Scott Webb (Host): Though we may not be in full opioid crisis mode as we were a few years ago, far too many Americans are still overdosing on opioids and fentanyl, including folks in Monterey County. And joining me today to help us to understand opioids, the potency and dangers of street drugs, and what's being done to educate and save lives are Dr. Erica Locke, she's an Emergency Medicine physician at Salinas Valley Health; and Michael Isaacs, he's a clinical nurse educator, Emergency Services with Salinas Valley Health. 

This is Ask the Experts, the podcast from Salinas Valley Health. I'm Scott Webb. I want to thank you both for being here today. We're going to talk through the opioid crisis, fentanyl, what it is and, you know, why it's so dangerous and all of that. And, you know, kind of speak broadly, in terms of how it's affecting all Americans or affecting folks globally, but also, you know, in Salinas Valley and Monterey. And so, we've got a lot to cover today. And Dr. Locke, I want to start with you and just have you give us an overview of the opioid crisis, how fentanyl became such a major factor in it. You know, just give us a good baseline.

Dr. Erica Locke: In the opioid overdose crisis, we've really seen kind of four timeframes in the past 40 years. In 1999, we started to see an increase in prescription opioid overdose deaths. And particularly in 1990, that was when oxycontin came onto the scene. So between 1990 to '99, we had this big increase in physicians and clinicians prescribing opioids for pain. And we were led astray a bit by the marketing practices and the marketing of telling us that these were not addictive. However, we've come to learn that they were very addictive.

And so, about 1999 to 2005, we saw this huge increase in prescription opioid overdose deaths, and that was heartbreaking. Around 2005, we started to realize that this was a problem and there became a big crackdown on clinicians. Doctors' licenses were scrutinized if you were prescribing excess opioids. And so, a lot of patients very sadly, got suddenly taken off their pain medicine that was prescribed for legitimate pain.

So between 2005 and about 2010, we saw this big increase in heroin overdose deaths, and some of these patients really were those patients who had been placed on these opioids by physicians after surgery in relation to chronic pain. So, 2005 to 2010, we see a lot of heroin deaths. And then, we see fentanyl come on the scene. So, about 2010 to 2013, we see this increase in synthetic overdose deaths. And so, 2010, we started to see the first lawsuits related to opioids. And then, about 2013, we saw a very sharp, you know, a hundred-fold increase in opioid overdose deaths related to fentanyl. And most of that was illicit fentanyl, of course, fentanyl procured on the street because there are very few forms of fentanyl that are prescribed. And so, these were mostly counterfeit pills and very, very just heartbreaking in incremental rise in overdose deaths.

Host: Sure.

Michael Isaacs: The interesting thing about fentanyl, kind of the rise of it is that it just became so easy to manufacture and so easy to insert into other drugs, that it exploded when it came to things like oxycontin and the start of everything. It was the pill. It was an oxycontin pill that people got hooked on.

Host: Right.

Michael Isaacs: Fentanyl came on the scene, and they're able to put it in so many other things that are being sold on the street, which is why we're seeing such the increase in not only addiction, but in opioid deaths, because it's permeating in all other drugs. It's not just like oxy was. It's become this whole new animal.

Host: So, you give us a sense there because there's just so much in the news and social media and it's hard to make sense of all this. So, I want to find out from you, Dr. Locke, like how does fentanyl compare to other opioids in terms of potency and risk? Like, what is Fentanyl exactly, and how does it compare to the other opioids?

Dr. Erica Locke: So, fentanyl is essentially 100 times stronger than morphine, and it is 50 times stronger than heroin. So, imagine a sugar packet. A sugar packet contains four grams, right? So, four grams of sugar. In that sugar packet, you could get 40,000 therapeutic doses of fentanyl. So if I had one sugar pocket full of little fentanyl crystals, I could treat 40,000 people therapeutically for their pain related to a surgery or, usually, we use this in the emergency department when someone has a broken bone, or they're undergoing surgery and we've cut open their body, or their body has been, you know, severely injured.

One sugar packet has 2,000 fatal doses of fentanyl. So, I could treat 40,000 patients for their pain in the Emergency Department, or you could kill 2,000 people with just one sugar packet of fentanyl. I know Mike can speak to how now this is becoming just adulterated in our street drug supply.

Michael Isaacs: For many years, people who can't get their medications, and I'm not talking, you know, things like oxycontin and pain medications, things like anti-anxiety medications like Ativan or Xanax that maybe they can't get into their mental health appointments, and people are selling them on the street. The problem is they're selling fentanyl-laced medications like that. And even in our community, we're seeing it. And when we talk about sort of the potency of it, there was a period of time last year at Salinas Valley Health where we had a string of patients all come in, all middle-aged who all died from overdoses. None of whom were known fentanyl users. And I know Dr. Locke has used this term in the past, but street chemists, as I make the air quotes.

Host: Right.

