The fentanyl epidemic: how to protect our children? With pain doctor, Andy Leitner MD

Episode 62 of Ask Dr Jessica discusses the fentanyl crisis with anesthesiologist and pain specialist, Dr Andy Leitner.   There has been a growing problem with street drugs laced with fentanyl, often in lethal doses.  Fentanyl poisoning is now the leading cause of death in adults 18-49.  With all of this news,  educating our children is more important than ever.  In this episode, Dr Leitner explains what fentanyl is exactly.  When it is used safely in the medical setting?  What is the fentanyl crisis exactly and why are we finding it more frequently on the street drug market?  What does a fentanyl overdose look like and what can parents do about it? 

Andrew Leitner, M.D., earned his undergraduate degree magna cum laude in biology from Tufts University in Medford, Massachusetts. He went on to receive his medical doctorate from the Washington University School of Medicine in St. Louis, Missouri. He completed his residency in the Department of Anesthesiology at University of California Los Angeles, where he also pursued a fellowship in interventional pain management. 

Board-certified in both anesthesiology and pain management, Dr. Leitner is fluent in Spanish, Hebrew and Hungarian. He is an active member in numerous professional associations including the American Society of Anesthesiology, the American Society of Regional Anesthesia, the California Society of Anesthesiologists and the North American Neuromodulation Society. He has also written several articles and abstracts.

Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children. Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner.

Do you have a future topic you'd like Dr Jessica Hochman to discuss? Email Dr Jessica Hochman askdrjessicamd@gmail.com.

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The information presented in Ask Dr Jessica is for general educational purposes only. She does not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your child's health care provider.

Transcript

Unknown: 0:00

Welcome to Ask Dr. Jessica the podcast where I aim to give you quality medical information to help you along your parenting journey. I'm your host and paediatrician Dr. Jessica Hochman. So on today's episode I have on one of the smartest, most thoughtful people I know. And that is my brother in law Dr. Andy Lightner. Dr. Lightner is board certified in both anesthesiology and pain management. So he is a true expert when it comes to the subject of pain medications. So in today's episode, we're going to talk about the growing problem of fentanyl. Unintentional fentanyl overdose is likely the leading cause of death and adults aged 18 to 45. So on this episode, Dr. Lightner explains what the Fentanyl crisis is exactly why it is happening, and what parents can do to keep our children safe. I believe that education on this topic is incredibly important. So please share this episode if you know anybody who may benefit from hearing this conversation. Welcome back. But we're back here today to talk about the Fentanyl crisis that's going on. And Andy, first I want to let everybody know what what are your qualifications? What do you do for work? Well, thanks for having me on. Again, in spite of my last performance. I am a practising anesthesiologist and interventional pain specialist. And I practice at a cancer hospital here in Southern California city of hope. And there are essentially two areas where I encounter pain medication, including fentanyl and others. One is in the operating room when I'm doing anaesthesia. And the other is in my clinic when I'm helping patients with pain. So what does that mean to be a pain specialist. So, pain is a multidisciplinary field. So people come into it from various areas within interventional pain. It's a specialty that focuses on procedures, injections, various interventions to help with pain, as well as managing medications rehabilitation. So my practice is a Comprehensive Pain practice. So we do a little bit of everything in helping, in my case, helping patients with cancer, deal with pain, as well as those who have survived cancer that have residual pain symptoms from their disease. I'm excited to have you for many reasons. But one is You're truly a pain specialist. Your job and your training is to understand pain medication. So we've been hearing so much about the Fentanyl crisis that's been going on concern from parents. And I know that you as part of your job you have been trained to prescribe and use fentanyl. So I wanted to get your perspective. How do you find that fentanyl used in the right settings is dangerous question about fentanyl? And is it dangerous to use in the right settings. I often tell patients, the way to look at use of pain medications or even anaesthesia, is similar to when you fly on a commercial airliner. You know, don't try this at home. But if you are flying in a plane with a trained pilot, who has comprehensive monitoring tools and redundant safety and engineering systems, it's one of the safer things that you can do. So similar to when Michael Jackson died with the administration of propofol at home, don't try this at home. But in the right setting and the right hands, it can be incredibly safe because of all of those safeguards that I mentioned. That said, we see as anesthesiologists on a daily basis, the direct physiologic effects of these medications. What do I mean by that? We have the opportunity. It's like a mini laboratory when you're in surgery or having sedation. With all of the monitoring