America’s medical system has been dealing with opioids for decades, but the experiences of both providers and patients with opioids has shifted significantly in that time. Opioid overdoses are seen nearly daily in emergency rooms across the country now, and providers are at a significantly higher risk of experiencing workplace violence when working with patients navigating opioid use disorder.
Emergency medicine physician Dr. Casey Clements and Workplace Violence specialist Chris Scheuler join us to discuss how America’s law enforcement is navigating the opioid crisis in partnership with medical providers, and how we can break the stigma around opioid use to focus on treatment and recovery.
- Purchase Ending the Crisis by Dr. Holly Geyer
- Learn more about pain management and safe opioid use on our Opioid Resource Center
- Comments or questions? Email us at mcppodcasts@mayo.edu.
If you or a loved one are dealing with a substance use disorder, visit Substance Abuse and Mental Health Service Administration.
Read the Transcript:
Dr. Benjamin Lai: Hello. Welcome to Ending the Opioid Crisis. I’m Dr. Benjamin Lai.
Dr. Holly Geyer: And I’m Dr. Holly Geyer.
Dr. Benjamin Lai: This is a podcast series aimed at getting a deeper understanding of the opioid crisis that has ravaged our country. Today, I’m thrilled to announce we have two guests with us today, Dr. Casey Clements and Mr. Chris Scheuler. Dr. Casey Clements is a consultant, physician and assistant professor of emergency medicine at Mayo Clinic in Rochester, Minnesota. He currently serves as the clinical practice chair of the Department of Emergency Medicine.
Describing himself as a recovering researcher, he focuses on large scale, interdepartmental, and interdisciplinary evidence-based practice improvements. Dr. Clements has worked on the development and deployment of opioid prescribing guidelines and serves on Mayo Clinic’s Opioid Stewardship Subcommittee. He previously chaired the Education and Toolkit Workgroup subsection of that group and was responsible for developing staff and patient education and tools to empower the practice to improve opioid prescribing. Dr. Clements speaks nationally and internationally on sepsis, emergency infection, the opioid epidemic, and violence in health care.
Chris Scheuler is currently the program manager of Mayo Clinic’s Workplace Violence Prevention Program in Arizona. He previously served as regional security director for a large health care system after retiring from his position as the Assistant Special Agent in charge of the U.S. Drug Enforcement Administration, or DEA in Arizona.
During his law enforcement career, he primarily investigated violent international drug networks that manufactured, imported and distributed illegal drugs. Casey and Chris, it’s great to have the two of you on the podcast today. Welcome.
Dr. Casey Clements: Glad to be here.
Dr. Benjamin Lai: I am so glad to have the two of you. You guys bring a wealth of expertise from multiple angles. You know, one of the things that we have heard on the news repeatedly over the years is the opioid epidemic. Maybe I’ll kind of get just a brief summary from both of you from your perspectives. Casey, we’ll start with you.
Dr. Casey Clements: It’s a good question because it’s kind of jargon that we use and we hear a lot, But there really is an epidemic of opioid use in this country. And it and it started really in the early 1990s, and it was accompanied with a shift in how we viewed pain medication. I think that prior to the early 1990s, if you were getting an opioid pain medication, it generally had to do with a severe injury or critical illness.
It was often given to cancer patients, for example, and if you were given some of those medications, you were usually in a bad way. There was a shift in the use of those medications in the 1990s, and there’s very well-known stories from the pharmaceutical manufacturing and marketing industry that they saw additional indications for some of these medications, including chronic pain or even other things that weren’t really associated with a life-threatening illness or a severe injury.
And so that really put us on a path to a different relationship with opioid medications than we had prior to that time. In parallel with that, it really caused a resurgence in illicit drugs like heroin, because when people started using a lot of opioid medications, it became very expensive or it became very difficult to access some of those medications, or they became less effective at causing a state of euphoria that people were getting used to or even staving off withdrawal symptoms. And so people turned to cheaper and more available heroin after that.
Dr. Benjamin Lai: That’s a really good summary. Chris, maybe from your perspective, having worked in the DEA previously, what did you observe and how did things change as this epidemic started to grow?
