Confronting the Growing Fentanyl Crisis and Saving Lives

00:00:00 Music 00:00:02 Host: Hello and welcome to this edition of Doc Talk. Today we're talking about the opioid crisis among young people here in the US and looking at what's being done to address the issue among health providers, law enforcement and first responders. We're joined by Artee Gandhi MD, Medical Director, Pain Management. Endowed Chair, Center for Pain Management and Integrative Health. Having seen firsthand the damage drug overdoses have done on young people and their families, Dr. Gandhi is a passionate advocate about preventing drug addiction, ingestion, misuse, overdose and death. She oversees the Safe and Sound program at Cook Children's, which promotes pain management techniques such as massage, yoga, aromatherapy, and virtual reality. In addition, she and her colleagues have been instrumental and developing clinical pathways for opioid ingestion, and pain related pathways, and has published numerous papers related to pain, addiction and opioid stewardship. 00:01:04 Host: Shakyryn Napier holds a doctorate in health science as well as a nurse executive advanced board certification. She's an RN CPN and the director of The Cook Children's Health Center 00:01:16 Host: Callie Crowe founder of Drew's 27 chains, CRO spent a 27 year career saving lives as a paramedic. She is the founder of Drew's 27 chains, an organization that provides free naloxone and training to law enforcement agencies and other first responders. 00:01:35 Host: Special Agent in Charge Eduardo Chavez leads the Drug Enforcement administration's Dallas field division, overseeing the daily operations of offices in the north Texas region, including Dallas, Fort Worth, Lubbock, Amarillo, and Tyler, as well as the entire state of Oklahoma. 00:01:53 Host: Thank you all for being here. Dr. Ghani, I'd like to start with you. According to the NIH, the development of synthetic opioids in the 2010s has contributed to a significant increase in overdoses, especially among young people. Among those drugs are fentanyl, which is 100 times more addictive than heroin and now novel potent opioids, which are said to be as much as 10 times more powerful than fentanyl, how did we get here and what steps are being taken or need to be taken by health providers to address this epidemic? 00:02:28 Dr. Artee Gandhi: Unfortunately, the United States leads all high income countries in overdose. And there's been a long long path or a long history of opioid use within our country, right? It was first used as a you know, as a pain reliever, it was something that was also illicit like heroin. And over the last 10 to 20 years, our awareness of pain and chronic pain, as healthcare providers has also increased. So there's just so many different avenues from which opioid medications have gotten into the system. We're also a pill-based society where we think a pill or a substance or a chemical can really fix everything. And then you compound that with the increase in mental health disorders and conditions, along with COVID, over the past couple of years, in that social isolation, I think it's just been a compilation of events that have led to this situation. And in the last year, we've had 110% increase in overdose in our adolescents or young adults. And it is now the third leading cause of death behind motor vehicle accidents and firearm injuries in the age of less than 20 years old. So we have not only an increase in substance use disorders, but we also have an increase in overdose from illicit substances like fentanyl, that you mentioned, that are now in counterfeit pills. So kids are able to get medications like oxycodone or they're able to get Xanax or they're able to get Adderall, or they're able to have access to marijuana. And all of those substances have been laced with this product, because it makes it more addictive and, you know, kind of brings kids back for more. Adolescents, their frontal cortex is not fully developed, so they don't have that regulatory ability to really understand the harms in their behaviors. Kids are naturally risk taking, they want to do things, they're curious. they don't understand the ramifications. There's social pressures, there's peer pressures, there's situations where they do have pain, or they have mental health conditions, which are all going to play a role in their ability to make sound judgment and sound decisions. And no matter how much we tell kids, when we say things over and over, when they're in a situation with a bunch of friends, they're not always remembering what mom said. So we try to say 65,000 times and whisper it in their ears when they're sleeping at night, so that they remember. But I was a teenager, and I probably did a lot of things that my mom and dad would not be too happy that I did. So we just have to, we have to continue to educate them and teach them. But yeah, they just they don't have the ability to regulate, they make dumb decisions. And unfortunately, you know, when we made dumb decisions as kids, it was, you know, you drank at a party, and you're told not to get in a car, you were told never to take a drink from someone that you didn't know, and that you saw the drink being handed to you because you're afraid of what we call the date rate drag back then. And now, it's one mistake and they don't wake up the next morning, which will change your life forever. 00:06:27 Host: So does the metabolism and overall accelerated growth rate in kids and teens have any bearing on how they react opioids as compared to adults? 00:06:36 Dr. Artee Gandhi: Yes, their physiology is different, their tolerance is different. Also, their metabolism is different, their enzymes are different. Their enzymes are not necessarily different. But their tolerance to these medications are different. Their exposure to these medications and other substances are different. And then just neurologically, like we talked about earlier, their ability to become addicted or for something to become habit forming at a younger age leads to those disorders as adults. 00:07:13 Host So how can health providers educate families, including kids about the growing danger and death rates among kids and teens of synthetic opioids like fentanyl, what resources are available. 