July 28, 2025 • 29 mins
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
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Welcome to the Addiction Medicine Made Easy
Podcast.
Hey there, I'm Dr Casey Grover,an addiction medicine doctor
based on California's CentralCoast.
(00:22):
For 14 years I worked in theemergency department, seeing
countless patients strugglingwith addiction.
Now I'm on the other side ofthe fight, helping people
rebuild their lives when drugsand alcohol take control.
Thanks for tuning in.
Let's get started.
Today's episode is going to beon using naloxone to save a life
(00:44):
when someone is experiencing anoverdose.
Now you may recognize thisepisode as it originally came
out in 2023.
It's an interview with the verylovely Dr Reb Close, who is my
colleague in our addictionmedicine practice and she's also
my spouse.
We're actually on vacation thisweek so I didn't have time to
(01:06):
record a new episode, so I wentback and cleaned up the audio
from this episode on naloxoneand I am putting it out on the
pod again, since knowing how tosave a life using naloxone when
there is an overdose is anessential skill for all of us as
community members.
When people die of overdose,they never get another chance to
(01:28):
get treatment for theiraddiction.
One quick point if you want todo a naloxone training in your
community and need resourcessuch 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 toenjoy our trip, and this episode
is a timely reminder of how touse naloxone.
(01:50):
Let's go, dr Close.
Let's start with you telling usyour story in medicine and what
you do now.
Speaker 2 (02:01):
Hi, thank you so much for having me on the pod.
I'm really grateful to be here.
Hi, thank you so much forhaving me on the pod.
I'm really grateful to be here.
My name is Reb Close and myfirst training was in emergency
(02:22):
medicine.
I trained at UCLA go Bruins andI worked in the emergency
department from 2003 until justa lot of people struggling with
undiagnosed substance usedisorder, dependency and
addiction they would present tothe ED with a multitude of
complications from untreatedsubstance use and mental
health-related issues, and overmy career I watched these
patients suffer and I watchedthem have challenges in seeking
and receiving care, and so laterin my career I really started
(02:46):
focusing on that incrediblyvulnerable population.
And then, with my colleague, drCasey Grover, we did our second
board certification inaddiction medicine and a couple
of years ago I took myself outof the ER and I now do addiction
treatment and advocacyfull-time, and I now do
(03:07):
addiction treatment and advocacyfull-time.
My three main areas of practiceright now is I work in a I call
it a brick and mortar clinic.
It's a typical clinic that wesee patients with really complex
addiction issues in our clinicand I'm fortunate for the
support we have there.
We have a peer supportspecialist that we work side by
side with.
My second practice is in streetmedicine, where literally we
see patients right there on thestreet and that is truly an
(03:30):
incredibly rewarding experienceto meet people where they are
and to be ready for anything youcan do to offer them, make that
available to people thatotherwise have really no access
to care, to people thatotherwise have really no access
to care.
And then my third practice thatI'm working with right now is I
help out in our jail, and ourjail is run by a private entity
(03:53):
that's the jail medical, but I'mable to go in, we connect with
the patients, we make plans fortheir discharge and aftercare
and then I get to follow up withthem in the clinics, which is
pretty incredible to see themget their lives back and get
follow up with them in theclinics, which is pretty
incredible to see them get theirlives back and get to work with
them in that setting.
So that's what I'm doing nowand how I got there.
So thank you for having me heretoday.
Speaker 1 (04:12):
Absolutely so.
That brings us to our firstquestion on the topic of
naloxone.
So you put in 20 years in theemergency department.
When you were practicing in theemergency department, how did
you use naloxone?
Talk us through how to naloxonelike a pro.
Speaker 2 (04:28):
So you know it's been really a lot of learning and
quite the journey.
But I learned pretty early onin my career that too much
naloxone could be a challenge.
And in the ER you have allthese things at your disposal
You've got a pulse oximeter, youhave nurses, you have extra
(05:03):
hands and extra people andequipment to really to get
naloxone on board as quick asyou can.
We would do it literallythrough the genes, do injections
and get naloxone in someonesignificant doses as quickly as
possible, because it wasliterally life and death.
Now the alternative is in the ERwhen someone's say recovering
(05:23):
from an overdose or you're notquite sure what's happening, you
can give a little bit ofnaloxone.
So I was a big fan of the 0.4IV and if someone their
respiratory rate was slow, theiroxygen seemed to be dipping,
let's give them 0.4 of Narcanand just see, typically for a
patient, that wouldn't wake themup to agitated acute withdrawal
(05:46):
.
Instead it would help theirbreathing, it would support
their respiratory status andtherefore they were in a safer
position In the ER you have thatoption and I learned over the
years how to really carefullywalk that line of too much
versus not enough.
When you have the rightresources.
It's a lot more nuanced than itcan be, so just summing that up
(06:09):
, critical presentation apneicblue.
Speaker 1 (06:12):
Just give it till they wake up, unresponsive.
But if they're more justdepressed or sleepy, it's maybe
titrate until they're not insevere withdrawal, but they're
breathing on their own.
Speaker 2 (06:23):
Yeah, they're maintaining their oxygenation.
They have a reasonablerespiratory effort.
It definitely is more nuancedand you can afford to do that.
You have the time for it, ifsomeone is not in that critical
life-threatening situation.
Speaker 1 (06:38):
So I and disclosure, dr Close and I have worked in
the same department for 10 years.
I've heard you make thiscomment to some of our nurses
let's not make a rhinoceros.
Tell me what you mean whenyou're telling the nurses let's
not make a rhinoceros.
Speaker 2 (06:51):
Right.
So one phrase that I've usedvery frequently in the ER is
don't poke the bears Likeabsolutely not.
I don't want to take someonewho is calm and comfortable,
breathing well, oxygenating well, their heart rate is good
no-transcript.
Someone is literally fightingthe staff.
(07:13):
They're in that fight or flightmode.
What I didn't realize early inmy career is that was acute
withdrawal.
And later in my career now Iunderstand that's exactly what
we were doing.
And so those big doses ofnaloxone we could easily turn
someone from a very comfortablepatient who's doing fine to
someone who truly is like a wildrhinoceros in my emergency
(07:36):
department.
In severe withdrawal Absolutely.
Oh my gosh, the agitation anddiscomfort.
When you step back and look atit from the patient perspective,
that level of discomfort almostwarrants that kind of a
response from them.
Speaker 1 (07:49):
So once again, critical presentation.
You're worried the person mightnot survive, just push naloxone
.
