Matthew A. Torrington, MD: Hi and welcome to “Around the Practice: Opioid Abuse and the Role of Naloxone.” I’m Dr Matthew Torrington. I’m a family medicine doctor with a specialty in addiction medicine and a background in clinical research and medication development. I practice in Culver City [California], and I’ll be the moderator for today’s conversation. We’re fortunate to have an incredible panel. Joining us are Daniel Buffington, PharmD, who’s the president and CEO at Clinical Pharmacology Services in Tampa, Florida. Thanks for joining us, Dan. We also have Dr Tom Kosten, who’s the JH Waggoner Endowed Chair and professor of psychiatry, pharmacology, immunology, and neuroscience, as well as the vice chair for psychiatry and a codirector of the Dan L. Duncan Institute for Clinical and Translational Research at the Baylor College of Medicine [in Houston, Texas]. Thank you so much for being with us, Tom. We also have Dr Bill McCarberg, who is the founder of the Chronic Pain Management Program for Kaiser Permanente and an adjunct assistant clinical professor at the University of California San Diego School of Medicine. Thanks for being with us, Bill.

Bill H. McCarberg, MD: Thanks, Matt.

Matthew A. Torrington, MD: In this program, we’ll discuss the state of the opioid epidemic and the role of naloxone for the emergency treatment of patients with a known or suspected overdose. Let’s get started. The first thing is, can you guys talk about the overall trajectory of the opioid overdose epidemic and where we stand?

Thomas R. Kosten, MD: One of the most striking things is that this isn’t a new epidemic. This is 1 that’s had its onset around 2015, certainly by 2017. One can say it was led into by the overprescribing of opioids, but what is taken over is fentanyl. Fentanyl is manufactured in China and Mexico and imported into the United States. We’re into the fourth wave of that epidemic, in which the fentanyl is being disguised. It’s being disguised in the illicit drug market mixed in with heroin and methamphetamine and cocaine because it’s all the white powder. More important, they started marketing it on the internet as pills that look like Percocet, Adderall, and Valium. But in fact, they contain substantial amounts of fentanyl. But the percentage of fentanyl in those pills is quite variable, so with some of those pills, 1 or 2 is enough to kill you.

That’s important because this epidemic has spread to the younger and opiate-dependent and abusing population, and the latest data suggest that the average age of the opiate overdoses is 75 years old. We’re talking about older Medicare and Medicaid recipients. This is a group of people who are buying medications on the internet because of prices, and what they’re getting is fentanyl; they’re dying from it. You never would have suspected that Grandma and Grandpa would be dying from fentanyl overdoses. What do they do? Where is it? Controlling the internet has obviously become a very big area, 1 that has passed into the drug abuse area and to people who aren’t even drug abusers. They’re looking for pain medications, and they’re dying.

Bill H. McCarberg, MD: Tom, you bring up a very good point about this. Certainly, people over the age of 60 years old having a substance abuse disorder that’s discovered at that age is unbelievably rare. In my practice, I never saw 1 that who older, yet you’re describing a population that’s overdosing on medications you can only get illegally. It’s a whole different paradigm. You’ve already mentioned this: it’s because they can’t afford them in the regular pharmacy, so they’re looking for other options. They don’t realize how dangerous this is until they start dying. It’s so important that we have a mechanism for treating that patient population as well as preventing them from getting the medication from an unreliable source.

Daniel E. Buffington, PharmD, MBA: It’s compounded by the fact that when you look at this age range, there’s already a prevalence of polypharmacy issues that can [benefit] outcomes and safety issues. Then you look at illicit substances—I’ll use the term clandestine production for many of these products—and they could be masked to look like commercially available prescription medications beyond fentanyl and into many of the other synthetics: carfentanil, remifentanil, sufentanil, and others that are attractive to those who are trying to push illicit substances. Very small quantities can produce a substantial effect in terms of potency.

Matthew A. Torrington, MD: I’m glad you brought up carfentanil, remifentanil, and acetyl fentanyl, sufentanil because these fentanyl analogs are thousands of times more potent than anything we’re used to dealing with. It’s much more cost-effective for the illicit market to bring them into the country clandestinely. Then they can compound them and make them into fake pills that look just like regular pills, and people have no idea. When they get the chocolate chip cookie with a little chunky batter in it, they die because this stuff is so incredibly powerful, and it’s not made with any quality assurance. It’s such a good point.

Bill H. McCarberg, MD: Once we restricted the use of opioids to treat pain because there was such an overdose problem during the 1990s—it became so popular for providers, especially in my primary care practice, to use pain treatment with opioids liberally—so they cut down on that. In 2010, it took off when heroin became the drug choice for patients looking for pain relief or for substance abuse. By 2013, that’s when these fentanyl products and overdoses became so pervasive. This is a long time that fentanyl has been on the market creating the overdose problem that we’re having today.

This transcript has been edited for clarity.