00:07:25 Dr. Artee Gandhi: So, it's really important that no matter what we always have a conversation about safe medication usage, storage and disposal. That's something that healthcare providers can do. We try to minimize exposure to substances that are habit forming are addictive in nature, such as opioids after surgery, for example. But there's a there's a time and a place when you do need that type of pain medication. So we don't want to neglect that. And we don't want to say that we're not going to, you know, adequately treat a child's pain because of our fear of addiction. But we do want to make sure that whenever we prescribe anything, that we have that honest conversation with our patients and our families, that there's a safe way to use medication, there's a safe way to dispose of medication, and there's a safe way to store medication. And that when we do screen children and adolescents for any type of substance use, whether it's marijuana, or misusing medications or an illicit substance, that we then have a path forward from that. When we get an answer, we need to be able to follow up and provide education and resources for patients and families when we get the response. And if they say no to all of the questions, we need to encourage that and reinforce that and praise that. And as health care providers, we have to understand pain is very complicated. And everyone's tolerance, everyone's response, everyone's coping mechanisms are different. And so if we have as many resources as possible to address both acute and chronic pain, that's really important as healthcare providers for us. And then, you know, we should bring into the conversation like I do when I see kids in my clinic, or if I see them in the hospital, and I prescribe them something, I go over the principles of safe use, storage, and disposal. But then I also bring up the conversation that, you know, unfortunately, there are counterfeit pills out there, and you may be in college, or you may be in high school, and you may go to a party and smoke marijuana. Or you may say well, I take a Adderall at home, and I've got a big test tomorrow, but I left mine at home, can I have one of yours?, that those things can be laced with substances that you don't know. And that it's very, very dangerous to take things that are not yours or that you do not know what they are specifically, and that things like marijuana are not as safe as you know, people think they are. And if fentanyl is in any of that, it can be deadly. And we can't control how much fentanyl is in each substance. And then I also say, you know, there's naloxone. It's a safety measure, if you're in a party if you're at a party, or if you're at home, unfortunately, most overdoses do occur at home. And 60% of the time, there's an adult or a family member or someone else at the home. And then 60% of that time, there's no naloxone at home. And so there are measures that we can have to keep kids safe. And then if you do recognize that a child has a substance use disorder, getting them help, and getting them the right kind of help. That means medications, that means psychosocial support, and only 3% of adolescents get adequate help. 00:11:02 Host: Wow. So Eduardo, there is a growing number of illicit labs in the US and Mexico and India, many of these drugs are coming into the country via mail and mules. That mail surprised me. But the delivery methods to young people are also getting more sophisticated every day, with things like online ordering and doorstep delivery. What are the challenges faced by law enforcement? And is there really any solution at this point? 00:11:28 Eduardo Chavez: Absolutely. And I think a lot of it starts with some of the things that Dr. Gandhi has already mentioned. And that's conversations that begin in the home. You know, it is not a specific answer from a school, specific answer from law enforcement, even treatment centers and educational resources. It starts with specific conversations with mom and dad, or grandma and grandpa or whoever might be raising you with regard to the the illicit drugs that maybe the baby boomers or even Gen X grew up with. And maybe even some of these millennials, are not the same types of drugs that we're seeing today. In particular, when you introduce illicit fentanyl, that is wrapped up in a capsule that we have been, again, much like Dr. Gandhi mentioned, very conditioned from a very young age to treat as something that is helpful. So drug traffickers are, at the root of it, entrepreneurial. They're capitalists looking toward making a profit. They also read the newspaper, they watch TV, they listen to what is going on in their consumer markets in that consumer environment. So when you have a uptick and increase in what is misuse of opioids, you know, beginning 2008, 2009, 2010, a lot of diverted legitimate pharmaceutical drugs that came from the closed system of distribution, that was then skimmed off the top from a prescription that was stolen out of a pharmacy, perhaps, unfortunately, rogue medical professionals, you know, selling prescriptions out the back door and things like that, that then translated into what we saw in the early 2010, 11, 12, up through probably almost 2017 of an increase in illicit heroin. That is when heroin entered the suburbs, and people were left scratching their heads when their loved ones would overdose from heroin. And the worst thing that they did when they were kids was, you know, smoke a joint out in the backyard at a party, and that jump to heroin just seemed so untangible for them in their minds to be able to do that. Well, drug trafficking organizations were watching. At that same time, drug trafficking organizations were also in the middle of experimenting, and being very successful with synthetic drugs, in particular methamphetamine. Back in the early 2000s, you couldn't throw a rock without being concerned that your neighbor was cooking meth in the house next door or in the outbuilding, or in the garage. With that, you couple that with now, the increase in consumer demand for opioids and they turn to fentanyl. Purely synthetic. You don't require opium poppy fields, you don't require sunlight and water and harvesting and the time to be able to have to to plant those crops to have heroin come from which, as we know, is comes from an opium poppy. So now, you can use all that knowledge you've gained over the last decade in cooking meth in laboratories where you have a little bit of chemical expertise. And you've got the glassware and all you have is a warehouse. And you now translate that into fentanyl pills. Initially, fentanyl pills to meet the demand that looks like things like oxycodone or Percocet or Adderall, or even Xanax. Things that chemically, Xanax and Adderall don't match up with what an opioid would do like an oxycodone or Vicodin, two different things. But from a traffickers perspective, if that gets you in the door, then you're going to be in the door. And so, at least up until about two years ago, there was a very concerted effort by drug traffickers to make sure these fentanyl pills -- because that's what they are. These fentanyl pills looked like name brand or even generic prescription drugs from Vicadin to Percocet to hydrocodone to Adderall and Xanax. Those are sort of the most popular ones. Most recently, we have seized throughout our investigations and even through interviews and information and intelligence that we've received through our investigations, there is no longer that urgency by drug trafficking organizations to make sure that those pills look like the medications. And why? Because the consumers don't care anymore. They don't care that they are getting a pill that looks like a Percocet or Xanax or an