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Scott Webb (Host): Though, we've all been a little sidetracked by the COVID-19 pandemic over the past couple of years, the opioid epidemic in this country continues to plague our communities and hospital systems. And joining me today to help explain opioids and the epidemic, help us to know how to speak to our children about opioids and share her experiences treating overdose patients in the emergency department is Dr. Erica Locke. She's an Emergency Medicine Physician at SVMH. This is Ask the Experts, a podcast from Salinas Valley Memorial healthcare system. I'm Scott Webb. Dr. Locke, thanks so much for your time today. I know that there's been a lot of conversations, nationally, internationally. There's been a lot of talk and a lot of concern over opioids and for every good reason. So I'm glad to have you on, glad to have your expertise. Let's just kind of have a baseline here. What is an opioid and how does it work in our bodies?

Erica Locke, M.D. (Guest): Opiates are or opioids are a class of drugs that are naturally occurring and they're found in the opium or the poppy plant. And they've been around for ages and they've traditionally been used in all forms of medicine to help with pain control. And so these substances bind to the mu receptor in the brain and they help to control pain. They're also really deeply linked to serotonin and dopamine. And these are our chemicals in the brain that provide attachment. And so with attachment chemicals in the brain, it is very easy to become addicted to an opiate, in the same way that when you first meet your parent for the first time, or you fall in love, serotonin and dopamine surge to really high levels.

And so when we use an opiate and there's no pain, serotonin and dopamine surge to incredible levels and provide euphoria. That euphoria is also sometimes present when we're using the opiate to help treat pain. And it's part of why we can become so addicted to these very dangerous substances, but they certainly have a great role in medicine when needed.

Host: Yeah. So there's a lot to unpack. And I actually listened to someone else's podcast about this, and it was with somebody who'd been addicted to opioids and the way it was presented in that podcast was basically that, you know, it's just one of those things that you could become immediately like you can take a pill and become addicted to opioids. And I mentioned briefly just this opioid epidemic. Right? And so when we say that, I say that out loud and others use that in social media or wherever, what does that mean exactly? Try to help contextualize and explain the opioid epidemic that we've been having over the recent past, both in the United States and around the world.

Dr. Locke: Basically the opioid epidemic, refers to the widespread problem that we have now with opioids. In the late nineties, the pharmaceutical companies basically reassured medical communities that patients would not become addicted to opiate medicines. And so they became very widespread in their use and subsequently in their misuse.

So around 2017, as these medications and drugs became more addictive and more widespread, there was declared a public health emergency and Health and Human Services basically announced a strategy to help try to combat this opioid crisis. So, basically when we say epidemic, we mean that this is widespread, effecting so many people. I think at this point nearly everyone has a story or knows someone that knows someone who has been affected by this opioid epidemic, whether it be from prescription drugs, when they got addicted and then subsequently moved on to using more street drugs or simply used some of these medicines, even medicinally and also maybe accidentally developed a dependence as well. So when we talk epidemic, it's basically widespread and a public health emergency at this point, really.

Host: Yeah, it really is. And there are a number of television shows. I saw one with Michael Keaton and a lot of shows about sort of the history you're explaining here of how this epidemic got started from the drug companies, to healthcare providers, to patients, and then, you know, people buying street drugs and so on. And so it's a lot to take in and I'm so glad to have you here to kind of sort through this. One of the things I have learned is that there is still a place for opioids, for pain relief. Now it seems to be the responsibility of providers, and healthcare systems to try to figure out how much is enough. When is it appropriate? You know, there was a time where it's just everybody, you get an opioid, you get an opioid and it's not like that anymore, but there still is a place for them. Right?

Dr. Locke: Certainly. So there is an important place for them when it comes to surgeries, broken bones, certainly in end-stage cancers when people have severe pain affecting their bones and widespread disease. So, there's certainly a place for opiates. We use them in the emergency department to help us sometimes with procedural sedation.

And so these are important drugs or medications. The big problem here is that these very addictive substances have made their way into our street drugs and our street drugs, unfortunately are not safe. And so one of the biggest things that we're tackling now is the synthetic opiate fentanyl, which is a synthetic opiate that's basically 100 times more potent than any of the opiates that we've known in the past. And so with fentanyl in the street drugs, it seems like our street chemists don't totally understand yet, what a microgram versus a milligram is. And so when they're creating these street drugs, you can have a very small amount of fentanyl that actually leads to devastating effects in our population. And that's part of why we're seeing so much death and overdose deaths associated with our street drugs and opiates right now, which is contributing to this real crisis that we have.

