Poverty, obesity, maternal health among local health concerns; explaining a widespread virus; reversing drug overdoses: Upstate Medical University's HealthLink on Air for Sunday, April 9, 2023
Onondaga County Health Commissioner Katie Anderson, MD, PhD, shares the top concerns from the Community Health Assessment during this, National Public Health Week. Microbiologist and immunologist Gary Chan, PhD, explains who is threatened by the cytomegalovirus. Toxicologist Ross Sullivan, MD, tells how naloxone can reverse an opioid overdose.
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," it's National Public Health Week, and the commissioner of health goes over the most pressing public health issues facing Onondaga County.
Katie Anderson, MD, PhD: ... The poverty rate amongst children in Syracuse is particularly significant, with one in two children of those under 18 living in poverty. ...
Host Amber Smith: We learn about cytomegalovirus research.
Gary Chan, PhD: ... In people who don't have strong immune systems, this virus can cause a lot of disease. ...
Host Amber Smith: And an emergency physician explains how to use Narcan to reverse a drug overdose.
Ross Sullivan, MD: ... 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. ...
Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news.
This is Upstate Medical University's "Healthlink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.
On this week's show, we'll explore cytomegalovirus and hear about research taking place at Upstate to treat this prevalent virus. Then we'll learn how Narcan can reverse an opioid overdose. But first, Onondaga County Health Commissioner Katie Anderson shares the annual Community Health Assessment during National Public Health Week.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
Rates of obesity and drug use and maternal health are identified as top local health issues in the most recent Community Health Assessment and Improvement Plan put together by the Onondaga County Health Department.
Here to talk about that assessment and plan is Dr. Katie Anderson. She's the commissioner of health for Onondaga County, and she remains an associate professor of microbiology and immunology, and medicine, at Upstate.
Welcome back to "HealthLink on Air," Dr. Anderson.
Katie Anderson, MD, PhD: Thanks for having me.
Host Amber Smith: Your term as health commissioner began in November, so most of this assessment was probably finished before you arrived.
Did anything in the report surprise you?
Katie Anderson, MD, PhD: Well, first, I encourage everyone who's listening to review the Community Health Assessment report. It's available on our website for the Onondaga County Health Department (http://www.ongov.net/health/documents/OnondagaCountyCHA-CHIP.pdf), and it's really an incredible resource, and it summarizes how our community's doing with respect to an array of health metrics, so there's lots of data.
And then it also went out into the community and assessed subjective perspectives on how our community thinks we're doing and what they're concerned about, and then, finally, reviews some of our assets in terms of environment and resources.
So for me, this was my first opportunity to review the Community Health Assessment as health commissioner. And the thing that struck me most wasn't necessarily a surprise, but it was really impactful and sobering, and that was that as we look through the report, and for just about every metric, from gestation to death, we see that the health outcomes for residents of our community who are residents of color, most notably Black residents of Syracuse, that they experience worse health outcomes than white residents of the county.
And this isn't a problem that's limited to Onondaga County. It's a national problem, and it's not a new problem. It's unfortunately longstanding, but it's undeniable, and it should be unacceptable, and it should be a call to action.
Host Amber Smith: And it's throughout the report. The disparities kind of show up in many different ways.
Now, health isn't just the absence of disease, and the report describes five social determinants of health. Can you kind of give us a synopsis of how our community is doing with regard to these five? We'll start with education.
Katie Anderson, MD, PhD: Sure. So this is one area where our county is fortunate to have a lot of resources, actually, in the area of education.
We have a large number and variety of post-secondary educational institutions, including those for advanced degrees as well as community colleges, with over 36,000 students. At the same time, even though we have lots of opportunities for education, we've got significant challenges.
If we look overall across the county, our high school graduation rate is on par with the state. But for economically disadvantaged students, their graduation rates are 20 points lower than non-economically disadvantaged students at 77% versus 95%. So there is lots of room for improvement.
Host Amber Smith: What about economic stability?
Katie Anderson, MD, PhD: This was another concerning statistic that came out of the community health assessment, for me, so looking at census data through 2020, we see that about one in three Syracuse residents lives below the federal poverty level, and that's compared to about 14% of county residents as a whole. So, underscoring these disparities for individuals who live in Syracuse, specifically.
And then, hidden in that statistic about the poverty line, is that there's 27% of households in the county who live just above the federal poverty line, but don't have enough to cover their basic resources to live and continue to struggle.