Adderall. They're specifically asking for a fentanyl pill. They've even corrected in transactions "Hey, I know this says m 30". Something that would mimic a Mallinckrodt 30 milligram oxycodone pill, probably one of the most commonly seized and used illicit fentanyl pills that are on the market that looks like one of those. And they'll get a handful of them. And they'll double check with the person selling them. And they will say, "Hold on. This isn't really an oxycodone is it? It's fentanyl, right?" And that's been the response lately, to where consumers are specifically asking for fentanyl. That's why a couple years ago, if you recall in the news, we saw the advent of rainbow fentanyl and multicolored fentanyl and it was going to hit you know your kids trick or treat bags. That was something that for me was sort of turning the tide when it came to what consumers were looking for. It was not so much drug traffickers trying to give a fentanyl pill to a five year old. It was about contraband. It was about trying to get your drugs from point A to point B, potentially make it look like something it's not, you know, a bag of candy or something like that, but not hand out, just to try and maybe deceive that pesky patrolman that might stop you along the way. But what it also said was the consumer doesn't care if it's pink, or purple, or tie dye, which we've seen all of them, because they're specifically asking for fentanyl pills. And when that threshold of a potential fatal overdose is two milligrams, the fentanyl pills that we are seizing -- and that's what I keep calling them because that's what they are -- we have no, we have not seen any evidence that fentanyl has been sprinkled on a legitimate medication that came from a pharmacy that came from a doctor's prescription, that has been added to an existing legitimate drug. So the closed system of distribution when it comes to pharmaceutical drugs is still safe when it comes to that. These are just strictly fentanyl pills. And what we've seen is these fentanyl pills weigh on average about 30 milligrams. And when only two milligrams is sort of that threshold for a non opioid dependent person to potentially start having that those some of those overdose responses ... you're really playing Russian roulette. The last several years DEA laboratories across across the country have consolidated their analysis when it comes to the amount of fentanyl that is contained in pills that we've seized in our investigations. And right now, the latest figures as of about 45 days ago is that seven out of 10 pills that we sieze through investigations contain more than two milligrams so that's a 70% chance that you are potentially gaining a pill that you bought off the street that has that potential threshold of a fatal overdose. 00:19:40 Host: Wow. That's a very scary thought. So Callie, as someone who was on the frontlines for many years with the increasing flow of these drugs, the barrage of cases health professionals deal with won't stop anytime soon. What challenges are facing first responders and emergency medicine staff, including the risks of their own health due to the highly toxic exposure of these opioids? It's my understanding is that you can actually, through the skin even, make contact. 00:20:12 Callie Crowe: So there's a lot of challenges that we face as first responders when it comes to this crisis. But I'd like to address what you just mentioned in the last part of your sentence, and that is fentanyl exposure. So it's actually a misconception that fentanyl in the powder form absorbs well through the skin. And that's not true. Would you agree with that, Dr. Gandhi? And so I spoke with several different toxicologists from all over the United States, and they all agreed, and we're on the same page with that. And so that's a that's a huge misconception amongst the majority of people. They think that once they touch that fentanyl, that they're immediately dead, right? And, and not only does it not work that way, but it also does not absorb well through the skin, if at all. It does take a significant amount of time for that to even happen. And then the odds of that overdose actually occurring, that's a whole different topic. And so this fear that has been instilled in people has done a couple of things, in my opinion. We have a stressful job as first responders in itself and so adding an additional scare, especially one that is not a legitimate scare, is detrimental to our own mental health. But it also causes hesitation with helping our patients, right. And so if we go in with this counterfeit, if you will, fear into help someone, we have a lot of things that have to play in our minds, right we're doing, there's a lot of wheels turning, because we're not just talking about patient care, we're also talking about the safety of the rest of the crew that we're with our own personal safety. These are not controlled settings, whenever someone dials 911, this is a high emotional, intense situation, the majority of the time. And in those situations, they can be very unpredictable. So it's just an addition to adding to things that we already deal with. And so it has created sort of a avalanche of things that have happened. And so there's it's multifaceted that question that you asked. But I did want to touch on that first to say that there have not been any reported first responder deaths secondary to fentanyl exposure in the United States. So when I do my presentations, that's one of the things that I ask, "How many people in the United States that are first responders have died, secondary to fentanyl exposure?" And I get numbers from 1000s, hundreds ... because that's what we are sort of led to believe in my opinion, that is sort of what the media will portray. And I get that information from the answers that I get from these people. I don't know exactly if there's a specific source that they're getting that from if it's TV or social media. But in my opinion, we are still not being trained as first responders appropriately. And that starts from basic training. Right. And, and in recent years still and still in especially law enforcement, they're not trained appropriately on the risks that are actually associated with exposures to fentanyl. And so again, it creates hesitancy. I have a particular situation that I've been a part of the discussion, wasn't there in the actual situation. But there was a delay in actually administering Naloxone because this person was a suspected overdose. And this particular officer was concerned because he was the only one on scene and the ambulance was significantly delayed, like 20, 30 minutes away. Another officer was not readily available and wouldn't be on scene with him for a while. And so his understanding of fentanyl was, if I even enter anywhere close to it, basically, if you're in the same state with it, you're going to die, right? Because that's sort of what they've been given the information that they've been given. And so he did not go in into the actual room