Chris Scheuler: Yeah, like Casey mentioned, when I first got into the DEA in the late nineties, prescription pill cases were the lowest priority of all the cases we had. The great investigators that I worked with, the top notch agents and officers would never work prescription pill cases. They were working cocaine and heroin, and back then methamphetamine labs were sprouting up all around the country and in people’s basements and backyards. And those were the cases that we really worked in and prioritized.
If you wanted to get promoted in the DEA, you didn’t work prescription pill cases. During my career, I saw a shift. I saw a big change. And really from the late nineties, early 2000s, we saw the pill mills, the mass marketing and distribution of opioid pills, and it really changed the dynamic. And we ended up honestly not anticipating that, snd we were behind the curve a little bit and trying to get ahead of that of that situation and it did get out of control.
And then once we did, like Casey mentioned, the drug trafficking and the trends in the way things go, they adjust to what government policy and law enforcement tactics, how we adjust – they also try to stay ahead of us. So, that’s when you saw the heroin flow into our country. You saw the of the heroin problem really go through the roof. And then the drug cartels got smart again once we started attacking the heroin, the manufacturing and distribution of it.
Fentanyl is much easier to produce because it’s made chemically. So, there’s chemicals that originate in China. They go to Mexico and Central America, and then they have secret labs that they mix these chemicals with. So, you don’t need to have farms and farm workers and you don’t have to worry about weather conditions and irrigation and things like that. You can make these super, super potent chemicals easily, and they’re easy to conceal and to smuggle.
Som that became a game changer for the international drug organizations that are manufacturing and distributing these drugs. And so, that’s the big change I saw during my career in DEA.
Dr. Benjamin Lai: Casey, you know, from your perspective as an emergency medicine physician, how did your practice change over those years? You know, Chris very nicely illustrated that evolution of the drugs, you know, from heroin to increasing prescription opioids now to the fentanyl. Has your practice changed and what have you observed that’s different?
Dr. Casey Clements: Yes, I think it’s actually changed in a couple of different ways. One is sort of on the supply side. So, we treat pain. We go into medicine to help alleviate suffering for people. And for some time, that meant trying to get people’s pain to zero to make it just go away, right? We call them painkillers, not pain dullers. There was a huge push towards actually using more opioids in patients, and it was thought that it would be cruel or just unkind not to be using these at relatively high dose.
We had things like “pain is the fifth vital sign,” where we want to make sure we’re recording pain on everybody and making sure that we’re addressing that. And I think that’s really important, we do want to address people’s pain, but opioids are not the only tool in the box, and not every kind of pain needs an opioid medication.
So, from the supply side, from the time that I came into medicine, which was not in the 1990s, so I can’t really comment back that far, but since the mid-early 2000s, we were using pretty high doses of opioids and when we were sending people out, we were giving them prescriptions that didn’t really match the way that people took the medication — there would be quite a few pills and the pain may only be expected to be lasting a few days in the current state and start to get better from there. But we were giving people opioids that would have lasted them weeks potentially. That changed after we realized some of this was really a problem and we started to ask ourselves some hard questions, like “Are we contributing to the opioid epidemic by what we’re prescribing?”
And I do think that we did in medicine early on, and we bear some responsibility for that. And so, the whole idea of opioid stewardship is to make sure that we’re giving people the right amount of medication to control their pain with the goal of maintaining the ability to function, not just to make their pain go completely away.
There’s really only one kind of drug that can make pain go completely away. It’s like novocain or lidocaine that you inject from the dentist. And other than that, these painkillers are really intended to maintain function. So, that was one way that it changed.
The second way that had changed is on the sort of receiving end of overdoses or of people who are dealing with opioid use disorder. That has increased drastically over the my time in medicine, and we see patients very frequently who are either there with an overdose…an overdose can look like a lot of different things. A lot of people imagine the overdose to be the pictures that we see of someone slumped over the wheel of a car and gray and they look like they’re dead. But, people can accidentally overdose from pain medication when they’re taking it even as prescribed, if they’re prescribed at very high levels.
