Articles, Blog

Barton Health Wellness Lecture: The Opioid Epidemic and Help That is Available

February 20, 2020


– Welcome to you all. It’s wonderful to have you here in the beautiful Center for
Orthopedics and Wellness at Barton Health. I am very honored to be
able to speak with you for the next little while. My name is Matthew Wonnacott, and I’m the Chief Medical
Officer for Barton Health. And we’ll be talking about
opioids, as you can see. Now, this is a topic
that touches everybody. And some people are coming
for a variety of reasons, be it personal, somebody you love or somebody you know of or just a topic, it’s kind of an interesting topic. I have been here in South Lake Tahoe for just under two years,
so I’m not a long timer yet. I’ve got about 20 years
to go, I understand. (people laughing) And hopefully we make it 20 plus years. But (laughs) I’ve learned a lot. I spent my first 26 years
in practice in the Air Force and had some unique things happening in the Air Force that were different than what I’ve experienced
here in South Lake Tahoe. But it’s been exciting to be here. And this was my home the
first couple of years, or first about 20 months. This is the Community Health Center. And I was a Medical Director there. And wonderful group of people, some of whom are here. And just really loved my time there. But this topic of opioid dependence became very important to me. And we see all types of
people here at Barton Health. We’ve got kids, and we’ve got
patients who are pregnant. We’ve got really every walk
of life, except that one. We don’t do that one. I just thought that was cute. (audience laughing) I thought that was cute,
so I put him in there. But no, we don’t do that. But everything else we take care of in the Community Health Center. And as is present throughout the country, opioids and dependence is
also a very important topic for us. We have as our mission delivering safe and high-quality care, and not only that but engaging like we are right now with the community for
the improvement of health and wellness. But let’s go right into right here. Anybody recognize what that might be? (people talking quietly) Yeah, those are opium poppies. And the name for that
is Papaver somniferus, so you hear the S-O-M-N, like
I’m somnolent, I’m tired. It’s kind of similar to the word narcotic, which comes from the Latin word narcos, and that, again, narcos means also sleep, or you’ve heard of narcolepsy, okay? So that’s how these things get, how these words have come,
because the opium poppy has been important throughout history. You really cannot go back far enough to find out when it
wasn’t an important part of man’s civilization. In fact, this is the Greek, or not Greek, it preceded, it’s about
1400 years before Christ, is the goddess of the poppy
from the island of Crete. And so the god of death,
even, the Greek god of death, Thanatos was oftentimes depicted with a wreath of opium. And Hypnos, who was the god of sleep, had opium when you look at
some of these old pictures. But so if you take that poppy
and you just score that, you get what they called
Lacrimus papaverus. So it was the tear of the poppy, this little latex that
about 14 or so percent of it actually can be made into
the opioid medications that have been used
throughout civilization. I thought it was interesting that when they take all of the
components out of the poppy, this is called meconium. And it was called that
before I think they called the newborn stool as meconium. So it, again, it goes all the way back. So if you look at the family tree, the morphine is that first agent that you can get out of
there and then can be, as well as the codeine and thebaine, which can be made into the oxycodone. The morphine of course has
a variety of components that they can produce
or put into a substance that I could take in and
can have an effect on me. And then later on in
history, really in the last 150 years, then we have,
starting to get some synthetic, semi-synthetic opioids, as
we were using biochemistry to kind of mirror what was
naturally in the opium. And so it really, opium was used all, as I’ve said, through all of history and then through the Dark Ages and on up. And this is a few hundred years old. But it wasn’t until really the Civil War that it became quite prevalent
in the United States. And in 1874, Bayer, you’ve
heard of Bayer Aspirin, well, Bayer produced the
first semi-synthetic opioid, the heroin, which was used for
a child’s cough suppressant and non-addictive alternative to morphine. (audience laughing) How ‘about that? All right, so the
medication, or that substance is able to bind to the
receptor in the brain, called a mu receptor. And as that binds, it has its effects that we’ve all heard about. It also then inhibits as it binds, and it stops some of the
flow of this other substance. And when you stop that
flow, then it puts out more dopamine. And that dopamine gives
people a little bit of a high. So it has a variety of actions. And the euphoria, the pain relief, these are things that can be helpful. Well, at least the pain relief is helpful. The euphoria people I think just like. But then the sedation,
relaxation can be helpful. So those are some of those effects that people are experiencing that we like. But unfortunately there
are so many other effects that have more problems
than that, as you see here, the dry mouth, the constipation. And in fact opioids have
been used all through the past as antidiarrheals. I mean, these are ones
that will stop you up. And of course the serious problems with respiratory depression
that we’ll talk about when there’s an overdose. But these things are all prevalent when we’re taking the opioid. And I want to really talk about three that are most important in
what we’re talking about here. And that’s the tolerance
and the dependence and the addiction. And so tolerance, as described here, means that to get the same effect, I need to start increasing. I need to over time have a little bit more of a dose to get the same effect that I had initially, okay? That’s called tolerance,
when I keep needing to up the dose a little bit
to get the same response. The dependence is where you rely on, that’s a pretty easy word to understand, we rely on, we need this
because we have certain symptoms when we don’t have it. And we’re trying to avoid the bad symptoms that come when I don’t have it over time when my body’s used to
