Articles, Blog

Buprenorphine For Opioid Dependency In The ED | Dr. Dylan Carney

November 9, 2019

– What is up Z-Pac? It’s your boy ZDoggMD,
today I have a special guest Dr. Dylan Carney, emergency physician, brother from another
mother and we’re gonna talk about something that is crazy important which is medication-assisted
therapy for opioid dependency. We don’t like to say addiction
any more do we, Dylan? – Yeah that’s fallen out of favor. – Why, why is that? – Oh, that’s a great question, I think it just carries a little
bit stigma with it, so we use dependency
or opioid use disorder nowadays. – So Dr. Brown’s in the back. There she is. What up?
– What’s up? You guys remember Denise Brown? So Denise Brown did a show with me, she’s from Vituity, and so is Dylan. Vituity’s the company
that’s sponsoring the show, they’re just giving us
backing to talk about things that really matter, that they’re actually involved in. But it’s not even a
commercial for Vituity, it’s us being able to actually talk about stuff meaningfully. And medication-assisted therapy, is crucial because when
people show up to the ER with opioid dependency issues, whatever you wanna call it, whatever the PC term is right now, it’s causing lots of suffering, and it’s causing suffering
for our frontline staff. Because we have no tools, we just say, “Well okay, go into a rehab program, “that I know you’re not gonna do, “or you’re not gonna
be able to afford,” or “I have no tools to treat you aside from “giving you Dilaudid,
and telling you to go,” or throwing my hands up
and then wondering why we’re seeing more violence
in the emergency department. So how did this sort of shape your path, ’cause you’re a Stanford-trained dude, UCSF, all this other hotshot stuff. But you’re struggling with the same issues that anyone on the front
lines is struggling with. How did that then lead you to medication assisted therapy? We’ll just call it MAT from now. – Yeah, absolutely. Well thanks for having
me here on the podcast. – Oh my pleasure. – I think this topic
kind of creeped up on me, and was something I didn’t anticipate finding myself in. But training over the last 10
years and starting my practice of course the opioid
crisis has been increasing, and I’m seeing it more and more in the emergency department. And everyone is, no matter where you are. So over 2016 to 2017, we
saw about a 30% increase in ED visits for opioid overdoses and opioid-related problems. – Where are you mainly practicing now? – I practice right now at MarinHealth. – Marin, okay gotcha.
– We’re in California. – We were up there recently, yeah. Okay. – So when I finished my residency, I did a fellowship in
administration and management with Vituity. And during that process
we picked kind of like a thesis project to work on. – So wait, you were training
to be an evil administrator. – Is that what I’m understanding?
– Sort of, yeah, exactly. – I’m sorry, this
interview’s officially over. No no, keep going. – And at that point, there
was a lot more evidence that we should be doing Buprenorphine, or medication-assisted treatment out of the emergency department. And actually it was something
that had just started during my chief year in residency at San Francisco General. And so even just that
one year of experience, using Buprenorphine in my own practice, I became kind of a relative expert and I just ran with it, and I continued learning more about it. And for my project, decided
to work with all of our other emergency department
staff at Vituity to train their docs on
how to use Buprenorphine to treat opioid use disorder. – So Buprenorphine is Suboxone, correct? – More or less, yes. – More or less. So you’re talking about
really, truly doing medication-assisted therapy, which you’re gonna see in comments. So people get very triggered by this idea of giving a drug to treat
dependency on a drug. How do you think about that in a sense, in terms of this trade-off between are you then making them
dependent on another drug, and as an emergency to physician, how does that work? – That’s the number one question I get is, “Aren’t you just replacing
one drug with another, “or one addiction with another?” But Suboxone or Buprenorphine is not a frequently-abused medication. It’s not euphoric. What it does is it helps
treat people’s cravings and stay off of use. Everyone in this area will
cite a big study from 2015 out of Yale. Where they did a randomized control trial, and they looked at
patients who presented to the emergency department
with opioid withdrawal, something we see very frequently. And they randomized them
to one of three arms. In the first arm, patients
got a referral to treatment. Which is kind of, I’d
say, the standard of care. A lot of places, when
patients come in with opioid use disorders, you have a list of referral treatment centers, and you say, “Good luck. “Go follow up with this program.” – Yeah, I’ve been there. Not as a patient, or I’d be violating my own HIPAA, but as a clinician… – Well fair enough. I mean the opioid crisis affects everyone in their own families as well. I can’t name one person
who doesn’t have someone in their family or friend group
– Hasn’t been touched by it. – Who hasn’t been touched by it. – By the way, in the comments, if you have a family or friend
who’s been touched by this, because I tell you, it’s
overwhelming actually. – So arm one was you got
a referral to treatment. Arm two is you get a brief
counseling intervention referral to treatment. And then arm number 3 was you
actually start Buprenorphine in the emergency department
and a referral to treatment. And they found that the
people who actually got their first dose of Buprenorphine in the emergency department
were nearly twice as likely to be retained in treatment 30 days later. – Wow. So just the act of getting
that first dose there was more likely to lead to 30 day… What we’ll call
– Retention. – “success,” right? Retention.
– Exactly. – So the other options were just you’re referred, and then tho other one is you’re counseled and referred. And how big was the trial again? – Ooh, I don’t know how many patients. – Right, but it was big enough to show a statistical significantly
difference there in outcome. So why do you think that is? What’s going on? – Well the other awesome
benefit about Buprenorphine is it’s the best medication we
have to treat withdrawal. Withdrawal is a really
challenging thing to treat without using an opioid. So you get someone who’s
nauseous, they’re vomiting, they feel awful, they have
abdominal pain, they’re shaking, in real florid withdrawal
because they tried to quit maybe one or two days ago. And they come in for help and
you give them some Zofran, maybe you max out your
Zofran, you give ’em Tylenol, ibuprofen, IV fluids. – I’ve been there. – They’re still barfing and
you’re not getting anywhere. They’re in your department
for hours and hours, and then maybe sometimes
you even admit them because you can’t get them comfortable. – I’ve had that call, yeah. – And then sometimes you
