The Role of Healthcare Professionals and Future Directions

EP: 1.The Opioid Epidemic and Fentanyl

EP: 2.Approaches to Pain Management

EP: 3.Challenges With Opioid Use

EP: 4.Using Naloxone Against Opioid Use

EP: 5.Dealing With a Fentanyl Overdose

EP: 6.Educating Family on Naloxone and Overdoses

EP: 7.Patient Case 1: 27-Year-Old Man With Car Accident Injuries

EP: 8.Patient Case 1 Discussion

EP: 9.Patient Case 2: 49-Year-Old Man With Suspected Opioid Overdose

EP: 10.Patient Case 2 Discussion

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EP: 11.The Role of Healthcare Professionals and Future Directions

Matthew A. Torrington, MD: What are the things that we can do to try and help educate people, to try and make sure more people know about Naloxone, people know more about opioid use disorder? If you could give people more of what you want them to hear, get on your soapbox and tell me about it.

Bill H. McCarberg, MD: I want make a plea to primary care to be more mindful of the fact that we’re undertreating pain and we need to ask about the pain and come up with something that’s more comprehensive psychologically, biologically in every manner of treating the pain. What we’ve done is we opted for the obvious and quick solution by doing opioids. That’s how for a decade we treated people that complained of pain, and we got into trouble with that. What we did then is we withdrew all of that medication and didn’t really address the underlying chronic low back pain from the failed back surgery or the fibromyalgia or the chronic daily headaches or the irritable bowel. We just ignored that, and we need to pay more attention to what other options patients have available. We need to address the pain, and if we do that, it is less likely patients are going to go to the street to get their access to pain medicine; that is no. 1. No. 2, what I see my colleagues doing in California since this requirement is they say, “Well, by the way, here’s a prescription for Naloxone. If you have an overdose that will take care of it. You just need to read the literature.” They’re given that. Without having a longer family visit about how dangerous these drugs are, if they’re going to use them. How dangerous the internet is and how available medication is on the internet, even though it shouldn’t be, and that if they dabble with that, for whatever reason, the chance of them having a death is much higher and that they should become very comfortable with how to use the medication. I was especially impressed with the studies that showed when you had a prescription in a patient’s hand of Naloxone, whichever form they had it, the chance of that patient overdosing is much less. It’s not because they’re using the Naloxone. If they looked at refill rates or how many times they went to the ER [emergency room], they went to the ER less when they have the Naloxone. Not because they used it, but because they were aware of how serious it was. The doctor gave me this medication. The patient says, “Man, this other stuff I’m taking that I have to use this injection for must be pretty serious or he wouldn’t have given me that.” Patients are getting the idea that these pain pills are really dangerous and they shouldn’t take them and we should have that discussion with the patient now when we have the Naloxone, as opposed to just an off the hand, here’s some medication in case you overdose the way we’re doing it now.

Matthew A. Torrington, MD: Great points.

Thomas R. Kosten, MD: Dan, you go first, please.

Daniel E. Buffington, PharmD, MBA: I was just going to say, I would add from a pharmacist perspective is that you have that benefit of having that full profile in front of you and looking for other risk factors. Like we’ve all said, there are times a person may take something and not realize the risk or ramifications. You can highlight that and help them realize that they need to take those medications, respect them for their potential potency or effects, and acknowledge that there are ways to reduce that risk by reducing the opiate burden per se with non-opiates so OTCs [over-the-counters], non-steroidal, other non-pharmacologic, and to communicate clearly with practitioners. The other is to educate on the importance of how properly to administer Naloxone, the role that it plays. Like we’ve said today, when one of those moments happen, that’s a moment that needs additional care and follow-up to evaluate. That risk of reemergence of signs and symptoms don’t look at it as a 1 dose is going to be it for sure. That window afterwards is a critical window to watch for potentially needing to re-administer.

Thomas R. Kosten, MD: I have to say it’s hard to add much to all of the comprehensive discussion that we’ve had and the points that Dan and Bill have raised already and, of course, we’ve all raised during this extended discussion. I think the recognition from my perspective as a psychiatrist of comorbid psychiatric disorders among patients who have substance abuse just cannot be emphasized enough. The patients who I typically see come in saying they have, or their family member says they have some substance abuse problem, and they want you to fix it, most frequently it’s because junior does not have the substance problem. What he has is serious depression and he’s, in fact, self-medicating it. This was frequently the case when I’d have high school students or early college students being brought in by their parents saying, “Johnny’s failing at school. He’s at the best places and it’s all going downhill now. I think he’s using some drugs.” The truth was he was using some drugs, and this was a time where the fentanyl was just starting so he wasn’t dying from those drugs, but what he had was serious problems with depression. Treating those depressive disorders is key. If you only take care of this substance abuse and you don’t do anything about the comorbid psychiatric disorder, you’re bound to fail just like psychiatrists have always been accused of trying to make the depression better or make the psychiatric disease better and the substance abuse will take care of itself. Well, that’s certainly not true. You got to take care of both of them and the both of them is the most common kind of presentation that we’re going to see. You have to be prepared to do something about that. Now, whether every primary care doctor is going to be savvy to this, I don’t know. There are lots of people that have the buprenorphine waiver, for example. The average number of patients that many are treating is 3 to 4 patients. It’s clear that we have enough providers for these interventions, but we don’t have them treating enough patients. They’d all have to treat 30 patients or so for us to match what the epidemic proportions are. More providers need to be engaged. They have to have an open mind that substance abuse and major psychiatric disorders are not totally divergent, that they, unfortunately, are totally convergent and come together. You can die of suicide. You can also die of an overdose just as easily and a whole lot more quickly.

Bill H. McCarberg, MD: Matt, that brings up a point I want to also make is I had a recent overdose rescue in my practice and what struck me was that the wife said, “I didn’t know if I should give it or not. I couldn’t tell. He sleeps really deeply, and I oftentimes have trouble waking him up normally, not when I’m even worried about him.” The question comes up should she use it when she’s not sure? Should we be advising family members to use the drug if they’re not absolutely certain that it’s an overdose? The side effects, the risk-benefit profile for using the drug is so much in favor of using the drug if you’re not sure because of the fact that there hardly are any side effects from the drug. There are withdrawal side effects, but if you don’t know, it’s better to use it than to not use it because a side effect or a withdrawal is much better than a death. If you don’t know for sure, err on the side of something that is less harmful to the patient.

Matthew A. Torrington, MD: Amazing. Another great point. Way to go you guys. I think that just to sum it up, I would say, an overdose is a real thing and it’s prevalent. It’s powered mostly by illicit fentanyl products which have completely taken over the illicit drug market so anybody who’s getting drugs from the internet or from drug dealers, they’re likely to have fentanyl in them. It’s incredibly dangerous and that Naloxone can be lifesaving. In order to have the benefits of lifesaving drugs like Naloxone, you’ve got to have them. They’ve got to be in patient’s hands. Then we got to work on increasing access, increasing education, and trying to save lives, which is our primary job. I think we’re basically out of time, but I just want to thank each of you so much for your time and attention and the expertise that you’ve offered to this session. It’s been incredibly informative. I’ve learned a lot and I really appreciate your hard work and dedication to this. Thank you so much.

This transcript has been edited for clarity.