equipment, I can see what happens to a patient as they are being administered an opioid. And I can see how that changes their breathing, and decreases the rate of their breathing, the volume of their breathing, their levels of oxygen, carbon dioxide, I can see all of that. And so that gives me a essentially on the job daily exposure to why it is in the wrong setting in the wrong way. Without the quality control and without the safeguards, why opioids can be deadly or deadly. And why fentanyl in particular is really wreaking havoc right now. So if somebody has a loved one that goes to the hospital and they hear that they have been given fentanyl, they don't have to be concerned because it's being used in a safe setting where they're being monitored. Is that what you're saying? Right. And I would take it a step further that the benefits of a potent and short acting pain medication like that is part of why it's used the ability to profoundly reduce the pain but also the stimulus that comes from it. painful procedure, surgeries, etc. By a medication like fentanyl is why it's, let's say on the list of essential medicines for the World Health Organisation. So it's not just used properly, it can be safe, but also it's deriving, you're deriving a benefit when it's used in that way. I also use these medications in the clinic setting. So for people who are struggling with chronic disease, or struggling with chronic pain after treatment, and in those cases, those patients need very careful counselling on how to take it the right way to take it, where to go if there are questions, how to keep others in the household safe and not exposed to it. So all those things are wrapped into the safety profile of these medications. But again, you know, in medicine, we have a few basic core principles, one of them is first do no harm. So these medications are in use for a reason. But counselling patients carefully on how to use them safely is just part of the job. I remember when I did my pick your rotation in residency, and my pick you attending used to love using fentanyl for quick for things that would require a quick use of pain control. So like if we ever changed someone's bandage, and she thought that they would need some relief for just a few minutes. She loved using fentanyl. So I remember it was very helpful in the ICU setting. Yeah, and it's not the only medication out there that's like that, there's more and more research into, you know, the, the essentially the the promised land will be an opioid that doesn't cause all of the negative side effects and the respiratory depression. A lot of research is being done. We haven't found it yet. But there are other medications that are non opioid that do somewhat similar things like ketamine. So there's, there's probably in our lifetimes, we will see major advances with this, but for now, because these are sort of a double double edged sword. That's why they have to be closely monitored in the right setting. And can you explain what respiratory depression is? Is that the side effect that we worry about from fentanyl? Yes, that is that is the thing that makes overdoses fatal when you know at the degree that we're seeing it right now. So fentanyl and all opioids work on what's called the opioid receptors. And there's many classes of those, but the important ones for pain control are the mu opioid receptors. And there are other mu receptors that do things like tell our body when to breathe. Breathing is a subconscious or unconscious activity. A lot of it comes from complex interplay in the brain, including the brainstem. And part of what happens with an opioid is not only is it acting on a pain receptor to decrease pain, but it's acting on other receptors, including the respiratory receptors that give us the drive to breathe. And so in what's called a dose respondents manner, so the higher the dose, or the more stacked doses you have, you can decrease how quickly you're breathing and your brain is telling you to breathe, how large a breath you're taking, and also what is the trigger to take a breath. So if you ever dunk in a pool, and you're swimming a lap underwater, you feel that discomfort, that urge I need to take a breath that's driven by some of the central brain centres and on opioids, the drive to breathe gets suppressed. Wow. So that makes sense. If it's if it's not monitored properly, and you're taking too much that it can cause some issues. That's right. What is fentanyl? Exactly? Is it human made? Is it plant derived? How do we find fentanyl? So fentanyl is what's called a synthetic opioid. So opioids have been around for 1000s of years been described in good chunks of civilised human history. And the original ones were derived from plants. There's a plant poppy plant called Papaver somniferum, which literally means the poppy that induces sleep. And so different human societies have been using those types of plants derived opiates for a long, long time. But it took until the 20th century before those were started to make in lab so synthetic versions of those were made in laboratories. Heroin is an example of a synthetic opioid fentanyl is a synthetic opioid that was made in 1960 by Janssen, the who started the pharmaceutical company, and it's been in use really since the late 60s, but synthetic so it's made in a laboratory but has a chemical structure that's quite similar to other of the plant or naturally derived opioids. So what's happening right now what what is the Fentanyl crisis? Why is it becoming such a subject in the news Why is fentanyl all over the news today comes down to a