Search for tag: "overdose"

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Interviewer: Dr. Jennifer Plumb is one of the founders of utahnaloxone.org and is also in pediatric emergency medicine at University of Utah Health. From what I understand, the chances of me dying from an opioid-based overdose now is greater than me dying in a car crash. That shocked me when I heard that. Does that shock you? Should I be shocked?

Dr. Plumb: Well, you know, it doesn't shock me because I spend a lot of time thinking about and educating about in this world, but it's the truth. Right now, if you were to look at the most likely cause of death for yourself, opioid overdose would surpass cars, would surpass guns.

Interviewer: Some of this other data that had been released also says that you're more likely to die from opioids than falls, drowning, or even a gun assault. And again, these are all things you hear about all the time.

Dr. Plumb: Right.

Interviewer: We think this is the big threat, but it's actually that little bottle of pills in your medicine cabinet.

Dr. Plumb: Right. Well, or think about your family members, the children in your home, the people around you, as well as yourself, the things that you would be most concerned about, and I'll tell you, when I speak with families about keeping their kids safe, it isn't always on the top of their list of things that they worry about. They think about helmets, and they think about gunlocks, and they think about car seats.

Interviewer: All good things.

Dr. Plumb: Really important, smart things that we should all have in our homes. We should all have fire extinguishers. But for whatever reason, we have not been as astute and as knowledgeable about opioids and their potential risk in our homes and in our lives. We've gotten to this dreadful point.

Interviewer: Now, are we talking about pain pills or overdoses on legal opioid-based drugs?

Dr. Plumb: More illicit substances?

Interviewer: Yeah.

Dr. Plumb: So all of the opioids get lumped together when we look at data, and, personally, I think that's appropriate. It really is the substance that's killing someone. And if we go down the path of saying, "Well, you know, pain pills, that's different than heroin," we go down the same path of not acknowledging that, actually, those substances are very chemically similar, and they lead to overdose the same way, and the overdose death risk is equally high for them, and you respond to them the same way with having naloxone. So I think that, for all of us as society members, the key here is thinking about these substances in the same way we think about other risky constructs. So peak car crash deaths were in 1972. That's when we lost the most Americans to car crash fatalities. Think about all the things that have happened since then. We've put in airbags, and we've put in the brake lights. I think they're referred to as Dole lights. We have campaigns about getting people to drive smarter, Click It or Ticket, Arrive Alive, zero fatalities. We have a lot more cars on the road and a lot more people driving cars, but we have decreased those deaths.

We need to start thinking about opioid substances the same way. How do we make ourselves safer and smarter around them? How do we limit our exposure to the riskiness of them? And how do we be prepared for worst-case scenario? Which, I think, every time that we have a new way of looking at this crisis, and every one of them is horrifying, they come out and our life expectancy is going down. We're losing now 72,000 people in 2017 in the United States to opioid overdose deaths. That's 197 people every day. That's a 737 falling out of the sky every single day. Right?

Interviewer: Wow, all right. All right.

Dr. Plumb: I mean, it's enormous. And so we have to be thinking about these substances in ways that I don't want everyone to think, you know, I'm calling fire in a theater. I'm actually really asking be smart. If you do have these in your world, be prepared. What does an overdose look like? How do I respond to an overdose? What if that overdose was in my child? What if that overdose was somebody else around me? And then, if I'm going to allow these substances into my world, do I need them?

So, if you have a physician, a clinician, a prescriber wanting to put opioids in your home, in your life, ask a few things. Is this really necessary immediately? Do we need narcotics? Tylenol and ibuprofen are great options. Physical therapy, occupational therapy, mindfulness, acupuncture, acupressure, yoga, all of these have been shown to really help with pain. Should we look at those strategies first? Okay, we think we might still need those. I have a brother who died of a heroin overdose. Does the fact that addiction is in my family make us any more concerned about bringing narcotics into the home? Have that dialogue.

Then, finally have the dialogue, if it really does seem like they think that's the next big strategy, what's your plan to get me off of this in five days? Because in seven days, you can start having a dependence risk. In seven days, you can start developing that physical dependence on a substance that means that maybe in seven months you won't be able to stop.

Interviewer: Yeah. Or I've heard like if it's a 28-day supply, and 28 days coming off that could be just as hard as coming off if you were on illegal narcotics.

Dr. Plumb: Absolutely the same, exact withdraw, absolutely. So, as consumers and as health care consumers and individuals, we need to take that active role as well in having that dialogue with our team.

Interviewer: Yeah, especially with such dangerous substances. And I think one of the traps that we might fall into is, "Oh, I have a prescription for these drugs. I'm not an illegal drug user. So it's somehow safer." But as you said earlier, you got to judge the substance. The substance is the same regardless of how or why you're taking it.

Dr. Plumb: Right.

Interviewer: And now it's in your world, so what are you going to do to be safe about that? So I think that's a great point you bring up. Talk to your physician if they're going to recommend those, if you have a procedure coming up or whatever. Ask those questions that you asked. If you have somebody in your world that's a drug user, then you should also have naloxone around, because even if they're off now, they could relapse.

Dr. Plumb: Absolutely.

Interviewer: Or even if you just have the prescription opioid pills, have naloxone. It comes back to the substance again.

Dr. Plumb: Absolutely. And it is just like, to me, it really is just like a fire extinguisher. You have a kitchen. That means there's heat. That means there could be fire. Having a fire extinguisher is smart. It's safe, it's okay. Same thing, you have opioids in your world, whether it's for yourself or someone around you, you should have naloxone as well. Be prepared for that just-in-case scenario.

