How Do We Contain the Fentanyl Crisis? A Panel of Experts Weighs In

0:00:13 William Moyers
Fentanyl. An opioid that is everywhere these days. And everywhere. People who use it, including many who don't know they're using it, are dying. Thank you for joining us today for Let's Talk, a podcast series brought to you by Hazelden Betty Ford. I'm your host, William C. Moyers. And with me today, in studio and virtually, a panel of my colleagues and experts in the field of addiction treatment, research, prevention, and recovery. Dr. Alta DeRoo is the Chief Medical Officer at Hazelden Betty Ford. Dr. Quyen Ngo leads Hazelden Betty Ford's Butler Center for Research. Dr. Stephen Delisi is the Medical Director of our Enterprise Solutions Division. And virtually, joining us is Kerry Hettinger. A Registered Pharmacist in Indiana and Kentucky who also serves as a Doctor of Pharmacy in the Enterprise Solutions Division at Hazelden Betty Ford. Welcome, everybody!

[GROUP SAYS THANK YOU]

0:01:09 William Moyers
Kerry, we're gonna start with you virtually. You're coming to us from Kentucky today I believe. What is Fentanyl?

0:01:17 Dr. Kerry Hettinger
Sure! So Fentanyl is an opioid similar to other opioids that was discovered in the neverending quest to find an opioid that could have pain relief properties but not have the euphoric properties. They didn't find that with Fentanyl, but what they did find was an opioid that really revolutionized surgeries. It was an opioid that was very potent, something that came on very quickly, and then left the body very quickly. However it's those same exact properties that have been so beneficial in surgeries that also have made it so dangerous as a drug when it's misused. Additionally, the Fentanyl that we're using in those surgeries is not the same Fentanyl that's being used right now and that's causing all the overdoses. Unfortunately, what we had with the Internet, we often will have the recipes if you will or the chemical formulas, of how to actually make different medications. And that's what happened within the last couple decades is that formula was released online. And it allowed anyone to be able to access it and therefore learn how to make their own Fentanyl.

0:02:29 Dr. Kerry Hettinger
[continued]
So, it's the illicit Fentanyl that we're seeing that's causing the overdoses, very different than what we see in the operating room. And unfortunately, even though it has all the same potency and the same other properties like coming on very quickly and leaving very quickly, it also is often really contaminated with some of those manufacturing contaminants that can get into the chemicals in the process. So, lots of reasons that Fentanyl's very dangerous. But the high potency and the fact that it comes on quickly are two of the most important qualities that are really part of that overdose equation that we're seeing right now.

0:03:09 William Moyers
Dr. DeRoo, how has Fentanyl affected what we do at Hazelden Betty Ford?

0:03:15 Dr. Alta DeRoo
Yeah, great question. We see our patients coming into residential treatment facilities and they're aware that they're using something, possibly an opioid, and we're unsure of what that opioid may be. In the past it's been heroin, which its base is morphine. But if it's something like Fentanyl, the approach is very different. Fentanyl lives in the fat tissue, so it takes a while for it to come out. So it's not as predictable as heroin or morphine would be.

0:03:42 William Moyers
Hmm.

0:03:44 Dr. Alta DeRoo
So our treatment patterns that we've used in the past, opioid agonist, Buprenorphine-Naloxone, we can't use right away because the person doesn't go into withdrawal right away.

0:03:54 William Moyers
Hmm.

0:03:55 Dr. Alta DeRoo
Traditionally in the past, with somebody who's been using morphine or heroin, we can predict that they'll go into withdrawal 18 to 24 hours after their last use. However with Fentanyl, they may not go into withdrawal until two or three days. And if you were to start treatment with something like Buprenorphine-Naloxone, before the Fentanyl has left the body, then you can put that person into a precipitated withdrawal. So even though it's not life-threatening, it's very uncomfortable for our patients. And we don't want that to be their first perception—

0:04:24 William Moyers
Mmm-hmm.

0:04:24 Dr. Alta DeRoo
—Of what treatment is like.