to where this 18 year old male was suffering from an opioid overdose. He was still breathing slightly at the time still had a heartbeat, so optimal time for administration of Naloxone. And unfortunately, because of that delay and hesitancy because he himself did not want to be a victim because that's how we're taught right? Scene safety first. Then he was doing it legitimately, then another office arrived, EMS arrived, they immediately go in. He's like, no, no, you don't understand this could be a fentanyl overdose. Oh my gosh, what if y'all get exposed, and I don't have enough Naloxone for everybody. And so it just turned into this, an EMS turns around. And thankfully, that person was educated about fentanyl. And they were like, No, it doesn't work like that. And so eventually, that young man died. And, you know, a similar episode happened with my own son, which is why I'm here today. But you know, that hesitancy creates death, essentially. And so the lack of education surrounding actual fentanyl and how it works, even inhalation would be a difficult, it would be difficult for someone to overdose even with a high concentration of inhalation over a long period of time. So it's just the misunderstanding about fentanyl, and how it works, you have to actually ingest it into your body in order for it to take effect. And most people believe that overdoses happen very quickly. And that's usually not the case, it's over time. Because it takes interact, the way that interacts with your body. And so we have a lot of time to prevent that overdose once it's actually happened. And that's through administration of Naloxone, which anyone in the state of Texas can carry it and administer it. And there are actually some laws that are in place that protect you, even if it's not an overdose, so you don't have to be medically trained. It's, it's, it's actually a very safe drug. Even if it is not an opioid overdose, it is not going to affect that person. And so, you know, you give it and it doesn't work because it's not an opioid overdose, you're okay. If you give it and it works, you just possibly saved that person's life. And so, but to wrap back around here, to answer your question, sorry, that was a very long way around that. There's multiple challenges with first responders. In this opioid crisis, not only do we have an increase in patients, and calls, but we have an increase in severity of these calls, when we have multiple people in cardiac arrest secondary to opioid overdoses. And so, and then the fentanyl exposures and totally different layer to that. So affects us in multiple different ways. 00:27:26 Host: I would imagine it puts quite a strain then on on emergency rooms, and maybe even helps ... has some delay in other patients that are there not for that in getting care. 00:27:38 Callie Crowe: Yeah, and I'm glad you brought up the emergency room aspect of it. Because one of the frustrations with me as a paramedic that I saw was, you know, we got into this field to help people. And when it's a very frustrating process, so let's say we go out. And these are just my personal numbers, these are not these are not studies in particular, but if I had to guess I would say about 90% of our calls that we run are associated with substance use and mental health or addiction. And that doesn't mean it's an active addiction issue or an active overdose. That just means that a person has either abused their body for so many years that they are now in a medical condition, which requires us to come out to them. Or it is actually, you know, an act of addiction or alcoholism and things like that. So that's increased a lot of our calls, however, our education, right, so I still teach EMT and AMT classes. And the mental health and substance abuse chapters of our books are very, very small. And that those numbers don't make sense to me, considering that such a high number of the calls that we run are associated with this problem. And so we're not set up for success. We're actually set up for failure. We have the expectation that we're gonna go out and run cardiac emergencies and strokes and wrecks, that's what that's what we trained to do. But that's actually not reality. Reality is that what we are seeing and what we're dealing with pre hospitally is mental health and substance use. And so in my opinion, we need to be preparing our people because it's changed, 911 system has changed drastically, especially over the last 10 years. I started my career in 1995. It is a completely different world than it was in 1995. And so we need to be altering our education and channeling it to be ... help these EMS providers to be more successful. I think that that also plays into part of why we're seeing a greater amount of burnout, suicide rates and substance abuse in within the first responder world. Because, my point that I was making earlier is, if I am anticipating that I'm going to go work for an ambulance service as a brand new paramedic, or an EMT, I think I'm going to put my cape on and save the day every day. Except for the first 10 calls, in my opinion, are not emergencies, their mental health issues, right. And so I load my patient up in the ambulance, and I take them to the emergency room, where they also do not have a lot of resources. And then when I come back later to bring another patient back, then I have my patient that I brought in 10 miles from their house sitting on the curb because they got discharged, because there's nothing wrong with him. They also got no resources. And now I'm looking at this person who has no family support, because that's what addiction ... that's what addiction does, it drops everything that you've had as a support system, because people get worn out by it. We're exhausted by it. Drew, my son that I lost in 2020, he spent 10 years in active addiction to opioids. And by the time we were done, there was nobody to be found to help us. Because we had worn those resources out, people become exhausted by it. And so when you drive back up to a hospital, that you have taken a person to that you're hoping that you're helping that person. And you see that person sitting on the curb that is now cold and exposed to the environment, they're hungry. And I've driven them 10 miles from their house, and they have no support system and no one to come back. That's a failure to me, right. And so I leave with that heaviness, knowing that I really didn't help that person. And so when you're getting 90% of those are your calls, and you do not have resources to help these people, you become yourself engulfed in that emotion. And so it definitely begins to affect to you as a first responder, we become disconnected with not only our jobs, but our families and everything starts to sort of fall apart. We begin abusing substances on our you know, ourselves. And so, you know, it's, I could sit here all day and talk about the first responder world, but but I think I answered your question, or at least touched on it. 00:32:26 Host: Oh, absolutely. And