give up, and you’re like, “Okay, I’ll just give you
a small dose of an opioid. “Or maybe I’ll give you
one dose of methadone.” – Yeah, methadone, right. – Or tell them like, “Why don’t you go home and
try to taper it yourself, “instead of quit cold turkey?” Or what you do is you skip the middleman, you just start them on Buprenorphine. And within one hour they
can be symptom free. And feel great. And it’s when they leave the
department feeling fantastic, and when their symptoms are gone, that they’re like, “Wow,
this is a great medication.” And that’s their destination treatment. So that’s what they’re gonna be on. That’s what their provider
is gonna start them on as an outpatient. – Why is Buprenorphine
physiologically affecting them this way? In other words, does it also have an antagonistic function
to opioid receptors? What’s going on? – Yeah. It’s like you’re a plant. – And the truth is,
listen, all joking aside, we’ve met five minutes before we did this. But I just heard what his topic was, and I’m like, “We need
to talk about this.” So he’s teaching me, and honestly? I’m not an expert in this, so I’m learning along with you guys. – So when I first learned,
it seems very complicated but actually, Buprenorphine
is an opioid agonist and an antagonist in one. So what that means is in lower doses, it acts like an opioid. You can actually treat
pain with Buprenorphine, there are people who are
on Buprenorphine for pain. But in higher doses,
there’s a ceiling effect. So unlike morphine, where you
give more and more and more, and you get more respiratory
suppression and sedation, you have this ceiling
effect with Buprenorphine, so that you do not get
respiratory suppression and sedation. – So can you overdose
at all on Buprenorphine? – I’m not gonna say that
you absolutely cannot, there are cases of reported overdoses, but they’re usually
polysubstance overdoses. – So something else.
– So it’s mixing with Xanax and alcohol and all this other stuff. – Which by the way, we’d
be remiss if we didn’t say, the co-administration of
benzodiazepines, suppressants, and opioids or other drugs
is a toxic stew of disaster. So don’t do it. So I was dating this girl in high school, and her dad was the teacher in the band at our high school. And I was a band geek when I was younger. He would be the surrogate father figure ’cause my dad was Indian
and didn’t understand the American system at all. And he said, “You’re going
to Berkeley as an undergrad, “the one piece of advice I’d give you is, “don’t mix drugs.” (laughter) He didn’t say “Don’t do drugs.” He’s like, “Don’t mix drugs,” which I think is very good advice. – Fair enough. – So back to Buprenorphine,
there’s a ceiling, assuming you’re not polysubstance, that’s the advantage. So it can treat withdrawal,
and it can treat dependency. And what’s the theory on dependency? What’s the idea there? How is it helping with that? How are you not just substituting
methadone for morphine? Another narcotic for another narcotic. – Well even for the dependency, it really prevents these cravings. These cravings persist for a long time. People who have abstained
for years still end up with cravings, and people who are on Buprenorphine
or Suboxone for years, when they wean themselves off, they oftentimes find
these craving coming back. The partial agonist, the antagonist had another interesting effect, which means that if you’re not
in withdrawl to begin with, say you use IV heroin,
and you just shot up. And then you go take a
bunch of Buprenorphine, it has such a high receptor affinity that it’s gonna kick off all that heroin and put you into withdrawal. – So let me ask a question
then, relating to that. Someone comes in EMS,
they’re all out of Narcan, and their respiratory sedation, they’re unconscious, you
would normally give Narcan, let’s say it’s all gone,
you’re on a desert island. Could you give Buprenorphine? Or would it make it worse? – That’s an awesome
question, I think we’ll start to see some research on that. It’s something that we’ve
heard people do in the field. And that if your friend just overdosed, and you guys don’t have Narcan, but you know I’m on Buprenorphine, you can maybe put the sublingual strip in that person’s mouth. And there are reported cases
of people being reversed. – So then you could change
the name for that application and get a new patent and
call it “Bro-prenorphine.” Like, “Bro, I got you, okay?” That’s really dumb. And also inappropriate. – And then there’s a
though that if we use this to reverse someone, it’s a more gentle reversal than Narcan. – Yeah, because they’re
not going (screeching) shouting curse words and hurling feces. – Although if they are doing that, you can give ’em Buprenorphine. – That makes sense. So you’ve hit ’em with Narcan, they’re jumping out of their skin and screaming bloody murder. At that point you can give
’em a little Buprenorphine. – Yeah. – Dude, that’s awesome. So I’m learning a lot here. So let me understand this now. How do you initiate therapy
in the emergency department? Do you have to have counseling? Do you have to have a plan for discharge, or can you just give them Buprenorphine? Do you give them a prescription? How do you go about that? – All great questions. I mean ideally, you do have counseling and all of the other support services. You know adequate treatment
of opioid use disorder is not just a single medication, it’s all the treatment, counseling, and case management that comes with it. Unfortunately, Buprenorphine has some special licensing requirements
that make it really hard for providers to just prescribe it. So you may have heard
about the DEA X Waiver, or the Data 2000 Waiver. – I’ve heard. Explain it to us. – So if you have a DA license, you have a license to prescribe narcotics. – (laughs) Yeah baby! I’m the candy man. – But unfortunately you can’t
prescribe Buprenorphine. – That is dumb. – Yeah. – Continue. – So, in order to prescribe Buprenorphine, you need this thing
called the DEA X Waiver. And it’s an eight hour
course for docs to take, you can take it entirely
online, and for free. – Eight hours though. – Eight hours, yeah. I’ve heard you can click
through it a little bit faster than eight hours. I didn’t say that though. – Yeah, that was not said. – And NPs and PAs can do it as well. For them it’s 24 hours. Again, onerous. But I mean I can teach you doc to doc, or doc to NP or PA, within 15 minutes, all you need to know to feel
comfortable giving this. And interestingly, and importantly, in a hospital setting or
emergency department setting, as a hospitalist or
emergency medicine provider, you can administer it without the waiver. Because you’re operating under
the license of the hospital. – That’s important to know. – So just like residents
when they start out can prescribe at a hospital, any ED provider can start
this without getting a waiver. – But can you send them
with a prescription, or you can start it with a