0:04:25 William Moyers
I wanna come back to that and talk about how we've had to re-educate our own clinicians. We'll come to that in just a minute. But I wanna talk to Dr. Delisi and Dr. Ngo about the pervasiveness of Fentanyl in communities and particularly in communities of color. So Dr. Delisi, if you would tell us, what is the impact of Fentanyl in communities that you work in?

0:04:44 Dr. Stephen Delisi
Yeah so we work across the country with our training and consultation division. And I can tell you that Fentanyl and analogs of Fentanyl, are everywhere. And they're not just in—it's not that the Fentanyl is just in the opioid supply, it's in the methamphetamine supply, it's in the cocaine supply, it's in the Benzodiazepine supply, it's in the marijuana supply. So one of the things that makes it so dangerous is we don't know what individuals are using when they're using any of the substances.

0:05:18 William Moyers
Mmm.

0:05:19 Dr. Stephen Delisi
It may have Fentanyl in it. Everyone has heard about the rising overdose rates. Those overdoses now are 70 percent of the time related to having Fentanyl in the substance. It's really been catastrophic.

0:05:36 William Moyers
And what about Dr. Ngo, in communities of color, or inner cities and places where drug use is prevalent?

0:05:45 Dr. Quyen Ngo
So, we have seen especially as the pandemic has started, that overdoses with synthetic opioids and illicit use of opioids, has really hit communities of color in particular. So among black communities, among Native American communities, and I know Steve and his team has done a lot of work with that as well.

0:06:10 Dr. Stephen Delisi
Yeah no we certainly have. Because we've seen within the pandemic that overdose rates across the country have gone up. But in communities of color, African-American communities, Native American communities, much higher rates—

0:06:24 William Moyers
Mmm.

0:06:26 Dr. Stephen Delisi
—In fact there was just a study that was released this year that showed that for the first time since 1999, African-American overdose death rates were higher than white communities. And I would say that yes, part of it is the exposure in the illicit drug supply to Fentanyl and the other high potency opioids, but there's also been a disparity in our response within the pandemic. Both in terms of the actual pandemic and the healthcare for COVID-19, but also in our mobilization of the life-saving medications like, as Dr. DeRoo mentioned, the Buprenorphine-Naloxone, or Naloxone that people know as NARCAN. That hasn't been equally distributed across our country.

0:07:15 William Moyers
So Kerry, how do communities get educated around the impact of Fentanyl and what to do about it?

0:07:24 Dr. Kerry Hettinger
There have actually been several initiatives that I think are really helping to get the word out. One of the most important ones is your local Health Department. A local Health Department's work with the DEA. The DEA also has a website called One Pill Can Kill. Which gives all of the updated information about any type of illicit Fentanyl counterfeit pill that's out there. Like Steve was mentioning, we're seeing Fentanyl showing up in illicitly made Benzodiazepines and illicitly made MDMA, which is ecstasy. So the local health departments will get this information about what the FDA is seizing, you know, in some of their trafficking operations. And they are putting pictures of those substances on their website. So first of all, contacting your local health department is really important. Additionally, there's a national harm reduction coalition that exists in the country, and there's a chapter in every state. And they offer different kinds of Naloxone trainings as well as, once again, these informational web pages which are providing the information about what type of Fentanyl is out there and what is active and prevalent in your community. That's a really important thing to understand too is that we see real regional differences in terms of what type of illicit—whether it's Fentanyl or a different kind of synthetic opioid that's related to Fentanyl, can be prevalent in one state whereas another one can be prevalent in the state next door. So understanding that finding out your community's kind of epidemiology is important.

0:09:10 William Moyers
What about internally, Dr. DeRoo? How has Fentanyl affected the education of our own clinicians and how we approach treatment of our patients?

0:09:20 Dr. Alta DeRoo
So because it's unpredictable and we can't treat it in the past like we would assume somebody's using heroin, we've had to modify our treatment. We would still use a Buprenorphine-Naloxone, but now we give it in different doses. So we can microdose with small amounts of Buprenorphine-Naloxone.