Interviewer: I hope that the big takeaway after somebody is done listening to this conversation is that these are serious substances that need to be treated seriously, and the data shows that a lot of people accidentally die from them.

Dr. Plumb: They do and that they perhaps are not perceiving just how risky they are. Be educated. Be aware. Be prepared.

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Interviewer: What would you do if a child or a grandchild accidentally got into your opioid pain pills? It can be a deadly scenario. Dr. Jennifer Plumb, what's your advice?

Dr. Plumb: I say the best strategy is to be prepared for the possibility. Even the most careful and prepared homes have incidents where children get into their pills. Kids get into everything. They get into cat litter, and they get into cosmetics. They also get into pills, which oftentimes look like candy. Being prepared with a naloxone rescue kit, which is the antidote to an opioid overdose, can absolutely save the life of a child.

Interviewer: And how do you, as a parent, get one of these kits?

Dr. Plumb: They can get a kit by talking to their physician to get a prescription. There are also several participating pharmacies where you can acquire a kit without a prescription and also local organizations who can help get you a kit if you need one.

updated: November 9, 2021
originally published: September 18, 2017

Interviewer: How should you handle an overdose situation? We'll talk about that next on The Scope.

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Interviewer: Hopefully, this is a situation you never find yourself in, but, in the event that you happen to be around when somebody is having a drug overdose, what should you do? Dr. Troy Madsen is an emergency physician with University of Utah Health. What should I do? That could be very scary I'd imagine.

Dr. Madsen: It can be. So drug overdoses, you think of a lot of different things. You can have people who just accidentally take too much of their medication, people who are taking opioids or illegal drugs and overdose on those, or people after suicide attempts who may take any of a number of different medications. And we see all of these in the ER. So I think the number one thing is, you got to get them to a hospital, and if it's as serious thing where they're not breathing, obviously, you've got to get 911 there and get them help as quickly as possible.

The other thing you can always think about is if you live with someone or if you are someone who uses opioids, potentially has an abuse problem, you can get naloxone. This is a medication that reverses opioid overdoses. You can get it through EMS departments, through state health departments, county health departments, and it's something that can absolutely be lifesaving. It reverses the effects of opioids, obviously that's a huge issue in the country. It's a huge issue in the state of Utah, I think we're number five or six right now in terms of opioid overdose deaths. So, if you have that issue, if you know someone who does, have that medication around.

Other overdoses we think about are things like, I mentioned like suicide attempts, and they're really serious thing there. It can be things like Tylenol, opioid medications again, things that make you stop breathing, some of the heart medications that can cause big heart problems. There, there's not a lot that you can do emergently.

I would tell you one thing not to do it, is not to make the person vomit. And some people may think, okay, person swallowed a bunch of pills, let me stick something down their throat or have them try gag themselves to vomit this back up. That can just create worse problems because if they're already a little bit drowsy or they're trying to vomit this stuff up, they can then breathe that into their lungs and that can make it a lot worse. So you don't try and do that.

You may have heard someone say, "I went to the ER and got my stomach pumped, someone put a tube down there and sucked everything out," we don't even really do that anymore. We just found out that the risk of aspiration of breathing that stuff into lungs was much greater.

So I would say the number one thing to do, any of these overdose scenarios, make sure the person is breathing okay, make sure they're alert, get them to the hospital, if it's a time dependent issue where they're not breathing well or they're drowsy, get 911 there, have naloxone around for people who have potential opioid problems or abuse issues and make sure that they get the help they need.

Interviewer: I'd like to back track just briefly here. What's that fine line between having too much and going to be okay versus going to go into an overdose situation? How do you make that call? What should I look for?

Dr. Madsen: Yes, that's a really tough call, because in medication like Tylenol, you may not know that's a serious overdose for several days. But, you've got to get the treatment for it as quickly as possible. So, if you live with someone and they're just not sure how much of the medication they took, it's going to be really tough just to look at that person, say, "Well, they're probably fine," because if they took too much of their blood pressure medication, they may act okay, but their heart may be in an abnormal rhythm that could then worsen to a life-threatening rhythm.

So it's hard to say, just look at how they look, look at how they're acting.

Interviewer: Really kind of follow your gut on that sort of a deal.

Dr. Madsen: You do.

Interviewer: What about like illegal drugs.

Dr. Madsen: So illegal drugs, yeah, I mean there it's . . .

Interviewer: If somebody is passed out after doing illegal drugs, would you call someone for it?

Dr. Madsen: Yeah, you really do. If they're passed out, you know, you don't know if they're just going to come to within an hour or so, versus are they passed out and they're just not breathing well and they're potentially having severe brain injury because they're not getting enough oxygen? That's really a tough situation. But I'd say, if they're not responding, you really need to get them to the ER.

Interviewer: Something not to mess around with?

Dr. Madsen: Yeah.

Interviewer: What about myths? You had mentioned one, that you want to get somebody to vomit up whatever it is they had, which you say, don't do because it just causes more problems. What about you got to keep somebody awake and they're going to be okay then?

Dr. Madsen: Yeah, you know, I guess it's more just monitoring them to see if they're staying awake, but if it's at that point where they're nodding off and you're really worried they're not going to stay awake, you really need to get them in for help because at that point, yeah, I mean, you're going to be trying . . . some of these medications are going to last at least four to six hours. And some medications they overdose on could last 24 to 36 hours. So you've got to get them in and get them help. You can't just sit there and try and keep them awake for hours on end, exactly.