Michael Isaacs: These street chemists are mixing it because it brings people back. If somebody takes Xanax, which is an anti-anxiety medication, but it's different than the normal one they've taken because it's got fentanyl in it, it brings them back because fentanyl makes you feel good. It causes that euphoria. So, they go back with it and they take more of it. And then, they overdose on it because they don't know that fentanyl's in it. They just know it makes them feel better than the normal drug they're taking, and they take more of it and it causes the overdoses.

Host: Yeah, I appreciate the air quotes. And Michael, I just want to get a sense of some of the biggest misconceptions. I think there's so much misinformation and misconceptions about fentanyl and just the opioid addiction crisis.

Michael Isaacs: I mean, the biggest myth, and much like any addiction, is that addiction only affects people who have no will or socioeconomically disadvantaged. Opioid addiction can literally affect anyone of any age. I mean, the other part of it is that fentanyl in the streets is the only fentanyl there is, so it kills people. Fentanyl kills you no matter where it is. And Dr. Locke spoke to this. Yeah, if you take the large doses of fentanyl that are given in the streets, yeah, it could kill you. But if you come in and your bone is snapped in half, I'm going to give you fentanyl, the right dose, the right medically prescribed dose, because it's going to help your pain. It's the best thing I have. We're not giving you the hundred times the dose that they're giving you on the street.

Dr. Erica Locke: One of the biggest misconceptions I think that we see is that, one, "Oh, this can't happen to me." One-hundred percent, if you are a human and you were born, this can happen to you, right? If you don't have adequate supports in your life, or just if you have a brain that happens to be affected significantly by these chemicals.

 Think part of what is so heartbreaking in this epidemic is that we do not treat this enough as a society, as the medical condition that it is. We criminalize people, we criticize people. We say that, "This is your fault. You put yourself here." When in actuality, this is a fundamental part of being human. These are chemicals that create medical conditions. And just like we have kindness and compassion for people who are schizophrenic or who have mental illness or who have diabetes, this opioid dependence and chemical dependence, alcohol dependence, all of these kind of drug dependencies and addictions should really be treated as such and thought about as such. We need to have more compassion. Yeah, just can't stress that enough.

Host: Dr. Locke, let's talk about how these drugs are impacting communities, especially in terms of public health, safety, all that kind of stuff.

Dr. Erica Locke: Basically, every day, in America, it's estimated that 260 Americans die from opioid overdose. That's like essentially a plane crashing every single day. And to put that into perspective, daily in America, 100 people die of car crashes, and about two people die in a plane crash, if you were to use that kind of daily statistic, every day. So, that's a more than a hundred-fold death rate than people are dying in motor vehicles, right, which is staggering.

One of the most heartbreaking things that I think and trends that we are starting to see is this trend towards young people using, or young people experimenting or trying. So, very sadly, in the past, kind of five to 10 years in our county and across the nation. We've seen this rise in fentanyl deaths in the demographic of like age 14 to 18. So, these are often people who have taken one pill, one pill at a party, and then they've died. I have kids at this point. My kids are middle school age. They carry Narcan. They have come around to these presentations with me. They carry Narcan in their bag, and they carry Narcan in their bag as young children, not because I think that they're going to overdose, but I almost guarantee they will come a day when someone goes down in a bathroom or in a mall or at a concert, at a music festival that they're at, and they will be able to save a life, because they know kind of what to look for, which kind of brings us to this other new law that was recently passed in Monterey. Mike, can you talk about Melanie's law a little bit?

Michael Isaacs: I believe it was in October of 2023, a bill passed in the California legislature. It was SB-10, it's called Melanie's Law. And basically, what it says is that, in an effort to prevent more fentanyl overdoses in the schools, they now have to have a plan and a program for education and response. So, part of that is what myself and Dr. Locke are doing is literally going into the schools and providing education about Narcan and about fentanyl. But then, having Narcan in the schools, and that's the response part, is teaching kids how to recognize, teaching kids what fentanyl is, but then how to respond if somebody they know has an overdose. 

Host: Yeah. Mike, I wanted to ask you what Narcan is and is that the go-to if it's nearby, if you suspect that someone is having an opioid overdose?

Michael Isaacs: Absolutely. Narcan is the opioid savior. Basically, it is the best and number one reversal agent for opioids. In layman's terms, when you take an opioid, when you take fentanyl, it attaches to the pleasure centers of your brain. Problem is it also slows down your breathing because of it. And if you take too much, it slows down your breathing to the point of no breathing. And that's what kills people. What Narcan does is you inhale this Narcan through your nose, that's the way that we're doing it and the way we're teaching it to the community, it's a nasal spray, and the Narcan goes into those pleasure centers and your brain pushes the opioid out. So now, you can breathe, eventually you can wake up, and the opioid is no longer affecting you the way that it's trying to. The Narcan takes the place of that. So the way that we teach and the way that we use Narcan and the way it's in the community is literally a nasal spray. Just like you're going get your Nasonex for your allergies, it's a little nasal spray, and you put the end up somebody's nose and you press the plunger and it sprays the Narcan into their nose.

