Addiction Medicine Made Easy | Fighting back against addiction

How To Use Naloxone Like a Pro with Dr. Reb Close (Rebroadcast)

• Casey Grover, MD, FACEP, FASAM

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Addiction medicine specialists Dr. Casey Grover and Dr. Reb Close share essential information about using naloxone (Narcan) to save lives during opioid overdoses. They discuss how naloxone administration differs between hospital settings and community response, emphasizing that having this medication readily available is crucial in today's world of fentanyl-contaminated street drugs.

• Naloxone should be as normalized and common as fire extinguishers in homes and workplaces
• In medical settings, naloxone can be carefully titrated to prevent precipitating severe withdrawal
• In community settings, the protocol is simple: administer nasal naloxone, call 911, wait for help
• Only 4% of naloxone prescriptions are actually picked up at pharmacies, making direct distribution essential
• Almost all street drugs now contain fentanyl, placing anyone who uses illicit substances at risk of opioid overdose
• Effective community training includes brief videos, hands-on demonstrations, and normalizing the medication
• Emerging substances in the drug supply (xylazine, synthetic benzos) make naloxone even more important
• Framing naloxone as a tool to help others rather than oneself can overcome stigma-based resistance

If you want to conduct a naloxone training in your community and need resources like videos, slide decks, or handouts, please email Dr. Grover. 

Together we can ensure everyone has the knowledge and tools to prevent overdose deaths.

To contact Dr. Grover: ammadeeasy@fastmail.com

Speaker 1:

Welcome to the Addiction Medicine Made Easy Podcast. Hey there, I'm Dr Casey Grover, an addiction medicine doctor based on California's Central Coast. For 14 years I worked in the emergency department, seeing countless patients struggling with addiction. Now I'm on the other side of the fight, helping people rebuild their lives when drugs and alcohol take control. Thanks for tuning in. Let's get started.

Speaker 1:

Today's episode is going to be on using naloxone to save a life when someone is experiencing an overdose. Now you may recognize this episode as it originally came out in 2023. It's an interview with the very lovely Dr Reb Close, who is my colleague in our addiction medicine practice and she's also my spouse. We're actually on vacation this week so I didn't have time to record a new episode, so I went back and cleaned up the audio from this episode on naloxone and I am putting it out on the pod again, since knowing how to save a life using naloxone when there is an overdose is an essential skill for all of us as community members.

Speaker 1:

When people die of overdose, they never get another chance to get treatment for their addiction. One quick point if you want to do a naloxone training in your community and need resources such as videos, slide decks or handouts. Please email me. We'd love to share our work. My email is in the show notes. With that, we are going to enjoy our trip, and this episode is a timely reminder of how to use naloxone. Let's go, dr Close. Let's start with you telling us your story in medicine and what you do now.

Speaker 2:

Hi, thank you so much for having me on the pod. I'm really grateful to be here. Hi, thank you so much for having me on the pod. I'm really grateful to be here. My name is Reb Close and my first training was in emergency medicine. I trained at UCLA go Bruins and I worked in the emergency department from 2003 until just a lot of people struggling with undiagnosed substance use disorder, dependency and addiction they would present to the ED with a multitude of complications from untreated substance use and mental health-related issues, and over my career I watched these patients suffer and I watched them have challenges in seeking and receiving care, and so later in my career I really started focusing on that incredibly vulnerable population. And then, with my colleague, dr Casey Grover, we did our second board certification in addiction medicine and a couple of years ago I took myself out of the ER and I now do addiction treatment and advocacy full-time, and I now do addiction treatment and advocacy full-time.

Speaker 2:

My three main areas of practice right now is I work in a I call it a brick and mortar clinic. It's a typical clinic that we see patients with really complex addiction issues in our clinic and I'm fortunate for the support we have there. We have a peer support specialist that we work side by side with. My second practice is in street medicine, where literally we see patients right there on the street and that is truly an incredibly rewarding experience to meet people where they are and to be ready for anything you can do to offer them, make that available to people that otherwise have really no access to care, to people that otherwise have really no access to care.