And so we’ve certainly seen medically complex patients come in who have low oxygen reading or they’re really sleepy. And we find out that they’ve been retaining CO2 in their blood because they’re breathing very slowly from an opioid overdose or from having too much of that pain medication. And so the complications from opioids have really been pervasive throughout emergency medicine, at least for some time now.
Dr. Benjamin Lai: Have you had to use more naloxone or Narcan?
Dr. Casey Clements: Yeah, we use naloxone pretty frequently. So naloxone is a reversal agent for opioids. It is a competitive inhibitor, so it binds to the same receptors that opioids bind to and essentially knocks the opioid medication off that receptor. And it works very well and very quickly, traditionally for some of the medicines that we saw, but things like heroin or things like morphine, it was very effective even at low doses.
Now, Chris mentioned fentanyl. Fentanyl is a great medication in a medical setting because you can dose it very carefully. It’s a hundred times more potent than morphine. And there are other kinds of fentanyl that aren’t just a pure form of fentanyl that have, you know, chemical groups clamped on to them that can make them even much, much more potent.
We have heard things in the news and things like carfentanil or an elephant tranquilizer or an elephant pain medication that works extremely strongly. And some of these medications, while we don’t use them frequently in medical care, they can be present in illicit drugs. The naloxone doesn’t always work as well for those, or it can require a very high dose.
Sometimes, if the naloxone doesn’t work, we need to do other supportive care, like even putting a patient on a ventilator and breathing for them for some time while they can get that drug out of their system.
Dr. Benjamin Lai: Wow. Chris, I want to shift over back to you, bringing along Casey’s point of overdoses. Have you in your line of work, your experience, or hearing other colleagues, have there been more overdoses in the communities and who is overdosing? Where are these drugs going to?
Chris Scheuler: I’ll read you a step. In 2021, there was 107,000 drug overdose deaths in the United States. Two thirds of those deaths were caused by fentanyl. So really, that is a huge number. And we are seeing it as fentanyl is coming across. Casey mentioned how addictive it is. It is coming across like never before. And we’ve had DEA and other federal agencies seized 380 million potentially deadly doses of fentanyl in 2022.
What I like to point out is we’re seizing a lot of it, right? A lot of it comes across. We used to say the DEA maybe gets 10% of what’s coming in. That’s a reasonable amount that we guess now. That means 90% gets it right.
And we talk about a lot about law enforcement, you know, the “war on drugs” is a tricky term. It’s not an accurate term of what is actually going on as far as the efforts of the government and the community to to try to put a stop to this. But I’ll say this: law enforcement does have a role. It does put pressure on these organizations and cartels. DEA realized long ago that no matter what we did, there’s always going to be a demand for drugs, and so really addressing the demand is the most important piece.
The supply is going to be there. If someone wants it, someone will find a way to get it to them, right? That’s just a human situation that’s impossible to stop. But what we can do is reduce the harm that happens to patients and people that are using these drugs.
I think as a community, there’s a lot of different things we could be doing better from a demand side, reducing demand, and a lot of that is societal. It’s a big issue. From a law enforcement standpoint, really, when I was in DEA, our main mission was to attack these cartels and go after these organizations. That’s what we were good at.
The demand side has always been an afterthought, in my opinion. So really, there’s a lot of work to be done in society. If we want to look at this, that the amount of overdose deaths is unacceptable. It’s really, really terrible. And what we’re seeing is also the fentanyl is coming across now in counterfeit pills that are designed to look like oxycodone and different controlled, prescribed pain relievers.
Even folks that know that they’re not real, there’s no quality control. So you don’t know what that dosage is when you’re taking it, even if you know it’s not a real pill, which I imagine many do. So really, the quality control is what’s leading to a lot of these overdose deaths. You don’t know what you’re getting when you take them.
The ways that they’re trying to advertise these and market them among folks that would be vulnerable to taking these drugs…it’s ingenious. It’s evil. The drug cartels are great marketers. They’re amazing business people. You got to give them credit. They are geniuses at this stuff, unfortunately, to the detriment of the folks that are suffering for this epidemic.