But again, if there is anopportunity to be a might not
survive, Just push naloxone.
But again, if there is anopportunity to be a little bit
more careful.
You titrate, absolutely,absolutely.
So let's change the scenario alittle bit.
I know you work in a streetclinic for patients with opioid
use disorder and you, as youmentioned, also have an
outpatient clinic.
Now that you're out of theemergency department, talk us
(08:12):
through how you use naloxone inyour practice now.
Speaker 2 (08:15):
Okay, so I mentioned in the ER you have nurses and
you've had pulse oximeters andyou have patients on monitors
and you can give little tiny IValiquots and make sure that you
can go through the nuance of acomfortable situation for the
patient On the street.
I don't have that.
Typically, when I'm respondingon the street I grab a box of
our nasal naloxone and that'swhat I have and I don't have a
(08:38):
pulse oximeter and fortunately,with my medical training I'm
very comfortable.
I'll check their pulse, I'llput my hand on their chest.
I can easily see what'shappening from basically my eyes
and hands on a patientno-transcript without sending
(09:26):
someone to the hospital.
Well, I don't get the choice ofwhether or not they go to the
hospital.
I get the choice of whetherthey get evaluated by EMS, and
it is my standard of care is tocontact 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 playby myself, okay, I was going to
(09:46):
say so.
Speaker 1 (09:47):
For every one of these out of the emergency
department, you're calling 911.
I mean, you and I both know whoknows what they overdosed on
right, was it methadone?
Was it isotonitazine?
Speaker 2 (09:56):
We have no idea what they overdosed on or if that's
really what's happening Like.
You need 911 in that situationjust like anybody else, and this
is a big part of what I teachin the community.
Speaker 1 (10:06):
You got to have that help A little bit of a take home
here Any overdose outside ofthe emergency department or
inpatient, setting 911, givenaloxone if you've got it and
then most likely they're goingto get transported to the
hospital unless, for some reason, ems decides they don't need to
, absolutely.
Yeah, yep, all right, so we'vetalked about using naloxone as a
healthcare provider.
What's the best way to getnaloxone in the hands of our
(10:29):
patients who are the highestrisk of having an overdose?
Speaker 2 (10:32):
who are the highest risk of having an overdose,
normalize.
We need to make this like afire extinguisher, a seat belt.
I mean, truly I don't believeI'm about to burn my house down,
but frankly it could happen.
So you have to have a fireextinguisher.
You've got to be ready for anemergency situation, and that's
really what I talk about whenI'm trying to help the community
(10:52):
understand why we want to getnaloxone, basically anywhere we
possibly can is you don't knowwhen something bad is going to
happen, but if you're not ableto handle it, unfortunately
these are fatalities that resultfrom us not having naloxone and
not being able to respond to anemergency situation.
So when I want it in the handsof my patients and their family
(11:16):
members, I hand it to them.
You know, this morning I waschecking on one of my patients
and I literally handed his dadfive boxes of.
Speaker 1 (11:25):
Narcan?
Do you not prescribe it?
What makes you give it to themas opposed to giving them a
prescription?
Speaker 2 (11:30):
So one of my dear friends who is also our lead
pharmacist for our regionalcoalition.
She taught me that about 10% orless of the naloxone
prescriptions that come throughthe pharmacy actually get picked
up.
So people will pick up theirother medications, they will
pick up, you know, anything elsethat they want at the pharmacy,
(11:50):
but they will leave the Narcan.
And is that because of stigma?
Is that because of cost?
It is for some patients, buteven when it's covered by their
insurance and it is free ofcharge, people will decline.
I don't know all of the reasonsfor that, but I assume many of
them are related to perceivedstigma or actual stigma.
(12:11):
So what I have learned is it isso empowering to tell a patient
, to tell a family member, totell 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'mgoing to give you this
medication that you can use tosave a life, and people can
(12:34):
relate to that.
I actually read something just acouple of days ago that said 4%
of prescriptions are actuallypicked up at the pharmacy, 4% of
prescriptions for naloxone.
It's better to put it in theirhands and then you also get to
have that conversation Put it inyour purse, keep it in your car
.
I tell them about a timedriving back from something with
my daughter and literally therewas someone slumped over on the
(12:55):
side of the road doing theU-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 ofour community is hand it to
them literally and then helpthem understand that this can
happen anywhere, anytime, andthey need to be ready.
Speaker 1 (13:10):
Yeah, just one clarification.
You know, naloxone is thegeneric name Narcan.
I don't know what marketingthey did, but they just burned
it into the memories ofhealthcare providers, I mean.
Most people still call itNarcan, oh, totally.
Speaker 2 (13:21):
I'm one of them.
Speaker 1 (13:22):
There's some yeah, me too there's Cloxado and there's
Evzio.
There's all these other brands.
For the most part here inCentral Coast of California
we're using nasal naloxone inthe community with the brand
name is nasal Narcan.
So both of us will slip up hereand there and call it naloxone
or Narcan, just to clarify.
We've had a lot of support herein California from the state in
actually paying to give theboxes of nasal Narcan into the
(13:45):
community and we'll talk aboutcommunity distributions in just
a little bit.
Yep, one thing I wanted to sharethat I've done and I love this.
I asked my patient who hasopioid use disorder you want
some Narcan?
No, no, what if you could savea friend?
Hey, doc, maybe you're right.
So I think what I tend to do isI tend to displace the need for
Narcan.
You would never need Narcan,but gosh man, we get overdoses
(14:05):
the safe way.
And gosh, I mean, what if afriend of yours who's using I
tend to find that the offer ofcould you be a community member
and just respond?
People really respond well tothat.
Even when I'm giving peopleboxes of naloxone, unless I
displace the need from them tosomeone else, I find that I get
resistance.
Speaker 2 (14:24):
I like that.
I like that a lot.
And that goes back tonormalizing Totally Talking
about overdoses from Safeway andtalking about overdoses behind
the library and gas stations.
We do this all day, yeah.
Speaker 1 (14:33):
Okay.
So when you have a patient whoyou know is very high risk for
having an opioid overdose, whatdo you think is the best way to
make sure naloxone is where itneeds 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 (14:52):
Again, it's with normalization and getting it to
anyone who will take it.
Essentially, you know we try toget it throughout the community
, but specifically in our region.
Basically, if you have gotten asubstance off the street, it's
going to have fentanyl in it orsomething worse.
Correct, that's true.
But if you're using cannabisoff the street, we have had
(15:15):
cases where those have hadsignificant amount of fentanyl
in them and have unfortunatelyresulted in overdoses.
