AUSTIN (KXAN) — It keeps Zach Timber up at night.

It is a constant anxiety of the next person who could walk in and might not be so lucky to survive taking a pressed pill laced with fentanyl.

“Any patient who comes in saying they are taking pills they bought on the street almost never test positive for the substance that they believe they are purchasing, but instead simply pills that contain fentanyl,” Timber said. “Pressed Xanax, pressed Adderall, pressed hydrocodone and it seems that they’re all containing fentanyl.”

In the past year Timber, program director at Rise Recovery Services, has seen more and more people taking these potentially deadly substances.

Rise Recovery Services is housed at two of Family Hospital Systems locations in Round Rock and near Lake Travis. The system is known for its freestanding ERs and hospitals around Central Texas.

The team specialize in non-narcotic medical stabilization for substance abuse patients. 

“I myself am in recovery and am concerned — as almost all patients who admit with us are surprised — that what they are actually taking is fentanyl and not the substance they believe they are purchasing,” Timber said.

The synthetic opioid is up to 100 times stronger than morphine and can be deadly. 

When asked how so many patients have survived an unknown brush with the drug, Timber said, “it’s purely been luck.”

Fentanyl a leading cause of death

Timber explained something else he’s noticed is the patients he’s helping are younger now.

According to Families Against Fentanyl, an organization formed to raise awareness of the drug’s dangers, in 2020 the leading cause of death in 18-45 year olds in the US was fentanyl — more than suicide, COVID-19 and car accidents. 

It’s affected families in the suburbs in Cedar Park and even the Texas Longhorn community. Linebacker Jake Ehlinger’s family said he died in May from what they believed to be Xanax laced with fentanyl. 

“The spread of counterfeit pills is an ongoing and significant issue throughout our country, particularly in schools, colleges, and universities,” the family wrote in a statement last October. “We felt it was important to share these details with the hope that Jake will not have died in vain. We pray that sharing Jake’s story will help shed light on this problem and prevent other families from also tragically losing a loved one.”

KXAN reached out to the Ehlinger family attorney for this report but they were not ready to talk.

In Texas, CDC data shows since January of 2020 deaths caused by synthetic opioids like fentanyl have increased rapidly, becoming more common than cocaine and heroin. 

From 2019 to 2020, there were 658 synthetic opioid deaths in the state. The next year, that number more than doubled to 1,482 overdoses. 

While the majority of the country saw a spike in overdose deaths from synthetic opioids like fentanyl, the numbers went down during the most recent 12-month span of data available. 

A breakdown of the data by KXAN investigators shows that over that year’s time, four states had fewer deaths: New Hampshire, Delaware, New Jersey and South Dakota.

South Dakota had a 23% decrease — the greatest among the states. 

KXAN investigators repeatedly asked the South Dakota health department and governor’s office about what contributed to the decrease for the state but so far they haven’t answered any questions. Other states, though, shared the strategies they’ve used to save lives.

Naloxone is making a difference

New Jersey’s data during the 12-month time shows a 7% decrease in deaths.

The state credits the fewer deaths to the number of initiatives launched over the years and during the pandemic to combat its opioid crisis. 

“Our goal is to save lives and to help put people on the path to recovery because treatment works, and recovery is attainable,” said Acting Commissioner Sarah Adelman with the New Jersey Department of Human Services. “One life lost is one too many. So, if we can get naloxone in people’s hands and save lives, we’re going to do everything we can to make that possible.”

Since last August, anyone can go to a pharmacy and pick up naloxone without a prescription. It’s a lifesaving medication used to reverse an opioid overdose. 

The New Jersey Department of Health expanded access after seeing the response during naloxone giveaway days. That effort started in 2019 and people picked up 64,000 doses at more than 320 pharmacies.

“On those giveaway days, we saw that huge need in the community, that people had to be able to go to a pharmacy and pick it up — maybe not for themselves, but so that they do have it on hand for a loved one or a friend or a coworker who they may know struggle with addiction,” Adelman explained. “We believe that with the standing order in place year-round, it’s going to allow for this demand to not be met on a couple of days of the year, but all of the time.”

The state explained one of the challenges early on was having pharmacies voluntarily participate and getting approval from the New Jersey Board of Pharmacy to distribute naloxone for free with no prescription or identification. The state said it was able to do both since there was a lot of cooperation. 

Entities like Emergency Medical Technicians are also able to distribute naloxone after they leave the scene of an overdose. 

The state health department also launched an overdose data dashboard which shows information about naloxone use, treatment, opioid prescriptions and drug-related hospital visits. 