0:09:37 William Moyers
Hmm.

0:09:37 Dr. Alta DeRoo
—To displace the Fentanyl from the receptors. Or we can try to macrodose. So we can give a lot of Buprenorphine-Naloxone to totally wipe it away and treat the person that way. That's a discussion that we have with the patient. Because we do know that the patient's gonna be uncomfortable at some point. So that's really a shared decision that we make with our patients. The other thing that we've done is that we've really broadened our reach with NARCAN training. So no longer is it just in the detox units. It's everybody on campus.

0:10:04 William Moyers
Explain with NARCAN is.

0:10:06 Dr. Alta DeRoo
Oh so NARCAN is a life-saving treatment. It's a medication that preferably the easiest one is you give a little nasal spray up the nose. And NARCAN wipes away the opioids from the receptors—

0:10:19 William Moyers
Mmm-hmm.

0:10:21 Dr. Alta DeRoo
—That will allow a person to reverse the overdose. So it reverses the overdose when somebody passes out. And it's a life-saving measure that EMS carries NARCAN, police carry NARCAN everywhere out in the community. And so, because our patients at increased risk for overdose, we've also asked all of our providers on campus to be familiar with NARCAN. Because sometimes when a patient comes into treatment, they may not be ready to stop using yet.

0:10:50 William Moyers
Right. Right.

0:10:50 Dr. Alta DeRoo
And you know it may be an issue where they're out in campus and they find a way to put some in their system. And we have to respond. So because it's become so lethal, we've had to heighten this response and this education to all of our colleagues on our campuses.

0:11:05 William Moyers
Mmm. [nods] Dr. Ngo, what were you going to say?

0:11:09 Dr. Quyen Ngo
Oh I was just going to add to what Dr. DeRoo was saying and really say the important thing to know about NARCAN too is that it doesn't hurt. If you administer it to somebody who is not having an opioid overdose. And that's really critically important to know is that if it's suspected, if there's any thought that there might be opioids on board, it's important if you have access to that NARCAN to administer it. And I think this is really important right now because there are challenges in terms of the research behind Fentanyl use, which can impact clinical care. You know because patients and individuals don't always know if they're using it. So a lot of times when we're collecting that data and we're trying to get that information about prevalence of use, often times it's undercounted because someone may not even know that they've used it.

0:11:53 William Moyers
Oh yes. Yes.

0:11:54 Dr. Quyen Ngo
Often it's related to an opioid overdose, but you know, many overdoses if they're not lethal—

0:12:02 William Moyers
Mmm-hmm.

0:12:02 Dr. Quyen Ngo
—People may not seek treatment. And so we may not know that. And so, many of the numbers out there are likely undercounts of actual Fentanyl use. [nods]

0:12:10 Dr. Stephen Delisi
Yeah that's very true. And William, at the community level, just to expand to across the country, because Fentanyl and its analogs are in everything, there's a growing importance of training and access to Fentanyl test strips.

0:12:30 William Moyers
Yes.

0:12:31 Dr. Stephen Delisi
And I just wanna make sure that anyone watching and listening to this today knows that they exist. That there are test strips that—

0:12:38 William Moyers
Where do you get them?

0:12:39 Dr. Stephen Delisi
You know what, Kerry talked about the harm reduction coalitions that are in each state, they frequently have access to the Fentanyl test strips. I know that in the state in which I live, the nonprofit that does the Naloxone NARCAN training and distribution now does Fentanyl test strip and access to the test strips. So that if the individual is not yet at a place where they're stopping their chemical use, they're able to test those substances for the presence of Fentanyl. And it can save lives. I just wanted to make sure that people were aware that that—that's out there.

0:13:17 William Moyers
Yeah. Yeah. Kerry, who should be trained in recognizing and responding to the threat of Fentanyl in communities? Is it just doctors, is it just clinicians, or are there others who need this training?