Dr. Benjamin Lai: I’ve got a couple of follow up questions, maybe just to clarify and probe further, too. You had mentioned the demand. What would be a good strategy to start tackling that demand side? And question number two is, you mentioned several times that drugs are coming across. Have you noticed any changes in terms of the source, where it’s coming from over the years?
Chris Scheuler: Well, no. There’s two main cartels in Mexico that the US government has designated as the targets that we’re going after. The Sinaloa cartel and another cartel called the CJNG. Now, those are large organizations. The Mexican drug cartel since the late 1970s have controlled most of the illegal drugs coming across into America, coming from wherever. So, those are the major organizations and they’re they’re getting stronger.
We’re making a dent, but I wouldn’t say they’re going to be toppled anytime soon, right? They’re in a very strong position. The corruption in foreign governments really allows them to act almost with impunity sometimes. We build up those relationships and we chase down these kingpins and cartel leaders. But there’s always an organization to step up, to fill that void.
So, yes, I do believe from a demand side, from society, I think a lot of it is treatment related. We need more treatment. We need better treatment. We need more people and more resources available for the folks that need it. We talk a lot about education, drug prevention, getting to the youth.
The old model, when I grew up, was a police officer came to your school. They did an assembly, they gave a lecture trying to scare you about how drugs are horrible and you’ll ruin your life, and then everyone goes on with their day and then it’s forgotten 4 hours later.
So one of the things they’ve done now is that the government has partnered with other educational companies that are creating basically a curriculum that will go into the schools, that will be what you’re studying as part of your health and your wellness, and it’ll talk about evidence-based things, not scare tactics. [It’s] not trying to make it so you’re scared and you don’t know what to do, and you never try – the “just say no” generation, right? So we’re really looking towards a more of a curriculum-based, evidence-based, science-based approach to educating children, because that’s the target audience right now.
When you try to do drug prevention efforts, you want to try to get them as young as you can. I have teenagers that are in school right now, and the amount of drugs that are available is shocking. It’s really, really prevalent. And it’s not hard to get. And I hear stories all the time from my kids. So, yeah, it’s a scary situation for parents, but there are some other ways to do it.
I believe in medication-assisted treatment. I believe in telling it like it is for our kids, but making it evidence-based, and also more resources or places for people to go that need help or have questions.
Dr. Benjamin Lai: That’s great to know. A great perspective.
Dr. Holly Geyer: Every 8 minutes, someone in the US dies of an opioid overdose. The drugs we have long trusted to help kill pain are now killing us. But what if we were equipped with the information to use opioids wisely, store them safely, avoid their risks and reverse their problems? What if we could help the loved ones misusing opioids and support them as they seek treatment?
My book, “Ending the Crisis”, shares Mayo Clinic’s collective insight into the lives of every person struggling to understand opioids and their role in managing pain or dealing with the complications caused by these powerful drugs. Visit the link in the notes of this episode or visit mcpress.mayoclinic.org/opioids to get your copy today.
Dr. Benjamin Lai: Casey, I’m going to kind of shift over back to you. Chris had mentioned education is important. Having treatment programs is important. You know, you mentioned before that you see a lot of patients, or an increasing number of patients where naloxone is needed. How do you counsel those patients, and, when you discharged from them from your emergency department, how do you make sure that they have a good treatment plan once they’re discharged?
Dr. Casey Clements: It’s a really, really hard question, actually, because for people who are dealing with opioid use disorder or really any addiction, our systems of care are generally separated by vast oceans of challenges that they have to overcome in order to get the help that they need. In general, people are not going to go directly from an emergency department after an overdose into rehab.
There’s not open and available places that are just waiting for people to be sent to them. So there’s going to be some time between when they’re cared for initially for either their intoxication or withdrawal state, and then they can actually get into treatment for their use disorder. In addition to time, those generally happen in different places. So we care for people very well for intoxication and withdrawal states in emergency departments and doctor’s offices and hospitals across this country.
