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The Other Epidemic: Recognizing fentanyl abuse with Dr. Craig Allen
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In this episode of More Life, Hartford HealthCare’s Steve Coates sits down with Dr. J. Craig Allen, Vice President of Addiction Services for Hartford HealthCare’s Behavioral Health Network. They discuss the recent tragedy in which a 13-year-old died from a fentanyl overdose at his school in Hartford, Connecticut.
The pandemic and societal stressors are putting our children, and others, at more risk than ever before. Dr. Allen provides some critical warnings we all need to be aware of to help us get a handle on the dangerous and sometimes deadly pandemic of substance abuse.
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PREVENTION IN OUR SCHOOLS AND COMMUNITY NARCAN AND FENTANYL
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CDC: Connecticut Opioid Deaths in 2020 Spike Almost 15 Percent to 1,359
Change in friends, change in energy level, change in interests, change in the way they're taking care of themselves, uh, they don't want to play sports anymore. All those kinds of things can be indications that a kid is using substances. Pinpoint pupils. So the black part of your eye, your pupil right there, very, very, very small telltale sign of opioid use with new users. You can see itching all over, itching or splotches and stuff.
SPEAKER_00Welcome to More Life. In this episode, Hartford Healthcare's Steve Coates sits down with Dr. Craig Allen, Vice President of Addiction Services for Hartford Healthcare's Behavioral Health Network. They discuss the recent tragedy in which a 13-year-old died from a fentanyl overdose at his school in Hartford, Connecticut. This pandemic and societal stressors are putting our children and others at more risk than ever before. Here, Dr. Allen is going to provide some critical warnings we really all need to be aware of to help us get a handle on this dangerous and sometimes deadly pandemic of substance abuse. Here's Steve Coates.
SPEAKER_01He says, no one's going to tolerate that. You have to think that this wasn't really either someone who wasn't very, very skilled or uh in this is not the kind of project that's on the street. One of the things that he pointed out, uh, Sergeant Mastrione from uh the uh Hartford Police Department was uh typically is 2% potent uh fentanyl, and that's what you buy in a bag, and the rest is all filler. And he said this was 58%.
SPEAKER_05So how is the drug getting to middle schools? Is it directly through dealers?
SPEAKER_01You know, we don't know that active investigation. Um, it's very rare. I can say this, it's very rare for very unusual for someone this age to use it, to have it. If a kid this age is going to be using a substance, and and you know, it's developmentally expected that kids are going to be interested in novel new experiences, and drugs happen to be one of those things. Um, but vaping, nicotine, cannabis, alcohol, not good for a 13-year-old's brain, not good for an adolescent's brain. It's still developing and it's harmful. But kids this age are more likely. So um eighth graders, we'll say eighth graders, great, um, they're significantly more likely, although it's rare, to be huffing, using uh like solvents from under the sink or in the garage. And that's fairly unusual. But for kids that age, that's what they can access. Using opioids, far less than 1% of those kids are actually, you know, typically in information that comes from uh monitoring the future, which is a study that comes out yearly from the University of Michigan. Very, very small percentages of kids, you know, when they look at last 30 days, they do this survey uh would be accessing opioids. Number one is alcohol for seniors in high school. Number two is two is cannabis. Number one is alcohol for eighth, tenth, and twelfth graders. But the very bottom, very, very bottom of the list is opioids. So this is very unusual. You know, the way I see it though is there's so much fentanyl in the state of Connecticut and across the country. Uh it's cheap, it's potent, it has replaced heroin and then some. Um and in non-Hispanic black and Hispanic communities, the number of opioid overdose deaths, the rate of opioid overdose deaths has skyrocketed in 2020 and 2021. Uh non-Hispanic white population, highest opioid overdose death rates from the 90s up until 2019. 2020, non-Hispanic black population jumped ahead of uh non-Hispanic Caucasian. 2021 almost doubled, almost doubled the rate of non-Hispanic white, the non-Hispanic black. And for the first time ever, the Hispanic population rate of opioid overdose death larger than for non-Hispanic white. What that means to me is as the numbers of opioid overdose deaths have have also gone up, you know, uh close to 15% in 2020, and they're going to be higher 2021, although the totals aren't all back. What that says to me is it's all over the place. It's in the cities, it's in those neighborhoods, and we're we're saddened, we're unhappy, but we shouldn't be terribly surprised that a sea of fentanyl leaks into the school.
SPEAKER_05With the increase you mentioned, can that be correlated? Do you think it can be correlated to the pandemic?