prescription still, or no? – So you can do either. So if you have the waiver,
then you can send them with their prescription. If you don’t have the waiver, fortunately the half
life is like 23 hours. And so you can load them
with enough Buprenorphine that their symptoms are gonna be managed until they follow up. And that’s where you
really need good linkage with an outpatient treatment program. No you’re not just giving
a piece of paper and saying “Good luck.” You are giving them hopefully
an appointment tomorrow. – Dumb, crazy, stupid
question from a hospitalist that doesn’t know this stuff. Is it PO-only or IV? – It is everything. – Everything. – Yeah, sublingual, usually. – Per rectum? ‘Cause that’s how I like my meds. I’m just saying, no judgment. – Probably. – And then the other question is someone here, Thuong Trinh, is saying “Suboxone crazy price. “$3,000 per 300 month cost.” I think he means per month, maybe? How expensive is it? – So that may be their formulation, because it’s generic. And you can get sublingual
film that’s generic and cheap. – Oh, got it. – And it’s covered by almost every payer. – Sublocade. Got it, yeah. Okay, right. And what about people– – So sublocade, that comment, that actually refers to another concept, which is that if a
person’s opioid receptors are blocked by Buprenorphine,
then it’s protective. So I give a patient a ton of Buprenorphine and send them on their way, say they say, “Screw this appointment, “I’m not gonna go into
treatment right now. “I’m gonna go shoot up.” You’ve kinda blocked their receptors. For the next 24 hours.
– Oh snap. You’re like their wing man that’s actually trying to get the girl. – Exactly. – And totally blocking. Okay, let me rewind for a second. It seems to me like this drug, apart from the obvious harm-reduction, can be used in a variety of circumstances in the emergency department to
prevent death and suffering. Why isn’t it used more? What are the blockades against this apart from cost and the
the things we talked about? ‘Cause you don’t need to
have all that training if you’re an emergency
department provider. – And I would say not just
ED, but inpatient too. I mean, this affects
our inpatient colleagues just as much. You admit someone for cellulitis, they then tell you that
they’re on opioids, they then go into withdrawal. These patients AMA at a 30% rate. So 30% of these patients
who start withdrawing end up AMAing from your inpatient service.
– By the way, I gotta say that’s great dispo for me. 30% discharge rate? That’s barely any paperwork. – Fair enough. Or you start them on their treatment and then they don’t bounce back. So you save yourself that reaction.
– That’s good too. So again, preventing bounce backs, hospitalists, other docs
in the hospital can do it, emergency department providers can do it. And again you learned
about all this through your fellowship at Vituity, this administrative fellowship? That’s how you got pointed down this? – Yeah, in a combination from
the administrative fellowship and then getting to work
with a lot of people in the community. I mean Yale and Highland,
have been doing a lot of the research and kind of pioneering this. – Highland in Oakland? – Yeah.
– Yeah, great place. My buddy did his training there as well. And again guys, again,
this is not to pitch the sponsor of this show, but I’m gonna pitch the
sponsor of this show. This is why we work with
companies like this. I told you, I promised you
guys I was never gonna work with shitty, stupid companies again. And again, I’m not even supposed to curse on sponsored shows, but
I’m just being real here. These guys are awesome,
their leadership is awesome, their doctors are awesome, I run into them on the
street and they’re like, “Oh we saw your show with Denise.” We love working with these guys, they’re doing the right thing, and these are the kind of organizations and bright spots we should promote. It you’re saving lives,
if you’re teaching people about Buprenorphine… So what else around that topic, before we take some comments, would you wanna make sure we knew that I’m not asking? – I mean it really is a
lot easier than you think. You asked why we’re not
doing it more often, why not everyone’s doing it? You know, two years ago when I started working on this project
with all of our sites we surveyed everyone and there were about nine sites doing this in our group of emergency departments. And then we asked them again a year later, “Are you guys using Buprenorphine? “Are you starting a program?” And that quadrupled in one year. – Oh wow. – And so there’s more and
more interest in doing this. A big component is education. And then I think the other big component there was this big study a while back, that showed it takes 17 years for evidence to become standard of care. – Sounds right. That’s actually conservative. – Yeah. And so it’s the translation
of that evidence, that really excites me. How do we get a bunch of docs who maybe trained one year ago or 25 years ago, how do we teach them something new? How do we show them all this evidence, and how do we translate
that into practice? – I’m gonna give you a hug. Because that’s the whole point of what we try to do here on this show. So in this episode, we
might reach more people in a single episode than
10 years of conferences. – Exactly. – See now they’re gonna wanna go out, and they’re gonna learn how to do this, and whether you’re teaching them, or someone else is teaching them, it will transform care in
a catalyzed amount of time. So I’m a big believer in this platform for that purpose. So thank you for bringing
that wisdom to us. – Absolutely. – And one thing I wanted
to ask you about too was how does this relate? ‘Cause we’re talking in
our five minute pre-show, we were talking about caregiver wellness. So the nurse practitioners,
the PAs, the doctors, the rad techs, everybody
else who’s touching patients on the front lines, how does this affect them when we’re quote-unquote “burning out?” Okay, one second. I talk about moral injury a lot, right? This idea that we are forced to do things that are morally repugnant. It’s morally repugnant to me that we would put a
patient out on the street with no capacity to help themselves when we know they have a fatal illness which is opioid dependency,
and we do nothing. We’re hamstrung, we’re powerless, and we’re afraid. And to some extent we
created this epidemic, co-created it by handing this stuff out, because pharma told us this was the thing to do to treat pain, and we’re worried we’re gonna get sued, and think of the conflict, right? So how does this affect that sort of wellness component of
what we’re trying to do? – Absolutely. We walk a lot in wellness, there’s I think the Stanford
Model that has three arms and one of them I think
is efficiency of practice. And I think of that as you know, I went into emergency medicine because I like to be able to treat everything, I think of myself as having
