Preventing Overdose from Combined Substances

In the U.S. in 2020 the number of people who died  from a drug overdose spiked by 30 percent between   May 2020 and April 2021 100,000 died from an  overdose the rise is attributed to synthetic   opioids stimulants and use of multiple substances  in combination and is known as the fourth wave   what started in 1999 largely with prescription  opioids continued in 2010 with heroin use   then by 2016 was driven by lethal  synthetic opioids like fentanyl   and by 2020 stimulants like methamphetamine and  cocaine and depressants like benzodiazepines   were being combined with fentanyl to  cause record numbers of overdose deaths this polysubstance overdose  crisis has also struck Appalachia   where in 2020 more than half the calls to poison  control across 23 rural counties in Kentucky,   New York, Ohio and West Virginia  involved more than one substance The fourth wave of the overdose epidemic well  initially was attributed to stimulants and   fentanyl use it's pretty much now fentanyl is in  almost all the drugs you have adulterated pills on   the street so anyone buying an Oxycodone you know  30 milligram tablet they think they're getting   Oxycodone really they're getting a bunch of fentanyl we're seeing an increase in counterfeit   pills and overdose deaths nearly everywhere so in  urban communities as well as in rural communities   including areas in Appalachia in Ohio, Kentucky,  West Virginia, the Southern Tier of New York you   know even when heroin was truly heroin there  was some variability in how much was in a bag   but people generally had an idea on how it would  affect them now they get fentanyl and they may   get a lot of fentanyl in the bag or they may get  a little fentanyl and it's when you have an opioid   as potent as fentanyl and sometimes mixed

with  other things that are going to make it stronger   potentiate it is really dangerous and really  unpredictable I've experienced two overdoses   both times I went and I'm gonna buy a  small amount usually I would do let's say five   bags of heroin at a time well this time I'm only  gonna do one because that'll keep me safer I'll   still get an effect from it but I'm not doing  so much so that'll kind of better ensure that   I don't overdose and I couldn't even tell you what  force it was that made it so that I could still be   here because I was driving my car I pulled out  of Tops on

North Clinton and the next thing I   know I'm getting yanked out of my car by EMTs  up on Main Street I have no idea how I got to   Main Street I don't remember any of it and I  was just stopped in the middle of Main Street   like my foot wasn't on the break I wasn't in  park I didn't hit anything my car just stopped   and somebody luckily had narcan on them called  9-1-1 so they gave me some narcan I wasn't quite   responding to the first dose but them giving  me that narcan kept me alive we'll say long   enough for EMS to show up and give me more  narcan and then I was brought to the

hospital   but when they did my toxicology it was all  fentanyl we get a lot of unintentional overdoses   because people don't know what they're getting in  the last couple of days that I was on consult I   had one each day one was a patient that had  been in a bar bought a line of cocaine and   woke up in the ED she was with somebody  that had naloxone and fortunately was able to   be reversed but had she been in the bathroom  without you know someone around it would have been   a fatality I had a therapist tell me one time and  I hold this very true and remember it because the   way he

presented it was very very blunt and  direct I was complaining because I had to do   a screen in outpatient and I was testing  positive for substances that I didn't use   and I you know was complaining about this I had a  problem well I didn't do that and that's not fair   I didn't use it was cocaine I didn't use  cocaine and he looked at me and said well   yeah the quality control on street drugs has  really gone down he meant it in a sarcastic away but   it really kind of illustrated the fact that you  can go to the same person and buy your substances   and feel like you're safe in that but

there is no  guaranteed safety out there and that those threads   that we're holding on to to convince ourselves  that we're keeping ourselves safe or safer   are starting to become thinner and thinner and  thinner and in a lot of situations they just break so the counterfeit pills are  dangerous for a number of reasons   people in probably the most common counterfeit  pills I see are alprazolam or Xanax   alprazolam is a very euphoric benzodiazepine  people really like it so it's a known   commodity it's not surprising that someone will  press a pill to look like Xanax but they don't  

contain alprazolam they contain other synthetic  benzodiazepines sometimes mixes of designer benzodiazepines that the end user doesn't have an idea  of the strength often the duration of effect    sometimes there's other things in it there  have been clusters of fatalities with   designer benzodiazepines that had fentanyl mixed  in it so if you have an user that's expecting to   use maybe a two milligram dose of alprazolam that  they know what happens when they take it and they   get a much more potent designer benzodiazepine may  be mixed with some fentanyl or some other drugs   it's a

perfect setup for overdose and fatality I  know that I would seek out prescription medication   off the streets before heroin because I felt like  well if it's prescription like chemists put this   together the FDA approved it whatever I know  what I'm getting then and now with counterfeit   pills that's completely changed the game and  I have seen people buy counterfeit pills that   they think may be Vicodin or Xanax and it turns  out that it's completely just pressed fentanyl there's a stabilization phase in treatment you  know for a lot of people a lot of times that   initial that initial