And then, finally, we see that the poverty rate amongst children in Syracuse is particularly significant, with one in two children of those under 18 living in poverty.
So these are significant problems, and they impact wide aspects of health, including access to fresh, healthy foods, opportunities to engage in physical activity, access to education and employment, and all sorts of other metrics that compound in an individual's health.
Host Amber Smith: What is the social and community context that's listed?
Katie Anderson, MD, PhD: So this is a really important one as well, and this is one of the more indirect ways that an individual's life experience can impact their health. But we know that strong relationships with others, family members, a strong community, can help protect individuals against mental, emotional, physical health impacts.
And one metric that's mentioned in the report is trauma and adverse childhood experiences. And that sounds like somewhat of an abstract concept, but these adverse childhood experiences are traumatic events that occur in childhood and can include violence, abuse, growing up in a family with mental health or substance abuse problems, and the stress from this experienced in childhood can change brain development and impact how the body responds to future stress.
So what you experience as a child impacts your future health. And this in turn impacts things like alcohol, substance abuse in adults, chronic diseases, suicide attempts, mental health. And concerningly, the report lays out that about 40% of Onondaga County adults report they've experienced two or more adverse childhood experiences.
So there's significant trauma for many of our community members.
Host Amber Smith: You know, as we talk about these social determinants of health, it's occurring to me: A lot of this stuff is out of our control, it sounds like, where you're born and how you're raised.
Katie Anderson, MD, PhD: That's where it can get really difficult to wrap your head around "How do we tackle these problems?" Because it's all so interwoven and complex.
But at the same time, I feel like the directive is clear as we look at these data. So from preconception to even gestation, some residents of our county are set up to be disadvantaged and to have adverse health outcomes, and that to me is a clear signal that we need to start working on this, and we have some clear direction for where we need to start working.
Host Amber Smith: Now, what about neighborhoods and built environments? That's listed in there as well.
Katie Anderson, MD, PhD: So this is another area where our county has a lot of things going for it in terms of the natural environment, parks, green spaces, we're increasing bike lanes and sidewalks and things like that. And then we also have some plans that will hopefully improve our built environment in Onondaga County, including some urban renovation efforts.
But there's also, again, some significant challenges in Syracuse. So for example, 90% of our homes in the city were built in 1989 or earlier, and one of the main problems with that is that that places them at higher risk for still having lead paint, for rodent infestations, for mold. And 60% of our homes in Syracuse are also rental units, which can decrease the likelihood that an individual can have ownership and properly maintain those properties.
Host Amber Smith: Now, the last social determinant of health is listed as health care access and quality.
Katie Anderson, MD, PhD: This is another area where our county is doing quite well in some ways and has a lot of room for improvement.
Fortunately, 98% of kids in our county have health insurance and a similarly high percentage of adults.
We have lots of medical resources in our county, with four health systems, a multitude of private practices and specialty services, but, and laid out in the health assessment, despite this apparent abundance of medical resources, there are issues with access and delays. So one in two adults who answered the survey reported long wait times to get appointments. And then, in our county, similar to the rest of the country, we're challenged by medical staffing levels and availability of primary care and other appointments.
Host Amber Smith: The assessment points out that 23% of county residents die before reaching the age of 65, but the premature death rate is much higher for black residents at 48% and Hispanic residents at 41%. What are the reasons for the disparities?
Katie Anderson, MD, PhD: So this is a really troubling statistic, and I think it reflects the cumulative impact of many factors and disparities that are experienced over the course of a lifetime by some residents of our county from the time that they are gestating, or in the womb, to the time that they die.
So we know that residents of color in our county are more likely to experience preterm birth, so, to be born before a due date, be born early and to have higher rates of infant mortality. They're more likely to experience childhood obesity, and they're more likely to experience violence and other factors that drive childhood trauma and to impact mental health.
Lastly, they're also more likely, this is just another metric of many, to experience higher mortality rates related to cancer. This is also in the report.
So this twofold higher rate of early mortality for residents of color in our community is absolutely terrible. But it's also important to underscore that this is not an innate difference.
Everybody should be likely to experience the same long, healthy life. These disparities underscore the critical need for improved health equity in our region.