number of parallel tracks, I would say. The first is in America, we've known and been dealing with the opioid epidemic broadly for a number of years. And there's connections with the opioid epidemic broadly. But then there's also specific things about fentanyl and the market forces that are causing more and more fentanyl to be in the drug supply. So I can talk about the opioid epidemic broadly. But then we can get into why fentanyl is is more of a issue and is, in fact making the numbers even worse. So it seemed like we were going to get our hands around this opioid epidemic within the last decade, huge public health efforts, much more awareness. The overdose deaths from opioids today are worse than they've ever been. And that's because of fentanyl. The original opioid epidemic dates back not decades. But you know, well over a century. And so that's a whole other topic as to where Americans but also globally, people started using and being exposed to opioids of various forms, but more modern history, the prescription opioid epidemic was the major source of scrutiny that started around late 90s, early 2000s, where you just saw much, much more prescribed opioid medication in the marketplace, being given to patients from doctors for various reasons, some of which were sort of established medical practice, others somewhat more dubious, as has gotten a lot of press coverage, I will say, there was a time where all doctors were given specific training that we were under treating pain, that opioid should be prescribed for any number of conditions, and that the risks of opioid use long term were negligible. And I think it's helpful always to look back. This wasn't that long ago, 20 years or so, it's helpful to look back at the received wisdom of sort of scientific dogma at any given time, and always challenge that, is it still the right thing to do. And of course, as we all know, now, many studies have borne out that opioids for everything in everyone is a mistake. With the right patient, the right condition in the right hands can be profoundly beneficial treatment, like broadly applied caused a lot of misery. You know, and let me be clear, I, I prescribe opioids every week, and I have a number of patients that are on rather high doses for prolonged periods of time. And our practice does not face the sort of the levels of opioid related harm and addiction that you might read about in the news. But again, it's under close supervision, careful patient selection, and and an important part of this is the sort of the doctor patient relationship, trust, monitoring, open communication. But, you know, getting back to this prescription opioid epidemic, this, this took place over really a couple of decades, where you saw just the sheer supply of opioids available, skyrocketed. And if you look at the trend line, CDC maintained really good charts on this, if you look at the trend lines of how many pills were in the marketplace dispensed, and you compare it to number of er presentations with overdose, or a number of deaths, these were parallel lines, just like this. And by the time the CDC started to make this an area of intense scrutiny, and so did the FDA and many other health agencies. One of the goals there was we need to significantly reduce the supply on the marketplace significantly reduced the amount of prescribing. And that way we can tackle the problem. And I think I wrote down a number here that talks about the response to the prescription opioid epidemic, but basically between 2012 and 2020, there was almost cut in half the number of outpatient opioid prescriptions, and yet there's been a three fold increase in opioid overdose deaths in that same timeframe. And that's where fentanyl comes into play. That's where heroin comes into play. And so the law of unintended consequences, there are a couple couple effects of the recognition that we're having a prescription opioid epidemic and what the response to it was. One effect was patients that were already opioid dependence, meaning they had a physical dependence to opioid I would not be able to tolerate being cut cold turkey from those medications had legitimate medical conditions where they needed pain medications and a Comprehensive Pain Treatment. Those patients who were then cut off often resorted to things that were even less safe than perhaps what they had been doing before. And that street drops. So that was one unintended consequence. And then the, you know, the other aspect is market forces on, you know, drug cartels supply in the marketplace, how to create more for less. And that's a whole other topic, I don't have a lot of expertise on it. But I'll just give you a sense of kind of the ranges we're talking about. So fentanyl is about 100 times more potent than morphine, which means the same amount of the substance can deliver 100 times the potency of both what depending on what the purpose is, whether it's pain control, whether it's drug use euphoria, whether it's in most cases with opioid dependent people, it's less of pursuing a higher euphoria. And it's more about treating the dope sickness. Most people will be familiar with that concept through the book and television show. But the profound discomfort and true suffering that someone faces if they've been on an opioid, and then are off is is something that drives a lot of the behaviour of continuing to seek out the next source of the opioid. So they don't have to get into the pits of of withdrawal. And so what happened is, over time, fentanyl became available on the marketplace for reasons I can explain. And it's just a