Host: Yeah, I'm assuming when you said the street chemists, you used air quotes.

Dr. Locke: Yes. Yes.

Host: I pictured you using air quotes, street chemist. Right. And as you say, it's alarming and there've been a number of high profile cases of famous folks using these street drugs, that were, you know, made with fentanyl too much of it, obviously. And it seems that it's just an immediate overdose in most situations, it's, absolutely frightening. And I'm sure it is for providers as well, you know, especially folks coming into the emergency department. I'm sure it's frightening. It's alarming.

Dr. Locke: It is, it's terrifying, certainly as a physician it's scary, as a parent it's even scarier. Just to give an idea of just how the small amounts. So if you think about one sugar packet, right? One little tiny sugar packet has four grams of sugar in it. So if you took that amount of fentanyl, four grams, that is enough to provide 40,000 therapeutic doses in my emergency department. So in our ER, we could treat 40,000 people's pain essentially. And that is essentially 2000 fatal doses. So when you think of that tiny little amount could lead to 2000 deaths, it's really scary, certainly.

Host: In general, how do we speak to our kids about opioids, opiates, this entire epidemic?

Dr. Locke: The messaging has actually really changed. So now with my kids basically don't buy anything on the street and then I go even further to talk to my kids about exactly why. So in Monterey County recently, we've had children start to die. And when I say children, I mean, you know, kids age, raging 14 through early twenties, and some of the most heartbreaking deaths, all of them are heartbreaking, but have occurred when it was a child who went to a party, took one pill and then all of a sudden they stopped breathing.

Their friends were afraid, you know, didn't activate EMS fast enough or didn't have Narcan and they ultimately died. So what's so scary about fentanyl and about the opiates on the street right now is that issue of just how potent they are. And so when I speak to my kids, I tell them again, do not ever take anything on the street. Do not even accept prescription drugs, if they were not prescribed for you, because now there's a lot of pills that are out there that look like prescription drugs that someone might say, oh, this is my mom's or this is my dad's or this is my, you know, so-and-so's but they're actually counterfeit street drugs that are made to look like prescription drugs.

And these do have fentanyl in them and they're quite deadly. So I also then we'll take it a step further. And when my kids are old enough to go to parties, I like to carry Narcan in all of my cars. We have Narcan, and you know, I plan to tell my kids about Narcan, how to use it. And if you're ever in a situation where a friend may have had this issue, this is how you use this life saving medication.

And so what Narcan is, is a reversal drug. And so this is a medicine that's carried by all first responders. It's at this point, pretty easy to get. In the past, you did need a prescription, but in California, the laws have became much more liberal now and, you know, get Narcan now at many treatment centers, you can get it at our hospital ER, as well, we have a supply.

And so at these sites that are friendly to trying to treat this opiate epidemic, you can walk in and just grab a box of Narcan to keep with you. And so, Narcan is a reversal agent and it's a spray that gets sprayed into the nose of someone who has may have overdosed and it can save a life and we watch it save lives every day in the emergency department with these patients.

Host: Yeah. And so, what are the treatment options for someone struggling with opioid use disorder?

Dr. Locke: Great question. So people tend to need to be ready to quit or, you know, to work towards abstension and then when they're ready, we really need to make sure that we meet them where they are as soon as possible. So we need to, when someone presents to our emergency department or to our clinic or to our treatment facility, we need to be able to offer immediate services.

Which is a real struggle now with our healthcare system when it comes to prior authorizations and, you know, access to medication, access to referrals and treatment and specialists. So, when someone is ready, getting into a medication assisted treatment program is really key. And the reason for that is because as we discussed, these are chemical changes that happen in the brain. There are physical changes that happen. Withdrawal is very uncomfortable. There's diarrhea, there's sweating, there's vomiting. There are very visceral and biological things that happen. And we, as a health care system and as providers and just as a community, finding the ways to help people with that are, is very important. So medication assisted treatment is key. There are a few ways to do that. One is a more kind of a, an older, well known pathway has been methadone.

Methadone is a very powerful, long acting opiate and that's been traditionally dosed through a methadone clinic and people go to the methadone clinic every morning and they receive their dose. It's a very stigmatizing way to receive treatment. It's also very hard to hold a job down if you're going to a methadone clinic every day.

