

For example, in 2017, the state adopted a law requiring naloxone and opioid overdose education for all patients in an opioid treatment program and all inmates upon release from correctional facilities. And, in 2016, lawmakers passed a law requiring that practitioners who prescribe or dispense opioids obtain and review reports of all other controlled substances received by that patient. This year, New Mexico became one of the first 10 states to decriminalize fentanyl testing strips, allowing people to identify whether their stash is laced with fentanyl, a controversial move that didn’t take in many nearby states, including Texas.

Bhatt, too, beams about the innovative, statewide NM Bridge project, funded by a federal Substance Abuse and Mental Health Services Administration grant, and led by providers at UNM in collaboration with Behavioral Health Services Division. The only other program that resembles it is in California. NM Bridge offers emergency rooms and other providers across the state on-demand training and consultation for medication-assisted treatment to help get patients with opioid use disorder started on medication immediately and then links the patients with follow-up care.

Insiders say that to ensure that the opioid settlement money is spent effectively, stakeholders must collaborate and communicate.

Garcia is poised to do so. He speaks highly of the UNM team, calling them “one of the nation’s best” and hopes to work with them on future bills addressing substance abuse abatement programs throughout the state. “There’s a really, really kind of sophisticated network with UNM and the rural clinics that...goes unnoticed.”

Garcia hopes to appear before the Senate Finance Committee soon to discuss the funding for his proposed opioid bills.

Bhatt is also a strong believer in the power of collaboration to make change. In addition to his evident passion for existing programs that link patients and providers throughout the state, like the NM Bridge project, he wants to keep working with politicians such as Garcia. He also dreams of an extensive “system of care throughout the state, where patients can flow back and forth, depending upon the level of care they need.”

Balderas feels hopeful about the case that’s playing out now in a Santa Fe courtroom, and he reports that prosecutors have strong testimony, for example, from a Walgreens employee who was told by corporate leaders to basically “mind their own business” when she repeatedly raised concerns. Other key witnesses for the state have presented compelling data showing Walgreens pharmacists tended to not use due diligence when asked to fill suspicious prescriptions, and should have investigated more before filling.

Driving home the impact of the opioid crisis has not been a problem for Balderas’ prosecutors and their expert witnesses. The association between excessive opioid prescription supply and opioid use disorder is much stronger even than well-established ones like between smoking and lung cancer, Keyes, the epidemiology professor, testified last week. She estimated that 4% of New Mexicans are struggling with opioid use disorder—”orders of magnitude more than lung cancer.”

Despite his enthusiasm about the trial, Balderas is keeping his eye on how the already-resolved money will be spent, and hopes it will be maximized to best serve New Mexico families.

“I would say that there’s probably not been enough coordination among state agencies, providers, activists and politicians,” which will be essential to efficiently deploy the funding to best help families. He says he will start attending town halls more frequently to raise awareness. The state is awaiting a court order concerning litigation costs before it receives, then distributes, the settlement money. It is not clear when the court will issue an order.

Balderas would also like to see the governor or state administrators use some of their historic surpluses to match the dollars his office is bringing into the state.

“Lawmakers and local government leaders cannot miss the mark with this critical funding,” he says.

Claire Wilcox is an addiction psychiatrist and has treated hundreds of patients with substance use disorders. She gives regular trainings on medication-assisted treatment for opioid use disorders across the country and is adjunct faculty at UNM.