Our cocaine in our community,absolutely, If you're using
cocaine in my community, justassume it's fentanyl and you're
at very high risk for overdose,sometimes without any cocaine,
it's just fentanyl, absolutelyDo the talk screens.
There's no cocaine, onlyfentanyl.
So you know the meth in mycommunity.
(15:37):
I often speak about howfrustrated my patients are who
are preferring to usemethamphetamine, 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 tobe everywhere and that's really
something I try to help mypatients, their family members,
their friends.
I help them understand.
So I talk about the cannabis, Italk about the cocaine, I talk
(16:05):
about the meth and let them knowthat any exposure could
potentially be fatal from a doseof fentanyl.
So I enlist them and empowerthem that you could save
someone's life, whether it'syour friend or anybody else.
But because of what's on ourstreet right now and what's in
our community, I need to givethis to you so you can save
someone's life.
Speaker 1 (16:21):
Yeah, I think for me.
I just think who's likely to bethe 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 thestreet?
So I think that's where Itarget.
Go ahead.
Speaker 2 (16:32):
And then give it to all of them yes.
So I think that's where Itarget Go ahead and then give it
to all of them.
Speaker 1 (16:35):
Yes, like every one of those people needs it Totally
, Because then again they mightsave someone else on the street
too.
Speaker 2 (16:42):
Well, and totally, I actually have been known to say
you know if you are aroundhumans or pets that you really
like you need to have Narcan.
Speaker 1 (16:47):
I mean just this has got to be everywhere.
Yeah, totally agree.
All right, so now you and Ihave done too many naloxone
trainings for our community, inour community, to count.
As you reflect back on thevarious trainings that we've
done, what do you think has beenthe most effective way to train
community members on how to usenaloxone and to get naloxone
into the hands of communitymembers?
Speaker 2 (17:09):
So there's two parts to this.
One is how do you make it easyfor people to stop by after work
, grab some Narcan, learn how touse it and then move about
their day so structurally?
I believe what was one of themost effective ways we did it is
we rented out a center in ourcommunity and we set up in
(17:30):
English a six-minute videoplaying on loop of how to give
naloxone, and we did the samething in Spanish in another room
and we had flyers andinformation and pamphlets in
each respective language in eachrespective room and people
would walk in and somebody woulddirect them.
Hey, just take a minute, watchthis six-minute video you can
(17:50):
watch it a couple times if youneed to and then jump over there
, talk to that lady who is me,and she'll get you some Narcan.
And they did.
People walked in, they watchedthe video once or twice, they'd
come over and I would ask thempersonally.
I spoke with every person thatcame through my line do you have
any questions?
And some people were like nope,thanks, doc.
And they were gone, and otherpeople were yeah, I have some
(18:11):
questions.
And what was crazy is there attimes was a line.
It was like a receiving line ata wedding.
Speaker 1 (18:16):
I remember that you looked like you were getting
married.
Yeah, it was crazy.
Speaker 2 (18:18):
Total receiving line.
It was like 50 people waiting totalk to you and they were
patient and they were kind andthey were very respectful of.
This is education I need andwant and it was a really, really
powerful, powerful scene thatwe had there.
No-transcript.
(18:48):
And essentially every time Itrain on Narcan, either myself
or Dr Grover or one of mypartners gets Narcan.
I have had oh my gosh if I say ahundred, it's probably an
underestimate doses of Narcan inthe last 10 years of training
and literally you show people,you give it, and then you
literally take the plasticdevice and you poke it on your
(19:10):
hand, showing them there's noneedle, nothing to get harmed
with, and the eyes in theaudience when you do that,
they're just oh my gosh, and shedidn't explode or fall over
dead or all these things thatthey're afraid of.
And so they get to see in realtime a live human getting Narcan
and having no side effects, noissues.
(19:31):
And after I do thesepresentations, so many people
will come up and like you gaveyourself Narcan.
Yeah, I do it all the time.
And just normalizing again thatthis isn't something scary, it
isn't something dangerous, therearen't fireworks or spiders
that climb out, it's super easyand it's safe and I think that's
the most important thing that Ido in my trainings yeah, I
(19:55):
usually laugh afterwards andtell people that's a little bit
bitter.
Speaker 1 (19:57):
I've probably given myself or you've given me, I
don't know how many doses ofnaloxone, you know to our
audience.
We've been doing like we said,countless naloxone trainings.
I can get you the video thatwe've recorded.
I can also get you our slidedecks.
We're happy to share Gosh.
we've trained thousands ofpeople on how to use naloxone.
A couple other points that kindof I would make.
(20:17):
I think the first thing Iusually do is whenever I go to a
naloxone training, I bring anexpired box with me and I like
it to be sealed, and usuallywhat I'll do is I'll go through
my slides, we'll talk about whento give it, call 911.
We go over the expiration date,we let people know that after
the expiration date the naloxoneis still good.
It loses about 5% potency forevery year after the expiration
(20:40):
date.
And then I walk them throughthe box.
I literally like almost abovemy head.
I open it, I show them the twoblister packs Again, we use the
nasal Narcan here in the CentralCalifornia area that we're
working in and then I open oneof the little blister packs and
I show them.
This is what it looks like.
I press the syringe and thenthe spray goes into the air and
(21:01):
then I explain to them that'show 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 myselfa dose as well, or I ask for a
volunteer.
But yeah, I think unpacking thebox has been really helpful for
me.
Speaker 2 (21:20):
I think there's one other thing on.
That is, if someone and I dothis as a demonstration, if
Casey and I are presentingtogether, 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 tosomeone who is high and that was
(21:41):
an air quotes If they areunresponsive and poorly
breathing and you areconsidering they are probably or
possibly dead, you're givingNarcan and realize that
difference between oh, you knowhe's nodding off but he's
responding to me versus oh, mygoodness, I'm afraid he's dead
(22:01):
or dying.
That's when you're giving 9-1-1.
And it takes some of the fearaway as well, because otherwise
you just watch someone die.
Speaker 1 (22:07):
Just to clarify.
You said that's when you'regiving 9-1-1.
That's when you're calling9-1-1 and giving naloxone.
Speaker 2 (22:11):
Thank you.
Yeah, you're welcome.
I was paying attention.
See Love it.
Speaker 1 (22:15):
All right.
So, thinking back on yourcareer, what clinical case
involving naloxone stands out toyou the most, and why?