Host Amber Smith: So the disparities at the end of life. There's also disparities at the beginning, or before birth, with racial and ethnic disparities in maternal and infant health. The preterm birth rate among Black moms is 11%, among Hispanic moms it's 12%, compared with just 8% among white mothers. Are the reasons for this the same as the reasons for the death rate at the end of life?
Katie Anderson, MD, PhD: They're likely similar and somewhat related to the concerning differences in mortality rates.
The differences in preterm birth rates across residents of color versus white residents of Onondaga County are possibly due to things like higher rates of teenage pregnancy, as well as access to quality prenatal care.
And, terribly, these same disparities are also likely reflected in the higher rates of infant mortality that are observed among residents of color in Onondaga County.
Host Amber Smith: Should these numbers be similar among the races? Should it all be equal?
Katie Anderson, MD, PhD: That's an important question, and I would say these numbers should be similar among the races or equally optimized, across residents of different colors. There's likely, and it's important to say, there's likely room for improvement across the board, but there are no inherently biological reasons driving these racial disparities. They derive from a combination of social, economic and features of our system that cumulatively come together to impact the potential for some of our residents to achieve their maximum health.
Host Amber Smith: So what is health equity? And do you think it's achievable?
Katie Anderson, MD, PhD: It's maybe most helpful to contrast the term "health equity" with "equality," and equality means that we go about providing the same resources, the same approach to different groups and to different members of our community. It doesn't take too much thought to recognize that while this is somewhat easier and more straightforward, things don't work the same for everybody.
Health equity is a more complex but more optimal state, where everybody has a fair and just opportunity to attain their highest health. But it's harder. It means that we need to consider social determinants of health. We need to talk about and recognize disparities, and it's not comfortable always. We need to acknowledge and address things like racism as a threat to public health.
So it's not easy, but it has to be our primary goal.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith.
I'm talking with Dr. Katie Anderson. She's the Onondaga County health commissioner.
Now, the report says the county's rate of preventable hospitalizations is 144 per 10,000, and that's higher than the state, excluding New York City, which is 120 per 10,000.
What are preventable hospitalizations, and why do we have so many more of them?
Katie Anderson, MD, PhD: The term "preventable hospitalizations" can cover a wide variety of clinical conditions, but maybe the most relevant ones for this discussion and for our county are related to issues of health care access, and these would be conditions that represent worsenings of chronic medical conditions that typically and should be managed well outside of the hospital. So this could include asthma, heart failure, high blood pressure, conditions which optimally would be managed by an individual and their primary care doctor.
So my guess is, and we need to look into this further, that our higher numbers reflect issues with access to preventive care and primary care and also wait times for appointments.
But this is something we need to delve into further.
Host Amber Smith: Now, obesity is also addressed, with 34% of public school kids and 60% of adults in Onondaga County being overweight or obese. What are the public health implications of this?
Katie Anderson, MD, PhD: I think that this is really important, again, thinking about how early health can impact later health, because childhood obesity is tied to higher rates of diabetes, heart disease, other serious chronic medical conditions, and it's a real cause for concern, and there are disparities in rates of obesity as well.
Our high rates of obesity are likely tied to economic and environmental determinants of health, so things like: Can individuals access healthy food, fresh fruits and vegetables, both in terms of the cost as well as transportation and thinking about food deserts (areas where it is difficult to buy affordable fresh food) as well as healthy spaces for physical activity.
We already have programs in place, both the county and many people out in the community, to increase physical activity and nutrition in schools, but these need to continue to be prioritized.
Host Amber Smith: I know this report focuses on Onondaga County. Do you have any idea, does it apply, do we see the same sorts of things, do you think, in the counties bordering Onondaga?
They're more rural, so I know there'll be some variants there, but do you suspect that obesity might be an issue in our adjacent counties as well?
Katie Anderson, MD, PhD: I think that it likely is. I think that obesity and issues with access to proper nutrition are things that go along with being economically disadvantaged, which certainly rural communities as well as city communities can experience, and I'm guessing that's an issue everywhere.
Host Amber Smith: The suicide rate in Onondaga County is 11 per 100,000 population, which compares with eight per 100,000 population for the rest of the state, so that seems pretty significantly higher. What are the reasons that the suicide rates might be higher here?
Katie Anderson, MD, PhD: It's difficult to pin down exactly why our suicide rates are higher than other areas or higher in some groups.
