Psychiatry & Psychotherapy Podcast - The Fentanyl Epidemic

Episode Date: November 14, 2019

Fentanyl is a highly addictive drug which has led to the deaths of countless people including several well known celebrities. Fentanyl is being used to strengthen the potency of other drugs, such as cocaine, which means that people are being exposed to it without their knowledge. In this episode, David Puder, M.D. discusses the history, impact, and statistical analysis pertaining to the dangers of Fentanyl.  By listening to this episode, you can earn 0.75 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast? Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is email to you in seconds.

Welcome back to the podcast. I'm joined with Amir Abu Chow. we are going to be talking about fentanyl and designer drugs today and why this is so, so important for mental health providers, for people, for the general public, to understand that this is a big issue. This is becoming probably the biggest epidemic of deaths of new increased fatalities that we have had in the U.S. since like maybe the last plague hundreds of years ago. And the fatality rate has gone up

from way below, you know, car accidents, you know, how many people per year die of car accidents, now it's above the fatality for car accidents, for accidental deaths. It's above suicide rate, opiate deaths. And fentanyl is one of the leading causes of this. Fentanyl is, it is like morphine or heroin, it's an opiate, it acts on the mu receptors. And so today with Amir, we're going to go through. A little bit of the history. I had Amir to dig into the pharmacology.

We're going to go through how to treat people who are overdosing. We're going to talk about long-term treatment, different options that are out there. And one of the big things we're going to talk about is the three stories of different types of people who are using this. We're going to talk about people who are using it and they don't even know they're using it. We're going to talk about those who seek it out as kind of like the new high. A high so much better than heroin. Like someone who's addicted to heroin, they say that when they get on this, it's like using heroin for the first time. We're going to talk about a bunch of famous people that have died from this.

So we're going to be putting all those pieces together. And so welcome to the podcast. Thank you, Dr. Peter. It's definitely a pleasure to be here and being able to work on the podcast. I really want to get started with the, um, the, three stories of people who are using fentanyl. So the three that we would cover are things like people who are using fentanyl don't know. People who are seeking it out as a new high.

And death of famous people recently that's been happening since 2000s, that more of them are happening since the 2000s. Yeah. So, I mean, this is like a brand new. drug in terms of the amount of people who are using it, it's really escalated in the last 10 years and even in the last five years. And so the people who are using it and don't know that they're using it. We're talking about people who are using cocaine and sometimes the cocaine is laced. So there's been a couple cases of people thinking that they weren't using fentanyl and then they

die of an overdose from fentanyl-lase cocaine. Yeah, it's pretty tragic because with a lot of the increases in drug usage that we see that have been happening in the early 2000s until now, many people who may not be able to have access to some of these drugs try and get them off the street. And what's happening is that a lot of their drugs are being laced with fentanyl to try and give them the same effect. what happens is that like you said drugs like cocaine and also recently there's been weed that has been spiked with fentanyl and there was one study one news article that showed that 70 people in a park were affected with fentanyl-laced weed and in addition there's on the streets when people are going to get people are going to get opioids or things like benzos, those are also being affected by fentanyl as well. Yeah. And, you know, imagine you're getting Street Xanax or Street Clonopin or Street Oxycodone has been, they found that sometimes fentanyl's there. And it's like you're getting this stuff because maybe you ran out early. Maybe you're at a party and people are using it.

and you don't realize like how strong this stuff is. And sometimes I don't think the people who make these pills don't even realize how strong it is. Because literally the amount of fentanyl it takes to overdose is like if you were look at a penny and if you were just to cover the date, you know, 1996, you cover that with a little couple grains of sand and that's like the amount that you would overdose on.