SPEAKER_01Yeah, yeah, yeah. I do. You know, the the way that um the pandemic has affected all of our mental health has um disproportionately in a negative way impacted people who have pre-existing uh anxiety, depression, psychiatric disorders, and pre-existing either heavy use or actual substance use disorders. Um, you know, we know from other tragedies that when there's huge societal stressors, the amount of alcohol goes up that's being used, look to be similar with cannabis at places that could track that, uh, states that could track that with so that's clear. And this big jump in opioid overdose deaths that took place across the country after COVID uh came into play, um, you know, points it out. People trying to manage their anxiety and their stress by using substances, people not being able to access their wellness activities, people being quarantined and isolated, which is, you know, the opposite of addiction is connection. It's hard to be connected if you're isolating and quarantining. Uh, recovery programs, AANA, you know, initially um not able to meet in person anymore, people going back to using, uh, and and then um, you know, treatment programs, barriers to access with treatment programs, people having to go virtual, some people not having access to the technology to go virtual, um, all of those things impacting substance use disorders, people using substances. And then the harm reduction programs also could not function very well. Um, I think in all those areas, there's been a big bounce back in 2021, and efforts are made to be very creative. But you know, harm reduction organizations with sterile syringes and naloxone on the streets, they also were impacted. It's not just people who are using, it's people who are working in the programs, people who are working in those harm reduction organizations. Everybody is under the same type of stressors from potential illness, uh, injury, financial stress, worry, worry about uh, you know, loved ones' health, worry about your own health.
SPEAKER_05Back to the Hartford tragedy and fentanyl in general, there was a lot of talk in the media and among police in this particular incident about the potency of this drug and the dangers of just coming into contact with it. Does that mean getting it on your skin, inhaling it from a distance? What what does that mean?
SPEAKER_01Right. Um You know, it's it is dangerous um because if you were to get it into your an open sore or into your eyes or into the mucosa on your mouth, then you might experience effects. If there was a cloud of it and you breathed it in, you could experience some of some of those effects. Studies have shown that it it's it's not really absorbed through your skin. But as the the sergeant has been saying at these forums that I've been part of, still protocols to wear uh safety uh gloves because you get on your hands, you can touch your eyes, you can touch your mouth, you can it can get get absorbed. Um it's you know, I think so that's what they're talking about. And you know, they they encourage you to call the police to come, they will come in and and take care of it. Um, I I think all of that is is certainly uh worth paying attention to. My concern with coming into contact is is less literal and more coming into contact might be those kids who are maybe using marijuana or alcohol or or something else, and they come into contact with fentanyl because uh the people they're getting it from have that, or the people they're using with have are using it or have access to it, and they may it come into contact that way. And uh, you know, and and there should be an awareness that fentanyl gets into the cocaine supply. Uh people are adulterating cocaine with fentanyl, makes a more potent product, apparently. Um, it's also, you know, with illicit pill presses pressed to look like Xanox, pressed to look like Valium, pressed to look like uh benzodiazepines. People think they're taking something else and they're actually getting fentanyl, and that can kill you. Pressed to look like oxycontin or Vicodin, and people think that's what they're getting.
SPEAKER_05So, why are dealers doing that? Is it cheaper to put fentanyl in things? Are they making more money from it?
SPEAKER_01Yes, yes, much cheaper. Much cheaper to use fentanyl than the real thing. It's much more potent, so you will be creating a market. Uh, people get addicted much quicker with a more potent substance. So it makes sense if you, but you know, there's there's no regulation, there's no standards, and so you make mistakes sometimes and you get put a little too much in there and you lose some of your customers. I mean, I'm saying that and uh facetiously, and and it's it's it's a tragedy, but it's some kind of a business model. Fentyl is so inexpensive. Um, you know, $50,000 for a kilo of heroin. You've got to grow the opium plant and harvest it and all this stuff. $3,000 for a kilo of fentanyl. You make $100,000 off the $50,000 you spent on heroin. You make $100,000 off the $3,000 you spent on fentanyl. There's the business model. That's why fentanyl, one of the reasons fentanyl is taken over the market, you can't find heroin anymore.
SPEAKER_05It sounds similar to when crack became an issue in the 80s, where it was a cheaper alternative to cocaine.
SPEAKER_01Well, I, you know, the crisis has been here for a number of years. Uh, it has been an epidemic. You know, I was looking at uh talks I gave back in 2014, uh yesterday. And the uh in the state of Connecticut, there was shock and concern because 300, over 300 people had died from opioid overdoses in the state. In 2020, the number was uh 1300 and you know, what was the number? You gotta if you got it sitting there like 1300 and uh 50 or something like that. I mean, it's it has uh quadrupled, and the number is gonna be higher. So this was an epidemic uh when people were using uh heroin and had started by using you know opioid pain pills like the oxycontin. This was an epidemic eight years ago. Yeah, yeah, yeah. It's it's an epidemic.