“We use this to help inform the decisions that we’re making. So public health professionals, law enforcement, researchers, journalists and other community members can use this data to inform their own opioid response strategies and conduct research and apply for grants and and make new state policies,” Adelman said. 

During the pandemic, the health department also worked to make sure Harm Reduction Centers were considered essential and could operate. Harm Reduction Centers are community-based programs that provide a safe space for people who use drugs to access sterile syringes, needles, injection equipment and naloxone, along with education on safer use, overdose prevention and safe disposal of used equipment. 

A health department spokesperson said it used CDC funding to allow the centers to operate safely, making it possible to retrofit mobile vans with plexiglass and plastic curtains to reduce exposure to COVID-19 for staff and clients. “Grab and go” overdose prevention kits and written information about safer injections practices were offered to clients across different communities.

“There is a belief in in New Jersey that one death is too many. And that’s, you know, there’s no time for stigma in tackling the opioid crisis,” Adelman said. “Everyone knows someone who has been impacted by the opioid crisis. And so, you know, at this at this point, it’s time to get past talking about stigma and start focusing on how we end this.”

Increase in treatment 

In New Hampshire, the focus on fentanyl has been years in the making. 

The state saw a 10% decrease in deaths from synthetic opioids like fentanyl, according to CDC’s recent 12-month period.

“New Hampshire, unfortunately, experienced fentanyl deaths prior to many other states and this led to some of the programs we had to stand up to deal with fentanyl,” explained Dr. Jonathan Ballard, chief medical officer of the New Hampshire Department of Health and Human Services. 

He said the state increased drug treatment programs, added 600 prescribers who could treat using buprenorphine — a drug that can curb withdrawal symptoms and craving — and during the pandemic made the medication available through telemedicine. 

“We actually saw in New Hampshire an increase in persons starting these medications, staying on these medications than prior to the pandemic,” Ballard said. “So, our experience in New Hampshire for the COVID-19 pandemic is we actually saw an increase in treatment.”

The state also launched a program in 2019 which provides 24/7 access to treatment and naloxone and ensures help is less than an hour away from anywhere in the state. 

Like New Jersey, New Hampshire has an opioid data dashboard used for monitoring the latest numbers and to help with policies and programs. 

“Part of our message is that ‘You are not alone.’ ‘Help is available’ and that ‘treatment works.” This is the message that we’re trying to drive home, that in communities all throughout the state, there is an infrastructure available to seek help, and offer treatment, and provide and connect you with resources in your communities that can help you overcome the addiction,” Ballard said. “We’ve implemented recovery-friendly workplaces, and we work to change the tone, the conversation, the stigma associated with substance use disorder.”

Treatment services moved to a hotel

In Delaware, the fight to combat overdoses including synthetic opioids like fentanyl became more urgent during the pandemic. 

The state had a 7% decrease in deaths, according to data available during the most recent 12-month period.

“Each number of an overdose death is a family member. These are young, productive citizens for the most part, and is preventable death,” said Delaware’s Lt. Gov. Bethany Hall-Long. 

As a nurse, Long-Hall was among those hitting the streets and trying to reach people needing help. 

She said a number of initiatives made a difference, including the state working with a recovery program to move treatment services to a hotel during the pandemic.

“They literally took over the entire hotel, so they had access to all the rooms there. So they were able to do groups, again with social distancing, PPE — and so literally, they really didn’t miss a beat,” explained Susan Holloway, Delaware’s Opioid program manager. “It was just a place for folks to come continue their treatment, but do it in a very safe way. So we were able to control the spread of COVID while allowing people to actually be more focused in their recovery.”

The state also provided high-risk individuals cell phones to be able to stay connected either by phone or virtually.

Holloway explained people stayed in recovery longer.

“Where the average person may have stayed in for 30 days, they were in the hotel setting for more than 60 days in some cases,” she said.

State-run Bridge Clinics stayed open, which allowed individuals to have treatment while they moved from one point to the next. 

The state also passed out naloxone kits and information at COVID-19 vaccine sites specifically targeting construction and restaurant workers. 

“We made sure vaccine pods — we had somebody in that post admin unit — with both naloxone kits and information,” Hall-Long said. “I personally, one day in the freezing cold at a vaccine spot, I gave out over probably 2,000 naloxone with a Bridge Clinic to high risk, you know, to construction workers.”

Push in Texas to save lives 

The Texas Health and Human Services said it was awarded $250 million and it’s in the process of allocating funds to substance use treatment providers.