Interviewer: What about privacy concerns? Because if I was in that situation and somebody overdosed because of illegal drugs, for whatever reason I happen to be there, if I call 911, now I'm afraid that there's going to be a bigger problem on the other end of it for everybody.

Dr. Madsen: Yes. That's a common concern. In the ER, everything is private. We're not reporting someone for drug use. I've never asked the police to come and arrest someone for drug use, that's just not something that happens. So don't let that stop you from getting help. All those things, things not to worry about and things, they're not going to be prosecuted for.

Interviewer: So don't play the what if game.

Dr. Madsen: Right.

Interviewer: If you truly are scared, probably best just to call 911.

Dr. Madsen: Exactly. Best to call 911, best to get them to the ER. understand that we see these sorts of things all the time. The good news is, 70, 80% of that time things are fine, the other 20% of the time, we may need to keep people for a while and admit them to the hospital to start treatment.

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Interviewer: Using Imodium to treat opioid withdrawals: a bad idea. We'll find out more about this disturbing trend next on The Scope.

Announcer: This is "From the Frontlines" with emergency room physician Doctor Troy Madsen on The Scope. On The Scope.

Interviewer: Doctor Troy Madsen is an emergency room physician at University of Utah Health Care and he said he'd seen a couple instances where people are using Imodium, which is an anti-diarrhea medication, as a way of trying to treat their withdrawal symptoms from opioids. I find this hard to believe. What's going on?

Dr. Madsen: Yeah. So this is really interesting. So as you may know, there's an opioid epidemic in our country and the Centers for Disease Control has acknowledged this and said we have so many people who are using opioids now. So prescription opioids, things like Percocet, Norco, Oxycodone are using that for to get high. Essentially what they may consider it legal high because they're getting a prescription or it's a prescription medication they're buying from someone.

So then, these individuals may then be saying to themselves, "I really can't be doing this. I need to get off this medication." So they're finding things on the Internet that discuss using Imodium or loperamide is the generic name and using that to sort of detox, taking that as a bridge to give yourself some of the same effects as the opioids give you while allowing your body to adapt and adjust and then gradually get off the medication.

Interviewer: So, first of all, bad idea trying to self-treat an addiction like that?

Dr. Madsen: Absolutely, not a great idea. But the reason they're doing this is because it's probably been out there for years and then I think it's just gained steam with some people posting things on the Internet about this. But Imodium or loperamide is actually an opioid. It doesn't give you the same high as things like Oxycodone, but it has kind of the same effects, acts on some of the same receptors in the body.

That's why it help with diarrhea because if you've ever heard of someone who says, "Hey, taking all these Percocets and I can't have a bowel movement. It constipates me." Well, that's kind of how this stuff works for diarrhea. Same kind of idea. It slows down the bowels but also then acts on somebody's same receptors in the body that opioids act on that people are using for highs.

Interviewer: Yeah. So self-treating bad but, above and beyond that, Imodium causes other problems that you see then?

Dr. Madsen: It does. And the big thing we're seeing is some of these people are just taking such incredibly high doses that it's been putting their heart into these arrhythmias, these abnormal heart rhythms that are life-threatening. And that's where we see it in the ER. I've seen cases of people coming in who are in just these crazy heart rhythms, these life-threatening heart rhythms and it's because they're taking large doses of Imodium and then that is triggering this heart rhythm.

And really, it's the kind of heart rhythm where you've got to shock their heart to get them out of it, get them on medication, do something for it or their hearts just not going to keep working and they're going to die from this.

Interviewer: That doesn't sound much better.

Dr. Madsen: It doesn't. It's not a great thing to do.

Interviewer: It doesn't sound like a great solution to the original problem.

Dr. Madsen: Yeah, there's not. There are much better solutions to opioid addiction and to getting off that. It's a sort of thing where you've come into the ER, we will often get people into in-patient detox programs. We can also prescribe medications that can help with this. So I would not recommend taking Imodium or loperamide. Again, that's the generic name for it. I would not recommend taking that to treat an opioid addiction because of the threat of these abnormal heart rhythms.

And this really comes up because there was actually just a study published or report in one of the big emergency medicine journals talking about increasing cases of this and increasing calls to poison centers for people who are taking more and more of these medications to try and treat opioid addictions and then are having very bad effects from this.

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Interviewer: Dr. Higgins, so when it comes to opioid pain pills, I'm getting the point personally, and I want to see how you would react to this with the physician perspective, that opioid pain medications, they're just really bad news and we really shouldn't have them in our medicine cabinets anymore. We really should look for other ways to treat pain because you continue to hear about deaths and overdoses and addictions. Am I being a little overstated on that?

Dr. Higgins: Yes and no.

Interviewer: Okay.
Dr. Higgins: There are certainly indications and uses for opioid pain medicines, where appropriate. And the presence of them in your medicine cabinet, by themselves, is not harmful. It is the chronicity of use, using them over a longer period of time, and ramping up the doses, which is, and this is proven in the literature, this is where people get in trouble.

Interview: What should we do about what seems to be going on? It seems almost like a national health epidemic. And there again, I may be overstating this.

Dr. Higgins: It's absolutely not overstating it. It is a national health epidemic. If you set aside cancer and heart disease, the thing that was most likely to kill an American under 65 was their car with some sort of motor vehicle accident. It was that way for some time. In 2003, it was the first year in the state of Utah where a prescription opiate was more than likely to lead your demise than a motor vehicle wreck. That was kind of revolutionary at the time. Now, it's that way in greater than half the states.