SPEAKER_05And generally, how are people taking fentanyl? Are they smoking it, injecting it, ingesting it? How are they doing it?
SPEAKER_01Snorting it. They're gonna snort it. So they're insufflated through the nose, through the nostrils. It's it's it's incredibly important. You you die that way too. You get addicted very fast that way too. Um you can inject it, you can smoke it, um, you can snort it, you can eat it. You know, you uh break the bag open, put it on the back of your hand, snort it in.
SPEAKER_05Is death from usage usually brought on by respiratory failure?
SPEAKER_01Yeah, so um, you know, the opioid pathways in the brain, there's the pain pathways, that's why opioid analgesic pain medications used medically. There's the pleasure pathway, that's the recreational uh pathway that lights up. Opioids bind to the mu receptors there, um, and opioids bind to uh receptors in the GI tracts while you get constipation when you use an opioid analgesics. But the problem with it is in the brainstem, um, the part of the brainstem that controls your breathing also has mu opioid receptors. Opioids bind there, decrease your respiratory rate, and decreases your sensitivity to uh carbon dioxide. And so as carbon dioxide goes up, our brains, our receptors say, breathe, get that out of here, get more oxygen in. Um, but but that doesn't work when you've used opioids. You're not breathing regularly, you're not breathing deeply, you're not sensitive to the to the changes in oxygen level and and um carbon dioxide level levels in your body. So you have anoxia. You have a lack of oxygen to the brain, it caught can cause brain damage, and people get brain injury, or they can die.
SPEAKER_05You mentioned earlier about how Hartford Healthcare, Connecticut Children's Medical Center, and police have been teaming up with forums at the school. What has been the focus?
SPEAKER_01So the focus of the forums has been education about fentanyl. Uh, just the fact that it's around, what it is, what it looks like, how it's often used, what's the paraphernalia if you see it around, how it might affect someone who uses it? So, what does it look like if your kid's intoxicated with an opioid? Uh, also, you know, what are the why is it that kids are vulnerable to using all substances, but opioids as well, and fentanyl? And um how do you talk to your kids about these risks and um try to uh help them to be safe? Uh and a big part of this also is um what can we, what else can we do? And certainly in the in the short, maybe long term too, it's uh naloxone focused. So opioid overdose, reversal medication, the importance of identifying the signs and the symptoms of someone who's been poisoned by opioids, and how do you use naloxone, uh, which can potentially save their lives, reversing this overdose, reversing this respiratory drive suppression because naloxone binds to those mu receptors in a stronger way than the other opioids do. And so the person can breathe again. It won't work if you drink too much alcohol. It won't work if you're obtunded because you took uh sleeping pills. Uh, naloxone won't work only if you are uh succumb to the effects of opioids. Um, but on the other hand, naloxone won't harm anyone who hasn't taken opioids, safer than aspirin, safer than Tylenol. So important to have it out there. We've been working with schools, teaching school nurses uh about naloxone and how to use it for four or five years at least.
SPEAKER_05The tragedy in Hartford and the rise in opioid deaths in general has parents concerned, no question. What is your advice? What should they be looking for?
SPEAKER_01So, you know, so one thing is uh as I I've mentioned, parents should be alert to any substance use that their kids are engaged in, because it can lead to other substances and exposure to situations and places where phenyl is. Um, so any sign or symptom of substance use, you know, change in friends, change in energy level, change in interests, um, change in the way they're taking care of themselves, uh, change in the way they're you know coming home or you know, they don't want to play sports anymore, that kind of thing, all those kinds of things can be indications that a kid is using substances. With uh opioids in particular, if you're intoxicated with opioids, uh you can be uh sedated. You know, they make you feel euphoric and high. Um, they can make you feel sleepy, groggy. People talk about nodding off, so like falling asleep and mid-sentence, hard to arouse, decreased respiratory rate, constipation, pinpoint pupils. So the black part of your eye, your pupil right there, very, very, very small telltale sign of um opioid use with um with new users. Um, you can see itching uh all over itching or splotches and stuff. And I it reminded me of a patient that that I had treated um a number of years ago, whose mother was certain she was getting into stuff. And we would do what we had then, these urine drug screens that didn't pick up um the drug she was using, which was a synthetic opioid. Um, like the some of the urine drug screens now won't pick up fentanyl. And so it wasn't until we sent it to the lab for gas liquid chromatography that we identified she was using a synthetic opioid. The only thing that that we would hear about was the itching and the itching is crazy, crazy, crazy itching. Um, so so those are some of the signs of someone who's intoxicated. It's important to know that, and then it's important to have naloxone and know how to use it, and to understand that the effects of an opioid can be immediate person, uh pale, blue lips, uh difficult to communicate with and arouse, breathing slowed down, or it can come on over the course of hours. And uh, you know, I had a patient a number of years ago who had gone out to a party with a friend, drove him out there, he had used something at that party, he came home in the car, uh, dropped off, went inside, kissed his mother good night, and went to bed and stopped breathing. And his mother was a nurse, his mother had an eloxone, she was suspicious, she was vigilant, she heard this funny breathing, raspy breathing. She went in there, it was blue, she used naloxone, she did CPR. First, she called 911 and uh he was saved, and and actually he's doing he's doing great. He's been in recovery for a couple of years. Um, but if she didn't have it, if she wasn't alert to it, if she wasn't looking for it, um it could have been another tragedy.