so how can health providers, law enforcement and the community work together to save lives and help stem opioid addiction? And who wants to take that? 00:32:37 Dr. Artee Gandhi: I can go first, I think it starts on many different aspects, right? I think each one of us has a role in providing education to our patients and treating them in a safe and ethical way. In listening to their concerns, you know, two out of five children that die from an overdose have pre-existing mental health conditions. Only 3%, like I mentioned earlier, that die of an overdose have had adequate treatment in a substance use program. And what's really important to understand is that substance use programs are not just psychological interventions. Medication assisted treatment is the gold standard. And that is what these adolescents or young adults need. I speak more from the pediatric perspective than Callie is able to she treats more adults but her child was a child. And when he started to struggle, he was a child. And then it stemmed into young adulthood. So we need to be able to be mindful of the so many different avenues that opioids and substance use can affect our patients and our children. There is medication misuse that starts in adolescence that can then lead to the substance use disorder or addiction. Prescribers have a responsibility to educate their patients on the safe use, storage and disposal of medications, I'm going to say that a million times, and to treat pain in a multimodal avenue. So using all the resources that you can to treat pain and then to be able to look at what those coping mechanisms are and their mental health when they're addressing pain. There is accidental ingestions so there are the toddlers. Opioids are the most dangerous substance for a toddler to get into and can lead to overdose and death. So we need to be careful about how we lock up our medication. If you have an adult that has a substance use disorder, I have a, you know, just had a patient that's two years old, their hair follicle was positive for marijuana and methamphetamines and they're two. So I'm going to send that child home with Naloxone. I'm going to make sure that it's in their home. There's the adolescent that will misuse medications, they'll take their brother's opioids that they have for surgery, and come back to the emergency room overdosed on medication, or they're the ones that get an illicit Adderall because 'I had a big test the next day.' And they're in college, and they're 18 and they just didn't think any different because they've always taken Adderall. But when they went to college, they thought that they didn't need their medicine anymore. So they got a pill, and they didn't wake up the next morning. There is the impact that opioids have on neonates and intrauterine exposure and the effects that it has on them developmentally, as they grow up. Texas is leading in CPS cases and foster care placement for parents with substance use disorders. We take all those kids out of those homes, that those families don't get the resources that they need, the pediatrician doesn't necessarily ask about, you know, exposure to these substances as a child, but then it affects their growth, their development, their education, their IQ, their coping mechanisms, and then there's a genetic predisposition to substance use. So there are so many aspects and anyone can get these medications at any and get into these medications at any time, you know, people throw away their unused amoxicillin that they are, they're unfinished amoxicillin, but they never throw away their hydrocodone. Like, it's just something that stays in the medicine cabinet forever. Or the valium that they got because of their muscle spasms, those stay in the cabinet. And pills are everywhere we just We're such, you know, like I said at the beginning, we're a pill chemical based society. There's a reason that the United States is the number one leading user of these types of medications. And when I had talked to DEA agents before, and special agents since then, and had asked, you know, "Are we getting a handle on this?" You know, the question, the answer was, "No, we are working hard, we are trying, but this is a product that is going to stay in as long as there's a demand. And so there's a demand in our society for pills. And they know that. And so what we can do is be as responsible and shout from the rooftops, "Be careful, be careful, be careful, and here's your naloxone." And I want to say again to Callie, that it is really important that everyone understands that you can't be in harm if you touch someone that's had a counterfeit pill or fentanyl in their system. And so parents shouldn't be afraid teachers shouldn't be afraid, friends shouldn't be afraid. You know, para-EMTs shouldn't be afraid, doctors shouldn't be afraid. This is not one of those situations. So if we can all have naloxone spray in our house, and if our child looks funny, acts funny, isn't breathing correctly, if their pupils look small, if they're agitated, or they're delirious, or they're just getting more fatigued or more tired, and you don't know why. And you give them each a spray of naloxone in their nostrils, and they don't do anything, then it's fine. But if they do, then, like you said, you saved a life in calling 911 and Good Samaritan laws will keep you from getting in any kind of trouble. 00:39:11 Eduardo Chavez: I think there's something to be said about stereotypes and stigmas when it comes to this environment. Hollywood has done perhaps a disservice in what you know, I think the general public might consider a stereotypical drug addict or a person who is suffering with a substance abuse disorder. They picture them from an inner city, in a broken home, homeless, you know, skinny on some park bench with a needle in their arm. And while that might fit the category for some of those individuals who are struggling with that, there's also the suburban, two-parent, gated community household with an ATM card that was given to their parents a car at 16 years old. And a idea that that only happens over there, wherever that over there may be, but not here. And so there is a degree of denial that that could enter our home. And with that becomes problematic, when it starts with marijuana, it starts with THC gummies. And the slippery slope of, "That's just a phase, I don't want to have to argue with my adolescent over these types of things, because they'll get over it, it's just weed," for example. And later on, "They'll figure it out for themselves." And that was actually the response given to me by a 28 year old that he had arrested for fentanyl trafficking, that his parents were so concerned about kind of actually what you mentioned earlier, Dr. Gandhi about getting a DUI in high school, his parents thought that that would be the end of his, you know, ability to get into a good college and, you know, get a good job. And he says, "Little did they know that I was so high on pills that I didn't have a beer at all," but