Speaker 2:

And then my third practice that I'm working with right now is I help out in our jail, and our jail is run by a private entity that's the jail medical, but I'm able to go in, we connect with the patients, we make plans for their discharge and aftercare and then I get to follow up with them in the clinics, which is pretty incredible to see them get their lives back and get follow up with them in the clinics, which is pretty incredible to see them get their lives back and get to work with them in that setting. So that's what I'm doing now and how I got there. So thank you for having me here today.

Speaker 1:

Absolutely so. That brings us to our first question on the topic of naloxone. So you put in 20 years in the emergency department. When you were practicing in the emergency department, how did you use naloxone? Talk us through how to naloxone like a pro.

Speaker 2:

So you know it's been really a lot of learning and quite the journey. But I learned pretty early on in my career that too much naloxone could be a challenge. And in the ER you have all these things at your disposal You've got a pulse oximeter, you have nurses, you have extra hands and extra people and equipment to really to get naloxone on board as quick as you can. We would do it literally through the genes, do injections and get naloxone in someone significant doses as quickly as possible, because it was literally life and death.

Speaker 2:

Now the alternative is in the ER when someone's say recovering from an overdose or you're not quite sure what's happening, you can give a little bit of naloxone. So I was a big fan of the 0.4 IV and if someone their respiratory rate was slow, their oxygen seemed to be dipping, let's give them 0.4 of Narcan and just see, typically for a patient, that wouldn't wake them up to agitated acute withdrawal. Instead it would help their breathing, it would support their respiratory status and therefore they were in a safer position In the ER you have that option and I learned over the years how to really carefully walk that line of too much versus not enough. When you have the right resources. It's a lot more nuanced than it can be, so just summing that up, critical presentation apneic blue.

Speaker 1:

Just give it till they wake up, unresponsive. But if they're more just depressed or sleepy, it's maybe titrate until they're not in severe withdrawal, but they're breathing on their own.

Speaker 2:

Yeah, they're maintaining their oxygenation. They have a reasonable respiratory effort. It definitely is more nuanced and you can afford to do that. You have the time for it, if someone is not in that critical life-threatening situation.

Speaker 1:

So I and disclosure, dr Close and I have worked in the same department for 10 years. I've heard you make this comment to some of our nurses let's not make a rhinoceros. Tell me what you mean when you're telling the nurses let's not make a rhinoceros.

Speaker 2:

Right. So one phrase that I've used very frequently in the ER is don't poke the bears Like absolutely not. I don't want to take someone who is calm and comfortable, breathing well, oxygenating well, their heart rate is good no-transcript. Someone is literally fighting the staff. They're in that fight or flight mode. What I didn't realize early in my career is that was acute withdrawal. And later in my career now I understand that's exactly what we were doing. And so those big doses of naloxone we could easily turn someone from a very comfortable patient who's doing fine to someone who truly is like a wild rhinoceros in my emergency department.

Speaker 2:

In severe withdrawal Absolutely. Oh my gosh, the agitation and discomfort. When you step back and look at it from the patient perspective, that level of discomfort almost warrants that kind of a response from them.

Speaker 1:

So once again, critical presentation. You're worried the person might not survive, just push naloxone. But again, if there is an opportunity to be a might not survive, Just push naloxone. But again, if there is an opportunity to be a little bit more careful. You titrate, absolutely, absolutely. So let's change the scenario a little bit. I know you work in a street clinic for patients with opioid use disorder and you, as you mentioned, also have an outpatient clinic. Now that you're out of the emergency department, talk us through how you use naloxone in your practice now.

Speaker 2:

Okay, so I mentioned in the ER you have nurses and you've had pulse oximeters and you have patients on monitors and you can give little tiny IV aliquots and make sure that you can go through the nuance of a comfortable situation for the patient On the street. I don't have that. Typically, when I'm responding on the street I grab a box of our nasal naloxone and that's what I have and I don't have a pulse oximeter and fortunately, with my medical training I'm very comfortable. I'll check their pulse, I'll put my hand on their chest. I can easily see what's happening from basically my eyes and hands on a patient no-transcript without sending someone to the hospital.

Speaker 2:

Well, I don't get the choice of whether or not they go to the hospital. I get the choice of whether they get evaluated by EMS, and it is my standard of care is to contact EMS for a full assessment. They can do that pulse oximeter. They can put them on a monitor, they can talk with the patient. This isn't a game that I play by myself, okay, I was going to say so.