But that’s not where people generally receive treatment for their use disorder. It’s certainly not multimodal treatment that is going to be very effective. In addition to just being difference in time and difference in space, it’s also a difference in how it’s paid for. Many people’s medical insurance doesn’t pay for a rehab stay in the same way. Many people who are on public assistance need to actually have a separate legal evaluation to be able to enter into care for their addiction.
And so all of these gaps are really, really challenging for people. And, you know, when I came into emergency medicine, I thought we treat addiction really, really well. We don’t. We treat intoxication and withdrawal states pretty well, and we’re just starting to scratch the surface on addiction. Chris mentioned medication-assisted therapy or medication for opioid use disorder. That is probably the most effective thing that we can do from a medical side right upfront to get people headed towards recovery, and we need to be oriented towards recovery.
In addition to that, though, there needs to be some coordination with those other services. Historically, we’ve relied on people like social workers — who are just worth their weight in gold — to help provide resources and to help coordinate some of those situations. We’ve actually moved towards using peer recovery specialists, even in the emergency department, so when patients are ready to talk about seeking sobriety and seeking recovery, we actually bring in community partner organization folks who are peer recovery specialists and who themselves are living in long term recovery.
We found them to be remarkably effective at keeping people on that straight and narrow and towards recovery. They’ll follow up with them on a regular basis. They oftentimes can help get those government-mandated assessments done, and they can keep people with them in some of that time between when they’re seeking care for their intoxication and withdrawal state and when they’re actually going to go towards rehab or further recovery treatment. So, it’s really complicated how we treat some of these addictions.
Dr. Benjamin Lai: You’re right. It’s super complex. I want to pick up on the point, Casey. I know, having worked with you, that you’re a champion of buprenorphine for patients with opioid use disorder. And I know that you and some of your colleagues in the emergency medicine department have started patients on buprenorphine, Suboxone, for example. Starting patients on this medication in the emergency department, what have been some of the challenges or maybe some of the surprises, and how have staff and patients generally taken this approach?
Dr. Casey Clements: First of all, the surprise is how wonderful this actually makes the caregivers feel, the nurses and the physicians, because traditionally we’ve tried to treat people’s symptoms of withdrawal, which are just awful, with a number of therapies that are directed towards alleviating those symptoms. And so, if they’re nauseous, we can give them things like ondansetron. If their blood pressure and their heart rate is up, we would give them some kinds of blood pressure medication and we would treat some of their nausea, even with some motion sickness treatment.
We would just throw medicine after medicine after medicine at these people and it never worked very well. The people still felt awful. It didn’t help their cravings from going back to using again, which they know will take their withdrawal symptoms away better than the medicines that we threw at them. And so being able to do ED-based inductions of buprenorphine has been like a godsend to our staff because we start folks on this medicine and all of a sudden the patients feel better and they say, “thank you so much.”
And even if they had thoughts of going back to using, their use is not going to be as effective at getting them high because of the way the medication works, and it’s been a surprise at how really good it’s been for the staff and how good it feels to make people feel better. So that’s the sort of biggest surprise.
The second thing is that this is really the first step towards recovery. People want to get off of those drugs. They want to get off of that pain medication. Being able to make sure that they’re not having horrible withdrawal and going back towards using again is the first step. And so it is one of the ways that we can bridge the treatment of intoxication or withdrawal states, specifically withdrawal, towards that treatment of the actual underlying use disorder, and that’s been a breath of fresh air for our staff.
Dr. Benjamin Lai: That is so good to hear. Chris, a question for you. Your current role is in the violence prevention program in the workplace. Have you observed any changes in your role now in terms of the relationship between drug use or substance use disorder and workplace violence?
Chris Scheuler: Yeah, great question. Thank you. So, to Casey’s point about the withdrawal symptoms: they cause a lot of agitation and restlessness, and you have a lot of patients that decide that they don’t want to do this anymore and they want to leave. And so, we had a patient recently that was found on the corner, had eloped from the hospital and was in a gown.
It was a patient that was withdrawing from opioids and decided that he just couldn’t take it anymore and got up and escaped the hospital and was walking down the street in his hospital gown. And luckily, our security teams and the care staff recognized this and they went and found him in the parking lot and they got him back in the hospital and back into his bed.