that they missed the boat. And you know, in others, we've spoken to a lot of families over the years, because DEA has become because of the delivery method of these pills. It's not like if I were to take out a an ounce of crystal methamphetamine right now and hand it over to you all, there'd be a little bit of a natural reaction of, Whoa, I'm not going to touch that, you know, is that real meth? Did you just pull out real math during this recording?" But I bet you, we are probably not that far from somebody who has probably a pill bottle in their glove compartment, their purse or whatnot, it could be just simply Tylenol. But there's a desensitization, we're all desensitized to the fact that these pills are actually more deadly than that ounce of crystal methamphetamine, if I would have pulled that one out. So it has that conversation. We were all very well aware. Dr. Gandhi mentioned it, you don't take an open drink from someone you don't know, don't leave your drink unattended. And, you know, young young females going to college, were warned that by all of their parents and older brothers and sisters about all of those things, it has to be the same conversation. You can't be in the locker room any longer. And say I have a headache. And for somebody to pull out of their gym bag, oh, here's a couple pills. Let me you know, help you with that. It's not the same anymore. 00:42:33 Callie Crowe: I'd like to also speak to this stigma that you talked about. Drew was 27, when he died, he was married. He was a student at the University of North Texas studying political journalism, he was six foot four, if you looked at him, you would have never known. But he had been addicted and dependent upon opioids for at least 10 years. And I was one of those people actually, that you referred to. That said this, you know, this doesn't happen to me, right. And I was actually exposed with my job to it constantly. But I've never done a drug in my life, never even smoked pot before. I don't drink alcohol. I've never smoked a cigarette, I don't vape. So my kids can't be addicts. That's not going to happen. And this is why this particular drug crisis is much different than any other drug crisis is because there is no particular demographic, no one is exempt. And Drew is, in my opinion, a prime example of that. Someone that had goals and, and was married, and they had lots of things that he wanted to do. He wanted nothing more, but to be a political journalist and go to the White House and do all those things. You know, and that's not what we think of when we think of a drug addict. And so we automatically think that it's not going to happen to us, or we put in a category of who that will happen to. And we can't think that same way. It's not the same anymore. 00:44:15 Host: So we're gonna talk a little bit about Naloxone, and then I want to get to shoot Shakyryn. So one of the biggest breakthroughs in combating the opioid crisis crisis is making Naloxone available as an over the counter drug. But there are some who say that naloxone is just a bandaid on or a bandage, a bandage on, on the on the opioid problem and that some even say it could encourage use because it's like, well, I'll just take naloxone. How do we address those two? I kind of combined two questions there, but how do we address that? 00:44:50 Dr. Artee Gandhi: So as a health care provider, I will say that I find the argument of education causing you or leading you to be liberated to do certain things, and I won't go into the whole political conversation of how that has been dictated to children in many other ways as well, but it is quite ridiculous for that to be the case. So education is important. Naloxone is a life saving measure, it is an acute measure, it is for a situation that is a life or death situation, it is not a treatment, it is not a service, it is not anything that will have long term effects on treating someone with a substance use disorder, or really delving into the mental health aspect or to the psychosocial or to the medical, it is something to have in your bag to be able to save someone's life to be able to get them to the next step. And that is what naloxone is, just as if it used to be if you swallowed a something at home, parents would have Syrup of Ipecac in their cupboard, and make their child vomit to get rid of it. But then you would also take the medicine or the chemical out of the cupboard and put it somewhere safely and store it. You wouldn't just say, I'm going to leave this here in the cabinet, but my kid can just keep taking it over and over, and I'm just going to make him puke every two or three days. And that's the end of it. So that is what I would say. 00:46:46 Callie Crowe: I always have a lot to say about naloxone. Yeah. It is very much the bottom line is it's a life saving drug. It is a very safe drug. It is a drug that anyone can carry and anyone can administer to anyone. So you know it. If something there's nothing like Naloxone, basically. And although Dr. Gandhi won't step over the line, I will. So you know, we taught ... people were always afraid if we teach our children or handout condoms to these teenagers, they're going to go have sex. Well, that is not the truth. Right? And another analogy that is less vulgar, if you will, is do you have a fire extinguisher? Does that mean that that's going to cause people to set fires because I have a fire extinguisher? No, that's not the way it works. Right. And so people and most of the time, you have to understand that most of the overdoses that happen are not that they're trying to get high necessarily, or that they're trying to push the limits. It's usually unintentional. And in Drew's case it was unintentional. But it was more of a he was seeking to avoid the withdrawal symptoms, it was no longer about being high, because that's what happens when people who are dependent upon opioids, it's no longer about the high, it's about I need to function every single day, in the same way that we I can almost I see one coffee at least. And I can almost guarantee that everyone sitting here has probably had some caffeine today. I'm not exempt from that. And so it's in the same way of you know, how we use caffeine to make it through our day. And that's where Drew was, but back to the naloxone. So there's in Texas in particular is Senate Bill 1462. And each state has a Senate bill that pertains specifically to carrying and administering naloxone. So I like to call them Good Samaritan laws on steroids. You can not be held civilly or criminally liable for any adverse effects of administering Naloxone period. And so that means that there are no risk to me. 00:48:55 Dr. Artee Gandhi: I would say, in addition to that, always call 911. 00:49:00 Callie Crowe: Yes, I'm glad you brought that up. This is not a save the day. It is a save the hour, right? It's to give you ... it's to buy you time. So yeah, I'm so glad you brought that up. Thank you, Dr. Gandhi. That is definitely you need to follow that. The first thing you need to do is dial 911 then you can begin to resuscitate. 