Addiction Medicine Made Easy | Fighting back against addiction
Addiction is killing us. Over 100,000 Americans died of drug overdose in the last year, and over 100,000 Americans died from alcohol use in the last year. We need to include addiction medicine as a part of everyone's practice! We take topics in addiction medicine and break them down into digestible nuggets and clinical pearls that you can use at the bedside. We are trying to create an army of health care providers all over the world who want to fight back against addiction - and we hope you will join us.*This podcast was previously the Addiction in Emergency Medicine and Acute Care podcast*
Addiction Medicine Made Easy | Fighting back against addiction
What I Say to High Schoolers When I Teach About Addiction
This is a bonus episode. I was asked to speak at several schools in the area around where I work about drugs and alcohol - both to students and to parents.
I wanted to make the education as impactful and real as possible. So I focused on the substances that are most likely to affect our youth and their families - alcohol, cannabis, nicotine/vaping, and fentanyl.
To help make my presentation as real as possible, I actually went to a liquor store, a tobacco shop, and a cannabis dispensary to look at how these products are sold and marketed - and how to interpret the labels on them.
Whether you are a student, a parent, or just a person concerned about substance use, I know you will learn something from this lecture. If you're looking to start a conversation with your loved one about drug and alcohol use, this lecture will help educate you on the current state of addiction, and give you information on how to start that conversation about drugs and alcohol.
To contact Dr. Grover: ammadeeasy@fastmail.com
Hello, my friends, welcome to the Addiction Medicine Made Easy podcast, where we take topics in addiction medicine and break them down into digestible nuggets and clinical pearls that you can use at the bedside. Dr Casey Grover here as your host once again. If this is your first episode, my name is Casey Grover and I am an addiction medicine doctor working on the Central Coast of California. If you are one of my regulars, welcome back. A little housekeeping before we start. Thank you to the Montage Health Foundation for their support of my quest to improve my podcast and produce fun and engaging education for healthcare providers on addiction, and thank you also to the nonprofit Central Coast Overdose Prevention for partnering with my podcast to help provide good education about addiction. Okay, today's episode is a bonus episode.
Speaker 1:I speak about drugs and alcohol at schools a lot I think I go to more than 20 schools a year and some of the schools allow me to speak both to the students and the parents, and I updated my school lecture on drugs and alcohol recently and I presented it at two schools and I got great feedback. One of the schools was my daughter's school, which you'll hear about, and one of the other schools asked me to make this lecture into a podcast episode so folks that couldn't attend could still listen. So I am turning my school student and parent lecture into a podcast episode. A few clarifications before we start. First, I speak about the man who made the art that is my podcast logo. His name was Paul Harper and I speak about him as I lecture. Unfortunately, we lost him to an overdose in 2019. He was a great guy and I appreciate how much he taught me about addiction.
Speaker 1:Second, I have to make a correction. While I'm lecturing, I mentioned a brand of beer called Voodoo Rider. I made an error there. It's actually Voodoo Ranger. And while we're on the topic of alcohol, I also wanted to clarify that the term proof refers to twice the alcohol percentage of a beverage. So 80 proof is 40% alcohol. Third, I mentioned that legal substances have warning labels. Both alcohol and nicotine packaging have warning labels on them and each is unique to that substance. As in alcohol, packaging has warning labels about alcohol, and nicotine product packaging has warning labels about nicotine. And finally, just to level set, cannabis is a plant. Thc is the substance in cannabis that acts as a downer and that is the substance that people are looking to get when they use cannabis. And my apologies, I used the terms THC and cannabis interchangeably during the lecture. With that, here we go. All right, so we're going to do a bonus episode.
Speaker 1:I was really hoping to record this live, but I wasn't wearing the right shirt and I couldn't put my iPhone in my breast pocket. So I'm actually going to go back and rerecord this. But I was asked by my daughter's school to give some education around drug and alcohol use, and I also go to a lot of schools and I wrote a lecture about a year and a half ago and it was starting to get stale. So I'm going to share with you today my updated version of substance use education for students, and, given the level of detail I go into, it's something that's also good information for parents.
Speaker 1:So with that, we'll dive in. So I'm going to give you what it looked like and felt like when I was speaking to both students and parents, and I'll pivot back and forth to talk about how I present the topic differently. So the first slide that I have is a giant picture of a box of naloxone, and, if anyone doesn't know, naloxone, also known as Narcan, is the nasal spray that can wake someone up from an opioid overdose. And I did something a little bit unique when I was at my daughter's school, and let's hear about it right now. Hello child.