drug dealer, a drug supplier can create the same end outcome with a lot less product. And it's just just a margin situation, that's much better for them. So financially, because they don't need as much as this what you're saying they don't need as much product that they can basically make more money. That's right, they don't need as much they can make more money. To give you a sense of the quantities, can you think of an American Lincoln penny, and the year that's on that penny? If you put enough fentanyl powder to kind of cover up the year? That can be a fatal dose for someone who's opioid naive meaning for someone who's not chronically on opioids, or not chronically using heroin or things like that. So not the entire surface of the penny, you're not the entire surface, cover the year, that can be a fatal dose. Wow. So if you get that medication, the harms are the wrong people that don't know what they're doing. You can see why this is a big problem. Yeah, let's just say, in the illicit drug supply, there isn't quality control over how much what's the purity? And are people really seeking fentanyl is that is that what they want? I mean, I always thought of heroin has been the most addictive. It's increasing. Increasingly, chronic drug users are seeking fentanyl. It has a shorter times to impact than heroin. And so many who are who are chasing the quick high are either seeking heroin mixed with fentanyl or sometimes purely fentanyl. So that is happening. But a lot of the overdose deaths again, are happening to people who are either opioid naive, or were on a, let's say, predictable amount of their illicit opioids for a while. And then they took something that was, you know, cut much more with fentanyl than it had been. The case of Philip Seymour Hoffman was one where he was sober for a short period of time, and then he relapse in the time that he got sober. He basically became opioid naive. And what that means is his tolerance to the respiratory depressions aspect of the opioid went away. So if you're on opioids for a long time, you can potentially be okay with higher and higher doses because you've developed a tolerance to that respiratory depression. But if you've cleaned up for a while, and you go back and take the same dose you were on before, that can be deadly, and that's what happened to him. That's a lot of what happens in these cases. So sometimes they're specifically pursuing fentanyl. Sometimes they're not even aware that fentanyl is in what they're using. The truth is, demand for these drugs continues to be really high. So it's essentially a cost of business for the drug suppliers and dealers to have some people overdose and die. That's just a cost of doing business. That's the calculus. Unfortunately, there is no logical business motive There's no logical return for lacing products for unintended users. For those that don't overdose on fentanyl, the hook, the dependence that can be created can be profound. And they've, they've essentially bought customer for whatever's left of their life. So that's the business proposition not randomly lacing the food supply. The other aspect here is fentanyl alone is a respiratory depressant. But it becomes an ever more potent respiratory depressant if mixed with other things. So most of the high profile overdose deaths that we've heard of in the last decades are usually when things were mixed, mixed with Xanax or other benzodiazepines mixed with alcohol mixed with other things where the risk of fatal what's called respiratory arrest goes up significantly with that mixing. So sad, because I think it's so sad what people will do for financial gain. You know, I would say that the, the supply demand and sort of market forces for drug suppliers hasn't really changed. They just now have this input in the form of fentanyl. And the whole other topic is methamphetamines that has somewhat similar inputs, they're not causing the fatal respiratory arrest in the same way. But those forces are not really different than they used to be. What has happened is, fentanyl is now being produced at scale for the illicit drug market, largely in laboratories in China with let's just say selective non enforcement of policies. They're those either fentanyl product or what we call precursors. So almost finished product, then make its way into other countries for distribution. And what is happening in the United States is fentanyl makes its way from China to Mexico, the Mexico drug cartels then cut it into the supply. Often it's of heroin. Increasingly, it's of actual counterfeit pills. And then it makes its way across the border. And there's just a glut in the marketplace. I saw an other statistic that said, of the seized counterfeit pills in the US. So when law enforcement does a drug bust, and they get a bunch of counterfeit pills. The percent that had a potentially lethal dose of fentanyl was 44%. Wow. So of the counterfeit pills out there, there's basically a coin toss as to whether it has fentanyl, and if it has fentanyl, it's a potentially fatal amount. And do all of these pills look a little fishy? I mean, can parents trust when they get Skittles or typical candies for their kids that they're not laced with fentanyl? So that's so that's a really important distinction to make. I was I was talking about counterfeit pills. And your question was about candy. I don't know that there has been a single corroborated case of laced candy for a for an end user target that's supposed to be consuming candy. If you think about it, there's really there's no point in that other than like an act of terrorism. And