Interviewer: Okay. So we were kind of ahead of the curve.

Dr. Higgins: Yeah, it's nothing to be proud of.

Interviewer: Yeah, in a bad way, yeah. So it is something that we need to address. As a patient, if my doctor says, "I'm going to prescribe you some pain medication that's opioid-based," should I say, "I'd rather look for a different solution?"

Dr. Higgins: If you want to do that, your doctor should definitely respond. The old teaching was that as long as you had discomfort, the opioids [Audio skips 00:02:12] likely to be taking someone else's medicines. The people in the 40 to 60 age group are more likely to be taking their own medicine and they were on it chronically and they were on higher doses. And there are people here doing some pretty fascinating research on what the susceptibilities are. We may all have genetic susceptibilities to flip that switch. So even if you don't think you have "an addictive personality," then you can certainly develop one rapidly even if you don't think it's in you.
The other thing is to not necessarily judge those people that have had problems. Plenty of very prominent people and people who we wouldn't necessarily expect have certainly run into problems and, in some cases, have been fatal.

Interviewer: So at the end of the day, a physician perspective, what do we do to solve the problem?

Dr. Higgins: I think it's critically important of late that the public becomes aware and this happens through the lay press. And then, from a physician standpoint, we have to educate the patient at the beginning, the initiation of treatment. Secondly, have an exit strategy. Thirdly, entertain other modalities we can be using besides these medicines to treat the pain.

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Interviewer: You may have heard recently of a drug called Naloxone. What it does is it reverses opioid-based overdoses. So if you have an opioid-based pain pill or if somebody has a drug overdose that's based on opioids, it can actually reverse it and save their lives. Dr. Jennifer Plumb is one of the founders of UtahNaloxone.org, is also in pediatric emergency medicine here at University of Utah Healthcare, and Sam Plumb is the program's manager at UtahNaloxone.org.

I wanted to ask you both, why is this important to you? I've gone to the website. I see that you've put a lot of work into it. I see on my Facebook feed a lot of times you're trying to increase awareness. Dr. Plumb, why?

Dr. Plumb: We are in this position, I think, at a position of passion, but also at a position of a true desire that we can bring awareness to the epidemic that's gripping our state with opioid overdoses. We are fourth in the nation, which is a distinction that certainly nobody wants. We're not talking about it a whole lot, and I think that there are a lot of people out there who have at-risk family members.

We unfortunately lost our brother in 1996 to a heroin overdose, and since that time the situation has just gotten worse and worse. Naloxone was not legal to have in the home setting when Andy died, and it is legal now. So I think that we both feel very passionately that if one family can be spared what we went through, it's all worth it.

Interviewer: It would've saved his life you believe?

Dr. Plumb: Absolutely, I believe it would've saved his life. It would've saved his life.

Interviewer: So when you say we have opioid-based overdoses, are you talking about pain pill overdoses, intentional, accidental? I mean, what are we talking about here, people abusing?

Dr. Plumb: When the figures all come out, the Health Department puts them together and the CDC also puts them together, and they do look at all of those categories. They look at intentional or suicides. They look at accidental or poisonings. We are seeing in this state that we have continued accidental overdose increases. So what do these look like from an opioid perspective? Most of these poisonings and overdose deaths in Utah are from opioid substances.

There are some others, cocaine, methamphetamine, alcohol, that can also kill people, and unfortunately does kill people. But the majority are from the opioid-based substances. Of those, the majority probably still is prescribed pain medications. So the pain pills, OxyContins, Percocets, codeines, these medications that we all have heard about in different incarnations in our lives, but heroin is another big one.

The CDC just this year basically released data and released recommendations calling it an epidemic. It's truly an epidemic what's happening. Since 2000, I believe, we're almost up 400% for heroin overdoses nationwide. It's everywhere.

Interviewer: Not a problem here, though, right? Not in Utah.

Dr. Plumb: You certainly wouldn't think so.

Interviewer: But it is.

Dr. Plumb: It absolutely is. It's really challenging, because I get that people don't want to talk about it. There's a lot of stigma around it. But to me, it really is just another medical problem, a critical one and one that will kill someone if it's not dealt with, and if we don't get people help. But we don't talk about it. You're exactly right. It doesn't exist if we don't talk about it. We don't see billboards about it. We don't see PSAs. We need to. We need to start encouraging conversations surrounding these substances so other families don't go through what we have gone through.

Interviewer: Sam, you're also involved in UtahNaloxone.org. You're the program's manager, and I understand you do a lot of outreach to people that have a drug addiction problem. Talk about that a little bit, and how Naloxone can change things.

Sam: Well, I think it could potentially have a drug addiction problem. When you're doing community street outreach, you're dealing with a population that they obviously aren't in a good place. If they themselves aren't active users, they could know people who are at risk of an overdose, for instance. So the idea is these are people that are typically missed by other realms of the medical field.

They don't typically go to the doctor. They don't have access to the pharmacy. They don't often have insurance. So for that reason, these people are most at risk for having an overdose and not having the access to Naloxone, which can save them.

Interviewer: You actually make these available to those at-risk individuals.

Sam: Yes. We go out to different areas, and you start to have an understanding of more at-risk areas of the city. For instance, I know Pioneer Park is one that people typically think of. The Road Home, places where there are typically going to be people that are living outside or don't have the means to often take care of themselves, or provide themselves the shelter. We will go out and we will educate each and every person that gets a kit so that they know everything that they need to do should they witness an overdose, or should they themselves have an overdose.