It's a remarkably small amount compared to, anything like the prescription drugs that people are getting off the streets, or prescription drugs that people get off the streets or from their doctor. So it makes it that much more dangerous because before they know it, they've taken a pill and their breathing rate starts to go down and they start to lose consciousness to the point where their friends or people that are around them get worried. And there might not even be enough time for paramedics to respond.

on. Yeah, and we're going to get into the details on why it gets into the system so fast and why the death, why the death occurs so quickly that, you know, people stop breathing. Usually, with heroin, it's like 30 minutes or so. With fentanyl, it can be two minutes. Yeah, two minutes. If you think about it, two minutes is nothing compared to the 30. Paramedics can take maybe even in 10, 15 minutes they can get to your homeboat in two minutes and you stop breathing, there's little to nothing that can be done, which is why we need to address what's going on with fentanyl. Yeah. So the second group of people is the people who are seeking it out as a new high.

And I recently had a patient. I was in an addiction unit, and I asked him about fentanyl. You know, are people using this? Are people looking for it? And he said to me, actually, when people hear that someone died of an overdose, they try to get some of that, you know, whatever that was. They try to get some of it because they know it's going to be a killer high. He actually said killer high.

I think he wasn't meaning to be ironic. And he said what he does to test out how strong it is is he takes a very small puff of it. And then that can help him engage, you know, how strong the full dose would be. But even that seems like really kind of a bad idea. and he knew that there were risks involved. But he said, look, like, when you're used to heroin, and heroin just isn't doing much for you anymore, you know, it just makes sense to go to the next level.

The next level in this case that we're seeing, starting on the East Coast, slowly transitioning to the West Coast, is fentanyl. And like you said, these people are seeking it out as a new high. A lot of personal points of view that are, have been taken from patients, they're admitting to it. They're stating that I actually go and look for fentanyl. And a lot of patients at times are saying if they find out one of their friends has overdosed. Instead of being afraid, they say, hey, where did you get that stuff? I'm going to go look

exactly for that type of thing because that high that they seek out is that much more potent. And like you said, heroin isn't doing the job for them. Yeah, there was one study in particular that showed that 30% of drug users prefer their drugs contain fentanyl. And that's really remarkable because if you think of 30% of drug users, that's no small amount of patients. And due to its potency, and as we get into it, we're going to see how fentanyl is even acquired and the quality control process, we're going to see just how dangerous it can be for some of these people. Yeah. And, you know, once again, if anything we say here is interesting to you, if you want to look into it further, we're going to put up on the website, a blog and in the resource library, a link to all the studies. And you can, you can dive into this as well. It's super interesting. And I think we should pay attention to this. Okay. So let's talk about the famous people who have passed away. Take me down the list. Yeah, the list of people, lately it's been starting in about the early 2000s, but there have been some deaths even earlier.

One of the most notable ones was Mac Miller. He was a famous American rapper. He was struggling with opioid addiction, according to some news reports. But one day he was found unconscious in just last. year in 2018. He passed away at 26 years old. They found in his system opioids, alcohol, and fentanyl. Another rapper that passed away was Lil Pete in 2017. He was found having overdosed on fentanyl and Xanax. 21 years old. 21 years old. This is affecting a lot of people that are younger, especially younger generation. And some of the older generation prints,

who's, you know, famous, famous singer, songwriter, overdose in fentanyl, 2016, 57 years old. Tom Petty, American singer, songwriter, instrumentalist, you know, had a lethal fentanyl overdose, along with Benzos, 2017. He was 66 years old. And the list goes on. Yeah. So a lot of famous people, and a lot of people,

and when I hear stories from parents, you know, who come in, they've had kids that have died. Sometimes it doesn't make sense to them. Like, I don't even know. It's like they didn't even know, you know? And so sometimes I wonder, are people overdosing on this more than we realize? And, you know, it's just truly unfortunate. It is a lot of the people that are overdosing may not be losing their lives to fentanyl,

but because of that overdose, they come back and they might not tell their friends. and they lead to just continuous use of fentanyl. And then one day they might not even, they might not recover from their overdose and they may not wake up. And this leads to what you're saying. Families are shocked. There's a lot of trauma involved for the families involved. And the question is, what can we do?