And then he ended up staying and getting treatment that he needed. But it’s an example of of the feelings that this patient had of just having to get up and go and leave because these withdrawal symptoms are so strong, they just feel lousy. I mean, there’s no other way to put it. They just feel awful.
So, that manifests sometimes into aggressive behavior. Not always, I wouldn’t say it’s one of the main factors of aggression that we see, but we are right now in the middle of a pilot program where we’re trying to capture some of that data about our patients, about the alcohol and substance withdrawals and how does that affect workplace violence. So, I don’t have great data for you to share today, but it is something that we’re looking at and working on and I will say this: since the Workplace Violence Prevention program officially kicked off here in Arizona last year, we’ve really stressed having a collaborative team approach with the provider, the nursing staff, the social worker in psychiatry, security, and workplace violence prevention team, all working together and coming up with plans for these patients, and then sharing those plans through the shifts and through the teams because we feel like that’s the best way to prevent workplace violence assaults.
So, for someone who’s either intoxicated or withdrawing from a substance, that is someone we’re going to pay a lot of attention to. That’s someone we’re going to give extra care for because we know what they’re going through is very hard, and that it can lead to other behaviors that aren’t necessarily that person’s personality or their baseline, but it’s the situation they’re in that leads them to some of these behaviors that are challenging for our staff.
So really, I guess the answer is yes, it is a factor in some of our workplace violence. We have seen it. We’re addressing it and we’re aware of that. And from an organizational standpoint, Mayo Clinic has really stepped up their efforts to understand this phenomenon because it is a rising and challenging situation.
Workplace violence in health care is a major challenge. It’s something that Mayo Clinic recognizes and has put a lot of things in place to really study it and learn how to prevent it. Prevention is the key for us. The old health care security model was to manage behavior until it was unmanageable and then hit a panic button and call security and run in when it’s in crisis and everyone tries to de-escalate.
So really, we understand that that’s not the best way to do it. The best way is to have these interventions in place, have this information to know how to best treat these patients, have a plan for them, and then communicate that plan effectively. And that plan would include: how do we manage these symptoms of this withdrawal to keep this patient safe, to make sure that they’re being cared for?
So, yes, I will have some more data for you eventually. We’re working on it and we hope to have it soon. But I think it’s going to be interesting once we do that.
Dr. Benjamin Lai: Fantastic. We’re looking forward to updates.
Dr. Casey Clements: So, I also work on workplace violence and have worked with Chris in the past on this and I will refer you to a great publication from the Emergency Nurses Association about the causes of workplace violence. And for those who don’t know, workplace violence is a huge issue in health care. 74% of all nonfatal injuries from workplace violence in the country happened in health care in our most recently available data.
So it’s a really, really big problem. But the Emergency Nursing Association has been on top of this for years. And there’s a publication that they’ve done that looked at: what are the contributing factors to violence events in the emergency department? Drugs seeking behavior, intoxication or withdrawal are number one, two and three as the contributing factors to violence in emergency departments.
It’s a little different on the inpatient side because they deal with some other issues, but it’s still an important factor. As society, we don’t realize that. We tend to think about violence as something to do with mental illness. Actually, psychiatric illness is not associated with violence strongly at all outside of chemical issues like intoxication and withdrawal states. And so it’s actually probably one of the biggest contributing factors to workplace violence that’s keeping Chris and I with our noses to the grindstone.
Dr. Benjamin Lai: Are both of you aware of other institutions or other efforts beyond Mayo Clinic? Is this becoming more commonplace? Is this issue getting more notice?
Chris Scheuler: I can answer that for sure. I noticed that the Joint Commission recently published new standards for all accredited health care organizations and hospitals, too, to follow that really spell out a lot of workplace violence prevention, best practices, and what needs to be put in place for regulations. You know, here in Arizona, there’s a new state law that’s about to take effect in July that really drills down into having a written workplace violence prevention plan and what that plan needs to include.