Then, we distribute the kits, and we've really had a great response for that matter from that group of people, and they're very willing to be honest about it. If you ask them if they're using, they will tell you frankly, "Yes, I am." When you tell them that you're willing to help them, to say that they're gracious is an understatement.

Interviewer: I'm going to be cynical here for a moment and say, what do you say to individuals that would say, "Well, they have a drug addiction, that's their own problem?"

Sam: I mean, that is probably what we hear the most frequently about that population. But these are people that do not have the typical resources that even somebody of no means may have, for instance family, support, friends, a place to stay, any type of income. Without some type of help, that doesn't mean that they should just die as a result. For these people, you can't recover if you're dead. So Naloxone gives them that chance to actually recover from a potentially fatal overdose, and then also have the opportunity to seek some type of treatment or go into recovery.

It's really surprising, and I think that if you have a doctor or an EMS responder, they revive you, well that person is just doing their job. But if you have a friend, or a mother, a father, actually revive you, I think that that has more of an impact on your future usage as well.

Dr. Plumb: We've seen that too. We've seen firsthand, as well as anecdotal reports from other states. But we've seen firsthand, if someone is revived by their mom, and they wake up and their mom is begging them not to die, there's a different lightbulb that goes off. There is a realization that, "Wow. Somebody really wants me to be alive. I need to be here for myself. I need to be here for them. My life does matter to them." It's been reported in the literature too that actually bystander-administered Naloxone is a much more powerful tool to get people to have that realization that their rock bottom has come.

Interviewer: So that very much near death experience is actually the thing that will help turn them around and perhaps get them unaddicted, or more willing to seek treatment?

Dr. Plumb: On a healthier path, basically.

Interviewer: Yeah.

Dr. Plumb: Just to have that realization that, "Wow. I actually need to be here. Someone else sees that I need to be here, not just someone whose job it was to save me. Someone else made the conscious decision to save my life. They're not medical. They just care about me."

Sam: It also is very important to mention that the experience of having Naloxone administered to you, especially if you are an active user, an addict, it is something that is terribly painful. It kicks them into instant withdrawals. Some of the people that we've spoken to have said, "I'd rather be tazed or shot before I get that Naloxone again." You're like, "Well, would you rather be dead?" "No. Well, if I'm going to die, then yes you can give it to me." But other than that, I mean, it's a terribly painful experience. So it's not something that people would use or to . . .

Interviewer: Yeah. Because I was going to ask, I was going to say, now I've got my safety net so, woo, party's on. Right?

Dr. Plumb: Your parachute, kind of. We hear people say, "Oh, you're providing a parachute to people," and that's just not the reality.

Sam: Because if you think about it too, these people who are active users, number one, nobody wants to overdose, nobody wants to be an addict, and beyond that they don't want to waste their last fix. So if you give them Naloxone and they've overdosed, they've just lost their last high. So it's another way to think about it.

Dr. Plumb: Yeah. We do get questions about that, though. "Well, aren't you just enabling use? Aren't you just enabling riskier use? Aren't you just basically telling people you're okay with this choice that they make?" The reality of it is, no, we're not. What we're telling them is, "Hey, listen. We want you to get to a healthier place. We want you to get to a place where your life is not so encompassed by your addiction. But we can't get you there and you can't get yourself there if you're not alive." Naloxone will get you basically breathing again if you've overdosed. That's all it does.

Interviewer: So I know that you're an advocate for having the conversation. It's not just for people that are homeless or at The Road Home. There are plenty of other people that have drug addictions, that have families and live in homes. What would you say to a person that's in that situation that's listening?

Dr. Plumb: Well, I think probably the best way to speak to them would be to provide some examples of folks that have reached out to us. Sam and I can both give you examples of different conversations that we've had with people. I think one of the most powerful ones for me thus far, since we have embarked on this, has come from a mom who desperately reached out to us to get Naloxone. She had asked multiple providers, her physician, other physicians, emergency department physicians, addiction physicians.

She'd asked for a prescription for Naloxone for her son, who was a heroin addict, and at the time he was clean. We all know that one of the times that you're most at risk of overdosing is when you've had a period of sobriety. So your body is not at all accustomed to opiates, even as short as a period of three days and you go back to using what you used before, and you can overdose. So this mom reached out to us and in desperation said, "Can you please help me get Naloxone?"

She came up to Primary Children's and met with me. I educated her on how to use that. I was willing to write her a prescription. She was so uncomfortable getting it from the pharmacy that I ended up just giving her a free kit, which we have the ability to do. She didn't want that on her record. She didn't want that anywhere in the medical record.

Despite the fact that it's completely legal, insurance companies cover it, that it's been done for two decades now in the U.S., she had that stigmatization worry. She got the kit, and within a week she had to use it to save her son. I mean, it gives me chills even now thinking about it, because whether it was her motherly sixth sense or her experiences from the past, but she knew, and she almost didn't have that opportunity to save her son's life. Sam took a call today from a gentleman . . .

Sam: He has some type of chronic back disorder and he's in tremendous pain, and surprisingly he told me that his prescription for pain relief is morphine. He's receiving six doses of morphine throughout one single day of 60 milligrams each dose. Typically, 100 milligrams is something where you start to think of somebody as very high risk, or is a very high dosage, and he's taking 360 milligrams a day.