Speaker 2:Hello father.
Speaker 1:What's up?
Speaker 2:The sky.
Speaker 1:All right. So what happened on Monday?
Speaker 2:So Monday you came to my school and you talked to everyone about drugs and alcohol and we did a Narcan training at the beginning.
Speaker 1:Who did the Narcan training Me Very nice and who was your victim when you Narcan them?
Speaker 2:You and it was really fun because you were just like laying on the floor and then randomly you got up. And then I was confused because you weren't supposed to get up, but then you laid back down.
Speaker 1:You were having trouble opening the package with a microphone in your hand.
Speaker 2:Well, yeah, I just wanted you to hold it, not stand up.
Speaker 1:Okay, so minus my bad, acting as an overdose victim, exactly.
Speaker 2:Overdose victims don't stand up bad.
Speaker 1:Okay, was it hard to give the?
Speaker 2:Narcan. No, you just put your pointing finger on the top, your middle finger on the other side, then you put your thumb on the bottom and push the plunger, not hard.
Speaker 1:Do you think your friends got a lot of education out of it?
Speaker 2:I feel like most of them, if they paid attention.
Speaker 1:And do you carry Narcan in your backpack? Yep.
Speaker 2:It's in my front pocket so I can get it really easily.
Speaker 1:Anything else you want to add about giving me Narcan for the first time Actually, the second time, because I dragged you to a Narcan training two days before, and you gave me Narcan then too.
Speaker 2:Whee, isn't it so fun to be the child of two addiction specialists.
Speaker 1:Thank you so much to my kid for doing that. I am obviously so proud of her. But yes, naloxone is a nasal spray. It wakes people up from overdose, specifically an opioid overdose. Each overdose looks a little bit different. An opioid overdose is going to present as unresponsiveness and also not adequate breathing, so a person might be gurgling or just not breathing well and in that case what you're going to do is call 911 because clearly they need medical attention. And then you're going to open up your package of naloxone and you're going to put the spray in your hand, as my daughter pointed out, and then put it in their nose and press the plunger and then 911's on the way. They bring more Narcan and I've probably gotten 80 doses of this stuff when I educate. It does not hurt anyone if they're not having an opioid overdose. Does not hurt anyone if they're not having an opioid overdose.
Speaker 1:Next up, I want to talk about addiction, and if you look at the podcast tile the icon of my podcast it's a painting, and that painting was done by a friend of mine named Paul. Now I learned addiction after my residency training, after I was done learning as a doctor, and I learned a lot of what I know about addiction from my friend Paul. His name was Paul Harper and this is his art and I show the families his art and I talk about what addiction is. And at the simplest level, addiction is the idea that people don't like how they feel in some way and they seek a substance to feel differently. And for many people they get an unexpected response where their brain gets intense pleasure from the chemical or it helps really numb out a trauma that couldn't be dealt with before. And it starts usually as casual use and progresses to more regular use because of a couple of things. One is that people develop tolerance Over time. You have to use more to feel the same effects. People know this. With alcohol, people can quote hold their liquor. That means they have a tolerance for alcohol. They can drink a lot and they won't feel as much. And the other is dependence. People will use a substance regularly and when they stop their brain chemistry is out of balance and they feel sick. That's called withdrawal, and addiction is largely characterized by three Cs Cravings, an intense desire to use substances, compulsive behavior. With addiction the brain really loses the ability to make rational thought, the human part of the brain, the most advanced part of the brain called the prefrontal cortex is under-functioning with addiction and people really get very impulsive with addiction. And people really get very impulsive with addiction. The last thing is consequences. People develop health consequences like liver disease or heart disease, or they have an overdose, or legal consequences, they get DUIs, they go to jail and my poor friend, paul, who painted the art that you see in my podcast logo he paid the ultimate price.
Speaker 1:We can talk about all sorts of different substances, but when I'm talking to families, I usually start with the big three, the legal ones Nicotine most commonly we talk about vaping, alcohol and cannabis. And for an entire year when I was still doing shifts in the ER, I actually kept track of which addictions I saw the most. And alcohol, hands down, was the most common. And it's everywhere, right, you go to a grocery store and there's alcohol. You go to the gas station there's alcohol. Good heavens. We just had an event at my hospital for doctors. And what do we serve? Alcohol, it's everywhere.