it, which is similar, not exactly the same as addiction. Addiction is where we have
such a compulsive need that I would be willing to do something that is otherwise not a
good thing for me to do, but I’m willing to do
that because I really need that medication. So potentially you could
even do something harmful, like go and, I need it bad
enough that I’m going to go and steal, or I’m
going to do other things. So that’s important. Now, the withdrawal is being in a state that is downright, as it says here, downright uncomfortable and painful. And boy, if you’ve known somebody who is going through that and has been on a decent dose of the
medicine or the drug, it’s pretty miserable. And those are some of the symptoms that one would have, that, the cramping, and people would describe to me how, and a lot of people feel like, oh, it’s just the pain coming on. But it’s more than just the pain. It’s also the cramping and the diarrhea and these other symptoms
that are very uncomfortable. So let’s talk a little
bit about this opioid, on heroin, and the withdrawal. So the start of the
withdrawal really happens within the first six to 12 hours. And so I feel comfortable, and by that about sixth hour, I’m starting to feel a little bit uncomfortable. And then that starts to peak. And for those first one to three days, it can go from being mild to being just something that people would be willing to do anything to avoid. And then gradually subside. There are some who have
this withdrawal syndrome that can even persist, and
they just feel uncomfortable all the time. Those who have studied
this have found that some who become dependent,
and that can happen very quickly, some will
have a change in their brain such that they are always going to have a little bit of a discomfort that comes when they don’t have the
medicine in their system. So it’s almost scary, you know? I think about, as my
son, he’s broken his hand and hand surgery, had some screws put into his hand, and
knowing what I know, I was a little bit nervous. Just, I had some hydrocodone,
which is an opiate. And I’m like, well, let’s
see if he can do without it. I didn’t even want to
give him one, you know? And there was pain enough that night, he couldn’t sleep, and so one tablet, and he was fine through
the rest of the night. The next day, about three o’clock in the afternoon, it was
just kind of hard to bear, ’cause he had these new
screws right in his bones. And I gave him one more. And fortunately after that he was okay, and ibuprofen and Tylenol
was all that he needed, those two tablets. Unfortunately I had about
18 tablets left over that I had to get rid of. So we didn’t need that many. But in that case, I was
constantly wondering, is he going to be one of those that could potentially get a liking for or could get a feeling
like, oh, I need more or more of that. And after only two, nope, not a problem. But it is a concern. The stats have been shared, I think, with a lot, I mean, I have heard the stat that one in every four who
is prescribed the medication, an opioid, will have a
problem of some dependence eventually or have a
problem getting off of that, have a need for that. That’s huge, isn’t it? All right. So overdose, too much of the dose has an appearance that,
boy, nobody wants to see. But what happens is the patient may get, or the person of course
is going to be very drowsy when you get too much in you. The pupils will look pinpoint. Cold and clammy skin, and of course if you’re so somnolent,
you’re going to be asleep. And maybe you’ll find that
somebody’s sitting there with gurgling sounds
and not breathing well and essentially unresponsive
in the worst case. Now, so with overdose, there are some aspects of this that I really
try to hit home with people who are bewaring, this
is what I would see, people that come into
the emergency department who are, that the common
theme in an overdose are these things. Either combining the
opioid, that medicine, with alcohol,
benzodiazepines, which is like your Valium, your Xanax, your Klonopin, you combine that with the opioid, and a much higher risk
that you’re going to go through into overdose, okay? So that’s a big concern. Certainly what is becoming
more and more prevalent is that the heroin that
a person might be getting or whatever medicine they might be getting may not be pure what they’re
used to getting, okay? More frequently now,
we’re seeing fentanyl, and we’ll talk about that in a second, or some other powerful opioid
that’s been mixed in there. And so these impure things
that you’re not expecting, and it might be put in there
just so it’s a little bit more addicting, but it can be extremely dangerous, obviously. So then this just states the amount of the opioid that we start getting really concerned about is
greater than 90 milligram equivalents of morphine. So each of those medicines
that I was describing before has a certain amount that it’s equivalent to this much morphine. And we kind of use
morphine as the standard to tell us, this is
objectively about how much of an effect of the
opioid they have in them. So at this point we start
having more concern, and there’s certain laws
that are now coming out that use this level as the amount of when I have to do something differently as the physician. And then this is
probably, I put this last, but I have seen this
probably more frequently than anything. And that is somebody who
has been off of the drug for a while may have
gone through withdrawal, might have even been a
week or two or months. And then something happens to where, if it’s something emotional or some reason that they say, I’m just
going back to my meds, to my drug, and they go
back to the same dose that they stopped. And remember tolerance,
the word I shared with you? So if that person had become tolerant and had increased and increased the dose to get that same effect, well, all of a sudden they take that same dose on a body that’s no longer
tolerant to the drug, and they die. And so these are the
things that I think of that are most scary to me, is combining it with other drugs, and the things that, I mean, the unknown substance, that’s a hard one to get away from when you’re getting it off the street. But I can be careful with anything else I’m taking with that, and
then being very cautious when you start a medication