00:49:17 Host: So educating families and care providers on the use of naloxone is important and it goes hand in hand with educating them on the symptoms of an opioid overdose. Shakyryn, this is a scenario you know, all too well. Can you walk us through your personal experience? 00:49:33 Shakyryn Napier: Yes. And it kind of addresses what some of you brought up about the time it takes. So it was about 2 a.m. when my daughter said I can hear Ty breathing really loud. And so we went and checked on him. My husband checked on him and he started doing sternal rub he woke up a little bit and you know he was breathing heavy but he was a loud snorer so it kind of like, okay. And my My son kind of was the same. He's not stereotypical. He had mental health issues. So stereotypical from that standpoint is that he did have schizophrenia, but he was, you know, homecoming king, just just a good, good kid overall. So my husband called me, I was not at home last night. And he called and said, you know, he's breathing really loud, he's hard to wake up. And I said, oh, you know, turn them on his side. And, you know, just let him, let him sleep off whatever he's done, because he did use drugs here and there, but mostly marijuana. I did not know him to take anything over that. He didn't walk around my house high. He wasn't, you know, that just wasn't him. So I said, just turn them on his side and let him go. My husband set an alarm to check on him every hour. He woke up at 3 a.m., and he heard him breathing until he went back to sleep. He woke up at four, he heard him breathing. So he went back to sleep. He woke up at five, he was okay. He said when he got up at six, he didn't hear anything. And it took him a second to really, you know, put everything back together. And when he went to his room, he was foaming at the mouth, lips were blue. So my husband took him off his bed, he was at home, put them on the floor, and immediately called 911, and they started walking him through compressions. He said, he was at his side, just saying, Please, Lord, don't do this to me. And he started compressions and worked on him, and my husband called and said, I don't know what to do. 911 is on the way. So I started making my way there. And I could hear 911, I could hear the EMS providers, they were there at my house, and my daughter was on the phone. And luckily, my granddaughter who was about four at the time was asleep. And I could just hear them working. So I knew I was like, okay, they're working on him, it's gonna be good. They're working on him. I was like, I'm on my way, I'll be there in a few minutes. And I pulled up and my husband and my daughter were outside. And as soon as I got out the car they said, well, he didn't make it. And at that point, I really just didn't know what to do. And a couple hours after that, I realized that I had a kit in the back of my car that had naloxone in it, I'd gotten it from a conference and they were giving it out. And even though I had that, I don't know that we just didn't recognize that's what it was. And we still didn't know. It wasn't until his autopsy came back that it was an accidental fentanyl overdose that we knew what had happened to him. And I don't think people will ever understand what it feels like. When I looked in the room. At first the police were there and they would not let us they stayed in our house until the ME was able to arrive. And because it was a potential crime scene, they just they did not allow allow us to go back. So there was a police officer in my hallway. And he said, you know, you can't go back there. And then when the ME arrived, he said, that is not the last, that's not the way you want to see your loved one, I really don't think you should go back there. And there just wasn't any way I couldn't. And to go back there and see my child, both his pant legs cut off, IOs in both knees, he still had an OG tube in. His shirt, cut down the front where they had tried everything to save him, but they just couldn't. And to go back and think that my first response was, you know, just let him sleep it off, will haunt me for the rest of my life that I didn't. I just didn't know. And we had four hours that we potentially could have saved him, but we just didn't know. So the education portion that they are speaking of is so, so important. And, and I work at a hospital, I've even you know, I knew Dr. Gandhi prior to this. I knew all those things. But that was not anything that I thought would happen to him. So the education piece in the community is so paramount, because you just never know what … what has happened, what is going on. And if you don't recognize any of those symptoms, like they said, if we've given them Naloxone, if that wasn't it, it wouldn't have mattered, but it could have. So we need to have that out there. And we need to know that there is time. And yeah. It's just like you said, it's life changing. As a parent, you will never ever, ever be the same as you were before you lose a child. 00:54:45 Host: So that really kind of brings us back around to the education we've talked about the growing danger of synthetic opioids, the rising death rate among young people. The challenges facing law enforcement, first responders and emergency medicine staff. So let's circle back for a minute, Dr. Gandhi to you, you've been extremely active in developing education materials for both health providers and families, including kids, about the dangers of opioids, the signs of abuse and overdose, the use of Naloxone and addiction prevention. Can you share with some of these materials are and maybe how we could get them into the hands of more families and kids? 00:55:28 Dr. Artee Gandhi: Yes. And, you know, I just want to follow up with Shakyryn, because I have known her for a long time, and worked with her, and I just can't imagine anything more devastating. And I think it's hearing those stories, and then having your own children that just make you more aware of, of what a different world it is now. And that something that, you know, my friends did in high school, you go to parties, and you never expected that to be the case, and we're so cavalier, we just don't, we just, it's just a different world. And so as parents and providers, we just have to be aware of that. We just, we just have that's just unfortunately, the way it is now. And so, you know, what, what can we do? Like you said, we've created educational material. We do ... we have multiple Grand Rounds, presentations that are online, we have videos, we've talked to family, or pediatricians and primary care providers about this topic. We have an internet site through the Center for Community Health that has information and for the first time this year, it's been a system program for our Cook Children's to say that we want to talk about ... we want to address the adolescent population. Up until this point in the 100 year history of Cook Children's the Center for Children's