0:13:36 Dr. Kerry Hettinger
Well it's easy, it's one word: it's everyone. Everyone! [chuckles] But I'll expand on that a little bit, yeah. So basically the rule of thumb is that anyone that potentially could be a witness to an overdose should be trained in recognizing the signs and symptoms and in the response. And given that we have this year once again, now hit another record of overdose deaths, last year was the record in U.S. history, and now this year, we've surpassed last year. So I think that that really, you know, kind of enlightens us in terms of all of us should be prepared to respond and the thing is you can do some of these trainings online as well and they will mail you the Naloxone prescription. Different states have different rules on their prescriptions on Naloxone. But there are online agencies, Harm Reduction Coalition being one of them. You can do a quick online training that takes 15 or 20 minutes. And then they'll mail you the Naloxone. But certainly if someone in your family is someone suffering from a substance use disorder, or if it's just very prevalent in your community, all healthcare professionals most certainly. [nods]

0:14:48 William Moyers
Dr. Ngo, I know you're the leader of our research at Hazelden Betty Ford, but I want you to put that Psychologist's hat on for a second. [Dr. Ngo laughs] And answer this for me: Why is it that with the dangers of Fentanyl and the toll it's taking in this country as Kerry was just talking about, why is it that that fear alone is not enough to get somebody to stop using or to make sure that what they're using doesn't have Fentanyl in it? What is that about?

0:15:16 Dr. Quyen Ngo
That's such a great question. And I think it really gets at the way we talk about addiction and alcohol and drug use, Fentanyl use, in our country. Is really you know we think of it as oftentimes still a moral failing. Like if you would just stop. If you could just—you know, you know it's bad for you, you know, so just stop. And that really ignores the impact on the brain that drugs have. And the impact of previous traumas. And so if it was just a matter of will, right, our country would probably be full of really healthy, you know, like strong, exercising, superhumans, right? [Everyone chuckles] If it was just about willpower, right? We would not have that extra slice of pizza or we would put down that donut. It's not that easy, right? It is a combination of habits that form and so, you know, our muscles even learn routine and habit, our brain learns that. And so we really have to understand that the only way we're going to address this, the only way we're going to really help with this Fentanyl epidemic, and with addition overall, is with good treatment, science-based data-driven treatment, that has underneath it a lot of compassion and understanding for the impact—

0:16:47 William Moyers
Hmm.

0:16:48 Dr. Quyen Ngo
—That alcohol and drugs has on our bodies and our brains.

0:16:51 William Moyers
Hmm. Mmm-hmm. Dr. DeRoo, how is—what do you see in terms of the future of addiction treatment as it relates to highly deadly drugs like Fentanyl?

0:17:02 Dr. Alta DeRoo
So, I'm hoping, and what we're seeing in the innovations part that we employ with Hazelden Betty Ford, is new ways to treat opioid use disorder and withdrawals. So not only will we be using opioid agonists like Buprenorphine-Naloxone—

0:17:18 William Moyers
Mmm-hmm.

0:17:18 Dr. Alta DeRoo
—But also patient-wearing devices, apps that have been you know there's data to show that some apps work, and some other FDA-approved devices. Other modalities so that our patients have options. Instead of just going to one tool. So I see that as the future of treatment for opioid use disorder.

0:17:35 William Moyers
What about, I know I'll put you on the spot here 'cause I didn't tell you I was gonna ask you this. [Everyone laughs] But you are the Chief Medical Officer at Hazelden Betty Ford, so here we go. What about recovery management on the back end? How do you think the application of Twelve Step, abstinence-based, with medication, tools will evolve to support people after they have treatment and are needing to stay abstinent from this?

0:18:03 Dr. Alta DeRoo
So I think there's gonna have to be—and we are looking into this—more higher touch opportunities.

0:18:08 William Moyers
Ah!

0:18:08 Dr. Alta DeRoo
More opportunities to engage that patient once they've left our residential treatment.

0:18:12 William Moyers
Mmm-hmm.