that you’ve been off of for a while, okay? I thought this was just so dramatic. This is from Ohio. This is a couple who did not die, but they were saved, rescued. But there at the backseat
is a four year old, just sitting there in a car seat with mom and dad almost
dead in front of them. And what a sad state. I thought that was dramatic and I’d throw that in there. But it’s a difficult thing. The overdose deaths, and you’ve all been hearing this a lot in the last two years, has just been skyrocketing
in the last little while. So we went from 2002 down here to 2017 when almost 50,000 deaths
in the United States occurred to opioid overdose. So that’s huge. When you heard the government
was coming out with a bill we’ll talk about in a
minute, and they said every three weeks we’re having a 9/11. We’re having that many
deaths in three weeks just from this, more than
we have from car crashes. So it’s pretty remarkable
what’s been happening. And I’m going to look at
that a little bit more. This is a graph you’ll
see quite frequently when we’re talking about the changes in the last 18 or 20 years on opioids, with the different types of medicines that are being used that
are causing the deaths just jumping up here. The light blue, you can hardly read that, but that’s the heroin. And then these are the
prescription medicines right here. And then this darker green line right here are synthetic opioids
other than methadone, things like the fentanyl, okay, or more potent synthetic opioids. But I’m going to break that down into, just show you that timeline real quick. And you can’t really read
this, but I’ll tell you. There are three waves in
this I’m going to talk about. Starting about the turn of the century, when there became a real
rise in prescription opioids, and it’s amazing when
you look at the numbers. And this was, I had been
resident before this. I was brand new in a practice. And I do remember some of the talk about, well, we need to treat pain a little bit more than, we
have to be more sympathetic and careful in helping people
and treating that pain. So in fact, some people
would blame big pharma, because that was a time when
those who were producing the medications were
just really saying, hey, this is not addictive like you thought, like you would think it is, which ended up being completely false. And they’re paying out a lot
of money for that falsehood, and then there were even
quality experts who jumped on, and I didn’t dare put
Joint Commission up here. I didn’t want to get them mad at me. (laughing) If they ever saw these slides. But I can point out that
the Joint Commission put this out in 2001,
Current Understanding of Assessment, Management, and Treatment, or in Treating Chronic Pain, Pain Management Through
Management and Action. But in there, there are
some of these statements that came to me, as a
medical professional, that said that the patient
is the authority on pain. You have to believe them,
which, yeah, that makes sense. I don’t know how much pain you’re feeling. So I just have to go with
what the patient is saying. And then it actually stated in there that it’s a common
misconception that opioids, that patients taking opioids
will become addicted. And we were being taught at that time a very small number are
going to become addicted. And in general, patients in
pain do not become addicted, although the actual
risk of this is unknown, it says, it’s thought to be quite low. And then they started talking they, meaning the experts, were saying to be more helpful to our patient, pain is really the fifth vital sign. I can do the blood pressure
and the heart rate, but I have to also include pain, out of one out of 10, how
much pain are you feeling? And I mean, it’s important. People are in a lot of pain. I’ve had people tell me, one out of 10? No, the scale’s wrong. I’m 12. And I’m, okay, you’re 12. That’s a lot of pain. But there were times when
the surveyors would come, and they would look at how
well I was treating pain. And they would say, you aren’t taking care of the pain well enough. A lot of pressure for people to say, okay, I can treat the pain. And consequently, oh, you know, I might have gone past that. But let me see, I did
go past it (the slide). There, I did. Look at this, the
prescriptions from 99 to 2011, look how much that went up, prescriptions for opioid medication. Isn’t that remarkable,
that much of an increase? And so that really, that’s I think, when we’re looking at opioid death and we’re seeing this rise in the number of deaths due to just
the prescription drugs, that was the wave one, okay, because there was just so
much more of it out there and people being able to use that. Well, then about here,
what started to happen? Then it was very apparent
to me, as a physician, that, you know what? A lot of my folks are becoming dependent. This is not good for chronic pain. I need to figure out something else, because I’m seeing a lot of
the harmful effects going on. And so a lot of people
started pulling back. And when you’re pulling back
and somebody is in dependence and they don’t want those
withdrawal symptoms, and they’ll do almost anything not to have those withdrawal symptoms, what’s going to happen? If they can’t get it from the doctor, they’re going to find it
some other way, right? And so I think that’s a real reason that you see this yellow line,
which is heroin overdoses, starts to rise. And then finally, this
rise in these new synthetic or very potent opioids, the fentanyl that you’re
hearing so much about was really, it came about,
we’re trying to treat this bad cancer pain,
and it’s very important that we’re able to help people with this, which is wonderful. And you’re so grateful for it. But unfortunately, that gets abused. It gets into hands, and
it becomes such a problem. And so this is just showing about how much of an increase
this fentanyl is causing in the overdose numbers. So this is stating, if
you can’t see it up there, just shows from 12 to 15, in three years, 196% increase. And actually it’s really in two years, almost a 200% increase in
overdoses due to fentanyl. So it’s quite remarkable. And it just kind of gets
mixed in with the heroin or even in with cocaine,
which is not an opioid. But they’ll mix it in there, because what’s the goal? It’s to get people hooked and be able to get money off that. So just much more potent than morphine is the fentanyl. So let’s talk about where we live, okay? So in California, the overdose deaths have kind of gone along with the nation. And it’s gone up, and we’re at a point where it’s not gone up