so I think parents have been concerned about laced candy from a number of sources for years. But the the fear hasn't really borne out so far. Is there some potential for that to exist? I think so theoretically. But the concern about fentanyl in my mind is not about candy. In a candy distribution network being laced with fentanyl. It's more about counterfeit pills where people are specifically taking them as they are pills or drugs to pursue any number of things, whether it's a high or they're pursuing pain control, avoiding dope sickness, what have you. But using a non pharmacy provided doctor prescribed medication, they have this counterfeit pill, they can look pretty similar. But if you're not getting it from a prescribed source from a pharmacy, there is significant risk that that pill has fentanyl in it. Some of the more tragic cases we have heard of kids really and on a first experimentation with a counterfeit pill dying come from that source. So again, I don't believe we're in a situation where candy needs to be scrutinised for being tampered with or being laced. It's of course every parent's fear. It's just not been borne out by you know, even some of the news stories have been debunked on on when that US hypothesised theoretically possible, but not happening right now. I'm so glad you're clarifying this because I think a lot of parents have been worried. I've been seeing a lot of articles being sent to me about potential for candy being laced. But it makes more sense that, from what just if I understand what you're saying that these fentanyl overdoses are coming more from street drugs when they're purchased, and they're not being, you know, maliciously put into kids candy. The I will say, the one cause for concern that I have is sometimes candy can be used as a way of smuggling. Right? So if you're trying to move product across the border, it's easier to you to move things that aren't of the appearance of pills or drugs than it is to move other things. So is there a theoretical potential that that gets in the wrong hands, and it's mistaken for candy? Certainly, there's that potential. But the idea that people are going to their grocery stores and buying packages of candy from the distributors that are tainted with fentanyl? I don't I have not seen any evidence to support that there hasn't been a single instance of that being found. It has to come from drug supply, black market, etc. The scary part, however, is what's the actual use case of teenagers and kids at parties. A use case is not uncommon for somebody will be passed a drink, some people will be passed a, you know, a bowl a pill like here, pick a random pill. That's that's the scenario that is truly worrisome. There have been many instances of that, you know, leading to a pill that in fact has been intentionally made with fentanyl. And that's that's the nightmare scenario right there. Now, what about these test kits, where I've heard that you can actually test products before you try them to make sure they aren't laced with fentanyl? Is that something that you support agree with? Do you have thoughts on that? I think test kits for fentanyl is not a bad idea. But I think the whole premise is playing with fire. You already heard me describe how little amount of fentanyl can be lethal. And so unless a test kit is doing a broad sampling of the entire whatever it might be. So somebody may be like, heroin user may be testing for the presence of fentanyl, do they sample the whole thing? Counterfeit pill, you split it you take apart. I'm just worried that that's not enough. It may help in some circumstances. But the only way to foolproof know that you're not consuming fentanyl is to just never take a counterfeit pill period to never use a drug period. Most of the heroin overdoses have in recent years now been found to include not just heroin, but fentanyl as well. So your advice to parents would be to explain to their children, all of this just not to take anything period. So I am not an expert on child development or advice to children that said, and perhaps the reason why I'm most interested in talking about this topic with you is I have kids, and it's a question that's asked, and I think times have changed a generation ago, I think the the impact of experimentation, we was very different than what it is today. So it's a whole other topic about what are the risk factors for substance dependence and the age at which you start and where you're exposed and how much in genetic risk factors. And that none of that has changed. That's all stays the same. But there was an era in which if a kid experimented, or messed up once, that was not going to kill them. Right. But now you are seeing across the board, even with the potency of marijuana, everything has gotten more potent. And as many of these drugs are now synthetically derived. The sky's the limit for how potent they can be. And so more and more of the overdose deaths are happening. Not with necessarily chronic drug users, but on first or early exposure to a drug. So I feel that the environment has changed enough where I it's hard for me to understand anything but an abstinence policy about drugs. And, and then, you know reaching a certain age and and having sort of appropriate judgement kick in about what's under medical direction, how to tell how to test. I think that's all fair. But the idea of kids experimenting with drugs, I just don't See how we can abide by that anymore with what's out in the marketplace. It's just too deadly just too deadly. You can make Can you tell you can have, you can have one