He's bedridden, he can't work, but he made the effort to call out to get Naloxone, because he said, "I fear for my life with the amount of medication that I am being prescribed, and I worry that my doctor may prescribe more. I want my family to be able to save me if I overdose."

This is a similar story that we hear from other people as well. These aren't just people that are down on their luck. These are people who are taking their medication as prescribed.

Dr. Plumb: And are still just at risk, because at the bottom line, end of the day, these are risky substances. It isn't about a risky person. It isn't about a moral character judgment. It's about these are risky substances, and they are everywhere in our society. I think all of us should take a little thought about, "Do I have these in my home? Do I have these in my home for a legitimate reason, or what may be an illegitimate reason?"

It doesn't matter to me. If they're in the home, they don't discriminate. They can absolutely cause an overdose and a death, and being prepared is really just not only smart, but it's appropriate. It's not asking for anything wrong by asking to be able to keep yourself or the people that you love alive.

Interviewer: It's like having a fire extinguisher or a first-aid kit, or an EpiPen, or an inhaler, or any of those things that you would use.

Dr. Plumb: Absolutely. Although, interestingly, an EpiPen which is absolutely vital for people who have anaphylaxis or allergic reactions to things, an EpiPen can actually hurt you. It's epinephrine, adrenaline. That can cause heart arrhythmias. That can actually hurt you. Naloxone can't hurt you. So I mean, even a level beyond it, I absolutely advocate for EpiPens and think they should be everywhere we know where they should be, but Naloxone is even safer. But it is very much the same thinking, that if there were to be that worst case scenario, you'd be prepared.

Sam: I think that's something that is particularly salient here in Utah, because we have our own culture here and it is a very stigmatized issue, whether it's an opioid pain medication or if it's an illicit substance. But we do hear from people that call us to talk about Naloxone after it's too late. Oftentimes in Utah, unfortunately, the conversation starts too late, when somebody has already been lost and there's nothing that can be done. So given how simple it is and how safe it is, it just makes complete sense to have it.

Interviewer: That's right. This can be that conversation.

Dr. Plumb: Right. Absolutely.

Interviewer: Right?

Dr. Plumb: Think about it.

Interviewer: This is the conversation and now go out and get . . . So do you just, prescription from your physician?

Dr. Plumb: Yeah. Your physician can absolutely prescribe it there. It's 100% legal for them to do so. Some physicians are a little uncomfortable with it, and I think that this will come in time. The law is pretty fresh still. I think physicians will become more comfortable with it.

But if you do run into a conversation where your physician states they're not comfortable, reach out to us. I can absolutely call in a prescription statewide, and we have done so from St. George to Brigham City and Wendover to Vernal, statewide. It's absolutely legal for me to call in a prescription for anyone who's either at risk of an overdose or at risk of witnessing an overdose.

Sam: For more information or to view our training videos, or even for other resources such as treatment and medication-assisted treatment, we have all of that listed at www.UtahNaloxone.org.

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Aaron: Prescription drug monitoring, that's next on The Scope.

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Aaron: I'm here with Peter Kreiner PhD, he's a senior scientist at the Institute of Behavioral Health of the Schneider Institutes for Health Policy, a researcher for the Heller School for Social Policy and Management and he's an expert in prescription drug monitoring. Welcome Dr. Kreiner.

Dr. Kreiner: Thanks, Aaron.

Aaron: Dr. Kreiner, here in Utah, deaths due to prescription overdose have been increasing since about 2001 and we have about 21 Utahans die from prescription overdose every month. Is this a nation wide problem?

Dr. Kreiner: It certainly is, Aaron. Probably from the early 2000's on, public health officials started recognizing opioid and prescription drug overdose death as a huge and increasing problem and recognition has just grown from there. So in the last few years, all federal agencies and national organizations, state governments have grown increasingly concerned with the problem and have started reaching out in a lot of different directions to look for solutions.

Aaron: Now what is a prescription drug monitoring program? I understand that's one of the solutions that they're looking at.

Dr. Kreiner: Prescription monitoring programs are essentially a data repository. Forty-nine states have now passed legislation authorizing such a program. Forty-eight states have actual operating programs. The hold outs are Missouri for legislation and New Hampshire is just about to have an operating program. They're repositories of filled or dispensed prescriptions for controlled substances that pharmacies are required to submit to each state program. So they are databases that are intended to serve multiple stake holders, typically prescribers and pharmacists and often other individuals can establish an account with a prescription monitoring program and log in and query it about a patient to inform their clinical decision making.
In many states law enforcement can access the data in relation to an active case investigation and increasingly the value of this data is being recognized and so monitoring programs are providing data to other entities like medical examiners, drug courts, to follow some of their clients. Treatment facilities are accessing the data to see if patients in treatment facilities might be obtaining prescriptions that their clinicians don't know about. So there's a lot of innovation going on now across the country about use of this data

Aaron: What sort of data is maintained by these monitoring programs?

Dr. Kreiner: It's a record of each prescription that's dispensed, includes information about the patient, the prescriber, and the pharmacy that dispensed it, including dates the prescription was written, the date it was dispensed and info about the specific drug prescribed, the dosage the, date of supply, often whether or not it was a refill or if refills are allowed. In many states it includes information about the payment source. So, kind of insurance, cash, that sort of thing.

Aaron: What's the value of the program overall for patient safety?