0:18:13 Dr. Alta DeRoo
Whether that be IOP later on, more engagement with counselors, virtual opportunities, applications that they can use with their personal devices. So more of an opportunity to stay engaged with that patient after we help them with the skills that they need to learn—

0:18:29 William Moyers
Mmm-hmm.

0:18:29 Dr. Alta DeRoo
—To treat their substance use disorder. More of this engagement and wrap-around care on the back end.

0:18:35 William Moyers
So do I hear you saying that recovery from Fentanyl dependence or opioid dependence in general is possible?

0:18:42 Dr. Alta DeRoo
Oh yeah! Oh absolutely. Absolutely. Lots of success stories out there. [nods]

0:18:46 William Moyers
And what about the training of doctors and other healthcare professionals, Dr. Delisi? We know that they're on the frontlines, whether they're in the Emergency Room or pediatric center, what role does training of doctors have?

0:18:57 Dr. Stephen Delisi
Yeah absolutely. Training of docs and across the healthcare system is critically important. We've made strides over the past decade, we have seen an increase in the training on substance use disorders, opioids, alcohol, in our health professionals. And it's having an impact. [Dr. Ngo nods in agreement] We see the impact that we've had. And we're gonna continue to double down on training and education. Medical centers are increasing their curriculum on addiction and that's really important. The other thing that I would say in your question about recovery is the exciting move in the field with peer support specialists. And that's where there's training, but for peer support specialists to get the training that they need to have more impact with patients, but then also the healthcare professionals on how to integrate with and work with peer support specialists.

0:20:01 William Moyers
Mmm-hmm.

0:20:01 Dr. Stephen Delisi
So what we're seeing, William, is a blending of the treatment providers and the communities of recovery where people live, bringing them together. And I think that's one of the most exciting movements in the field today.

0:20:15 William Moyers
So—go ahead. [motions to Dr. DeRoo]

0:20:15 Dr. Alta DeRoo
Yeah, definitely Steve, you know, I would agree with that. The ongoing care. That the treatment doesn't just stop with the three weeks.

0:20:21 Dr. Stephen Delisi
Yes.

0:20:22 William Moyers
Yes.

0:20:22 Dr. Alta DeRoo
And one thing I would also augment with the medical students is the SIMS program. How we're actually bringing them into training.

0:20:30 Dr. Quyen Ngo
Mmm-hmm. [nods]

0:20:30 Dr. Alta DeRoo
And we're reaching down into the medical schools and inviting them in—

0:20:33 William Moyers
Mmm-hmm.

0:20:33 Dr. Alta DeRoo
—For a look at what we do, so that they can get acclimated and introduced to addition medicine.

0:20:36 Dr. Quyen Ngo
Yeah.

0:20:38 William Moyers
We've covered a lot of territory today, and Kerry we started with you so we're gonna end with you in the 35 seconds that we have left. Just if there was a magic wand that you could wave, down in the trenches, or at the community level, as it relates to addressing Fentanyl and even addiction in general, what would it be?

0:20:56 Dr. Kerry Hettinger
If there was a magic wand, I would wanna speed up the research. Because we have so much exciting research going on that's looking really deep into the disease of addiction. For a long time we really only kind of knew the superficial aspect of the disease, and now we're going deep into the brain and we're discovering the root causes, and we're really facilitating this research that's actually gonna be treating the root causes. So if I had a magic wand, I would speed that up so we can get this information out there. We also have vaccines in the works as well that will help opioid use disorder and methamphetamine use disorder. So, get that faster. [chuckles]

0:21:40 William Moyers
All right. Good job. [The group chuckles] And we'll bring the four of you back a year from now when we'll see how that magic wand has actually applied to what we do at Hazelden Betty Ford and add 'em to the communities as well. We're out of time but I wanna thank Kerry Hettinger and Dr. Delisi, Dr. Quyen Ngo, and Dr. DeRoo for joining us. And thanks to all of you for tuning into this important conversation about the opioid Fentanyl. We hope you'll tune in again to learn more about substance use disorders, treatment, and recovery issues. We'll see ya again.