quite so dramatically over the last couple of years. But it’s still much higher than it was before the 2000s, when
we’re talking about. And if you look at those deaths by county, all this dark red is where per capita you’ve got the most overdose deaths. And unfortunately El Dorado is red, good and red there. Okay, northern California, per capita, isn’t doing great. I’m sure they have a lot down here, but per capita, we’ve got a worse problem. Okay, and then of course,
no big surprise here, or is it a surprise, that California is like almost tripling everyone else in how much they’re spending
on substances abuse, okay? So the next state spending the most on substance abuse is Texas. And look at that, it’s like half. So California is doing
a good job of spending. And we’re hoping that that is
going to make a difference. So let’s go to Nevada, since, how many of you live in Nevada? Some of you do, I’m sure. Okay. Well, nothing really happens too much when you step over the line. It’s kind of similar. But the total deaths has not really risen. It’s already higher. The yellow is just the
total amount of deaths. It really rose, and it’s
just kind of staying stable at a higher rate than it ever had been before the turn of the century. And the heroin overdoses
are going up a little bit, overdose deaths. And this is just showing
our area of Nevada. And we’re talking Douglas County here, for high school students
who have used an opioid that was not prescribed to them. And look at the number. One in five. That blew me away, when I though of that. One in five took an
opioid in the last year that was not prescribed to them. So we’re winning in this
part, or losing, I guess. And this is high school and heroin. And surprisingly, in Douglas County, right here, this dark blue, nine percent of high school students have tried heroin. That blew me away. Yeah, well, so the others are, this is Churchill,
Humboldt, Lander, Pershing, and I don’t know all the
Nevada counties, 2.1%. The next closest actually is 4.6%. So Douglas County is doubling the next county per capita
that has high school students trying heroin. That’s scary, huh? All right, so let’s go to
really just our community. And if you didn’t know,
Barton does a community health needs assessment every three years. And we love the information that we get. And it’s kind of turning out the same in the last couple times we’ve done it. It has not really changed much. Guess what was one of our prime problems? Opioid use and substance abuse. So this is just basically a graph that shows who was
surveyed, equal men, women, it kind of, you don’t need to really look at this too closely. But in that survey, I’m
just going to pull out a couple of things. First of all, surveying our own community, what have we experienced? Unintentional drug-related deaths, and this little rain cloud, it’s a rain cloud, if you
can’t tell from a distance, just means that we’re worse
than Nevada as a whole, California as a whole, the
United States as a whole, and then the goal that we had with the public health people. And in any case, we’re much, much higher than other communities on average. (person talking quietly) PSA is prime service
area, so that’s the area that we’re surveying, our people, okay? I just threw these in. This isn’t opioids. But in case you didn’t know, there’s also apparently
an alcohol problem. And I thought pretty remarkable how much higher we are than other places. But then the next little graphic was percent of people whose life is negatively affected
by substance abuse, 57%. And this is, we didn’t have a comparison for every group. In this case we did have a comparison for the United States. And in general in the United States they said 37.3 people surveyed say that they are negatively
impacted by substance abuse. And yet we’re 57, so much higher. It’s a party town, is that it? Okay. And this just is showing
that in that group for substance abuse really
negatively affecting you, it’s not just the rich or the poor, the old or the young. It’s everybody. It’s kind of across the board, okay? And again, another common,
those who used opiates in the last, past year, and that means they could’ve been prescribed or not. But a pretty large number,
when the number’s 22.1, that’s nearly one in every four people who live here have used an
opioid in the last year. That’s a lot, to me. I think that’s pretty impressive. And so key informants, these key people who were taking this survey were asked specific, special questions which stated, in their opinion, and this may have been some physicians, and I don’t know, Natasha, how many, what the different key
informants were all from, but what they determined was that, what they said is that substance abuse, this red here is saying
that it is a major problem of all of these problems
that we’re assessing in the needs assessment for the community. And this is heart disease, stroke, and injury and violence, various other problems, arthritis, even, oral health, dental care, tobacco use. Of all of those health problems, number one that people
feel like is important in our community that we need to work on is substance abuse, okay? And this is just showing, now, the primary thing that our key informants were really worried about, they have alcohol here. So we have a real alcohol problem. But then the next,
heroin and other opioids. And then if you add into that
just prescription medications, which includes some opioids, then it’s going to be higher than this. But what this is just, again, emphasizing is substance abuse is such a problem. Okay, I’m going to go
back in history again. And these are the British and the Chinese. Anybody know the name of the war? The Opium Wars, right. So again, opium, been around
since the very beginning. And people have always
had these problems of addiction, and that addiction
can lead to wars, even. It’s pretty remarkable
how you see this cycle. And here China had been one of the main users of the drug. And the British were helping
them get it from India. And when the Chinese government said, this is back in the 1830s through 1860s, when the Chinese government says, we’ve got a real problem. Our people are not doing
well on all this opium. They started to put all this tariffs, started to make it