Dr. Kreiner: For patient safety, again if a patient presents a prescriber or their physician, could be an emergency room or could be their primary care physician, that physician may or may not know about the prescription history of that patient. Often physicians think this is a legitimate patient, have legitimate symptoms. I'm interested in prescribing a pain medication opioid analgesics and yet when they check the monitoring program, they find that person may have obtained half a dozen prescriptions from a number of different prescribers in the last month. That's a very different picture of that patient then they might have had.

Aaron: So ultimately this can help a health care provider help a patient stop an addiction or at least get help for an addiction before it goes too far. Is that safe to say?

Dr. Kreiner: Patients may be obtaining multiple prescriptions for lots of different reasons. So they may be misusing or abusing, they may be addicted, they may be diverting. And certainly the prescriber, it's intended that they might have a discussion with that patient and really try to help that patient to seek appropriate help. It's an ongoing issue about what treatment resources are available and that's an issue in every state.

Aaron: Utah has a prescription drug monitoring program. I don't know how familiar you are with Utah's particular program, but based on what you've seen nation wide in your experience, how do you think Utah could better use its prescription drug monitoring program to prevent overdosing?

Dr. Kreiner: Our center, so we have a prescription drug monitoring program center of excellence at Brandeis University, studies best and promising innovative practices that monitoring programs are doing nation wide. So we've identified 30 some odd practices that keep increasing all the time. Some of the more impactful ones that we've seen in other states that I believe Utah is not currently implementing include what's called unsolicited reporting where a monitoring program proactively analyzes this data and pushes out a report or sometimes an electronic alert to a prescriber or pharmacist for a patient to bring that information to their attention.
Several states have enacted mandates for prescribers and or pharmacists to register with the program and query it under specified conditions. For example recently New York, Kentucky, Tennessee and even though those programs are quite recent, it's already had an impact on the amount of use of that program. But also in certain indicators of doctor pharmacy shopping and opioid prescribing.

Some other practices that seem very valuable that we've been using in Massachusetts is use of de-identified prescription monitoring program for public health surveillance purposes in particular to provide it to counties and communities, we're working to prevent and reduce prescription overdoses, prescription drug related problems. I could go on, but those are some leading practices that I think Utahans could benefit from.

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Interviewer: Energy drinks, accidental overdose, and who is most at risk. That's next on The Scope.

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Interviewer: We're talking with Dr. Barbara Crouch, the Medical Director of the Utah Poison Control Center today. She also happens to be an expert on energy drinks. Tell us a little bit about energy drinks, Dr. Crouch.

Dr. Barbara Crouch: Well energy drinks have just exploded on the market in the last decade, and they are very popular, especially among teens. And energy drinks contain a lot of caffeine, and caffeine in a variety of sources. So I think one of the issues with energy drinks is that we tend to add a lot more caffeine into our diet every day in addition to maybe other sources of caffeine. So it's important to be aware of the fact that energy drinks contain a lot of caffeine, so that as we balance the rest of our diet we can take that into consideration and avoid any adverse consequences.

Interviewer: Because there's some real danger from caffeine overdoses, isn't there?

Dr. Barbara Crouch: Yes there is, and caffeine is the most common psychoactive substance in the world. Almost all of us consume some sort of caffeine on a regular basis, whether that is in coffee, or tea, or in a soft drink, or even chocolate. So it is common, and we use caffeine as a pick me up to avoid sleeping, and normally we tolerate it fairly well.

Now we have an explosion of other sources of caffeine, and I think vulnerable teens may not recognize that they are adding so much more caffeine into their diet. There are so many energy drinks; they are marketed to toward young adults. Their marketing is sort of edgy, and they have lots and lots of caffeine, even more caffeine than you might find in a very large cup of coffee from Starbucks.

So if you were to look at the label of an energy drink you might see a variety of natural substances listed. It may also list caffeine itself, and you don't really know how much caffeine you're consuming, because there is synthetic caffeine, and then there might be a variety of natural sources. So the total amount of caffeine isn't clear.

And then we have other natural stimulants, and so a lot of the energy drinks have boosted their products by adding additional stimulants, like ginseng, and synephrine, taurine, and a variety of other things that sort of add to and contribute to that stimulant load, if you will. So it's hard to know exactly how much you're ingesting.

Some of the products, if you were to look at the cans, you'll look at the serving size; they will tell you that you open up a can and it contains two servings. I don't know about you, but I don't open a can of something and not finish it. So again, there's this sort of almost deception as to how much caffeine may be included in a product.

Interviewer: It sounds like with energy drinks the risk for caffeine overdose increases.

Dr. Barbara Crouch: Yes, caffeine is a stimulant, and as a stimulant it can exert a lot of adverse effects. In toxicology we like to say that the dose makes the poison. So the more we take the more likely we are to experience an adverse effect, or even a toxic effect. As a stimulant, you know, the first thing that you might feel if you drank too much caffeine is you might feel a little jittery. You might be shaky. You might have a tremor. And as you increase that load your heart starts to beat fast, and it may be very irregular. So somebody who has an underlying heart problem is at risk. And then in very high doses you can seize. So again, it's sort of the dose.

When I drink a cup of coffee I might have a strong cup of coffee, but it's a warm beverage that I am sipping over a period of time. And as I'm ingesting the caffeine, my body is metabolizing the caffeine. What happens with the energy drinks is a lot of them, especially again with the young adults, they tend to drink them fast, and they may have more than one. So all of a sudden the amount of caffeine being consumed and absorbed into the body is much higher over a shorter period of time.