Speaker 1:And I start my education by talking about how alcohol affects us. And that's really looking at the concept of a blood alcohol concentration or BAC, and the idea is and this is really dumb the more you drink the drunker you get. Most adults drink in maybe the one to four drink range. They drink a little bit, they maybe feel a little bit disinhibited, jokes are a little bit funnier, and alcohol is a downer. It's a depressant, it slows everything down. And so as people drink more and as adults we know this, but many of the students don't as we drink more, alcohol has a more profound effect on the brain. So maybe with five drinks it's hard to enunciate words. People begin to slur their speech. With 10 drinks we start to lose our balance. I can't even count the number of people I have had to sew up because they fell while under the influence of alcohol. People keep drinking 15 drinks. Now you get a blackout. The body can't actually make any new memories.
Speaker 1:Now, the one good thing about alcohol if there is one when it comes to my line of work is that high amounts of alcohol make people vomit, which is great, right. They get out the unabsorbed alcohol from their stomach and they usually stop drinking because they're so nauseated. So that's good, right. People vomit and they stop drinking. And then people get sleepy as their BAC goes up and then they stop drinking as well. And it's actually relatively hard to have a true life-threatening overdose on alcohol because of that, and we'll talk about that in just a minute.
Speaker 1:Now the next topic we discuss is alcohol poisoning and, if you're wondering, that's not a medical term. Alcohol poisoning is a non-clinical term. Essentially, and forgive me for being blunt, alcohol poisoning is when you drink enough and you get sick enough or sleepy enough that your friends and family can't take care of you. Right? If Bob has 10 drinks and barfs and we put him to bed and it's easy peasy, that person's probably not going to go to the hospital. But when family members are really worried, they can't wake someone up or they can't get him to stop vomiting. That's what we call alcohol poisoning as humanity. I'll talk about the clinical definition in just a sec. But we get as many at my hospital as five ambulances every day for this Very common and what I would need the students and the parents to know is that if you're worried someone has alcohol poisoning and this is again you're worried, they're vomiting too much, you can't wake them up, they're too sleepy.
Speaker 1:Please call 911. There's a couple of reasons. The first is they may not have absorbed all of the alcohol yet. So let's say, you get to a party and there's a guy on the couch barfing and there's a guy next to him and he's asleep. Okay, we don't know if that guy who's asleep just took five shots and then fell asleep and hasn't even absorbed those five shots yet, so they could actually get even drunker. So I tell everybody if you think there's any concern for alcohol poisoning, please, please, please, call 911. And the good news is there is a law that protects us. It's called the Good Samaritan Law. If you are using an illegal substance and someone near you has a substance-related emergency, an overdose, call 911. You will not get prosecuted for your illegal drug use. For the kids out there, if you're underage and drinking and your friend is having alcohol poisoning and you're worried, call 911. They will not bust you for underage drinking. We actually had in my community a 16-year-old that died in the back of a car because she'd overdosed on fentanyl and her friends were afraid to call 911. You can save a life. Please, please, please call 911.
Speaker 1:Now the adults usually have some experience with alcohol, but for the students, I wanted to give them a sense of how alcohol is sold and that there's value in them learning how to read the signage, the labeling of alcohol containers. So I went to a liquor store and I took out my iPhone and I took some photos. So I have photos on my slide deck you obviously can't see it of wine, of beer and liquor. And I show everybody on screen glasses of alcohol that are unlabeled. And I make the point you can't tell how much alcohol is in this by looking at the glass. So I show them a wine label it's a Malbec from 2023, and it's 13.5% alcohol. It has to be labeled. It's a legal, regulated product.
Speaker 1:We then look at a label of tequila. It is 40% alcohol. That's three times stronger than wine. And I make sure the students know if you drink tequila, make sure you drink about a third as much as you would wine, or you're going to get a lot more intoxicated. We then look at a brand of rum called Sailor Jerry. It's a little bit trickier. It doesn't list the percentage, but it lists the proof. Proof on this rum is 92. That's double the alcohol percentage, and so this is 46% rum. This is even stronger than the tequila. So you would want to drink less of Salo Jerry than Jose Cuervo because it's 6% stronger. Otherwise you're going to end up getting a lot more intoxicated.
Speaker 1:And the last thing we look at is beer, and beer has really gone a lot of different directions. You have the ultra light beer that's marketed to athletes. So I show a photo of a 98 calorie beer. That's only 4% alcohol. And then I found a brand of beer called Voodoo Rider. That's 9.5% alcohol, and I make the point. These are both cans of beer and yet the Voodoo Rider is over twice as strong as the light beer. In other words, I tell these kids if you haven't been offered alcohol yet, it's only a matter of time. Humans love alcohol. We've been drinking alcohol for thousands of years. I need you to know what you're up against. If someone hands you a can find out what the percentage is. At least you know how much you're going to get.
