Disclaimer: This podcast is for informational purposes only and is not intended to be used as personalized medical advice.

Caitlin Whyte (Host): Fentanyl is in so many street drugs these days and taking lives unexpectedly all over the country. To talk more about this startling epidemic, we are joined by three Skagit regional health doctors. Dr. Connie Davis is our Chief Medical Officer; Dr. Krishnaraj Jayarama is an Emergency Medicine specialist; and Dr. Michael Thompson is a Pediatric Hospitalist.

Welcome to Be Well, the podcast from Skagit Regional Health. I'm your host, Caitlin Whyte. Well, thank you all so much for joining us today and for doing this important podcast with us. Dr. Davis, I'll start with you. Tell us first, what is fentanyl?

Dr. Connie Davis: Well, fentanyl is a man-made opioid, and opioids are medications that are originally for the treatment of pain, but they also come with a euphoric effect, and that is where it gets into trouble as far as taking doses that you don't need from a clinical perspective. Fentanyl came to be in the late 1950s. It is about 100 times stronger than morphine itself and around 40 times stronger than heroin or oxycodone. So, therein lies part of its problem because it is a very potent medication and there is opportunity for dangerous side effects and for abuse.

Caitlin Whyte (Host): Dr. Jayarama, how has the number of fentanyl-related cases in emergency rooms changed nationally and locally in recent years?

Dr. Krishnaraj Jayarama: The latest data from the Washington DOH dashboard is about 42% of all injury deaths were overdoses and 8% of the hospitalizations were all for non-fatal fentanyl overdoses. And then, 4% of those ED visits were for non-fatal overdoses. About 8% of all EMS injury responses were suspected opiate overdoses, so including fentanyl. So, the number has gotten up. The same quarter of the year before, the respective numbers were 32%, 9%, and 4%. So, the number of deaths has reduced some, but the number of ER visits and hospitalizations has increased as well as the number of EMS calls for fentanyl overdose.

Caitlin Whyte (Host): All right. Well, I'll stick with my question here as well, Dr. Jayarama. What are the signs and symptoms of fentanyl exposure?

Dr. Krishnaraj Jayarama: Signs and symptoms of fentanyl exposure and overdose are typical for any opioid period. It's miosis which is basically pinpoint pupils; CNS depression, and the main issue we usually have to deal with is respiratory depression, which can result in hypoxia or low oxygen, which can result in seizures, cardiac arrhythmias and hypoxic brain injury.

Caitlin Whyte (Host): And Dr. Davis, what is the difference then between fentanyl exposure versus fentanyl overdose?

Dr. Connie Davis: Fentanyl overdoses classically are categorized as taking more of the medication than your body can really metabolize or break down. So, leading to the depressive symptoms that Dr. Jayarama was talking about. From an exposure, that usually means that people that are coming into contact with the drugs are doing so unknowingly. So, it may be present in the environment. So, folks like law enforcement or EMS or other folks in the healthcare industry or even family members of people who are taking these substances may come into contact with it unknowingly. And the exposure itself depends on the type or the form of the drug. And many different things can be contaminated. It just really depends on if it's a powder, tablet, or liquid format.

Caitlin Whyte (Host): Interesting. Thank you. Now, Dr. Jayarama, can you share some of the unique challenges in diagnosing and treating fentanyl exposure in children compared to adults?

Dr. Krishnaraj Jayarama: The treatment in children is the same. We do run into the issue where there are medications that adults take that can mimic opiates such as clonidine. The treatment for fentanyl, overdose in children would pretty much be the same. We just have to dose adjust the Narcan®, especially under the age of six. We also have to rule out other ingestions.

Caitlin Whyte (Host): All right. Now, Dr. Thompson, I'll turn to you. What should parents know about fentanyl and young people?

Dr. Greg Thompson: The first thing I'd like parents to know is kind of the bigger context. And part of that is most kids are making good decisions when it comes to substance use. And I say that because we've been surveying high school kids since the 1970s, asking the same questions every single year. And people might be surprised to know that currently, in the last five years, this is the lowest rate of illicit drug use we have ever seen since we've been surveying kids in the '70s. That's, you know, one-sixth of what we were seeing in the 1980s in terms of illicit drug use. And when I say illicit drugs, that means drugs other than alcohol and marijuana. So, it includes the opioids and all these other illicit drugs. So, teen drug use is actually down significantly, but we have seen in the last few years a significant rise in overdose deaths or drug poisoning deaths in teens, and that's really because of the presence of fentanyl because it is so much more potent.

One of the things that's different about how children die compared to adults from fentanyl overdoses is that the vast majority of children who are dying of these drug overdoses or drug poisonings don't have a prior history of opioid use. So, two-thirds to three-fourths of cases of these kids who are passing away, they do not have a prior use history. And that's why we warn people that essentially any drugs that you get on the street now, if you don't know that this drug was given to you by a pharmacist, you should assume that there is fentanyl in there and a potentially lethal dose of fentanyl. Seventy percent of the street drugs that the DEA is testing now have enough fentanyl in them to kill a first-time user.

Caitlin Whyte (Host): Well, with that number 70%, Dr. Thompson, what are some protective factors that parents could do in reducing the risk of teen substance use?

Dr. Greg Thompson: Yeah. So, there are a lot of things. There's been a lot of research on what we call the science of hope. We find that children who have hope for the future, teens and young people who have hope for the future, are much less likely to engage in substance use. Some of those things mean giving people opportunities and having a sense of community, whether that's connection with sports activities, cultural activities, religious groups, or just strong friend groups that they have.