Speaker 1:

For every one of these out of the emergency department, you're calling 911. I mean, you and I both know who knows what they overdosed on right, was it methadone? Was it isotonitazine?

Speaker 2:

We have no idea what they overdosed on or if that's really what's happening Like. You need 911 in that situation just like anybody else, and this is a big part of what I teach in the community.

Speaker 1:

You got to have that help A little bit of a take home here Any overdose outside of the emergency department or inpatient, setting 911, give naloxone if you've got it and then most likely they're going to get transported to the hospital unless, for some reason, ems decides they don't need to, absolutely. Yeah, yep, all right, so we've talked about using naloxone as a healthcare provider. What's the best way to get naloxone in the hands of our patients who are the highest risk of having an overdose?

Speaker 2:

who are the highest risk of having an overdose, normalize. We need to make this like a fire extinguisher, a seat belt. I mean, truly I don't believe I'm about to burn my house down, but frankly it could happen. So you have to have a fire extinguisher. You've got to be ready for an emergency situation, and that's really what I talk about when I'm trying to help the community understand why we want to get naloxone, basically anywhere we possibly can is you don't know when something bad is going to happen, but if you're not able to handle it, unfortunately these are fatalities that result from us not having naloxone and not being able to respond to an emergency situation. So when I want it in the hands of my patients and their family members, I hand it to them. You know, this morning I was checking on one of my patients and I literally handed his dad five boxes of.

Speaker 1:

Narcan? Do you not prescribe it? What makes you give it to them as opposed to giving them a prescription?

Speaker 2:

So one of my dear friends who is also our lead pharmacist for our regional coalition. She taught me that about 10% or less of the naloxone prescriptions that come through the pharmacy actually get picked up. So people will pick up their other medications, they will pick up, you know, anything else that they want at the pharmacy, but they will leave the Narcan. And is that because of stigma? Is that because of cost? It is for some patients, but even when it's covered by their insurance and it is free of charge, people will decline. I don't know all of the reasons for that, but I assume many of them are related to perceived stigma or actual stigma. So what I have learned is it is so empowering to tell a patient, to tell a family member, to tell their friends. I'm going to give this to you. You may need it for your friend, you may need it for any one of our community members, but I'm going to give you this medication that you can use to save a life, and people can relate to that.

Speaker 2:

I actually read something just a couple of days ago that said 4% of prescriptions are actually picked up at the pharmacy, 4% of prescriptions for naloxone. It's better to put it in their hands and then you also get to have that conversation Put it in your purse, keep it in your car. I tell them about a time driving back from something with my daughter and literally there was someone slumped over on the side of the road doing the U-turn, grabbing the Narcan Like you just need to normalize this, and I think that's the way that we get it into the hands of our community is hand it to them literally and then help them understand that this can happen anywhere, anytime, and they need to be ready.

Speaker 1:

Yeah, just one clarification. You know, naloxone is the generic name Narcan. I don't know what marketing they did, but they just burned it into the memories of healthcare providers, I mean. Most people still call it Narcan, oh, totally.

Speaker 2:

I'm one of them.

Speaker 1:

There's some yeah, me too there's Cloxado and there's Evzio. There's all these other brands. For the most part here in Central Coast of California we're using nasal naloxone in the community with the brand name is nasal Narcan. So both of us will slip up here and there and call it naloxone or Narcan, just to clarify. We've had a lot of support here in California from the state in actually paying to give the boxes of nasal Narcan into the community and we'll talk about community distributions in just a little bit.

Speaker 1:

Yep, one thing I wanted to share that I've done and I love this. I asked my patient who has opioid use disorder you want some Narcan? No, no, what if you could save a friend? Hey, doc, maybe you're right. So I think what I tend to do is I tend to displace the need for Narcan. You would never need Narcan, but gosh man, we get overdoses the safe way. And gosh, I mean, what if a friend of yours who's using I tend to find that the offer of could you be a community member and just respond? People really respond well to that. Even when I'm giving people boxes of naloxone, unless I displace the need from them to someone else, I find that I get resistance.