this quiver of solutions for everything. But up until this, I didn’t
really have a great solution for opioid use disorder
and opioid dependency. So these patients come in,
and like I mentioned earlier, they’re vomiting, they feel awful, I’m trying my best with all of my non-opioid pain medications
to get them comfortable, and I’m just not succeeding. And now suddenly, we have this
medication that we can use that not only makes them
feel better immediately, but it actually improves mortality, it improves retention in treatment, it reduces healthcare costs, ’cause these patients stop
bouncing back as much. So when I go to work and I have solutions for all my patients, that’s a shift that I feel like I won at. Whereas if I go to work and
I just don’t have solutions, and I can’t fix anyone’s problems, that’s where I feel burnt out. – God I love this man so much. That’s the heart of it. Finding solutions. I’m tired of complaining,
I’m tired of feeling hurt, I’m tired of feeling burned out, I’m tired of feeling powerless. Learned helplessness is so terrible. Here you are, young kid, fresh-faced, goes out and says, “I’ll have a solution. “Let’s start pushing it. “It’s there in front of us. “Why should we wait the 17 years “for it to become practice,” right? Alright, at this point, I’m gonna say bye to people who wanna check out, and if we end up sharing
this clip as a smaller clip, we might cut it right here. So thank you, hit share on this one. Spread the word about
medication-assisted therapy for opioid use disorder. Now we’re gonna take questions. So Dr. Brown, was there
anything that popped out at you, or should I start peekin’ ’em? Yell at me, holla at a boy. – [Denise] So, how long can you take this? What’s the kind of duration? Would it be safe to
take it for five years? Would it be safe to take it for 10 years? – So what’s the duration
of safety for using this? Do you have to use it for life? – You can. So, it’s safe to take for life. And this is where we hand off
to the addiction specialists. ‘Cause I think that is a
patient-specific answer. There are some people
who are really motivated to taper off of it, there are some people
who use it for a year. I had a patient the other
day who developed dependence within 30 days after her knee replacement, and came in because she tried
to quit her meds cold turkey. And that might’ve been a
patient who really only wants to be on it for a little bit of time, because her dependence was new, it just developed in the last 30 days. Although I’ve also seen
people who have been on Buprenorphine for a year or two, they tapered themself off, and then relapsed and came back into the emergency department to restart. – Okay, so I’m gonna read this comment because it’s provocative in this sense. So Richard Wan says, “If Suboxone strips work, “why doesn’t Alcoholics Anonymous adopt “a shot of whiskey a day
to prevent alcohol abuse? “This is about money. “Money for the docs that
are specializing in it,” except you don’t get paid, “and money for the manufacturers
who make this stuff. “I’ve never seen any definitive proof that “opioid maintenance works long term.” Okay, I’m gonna answer one part of this, and then you can take the second. The reason that AA doesn’t
give a shot of alcohol for alcohol dependency is two-fold. Number one, alcohol is
actually a direct liver toxin and will kill you over time, whereas this is actually
reasonably safe, alright? Except for constipation
and those sort of things that you get with opioids. The second thing is that
alcoholics cannot drink a shot of whiskey without
going down the rabbit hole of drinking a whole bottle of whiskey. Buprenorphine has that ceiling, so you’re not gonna go
down this rabbit hole and end up in trouble with that, it just is not physiologically
likely or possible. Now, your thoughts on this? – In terms of the financial aspect, it’s a generic medication and there’s no billing
difference, it’s just an ED visit. It doesn’t matter
whether or not I treat it with Buprenorphine or I
treat it with something else. What was the second component of the question?
– The second component was “I’ve never seen evidence
that it works long term.” – Oh, the evidence. Well there’s a big meta
analysis that looked at every trial of
medication-assisted treatment. So every randomized control trial. And there were at least 20. And all of them showed a
reduction in mortality. When you compare patients that are on MAT to patients who are not. And I’ll qualify that and say
15 of those studies at least were methadone. So there have been a lot of
questions about methadone here, because the concept of
MAT is giving a medication to treat symptoms of
withdrawl and cravings. And so there are three
medications we use for MAT. There is methadone, there’s Buprenorphine, and then there’s Naltrexone. Naltrexone is a long-acting,
kind of Narcan opioid-blocker. And so I know that methadone
conjures up a lot of fear in some people’s minds. I mean we see a lot of overdoses.
– Going to the methadone clinic,
overdose, long-acting. – And that has a different
set of regulations federally. And for a lot of reasons,
we can’t necessarily start someone on methadone. But the honest truth is that the outcomes are great on methadone as well. Mortality improves on methadone. – Real quick, Robbie Westerman said, “I never got high on my
Suboxone, it gave me a life.” Robbie, weigh in, are
you still on maintenance, or were you able to get off? Because I think one of
the questions that I think I have always is, “What’s the root cause
of opioid dependency?” Is it some deep unconscious
need, emptiness, void, that’s psychological
that can be dealt with over years with therapy? Is it a physical receptor,
genetic tendency, or is it a mix of those things? What’s your instinct on this? – I mean, I think it’s
a mix of everything. Your biology, your
genetics, your environment. Kinda like everything else, similar biology, yeah.
– This “Hungry Ghost” theory some people have put out, so when you take one piece off, you go, “Okay, let’s satisfy the receptor piece, “now let’s dig into the therapy.” – I was gonna say, some people start because they had a knee replacement and that was their first use of an opioid, other people start because they were having a really hard time in their life and they turned to using. And then some of these people
have an easier time stopping, and other people have
a harder time stopping. So I think it’s a case-by-case scenario. – Tanya, thank you for the stars. Dr. Brown, you had a comment. – Well I think Vanessa Medina has talked a couple of
times about something that’s recurring here
on some of the comments, and that is “How do we
address the stigma?” So we’re trying to
address a medical issue, a crisis of epic proportions. But then there’s still
somehow this stigma attached to Suboxone, or to Buprenorphine. What should we be doing about that? – This’s a great question,
because I can tell you in the comments I see the stigma. So how do you think about that? – It’s constant, it’s not