And so recently better drugs have come out. We now have buprenorphine and there's a formulation of buprenorphine with naloxone or with Narcan that is actually very safe to use. And so these medications are better and actually, have been proven through evidence-based medicine to lead to longer lasting abstention from opiates and safer treatment and a more successful treatment as well.

So there are a few resources for medication assisted treatment in our community, and we're working towards establishing many more with buprenorphine. And buprenorphine naloxone, the brand name is known as Suboxone. And so in our hospital, we are really working towards getting more access to medication assisted treatment, particularly with buprenorphine and Suboxone for our patients.

Host: That's awesome to hear. And you mentioned the hospital, let's talk about the hospital, the clinics, you know really, the entire healthcare system here in Salinas and Monterey. How are you rising to meet this need? And it is a substantial need as we've established here. So, maybe brag quote-unquote a little bit, but in general, share with folks, everything that's being done, all the resources that are available to them and so on.

Dr. Locke: Certainly. So here in Monterey County, the Monterey County Prescribe Safe has done an amazing job of working to unify all of our hospitals and get everyone on the same page. And there are two amazing physicians, Dr. Rob Close and Dr. Casey Grover, who have really championed to that. And so the Monterey County Prescribe Safe is a great resource that anyone at any hospital, clinic can go to. For our hospital community over the two years really we've seen a huge uptick in our opiate use disorder patients and we're seeing younger patients. And so, Dr. Radner has really worked to unify all of the departments.

And now we have a task force that basically brings the multidisciplinary approach to meeting this need. And so most recently, we were able to work with the pharmacy as well as the lab. And so our most recent wins are that we've got a supply of Narcan to just hand out from our emergency department whenever anyone needs it.

Any of the nurses, any of the docs, really any human that's in our system can come down to the ER and say, you know, I have a loved one who needs Narcan and no questions asked. We simply hand them some Narcan if they need it. So that's been a big one partnering with pharmacy in order to, provide that. Up until a short time ago, we're not able to actually test for fentanyl in our labs and our lab director has been incredible to get that. That is now available in our hospital. And the lab has been really wonderful about whenever we have any overdoses that are kind of puzzling, they work together with other labs in the area and up in San Francisco to figure out what's in our drug supply at this point and what we're facing day to day. Our hospitalists and our ER doctors are all working towards getting their X waiver.

And so in order to be able to prescribe buprenorphine or Suboxone, physicians need more than just a DEA number, which is, you know, another hoop we have to jump through to treat this very, vulnerable population. But so our docs and our providers are working towards having everyone have an X waiver so that we can meet people where they are and prescribe that Suboxone or that buprenorphine immediately when they come to us and they have that need so that we don't lose the opportunity that we have when people do come to us ready to move towards abstention from these very dangerous drugs.

And then in addition to that, our outpatient clinics have done an incredible job of beefing up their resources so that when we have a patient who we've identified in the emergency department or in the inpatient setting as a candidate who's ready for medication assisted treatment, the doctors on duty, our local clinics have really worked towards getting their providers X wavered as well and creating pathways and then last, but certainly not least the most important piece of all of this is our social work department. And our social work department works just tirelessly to, you know, speak with our patients and get them into treatment because it's more than just a prescription, right. It's more than just when you come into the ER, here's your prescription, we'll see you later. Good luck. There's a whole network of therapy and peer support and life support that people really need because opiate use disorder just can completely devastate a life when it comes to your finances, your housing, your food, your access to your family, your children, maybe.

And so there's a huge network of social services that our patients need when they come in. And so it goes so much more beyond just the prescription and our social work department is just so vital in this, and they've really worked to champion this and also bring us all together onto the same page so that we can best meet our patients where they are and provide the most cutting edge and current evidence-based treatment for this really, really heartbreaking epidemic that we're dealing with.

Host: Yeah, I mean, well said, and it is heartbreaking and it is a heavy topic. But I really appreciate the education today, your just compassionate way of going through all of this. I'm sure listeners do as well. So for the education, the conversation, which obviously unfortunately is going to be an ongoing conversation, I really appreciate this. Thanks so much. And you stay well.

Dr. Locke: Definitely. Thank you. You too. Thanks for the opportunity. Take care.

Host: And for a complete list of all of our podcasts, please visit svmh.com.

And if you found this podcast to be helpful, please be sure to tell a friend, neighbor or family member and subscribe, rate, and review this podcast and check out the entire podcast library for additional topics of interest. This is Ask the Experts from Salinas Valley Memorial Healthcare System. I'm Scott Webb. Stay well, and we'll talk again next time.