Toxicologist explains how it helps combat opioid epidemic

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Drug overdose is a serious public health concern, and today we'll talk about what you can do to help someone that you suspect has overdosed. My guest is Dr. Ross Sullivan. He's an assistant professor of emergency medicine at Upstate and Director of medical toxicology. Welcome back to "The Informed Patient," Dr. Sullivan.

[00:00:32] Ross Sullivan, MD: Hi, good morning. Nice to be here.

[00:00:34] Host Amber Smith: An FDA panel recently recommended approval for naloxone, or Narcan, to be available over the counter as a nasal spray. This is a drug that was first approved in 1971 and used mostly by first responders and hospitals to resuscitate people who may otherwise have died from an opioid overdose. Do you think it's a good idea to make it available to anyone to purchase as a nasal spray?

[00:00:58] Ross Sullivan, MD: Well, yes. In general, it's a great idea for someone to be able to go into a pharmacy and get themselves naloxone or Narcan nasal spray, easily, right over the counter, right? I think it makes a lot of sense. But there's two sides to everything and we want to make sure. I mean, one of the things is -- and I don't know the answer to this question is -- but how much will it cost? You know, just because things are over the counter doesn't necessarily mean they'll be cheap. I don't know the answer to that question. I'm hoping that it will be affordable. That's one of our biggest things.

But overall it's a great idea. We want to get it into everyone's hands, something like Tylenol or Motrin, or even sometimes people get allergy sprays for their nose that maybe at one time were by prescription. So, we want to be able to have that in as many homes as possible because people who overdose are not just what some people might think about in their head, right? It's people in every walk of life, in every socioeconomic platform. These people are overdosing, or overusing, whether it's heroin or pain pills. So getting naloxone or Narcan into these homes is very important.

[00:02:05] Host Amber Smith: It's been available in New York State at pharmacies without a prescription. Has that been helpful?

[00:02:11] Ross Sullivan, MD: Yeah, I think that it has been. It's been a lot of different components adding together in New York State. I mean, they've been able to offer at pharmacies without a prescription. This is what was called like a non-patient specific prescription. So they're for any person that goes to a pharmacy, and most insurances pay for it or pay most of the cost of it.

But it's an extra step. You go to the pharmacy. You'd have to ask for it, and some people aren't going to do that or don't know or don't want to. They've also been available by prescription in New York State. So, medical providers can also write a prescription for it and have insurance pay for it. And then another option is something that we call O O P P, which is a Opioid Overdose Prevention Program, of which there's many throughout our county. We run one here at Upstate for our emergency department, in our toxicology program that I run.

And, those also have been very important to getting medications in the hands of people other ways. And they go to police departments this way, and EMS departments, and fire departments, so on and so forth. So it's in our community in a lot of various ways.

[00:03:15] Host Amber Smith: Is anyone keeping track, or is there any way to track, how often or how many people have been saved by Narcan use in the field?

[00:03:24] Ross Sullivan, MD: Yes and no. There is some local EMS (Emergency Medical Services) data that our county keeps that shows a number of naloxone administrations by reportable agencies like, like EMS and the police. So we do have some of those. And every year it's, I believe it's over 700 administrations, which is a lot. What's unaccounted for, and there's no way really to account for all the people giving it to other people that are not part of any type of reportable agency. So those are really difficult; you can't really track those. But, it's probably easy to say that in our county, well over a thousand times a year, thousands probably, it's being given by people in the community.

[00:04:07] Host Amber Smith: Well, let me have you walk us through how Narcan works. It's available as an injection in the hospital, right?

[00:04:14] Ross Sullivan, MD: Yes, it's available as an injection in the hospital. And that's, historically how it was used as you mentioned earlier, by medical providers or EMS. It was given as something that was given intravenously or maybe even intramuscularly, so in a vein or in the muscle. But there's some other delivery systems in the body, and one of them is in your nose because you can aerosolize or make thousands or millions of little particles that will go into your nose. And there's a surface area there where it gets absorbed relatively easily.

So, you take it within your nose. And what's nice about that is it's perfect for a medication for lay people or non-medical people to give. It's a nose spray that you really need minimal to no training, right? And you can put it in the nose, pull down on the plunger, push it, and it goes off, right? You don't need any training whatsoever, really. And what it does is, in our body, there's receptors, right? That's just things that medicines or drugs or things bind to in our body. And then there's a response.