Speaker 1:Now, at this point in the presentation, I show a really disturbing photo. It's of a 14-year-old girl on life support, and this is a true life-threatening alcohol overdose. This is a girl with a breathing tube down her throat, into her trachea, her windpipe, and it's breathing for her. And at this point we talk about when alcohol can be lethal. When alcohol can be lethal and I remind everyone that we've talked about how alcohol usually when people drink it. It makes them vomit and it makes them sleepy, which is great because they stop consuming more alcohol. But this poor 14-year-old did something very, very unique. What she did is she drank really hard, really fast, and it's that particular style of drinking that leads to you getting enough alcohol in your system to actually make you stop breathing. And the way that this young woman apparently drank and her mother wrote about this in a UK newspaper to warn people about it is it's estimated that she drank something like more than 20 drinks in a period of one to two hours. Her blood alcohol level went up so fast she didn't have time to vomit or get sleepy. And I warn the students if you're at a party and somebody's drinking really hard, really fast, try to slow them down. You could make a big difference in them really having a life-threatening event.
Speaker 1:Okay, so the next substance that we see that's just as common as alcohol is vaping, and vaping is interesting. Right, you can va battery. It has a little tank where you can put in liquid and then it has a heating element. That's all it is. You could put in water, but it would likely produce steam and probably damage the device. But it's a very, very simple machine. Why do we have it? About 450,000 Americans die from tobacco every year.
Speaker 1:So somebody was just trying to make a safer cigarette and the kids don't necessarily have a sense of how this stuff is sold. So I went to a tobacco shop and I got my camera out and I took some photos and I started asking the guys that worked there so I show the students and the parents what I saw. I put up a photo of all these different examples of pre-filled vapes and they come in all sorts of shapes and colors. You can have watermelon and blue, raspberry and vanilla. And I even actually found three pieces of vaping paraphernalia One is shaped like Toad from Mario Brothers, one looks like Mario and one looks like Spider-Man. They actually look like McDonald's Happy Meal toys. So obviously there's certainly a component of marketing to kids.
Speaker 1:So I bought a vape. I thought it was really funny. It actually came as the flavor Virginia tobacco. I was just thinking who would buy a tobacco flavored vape? But they did. There's a huge warning flavored vape, but they did. There's a huge warning, warning. This product contains nicotine. Nicotine is an addictive chemical and that same warning was on the alcohol labels too. The vape container, the box gave me the ingredients vegetable glycerin, propylene glycol, nicotine, natural artificial flavors. It gave me the strength it was 5%. Nicotine salt. It gave me the number of puffs, which is an incredible 5,000. And it also let me know that it had short circuit protection, because early on vapes were actually exploding due to short circuiting and this one actually protects against that.
Speaker 1:Now, if you look at the ingredients of the vape, one of them is propylene glycol. And now I know what that substance is, do you? So the next slide I show is an Amazon search for a particular product, and it actually is antifreeze Premium Boiler System. Antifreeze, propylene Glycol Cooling System Fluid. Yes, if you are wondering, propylene glycol, the same ingredient as antifreeze, is in the vape liquid and actually what it is is. It makes the vapor so when people exhale and it looks like there's smoke coming out, that's hot aerosolized antifreeze. If you're wondering, we have no idea what the long-term health effects are. Now it's also important to know that vaping basically took the guardrails off traditional nicotine use and humans have been using nicotine like other substances for thousands of years.
Speaker 1:And let's start by talking about cigarettes. So a cigarette is basically dried tobacco leaf, cut into small pieces and put in a rolling paper to be burned Right, you light the tip. It makes smoke you breathe in. Cigar is a rolled tobacco leaf. It makes smoke you breathe in. Cigar is a rolled tobacco leaf. And chewing tobacco is basically minced up tobacco leaf that you put against your lip.
Speaker 1:And a cigarette contains about 10 milligrams of nicotine, but you don't get all of it when you smoke. So if you think about it, you light the cigarette and the thing burns right. So you sit there and hold it and if you don't inhale minus the secondhand smoke from being near it, you don't really breathe it in. And a lot of times people are smoking in a social situation where they just let it burn. So, for example, the average person only gets about two to three milligrams of nicotine with each cigarette, and on the screen I show a custom vape liquid that is a 100 milligrams of nicotine per milliliter. So that is 50 cigarettes worth of nicotine in a single tiny milliliter.