Speaker 2 (22:22):
So it was in 2019 and we were starting to see
something weird in my community.
People were having overdosesand it didn't make sense.
And I'll never forget thisyoung man.
He came in in an overdosesituation.
He'd gotten naloxone in thefield and we were talking.
He's like no, no, no, dude, itwas just a Percocet.
(22:43):
I was like, okay, all right.
And then half hour later thenurse calls me and she's like
he's not responding.
He's not responding.
So we gave him more Narcan andhe responded.
And that happened three moretimes.
We finally put him on a Narcandrip and admitted him to the ICU
and that's when we startedpiecing together that fentanyl
had come to our community.
And the reason that's soprofound to me is I didn't know
(23:08):
what was happening.
I didn't know why he wascontinuing to overdose.
It wasn't making sense and as aknee yard doc, I knew something
was wrong, but I didn't knowwhat.
And I mean, obviously, I thinkwe all know where fentanyl has
taken us since then.
So that case really stands out.
Speaker 1 (23:24):
Yeah, I'm going to share one from my residency.
So I was a second year residentin the pediatric emergency
department and we get a callthat there's an opioid overdose
coming in on Opana.
If you remember, that washydromorphone, it was briefly on
the scene and 2011,.
That was a bad time withprescription opiates in America,
and so, in any case, I'm asecond year resident, I was the
(23:44):
senior resident in the PZD andthey're like Grover, you're on
it.
I was like I got it and I'llnever forget the paramedics
wheeling him into ourresuscitation band, him yelling
please don't Narcan me, pleasedon't Narcan me.
And I remember the anger risingin my gut of like, oh, we're
going to totally Narcan you, youdeserve it.
(24:05):
But I, of course, clinically,was like well, sir, we're just
really worried about yourbreathing.
We'll just give you a littlebit of naloxone, see how it goes
.
But I was taught punish thesepeople, make them suffer.
I'm embarrassed.
I mean I have goosebumps rightnow just thinking about the raw
emotion and just I was hurtinghim.
I mean I've read so manyrecovery novels and people talk
(24:27):
about back in the nineties ifyou went into an ER, they'd push
naloxone just to punish you,like you deserve it.
So let's just take a minute andbe grateful that we've learned
and things have changed.
And the man was yelling at me.
He clearly did not neednaloxone and yet my training was
really to punish people andmake them withdraw so they would
(24:47):
know how bad their decisionswere and that would fix them.
I mean, this goes back to mysaying of all these years why do
patients with addiction not getbetter?
We judge them, we don't offerthem treatment and it's
impossible to get treatmentright.
One in seven Americans willdevelop a substance use disorder
, yet less than one in 10 hasaccess to treatment.
This is what you and I aretrying to do.
Let's make treatment foraddiction as friendly as
(25:11):
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 mytraining was to harm him.
It just goes to the deep, deepstigma that's in health care
against patients with addiction.
It is truly systemic, systemicstigma.
So, before we wrap up, anythingelse on naloxone that you
(25:33):
wanted to add, so we tease a lot.
Speaker 2 (25:38):
that and this sounds so weird to say and I know this
audience will understand.
But you have gotten to a pointof missing heroin, because it
was something you somewhat knewwhat was going on with your
patients, you had an idea ofdosing and you had an idea of
how you could startbuprenorphine easily, safely.
Those were the days, so tospeak.
(25:59):
Or prescription opioids oh, mygoodness, You're using how many.
Speaker 1 (26:02):
Norco a day.
Great, how many milligrams isthat?
Yeah?
Speaker 2 (26:04):
I miss those days.
It was a different world.
And then we back, as I said, in2019, we started dealing with
fentanyl and we've learned somuch over the last four years of
dealing with fentanyl and we'regetting a handle on it and,
granted, it's super nuanced, butwe're getting there.
What scares me is what's next,and in our community.
(26:26):
What's next are the novelbenzodiazepines we're seeing
carfentanil, we are seeingatizolam, we are seeing xylizine
, bromazolam, I mean it's we'reworried about isotonidazine,
totally.
It's just.
It's anybody's guess and mypatients literally that I'm
taking care of in the streetclinic specifically will ask me
(26:48):
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 Italk very openly and honestly
with my patients about that thatI have no idea what's in your
body Couldn't tell you.
So we try to partner with themand talk with them through it.
But the one thing that I wouldstick with as far as it goes in
(27:09):
this episode about naloxone isthat's the fire extinguisher we
do have.
So I don't have a magicantidote for bromazolam or
atizolam or xylosine.
I don't.
But fortunately and it's weirdto say that, and you can hear
the hesitation in my voice thatthe majority of these are mixed
(27:29):
with an opioid, such as fentanyl, parafluorofentanyl,
carfentanyl or something.
So you still have a fireextinguisher that is likely to
work.
It may not reverse the entireoverdose.
That's why that 911 thing wasso exciting and so important in
the beginning.
You still have to call for helpbecause you can reverse the
fentanyl or other opiates, buteverything else that may be in
(27:52):
their system, you don't haveanything to treat them with.
So, yes, narcan is one.
It's that hammer and nailanalogy.
You know, all you have is ahammer, everything looks like a
nail.
Well, this is the hammer wehave and fortunately most of our
scenarios have nails, at leastas part of the problem.
Speaker 1 (28:09):
So it's almost like don't be nihilistic about
naloxone Just because the drugsupply is tainted, you could
still save a life.
Speaker 2 (28:14):
You absolutely can and don't miss that opportunity.
You know, because if someonedies, they never get a chance to
recover.
Speaker 1 (28:22):
If you look at the artwork that's my podcast.
That's a painting made by afriend of mine named Paul, and
we lost him in 2019.
Yeah, yeah, yeah.
So we did talk about why do welike recovery.
It's giving people their livesback.
When you die of an overdose,you never get that chance for
recovery.
Before we wrap up, a huge thankyou to the Montage Health
(28:45):
Foundation for backing mymission to create fun, engaging
education on addiction, and ashout out to the non-profit
Central Coast OverdosePrevention for teaming up with
me on this podcast.
Our partnership helps me getthe word out about how to treat
addiction and prevent overdosesTo those healthcare providers
out there treating patients withaddiction.
(29:07):
You're doing life-saving workand thank you for what you do
For everyone else tuning in.
Thank you for taking the timeto learn about addiction.
It's a fight we cannot winwithout awareness and action.
There's still so much we can doto improve how addiction is
treated.
Together, we can make it happen.
Thanks for listening andremember treating addiction
(29:28):
saves lives.