Yeah. So let's go a little bit into the history. Maybe I'll start. And then I'd like you to go through some of the designer drug history. But really there's three phases. of the opiate epidemic that we're facing. The first phase is the prescription opiates. You know, Purdue created this wonderful long-term opiate drug for cancer.

You know, so it would last in the system all day. And unfortunately, they marketed this successfully for all sorts of aches and pains. there's a huge lawsuit, actually one of the biggest lawsuits of all time, that they lost about this and their sort of false marketing strategies. Initially, they were saying that only like 1% of people got addicted to opiates. It was coming from a letter to the editor in the New England Journal of Medicine. That was a very old letter. And, you know, more recent data says actually people get addicted quite free. frequently. And unfortunately, you know, these sort of long-term preparations, these extremely strong

medications can be easily diverted. The market or the cost on the street is about $1 per milligram. And so, you know, imagine if you're a person and you're taking, you know, 200 milligrams a day, that could be $200 a day. That could be almost more than you would make in a job, right? Or it is more than you would make it a job. And so the potential to sell it on the street is really high. it can be smoked, it can be injected. And amazingly, the DEA allowed for a 400% increase in production from the years between, what were the years? From 2013 to about 2017? Yeah, a 400% increase.

Recently, the DOJ did a long evaluation of the DEA, and one of the critiques was that, that why did you guys allow? such a huge increase in this in this drug and that is the shocking thing going from about 35,000 kilograms a year in 2013 to up to 153,000 kilograms of opioid like substances being produced and the question is why and why would they allow something like that to happen and the question we want to ask is what is or what was the DEA doing at the time? What fell through the cracks? During this time, it's important to point out that fentanyl actually started to increase

at a rate of 8% per year from 1999 to 2013. More remarkably, there was a 71% increase per year from 2013 to 2017. We're talking about legal prescribed fentanyl legally prescribed fentanyl yeah and so you know most of the fentanyl that we're talking about in this episode is created on the black market um in laboratories in china shipped through mexico and canada and um actually it's interesting to read that in china um at first they weren't

really penalizing these companies for producing this and selling it but a long side of that you have the DEA sets how much can be produced by different companies and the percentage has been just going up so fast. Okay, so the second phase is heroin. And so mostly black tar heroin. And there's a really good book, Dreamland, if you want to learn about how this sort of propagated and expanded in the U.S. But basically, there were small towns in, um, Mexico that would kind of become really good at one particular thing. So, for example, it's known that like a small town created popsicles. And another small town like really got, you know, did a really good job doing this.

And then once a town would kind of develop like a really good way of doing this, then they would go throughout all of the Mexican cities and like sell their, you know, things and then come back. And the same sort of thing happened for a small town in Mexico and coming to, to the U.S. and selling heroin. And so what happened was they moved out the middleman and they went direct. So it was like wholesale direct. And it was a delivery system that was through telephone. So you get a telephone, you get a bag dropped off to your home.

And if the police pulled over a person that was delivering, they would have all the baggies in their mouth and they would just swallow them. And it was just one person that was easily replaced. you know, so it became this huge issue of, you know, we have this incredible market. And from the market of people who were already addicted to opiates, prescribed opiates, then some of them slipped through into heroin and using heroin. So this was the second phase, and that was like heroin, and the increase of heroin use in the U.S. And interestingly, if you think about drug cartels, about $100 billion is,

spent on drugs. And about 30 billion of that goes to drug cartels. And that's a huge amount of money that's just being pushed into criminal organizations. And so you have this second wave. And then that kind of, the first wave kind of led to the second wave and the second wave kind of led to the third wave, which is fentanyl and fentanyl derivatives. So in, fentanyl, there's a lot of analogs, things like alpha-methyl fentanyl, China White, which was found inside of China White, which is kind of a form of heroin, which they put additives in. There's tetramethyl fentanyl, fentanyl, which is 10 times more potent than the standard fentanyl. There's car fentanyl, which is 100 times more potent than fentanyl, which is normally used for, you know,