Speaker 1:And so what we're actually seeing is people's nicotine tolerance goes up so much higher with vaping because we're able to get it in a much more concentrated form, and this is a problem. It's so much more nicotine that it leads to side effects. The kids call it getting Nick sick when you get side effects from nicotine upset, stomach nausea, abdominal cramping. One school I went to was noting that they had a group of boys that were vaping and after they would go vape in the bathroom they'd all come out with abdominal pain. And the teacher asked me do you think that's related? And I said yes, they're all consuming too much nicotine. So one of my messages to the kids is someone hands you a vape, how strong is it? Do you even know?
Speaker 1:And the other thing I will point out is that nicotine is not benign. So I'm showing a custom vape liquid that is 100 milligrams of nicotine per milliliter. 60 milligrams of nicotine will kill a toddler. It can actually cause seizures and some other serious side effects. And we actually are seeing nationally more calls to poison controls when kids see a brightly colored liquid that smells good and they drink it and they get toxic on nicotine. The last point I make about nicotine is it is one of the harder drugs to quit. It takes the average person nine good faith attempts to quit nicotine and for kids under 18, we don't really have any options besides nicotine replacement therapy. In other words, people are dependent on nicotine. They feel withdrawal when they're not using it. All we can do is give them back some nicotine in the form of a gum or a patch or a lozenge and then wean them down. Very frustrating problem, all right.
Speaker 1:Next up is cannabis. Now, if you didn't know, more people smoke everyday cannabis in America than people who drink alcohol everyday in America, and my biggest message around cannabis is that cannabis is changing. I put together a chart that looks at the percentage of THC in cannabis over the last 50 years. In 1970, the cannabis was 1% THC. By 1980, it was 2%. By 1990, it was 3%. By 2000, it was 4%, and then we see a spike. By 2010, it's 10%. By 2020, it's 15%. By 2022, it's 18%. Cannabis is changing and this is exactly what happened with seedless watermelon. Right, we love watermelon, we don't like the seeds, so we used farming technology to breed watermelon that didn't have seeds. Same thing with cannabis. We just bred strong strains with strong strains and cannabis has increased in its potency over time.
Speaker 1:And I show the kids a picture of a cannabis cigarette, a joint, and I say take a look, you actually can't tell how strong this is by looking at it, and you can bet what I did next? I went to a cannabis dispensary. I have never been to one before. I was totally out of my element. But I went and I showed the kids a picture of what it looked like, as I did with the tobacco store and the liquor store. So I go into the cannabis dispensary and one of my friends uses CBD for chronic pains. I called him like hey dude, if I go to a dispensary cause I got to teach some kids a class, do you need anything? Because I didn't want to walk in there and just take photos and walk out. I thought that would be suspicious. So I bought some CBD for my friend. But while they were getting the CBD for me, I put my iPhone down on the display case and started taking photos.
Speaker 1:So here's the first strain of cannabis or cannabis product that I found. It is a cannabis pre-roll, so it's a pre-made joint, and this is 28.28% THC cannabis, so that is even stronger than the cannabis I was telling you about in 2022. So cannabis has already upped its game even more. The next photo I took was of a cannabis infused beverage and it was about a two inch bottle. It was two fluid ounces, slightly bigger than a shot of alcohol, and each bottle had 100 milligrams of THC.
Speaker 1:Now it's important that we know that we don't know the standard dose of cannabis that we, as healthcare professionals, think is a standard recreational dose. We actually do. For alcohol, a standard drink is exactly 14 grams of alcohol. So for alcohol, we've decided this is a standard recreational dose. We actually do. For alcohol A standard drink is exactly 14 grams of alcohol. So for alcohol, we've decided this is a drink Cannabis. We have no idea. Some people say it's as little as 2.5 milligrams. Some people say it's as high as 15. My guess is it's probably around five. So this is a two fluid ounce bottle and they're saying it has 10 servings and by my estimate it's more like 20 servings. So you can imagine what happens here, right? Somebody gets this tiny little bottle, drinks it all at once, and then it's a ton of THC in their system. And, just to level set, thc is the downer chemical in cannabis that usually humans use cannabis to get the effects of. Now it gets a little crazier.
Speaker 1:I found a brand called Henry's Original, and these are pre-made joints. There are four of them in the package and this cannabis was 43.23% THC, that is, 43 times stronger than the cannabis in 1970. And what's amazing is this package of four joints contains 864 milligrams of THC. That is anywhere from 80 to 160 times the recreational dose. That is an incredible, incredible amount of THC. What's amazing is my patients bring their THC products into clinic with me.