And so, recently there’s been a memo that came out from Health and Human Services. So, there’s there’s a lot of people that are recognizing this this problem. And I think a lot, yes, in this industry it is being addressed. There’s people realizing it and you’re seeing a lot of changes. I do believe that it has gone on for a very long time in a way that it was underreported, it was underappreciated, it wasn’t taken as seriously as we are taking it now. So I’m glad to see that those changes are made. The Joint Commission and other other entities have realized it as well and are now requiring health care to do a better job of keeping their patients safe and their staff safe.
Dr. Benjamin Lai: You guys gave a really comprehensive answer, and I appreciate that. I’m hoping to get both of your opinions and input on things like naloxone. What is your perspective about people having naloxone in our community or even things like fentanyl test strips in our community? You know, I think, Chris, earlier you mentioned harm reduction as one of the strategies. Maybe I’ll start off with Casey and then I’ll go on to Chris after.
Dr. Casey Clements: Yeah, they’re great questions. I’m going to start with your second question, which is fentanyl test strips. They’re not as useful anymore because essentially 100% of everything that we’re going to test has fentanyl. Chris pointed out how prevalent this is. Fentanyl is so easy to make from chemical precursors and it causes euphoria no matter what drug it’s put into.
It causes a lot of problems, but it is in almost all illicit drugs now. And so there certainly have been studies that have looked at the utility of fentanyl test strips and there was some early success in that. In 2023, I’m going to tell you, I don’t actually think that they’re that useful anymore. I think you should just assume that any illicit drug that you get may have fentanyl in it.
As for naloxone, naloxone is absolutely a key to helping us fight the opioid epidemic, because the first step towards getting people off of these medicines and off of these drugs is to save their life so that they can have a chance to recover. So it begs the question, who should we be giving naloxone to? Now, there’s a lot of states and there’s a lot of places that naloxone is available without a prescription or over-the-counter.
There is a federal discussion going on right now about making it available everywhere over-the-counter. But who should say go get that? Who should pick it up? I think that’s a really good question. First of all, people who are on high doses of opioids, even for very much legitimate medical reasons, should have naloxone on hand so that if they have a problem, they can take that and then present for further care.
Certainly anybody with a history of any opioid overdose should be given naloxone. Anybody who is diagnosed with the opioid use disorder should have naloxone and not just the people who are affected, but their families and friends and people that are going to be around them. It’s part of the nature of the beast of these drugs that they put you to sleep.
And so certainly there are people who may realize that they’re getting sleepy or that they’re not breathing as well, and they may be able to administer it to themselves. But those are relatively few and far between. Most people who have an overdose risk or who are going to overdose, they’ll fall asleep and then slow down their breathing until it stops, so it’s important that their family, their friends, the people around them have that medication on hand so that they can administer it if it’s needed.
And then lastly, I do think that there’s a public health effort here that’s needed, that we need to have naloxone available in first aid kits. I personally advocate for them being placed with AEDs. So, automatic defibrillators are available in many public places and they should have access to those within 2 minutes of any place within a public area to help treat a cardiac arrest.
I think about naloxone in the same way because it’s the same idea that you have about 6 minutes from the time that somebody stops breathing, if they’re a healthy individual, until they’re really having brain injury and potentially death. And so because that time matters. I really advocate that naloxone be available publicly in places like where we keep AEDs.
Dr. Benjamin Lai: Thanks, Casey. Chris, anything else to add?
Chris Scheuler: I do. I’ll say about fentanyl testing, Casey is correct. It’s not that helpful because, unfortunately, what we’ve seen is even if someone knows there’s fentanyl, they still want it. And matter of fact, there’s true stories about really strong fentanyl coming in to a certain neighborhood area and causing a lot of overdoses. And then people that are addicted to fentanyl will go to that area hoping to find it because they know that’s the strong fentanyl. That that’s really what’s motivating them.
And the other question that begs is, we talk a lot about the overdoses and the deaths, but these organizations and cartels are supplying this fentanyl. I just read the other day that six of ten pills that are coming across, that are being seized by DEA, have a potentially lethal of fentanyl up from four out of ten in 2021.