But it could be driven by things like higher rates of substance use, financial issues, mental health, lack of community supports or social supports. And easy access to lethal means, like guns or drugs, can place some groups at higher risk for suicide.
Host Amber Smith: Are there things that public health can do to try to reverse this trend?
Katie Anderson, MD, PhD: Our health department is maintaining a high focus on trying to better understand the drivers of the suicide rate in our area and to address it. So some of our programs, again, in collaboration with folks in the community, are to promote resilience training in schools, to try to address social determinants of health through a wide variety of our programs, and then we also complete a suicide fatality case review of everyone who dies by suicide in our county so that we can start to identify trends and themes and try to find ways to act.
Host Amber Smith: Now, in looking at substance abuse, the report notes that emergency department visits for opioid overdoses is 59 per 100,000 population compared with 55 per 100,000 population for the rest of the state.
What are your thoughts on those numbers?
Katie Anderson, MD, PhD: First, and again, I refer folks back to look at the Community Health Assessment, because this is one figure that is very dramatic, in terms of looking at the number of, in this case, opioid-related fatalities from 2012 to 2021, and the dramatic rise.
So substance use has been on the rise in our area, as have overdoses, and this largely relates to an influx of fentanyl. But the opioid overdose, emergency department visit data, is likely driven by two things. One, a true and high level of substance use and overdose in our area. But also, and this is maybe a little bit counterintuitive, we have been, and others have been, really trying to get naloxone, which is a lifesaving drug reversal, that can be administered to individuals who are overdosing. And it's possible that as Narcan (a commercial brand of naloxone) -- there's thousands and thousands of doses in our community -- actually has a beneficial effect, more people may survive to get to the emergency department.
Host Amber Smith: Let me ask you about your assessment for how the pandemic affected our community. We've just passed the third-year anniversary. Are there any public health lessons that were learned in the past three years?
Katie Anderson, MD, PhD: I think there have to be. It's amazing to think that it was three years. So when I reflect on the pandemic now, especially in my new role with the health department, my perception and my experience was that our county and our community really rose to the challenge of the pandemic admirably.
And it brought groups together to think creatively and collaborate and respond quickly across sectors, community-based organizations, academia and education, clinical groups, in the county, and I hope, and I intend, that we continue to strengthen these partnerships and we continue to collaborate and now to address some of these larger, I don't want to say day-to-day because it shouldn't be day-to-day, but the health assessment really underscores the fact that we need to continue to work together, and we also need to be continuing to prepare for the next health emergency, because there will be others.
Host Amber Smith: Well, Dr. Anderson, I thank you very much for making time for this interview.
Katie Anderson, MD, PhD: Thank you.
Host Amber Smith: My guest has been Onondaga County Health Commissioner, and Upstate associate professor of microbiology and immunology, and medicine, Dr. Katie Anderson.
I'm Amber Smith for Upstate's "HealthLink on Air."
Who is most vulnerable to human cytomegalovirus -- next on Upstate's "HealthLink on Air."
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
Today, we'll learn from one of Upstate's scientists about the human cytomegalovirus (or CMV). Dr. Gary Chan recently received a substantial federal grant for his work on this virus. Dr. Chan is an associate professor of microbiology and immunology at Upstate.
Welcome to "HealthLink on Air," Dr. Chan.
Gary Chan, PhD: Hi, Amber. How are you?
Host Amber Smith: I'm great, thanks. I'd like to start by having you tell us about human cytomegalovirus. Is it true that up to 80% of the population carries this virus?
Gary Chan, PhD: Yeah. What you can say is it's called a dormant virus or silent virus. Once we're infected, we have it for life, and about 80% of us have it, just depending on different populations and where you live, but on average in the world, about 80% have it.
Host Amber Smith: Is it important to know whether you have it or not, or if it's dormant, does it not cause any trouble?
Gary Chan, PhD: For the most part, it doesn't cause much trouble, but it is important for you to know. It's important for when, if you ever need blood transfusions, transplants and things like that, at that point, the virus, you could say, quote unquote, "wakes up," it can cause a lot of problems.
Host Amber Smith: So how are people infected, or how does the virus spread from person to person?
Gary Chan, PhD: It's really through infected fluids, bodily fluids. The major point of transmission is usually when you're adolescent. So when you're a little kid, you get infected, a lot of the times, (it's) mothers kissing their kids, kids sharing food and all that. That's when most of it is spread.