difficult for the British. And that alone caused this war. Well, the wars are continuing. It’s remarkable. This is in Afghanistan. And I was there in 2011. And this is an article saying, hey, we’re really excited it’s poppy season. They’re about to harvest their opium, so we don’t get so many battles
going on here, you know? What an effect the opium
has on everything, even war, is remarkable. But there’s a war going
on right now, right, from our government. And there’s our president, saying that opiate crisis is
a national emergency. We need to do something. And so what’d they do? Just the end of last year,
we had the House bill number six, and it’s
the SUPPORT for Patients and Communities, Substance
Use-Disorder Prevention that Promotes Opioid
Recovery and Treatment for Patients and Communities Act. They do a great job with
acronyms, don’t they? They come up with some really great ones. It takes you about 20 minutes to try to figure out what they’re saying. But anyway, it unanimous, I mean, huge, easy win. It was almost unanimous vote for that. And it was really, they
kind of pulled together a whole bunch of different ideas, and a whole bunch of
money needs to be spent to figure out how we can fix the problem we’re in right now that
you saw from 1999 til 2017. We got to do something. And so we’re going to
spend a lot of money. We’re going to try these
opioid treatment programs. And we’re going to talk about
MAT here in just a minute. That’s medication-assisted
treatment for opioids. And then the states are also
obviously getting involved. And so last year we started
having new requirements that the state of Nevada
was putting out there. And we at Barton, we’re
interested in Nevada, because that’s part of
our prime service area, and also our medical
record comes, we share that with Renown, and they’re in Nevada. So a lot of things that we do with how we’re documenting and
things needs to comply. And so in this AB 474, then
there was a movement to, we had to be much more
careful in our prescriptions that we’re writing. The licensed prescribers needed to get a certain amount of education on opioids. And then we have to check the database when we’re prescribing. And so each of the states
have a particular database so that we can follow and
we can check on somebody who may be getting opioids
or whatever medicine that could be controlled,
and we don’t want them getting a bunch. And yet they’re going to
different providers to get that. And believe it or not, California will not be outdone when
it comes to regulation. And so here we have AB 474 from Nevada. Well, we’ve got 14 bills. In fact, they were going to, they were discussing over 26 or so bills just for opioid use and substance abuse. So there were five of them
that were just talking about how we can curb the
amount of prescriptions that are being dispensed, from requiring electronic prescriptions,
because that’s easier to track, to the prescription
pads have to be specific and different with serial numbers. And that just started January first. And that’s been a challenge
for all of our doctor’s offices to all of a sudden get the new paper that it’s supposed to be
on, with the serial numbers. And a variety of other things, but provider training on addiction is one of the state bills, and then to educate on treatment and management
of opioid disorder or dependency. So there are those five. There was one bill on
expanding treatments, which means that we’re going to, there’s what’s called
a Drug Medi-Cal program that helps those who need counseling, and there’s not enough
money for counseling, but for this particular
problem of substance abuse. So we’re going to put
more money towards that so people can get the help they need. And then the Narcan or naloxone access to a medicine that is a
antagonist or a blocker of the opioid that could
be used in somebody who has overdosed. You saw those two people in the car? They would’ve gotten Narcan right then. It would’ve reversed the effects. And so the database, so
Nevada has their own one. You saw it’s PMP. And there’s a California one called CURES, and I don’t remember
what CURES stands for. It’s another acronym. But it just is the database
that I have to check every time I’m prescribing that medication to ensure that there’s
no other prescriptions coming anywhere else. And regulating rehab, as well as storing and dumping drugs safely. And the state is looking
to those drug companies who are producing and selling the drugs to also play a part in the taking back of the drugs and helping pay for that. There’s a lot going on there. Now, I’m going back in
history one more time to just, this sets us up for that medication-assisted treatment. Back in the Civil War, remember I told you that’s when it really became a problem? We had all these soldiers
who needed something, and so that opium, that
derivative was given to them. And it helped those amputees and others. And it was really
something that the country was very supportive of those who ended up needing the opium, needed the morphine. And I should say the morphine. And in fact we also had a lot of, it was the upper class that started getting dependent on the morphine. And so all through that century, the country was actually very supportive, and oh, you know, we’ll
take care of these folks, until about the turn of
the century, the 1900s. And we got into the 1900s, and then the view really switched. And instead of, oh, we’re
going to feel sorry for folks, it started to become more
prevalent on the streets. And this is just a picture of people who were arrested for vagrancy. But that was also a lot having to do with they were addicted on the drugs that they were using here. And so in 1914, there was an act that said patients can only be treated, or doctors can treat substance abuse. But because, well, but
because to be a patient you have to actually
have a medical disorder, and it was determined
by Congress at the time that this wasn’t a medical problem. This was a behavior problem. Therefore they’re
technically not a patient, and therefore you cannot
treat substance abuse. So it’s a difficult thing
to kind of understand. But in essence what this law was stating is physicians may not
treat opioid use disorder with medication, because
we’re not going to believe that opioid use disorder
is really a medical problem as much as it is a behavior issue. And so when I talk about