We have opioid receptors in our bodies. They're natural in our body. They're mu receptors, they're called, the word mu. (Not that that's so important.) But when you use heroin or fentanyl or pain pills, those medicines or drugs bind to that receptor in our body. They're in our brain, they're in our other parts of our body and our spinal cord and whatnot. Well, when you take heroin or fentanyl, it binds to a certain area in the brain where it stops your breathing. Well, Narcan goes and blocks that or it displaces those drugs because naloxone wants to bind to those receptors harder than heroin or fentanyl does. So naloxone will go to that area in the brain, and it will literally knock off the heroin or fentanyl.

And by doing that, it allows you to breathe again. In some ways it's really simple. In some ways it's really, really amazing and eloquent in some ways, you know, how it works. But it's very effective.

[00:06:05] Host Amber Smith: These opioid receptors in our body, are they the same receptors for prescription drugs as for the street drugs that are opioids?

[00:06:15] Ross Sullivan, MD: Yeah, great question. Absolutely. Same ones. And that's why it's so dangerous. It's not selective. They're the same receptors in your body that a pain pill binds to, that heroin binds to, that fentanyl binds to. They all just do them a little bit differently in terms of how tightly they bind to them, how long they stay on the receptors. And that's why they have different effects on people, because of how the actual medicine or drug interacts with actually that receptor.

Fentanyl's so dangerous because you always hear, oh, it's so much more potent. Well, that's because it binds to that receptor, fentanyl, 50 times stronger, harder than heroin, let's say, does. So that's why it's so deadly, right? Because it's 50 times or more potent on that receptor, so it has that much more of an effect on it.

[00:07:01] Host Amber Smith: What happens to the Narcan if a person gives it to someone, but they're not overdosing on opioids? What does the Narcan do in the body then?

[00:07:10] Ross Sullivan, MD: If you are not on any opioids at all, and let's say you're sedated from something else, nothing will happen to you. You know, it'll have no effect on you whatsoever.

Some people hear about withdrawal. People are scared. You hear this word precipitated withdrawal. That means making someone have an opioid withdrawal really quickly and fast. It happens rarely. So if you give it to somebody who is on an opioid let's say all the time, heroin or fentanyl, it could have them go into withdrawal, right? Because I'm taking all that opioid right off of your receptors right away. But the person will be breathing. So we tell people to not worry about it, you know? Because we want people to be alive, and we can worry about the withdrawal and all those other things afterwards.

[00:07:57] Host Amber Smith: Does Narcan lose its effectiveness if it's used repeatedly in the same person?

[00:08:03] Ross Sullivan, MD: No, we don't really think there's like a tolerance. That's the word we use. You know, "tolerant," meaning that I'm getting used to something and won't work as well unless I need more. So no, we do not believe so at all. We believe that it will work the same in that person. How much drug or fentanyl is in the person's body will have an effect on it. Sometimes people do need a little bit more. Sometimes they need less. But, no, we don't think that it stops working in a person because they've gotten it too much.

[00:08:32] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Dr. Ross Sullivan, an emergency physician and director of medical toxicology at Upstate.

I'd like to ask you to kind of walk us through how a person should approach someone who appears to have overdosed. I know calling 9 1 1 is probably the first thing you want people to do. Should they try to wake the person up before they give them Narcan? Or how would you navigate that?

[00:09:01] Ross Sullivan, MD: Yeah. I think it's very reasonable to just make sure the person's not sedated or sleeping just from actually sleeping. There are a lot of other things that people use, drugs that make people really sleepy, like alcohol, right? Which is still maybe the most abused drug in any area. Yes, it makes sense that if you want to maybe shake the person or gently move them to make sure to see if they're awake.

And if they wake up, they open their eyes, they're breathing, they make sounds still, call 9 1 1, but it would be reasonable for someone who could make some noises and breathing and kind of waking up to not give them Narcan, or naloxone.

Now in a person that really doesn't -- they're really slumped over, or it looks like they're barely breathing. Sometimes they might have pale, blue lips or sometimes they feel a little cold. But if you don't even really know, we still recommend giving it. If it's maybe it is, maybe it's not, then you should probably give it, if you have that much time to think about it.

And really that's what you have to do. You know, you're going to give the dose in the nose. You really should wait about two to three minutes for it to take effect. You might step away from the patient in case they kind of wake up and they kind of flail a little bit like this. And if in two to three minutes they don't wake up, you can give another dose. It's not unreasonable to think someone might need two doses. But almost no one really ever needs more than that. And if they're not waking up, it's most likely something else. And in our case, locally, it could be xylazine.

[00:10:21] Host Amber Smith: Does the typical person wake up coherent and aware, or are they groggy and confused, or are they violent?