Host Amber Smith: What does the virus do? I know you said it's dormant, mostly, in the body, but does it do anything while it's in there?
Gary Chan, PhD: Yes and no. For the most part, it stays pretty quiet, but every once in a while, if you're stressed, like any other herpesvirus -- many of you have heard of chickenpox before -- there are stresses that can wake this virus up.
And usually our immune system is pretty good at just stopping this virus from spreading too far.
Host Amber Smith: Do you know, is it one of the viruses that are tested in donor blood, like for the nation's blood supply? Do they test and look for this before they pass it to someone else?
Gary Chan, PhD: Yeah, absolutely. They screen for this virus now, and they have to know, especially for blood transfusions during transplants and things like that, they have to know whether you're CMV positive. In people who don't have strong immune systems, this virus can cause a lot of disease, which is why the NIH (National Institutes of Health) is very interested in this virus.
Host Amber Smith: And you got your grant from the National Institutes of Health, which I'm going to ask you about. But I'm still curious: CMV, cytomegalovirus, does it produce any symptoms? Would a person know that they have it by symptoms?
Gary Chan, PhD: In general, when you first get infected, it doesn't cause much problems.
It can sometimes lead to mononucleosis, or "mono." There's a couple viruses that cause that. CMV is one of the viruses that can cause that, so if you're healthy, that's probably the most extreme you can get. But, that said, with healthy individuals who have a full immune system, it has been associated with a lot of different cancers, and there are a lot of herpesviruses that actually can cause cancers.
And CMV -- I'm not going to say right now it's known whether it causes cancers, but it is definitely associated with a lot of different cancers, and it's an active field of research right now.
Host Amber Smith: How long has science known of this virus's existence?
Gary Chan, PhD: Probably since around the '50s There's three scientists independently, I think it was Margaret Smith and Thomas Weller and W.P. Rowe. They all independently discovered this virus, got together, and we've known probably for about 70 years of the virus. We haven't really been able to study it much, since until really the '80s, when we actually had the tools to be able to study a virus.
Host Amber Smith: Is the potential connection to cancers a newer development?
Gary Chan, PhD: Yeah. There's other herpesviruses that they know do cause cancers. EBV, or Epstein-Barr virus, is one of those herpesviruses. CMV has a lot of the similar traits, and so they always thought that it could cause or lead to viruses. And so there's a lot of people who are actively studying it right now, and they do find a link.
One of the big ones that everyone is studying right now is with glioblastomas (brain tumors). It's been associated with a lot of glioblastomas and breast cancers.
Host Amber Smith: Can CMV be treated?
Gary Chan, PhD: Yeah, there's a few antivirals that are out there. I won't get into the weeds, but it targets a protein, this antivirus target protein that's expressed (produced) by the virus that needs to replicate.
And most of these antivirals will stop the replication of this virus, so it'll never get rid of the virus because the virus lies dormant inside of us. But once it activates during a person who is immunocompromised, you can give these antivirals to prevent the virus from replicating.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith.
I'm talking with Dr. Gary Chan. He's an associate professor of microbiology and immunology at Upstate, where his lab focuses on studying the human cytomegalovirus.
The National Institutes of Allergies and Infectious Diseases recently awarded you more than $3 million to put towards your research.
Can you tell us about the work your lab is doing?
Gary Chan, PhD: The CMV causes a broad array of diseases. Lots of different organs can get affected, and so what my lab is really interested in is studying how this virus is able to spread around the body and how the virus hides from the immune system by laying dormant.
And so half of my lab studies basic biology, trying to understand how this virus is able to spread around the body, how it's able to cause disease and what unique changes that it causes to cells into the body so that we can target it.
The other half of my lab then takes the information that we learn from one half of the lab, the basic biology, and then we try to develop antivirals to target some of those unique changes that the virus makes to the cells, so we're able to target and maybe eliminate some of the infected cells within the body and prevent spread and prevent disease.
Host Amber Smith: At this point, and I know it's early, but do you know, does this virus behave like another virus?
Gary Chan, PhD: There's a whole bunch of herpesviruses out there, right? And it behaves similar to them. It has a lytic -- active -- infection, where it's replicating. It has a silent stage. All herpesviruses do that, so it's very similar in that way. In terms of how it spreads around the body, it can be a little different. It uses a specific cell type, they're called monocytes, they're a type of white blood cell, and it uses them to basically piggyback off of monocytes to spread around the body. Some of the other herpesviruses target different types of cells, but the basic principle of it being awake and asleep is similar among all the herpesviruses.