gonna change overnight. I think this is just where
we have to keep leading, keep being the positive change agents, keep talking to everyone about this. Talk openly about it. You know when you approach
a patient without judgment, and just ask them openly,
they answer openly, and you learn a whole lot more. And we should talk to
our colleagues this way, and I think also I try to
connect with my colleagues, when I do sense a little bit of stigma, whether that be another
provider, or a nurse. Like we said earlier,
it’s touched everyone’s family or their friends somehow. So it’s something we can all relate to. – I think personally, and
this is my own philosophy, I think moralizing about
this stuff is not productive. And I think again, holding
accountability is important, but I think moralizing
about it doesn’t help because we are largely
driven by these unconscious things that happen. And so anything we can do
from a system standpoint to nudge individuals
in the right direction, in a harm-reduction direction, in a direction that is
better for their family. Forget about them. Let’s say you think
they’re a piece of crap for being a weak person who’s addicted. And there are people who think this. I disagree with them strongly. But think about their families. If there’s a way you can
protect their families from the addiction, the sequelae of that addiction, then wouldn’t you wanna do it? And if it’s a chronic… We have diabetics on Metformin for life. We have diabetics on insulin for life. Why can’t we have somebody who suffers with this disease on it for life if they’re productive members of society, they’re doing okay, it doesn’t have a lot of
downside except for cost. And I bet the cost will come down the more you destigmatize it. – And even if you can’t
put your stigma away, there is so much evidence; you can’t ignore the evidence that it improves outcomes,
it improves mortality, it really achieves that IJ
triple aim, quadruple aim reducing costs, helps me in my efficiency of practice. – Oh, go ‘head. – So I’ve got another
one from Matt Slassman, “What’s the potential
pre-hospital application? “All the paramedics are getting fried “by repeat overdose patients. “We’re slinging Narcan like crazy. “Is this something we could look at seeing in the field in the future?” And I think when we talk about burn out, we talk about moral injury, we’ve gotta include all
those first responder, paramedic guys who are really seeing this up close and very personal at times. – I gotta talk to you
guys direct for a second. The pre-hospital people send me the most impassioned messages of anybody. They are suffering, you guys. And remember, these are guys that get paid a lot of times minimum wage to do the kind of work that would give a tough burly dude, stereotypical masculine person PTSD for the rest of their life. And so this question is very valid. Can we improve the conditions
and perceived power and efficacy of our front
line pre-hospital staff with this solution. – I mean they have been the
most eager colleagues I’ve seen. For every case that I
see, they see many more. Because they’re seeing patients
that decline transport, they’re seeing cases
that expire in the field and don’t come in. They see a lot more than we do, and they have been leading the way. Whether that is distributing Narcan, and don’t quote me on this, but I believe there are some EMS systems that are trialing initiation
of Buprenorphine suboxone in the field. – Oh wow. So, good. So we’re starting to look at it, we’re starting to study it. – Absolutely. – Other thoughts or questions? This has been an insanely
helpful discussion for me, because I get asked
these questions a lot, and I keep telling people, “Look, I understand the vagaries of it, “but I need to talk to an expert,” and now we have an expert. And I really wanna thank you Dylan. This was super helpful. If it influences five
people in this audience, and there have been like
500 people watching live. Five people in this audience to go out, learn more about it, implement it in their
own emergency department, hospital, whatever. Pre-hospital, paramedic on their rig, or it starts a new trial, we’ve done good I think. ‘Cause I’m actually a
believer in this approach, and until we figure out the
root cause of addiction, and figure out how to target that, we have to treat it the way we do, which is like this, with
medication-assisted therapy. – Absolutely. And the field has developed
some awesome toolkits and protocols. Two years ago it was an
entirely different scene, developing the protocols was
a little bit more challenging. Now we have them, if
anybody wants to learn more, feel free to email me. I’ll give this guy my email address, you can put it in the show notes, and I’ll be able to share information. We also published a
white paper with Vituity on how to start MAT out of the ED. So we can get that to you guys if you’re interested in that. – Ping us. So we’ll be make sure to
have contact information available in the show notes, potentially in the description and in the stuff when we repost it here, on YouTube, on the podcast
if you’re listening. And elsewhere. Denise, you had a follow up from? – [Denise] I just wanted
to give a special shout out to Robbie Westerman. I think your comments have
been incredibly insightful. It’s kind of like a
hair club for men thing. This is a guy– – I’m also the president! (laughter) – Who has basically gone from
a user of this medication and a homeless guy, to now almost finishing his
nursing practitioner degree. – [Dylan] Oh wow. – And I just think that is
pretty flippin’ spectacular. So I just wanted to say congratulations, and we’re all very proud of you. – [Dylan] That’s great. – I have goosebumps, dude. And that’s unusual for me. Because I’ve had my goosebumpectomy. Had a total parasympathectomy. So this is like a violation of the laws of nature. Robbie, congratulations. – Absolutely.
– Thank you for weighing in, thank you for being so
honest and vulnerable too in your own experience, because there’s so much stigma, and the truth is now you’re gonna go on to this amazing life, and you go from homeless to having a life and I think that’s the
most powerful statement that can be made. We can’t make statements like that, ’cause we’re third parties to this. So thank you again Dylan. What an honor, man.
– Thanks a lot. Thanks for having me, man. – Will you come back on
the show in the future? – Absolutely. Whatever you want. – And I wanna shout out to
Denise Brown and Vituity for making this possible. This is the kind of partnership we want to keep having, you guys. And I wanna thank my supporters, who support us with $5 a month, doing this thing. They make all this stuff possible. I have all this cool gear ’cause of them, and also this sweater. I used their money to buy a sweater. – Nice. – ‘Cause I need one. I’m cold, people. Alright guys, I love
you, stay safe out there, share this video. And we out. Peace!
– Next time.