Speaker 1:I ask them how strong is it? And they're like what? It's cannabis. I'm like no, no, no, this is important. How strong is your cannabis? They're like doc, it's cannabis.
Speaker 1:So many of my patients who use cannabis don't know that cannabis from a dispensary is labeled with the percentage and there's some really strong stuff out there, just a level set. If you buy cannabis from a dealer, it's not going to be labeled. It could be laced. And then the last thing I say is just like with nicotine, vaping allows us to break the guardrails on how much nicotine we can use. Cannabis is the same way. I found a product that is 96% THC vape juice that is so incredibly, incredibly strong and we can actually start to see cannabis overdoses.
Speaker 1:And the common term for this is greening out. Kids will say I've never heard of a cannabis overdose. And I let them know hey, we call it greening out. And they're like oh, I know what that is. So what is greening out. Greening out is when you consume so much cannabis. It makes you sick like alcohol poisoning and it looks one of a couple of ways Usually like alcohol poisoning and it looks one of a couple of ways. Usually there's intestinal symptoms like nausea, vomiting or abdominal pain. It makes some people very sleepy, so it almost looks like alcohol poisoning and some people it actually makes them really paranoid and anxious and even hallucinate. People can be totally paranoid when they consume a lot of THC and this comes from the fact that it's just so much stronger Now.
Speaker 1:When I was in high school, I was always taught or at least the word on the street was cannabis isn't addictive, and I need my audience to know. As cannabis has changed, cannabis is now addictive. So we see the psychological phenomenon of cannabis craving, compulsive use, using despite consequences in about a third of regular cannabis users. And, because cannabis is so strong, we also see cannabis dependence. People get horrible cannabis withdrawal when they use regularly and try to stop, and those symptoms are restlessness, irritability, nausea, vomiting, insomnia, anxiety and depression Of some of my patients.
Speaker 1:I have to medicate to get off of cannabis and the last thing I'm going to say about cannabis is there was a study in 2024, it just came out last month and the title of it is Cannabis Use During Adolescence and Young Adulthood an Academic Achievement, a Systematic Review and Meta-Analysis, and I talked about this in one of my previous podcasts. But there's some data that cannabis really affects academic performance, and this was a large study looking at many smaller studies and aggregating the data, and they found that for kids who use cannabis in their teen years, they are less likely to get a B average or better in high school. They're less likely to graduate high school. They're less likely to get a B average or better in high school. They're less likely to graduate high school. They're less likely to go to college. They're less likely to graduate college. They're less likely to get a graduate degree and they're less likely to be employed compared to the kids that didn't use cannabis. And the best way I can say this is drugs and alcohol change how your brain grows if you use them during the teenage years and it's almost like it doesn't let your brain get to its full potential.
Speaker 1:Okay, on to the last substance of this talk, which is fentanyl. Now fentanyl, as I've said many times on this podcast, is a very useful medicine. I use it all the time. At the hospital, when I was working in the ER, somebody comes in. They've got bad abdominal pain. I don't know what it is. Is it the stomach flu? Is it appendicitis? Okay, let's give them 50 micrograms of fentanyl. It's a very small amount. Let's send them for a CAT scan, get some blood work, get a urine test. We'll figure it out. By the time all the tests come back, the fentanyl's worn off and if it's a benign diagnosis, they can go home.
Speaker 1:Now fentanyl has been around since the 1960s and it's very useful for severe pain around surgery in particular. And the problem with fentanyl is that it is just so strong, and I actually show some photos in the slide deck of just how potent fentanyl is. But here's the best way I can explain to you how strong fentanyl is. Let's imagine a four gram sugar packet. That is a large sugar packet. The amount of fentanyl that would fit in that packet is enough for a drug dealer to sell 40,000 doses and enough to kill 2,000 people. Let me say that again the amount of fentanyl that would fit in a large four-gram sugar packet is enough for a dealer to sell 40,000 doses and enough to kill 2,000 people. It is so incredibly strong. Unfortunately, fentanyl is not the worst to come.
Speaker 1:Fentanyl is made in a lab and it can be modified in a lab. So we are starting to see these other fentanyls with side groups like you add a methyl group and now it's methyl fentanyl. You add a furanyl group and now it's furanyl fentanyl. Some of these we have no experience with as healthcare providers and they are here where I work on the Central Coast of California. Now I also show some pictures of fentanyl. Some of my patients use it as a white powder. Some of my patients find that the powder's a different color. It might be pink, it might be brown, rainbow fentanyl was a thing for a while and that was basically just powdered fentanyl pressed together and dyed different colors.