sedating things like elephants. And I read one story about how enough car fentanyl was found on one person in Canada that could have led to the overdose of every Canadian. Like that's how a small amount of this stuff can be so potent and have such a strong effect on so many people. There's other ones like butyterial fentanyl, which is 30 times less potent than fentanyl. other things like U 47,700 or pink or U4. So there's all these different ones And there's probably about 20 or 30 in some articles. I'm just making a rough estimate.

And there'll probably be a lot more that are made in the future. And the problem with these is that they're not coming up in urine drug screens like fentanyl. Fentanyl is not coming up in a urine drug screen. They're super potent. So they're super easy to move around. in an amount that would actually make a lot of money for someone. So imagine that fentanyl is really like very cheap and very easy to transport because of the potency. Right.

When you mention cheap, it's really, it's actually one of the main driving factors of fentanyl. There are some studies that show that buying heroin from many countries can cost, let's assume it costs the dealer, maybe $8,000 to $10,000 a kilogram, you can get per kilogram, which is only $3,000 per kilogram, and it's more potent. So you have that added benefit as a dealer. And what you can do is you can mix it into the drugs you're trying to make and sell it to your, sell it to your customers and give them the same high, if not maybe a better high. And it not only saves you money, it gives customers a better kick, a better high.

but more importantly, it is more dangerous. Much of the fentanyl that's actually coming in to the United States specifically is made, like you said, in China, where it's either shipped to Mexico or it's shipped to Canada and it's just transported through the border. And we're not talking about like one big shipment anymore. We're talking about like tens of thousands of very small shipments. There's stories of like breaking bad, like some guy who gets addicted to, do painkillers and then heroin, and then he finds that he can order fentanyl and he does it for himself, and then he starts selling it. And there's those cases. Like, you can just Google it.

And a lot of the fentanyl that's being ordered now is being done through the dark web. There's various websites that have been shut down, but there's always new ones coming out. You can access through the dark web, like on something called the Tor browser so that it's not tracked and a lot of people kids that are maybe 15, 16 years old can either pay, find a way to buy Bitcoin or use maybe a debit or credit card to actually go online on the dark web and a lot of the stuff can be sent through the mail and if you think about just how many shipments are going out either the USPS or a lot of these postal services don't have it's not only the manpower but legally we can't sit there and search every single package to make sure there's not

a small amount of potent drug being sent through the mail. Yep. And I read on Reddit or something that if it shows up to your house, you don't have to claim that you ordered it. And if you used Tor. So Tor allows no tracking of the IP address. And then there's certain types of Bitcoin that are untraceable as well, like different black market bitcoins.

So it's very, you know, it's very easy to hide that you purchase this. easy to get it to your house. And then if, if someone does say, hey, why did this show up to your house? You can say, like, I don't know. And just, you know, maybe a neighbor ordered it, you know. And actually, yeah, that sometimes happens as well, you know, like they'll order to one of their neighbor's house and then the neighbor, you know, maybe is checked out or isn't checking their mail. And then they'll just go pull it from their mailbox, stuff like that. So one of the interesting studies that I found was in this, the urine drug screens. And they looked at a big study of a million patients who had the urine tested. And they looked at those who were tested, who also

were tested positive for cocaine. And they found that the increase was from like 0.9% to 17.6%. Meaning that there's been this huge jump in the last, I don't know, how many years was this? I forget. This was in the last. This was in the last. last five years? Yeah, five years. So from 2013 to 2018, they tested this and they found that there was initially only about 1% of people who use cocaine and tested positive cocaine had fentanyl in their urine. And then that's jumped up within five years to 17.6%. Which I think shows that a lot of cocaine is being laced with fentanyl. And the same thing happened with methamphetamines in the same time period, it went from 1% to about 8% of people who had a urine