  • Reply Thomas Gronek November 6, 2019 at 1:59 pm

    So, what happens if someone with chronic intractable pain runs out of meds?

  • Reply Dinah Weaver November 6, 2019 at 2:12 pm

    So I work in the Nicu. We have many pregnant women who go to clinics or buy this drug on the street and they all are told that the baby will not withdraw from subutex or suboxone. So not true.

  • Reply Ari Land November 6, 2019 at 2:23 pm

    WOW. So you’re tellin me……… that I can take one of my moms Belbuca transmucosal films (administered for PM)……… to save a hapless soul in the grips of a life threatening overdose of opiates????!!

    Holy frick Z.

  • Reply Pat Mello November 6, 2019 at 2:34 pm

    All long term opioid users are physiologically dependent but not all are addicts. Addiction is a psychological need for the drug. This change in language is disturbing to me as it seems we are no linger making that distinction.

  • Reply Michelle T. November 6, 2019 at 2:38 pm

    Buprenorphine has helped my pain better than fentanyl and dilaudid ever did, and all without the high!

  • Reply Aby Lu November 6, 2019 at 2:40 pm

    This is amazing. As a pharmacy technician, I have distributed bupenorphine without any thought. I know what it's for but that was about it. With this information, I feel like I know my patients a little better and able to help them in the future, if the cause arises. Thank you for all you do, the both of you!

    PS. I know it's nitpicking but Suboxone is bupenorphine/nalaxone combination. Bupenorphine does come alone, I just haven't seen it brand since nobody so far has requested brand.

  • Reply Ari Land November 6, 2019 at 2:46 pm

    I wonder if this treatment can be administered in the setting of a case involving a poly-substance overdose. Such as opioid-alcohol or opioid-benzodiazepines. FACINATING.

  • Reply lhawk510 November 6, 2019 at 2:49 pm

    BUYER BEWARE! Saying that buprenorphine is not euphoric is FALSE! I have personal experience. This IS an opioid, don't be fooled. More big pharm push. You WILL withdraw from bupe just like any other opioid/opiate with l/t use. True, the suboxone version has opioid antagonist, but do not believe for a second that is not JUST as addictive!

  • Reply Chris W. November 6, 2019 at 3:19 pm

    You're wrong about subs not being euphoric. I agree with everything else you said. I'm not an MD, but I know people that have been going to the methadone clinic every day for years. Maintenance drugs are not the answer, you have to treat the root of the problem which is psychological. Otherwise you're literally replacing whatever drug your patient was addicted to with one that is legal because government.

  • Reply art queen November 6, 2019 at 3:20 pm


  • Reply Peter Saad November 6, 2019 at 3:25 pm

    I love that this treatment is finally making it to the front lines of medicine! I chose to go into medicine recently specifically because of how the opioid crisis has affected those in my own life. Along this journey I have fallen in love with emergency medicine, and have just wished for a way to merge the two interests, especially with the amount of substance use disorders we see in the ED on a daily basis. I would love to get involved somehow if at all possible!

  • Reply NappyHeaded_ZeroCombs November 6, 2019 at 3:29 pm

    As a Sickle cell disease sufferer, i have had a narcotic dependence sense as far back as i can remember. I was on Oxycodone 20s n 30s daily once i started having Avascular necrosis due to sickle cell. I was on a ton of opioids b4 i had both my hips replaced and was heavily dependent on them. Once the pain stopped, i wanted to ger off of them all so my hemotologist sent me to detox to be supervised medically while getting off the meds. They gave me Suboxone once i went into full withdrawal and i have to say that this medicine is a god send!! Its not like Methadone where you'll withdrawal after a certain amount of time, Suboxone stays in your system for days! I never felt withdrawals once i stopped but thats bcuz i wasnt on it long at that time. Now, my hemotologist has the authorization to prescribe it and has kept me on it for my pain. Like when im in a sickle cell crisis, i take Suboxone and it really helps my pain without the need to constantly take more n more. Opioids like oxycodone and dilauded are like keys that lock onto your receptors than over a few hours, unlock itself which leads to withdrawals. But Suboxone is more like a bag filled with rice that pours slowly out the hole in the bottom of the bag..if that makes sense lol…its like a slow controlled taper. I think thats why the withdrawals are very lil to none at all (depending on your use over time). Thank god for Suboxone cuz it gave me my life back.

  • Reply Summer Richardson November 6, 2019 at 3:36 pm

    I love the idea of trying to actually help the patient instead of criticizing them for their dependence. I’ve witnessed firsthand many ED doctors refuse to administer anything for patients that have a hx or substance abuse but come in with severe pain. I appreciate that you all are administering this and trying to help these patients from the beginning and helping them to find additional assistance beyond the ED. Substance abuse truly affects everyone- my mother passed away in April after OD’ing. I am a Registered Nurse. She did take subutex and suboxone at various points over the past couple years- the issue is independent living and noncompliance with meds. Unfortunately once they’re back home/in the community, without a major support system in place to hold them accountable, it is difficult for the patient to continue compliance and sobriety.
    I have also learned that buprenorphine is on the streets, many “addicts” really do want help, it’s just not always simple to find. Having this offering in your ED is a phenomenal asset & will certainly save lives. More work will need to be continued for compliance.
    (And for the comment re: long term use- I know a coworker’s family member that has been on it for at least 5 years now and has continued to do well.)

  • Reply orion khan November 6, 2019 at 4:04 pm

    So as a former opiate addict, the idea that Buprenorphine isn’t abused makes me laugh… it’s not about euphoria, it’s that next pill. This is absolutely replacing one pill for another, the trick to getting people clean is breaking the bond with the pills by creating another bond. My personal experience is that our thoughts on addiction are all wrong.

  • Reply jr8870 November 6, 2019 at 4:11 pm

    I’m a general surgeon with over 30 years academic and clinical practice… Be advised… Suboxone IS euphoric, and IS an opioid and IS addictive… Suboxone is similar to an older but still excellent analgesic called Nubain(nalbuphine hcl)… You can partially reverse fentanyl OD with this Med… done all the time in PACU…look it up….