being able to prescribe now, and we have a waiver for that
prescribing, this is why. It goes way back then. And so the idea was
either this is some person who is just weak-willed,
and there’s all these other environmental predilections. But the way we fix this is simply by tapering them and then ensuring that they are abstinent, pulling it away, keeping it from them. That’s really the only answer, is I’m not going to prescribe it. And that’s the final answer there. Versus, that this is
actually an incurable disease that requires long-term
maintenance with medication. So where in that spectrum are we? I mean, I think everybody has a little bit of a different idea of where we are. But I have learned a lot in
the past couple of years. And I’ve learned a lot
how people who have, they’re that 25% that have a change that are very uncomfortable,
even years later, that it may very well be something that is that disease
that’s talking about here. So the medicines that
then have been developed that can be used for
this, one is methadone. You’ve all heard of methadone? So it’s an opiate. It’s a long-lasting opiate that you take just once daily. And here’s some advantages of this. The methadone is truly a full agonist. It’s a full opioid like morphine, but it’s long acting,
and it really kind of blocks the effects of other opioids. If I’m taking methadone every day and then I add heroin to
it, it’s very dangerous to do that. It doesn’t give me much of
an increase in euphoria, so most people don’t do it. But it is dangerous. Tolerance; methadone does not have, minimal, minimal tolerance. You don’t have to keep
upping the dose, okay? Euphoria, it doesn’t have
a big euphoria effect. It’s not very sedating compared to others. It doesn’t have that same craving. And all of this really is useful, because then you’re
actually having an easier or less of a withdrawal type
of a problem with methadone. Now, as I said, methadone
is a full opioid. It’s like heroin in
the sense that it fully turns on those, remember those receptors I showed you in the brain? It fully turns those on. And so it is dangerous. But these certain effects that I said make it much safer than if I’m constantly using heroin, okay, or it makes it so that I can treat that
problem and be more functional. And then the second medicine
to mention is buprenorphine. And buprenorphine is also an opioid. It’s what we call a partial agonist. It doesn’t turn on that
receptor completely. And there’s some real advantages to that. So it has these same properties of, it makes it so that you
don’t feel much of anything if you take heroin while you’re on it. It doesn’t have an effective tolerance or these other, it doesn’t
have that big a euphoria that you get from the dopamine hits, and you don’t get sedated as much. And so it’s wonderful. But the nice thing is is
it’s a partial agonist. And I’ll talk about that here in a second. The other medicine that
I wanted to mention is the naloxone. You remember what this was for? It’s a blocker. It’s an anti-opioid, okay? So we’ll show you some examples of this. And one of the brand names here is Narcan. And that’s something that
at the end of this talk we’ll have just a couple minutes, people can stay and they
can learn more about this, because this is a medicine that now is becoming mainstream for people to have just in your medicine
cabinet if the one you love is on the medicines. It’s something that you
can save a life with. And so becoming more and more prevalent. And you saw that some of those state laws in California were about making it easier to get this out there,
for our law enforcement to have on hand, to everybody who’s on these chronic medicines to have on hand. Naltrexone is also an opioid blocker. It’s not one that we use
to immediately reverse the effects of these opioids, of like say the methadone or
the morphine or the heroin. It can be used to decrease
cravings over time. It’s a much longer acting, and it doesn’t have the same effect. It doesn’t just all of a
sudden reverse within minutes the opioid problem. So I just thought I’d mention that, because it is one that doctors may use. So these are available from any provider. And you’d have to talk to the doc. Naltrexone may not be what would be best in your situation. Naloxone, again, could be prescribed if you needed it because your loved one or you are taking the medicine, and you want your loved
one to have it on hand in case something were to happen and you had an overdose. The methadone is only in
the treatment centers. You cannot get this at
an outpatient clinic. You can’t get this in South Lake Tahoe, because you have to go
to a treatment center. And the closest treatment center on the California side is Roseville. It’s quite a ways away. And I believe there’s
one in Douglas County, I just don’t remember where that is. But if you were using an
insurance from California, you’d end up, be driving to Roseville. But they’re getting a spoke, a new facility, a piece of that facility is going to be moved to Placerville. So it’s a little bit closer. But it’s still quite a distance, right? The wonderful thing is buprenorphine, which is in Suboxone, that medicine is available from an outpatient clinic as long as a provider has that waiver that I mentioned, okay? We’ll just go a little
bit more about that. Okay, so quickly about
the Narcan nasal spray, those who are interested, when we’re done you can actually get training. And then you can walk away today with your own Narcan, okay? And there’re people who just carry that in their purse all the time because they may be among a population that is at risk. They might see them, remember
those overdose symptoms? They see them there, and
they’re a little bit blue, and they’re not breathing right. The Narcan may be the
lifesaver in that case. Certainly when you do give it, it not only wakes them up, what else do you think it does? Yeah, it puts them in extreme withdrawal. So they’re probably going
to be pretty dang mad. But they’ll be alive, okay? So that nasal spray, it’s a simple, spray it in a nostril. And then you can repeat
that if you need to. Immediately you’re calling 911, of course, because they could, the
effect could wear off and they could go down again. We need to get them care. But that minute, within seconds, even, getting them that Narcan certainly could save a life when