Welcome to the Addiction Medicine Made Easy
Podcast.
Hey there, I'm Dr Casey Grover,an addiction medicine doctor
based on California's CentralCoast.
(00:22):
For 14 years I worked in theemergency department, seeing
countless patients strugglingwith addiction.
Now I'm on the other side ofthe fight, helping people
rebuild their lives when drugsand alcohol take control.
Thanks for tuning in.
Let's get started.
Today's episode is going to beon using naloxone to save a life
(00:44):
when someone is experiencing anoverdose.
Now you may recognize thisepisode as it originally came
out in 2023.
It's an interview with the verylovely Dr Reb Close, who is my
colleague in our addictionmedicine practice and she's also
my spouse.
We're actually on vacation thisweek so I didn't have time to
(01:06):
record a new episode, so I wentback and cleaned up the audio
from this episode on naloxoneand I am putting it out on the
pod again, since knowing how tosave a life using naloxone when
there is an overdose is anessential skill for all of us as
community members.
When people die of overdose,they never get another chance to
(01:28):
get treatment for theiraddiction.
One quick point if you want todo a naloxone training in your
community and need resourcessuch 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 toenjoy our trip, and this episode
is a timely reminder of how touse naloxone.
(01:50):
Let's go, dr Close.
Let's start with you telling usyour story in medicine and what
you do now.
Speaker 2 (02:01):
Hi, thank you so much for having me on the pod.
I'm really grateful to be here.
Hi, thank you so much forhaving me on the pod.
I'm really grateful to be here.
My name is Reb Close and myfirst training was in emergency
(02:22):
medicine.
I trained at UCLA go Bruins andI worked in the emergency
department from 2003 until justa lot of people struggling with
undiagnosed substance usedisorder, dependency and
addiction they would present tothe ED with a multitude of
complications from untreatedsubstance use and mental
health-related issues, and overmy career I watched these
patients suffer and I watchedthem have challenges in seeking
and receiving care, and so laterin my career I really started
(02:46):
focusing on that incrediblyvulnerable population.
And then, with my colleague, drCasey Grover, we did our second
board certification inaddiction medicine and a couple
of years ago I took myself outof the ER and I now do addiction
treatment and advocacyfull-time, and I now do
(03:07):
addiction treatment and advocacyfull-time.
My three main areas of practiceright now is I work in a I call
it a brick and mortar clinic.
It's a typical clinic that wesee patients with really complex
addiction issues in our clinicand I'm fortunate for the
support we have there.
We have a peer supportspecialist that we work side by
side with.
My second practice is in streetmedicine, where literally we
see patients right there on thestreet and that is truly an
(03:30):
incredibly rewarding experienceto meet people where they are
and to be ready for anything youcan do to offer them, make that
available to people thatotherwise have really no access
to care, to people thatotherwise have really no access
to care.
And then my third practice thatI'm working with right now is I
help out in our jail, and ourjail is run by a private entity
(03:53):
that's the jail medical, but I'mable to go in, we connect with
the patients, we make plans fortheir discharge and aftercare
and then I get to follow up withthem in the clinics, which is
pretty incredible to see themget their lives back and get
follow up with them in theclinics, which is pretty
incredible to see them get theirlives back and get to work with
them in that setting.
So that's what I'm doing nowand how I got there.
So thank you for having me heretoday.
Speaker 1 (04:12):
Absolutely so.
That brings us to our firstquestion on the topic of
naloxone.
So you put in 20 years in theemergency department.
When you were practicing in theemergency department, how did
you use naloxone?
Talk us through how to naloxonelike a pro.
Speaker 2 (04:28):
So you know it's been really a lot of learning and
quite the journey.
But I learned pretty early onin my career that too much
naloxone could be a challenge.
And in the ER you have allthese things at your disposal
You've got a pulse oximeter, youhave nurses, you have extra
(05:03):
hands and extra people andequipment to really to get
naloxone on board as quick asyou can.
We would do it literallythrough the genes, do injections
and get naloxone in someonesignificant doses as quickly as
possible, because it wasliterally life and death.
Now the alternative is in the ERwhen someone's say recovering
(05:23):
from an overdose or you're notquite sure what's happening, you
can give a little bit ofnaloxone.
So I was a big fan of the 0.4IV and if someone their
respiratory rate was slow, theiroxygen seemed to be dipping,
let's give them 0.4 of Narcanand just see, typically for a
patient, that wouldn't wake themup to agitated acute withdrawal
(05:46):
.
Instead it would help theirbreathing, it would support
their respiratory status andtherefore they were in a safer
position In the ER you have thatoption and I learned over the
years how to really carefullywalk that line of too much
versus not enough.
When you have the rightresources.
It's a lot more nuanced than itcan be, so just summing that up
(06:09):
, critical presentation apneicblue.
Speaker 1 (06:12):
Just give it till they wake up, unresponsive.
But if they're more justdepressed or sleepy, it's maybe
titrate until they're not insevere withdrawal, but they're
breathing on their own.
Speaker 2 (06:23):
Yeah, they're maintaining their oxygenation.
They have a reasonablerespiratory effort.
It definitely is more nuancedand you can afford to do that.
You have the time for it, ifsomeone is not in that critical
life-threatening situation.
Speaker 1 (06:38):
So I and disclosure, dr Close and I have worked in
the same department for 10 years.
I've heard you make thiscomment to some of our nurses
let's not make a rhinoceros.
Tell me what you mean whenyou're telling the nurses let's
not make a rhinoceros.
Speaker 2 (06:51):
Right.
So one phrase that I've usedvery frequently in the ER is
don't poke the bears Likeabsolutely not.
I don't want to take someonewho is calm and comfortable,
breathing well, oxygenating well, their heart rate is good
no-transcript.
Someone is literally fightingthe staff.
(07:13):
They're in that fight or flightmode.
What I didn't realize early inmy career is that was acute
withdrawal.
And later in my career now Iunderstand that's exactly what
we were doing.
And so those big doses ofnaloxone we could easily turn
someone from a very comfortablepatient who's doing fine to
someone who truly is like a wildrhinoceros in my emergency
(07:36):
department.
In severe withdrawal Absolutely.
Oh my gosh, the agitation anddiscomfort.
When you step back and look atit from the patient perspective,
that level of discomfort almostwarrants that kind of a
response from them.
Speaker 1 (07:49):
So once again, critical presentation.
You're worried the person mightnot survive, just push naloxone
.