  • Reply Michael O November 6, 2019 at 4:19 pm

    I am so happy to see two doctors taking this seriously.

  • Reply Hannah DeBono November 6, 2019 at 4:40 pm

    Hey, ZDogg! It was awesome running into you in my city, San Carlos, the other day! It really made my day and thanks for being so happy to take a selfie!

  • Reply 11111Rich November 6, 2019 at 5:18 pm

    Better than CME I could have taken.

  • Reply Cristina Salinas November 6, 2019 at 5:27 pm

    Kratom worked wonders for me. Natural and nonaddictive. Works so well that the FDA is trying to stop distribution in the United States. And we all know FDA and big Pharma are the best of friends.

  • Reply vV Trey November 6, 2019 at 5:59 pm

    What would be wrong with prescribing a full opiate agonist for MAT? Several countries have tried it successfully.

  • Reply Pamela Curtis November 6, 2019 at 7:02 pm

    I'm a little upset by the conflation of addiction and dependency.
    I'm dependent on my prednisone for adrenal insufficiency. Without it, I'll die.
    I'm not addicted to it.
    There's a stigma on addiction for a reason. (ETA: Mainly because it's criminalized, not a moral failing imo.)
    Please stop trying to save people's feelings by lumping us all in the same group.

  • Reply Ted Phillips November 6, 2019 at 7:34 pm

    You see more patients come to the emergency room due to fructose addiction instead of misprescribed opioids. WHen are you doctors going to come together and demand fructose be banned as a food additive ? As far as opioids, the prescriptive regimen, by not taking into account the half life of the drug, is what contributes to addiction. Say a drug has a half life of 4 hours. Prescribing the patient to take 1-2 every four hours results in a blood serum level going from 2 to 3 to 3.5 to 3.75 over the course of 8 hours. The correct prescribing method should be -2 first thing then 1 every 4 hours as needed. This would change the maximum daily dose from 8 a day to 6 a day which would be far less addicting. The math proves the pharmaceuticals knew they were creating a problem.

  • Reply Jordan Rattanavong November 6, 2019 at 8:07 pm

    Kratom works much better in my opinion. I have used both for opioid dependency

  • Reply John Brakes November 6, 2019 at 8:15 pm

    I've been on buprenorphine/naloxone for almost 17 years. Saved my life. Haven't gotten high from it since the first week. No other opioid relapse during that time. You moralists can go tell diabetics that they're "addicted" to insulin, or just go jump in a lake.

  • Reply erynlasgalen1949 November 6, 2019 at 8:57 pm

    Thank you for pointing out the lack of stigma for lifelong insulin users. There is still a stigma for anti-depressant and anti-anxiety use, and heaven forbid a person with chronic pain approach a physician for pain relief once the OTC meds fail to do the job. The reception is often a note on the chart indicating "drug-seeker", as if we're lying about the extent our quality of life is affected and are looking to get high.

    The lawsuit pendulum has swung in the opposite direction, with doctors fearing for lawsuits and loss of licenses for prescribing these drugs. I have lived through at least two cycles of this, from the scheduling in the 1970s through the more generous treatment of pain in the late 1990s, to the current crackdown, and the problem keeps getting worse.

  • Reply Michele Eslick November 6, 2019 at 9:10 pm

    I was hoping for some Vivitrol discussion.

  • Reply GCT10/31/1990 November 6, 2019 at 9:27 pm

    So I do agree with the information shared here, these medications have there use and effectiveness… However I see these medication like a opiate in the first place… There's the 50/50 chance of having to now depend on methadone and or suboxone which I just don't see the point. I'd recommend to anyone struggling, trying Kratom for withdrawals.. It's how I was able to get free, you can do it within the comfort of your own home instead of embarrassing yourself self going to get your daily dose. The downside is that programs that give out opiate withdrawal combating drugs hold you accountable for continuing to use opiates after treatment has begun and with Kratom you have to really want to get off opiates altogether. Best of luck everyone

  • Reply Michele Eslick November 6, 2019 at 9:34 pm

    This was so GREAT!! I loved this! More more more.

  • Reply Ruth Baran November 6, 2019 at 9:45 pm

    Thank you so much for this discussion and advanced education.
    Throughly agree with the opinion that addiction cannot be considered from a moralistic point of view.

  • Reply S Cv November 6, 2019 at 10:30 pm

    We have been very familiar with this in the anesthesia world, and we are seeing many patients coming in for surgery on buprenorphine , which has significant implications for us. Overall, patients are happy with their treatment!

  • Reply Teresa Boze November 6, 2019 at 10:51 pm

    Whoa! You mean some people in the world are not touched by it?

  • Reply La Belle Lune November 6, 2019 at 11:01 pm

    As someone who was a heroin and fentanyl addict, suboxone has absolutely been a life saver. However, it SUCKS that I'm stuck on a new addictive medication and I've been struggling with depression because I feel like I've just moved from 1 substance to the next. This is why I'm starting my graduate degree to study new methods to get people off of drugs without withdrawal and to help people who are currently facing this problem. It's a life saver, but it's extremely expensive, hard to come off of, and doesn't fix the underlying problems that caused addiction in the first place. We need better protocols in place to help addicts A) avoid withdrawal (it is the worst thing I've ever experienced in my life and I've broken bones with less pain than withdrawal) B) work through any psychological issues C) make it AFFORDABLE (A huge problem I see in addiction is that people can't afford help, so they just steal to stay on the drug. If you dont have insurance, suboxone can cost up to 800 dollars per month depending on how much and what dosage you need. Not to mention rehab is even more expensive and if you don't qualify for assistance like I didn't, you're fucked). Too many people struggle making payments for required medication, rehab, therapists, etc. D) there needs to be places that provide additional resources to people struggling at an affordable cost such as financial counseling, rehabilitation back into life, therapy, job transition help, family counseling, resources for single parents, etc. Addiction affects everything in your life, so some meds and once a month expensive therapy/doctor definitely isn't enough in my opinion of course.