Speaker 1:But most often what I'm seeing here is fentanyl is in counterfeit pills and I show some examples. So Xanax is a popular downer, a benzodiazepine. A lot of times my patients think they're buying Xanax on the street. It looks like a Xanax. It's not. It's fentanyl. People get told oh, I found some oxycodone and it even looks like an oxycodone. It's got an M on one side, it's got a 30 on the other. It's blue. It oxycodone, 30 milligrams.
Speaker 1:It's fentanyl and unfortunately these counterfeit pills are not made well. So if you go to the pharmacy and you're given a tablet whether you buy it over the counter or from a doctor if you break it in half, half the medicine is on the left side of the tablet and half is on the right. These counterfeit pills are poorly made. The fentanyl is unevenly distributed through the pill and we actually saw this once come through my ER. So we had four high school students that thought, okay, we want to try a pill, but we heard it could be fentanyl, let's be safe. So they broke it into four pieces. One kid got the piece with most of the fentanyl in it. He overdosed and required naloxone or Narcan. Thank goodness someone had it no-transcript.
Speaker 1:Now when I talk to parents I also want to talk to them about what they can look for that suggests that their kid might be on one of these substances. So we unfortunately have made friends with some of the moms who have lost their kids to fentanyl poisoning, and the moms actually here where I work in the Central California area have a support group. It's called the Window of Awareness and Hope. You can actually check them out on the web. They have a website group. It's called the Window of Awareness and Hope. You can actually check them out on the web. They have a website. Horribly tragic, but they are coming together and finding strength, that they are trying to help families not suffer the same fate as their own, which is to lose a child to fentanyl poisoning, and we've actually had some of them speak about their experiences. And when we asked the moms, what do you know now that you wish you had known, then that would clue you in that your kid is using?
Speaker 1:The answer is look for a change, and this is pertinent for the students as well. If you're worried about your friend, what are some signs that your friend, your loved one, might be using substances? Changes in their mood, changes in their weight, missing responsibilities. You used to love soccer. Why don't you go to soccer practice? Sleeping more, sleeping less. Changes in grooming, changes in irritability or anger, changes in hobby participation and changes in hygiene. If there's something in your mind that says something's not right, listen to that.
Speaker 1:Now, the next question I always get asked is where do people get this stuff? I went to a liquor store, I went to a tobacco shop, I went to a cannabis dispensary. That's easy, right? People get substances that way. But how do people get harder stuff? How do people get the fentanyls, the methamphetamine, how do they get other stuff? And the answer is they get it from many sources. It might be a traditional drug dealer. You can buy substances on social media, you can go on the internet, you can go on the dark web. You can get them from a friend, you can get them from your family's medicine cabinet. Drug dealing is really changing.
Speaker 1:I graduated high school in 2002. At that time I always thought about drug dealing as you had to go find your dealer. Things are different. I'll give you an example. So we recently detected a substance in Monterey County, where I practice medicine called hexanolophentanyl and I wanted to find out what it was. So I Googled it and I found, as the very first hit on Google not the dark web a pharmaceutical company in the Cayman Islands that was willing to sell me Hexanoil, fentanyl. And these companies operate as legitimate pharmaceutical companies in other countries and American law enforcement has no jurisdiction. And these companies have gotten so brazen that they will actually guarantee you a second shipment if your shipment gets seized by law enforcement en route.
Speaker 1:I've talked to patients who talk about buying drugs on Craigslist. There are secret code words that let people know that no, these black roof tiles are not actually roof tiles, they're actually black tar heroin. There's actually and you can look this up on the web on the Drug Enforcement Administration they call it the emoji drug code. Certain codes of emojis suggest drug use. It's so easy to get substances and a lot of times dealers will actually come to your house and deliver it. So you text your dealer a certain string of emojis. They'll bring you substances.
Speaker 1:Now why would a person want to use substances? As I mentioned at the very beginning, people are usually trying to change how they feel. They may be sad, they may have been traumatized, they may feel out of place, they may feel hopeless, and the substances change how they feel. For many of our, our patients, they didn't think they were getting fentanyl. They thought they were getting legitimate oxycodone because of pain. There are so many reasons why people use substances and I think the best way I can tell you how to think about this is if I go to any third grade class in Monterey County or California or the United States or whatever country. If you ask the third graders what do you want to be when you grow up? A doctor, a soccer player, a movie star, an astronaut? No one says addicted to drugs and in and out of jail and in and out of homelessness. Getting addicted was never on anyone's radar as what they wanted to do.