But again, if there is anopportunity to be a might not
survive, Just push naloxone.
But again, if there is anopportunity to be a little bit
more careful.
You titrate, absolutely,absolutely.
So let's change the scenario alittle bit.
I know you work in a streetclinic for patients with opioid
use disorder and you, as youmentioned, also have an
outpatient clinic.
Now that you're out of theemergency department, talk us
(08:12):
through how you use naloxone inyour practice now.
Speaker 2 (08:15):
Okay, so I mentioned in the ER you have nurses and
you've had pulse oximeters andyou have patients on monitors
and you can give little tiny IValiquots and make sure that you
can go through the nuance of acomfortable situation for the
patient On the street.
I don't have that.
Typically, when I'm respondingon the street I grab a box of
our nasal naloxone and that'swhat I have and I don't have a
(08:38):
pulse oximeter and fortunately,with my medical training I'm
very comfortable.
I'll check their pulse, I'llput my hand on their chest.
I can easily see what'shappening from basically my eyes
and hands on a patientno-transcript without sending
(09:26):
someone to the hospital.
Well, I don't get the choice ofwhether or not they go to the
hospital.
I get the choice of whetherthey get evaluated by EMS, and
it is my standard of care is tocontact 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 playby myself, okay, I was going to
(09:46):
say so.
Speaker 1 (09:47):
For every one of these out of the emergency
department, you're calling 911.
I mean, you and I both know whoknows what they overdosed on
right, was it methadone?
Was it isotonitazine?
Speaker 2 (09:56):
We have no idea what they overdosed on or if that's
really what's happening Like.
You need 911 in that situationjust like anybody else, and this
is a big part of what I teachin the community.
Speaker 1 (10:06):
You got to have that help A little bit of a take home
here Any overdose outside ofthe emergency department or
inpatient, setting 911, givenaloxone if you've got it and
then most likely they're goingto get transported to the
hospital unless, for some reason, ems decides they don't need to
, absolutely.
Yeah, yep, all right, so we'vetalked about using naloxone as a
healthcare provider.
What's the best way to getnaloxone in the hands of our
(10:29):
patients who are the highestrisk of having an overdose?
Speaker 2 (10:32):
who are the highest risk of having an overdose,
normalize.
We need to make this like afire extinguisher, a seat belt.
I mean, truly I don't believeI'm about to burn my house down,
but frankly it could happen.
So you have to have a fireextinguisher.
You've got to be ready for anemergency situation, and that's
really what I talk about whenI'm trying to help the community
(10:52):
understand why we want to getnaloxone, basically anywhere we
possibly can is you don't knowwhen something bad is going to
happen, but if you're not ableto handle it, unfortunately
these are fatalities that resultfrom us not having naloxone and
not being able to respond to anemergency situation.
So when I want it in the handsof my patients and their family
(11:16):
members, I hand it to them.
You know, this morning I waschecking on one of my patients
and I literally handed his dadfive boxes of.
Speaker 1 (11:25):
Narcan?
Do you not prescribe it?
What makes you give it to themas opposed to giving them a
prescription?
Speaker 2 (11:30):
So one of my dear friends who is also our lead
pharmacist for our regionalcoalition.
She taught me that about 10% orless of the naloxone
prescriptions that come throughthe pharmacy actually get picked
up.
So people will pick up theirother medications, they will
pick up, you know, anything elsethat they want at the pharmacy,
(11:50):
but they will leave the Narcan.
And is that because of stigma?
Is that because of cost?
It is for some patients, buteven when it's covered by their
insurance and it is free ofcharge, people will decline.
I don't know all of the reasonsfor that, but I assume many of
them are related to perceivedstigma or actual stigma.
(12:11):
So what I have learned is it isso empowering to tell a patient
, to tell a family member, totell 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'mgoing to give you this
medication that you can use tosave a life, and people can
(12:34):
relate to that.
I actually read something just acouple of days ago that said 4%
of prescriptions are actuallypicked up at the pharmacy, 4% of
prescriptions for naloxone.
It's better to put it in theirhands and then you also get to
have that conversation Put it inyour purse, keep it in your car
.
I tell them about a timedriving back from something with
my daughter and literally therewas someone slumped over on the
(12:55):
side of the road doing theU-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 ofour community is hand it to
them literally and then helpthem understand that this can
happen anywhere, anytime, andthey need to be ready.
Speaker 1 (13:10):
Yeah, just one clarification.
You know, naloxone is thegeneric name Narcan.
I don't know what marketingthey did, but they just burned
it into the memories ofhealthcare providers, I mean.
Most people still call itNarcan, oh, totally.
Speaker 2 (13:21):
I'm one of them.
Speaker 1 (13:22):
There's some yeah, me too there's Cloxado and there's
Evzio.
There's all these other brands.
For the most part here inCentral Coast of California
we're using nasal naloxone inthe community with the brand
name is nasal Narcan.
So both of us will slip up hereand there and call it naloxone
or Narcan, just to clarify.
We've had a lot of support herein California from the state in
actually paying to give theboxes of nasal Narcan into the
(13:45):
community and we'll talk aboutcommunity distributions in just
a little bit.
Yep, one thing I wanted to sharethat I've done and I love this.
I asked my patient who hasopioid use disorder you want
some Narcan?
No, no, what if you could savea friend?
Hey, doc, maybe you're right.
So I think what I tend to do isI tend to displace the need for
Narcan.
You would never need Narcan,but gosh man, we get overdoses
(14:05):
the safe way.
And gosh, I mean, what if afriend of yours who's using I
tend to find that the offer ofcould you be a community member
and just respond?
People really respond well tothat.
Even when I'm giving peopleboxes of naloxone, unless I
displace the need from them tosomeone else, I find that I get
resistance.
Speaker 2 (14:24):
I like that.
I like that a lot.
And that goes back tonormalizing Totally Talking
about overdoses from Safeway andtalking about overdoses behind
the library and gas stations.
We do this all day, yeah.
Speaker 1 (14:33):
Okay.
So when you have a patient whoyou know is very high risk for
having an opioid overdose, whatdo you think is the best way to
make sure naloxone is where itneeds 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 (14:52):
Again, it's with normalization and getting it to
anyone who will take it.
Essentially, you know we try toget it throughout the community
, but specifically in our region.
Basically, if you have gotten asubstance off the street, it's
going to have fentanyl in it orsomething worse.
Correct, that's true.
But if you're using cannabisoff the street, we have had
(15:15):
cases where those have hadsignificant amount of fentanyl
in them and have unfortunatelyresulted in overdoses.