it could be otherwise many minutes before they’d get any care. Okay, so let’s talk about that, so this is the naloxone I just mentioned. It’s an antagonist. It blocks the receptor,
doesn’t have any effect. You don’t get anything out of this. In fact, it pushes out the heroin or morphine that’s attached here, and it blocks it all. And that’s why they go into withdrawal. That’s why they wake up, okay? Buprenorphine is the medicine in Suboxone. I mentioned that that’s a partial agonist, meaning it doesn’t totally
turn on that receptor. But it has very strong
affinity to that receptor, meaning, when you say affinity, that means it will kick anything else out. If you got heroin on there,
if you got anything on there, it kicks it out, and it sticks. And it is the strongest. It’s the most sticky to
that receptor, of all these. And this is just showing
a full opioid agonist, which includes methadone. The reason that we use that methadone is because it has those other
properties that are good. But we still have lots of
methadone overdoses, okay? So it’s not like it’s safe. Whereas with the buprenorphine, you actually don’t, you very rarely would have an overdose death. And the only death I’ve heard of is when you’re combining it with alcohol or benzos, benzodiazepines. So you can get a pretty high dose. In fact, you can fill
up all those receptors. But remember, it’s not
turning them on all the way. And if it’s not turning
them on all the way, then it’s not going to
stop your breathing, which makes it much safer. So it attaches. It can give you that fix that’s needed without the danger. So this just shows the full agonist, that as you increase the amount of it it causes you to stop breathing. And this shows that you give more and more buprenorphine,
and it stays down here. And you’re not going to get to that point. This also represents how strong it sticks, the affinity that it has. It’ll kick off heroin. So if I all of a sudden took somebody who has had heroin in the last six hours and I give them buprenorphine, guess what happens? They also feel a significant
withdrawal, okay, because all of a sudden
it kicks out the heroin. But it’s only partially
activating that receptor. And so people will
actually go into withdrawal by giving them this opiate,
which is remarkable. But it also sticks so strong that then if I add anything else to it, it’s not going to kick that off. It’s going to stay there. And it won’t have any effect. I had a patient who said she felt just really lonely and she just felt like she just needed it. And so she went and injected heroin. But because she was on buprenorphine, she didn’t have any effect at all. She didn’t even notice it. It’s sublingual. It doesn’t go in the stomach. It doesn’t get absorbed there. We have to absorb it through our mucosa, the lining in our mouth here. And interesting,
buprenorphine is in Suboxone. What else is in Suboxone? It’s naloxone. That’s the blocker. But remember, buprenorphine
is most affinity of anything. The naloxone being in there combined makes it so that, people are creative, and they would take these films and melt them down and inject them, because that gives you a
really quick, quick response. But if you have naloxone in
there, doesn’t do a thing. And so that’s really only thrown in there because of the potential
that people would have to abuse this drug, okay? So it’s a combination,
buprenorphine and naloxone. And you get from two
milligrams of buprenorphine all the way up to, you can
get up to a dose of 24. Some people may go even
a little bit higher using this, once a day, okay? Some people take it twice a day. They’ll even cut it up
and take it twice a day, ’cause they feel like that just makes it a little bit more even
through the 24 hours. But really once a day for most people is, that’s how we will prescribe that. Okay. So if I’m going to take
somebody who is on, who comes into, say the
emergency department or to the clinic, and they are obviously having a problem with dependence. Then we have an option
to use this Suboxone. And there’s certain
steps that we will take. And they’ll sign an agreement. We’ll explain how it all works. We actually want them to
be in some withdrawal. So if I’m going to start Suboxone, I actually have them stop,
I have them wait a while since their last dose of heroin because of the withdrawal. It’s more comfortable
if I actually get them into a state of withdrawal first and then start the medicine. And then it’s like, oh, that’s relieving, whereas if I gave it while
they were still high, then they’d go through a
worse withdrawal, remarkably. So I’m going to put them in
a little bit of withdrawal, look at those symptoms,
and we have a little measuring thing on how
bad the symptoms are that we can count up. We’ll also do a drug use survey, which gives us an indication of how much of a problem they have
that might be helpful to add counseling in with this, okay? We know that medication’s
only part of this. And so if we’re going to give
the appropriate counseling, we’re going to see what their use is like. What are they doing with that? And as we give that medicine,
we can titrate it up and get to the dose
where people feel that, I’ve had people, they just know. Eight milligrams, that hits it. That’s perfect. 12 milligrams, some
people, 20, or up to 24. And we’ll see them
repeatedly, quite frequently initially, and then when somebody’s been on this medicine for a long time, maybe even up to a month. And then there’s the question, of is this truly something that we’re going to go on forever or not? And so the experts in addiction say that there are many
people who will use this the same as a high blood pressure, a person with high blood pressure would use an antihypertensive and that it will be used for that person for the rest of their life, just like they would be taking a blood
pressure pill, remarkable. So that’s a question to
speak with a doctor about. What’s the long term? And so I usually tell people, don’t plan on this being a,
we’re going to take care of this over the next month and
then you’re going to be off. I work with people to
see what they’re going to be most comfortable with. Let me just mention that
this isn’t pain management. Buprenorphine can, it does help with pain, but it’s not a primary pain medicine. So we’re talking about
opioid use disorder. And that’s why we actually, before we start Suboxone, we make sure that’s a good candidate for, somebody who’s truly dependent. And if I were using