misstep. And that's fatal. That's the part that I feel has been a big change generationally. The like, what are the consequences from for experimentation gone awry. And the stakes are too high right now. We just can't afford it. Right. Now, can you tell parents what, what are the signs when somebody has overdosed on fentanyl? Because I know there's a medication that we can use to reverse the effects can you make people aware of what to look for? Yep. So a fentanyl overdose can include a whole constellation of symptoms, but the most important to look after is breathing. So being able to assess whether someone's breathing or not, some sometimes it comes to the ABCs. If people know CPR, first response, but you can see the chest moving, you can put your hand next to their mouth and nose. Typically, if someone's not breathing, they're also unconscious. And that combination is is an overdose in which minutes lost our brain cells lost. That's the way in which fentanyl kills it's because one stops breathing than there's not oxygen to vital organs than brain cells die. That's that's the sequence. And all of the other symptoms are important to recognise because they may come before that sort of final step. So if someone is slurring their sleeps their speech, I just slurred my speech as an example, if someone is slurring their speech, if they are groggy, if their pupils are quite narrow, in many cases, they may be vomiting, there may there are going to be lead up signs often. The problem especially with the way in which fentanyl is consumed, is it can be so fast that it just rips right through all of those developed symptoms. So if fentanyl is injected in an IV, in an IV form, like heroin, if it's consumed, even from the nose, there are ways in which the absorption is so quick that you may not even go through the steps of someone's feeling sleepy, they're starting to lose consciousness. They're stumbling around, it may go straight to unconsciousness and breathing stops. There was a huge campaign for Naloxone and it continues. At first Naloxone was stocked with multiple first responders, then pharmacies had a special allowance that they could dispense Naloxone without a doctor's order. Increasingly, we're hearing schools are considering stocking naloxone. The benefit of naloxone is it's an opioid antagonist. So it works on the same receptors to counteract and block the opioid effect. The thing to keep in mind, like with really any first response for, in this case, respiratory arrest. Using Naloxone, it's not enough like that has to be paired with calling 911 That has to be paired with getting paramedic on the scene. The reason is an opioid lasts in the bloodstream significantly longer than Naloxone lost in the bloodstream. So you may bring someone back only to five minutes later have them go back into their opioid related respiratory depression. So that may require more doses of the Naloxone also known as Narcan. And they need to get to a hospital. Okay, so just to summarise, if you do ever see somebody fall unconscious, you suspect overdose, and then you're lucky enough to have Naloxone or Narcan use it, but also you have to call 911. So I have a question for you. I did actually purchase Naloxone, I think as a response to everybody talking about the fentanyl epidemic. But do you think that's a good idea? Do you think I really need to have Narcan on me Naloxone also known as Narcan is a critical tool to have in the arsenal to deal with the fentanyl and opioid epidemic in general. And first responders carry it pharmacies dispense it. I think it makes sense for medical practices to keep it on stop the idea of you know, walking around having naloxone in case you witness something. Think it's similar to when people have defibrillator and easy access or epinephrine pens and easy access. Chances are statistically that somewhere around you somebody may have an opioid overdose. So I don't think it's a bad thing from a medical provider standpoint that, you know, we have Narcan readily accessible and people trained how to use it. I think The flip side is Narcan may give drug users a false sense of security. Because the only way that Narcan can be used is if done by someone who is witnessing the arrest and that someone needs to be conscious, responsible, trained all of those things, and ready to go the life circumstances in which someone is using respiratory depressant drugs in an unhealthy and unsafe manner to depend that they can kind of get out of that situation in an emergency every time that in my mind is Russian roulette. So Narcan I think, has addressed aspects of the public health emergency that we're facing. Something like 7070 plus 1000 individuals died from a fentanyl overdose last year. So this is a public health emergency. That said it does not address anything with root causes of what's happening. And those root causes are supply and demand. And those are thorny issues. They have a number of policy recommendations. Not easy to implement. But Narcan is essentially a bandaid that does not get to root causes. Is it necessary? Absolutely. But is it sufficient? No. So do you think it's overkill for all the schools to be requiring? The carrot, do you think? Do you think it's overkill that all the schools now are having Naloxone at the schools? Is it is it too much isn't necessary? I think it's a good idea for schools to have Narcan in their in their main offices the same way that schools will stop a few medications and epinephrine. I think it's reasonable. Not that expensive. Yeah, not easy. The statistics show that the major age groups