A spokesperson explained to KXAN investigators the federal funds will be used for substance use-related needs including developing a 24/7 virtual substance use disorder clinic that will offer virtual treatment services. 

“We need to provide harm-reduction strategies like naloxone, like sterile syringe access, like fentanyl test strips — so that people can identify potent drugs in their supply. We need to provide those strategies to people who are not interested in treatment — are not ready for it yet,” explained Dr. Lucas Hill, PharmD, an associate professor at The University of Texas at Austin College of Pharmacy. 

Dr. Hill’s team leads one of many Texas Targeted Opioid Response projects and conducts community-based research to help identify solutions to substance related problems.

He said, for starters, the state needs to expand naloxone distribution at pharmacies. 

In Texas, any pharmacist wanting to distribute naloxone can do it through a standing order which has to be signed by a physician, but it’s an opt-in process which limits access.

“One of our major focuses as a team is to increase the number of pharmacists who are proactively offering naloxone to people who may be at risk for an overdose,” Hill said.

Hill said he hoped a bill would have passed to legalize syringe exchange programs in large counties including Bexar, Dallas, El Paso, Harris, Nueces, Travis and Webb. 

It failed to pass last legislative session.

“I’m hopeful that with more organizing and more awareness that the push for legalization of syringe service programs will go forward in the next session,” Hill said. “Certainly, looking at the evidence base supporting it — showing that it does not encourage drug use, that it does not increase criminal activity, and that it actually protects first responders by decreasing their risk of having a needle stick from a use syringe.”

Hill explained the state is seeing for the first time federal funding specifically for harm-reduction solutions. 

“I think as long as we’re focused on supply reduction, reducing opioid prescribing, reducing the available supply of illegal drugs, illegal fentanyl, that we’re missing the real solutions.”

Dr. Lucas Hill, PharmD, Associate Professor, The University of Texas at Austin College of Pharmacy

In March, his team will be speaking to community members, healthcare professionals, and law enforcement about strategies and opportunities in the state at the Texas Substance Use Symposium in Corpus Christi. 

Gov. Greg Abbott held a roundtable in Fort Worth on Tuesday to talk about the fentanyl crisis.

Law enforcement and families who have lost loved ones joined the discussion, which included safe drug disposal methods and treating deaths as poisonings instead of overdoses.

“In the past, and maybe currently, it’s been treated as an overdose. Going forward, we seek to treat this as a poisoning,” Abbott said.

He also said he will be working with his staff on proposed legislation this upcoming session which would include drug-induced homicide laws. Family members told him the legislation exists in 25 other states but not in Texas. 

‘A Change for Cam’

Timber and his team also want to be a resource. 

He said education about the dangers of fentanyl needs to target younger Texans. 

“We need to destigmatize drug abuse. We need to be able to have these open conversations with our kids — with our family members. We need to educate the public on what’s out there, what’s on the street, what these kids are taking,” Timber explained. “A lot of it’s being sold on social media, which we all have.” 

It’s what Becky Stewart is doing after her son Cameron’s death. 

On March 20, it will be a year since the 19-year-old’s death. His family said toxicology results showed he died after taking a fentanyl-laced Valium pill. They explained that he had bought it from someone on Snapchat.

No arrests have been made in his case.

The Stewart family shared their heartache with KXAN investigators last July, hoping to help other families. 

Since their son’s death, his family has started a mission called “A Change for Cam” and his mom, Becky, talks to students across Central Texas about the dangers of fentanyl. 

The family wants it to be part of every school curriculum in Texas and nationwide. 

“Educating students, parents and communities on the dangers of fentanyl seemed to be a crucial piece of making a change,” Becky Stewart said in an article featured in the Lake Travis ISD parent newsletter. “It is my hope and prayer that you will educate yourselves and your children on the horrific crisis we are faced with so that no other parent has to experience what I have experienced. Don’t let MY reality become YOUR reality.”

A panel of experts will join her for a discussion Feb. 28 from 6-7:30 p.m. called “One Pill Can Kill: A Fentanyl Awareness Panel Discussion,” at Hill Country Bible Church in Austin. It’s sponsored by Hill Country Christian School of Austin where Cameron attended through 11th grade. 

Senior Investigative Producer and Reporter David Barer, Graphic Artist Rachel Gale, Creative Producer Eric Henrikson, Director of Investigations & Innovation Josh Hinkle, Photojournalist Chris Nelson and Digital Director Kate Winkle contributed to this report.