Speaker 2:

I like that. I like that a lot. And that goes back to normalizing Totally Talking about overdoses from Safeway and talking about overdoses behind the library and gas stations. We do this all day, yeah.

Speaker 1:

Okay. So when you have a patient who you know is very high risk for having an opioid overdose, what do you think is the best way to make sure naloxone is where it needs to be when an overdose happens? Do you give it to parents, significant others, do you put it in their closet? What's your approach?

Speaker 2:

Again, it's with normalization and getting it to anyone who will take it. Essentially, you know we try to get it throughout the community, but specifically in our region. Basically, if you have gotten a substance off the street, it's going to have fentanyl in it or something worse. Correct, that's true. But if you're using cannabis off the street, we have had cases where those have had significant amount of fentanyl in them and have unfortunately resulted in overdoses. Our cocaine in our community, absolutely, If you're using cocaine in my community, just assume it's fentanyl and you're at very high risk for overdose, sometimes without any cocaine, it's just fentanyl, absolutely Do the talk screens.

Speaker 2:

There's no cocaine, only fentanyl. So you know the meth in my community. I often speak about how frustrated my patients are who are preferring to use methamphetamine, or that's their drug of choice. They don't get that choice. If you use meth in my community, you're, in addition, using fentanyl, so I think it needs to be everywhere and that's really something I try to help my patients, their family members, their friends. I help them understand. So I talk about the cannabis, I talk about the cocaine, I talk about the meth and let them know that any exposure could potentially be fatal from a dose of fentanyl. So I enlist them and empower them that you could save someone's life, whether it's your friend or anybody else. But because of what's on our street right now and what's in our community, I need to give this to you so you can save someone's life.

Speaker 1:

Yeah, I think for me. I just think who's likely to be the most responsible adult? Is it the spouse? Is it the parent? Is it the brother? Is it the roommate? Is it the best friend on the street? So I think that's where I target. Go ahead.

Speaker 2:

And then give it to all of them yes. So I think that's where I target Go ahead and then give it to all of them.

Speaker 1:

Yes, like every one of those people needs it Totally, Because then again they might save someone else on the street too.

Speaker 2:

Well, and totally, I actually have been known to say you know if you are around humans or pets that you really like you need to have Narcan.

Speaker 1:

I mean just this has got to be everywhere. Yeah, totally agree. All right, so now you and I have done too many naloxone trainings for our community, in our community, to count. As you reflect back on the various trainings that we've done, what do you think has been the most effective way to train community members on how to use naloxone and to get naloxone into the hands of community members?

Speaker 2:

So there's two parts to this. One is how do you make it easy for people to stop by after work, grab some Narcan, learn how to use it and then move about their day so structurally? I believe what was one of the most effective ways we did it is we rented out a center in our community and we set up in English a six-minute video playing on loop of how to give naloxone, and we did the same thing in Spanish in another room and we had flyers and information and pamphlets in each respective language in each respective room and people would walk in and somebody would direct them. Hey, just take a minute, watch this six-minute video you can watch it a couple times if you need to and then jump over there, talk to that lady who is me, and she'll get you some Narcan. And they did.

Speaker 2:

People walked in, they watched the video once or twice, they'd come over and I would ask them personally. I spoke with every person that came through my line do you have any questions? And some people were like nope, thanks, doc. And they were gone, and other people were yeah, I have some questions. And what was crazy is there at times was a line. It was like a receiving line at a wedding.

Speaker 1:

I remember that you looked like you were getting married. Yeah, it was crazy.

Speaker 2:

Total receiving line.

Speaker 2:

It was like 50 people waiting to talk to you and they were patient and they were kind and they were very respectful of. This is education I need and want and it was a really, really powerful, powerful scene that we had there. No-transcript. And essentially every time I train on Narcan, either myself or Dr Grover or one of my partners gets Narcan.

Speaker 2:

I have had oh my gosh if I say a hundred, it's probably an underestimate doses of Narcan in the last 10 years of training and literally you show people, you give it, and then you literally take the plastic device and you poke it on your hand, showing them there's no needle, nothing to get harmed with, and the eyes in the audience when you do that, they're just oh my gosh, and she didn't explode or fall over dead or all these things that they're afraid of. And so they get to see in real time a live human getting Narcan and having no side effects, no issues. And after I do these presentations, so many people will come up and like you gave yourself Narcan. Yeah, I do it all the time. And just normalizing again that this isn't something scary, it isn't something dangerous, there aren't fireworks or spiders that climb out, it's super easy and it's safe and I think that's the most important thing that I do in my trainings yeah, I usually laugh afterwards and tell people that's a little bit bitter.