So then you have to think about it, that that's the energy drink. What other sources of stimulants are you taking in? Have they had a cup of coffee or tea or a soft drink that has caffeine? Are they taking any over-the-counter medications? You can buy caffeine as an over-the-counter drug and take it as a stay-awake drug. And a lot of kids in school do, to stay up to study for exams. There are now food products that have caffeine in them, like Cracker Jack'D that has 100 milligrams of caffeine in a packet.

And then we have stimulants, or medications that are stimulants, that can add to and contribute to adverse effects, and those include a lot of our ADHD drugs. So if you have a teenager who has ADHD and is on an ADHD drug, and they add a bunch of caffeine, they are more likely to have an adverse effect than somebody who isn't on those medications. So there are a lot of factors that play into somebody's risk for having an adverse effect.

Interviewer: The adverse effects have real consequences on a person's health, but you mentioned toxic effects earlier. At what point do adverse effects become toxic effects?

Dr. Barbara Crouch: Well that's a good question. And there is no good answer to that. I think we have an idea of certain amounts of caffeine if ingested all at once can be a problem. But it's going to depend on each individual. It's going to depend on whether they are on other medications. It's going to depend on how much total caffeine they are ingesting. And it's going to depend on their underlying health. So I know of at least one report out there of a teenager who died. They have suggested that it was due to an energy drink, and it turned out that the teenager had an undiagnosed heart problem. That probably contributed to her death, potentially. So I think underlying health is also an important component.

Interviewer: So obviously there are going to be certain people and groups of people that are going to be more vulnerable to caffeine overdose. You mentioned teenagers; you mentioned people who might be taking a stimulant drug for a medical condition, or people with heart conditions. Are there any other vulnerable populations or people that you can think of?

Dr. Barbara Crouch: Well certainly very young children. We don't typically give our children coffee or soft drinks at a young age. But you can imagine if you have an attractive container that's out and about in the house, that a toddler when they're exploring their environment might find that attractive and drink that. And so again, a fair amount of caffeine that might way too much for that small child.

Interviewer: I appreciate you visiting with us today, Dr. Crouch. Do you have any final thoughts that you'd like to share with us about caffeine?

Dr. Barbara Crouch: Well I think the most important thing is people need to be aware of the fact that it is a stimulant, and that it has the potential to cause adverse effects when ingested in large amounts.

Interviewer: And of course if you are worried about somebody that may have had a caffeine overdose, whether it be a child or adult, you can always call the Utah Poison Control Center. The number is universal and works in whatever state you are in, and the number is 800-222-1222.

Dr. Barbara Crouch: Great, yes, absolutely.

Announcer: We're your daily dose of science, conversation, medicine. This is The Scope, University of Utah Health Sciences Radio.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Drugs and the E.R., what happens if somebody comes in high or overdosing? We're with Dr. Troy Madsen, Emergency Medicine at the University of Utah Hospital.

Dr. Madsen: It's a tough question. Part of the reason it's a tough question is because anyone who's with that person is afraid of getting prosecuted. They're afraid of getting blamed for what happened to him, that they allowed it to happen. They're afraid of getting prosecuted for doing drugs themselves and being in that same situation. It really is a tough situation.

Interviewer: Or they're afraid that the person that's actually overdosing might get in big trouble.

Dr. Madsen: Exactly. Yeah. It's a concern of multiple fronts, so that's why occasionally we'll have the kind of . . .we don't get it so much here but elsewhere, you get the drive up and drop where you have people drive up in the car and drop the person out on the front of the E.R. It does happen.

Interviewer: Then they squeal away.

Dr. Madsen: Yeah, you see that in movies occasionally or TV shows, but it really does happen. That's the big concern people have. I think the biggest thing to keep in mind is that when you're in the E.R., we're not going to pursue any kind of action. I am not a legal authority. I am not an officer. Your information is safe with me. There's patient-provider confidentiality. I'm not going to report anything to the police from a drug overdose or something like that.
The other thing that comes out oftentimes is let's say it's not an acute overdose where someone just overdosed, but they're having some issues with something else and I ask them about their drug history, "Have you done any drugs?" I do find that people are very open about that. I think a lot of people have learned that I'm not going to go tell the police or report that sort of thing.
That is really important information for me to know when I'm taking care of you. In terms of the overdoses themselves though, just keep in mind once you're in the E.R. that's not information we're reporting. We're not turning either the patient in to the police or the individual who brought them. We just need to know that information and get them there to take care of them.

Interviewer: I don't know, maybe this doesn't happen in real E.R.s. On TV, sometimes you see police officers hanging out in the E.7R. What if they see you come in and they're like, "That looks like an overdose"? Can they do anything within those walls?

Dr. Madsen: They're not going to, no. We do have security guards in our E.R. That's for our safety to make sure things are okay there. If a patient were to come in after a domestic violence situation and that patient wanted to report it, then they can report it to the police. But the police aren't going to charge in the room in that situation or in a situation of a drug overdose or anything like that.
It's not like they're kind of just looking around, looking for someone to prosecute. Again, that patient information is protected. They're not privy to that information. That's not something they can even access without permission. So unless that's something you want to talk to the police about they're not going to be even aware of it nor can they take any action based on what you're telling me about in the E.R.

Interviewer: What's you're best advice, your takeaway message?

Dr. Madsen: My takeaway message is get help for the person. Think of them first. Be sure and get the assistance they need. Call 9-1-1 if they need 9-1-1. Get them to the E.R. Whatever you need to do make sire you get them the help they need.

Interviewer: We're your daily dose of science, conversation and medicine. This is The Scope, University of Utah Health Sciences Radio.