SPEAKER_05Doctor, you've been at this a long time, and it seems like every few months we're talking about a tragedy here in Connecticut or elsewhere. Do you feel like we're making some progress in addressing the situation?
SPEAKER_01I think that we're making progress. I do. I think it would be much, much worse if we were not. I think that there are uh the areas that need to be focused on more, and that has to do with um the this idea of harm reduction. And I actually think of harm reduction as a form of treatment, it's it's risk reduction and uh being able to meet people where they are at. Um, we shouldn't reserve treatment, help, and support only for those people who come in saying, um, only for those people who uh fit into our sometimes rigid treatment programs. I think it's it's um the responsibility of the medical community to have more flexible treatment strategies that meet people where they're at, and understand that not everybody is at the same stage of change. And you know, Prochesca's stages of change. Um, you've got the active stage, which we're all trained to work with patients who are in the active stage. And the active stage is I want treatment, I'll do whatever you tell me to do, doc, just put it on the list, and I'll go out and uh bring it and come back next week and tell you how I've done, how I've checked off all the boxes. That's wonderful. About 20, maybe 30% of the patients that come into us looking for substance use um uh help uh are at that stage. So the other 70% are a little more ambivalent about it. And we force them to say they want to be completely abstinent, although their intent is not to die from an overdose. Their intent is to cut back because it's making their life a little too hard right now. But initially, their plan may not be to stop using completely. And if If we turn them away, who's going to help them? And uh, you know, that that's something that is that has to change and is changing is this idea of what is substance use treatment. We do this in other parts of medicine, right? If you go to your doctor and you say, Oh, I haven't been feeling well, I'm going to the bathroom all night long and all day long, and so they say, Uh oh, let's check your sugar levels. Okay, you got a family history of diabetes. Here's what you need to do. We're going to have you do exercise and here's your diet and take these oral hypoglycemics and blah, blah, blah, blah, blah. And the person comes back in a couple of weeks to see the doc. And the doctor says, Okay, have you done all of those things? And the person says, You know what? I started walking every other day with my wife. The doctor says, Okay, obviously I can't work with you. We're done here. Uh, when you're ready, come back. No, that's not what your primary care doctor says. Your primary care doctor says, that's great. That's great. Maybe um, how far are you walking? Maybe even go a little further. Um, what about that diet stuff? Have you been able to cut anything out? Have you been able to cut back a little bit on the cake and the da da da da? It's a process. And that's the way we should be working with people who have substance use disorders as well. Um, but it's it's a different approach. There is the uh discrimination that we see towards people who have substance use disorders, and I think that keeps a lot of them out of our treatment programs, out of our emergency rooms, and not engaging uh with us and um you know in in treatment and and activities that would lead them towards wellness.
SPEAKER_05Dr. Allen, thanks for joining us today.
SPEAKER_01Thank you, Steve. Appreciate it.
SPEAKER_00Thank you, Steve Coates and Dr. Craig Allen. Hartford Healthcare is presenting an important Zoom forum this Thursday, January 27th. The topic is Narcan and Fentanil, Prevention in Our Schools and Community. Check the links in this episode's notes to join this free informational presentation featuring Dr. Allen and other experts, and we'll also include links to other similar events, articles, and resources. You can subscribe to More Life for more episodes on a wide range of important health topics. Just search Hartford Healthcare on your favorite podcast platform. For Hartford Healthcare, I'm Enron DePierre. Thanks for listening to More Life. I'm ready for my close-up.
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