Speaker 1:

I've probably given myself or you've given me, I don't know how many doses of naloxone, you know to our audience. We've been doing like we said, countless naloxone trainings. I can get you the video that we've recorded. I can also get you our slide decks. We're happy to share Gosh.

Speaker 1:

we've trained thousands of people on how to use naloxone. A couple other points that kind of I would make. I think the first thing I usually do is whenever I go to a naloxone training, I bring an expired box with me and I like it to be sealed, and usually what I'll do is I'll go through my slides, we'll talk about when to give it, call 911. We go over the expiration date, we let people know that after the expiration date the naloxone is still good. It loses about 5% potency for every year after the expiration date. And then I walk them through the box. I literally like almost above my head. I open it, I show them the two blister packs Again, we use the nasal Narcan here in the Central California area that we're working in and then I open one of the little blister packs and I show them.

Speaker 1:

This is what it looks like. I press the syringe and then the spray goes into the air and then I explain to them that's how this works. It coats the inside of the nose. You don't have to be breathing, it can be in any position that you want or need, I should say, and that, I think, helps people understand how the device works. And then I usually give myself a dose as well, or I ask for a volunteer. But yeah, I think unpacking the box has been really helpful for me.

Speaker 2:

I think there's one other thing on. That is, if someone and I do this as a demonstration, if Casey and I are presenting together, I'll kind of shake him and I tell the audience. If he wakes up and is like dude, come on, get off me, that's not a time for Narcan. You are not giving Narcan to someone who is high and that was an air quotes If they are unresponsive and poorly breathing and you are considering they are probably or possibly dead, you're giving Narcan and realize that difference between oh, you know he's nodding off but he's responding to me versus oh, my goodness, I'm afraid he's dead or dying. That's when you're giving 9-1-1. And it takes some of the fear away as well, because otherwise you just watch someone die.

Speaker 1:

Just to clarify. You said that's when you're giving 9-1-1. That's when you're calling 9-1-1 and giving naloxone.

Speaker 2:

Thank you. Yeah, you're welcome. I was paying attention. See Love it.

Speaker 1:

All right. So, thinking back on your career, what clinical case involving naloxone stands out to you the most, and why?

Speaker 2:

So it was in 2019 and we were starting to see something weird in my community. People were having overdoses and it didn't make sense. And I'll never forget this young man. He came in in an overdose situation. He'd gotten naloxone in the field and we were talking. He's like no, no, no, dude, it was just a Percocet. I was like, okay, all right. And then half hour later the nurse calls me and she's like he's not responding. He's not responding. So we gave him more Narcan and he responded. And that happened three more times. We finally put him on a Narcan drip and admitted him to the ICU and that's when we started piecing together that fentanyl had come to our community. And the reason that's so profound to me is I didn't know what was happening. I didn't know why he was continuing to overdose. It wasn't making sense and as a knee yard doc, I knew something was wrong, but I didn't know what. And I mean, obviously, I think we all know where fentanyl has taken us since then. So that case really stands out.

Speaker 1:

Yeah, I'm going to share one from my residency. So I was a second year resident in the pediatric emergency department and we get a call that there's an opioid overdose coming in on Opana. If you remember, that was hydromorphone, it was briefly on the scene and 2011,. That was a bad time with prescription opiates in America, and so, in any case, I'm a second year resident, I was the senior resident in the PZD and they're like Grover, you're on it.

Speaker 1:

I was like I got it and I'll never forget the paramedics wheeling him into our resuscitation band, him yelling please don't Narcan me, please don't Narcan me. And I remember the anger rising in my gut of like, oh, we're going to totally Narcan you, you deserve it. But I, of course, clinically, was like well, sir, we're just really worried about your breathing. We'll just give you a little bit of naloxone, see how it goes. But I was taught punish these people, make them suffer. I'm embarrassed. I mean I have goosebumps right now just thinking about the raw emotion and just I was hurting him. I mean I've read so many recovery novels and people talk about back in the nineties if you went into an ER, they'd push naloxone just to punish you, like you deserve it. So let's just take a minute and be grateful that we've learned and things have changed.