drug screen that was positive for methamphetamines, was also positive for fentanyl. That's pretty remarkable when you think about the percentages of those 1,815% increase with respect to the cocaine and an 800% increase with respect to the methamphetamine. and it really makes you wonder, what are these people experiencing when they start using their cocaine or their methamphetamine? And are they even aware of this? I talk to one of, I've asked pretty much every patient I've come to contact with who uses meth or cocaine. And some will say, you know, I know that there's fentanyl being laced because I'll get itchy or they'll have some withdrawal symptoms. Like they'll have, you know, when they stop using.

Or they'll say something like they've tested. There's these test strips, and they've tested it, and it is fentanyl positive often or something like that. So another interesting report was from this national forensic laboratory information system, which said the reports of fentanyl have steadily increased from 2001 to 2013 with a dramatic increase from 2014 to 2018. Yeah, and going off that, fentanyl appears to slowly be making its way into a lot of our, a lot of the counterfeit medications and drugs that are being sold on the street. I wanted to point out a few, well, one situation when it was actually used in, it was actually used in a hostage situation in Moscow when there was the hostage crisis of many of the Chechen revolution.

actually held this opera theater of 800 people hostage and they actually pumped fentanyl as an airborne substance into it it did get rid of the people who were taking them on the terrorists who were taking them hostage but I believe up to 120 to 130 people were actually killed in the process many of them died before they even got to the hospital showing just how potent it was at the same time, the government, the Russian government, refrained from actually providing details of what was used. Later on, there were some leaks that showed it was fentanyl. Yeah.

And that was, I don't think they expected it to have that effect on specifically the hostages. It was unfortunate. I think they were hoping that they were going to put this in and then go in and reverse them, you know. But we're going to get to. to why people can die very quickly from it. They can. And there was another study that showed that up to 89% of counterfeit oxycontin has some trace amount of fentanyl in it,

which is a substantial amount. Yeah. Some of the street names for fentanyl are dropped dead, flatline, Reaper, lethal injection, specifically with, like, you may ask, like, well, how do counterfeit pills get made? I've heard if there's someone in my town who does these counterfeit Xanax bars. And, you know, what they do is they make a slurry and then they basically have a machine that makes pills. And so it's like whatever they have, right, that's what

they're going to put in the pills. So you may not even know there may be a little bit of benz-o, but there may be just fentanyl nowadays. So I always educate my patients. Like, hey, do you you ever use street drugs when you run out of drugs? And I'm asking as non-judgmentally and I'll ask in different ways like, hey, you know, like sometimes we run out of, I'll have some patients who will run out of drugs and they'll go to street drugs. Has that ever happened to you? I just need to know either way. It's not like I'm going to report this to anyone. You get a more truthful answer. Yeah, and going off that, there's many more of these pills actually being produced because these pill presses exist now that you can buy from China,

where the slurry that you're talking about is just put into the machine, and the machine can make anywhere from 2,000 to 3,000 pills a day. And if you think of it over time, how many people are doing this and how much is being sold on the streets, it comes out to a large amount. Yep. Yeah, so overdose deaths. there was a paper, a recent one, 2019 by Spencer,

I talked about how, you know, in 2011, 1,600 deaths, 2012, 1,600 deaths, 2015, 9,500 deaths. And then all of a sudden, 2016, 18,000 deaths. You know, and I haven't seen, like, some of the newer data, but the seizures continue to, like the drug seizures, like how much they actually, like, pull, are pulling off the street is continuing in. increase. And so I imagine this will become a bigger and bigger issue as time goes on. Yeah. And on the topic of drug seizures, I know we mentioned this very early on. It has to do with

the DEA and what they're doing. And we'll eventually get to that. Another notable study is car fentanyl that we already mentioned was primarily used for vets and using to put down large animals like elephants and rhinos. And of the 5,000 opioid deaths that happened, that have been tracked, 7.6% of those were associated with car fentanyl. Right. So that's this one study of just looking at the percentage of deaths in this group sample that they had.