Host Amber Smith: Are you planning, or do you hope to come up with, a more effective treatment for CMV through some of this research?
Gary Chan, PhD: Yeah, that's the ultimate goal. Right now some of the problems with the current antivirals is they have a lot of severe side effects, and they target really a protein that's expressed by the virus. And because of that, it can develop resistance to these antivirals.
So my lab is taking a slightly different approach. We're trying to target cellular proteins, so proteins within the cell that the virus uses to replicate. And by targeting the cellular proteins, it's unlikely that these cellular proteins are able to mutate. And so if you target cellular protein, you can prevent replication.
It's unlikely that you'll develop resistant strains.
And on top of that, what we try to do is try to identify proteins that are really only activated within an infected cell, to limit the side effects.
A lot of types of treatments, if you target just a general protein, it can lead to lots of side effects if it's needed for just normal function. So we're trying to identify proteins that are only within a stressed cell, like a virally infected cell.
Host Amber Smith: And so these treatments really would be aimed to help someone who's immune compromised.
The general public doesn't necessarily need treatment day-to-day for this.
Gary Chan, PhD: Yeah, correct.
Host Amber Smith: But if someone suddenly developed kidney disease and was in need of a transplant ...
Gary Chan, PhD: Uh-huh ...
Host Amber Smith: ... they would perhaps find themselves with a compromised immune system, and this will be very important, it sounds like.
Gary Chan, PhD: All transplants, you're screened for CMV, and if the donor or the recipient is CMV positive, you're automatically put on preemptive, or prophylactic, antivirals to prevent replication of virus. So this will work in a very similar way. We can predict high-risk patients, and in those high-risk patients, we can give these antivirals early so that when the transplant happens, it prevents replication of the virus right from the beginning.
Host Amber Smith: Are you and the rest of the scientists in your lab concerned or worried about catching CMV through your work?
Gary Chan, PhD: There's always a little bit of risk involved, but the viruses we generally work with are lab-adapted, so they've been out of a human body for so long that it's unlikely that we can probably get infected by these strains of viruses.
They've changed probably enough, once we've pulled them out of the body and isolated them. And you grow them in tissue culture. They lose a lot of these proteins that are needed to infect a human being. So for the most part, we're safe unless we take clinical samples. In that scenario, then there is a risk, but we are pretty safe. We've tested all of us, and everyone in our lab is CMV positive, so we already have immunity against it.
Host Amber Smith: Can you talk about how humans can coexist in a world with potentially dangerous viruses like CMV, cytomegalovirus, and also, SARS-CoV-2 (COVID), which we're dealing with globally for three years and ongoing? How do we coexist?
Gary Chan, PhD: It's interesting that they're two very different viruses. With CMV, you would argue that we are coexisting because 80% of us have it. It doesn't cause a lot of disease.
This virus was actually, honestly, was probably here before we were here. So the virus didn't learn to coexist with us, we evolved to coexist with this virus, because it was already here. And we've learned to live with this virus for a very long time, and it really doesn't cause much disease, or a lot of disease, unless you're immunocompromised. With SARS-CoV-2, it's very different. It has been learning to live with us, right? And so the virus came, right? We were here before it came, and it caused a lot of disease. Over time, the virus will cause less disease, and we'll eventually learn to live with that virus as well.
But in the end, I think, with a lot of these viruses, whether it's SARS-CoV-2 or whether it's CMV, which are really endemic at this point throughout the world, we're just going to have to learn to live with it and develop some antivirals and more take an approach of protecting the vulnerable people versus trying to eliminate the virus completely, which I'm not sure if that's possible at this point with either virus.
Host Amber Smith: I was going to ask that. Could you, even if you set out to, eliminate CMV? That wouldn't really be possible, it doesn't sound like.
Gary Chan, PhD: Yeah, it would be really difficult because it's in most of us already. Maybe if you had developed a vaccine, and you give it to all kids and over a long period of time, but that would be a massive undertaking.
And currently there is no vaccine for CMV. It's one of the largest human viruses out there. It's really complicated, and so to develop a vaccine would be the first step, but even then, most people, especially in this day and age, aren't going to just take a vaccine if they don't feel unwell.
