Q&A: To Shape an Effective Response to the Opioid Crisis in Texas, You Need to Ask ‘Will It Work in Odessa?’

Karen Palombo

Karen Palombo is the substance use disorder (SUD) team lead in the Texas Health and Human Services Commission’s mental health and substance use division who helps shape state intervention and treatment policies. Before joining state government, she worked in hospital, mental health, and SUD treatment settings for nine years as a licensed chemical dependency counselor. Her first-hand knowledge of SUD treatment challenges in a state with an expansive mix of rural and urban gives her a unique perspective into how a state policymaker can use data, relationships, and grassroots connections to design and promote effective programs.

How did you come to work in SUD treatment in direct care, and then at a state policy level?

During my undergraduate and graduate years, I worked at a short-term residential treatment center for kids removed from their parents. About 80 percent were over age 12 and they talked a lot about seeing their parents drunk and high all the time. They were often prescribed depression and anxiety medications, but what they were really dealing with was trauma. They talked about how when they became parents they would do things differently.

My next job was in child protective services, where I worked with grown-up versions of those same traumatized kids, who still didn’t have the skills to do things differently. They had limited support, a mistrust of government resources, inappropriate social skills, and none or few coping skills. I wanted to work on a policy level to address that.

How did you come to focus on women and children?

I thought if I could keep women and children together during recovery, it would have the most impact. When women and kids don’t stay together, we know kids are safe, but are they secure? Unfortunately, children going through the child welfare system learn not to trust adults because if they tell them about their parents’ relapse and abuse, their family is separated and they are removed. My goal is for health care providers to have the community resources they need available so they know who to call and how to respond when a pregnant woman with SUD walks in the door to make sure her whole family is treated.

Like many rural states, Texas has inconsistent state data on opioid overdose deaths. As a policymaker, how do you make the case for more targeted resources to improve opioid prevention and treatment when data is unreliable?

In some areas, we have very good data, for example, we’re one of only two states that track if alcohol and other substances were involved — even if it was not the direct reason for a child’s removal. When we don’t have data, we rely on relationships with the people on the ground who know the things we need to know. I make tours around the state all the time and have the luxury of sitting on lots of committees where I’m always making the case for data collection. If I’m talking to a hospital, I know to talk about poison control, emergency department data, and hospital costs. It makes us better data collectors and sharers, but it’s done on a regional basis and relies on relationships.

I also know that when I call our Medicaid office and say, ‘I’m trying to find out how long newborns with neonatal abstinence syndrome stay in NICUs at the hospitals where I have given a community presentation,’ my contact knows what code to use and she can tell me from her data indicators what is happening on a statewide basis vs. on a regional basis. When individual staff persons see why they collect the data they do — when they see it in a report — it starts to matter.

Is regional information critical in order to fine-tune program design in such a large state?

When you work in a state the size of Texas, with its diverse rural and urban populations, knowing what’s happening on a regional level is critical. The types of [illegal] drugs used vary between regions. In some areas, opioids never really arrived and cocaine never left. From a public health perspective, we need programs that work no matter what drug is used. When I’m talking to officials in Odessa, they don’t care about a statewide picture, they only care about what will work in Odessa.

Your state legislature meets every two years, how do you get the resources you need to redesign or launch programs for a rapid response to this epidemic?

As part of legislative recommendations, Behavioral Health Services division moved from the Department of State Health Services to the Health and Human Services Commission, which has led to better collaboration and communication to address behavioral health alongside primary health. We have been able to reconfigure our programs, and now have a foothold so our workgroups now touch all of these government programs that affect women. For instance, Texas Medicaid now reimburses for SBIRT [Screening, Brief Intervention, and Referral to Treatment] and postpartum depression screenings. We were able to assist in writing language about the Medicaid benefit, which screenings would be reimbursable, and suggested at one meeting that it would be important at well-child visits to be able to screen for postpartum depression. This is now a benefit in Texas. We probably would not have been involved in this process if not for the state agency re-organization.

How are you breaking down traditional siloes that impede a collaborative response to this crisis?

I have attended monthly workgroup meetings for four years waiting for someone to turn to me and say, ‘don’t you do that?’ If we’re not there to share what we do and learn how to collaborate, nothing happens. Our team members work with child welfare, public health, maternal child health, community health workers, train-the-trainer programs in local communities, homelessness, housing, and recovery programs, education departments, and workforce development. Serving on those committees makes us better data collectors and sharers. Data is everything, you never know what the scope of a problem is until you identify the data you need.

Can you give me an example of how has data collection has resulted in better state policy?

At our workgroups, we started hearing anecdotal information about women with SUD miscarrying in jails. [Pregnant women are at high risk of miscarriage if they go into withdrawal and do not receive medication-assisted treatment (MAT), such as methadone.]

The Texas legislature instructed the Texas Commission on Jail Standards to collect data on miscarriages starting in 2016. When data collection began, we started to get more calls from jail nursing staff asking how to get methadone to pregnant women. The data collection led to awareness and to development of new policies to address the problem. Most jails that have nearby methadone clinics are developing standard protocol for when [incarcerated] pregnant women report opioid use disorder.

We’re also collecting data for the MOM – Maternal Opiate Mortality study. We know opioid overdose is the leading cause of death for women after childbirth in Texas. We’re looking at what happens that made women relapse, we’re interviewing these women and their families, and identifying how the state can make sure women who leave Medicaid after childbirth continue to receive MAT. In 2020, we’ll use the findings to develop guidelines for providers to screen more high-risk women and work to reduce maternal deaths.

What would you recommend to other states that are working to develop more effective SUD programs?

What I’ve learned is you never stop going back into communities and asking them what they want and need. When you work at a state level, you often stop doing community outreach, asking questions, or attending forums. If people in the community don’t agree with what you’re trying to do on a state level, it’s not going to work.

The biggest issue for us is getting treatment to rural areas. Communities with more people have more money and more access to health care. Rural communities will tell you they know that people don’t care about them. That’s hard to hear when you’re sitting in a room listening to them, but as a state official, you really need to know what’s going on if you’re going to develop effective policies.