buprenorphine just for pain, I wouldn’t even need that waiver. But really we use the Suboxone
just for opioid use disorder, because it’s not the best medicine when it comes to treating acute pain. And chronic pain is a different issue. Chronic pain, we’ve got to
find the underlying problem. If there is a physiologic problem that can be fixed, we need
to work on that, right? That’s the primary thing we do. So let me just finish. I’m about done. Doctor Velasquez at the
Community Health Center in Cameron Park down in Placerville area, she is working hard towards a,
what we call needle exchange, which seems so counterintuitive. Just, I would give needles to somebody who I want them to be off of heroin? But it’s interesting how bad, I mean, look at this. This was out in a park area. Somebody had stolen a sharps
container for the syringes. Okay? And look at this, people will go out in these areas and get just
huge bags full of needles. It’s terrible. And so we have other medical problems when we’re sharing needles,
right, like hepatitis C. And this is from 2010 to 2015. Hepatitis C is going up because, remember, heroin use went up. And it just, it all follows itself. And so fortunately we can treat hep C. But we want to stop all of these new diagnoses. So this is a van that goes around and will actually take away needles and provide clean needles. It’s kind of a strange idea. Okay, so let me finish now. Minimize exposure to opioids. We want, as a physician,
I need to prescribe fewer to begin, I mean, we’ll
really assess the problem. But I think the days of giving out 30 or 40 after surgery, even, are gone. I mean, it’s going to be a small amount, because you might be in that 25% that’s going to have a
problem with that, okay? Openly address dependence. It’s a real issue. It’s a medical problem. The Narcan, lessen risk for overdose death and other disease. And then provide access
to treatment with this. So we have a few of our providers who are, I don’t, Jared,
have you got your waiver yet? (person talking quietly) Not yet. Hasn’t come in the mail. But we got a few providers who are, to work under me, as the medical director for this issue, as their supervisor who would be able to prescribe. This is something that not everybody is going to be the right candidate for. And I don’t want to say that
this is just like the fix-all at all. But we have the capability
now in South Lake Tahoe. Prior to me there was one
physician who was doing it, and he had stopped doing
it a few years ago. He’s just, for various reasons. And now we’re working on
getting more and more trained. We’ve got a couple there in
the Community Health Center who have been, they’ve decided, I’m going to take that training. We get 24 hours of this kind of stuff so we know about it, and
then we can prescribe it. So for those who have a problem, this is really a wonderful,
let me just share with you finally, and then I’ll be done. And I have patients, I mentioned every demographic is affected. I had a patient who is
completely functional, has a great job. You would never know. She has a few issues that I could tell there was a problem, but she
finally asked about this. And I started asking her questions about her history. And she had had a surgery many years ago. She’d been in a motor
vehicle accident, or, yeah, a car crash. And she got the drug, and then she repeatedly got some prescriptions. And she has continued to have that craving for a few years. And here was a very functional person. You would never guess,
looks as good as all of you, and you all look great. And yet she said, and I’m trying to, it can’t be that bad. And yet she finally says, well, I’ve just been getting
methadone from a friend. Who would’ve thought? And so wonderful, wonderful, once we got her on the
right dose of buprenorphine, she was like, ugh, I’m
much more comfortable. So you have that end of the spectrum. And then I’ve got
patients who have come in who are just on opioids, have taken, the heroin has taken them out, completely. They’re homeless, without family or any, it just is amazing. I had a father whose daughter was in jail. And she’d been in jail for three days, so she’d been off heroin for three days. So she was like, crawling out of her skin. And he called me and said, I remember you were talking about
there’s a treatment for this, and can I bring her by? And I said, bring her by right now. And so she got out of jail, he had not seen her for 10 years, because she’d been out doing
her thing and homeless, and brought her to me. And she was writhing on the table. I mean, it was hard, I couldn’t have any conversation with her. It was really a mess. And she just looked terrible. I mean, hard to describe
how terrible it was. You just felt for her. It was uncomfortable being in the room. And we started her on the medicine, and I could start it right then, right? She was already in withdrawal. And so she’s going to have
a good effect from it. And we were able to
get her the medication. And about four days
later my assistant came to my office and said, so-and-so’s here. And she wants to ask you a question. And I go, oh, is she doing okay? And she goes, yeah. You go see. And I go to the lobby, and I looked out at everybody, and I didn’t see her. And I go back to my MA and I said, she must’ve left. And she goes, no, that’s
her in the corner. And I went and I looked, and
she had a great appearance. She was like put together, her hair, I mean, it was just amazing. And I went over to her, and she goes, you didn’t recognize me, did you? And I said, no, I didn’t. And I took her back, and
she had some questions. Can we do this with the dose, or whatever. And then she talked about
how she’s working now with her parents to get a job. And she’s going to be doing this and that, and it was very, and I came away from that feeling like I had done more good than almost any other visit I had done the whole time I’d been at
the Community Health Center, because I’d taken somebody
who was so dysfunctional and gave them a tool that at least made it so that they
could actually function. It was really wonderful. So you have all types. And I should, it’s been an hour. So I should be done. But I will, but I’ll probably
answer your questions. That’s one of my favorite pictures. And that’s Barton Health. Okay, so I’ll take questions.
(applause)

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