Our cocaine in our community,absolutely, If you're using
cocaine in my community, justassume it's fentanyl and you're
at very high risk for overdose,sometimes without any cocaine,
it's just fentanyl, absolutelyDo the talk screens.
There's no cocaine, onlyfentanyl.
So you know the meth in mycommunity.
(15:37):
I often speak about howfrustrated my patients are who
are preferring to usemethamphetamine, 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 tobe everywhere and that's really
something I try to help mypatients, their family members,
their friends.
I help them understand.
So I talk about the cannabis, Italk about the cocaine, I talk
(16:05):
about the meth and let them knowthat any exposure could
potentially be fatal from a doseof fentanyl.
So I enlist them and empowerthem that you could save
someone's life, whether it'syour friend or anybody else.
But because of what's on ourstreet right now and what's in
our community, I need to givethis to you so you can save
someone's life.
Speaker 1 (16:21):
Yeah, I think for me.
I just think who's likely to bethe 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 thestreet?
So I think that's where Itarget.
Go ahead.
Speaker 2 (16:32):
And then give it to all of them yes.
So I think that's where Itarget Go ahead and then give it
to all of them.
Speaker 1 (16:35):
Yes, like every one of those people needs it Totally
, Because then again they mightsave someone else on the street
too.
Speaker 2 (16:42):
Well, and totally, I actually have been known to say
you know if you are aroundhumans or pets that you really
like you need to have Narcan.
Speaker 1 (16:47):
I mean just this has got to be everywhere.
Yeah, totally agree.
All right, so now you and Ihave done too many naloxone
trainings for our community, inour community, to count.
As you reflect back on thevarious trainings that we've
done, what do you think has beenthe most effective way to train
community members on how to usenaloxone and to get naloxone
into the hands of communitymembers?
Speaker 2 (17:09):
So there's two parts to this.
One is how do you make it easyfor people to stop by after work
, grab some Narcan, learn how touse it and then move about
their day so structurally?
I believe what was one of themost effective ways we did it is
we rented out a center in ourcommunity and we set up in
(17:30):
English a six-minute videoplaying on loop of how to give
naloxone, and we did the samething in Spanish in another room
and we had flyers andinformation and pamphlets in
each respective language in eachrespective room and people
would walk in and somebody woulddirect them.
Hey, just take a minute, watchthis six-minute video you can
(17:50):
watch it a couple times if youneed to and then jump over there
, talk to that lady who is me,and she'll get you some Narcan.
And they did.
People walked in, they watchedthe video once or twice, they'd
come over and I would ask thempersonally.
I spoke with every person thatcame through my line do you have
any questions?
And some people were like nope,thanks, doc.
And they were gone, and otherpeople were yeah, I have some
(18:11):
questions.
And what was crazy is there attimes was a line.
It was like a receiving line ata wedding.
Speaker 1 (18:16):
I remember that you looked like you were getting
married.
Yeah, it was crazy.
Speaker 2 (18:18):
Total receiving line.
It was like 50 people waiting totalk to you and they were
patient and they were kind andthey were very respectful of.
This is education I need andwant and it was a really, really
powerful, powerful scene thatwe had there.
No-transcript.
(18:48):
And essentially every time Itrain on Narcan, either myself
or Dr Grover or one of mypartners gets Narcan.
I have had oh my gosh if I say ahundred, it's probably an
underestimate doses of Narcan inthe last 10 years of training
and literally you show people,you give it, and then you
literally take the plasticdevice and you poke it on your
(19:10):
hand, showing them there's noneedle, nothing to get harmed
with, and the eyes in theaudience when you do that,
they're just oh my gosh, and shedidn't explode or fall over
dead or all these things thatthey're afraid of.
And so they get to see in realtime a live human getting Narcan
and having no side effects, noissues.
(19:31):
And after I do thesepresentations, so many people
will come up and like you gaveyourself Narcan.
Yeah, I do it all the time.
And just normalizing again thatthis isn't something scary, it
isn't something dangerous, therearen't fireworks or spiders
that climb out, it's super easyand it's safe and I think that's
the most important thing that Ido in my trainings yeah, I
(19:55):
usually laugh afterwards andtell people that's a little bit
bitter.
Speaker 1 (19:57):
I've probably given myself or you've given me, I
don't know how many doses ofnaloxone, you know to our
audience.
We've been doing like we said,countless naloxone trainings.
I can get you the video thatwe've recorded.
I can also get you our slidedecks.
We're happy to share Gosh.
we've trained thousands ofpeople on how to use naloxone.
A couple other points that kindof I would make.
(20:17):
I think the first thing Iusually do is whenever I go to a
naloxone training, I bring anexpired box with me and I like
it to be sealed, and usuallywhat I'll do is I'll go through
my slides, we'll talk about whento give it, call 911.
We go over the expiration date,we let people know that after
the expiration date the naloxoneis still good.
It loses about 5% potency forevery year after the expiration
(20:40):
date.
And then I walk them throughthe box.
I literally like almost abovemy head.
I open it, I show them the twoblister packs Again, we use the
nasal Narcan here in the CentralCalifornia area that we're
working in and then I open oneof the little blister packs and
I show them.
This is what it looks like.
I press the syringe and thenthe spray goes into the air and
(21:01):
then I explain to them that'show 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 myselfa dose as well, or I ask for a
volunteer.
But yeah, I think unpacking thebox has been really helpful for
me.
Speaker 2 (21:20):
I think there's one other thing on.
That is, if someone and I dothis as a demonstration, if
Casey and I are presentingtogether, 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 tosomeone who is high and that was
(21:41):
an air quotes If they areunresponsive and poorly
breathing and you areconsidering they are probably or
possibly dead, you're givingNarcan and realize that
difference between oh, you knowhe's nodding off but he's
responding to me versus oh, mygoodness, I'm afraid he's dead
(22:01):
or dying.
That's when you're giving 9-1-1.
And it takes some of the fearaway as well, because otherwise
you just watch someone die.
Speaker 1 (22:07):
Just to clarify.
You said that's when you'regiving 9-1-1.
That's when you're calling9-1-1 and giving naloxone.
Speaker 2 (22:11):
Thank you.
Yeah, you're welcome.
I was paying attention.
See Love it.
Speaker 1 (22:15):
All right.
So, thinking back on yourcareer, what clinical case
involving naloxone stands out toyou the most, and why?
Speaker 2 (22:22):
So it was in 2019 and we were starting to see
something weird in my community.