that are encountering fentanyl overdoses are 20s 30s and 40s. But it's happening with teenagers too. And there have been a couple high profile and tragic episodes in Los Angeles high school. So I think for high schools, it's absolutely a good idea. elementary schools, I think it's not unreasonable to have them have them stocked as well. So I think what I worry about is when I see the news headlines, I wonder how much of this fear is real, and how much isn't real. So for example, my sixth grade daughter came home yesterday, and she said to me that her her history teacher warned the class not to eat candy when trick or treating. And she said, Mommy, is this true? You know, can I partake in trick or treating is a dangerous? What do you think about that is that to me, it strikes me as a little bit fear mongering. I think it's perfectly fine for kids to go trick or treating any candy. And I think parents should do what they've always done, which is exercise their good judgement and common sense, meaning they can candy. And frankly, anything that your kid is being given to consume should be inspected. And is it in a package? Or was it homemade? Does it seem like it could have been tampered with? This has nothing to do with fentanyl and the opioid epidemic and more about common sense about what your kids are consuming. But the idea that kids can't go trick or treating because they may be exposed to candy that has been laced? There's no evidence to suggest that it's happening. I think there's been fears of this for years. Common sense, I think should prevail with this. And we can keep going with the trick or treating. Do you have any advice for parents any any words of wisdom that we didn't that we didn't cover? My advice for parents is not born of experience. My oldest kid is seven, but rapidly approaching the age where I do want to talk to him about drugs, what they are, what they can do specific anecdotes about how drugs can affect people. I would love to see sort of robust evidence based approaches to talking to kids about drugs. It's not an area of my expertise. I do sense that sort of open and honest discussions and treating children as having more sophistication about serious topics is probably best. So withholding information because you think it doesn't affect your family or couldn't happen to you. That's just not the case anymore. It is so easy to obtain a counterfeit pill online to find one at a party. I saw another statistic that said something like over 3012 year olds that day use marijuana and in the exposure to drugs or substances of all forms is happening And whether you want to believe it or not. And so having, having early discussions about what it is, what to look for, and why it matters, I think is the way to go. You know, my wife, your sister, recounts being to have been given these discussions when she was a kid. And she found that your parents sort of very matter of fact, way of talking about drugs and Pointing to examples of where lives can can really be changed. In a moment, I think they were really instructive. Also, you're treating children with respect, and with trust and open conversation? It seems to go a long way. I do believe studies have borne that out. That's obviously easier said than done. And I think abstinence is a difficult thing for a parent to counsel. Teenagers are risk takers. And so perhaps creating some room for healthy risk taking as opposed to really dangerous risk taking may be important, because that's part of what teenagers do. Now, and I do agree, receiving those open, honest conversations from a young age. I do think one it demystified drugs. And I do think it really guided the way we were raised and the way we you know, I think we were pretty good kids because I think we didn't have the curiosity our parents sort of took that took that away from us by being so open and honest. So I do agree that I think that is a good a good approach, or one that I worked for us. You had a wonderful speaker on recently, Jessica Lahey, I found her words of wisdom about speaking to children to be very useful. She also pointed out which is true. The rates of drug and alcohol use among kids is actually lower than it used to be today. I don't know by how much, but there has been some decline that I think should impart why fentanyl and and drugs like it are so dangerous. Because even if overall, we are achieving some success in the number of kids that are using alcohol using drugs, the potency of what it happens is such that it's it's sort of a generational change. Yes. Now, Andy, big question for you. Halloween is coming up next week. Are you going to let your children trick or treat and consume some candy? Absolutely, you're wearing the locks on with you? Absolutely. I am not going to carry Naloxone trick or treating, I will let my kids go trick or treating as long as they share some of their candy with me. And I look forward to that. And perhaps it's a good reminder that it's probably time for me to have the discussion with them and continue to have a discussion with them about drugs and why their developing brains are their most important commodity and what we need to do to shore that up. Andy, I'm so proud of you. I always appreciate your words of wisdom. And thank you so much for coming on. Thanks, Jessica. Nice to see you. Thank you so much for listening to this week's episode of Ask Dr. Jessica. If you're enjoying this podcast, I would be so appreciative. If you would take the time to rate review. Hit that subscribe button and even better share it with your friends. See you next Monday.