So it's more protecting the people who are vulnerable is the approach we need to take right now.
Host Amber Smith: And so your lab is doing that. If you're able to come up with a more effective treatment, it doesn't eliminate the virus, but it controls it.
Gary Chan, PhD: Correct. Right. And in the vulnerable population, particularly in transplant patients or any type of immunocompromised individual.
Host Amber Smith: Well thank you so much for making time for this interview, Dr. Chan.
Gary Chan, PhD: No problem. Thank you for having me.
Host Amber Smith: My guest has been Upstate microbiology and immunology associate professor Dr. Gary Chan. I'm Amber Smith for Upstate's "HealthLink on Air."
Next on Upstate's "HealthLink on Air," how to reverse an opioid overdose.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
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 "HealthLink on Air," Dr. Sullivan.
Ross Sullivan, MD: Hi, good morning. Nice to be here.
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?
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.
Host Amber Smith: It's been available in New York state at pharmacies without a prescription. Has that been helpful?
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 OOPP, which is an 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 (Emergency Medical Services) departments, and fire departments, so on and so forth. So it's in our community in a lot of various ways.
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?
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.
Host Amber Smith: Well, let me have you walk us through how Narcan works. It's available as an injection in the hospital, right?
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.
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?
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.
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?
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.
Host Amber Smith: Does Narcan lose its effectiveness if it's used repeatedly in the same person?
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.
Host Amber Smith: You're listening to Upstate's "HealthLink on Air" with your host, Amber Smith. My guest is 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 911 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?
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 911, 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 (the street drug) xylazine.
Host Amber Smith: Does the typical person wake up coherent and aware, or are they groggy and confused, or are they violent?
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.
Host Amber Smith: If someone is revived with naloxone or Narcan, do they still need to go to the hospital?
Ross Sullivan, MD: We tell people to call 911 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 911, 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 911, 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 911. But oftentimes people give naloxone or get it and don't come in.
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?
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.
Host Amber Smith: How much of an impact do you think the Bridge Clinic is having on the opioid epidemic in Central New York?
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.
Host Amber Smith: Well, Dr. Sullivan, thank you so much for making time for this interview.
Ross Sullivan, MD: Yeah, it's been my pleasure, as always. I love speaking with you.
Host Amber Smith: My guest has been emergency physician Dr. Ross Sullivan. He's director of medical toxicology at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
Here's some expert advice from Dr. Zachary Vredenburgh from Upstate Medical University.
How can we keep our knees healthy?
Zachary Vredenburgh, MD: I think the best things we can do to preserve our knee health over a long period of time is keeping your weight healthy (and) watching what you're doing activity-wise in terms of anything that's going to have a high risk of having a major injury.
Now, that doesn't mean don't go out and play sports or be active, but some of the really, really high-impact things that you can do that put your knees at risk, I'd try to avoid that.
And I think those are probably the two biggest things. There's no really special medications or foods, or anything like that, that I'm aware of, that would help that.
Host Amber Smith: You've been listening to Dr. Zachary Vredenburgh from Upstate Medical University.
And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.
Deirdre Neilen, PhD: Jan Hanson's first chapbook, "I'll Never Play the Hammered Dulcimer," was published in 2019 by Finishing Line Press. Her poem "The Non-Verbal Pain Scale" is an excellent reminder to health care professionals to please take time when asking patients to describe their pain.
"The Non-Verbal Pain Scale"
Inside it's killing me.
The throbbing in my neck
goes all the way down my left arm
to the tip of my ring finger.
I have to prove my pain to them -- the nurse
and the doctor who breeze into my curtained space.
They can't see it; only I can feel it
I writhe and sigh and groan and move around
stand up sit down wince grimace
this is what pain looks like
but I can't say how it feels,
just a nine or a ten or a hundred
the round-circle faces on the wall chart
smiling all the way to the one with
mouth turned down and eyebrows slanted
how to tell if your patient is in pain
look at my face you will see
they poke at my pain
does it hurt here at all does it hurt
here here here yes yes yes
just make it stop, drugs are good
but if I smile they won't
believe my pain
Host Amber Smith: This has been Upstate's "Healthlink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "Healthlink on Air" -- how physical therapy can help alleviate low back pain. If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.
Upstate's "HealthLink on Air" is produced by Jim Howe with sound engineering by Bill Broeckel.
This is your host, Amber Smith, thanking you for listening.