Speaker 1:There's always a story. So when you meet someone with addiction, don't ask them what's wrong with you. Ask what's happened to you, and you can do that with friends and family and if you're a parent, you can ask your children what happened. What's wrong, friends and family? And for a parent, you can ask your children what happened. What's wrong Now for the parents and for, let's say, students who have a younger sibling? We need to have this conversation with our youngsters. I tell parents if you haven't started talking about drugs and alcohol by the transition from fifth to sixth grade, you are behind right.
Speaker 1:I always ask my patients how old were you when you started using drugs and alcohol? And most of them say somewhere between 11 and 13. And when I go to middle schools, I tell this to the kids. I literally say who is 11 in this room and the hands go up. Who is 12? Who is 13? The hands go up and then I tell the kids guess how young my patients are when they start using 11 to 13. So, as humans, we tend to get defensive.
Speaker 1:So start by talking about how it affects others. Talk about a national news article or a notable event nationally, frame it as a problem elsewhere and then inform yourself. Obviously, a forum like this is great for that. There's lots of great podcasts, including my own shameless plug about addiction. Even news podcasts can talk about fentanyl or naloxone, whatever it's going to be. But start with a simple question like hey, I heard about naloxone on the news. Have you heard anything about it? Do you think we as a family maybe need to carry Narcan? Gosh, I heard a news story about fentanyl. Do you know anything about it? Gosh? How can our family help? That's how to start the conversation. Frame it as how your family can be part of the solution for someone else's problem. Now you might have the conversation, and it went great. You might have the conversation and it didn't. Don't give up. It's such an important conversation, you've got to keep having it. It's really important to keep talking about this to keep our community safe, to educate our students.
Speaker 1:And I'll share with one last personal anecdote. A couple of years ago maybe more seven, eight years ago as a family. We had just had Halloween and my wife and I were debating which of the candy to let our daughter have and there was something with Red 40 and who knows what dye. And my wife is going no, I'm not letting our daughter have this. And I said sweetheart, the world is full of vices and candy is one of them. We've got to teach our daughter how to live in a world full of vices, and that's really the best message I can give the students is when you go to high school, you will be offered drugs and alcohol. When you go to college, you will be offered drugs and alcohol. I need you to learn about it now so you can understand the ramifications of the decisions that you're going to make. And to the parents teach your kids how to live in a world full of vices. Instruct them, teach them, give them knowledge.
Speaker 1:If you're wondering, giving your kids alcohol early to train them is actually the wrong answer. I have an entire podcast episode on that. The data would suggest that the earlier drug and alcohol use starts, the more likely addiction is to develop. If you start using drugs and alcohol before 13, you have about a two-thirds chance of developing addiction If drug and alcohol use starts at 15, that risk is now down to about 25%. And if kids wait till after 21, that risk of addiction drops to less than 10%. So we need to inform our youth, inform our families and encourage waiting as long as possible before starting. And that wraps up this episode.
Speaker 1:A few final clarifications. The first is the dosing of recreational substances For alcohol. As I mentioned, we as medical providers have determined that the recreational dose of alcohol is 14 grams of alcohol. That's called a standard drink. It's one 12-ounce 5% beer, it's one 5-ounce 12% glass of wine and it's one 1.5-fluid-ounce shot of 40% liquor. For cannabis, we don't know what the standard dose of THC is yet. As you heard, my estimate is that it's about 5 mg of THC, but estimates vary from as low as 2.5 mg up to 15 mg. Hopefully we get some clarity soon.
Speaker 1:And finally, I wanted to share how fentanyl can be used safely at the hospital but kills people in the recreational drug market. And the answer is the dose. The medical dose of fentanyl is 25 to 100 micrograms. That's micrograms. Those are tiny and when I asked the pharmacy for a dose, they give me that exact dose. In the recreational market no one knows how much fentanyl you're getting. It could be 100 micrograms. You can imagine that's a tiny dose. It's really hard to accurately measure that, so you actually could be getting more like two milligrams of fentanyl, which is enough to kill you. It's the fact that fentanyl is so potent and the fact that how much gets put into the drug supply is totally unregulated that's what makes it a killer. I hope you found this lecture to be helpful. Please share it with someone who needs this information and with that, thank you for listening and for the medical providers out there that are listening. If you treat addiction, thank you for what you do, and we cannot forget treating addiction saves lives.