Speaker 1:

And the man was yelling at me. He clearly did not need naloxone and yet my training was really to punish people and make them withdraw so they would know how bad their decisions were and that would fix them. I mean, this goes back to my saying of all these years why do patients with addiction not get better? We judge them, we don't offer them treatment and it's impossible to get treatment right. One in seven Americans will develop a substance use disorder, yet less than one in 10 has access to treatment. This is what you and I are trying to do. Let's make treatment for addiction as friendly as treatment for asthma or diabetes. Let's make it as accessible. Sorry, a bit of a rant here, but I just I'll never forget that young man and how my training was to harm him. It just goes to the deep, deep stigma that's in health care against patients with addiction. It is truly systemic, systemic stigma. So, before we wrap up, anything else on naloxone that you wanted to add, so we tease a lot.

Speaker 2:

that and this sounds so weird to say and I know this audience will understand. But you have gotten to a point of missing heroin, because it was something you somewhat knew what was going on with your patients, you had an idea of dosing and you had an idea of how you could start buprenorphine easily, safely. Those were the days, so to speak. Or prescription opioids oh, my goodness, You're using how many.

Speaker 1:

Norco a day. Great, how many milligrams is that? Yeah?

Speaker 2:

I miss those days. It was a different world. And then we back, as I said, in 2019, we started dealing with fentanyl and we've learned so much over the last four years of dealing with fentanyl and we're getting a handle on it and, granted, it's super nuanced, but we're getting there. What scares me is what's next, and in our community. What's next are the novel benzodiazepines we're seeing carfentanil, we are seeing atizolam, we are seeing xylizine, bromazolam, I mean it's we're worried about isotonidazine, totally.

Speaker 2:

It's just. It's anybody's guess and my patients literally that I'm taking care of in the street clinic specifically will ask me can you test me? I don't know what's in my dope. And the truth is they don't. They have no idea, and so I talk very openly and honestly with my patients about that that I have no idea what's in your body Couldn't tell you. So we try to partner with them and talk with them through it. But the one thing that I would stick with as far as it goes in this episode about naloxone is that's the fire extinguisher we do have. So I don't have a magic antidote for bromazolam or atizolam or xylosine.

Speaker 2:

I don't. But fortunately and it's weird to say that, and you can hear the hesitation in my voice that the majority of these are mixed with an opioid, such as fentanyl, parafluorofentanyl, carfentanyl or something. So you still have a fire extinguisher that is likely to work. It may not reverse the entire overdose. That's why that 911 thing was so exciting and so important in the beginning. You still have to call for help because you can reverse the fentanyl or other opiates, but everything else that may be in their system, you don't have anything to treat them with. So, yes, narcan is one. It's that hammer and nail analogy. You know, all you have is a hammer, everything looks like a nail. Well, this is the hammer we have and fortunately most of our scenarios have nails, at least as part of the problem.

Speaker 1:

So it's almost like don't be nihilistic about naloxone Just because the drug supply is tainted, you could still save a life.

Speaker 2:

You absolutely can and don't miss that opportunity. You know, because if someone dies, they never get a chance to recover.

Speaker 1:

If you look at the artwork that's my podcast. That's a painting made by a friend of mine named Paul, and we lost him in 2019. Yeah, yeah, yeah. So we did talk about why do we like recovery. It's giving people their lives back. When you die of an overdose, you never get that chance for recovery. Before we wrap up, a huge thank you to the Montage Health Foundation for backing my mission to create fun, engaging education on addiction, and a shout out to the non-profit Central Coast Overdose Prevention for teaming up with me on this podcast. Our partnership helps me get the word out about how to treat addiction and prevent overdoses To those healthcare providers out there treating patients with addiction. You're doing life-saving work and thank you for what you do For everyone else tuning in. Thank you for taking the time to learn about addiction. It's a fight we cannot win without awareness and action. There's still so much we can do to improve how addiction is treated. Together, we can make it happen. Thanks for listening and remember treating addiction saves lives.