So one of the questions I had was, do dealers like know what they're doing here, you know? And, you know, although they have no intention of killing their customers, I read this story about this one guy who was ordering it from China and he was selling it and he was selling it to other people who would sell it and when he finally got caught he was charged with about like 60 deaths that were known to happen from his supply and I doubt this guy even knew that 60 people had died until like you know people came through and charged him with all this

there's other stories from funeral directors that say like five years ago they would receive one to three overdose a year now they're receiving three to five a month yeah you would think that dealers have no intention of wanting to hurt or maybe even kill some of their customers but i was also doing some reading that was showing that for them it's more of a calling card going back to some of the people that are seeking out that next potent kick or high. And when people are saying that it's causing a lot of, it's causing a more massive hide,

they actually might go to it too. And what are the dealers thinking right now? It might be unclear. It might also be unclear to us. I think that they're mostly interested in making money. At the end of the day, dealers are interested in making money. In an economist article,

they talked about how one kilogram of fentanyl was $4,000 that you could buy from China. and it could literally be sold for $1.6 million in the U.S. In comparison, one kilogram of heroin is $6,000 to buy and only makes a few hundred thousand dollars. So it's hugely driven by profit. So let's look at the pharmacology a little bit, the mechanism, you know, is it renally cleared? Is it liver cleared? What did you find?

We found that the renal clearance is not as substantial, therefore actually in patients with end-stage adrenal disease, diabetics, it's actually preferred to be used. It doesn't produce as much damage on the kidneys. In addition, it only binds to 25% of the binding sites. We have the mu, the opioid, we have the mu opioid receptors, the Kappa, and the Delta. And it really, fentanyl binds only the Mew, is what I was reading. But something like Suboxone, buprenorphine, binds to Mew, Kappa, and DELTA. Delta binds to all of them.

And the fentanyl is very lipophilic, so that's why they can give it as like a transdermal thing, you know, so it can go across the skin. The duration of action is 30 to 60 minutes, whereas heroin is four to five hours. And once again, it only takes about two minutes for someone to get into serious apnea on fentanyl. interestingly in an article that you found it talked about suboxone and how suboxone kind of has like a plateau towards apnea so like it'll suboxone will cause a little bit of apnea right but then it kind of flatlines or it doesn't flatline people don't flat line hopefully um it causes a uh the curve is flat so that it doesn't lead to like

the levels of apnea that lead to death right right they gave not a maximum dose, but they give a very high dose of Suboxone to patients. And they saw that the ventilation rate in a lot of patients, even as they continue to increase the dose, only decreased by a maximum of about 50%. With fentanyl, they saw that there was no plateau. As you increase the dosage, you increase the likelihood that their minimum ventilation would go down. And it did approach, a lot of the times it did approach essentially zero.

Yep. I mean, that's like they literally stopped breathing, right? They literally stopped breathing. And it was a linear relationship. I think that's really important to note, is that it was like as the amount in the blood went up in a linear fashion, the breathing dropped. The breathing dropped the, when they did the math and they looked at the study, they saw that the peak action, the peak respiratory depression that they saw was only seen in 2.2 minutes. so within two minutes their breathing rate had reached its maximum decrease yeah so it goes away quickly more quicker than heroin and it hits faster and so you know EMS will be unlikely to be able to get there in time and I think this is one of the big causes of why people are dying

and EMS is arriving one of my buddies is an EMS driver he says says he's called in and it's too late. It's just too late. Okay, so anything else from the pharmaconetics, pharma dynamics that you think is worth mentioning? Most of the fentanyl that's given, again, since it's lipophilic, it gets in, gets out very fast. About 99% of it when it's given IV, even at higher dosages, is removed within one hour. showing how easily it's able to be cleared. But by the time it's cleared, you have to ask, how much has that person become hypoxic?