They know this is a lethal dose. They’re killing their own customers, but they don’t care because it’s a cost of doing business for them. And because this strong fentanyl is not keeping people from these pills, they don’t care. When you’re that desperate to get these drugs, the fentanyl strips and things like that aren’t going to be helpful because t’s not a consideration for these folks.
Dr. Benjamin Lai: Boy, I’m learning so much from the two of you today. We have a lot of work to do. I want to end our podcast by kind of asking each of you if you have any closing thoughts or any other messages you’d like to share with our listeners. Chris, maybe I’ll start with you first.
Chris Scheuler: Yeah, no, great. I appreciate the time and this is obviously a major attack on our communities. These drugs and the damage it’s doing is horrible, and we’re seeing a lot of pain and suffering. As a nation and as a country, we need to step up and realize the magnitude of this, realize that there’s so much more we could be doing.
There has been a stigma with drug usage over the years that’s really, possibly, in my opinion, restricted the resources that we put towards helping. You know, we incarcerate a lot of people that have possession of harder drugs. I myself conducted investigations and arrested many people for trafficking in drugs.
But what we learn is that there’s other alternatives. There’s ways to stop this from a comprehensive, whole of community, whole of government approach needs to be undertaken. And I don’t see the urgency, and I think my own opinion is that’s because it’s a stigma for people that use drugs. They get addicted to drugs and die from this. We probably all have some family or friend or someone we know that’s been affected by this, and I think when we look at it through that lens, we have to do more. We have to lose that stigma.
We have to look at all options, put everything on the table and really rally together as a society and as a country to really make a difference. These trends come and go, but I’ve never a trend like this and I’ve never seen it this bad, and I think it’s a very scary situation, as a parent, as a member of society, as a health care person, you see it from all different angles and it’s really horrible. So, my call to action is to everyone, step up. Let’s pull together. Let’s do the right things, do everything we can to help the people suffering from these misfortunes.
Dr. Casey Clements: My point was actually going to be very similar. I think great minds think alike, and so do you and I, Chris. I would take it a step further and say it’s not just stigma about those people. Nobody actually thinks about themselves that they’re at risk for this, and that’s really scary, right?
So, we’ve many times been prescribed pain medication through our lives. I don’t know about you, but when I’ve had to have those first surgery or whatever, I haven’t thought, “Oh, I should be worried because I could potentially have a problem from taking these medicines.” But it turns out that the biggest risk factor for using opioids is being human because the drug causes euphoria and there is nobody that is immune to that.
And so most of the time people don’t think that they’re at risk for addiction until they’re already in rehab, and sometimes not even then. So I think it’s really important to really turn the tide on the opioid epidemic, to really get down to the demand side of things like you and Chris had mentioned before, to realize that all of us are absolutely at risk for this and that there’s nothing different about the people who are addicted to injecting heroin than we are.
And I know that that’s a little uncomfortable for people to think about, and we use terms that are not medically sound or evidence based like “addictive personality” or some of those things, and that’s just not true. It’s convincing ourselves and our family and friends that that isn’t us. It’s somebody else that this happens to. That’s not the case. It’s absolutely us.
And once we can start to take that personal responsibility for how these medicines work for us and for how drugs would affect us, I think that’s when we can start to move the needle on the epidemic and really decrease that demand. And so, for the listeners, I would just ask you to to look at yourself and put yourself in the shoes of somebody who has gotten into a lot trouble because of really one bad decision where they decided to use a drug that made them feel good and say, is that really that different from who we are?
And I think that’s a really key message around the epidemic. And when we’re talking, we’ve talked a lot about illicit drugs and reversal agents, things like that, but stopping it upfront before it’s happening is really, really important.
Dr. Benjamin Lai: Casey Clements, Chris Scheuler, thank you so much for your time, your expertise. What an insightful and thought provoking conversation. Thank you.
That is all from us on today’s episode of Ending the Opioid Crisis. You can check at our website at mcpress.mayoclinic.org/opioids for more episodes of our podcast series and other resources for safe opioid use.
If you or someone you know are struggling with an opioid or another substance use disorder, we recommend speaking with your healthcare provider or going to the Substance Abuse and Mental Health Services Administration website.
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Ending the Crisis
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