The reason that it's so big in the schools is because kids have parties, kids are out. The reason that we teach it to kids to hold with them is you can't treat yourself with Narcan. You're usually unconscious. So if you see somebody on the floor and their breathing is slowing down, if somebody's not waking up, you rub them on the chests, you punch them in the leg, and they're not waking up, there's a problem. And the thing is, if this is not an overdose, let's say, God forbid they just passed out, or it's a stroke or some other medical emergency and you give them Narcan, no worries. The Narcan is not going to have any negative effects on a person if it's something else. Narcan has no negative side effects. But if it is an overdose, it's probably going to save their life.

Scott Webb: Dr. Locke, then, let's talk about the medical community. I'm sure education, things like this, podcast, presentations, things like that, we think about prevention, treatment of opioid addiction, getting more Narcan into the hands of folks who could really help on the front lines, if you will. Just talk about this, talk about what someone like yourself, medical providers can do or are doing to help folks.

Dr. Erica Locke: So as a medical community, making sure every emergency department knows how to do a buprenorphine start or issue a prescription for somebody to come off of their street opioids and have a pathway to a safe and effective treatment. We see fewer deaths when we have people in treatment.

So, there two main drugs that are used currently to help with opioid dependence. And they are methadone, which is very highly regimented, through methadone treatment programs that are very often hard to access, and you have to go every morning to , pick up your dose. Very hard to live your life in a methadone program. But for some people, the methadone programs work great. The other medicine that we have is buprenorphine, or also known as Subutex or Suboxone. So, these medications are also prescribed for opioid dependence. They prevent withdrawal. They help people to get their life back together, because basically this is a chemical dependence. And so, when you treat people's opioid withdrawal, when you replace that opioid with a therapeutic alternative that helps them to rebuild life, right, and to just get back on track. You really impact people's lives.

And I think the other piece of this that's very important that I think the medical community is just starting to kind of scratch the surface of, is really partnering with people who have lived experience. Partnering with people who have lived experience, creating jobs for people who have lived experience to be a partner and a motivation, and also just a warm hand to tell a patient, "I've been there. I know what this feels like. And while this doctor is going to help us to get you the meds you need, I'm here to also give you the hope."

And so, I cannot stress enough that we as doctors-- I always say I have the easy job. I can write a prescription, I can tell you how to take it. The real work comes with getting these patients into treatment with building supports. And so, the more we partner with people of lived experience, the better we will be at doing this and their experience is invaluable. So, I think as a medical community, we need to increase paths to treatment, increase access to mental health, increase access to the medication-assisted treatment, and then just partner and create some jobs for people with lived experience, for sure.

Host: Yeah. Such good information today to put out in the world. I feel like we're just kind of scratching the surface. But I'd give you a chance, both of you here at the end, just talk about some of the harm reduction strategies that have been effective in addressing the crisis. I'll start with you, Dr. Locke.

Dr. Erica Locke: So, harm reduction is vitally important. Studies show that if we provide access to harm reduction, we increase willingness of people to enter treatment. Our hospital was actually the first to approve the harm reduction policy that was created by doctors in every hospital in Monterey County. So, physicians got together from every hospital in Monterey County, and we came up with a harm reduction plan that included how are we going to offer needle exchanges, how are we going to offer supplies to make people who are using drugs more safe. So, supplies for injury and infection prevention is what we called it, or SIP. Harm reduction means, one, prevention, so good mental health resources and intervening young. And then, two, treating our population and our brethren with kindness, compassion, and letting them know that their life is valuable and providing healthcare to them and a means to safely continue their use before they're ready to get sober, and then offer fast and effective pathways to get clean and sober when they're ready. 

Host: Yeah. Michael, last word to you.

Michael Isaacs: We did a session at CSUMB a couple months back, and I haven't been on a college campus in a long time. And I remember when I was on a college campus 20 years ago, you walked in the door, the dorms, and there was the rack with the newspapers. You know, the school newspaper right by the front door.

Host: Right.

Michael Isaacs: Well, it's CSUMB now. There's a rack of newspapers, and next to it is the rack of Narcan, which I thought was very interesting and kind of telling about what's going on in schools that, "Okay, we know you're using, but we don't want you to die."

Host: Well, it's a lot to take in. Like I feel like we've really just scratching the surface today. But since we know that education is such a big part of this, both for the community, perhaps other medical providers, hopefully, we've put some good information, good resources out into the world today. So, I just want to thank you both for your time.

Michael Isaacs: Absolutely.

Dr. Erica Locke: Thank you so much. We really appreciate your time.

Host: And to listen to more of our podcasts, please visit salinasvalleyhealth.com/podcasts. 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 Health. I'm Scott Webb. Stay well, and we'll talk again next time.