  • Reply blue997 November 6, 2019 at 11:31 pm

    Thank you so much for doing this video. My hospital rolled out an inpatient buprenorphine induction protocol last year and I think it has gone really well. I still encounter a lot of stigma in the community but I think the tide will turn. We are studying the outcomes of our inpatient protocol and hoping we can prove that it reduces rates of AMA sign-outs and other outcomes. One thing that drives me crazy is that the NNT to prevent a death with MAT is like less than 10, I have seen the figure as low as 4 and I absolutely find that believable. If we had any other therapy that prevents death like this, we’d be shouting it from the rooftops and shooting it out of t-shirt cannons. But because of the stigma of opioid agonist treatment, it’s locked away behind the scary-sounding X-waiver. Never mind that anyone with a regular DEA number can write for all the OxyContin that their heart desires – but god forbid they try to save a life with buprenorphine!

    One thing I think you did not mention is that there is some profit motive behind buprenorphine that is a bit morally gray. There absolutely are for-profit buprenorphine clinics out there that are basically selling it with the implicit business model that suboxone is cheaper than heroin. I still think it’s better to have more opioid users on MAT and the profit motive can definitely shift practice more quickly than warm fuzzy feelings, but some of these clinics can be problematic. I think that’s what the one commenter was maybe getting at.

  • Reply NappyHeaded_ZeroCombs November 6, 2019 at 11:36 pm

    Its funny how different this so called "Opioid Epidemic" is versus the "Crack Epidemic". People in the 80s n 90s who smoked crack where demonized and looked at as criminals but this new age drug problem is considered a disease that needs treatment and compassion for those addicted to it. Maybe bcuz young white kids and young adults are the main ones dependent on it and dying from it but the black community during the crack epidemic were the main ones dying and using. There was no compassion for them and no real affordable treatment for them. They were sent straight to jail and called criminals. White privlige at its best. I said what i said 🤷🏾🤷🏾

  • Reply Mathisontanner November 6, 2019 at 11:48 pm

    Great topic! Unfortunately I am dealing with this personally with my adult son. He is currently in his 4th rehab. I’m afraid his heart/mind is not wanting to stay clean. I plan to do some research .
    Thanks again!

  • Reply Mark November 7, 2019 at 1:28 am

    In county jails, the use of substance abuse disorder (SUD) treatment such as with medication assisted treatment (MAT) programs and other behavioral interventions is increasing dramatically in most parts of the U.S. The underlying demographic that is typically arrested generally has a much higher instance of drug use and abuse. Many of these folks arrive in jails either high or already in withdrawal. In general, jails will then send to an emergency room for a welfare/health check prior to booking. This is one factor contributing to the rise in withdrawal cases in the ER setting.

    To pay for these services, many jails are seeking assistance from Jail-Based Behavioral Health (JBBS) grants funded via local, state and federal sources. What I find interesting about JBBS grants is that the jails are required to integrate with an external behavioral organization for MAT Continuation services and mental healthcare services. In ACA expansion states, you will find integration with local health plans and regional accountable care organizations for healthcare services. Finally, many grants provide funds for other integration activities such as employment assistance, housing services and food/clothing.

    It is a slow long slog up a steep hill, but at least we are moving in the right direction.

  • Reply Stephanie Ramey November 7, 2019 at 2:36 am

    As a psych major turned nursing student this is fascinating.

  • Reply Lea Gaber November 7, 2019 at 1:14 pm

    I am a pharmacist in the VA system and am titled a pain and palliative care clinical pharmacy specialist. I am dealing more and more with those who have complex opioid dependency and opioid use disorder. We have a scope of practice and work closely with the docs to initiate and follow those who qualify for BUP (not a magic drug for everyone unfortunately). I am SO happy that outside of the VA is pushing this for patients. I have seen many veterans get their lives back from the grips of opioids due to starting this drug. I am a HUGE advocate for BUP and those who say “trade one opioid for another” do not fully understand the condition they are treating OR the drug they are speaking of. I am hoping one day to give a talk during PAINWeek in Vegas that will hopefully give those providers a better understanding. THANK YOU both for what you are doing, together we can all make a difference in this crisis plaguing our nation!!

  • Reply Jeffery Roberts November 7, 2019 at 1:30 pm

    awesome Z! thank you

  • Reply MrsJohnson526 November 7, 2019 at 3:44 pm

    I’m a first year BSN, RN student and my patient at clinical this week was taking this for her opioid use since an injury/surgery from the late 80’s. Neither my clinical instructor or the nurse I was following had seen this before. Pretty neat and fascinating medication system.

  • Reply colbystudy November 7, 2019 at 5:14 pm

    buprenorphine is an excellent bridge that buys addicts time to work on their underlying anxiety, depression, ptsd,, get a stable job etc… and prepare for when they can taper off. Most people working in addiction medicine understand that people need more than just a medication. It is a damn good medication though. The ceiling effect and blocking effect it has due to its high affinity to mu receptors make it amazing. It is NOT just another opioid. Thanks for the discussion. I would like to see more ED's doing this. I have seen great success.

  • Reply Nikki Tea November 7, 2019 at 11:53 pm

    When reporting drug tests for the ER over the years. I’ve seen a lot of judgmental reactions when the test is positive for drugs like methadone, buprenorphine/sub, some people in healthcare see that and seem to act as though any complaints the patient has is either due to drug seeking behavior, or a complication from abusing those therapies, which isn’t always true.

    I’m sure that’s true in some cases, but people who are in that therapy can still get sick at the same rate as others , for reasons unrelated to that use . They aren’t necessarily abusing those therapies. I’m not sure why they seem to think that so often.

  • Reply Stacey Weeaks November 8, 2019 at 7:20 am

    You are making the assumption that they are going to follow up. Many times once someone is out of distress, they no longer have the desire to resolve their discomfort and be proactive in their own care. Wash, rinse, repeat…

  • Reply peanut12345 November 8, 2019 at 10:57 pm

    More Pharma crap for old crap and medical complex excuses for the same old protocol…….

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