[00:10:29] Ross Sullivan, MD: Very rarely do we ever see them violent. I mean, there's some stories and maybe rarely, occasionally, where they wake up violent. And if they do, it's because of this precipitated withdrawal thing where their body is just all of a sudden in a very quick withdrawal state. I mean, most people, it takes time to get there. Can you imagine in 30 seconds to two minutes having full withdrawal, which theoretically may happen very rarely. So it is possible, but very rare. Most people will wake up probably groggy, and then maybe the next several minutes wake up more. Or sometimes they just stay groggy, and very slowly they start waking up. But groggy is good. Full awake is good. All of it is good as long as they're breathing.

[00:11:10] Host Amber Smith: If someone is revived with naloxone or Narcan, do they still need to go to the hospital?

[00:11:16] Ross Sullivan, MD: We tell people to call 9 1 1 and let EMS decide. Surely we know that there's many, many, many naloxone administrations that are given by people who use, who never go to the ER (emergency room.)

And, really that's what we kind of want, right? We don't want to, have people come to the emergency department that don't need to. So that's part of the unintended benefit of a program like this too. When we tell people who are lay people -- in other words, people who are not drug users -- who are giving naloxone, we really do want you to call 9 1 1, because that's not a decision someone should be making. People who are drug users using together, we know that very often, almost always, they're using and giving naloxone and they're not calling 9 1 1, which also makes sense.

Of course we want anyone to come to the hospital that needs to and wants to. We do. But we realize that there's a lot of people that we force into going into the ER too, who don't want to be there. So, for people who are listening to this, who are going to give naloxone to somebody, absolutely call 9 1 1. But oftentimes people give naloxone or get it and don't come in.

[00:12:27] Host Amber Smith: Well, please tell us about the Opioid Bridge Clinic. This is something you started at Upstate. It's something a person would maybe learn about if they were treated for an opioid overdose at Upstate University Hospital, is that right?

[00:12:40] Ross Sullivan, MD: Yes, that's right. We have an addiction program in the hospital and in the emergency department, and what we do is when people are coming to the emergency department or they're in the hospital, we try to find them treatment when they leave. And one of the options is the Opioid Bridge Clinic. And really it's what we call "low threshold" treatment, so we really just require you to just show up, right? We want to give you medications, help you sort out some of the other things that you might need to sort out to help get yourself treatment. And we really just do what we can to help people. It's not just medications, but it's is there a way we help people with insurance and housing and other things, other medical needs they might have to kind of get them on their feet to help them move on.

So the Opioid Bridge Clinic's been maybe in existence now for seven or eight years. It's been great. We tell people there's, you can go to the Upstate webpage and there's the Bridge Clinic. https://www.upstate.edu/emergency/healthcare/bridge-clinic.php And if people are wondering or looking for appointments too, they can feel free to call that number: (315-464-3745.) And we don't just take care of people just from the hospital. We'll take care of others too, if they need help. So the number is on the website, and it's been a great program for the hospital and the community.

[00:13:48] Host Amber Smith: How much of an impact do you think the Bridge Clinic is having on the opioid epidemic in Central New York?

[00:13:54] Ross Sullivan, MD: You know, I think this is a great question. I think that it was very important to push the treatment agenda in our area. And so I mean just being here, it's important.

We know that the Opioid Bridge Clinic -- in a paper that we published several years ago -- people utilize emergency department at a high frequency. We know that if they go to the Bridge Clinic, if they're opioid users, they use the emergency department far less, 40 to 45% less after they go to the Bridge Clinic. So it's one of the few interventions -- it's really hard to measure how well is it working? -- Well, that's the way we have measured it. And that's, it's an astounding finding.

But even in addition to that, what we found was is that in 2015-16, the Opioid Bridge Clinic was, I can safely say, one of the only, or if not the only place locally that was offering low threshold buprenorphine or Suboxone --.low threshold, again, meaning we're giving it to people without having them to jump through a lot of hoops. And it was that original concept. And there was an article in the paper, that pushed all these local other agencies into what's kind of modern addiction treatment now.

And a lot of other things happen too, but we were really the first one locally to do that. And I'm proud to say in the Upstate Emergency Department, and the hospital should be proud too, to say that it really helped push the agenda of treatment for these people, immediate treatment. And that probably will be its long lasting effect in the community was, really the first program to really do that. And it's been a great experience.

[00:15:25] Host Amber Smith: Well, Dr. Sullivan, thank you so much for making time for this interview.

[00:15:29] Ross Sullivan, MD: Yeah, it's been my pleasure, as always. I love speaking with you.

[00:15:32] Host Amber Smith: My guest has been emergency physician, Dr. Ross Sullivan. He's director of medical toxicology at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at Upstate.edu/informed. This is your host, Amber Smith, thanking you for listening.