Health is only focused on accidental ingestions accidental poisonings, so focusing on those toddlers, those five year olds that accidentally get into their parents, medications. And so this is the first time that they recognize that we need to move beyond the accidental five year old getting into pills and look at the many different ways that accidents can happen, even for adolescents and teens. And I hope that one day we can make the next step to even look at those teens or those kids that have substance use disorders, to be able to help them in the right way through medication assisted treatment, which is so paramount and essential. But going to the Center for Community Health website has resources for families, has resources for patients. Working with the Challenge of Tarrant County, they provide a ton of educational material for adolescents. Working with the different schools schools have information on so they can go to their school counselors. The DEA has a one pill can kill campaign, so you're able to access all of that information. I know Callie has information that she can go into more detail about. And there's an organization called Brian's Song that talks about their child that also died from a fentanyl overdose with a counterfeit pill that he took in college. And they have resources. So there are much ... a lot of information. But if we were to look at Cook Children's going to the Center for Community Health is a great resource and med dropbox.org is also another great resource for being able to bring back medication. Any patient that comes to Children's Medical Center gets information about opioid safety. They get information about medication safety, they get information about naloxone. We've created pathways for any patient that gets admitted with an ingestion or come to the hospital with an ingestion gets a prescription for naloxone. All of our pharmacies are takeback locations. All of our pharmacies have naloxone. There's also a program in place that if for some reason a patient can't afford Naloxone, we're able to provide it to them. We also give lock boxes for medication storage. Lots of information. 00:59:51 I'd like to just jump in real quick. I am also a resource for Naloxone, so I will happily send anyone that would like Naloxone for free, they can go to my website, which is Drew's 27 chains.org, and request it through the contact me page through there or Facebook. And that will go directly to my email, my email's, also Drew's 27 [email protected] and request it. And I don't need a lot of information, I just need to know an address to send it to. And through things like that distribution of Naloxone and training, Drew has saved 60 people. And so I know that it works. And, and we will continue to save lives. 01:00:42 Host: And I think to go back to Shakyryn's point as well, the education for parents, and really anybody, teachers, medical providers, like knowing what those signs are, because I don't know that I would have any clue. And so I think really making sure that that that material is also available through what pediatricians or probably education with like schools and things I don't know, because parents get really funny about things like that. But I think it's such an important and important 01:01:12 Callie Crowe: I think Shakyryn had a really, I don't mean to put you on the platform and use your situation. But I think that it's really important, here is a medically educated person who actually had Naloxone, but still did not make that connection. And I was not any different. I actually did not know that you could have Naloxone on like, I didn't know that you could go in Texas to the back of the pharmacy, and request it. This is far before what's happened in the last couple of months, which is Narcan is now available over the counter. But I didn't even know that. And, you know, it's great that people are handing it out and things like that. And what part of my education is, yeah, I'm gonna give it to you. But I also need you to understand how it's used, how to recognize, and not only that, but keeping it in a place that is actually accessible, right? Because we have a tendency to take these things home and put it in our medicine cabinet, which could be used at right, because like Dr. Gandhi said, a large amount ... percentage of the overdoses do actually happen at home. So that's not a bad place to put it. But if you're going to a concert, or you're going to the park, you're going to the mall, you're going to the grocery store, and we've had saves all of those places. If you have it at home, what good is it? Right, and so having it on you and having it in the forefront of everyone's mind, when my youngest son went off to college to Texas Tech, they got some mounted in their dorm, in their apartment room in their apartment, and everyone there was trained on it, and so easily accessible. And the training has to do, with a lot to do with it for 01:02:59 Eduardo Chavez: If I may, just to close the loop on the education piece just from where I sit. Engagement with your loved ones, in particular with their cell phones and their environment. The Achilles heel of drug trafficking organizations is the fact that drugs don't just spontaneously appear in their possession, it has to get from point A to point B. The cell phones are the Achilles heel again, because they have to communicate with that person that they want to buy it from. That person has to communicate with them where to go get it. A lot of younger people that we've seen, you know, we've talked parents say my kids broke, my teenagers broke, he doesn't have two nickels to rub together. But yet, they're trading perhaps not great photos of themselves, or trading that Xbox game from 10 years ago when they were a you know, a tween that you don't even realize is gone because they traded that for some pills. Cash App tends to be weirdly one of the most common virtual or cashless based ways to transact. So in that particular occasion, it is you know, taking a look at those devices and just saying who is this and who is this person and understanding and educating yourself on Instagram and and Tik Tok and Snapchat understanding disappearing messages to be able to communicate with your kid without them getting one over on you. 01:03:03 Host: I really want to thank you all for being here today. And I know this is a very difficult topic but a very, very critically important topic for, I think, health providers and pretty much everybody else that might might listen to this today. So and I want to thank all the people listening to this episode. If you'd like to learn more about this topic, please visit our site at Cook Children's dot org. We're so glad you could join us today. If you'd like to learn more about this program or any program at Cook Children's, please visit us at Cook Children's dot org. Want more Doc Talk? Get our latest episodes delivered directly to your inbox when you subscribe to our Cook Children's Doc Talk podcast from your favorite podcast.