Another very strong protective factor is having at least one trusted adult in a young person's life. That could be a parent. In some cases, children are in situations where they don't have a parent that they feel they can trust, and that's why it's very important for other adults to reach out to young people and be there for them.

Within a family, just having conversations, asking open-ended, non-judgmental questions, you know, saying to your kids, "Hey, I've heard about fentanyl use. What do you know about that? Or what have you seen? What have you heard at school?" Ask things in a non-judgmental way so the children will open up because if they know that you're willing to speak with them without judging them, they're more likely to come to you with their questions.

Caitlin Whyte (Host): Absolutely. And how to further educate families about the dangers of accidental fentanyl exposure, Dr. Davis?

Dr. Connie Davis: Well, there are a multitude of ways that we can do so. Many of the public health departments are actively involved. The CDC has information about this. There are activities within school systems and, for instance, within Skagit public health itself, they have Skagit Rising, which has an opioid work group within it, that is going out to health fairs and there are other public events. We have a drug drop-off at the front door of Skagit Valley Hospital. There is a great leader at the Skagit County Sheriff's Office of criminal events. He's also the head of the Skagit County Interlocal Drug Enforcement Unit, and they are a great source of information and discussion.

Also, interestingly, SAMHSA, which is the Substance Abuse and Mental Health Services Administration, recently, as of last month, had a competition for an alert challenge, the Fentanyl Alert Challenge, to increase awareness among young people. And it was really amazing what these folks came up with. They were all teen events. And they came up with different songs, social media topics, video games, talking about escape rooms and safe clubs and putting out other fact sheets about fentanyl. So, I think there's a lot of reference material out there. It's just making sure that people connect to it.

Caitlin Whyte (Host): And back to you, Dr. Thompson. Can you discuss the importance of proper storage and disposal of prescription medications to prevent accidental fentanyl exposures?

Dr. Greg Thompson: Yeah, absolutely. And I would say that it's important to properly store medications, not just because of fentanyl, but because any medication ingestion can be toxic. So, there are a few things that are important. Number one is, when you get a prescription, try to make sure that you are only getting as much of the medication as you're going to need. And I think people are getting a better sense of that now when they're prescribing things such as painkillers. But if you have a dental surgery and you are only likely to need painkillers for two days, then you can question the doctor if they prescribe you a week's or ten weeks’ worth of painkillers and say, "I'd only like a shorter course." So, starting with that.

The next thing I would recommend is, once you're done with the prescription, to throw it out. There are a number of places where you can return drugs that you no longer need, whether it's police stations, fire stations, pharmacies or hospitals that all have availability of drop boxes. When the medications are in your home, if they need to be there, you can lock them up. You can get lock bags through public health departments, for example. In general, just only having medications that you are likely to need in your home, not having more than you are likely to need, getting rid of those once you no longer need them.

One other thing that I would recommend is that people be aware that everyone in Washington State can carry Narcan® or naloxone, which is the drug that reverses opioid overdoses such as fentanyl. So if you have any opioid painkillers in your home, that should definitely be in your medicine cabinet. And honestly, every person can carry it on themselves, carry it in their car. There may be some school rules issues with carrying it in schools, but I would advocate everyone carry Narcan® or naloxone. There is a statewide standing order that anyone can go to a pharmacy and request Narcan®. And as long as the pharmacist feels you are capable of administering it, they can give it to you without a prescription, and it is becoming available over-the-counter soon as well. So, again, I would encourage everyone to have this available. It's a life-saving drug. I have helped administer it to someone on the street before, and you really do have an opportunity to save lives if you have it available.

Caitlin Whyte (Host): Some really good tips there. Thank you so much. And lastly, Dr. Jayarama, if you find a person exhibiting signs or symptoms of a fentanyl exposure, what should we do?

Dr. Krishnaraj Jayarama: First of all, check them, make sure that they're breathing and they're arousable. And if they're not or if there's any concern that they may go downhill, I would call 911 and get EMS there right away. Lot of times, patients who come in for repeated overdoses will have intranasal Narcan® with them, and so you can check them and see if they have intranasal Narcan® and administer it as quickly as you can to avoid any further progression of their opiate overdose.

We dispense Narcan® from the emergency department, so any patient that comes in with a suspected overdose or an actual overdose, if they are being discharged from the Emergency Department, we discharge them with a free pack from the hospital, for Narcan® to go home with to prevent potential further overdoses or, you know, any death in the field, basically.

And one other thing, so they're actually mixing a lot of fentanyl now with a synthetic veterinary medication called Xylazine, which actually increases the tolerance of fentanyl, so the lethality, when it's mixed together, is lower. And so, patients are actually coming in sometimes with an overdose because they're used to a certain level of fentanyl when it's mixed with the Xylazine and they're not used to that when it's not mixed, your tolerance goes down and so you end up with an overdose. But you don't know which one you're getting. So when you go buy fentanyl off the street, you don't know if it's mixed or not. So, that's also a concern out there as well.

Caitlin Whyte (Host): Well, a heavy conversation today, but some really, really important information here. Thank you so much for the work you all do and for joining us doctors. For more information, go to SkagitRegional Health.org. And thanks for listening to Be Well, the podcast from Skagit Regional Health. If you found this conversation helpful, please be sure to tell a friend and subscribe, rate, and review this podcast on your favorite podcast app. I'm Caitlin Whyte.