The next thing I had is how much Narcan, which is also called naloxone, the generic is naloxone, is needed to reverse this? Is it more than something like heroin, or is it the same? And we found kind of some mixed findings on this, actually. So one of the interesting things about how much naloxone is needed is there's some reports of people who have come into the ER frequently who have needed up to 12 milligrams of naloxone.

So this is, you know, normally intranasal is 2 milligrams and intramuscular is 0.4 milligrams. And now in California, actually, they require us to offer the Narcan naloxone to. every patient who is prescribed an opiate or a controlled substance. So sometimes people are requiring more than one dose, which I think is really important to note. The other important thing to note is it takes about five to eight minutes for both intranazer or the intramuscular to work. Intramuscular might be a little bit shorter five to seven minutes, whereas the intranasal is seven to eight minutes. So this person may need to be bagged actively until this stuff kicks in. And it leaves their system.

And eventually the fentanyl's processed out of the system. But you're right. It's going to require additional staff, additional time. They might even need to be intubated if they can't, if they might not be breathing on their able to breathe and ventilate on their own. Yep. We also looked at how if someone's bleeding from their nose, if they have a lot of mucus intranasal naloxone might not be as effective.

And so the paramedics are really on the front line of this. And I think having a lot from, I watched a bunch of YouTube's on this and they're struggling. I mean, it's like ground zero in some of these cities where this is going on. They're really busy. Anything else you want to mention that's worth on that part? We've talked about how laboratories that you need to, specific tests to see if fentanyl is there. There's fentanyl test strips that people are using that reduce the, you know, that at least

allow people at raves or parties to know that fentanyl is in their ear, it's in their cocaine or whatever they're using. There's also a company that's made gloves that could detect fentanyl in one minute. So to summarize some of the treatment options, I really think first and form, that Narcan naloxone needs to be carried by anyone who's using or any, you know, that's the first thing I would, I would highly recommend if you have patients who are using, who are thinking about going to a party. I think that would be the first and foremost thing to equip them with the knowledge of, hey, you spray this into the nose, you know, and it can, it takes a while to

reverse. I think that's the first thing. The second thing is chemical detox. So at our center here at and Melinda, we do a lot of suboxone detox. It's like a lot less painful to detox on opiates. And just like Suboxone works for other opiates that people may be addicted to, it can also help them get off of fentanyl. And the way that it usually works is they come in, give them a minute for all the stuff to get out of their system. And then once they're having symptoms, they put on the Suboxone. and that really binds the opiate receptors very tightly, and then they titrate them down over the course of five days or so on the Suboxone. And it's a whole lot more humane than just going through withdrawals.

But what I found is that really partial and day-trune programs that follow detox are really, really important. I think that's what we heavily lean into in our sort of system, the Lomalinda system, is we have about three different partial programs that they can go to. they can go to a dual diagnosis program for if they have like, you know, coexisting depression or bipolar. They can go to the program that I run if they have chronic pain issues. And then there's also just the chemical dependency partial. And then, you know, they go to a sober living.

They live close by. And then they come in during the day, seven, eight hours a day to these programs. I think that that is probably the best option. There's also Suboxone maintenance or methadone maintenance, which I think are good options for some. someone who is having issues just doing something like the partial. There's also a long-acting now-trexone. It's an injectable, but it does cost there's $1,300 a month.

But, you know, if you're considering that this is going to save someone's life, then that might not be that much money. And, you know, really thinking about long-term psychotherapy, treating the underlying psychiatric issues. And in the handout, we'll go through more of the, prevention stuff that's out there as well. Harm reduction strategies. But in this episode, Amir, I'm so glad you came on.

I'm so glad you helped me dig a lot of this stuff up and organize it. And it's been really great. I'm corresponding with you on it. And I hope that you can come away from this episode knowing a little bit more about fentanyl, about these new issues that we face. So I'll leave it there.