People were having overdosesand it didn't make sense.
And I'll never forget thisyoung man.
He came in in an overdosesituation.
He'd gotten naloxone in thefield and we were talking.
He's like no, no, no, dude, itwas just a Percocet.
(22:43):
I was like, okay, all right.
And then half hour later thenurse calls me and she's like
he's not responding.
He's not responding.
So we gave him more Narcan andhe responded.
And that happened three moretimes.
We finally put him on a Narcandrip and admitted him to the ICU
and that's when we startedpiecing together that fentanyl
had come to our community.
And the reason that's soprofound to me is I didn't know
(23:08):
what was happening.
I didn't know why he wascontinuing to overdose.
It wasn't making sense and as aknee yard doc, I knew something
was wrong, but I didn't knowwhat.
And I mean, obviously, I thinkwe all know where fentanyl has
taken us since then.
So that case really stands out.
Speaker 1 (23:24):
Yeah, I'm going to share one from my residency.
So I was a second year residentin the pediatric emergency
department and we get a callthat there's an opioid overdose
coming in on Opana.
If you remember, that washydromorphone, it was briefly on
the scene and 2011,.
That was a bad time withprescription opiates in America,
and so, in any case, I'm asecond year resident, I was the
(23:44):
senior resident in the PZD andthey're like Grover, you're on
it.
I was like I got it and I'llnever forget the paramedics
wheeling him into ourresuscitation band, him yelling
please don't Narcan me, pleasedon't Narcan me.
And I remember the anger risingin my gut of like, oh, we're
going to totally Narcan you, youdeserve it.
(24:05):
But I, of course, clinically,was like well, sir, we're just
really worried about yourbreathing.
We'll just give you a littlebit of naloxone, see how it goes
.
But I was taught punish thesepeople, make them suffer.
I'm embarrassed.
I mean I have goosebumps rightnow just thinking about the raw
emotion and just I was hurtinghim.
I mean I've read so manyrecovery novels and people talk
(24:27):
about back in the nineties ifyou went into an ER, they'd push
naloxone just to punish you,like you deserve it.
So let's just take a minute andbe grateful that we've learned
and things have changed.
And the man was yelling at me.
He clearly did not neednaloxone and yet my training was
really to punish people andmake them withdraw so they would
(24:47):
know how bad their decisionswere and that would fix them.
I mean, this goes back to mysaying of all these years why do
patients with addiction not getbetter?
We judge them, we don't offerthem treatment and it's
impossible to get treatmentright.
One in seven Americans willdevelop a substance use disorder
, yet less than one in 10 hasaccess to treatment.
This is what you and I aretrying to do.
Let's make treatment foraddiction as friendly as
(25:11):
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 mytraining was to harm him.
It just goes to the deep, deepstigma that's in health care
against patients with addiction.
It is truly systemic, systemicstigma.
So, before we wrap up, anythingelse on naloxone that you
(25:33):
wanted to add, so we tease a lot.
Speaker 2 (25:38):
that and this sounds so weird to say and I know this
audience will understand.
But you have gotten to a pointof missing heroin, because it
was something you somewhat knewwhat was going on with your
patients, you had an idea ofdosing and you had an idea of
how you could startbuprenorphine easily, safely.
Those were the days, so tospeak.
(25:59):
Or prescription opioids oh, mygoodness, You're using how many.
Speaker 1 (26:02):
Norco a day.
Great, how many milligrams isthat?
Yeah?
Speaker 2 (26:04):
I miss those days.
It was a different world.
And then we back, as I said, in2019, we started dealing with
fentanyl and we've learned somuch over the last four years of
dealing with fentanyl and we'regetting a handle on it and,
granted, it's super nuanced, butwe're getting there.
What scares me is what's next,and in our community.
(26:26):
What's next are the novelbenzodiazepines we're seeing
carfentanil, we are seeingatizolam, we are seeing xylizine
, bromazolam, I mean it's we'reworried about isotonidazine,
totally.
It's just.
It's anybody's guess and mypatients literally that I'm
taking care of in the streetclinic specifically will ask me
(26:48):
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 Italk very openly and honestly
with my patients about that thatI have no idea what's in your
body Couldn't tell you.
So we try to partner with themand talk with them through it.
But the one thing that I wouldstick with as far as it goes in
(27:09):
this episode about naloxone isthat's the fire extinguisher we
do have.
So I don't have a magicantidote for bromazolam or
atizolam or xylosine.
I don't.
But fortunately and it's weirdto say that, and you can hear
the hesitation in my voice thatthe majority of these are mixed
(27:29):
with an opioid, such as fentanyl, parafluorofentanyl,
carfentanyl or something.
So you still have a fireextinguisher that is likely to
work.
It may not reverse the entireoverdose.
That's why that 911 thing wasso exciting and so important in
the beginning.
You still have to call for helpbecause you can reverse the
fentanyl or other opiates, buteverything else that may be in
(27:52):
their system, you don't haveanything to treat them with.
So, yes, narcan is one.
It's that hammer and nailanalogy.
You know, all you have is ahammer, everything looks like a
nail.
Well, this is the hammer wehave and fortunately most of our
scenarios have nails, at leastas part of the problem.
Speaker 1 (28:09):
So it's almost like don't be nihilistic about
naloxone Just because the drugsupply is tainted, you could
still save a life.
Speaker 2 (28:14):
You absolutely can and don't miss that opportunity.
You know, because if someonedies, they never get a chance to
recover.
Speaker 1 (28:22):
If you look at the artwork that's my podcast.
That's a painting made by afriend of mine named Paul, and
we lost him in 2019.
Yeah, yeah, yeah.
So we did talk about why do welike recovery.
It's giving people their livesback.
When you die of an overdose,you never get that chance for
recovery.
Before we wrap up, a huge thankyou to the Montage Health
(28:45):
Foundation for backing mymission to create fun, engaging
education on addiction, and ashout out to the non-profit
Central Coast OverdosePrevention for teaming up with
me on this podcast.
Our partnership helps me getthe word out about how to treat
addiction and prevent overdosesTo those healthcare providers
out there treating patients withaddiction.
(29:07):
You're doing life-saving workand thank you for what you do
For everyone else tuning in.
Thank you for taking the timeto learn about addiction.
It's a fight we cannot winwithout awareness and action.
There's still so much we can doto improve how addiction is
treated.
Together, we can make it happen.
Thanks for listening andremember treating addiction
(29:28):
saves lives.
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