process is getting some  medication getting stabilized physically and   then they can really focus on some counseling that  can help them look at recovery on a more long-term   level and figure out what is their pathway  to recovery the withdrawal the dysphoria   anxiety panic all those symptoms people are  often once they're physically dependent not   using necessarily for the euphoria anymore they're  using just to feel normal they live in a dysphoric   state and if you don't have the dysphoric  state taking away that withdrawal syndrome   you can't then move to the next step which  is to

start recovery to start learning about   addiction to get the support system in  place to work on things like safe housing   the rest of overall health MAT is vital  for people who really need it because with   withdrawal is I would not have been able  to do it if I did not have access to MAT to be able to stabilize myself and get into  treatment and hear a message and actually   utilize the time that I was in groups and  therapy sessions I wouldn't be here it would   not have worked because my entire mindset and  existence and everything would have just been   focused on how absolutely

miserable I feel  and I think that's something that a lot of   people who have not experienced withdrawal  whether it's opiates benzodiazepines alcohol   it you can't describe it to somebody who hasn't  experienced it you know in in rural communities   where everybody knows everybody a lot of  times it it's hard to even get people to come   to treatment so looking at that aspect of it is a critical it's a critical area to take a look at   how we can reduce the stigma associated with  treatment so that more people will access   care we have this this wonderful tool this  medication that can

help mitigate those   symptoms and allow you to get the help that  you need so we need to do that right away like   when it comes to this window of willingness that  people who are seeking recovery have seconds count so one of the things that's going  on with the fourth wave of the   opioid crisis that providers and pharmacists  should know about is that people are more   frequently mixing drugs and they are also using  stimulant a lot of stimulant medication such as   cocaine and methamphetamine and in  terms of the drugs that they're mixing   gabapentin and benzodiazepine type drugs are 

prominent and can cause a lot of problems and also   they're mixing drugs that they don't even know  about because sometimes they're buying drugs on   the street even pills that look like FDA regulated  pills but are not and these pills are are   counterfeit and they've had various things added  to them most concerningly fentanyl when you mix   drugs depending on the drugs you can get a lot of  different effects but most often when we see fatal   overdoses or you know somebody ends up in the ICU they're mixing depressants and that includes most   commonly an opioid usually fentanyl it could

be  from heroin it could be from a counterfeit pill   but in addition to the opioid another depressant  may be used like a benzodiazepine or a gabapentin   or alcohol even or all of the above and when  you have several depressants combined together   you have a greater effect on decreasing  breathing the decreased mental status   the combinations blunt the ability to recognize  that the oxygen saturation is low so people are   less likely to be breathing when their oxygen  drops or when their carbon dioxide rises   the opioids the synthetic opioids in particular  work very quickly and you

don't have a lot of time   to recognize an overdose in particular someone's  using intravenously so you know historically if   we had prescription opioids taken we had a  little bit of time for someone to recognize   somebody's passed out on the couch their breathing  is slowed now it's very abrupt fentanyl overdoses   happen really quickly you have not as much time  to react great risk of overdose of using alone Xylazine has been around for a while  but just not in the United States   northeast and now it's showing up in the northeast  Xylazine is a horse anesthetic it is added to   the to

the heroin because it kicks it in it  potentiates it if a user is using Xylazine   it makes them more dependent now if you're using  heroin whether it's fentanyl or truly heroin   and you have Xylazine the withdrawal syndrome is  going to be a lot worse the intoxication will be   much more significant and risk for fatal overdose  certainly more significant but if they stop using   they have much more severe withdrawal  gabapentin can be a useful medication for many   problems but when it's used together with opioids  it it confers a higher risk upon the person so   people need to know about

this problem it actually  gabapentin misuse among the general population   is is on the rare side but when you look at the  opioid using population those who misuse opioids   or have an actual opioid use disorder the amount  of people who misuse gabapentin is increased   one of the very important things to do after  you've talked to the patient and asked them about   drug use disorder and and also investigated  the results of a urine test or mouth swab   the next most important thing to do is check the  state prescription management program to see if   they are getting prescribed any other

opioids from  other doctors or other benzodiazepine types   of drugs and you can also see gabapentin reported in some of these prescription management   program databases not in 100 percent of states but in   certain states it's been mandated to report   gabapentin prescriptions as well because of all  the problems with gabapentin so examples of states   that have mandated such type of reporting are  Ohio, Virginia and West Virginia and and there are   several others as well and there's movements in  other states to get that legislation on the books it's important that we're educating people

that  are at risk as well as the general public family   members friends to to be aware of naloxone to  make sure that there's naloxone distribution   programs available in those communities and that  we're making it available to any and everyone   it's really dangerous to use alone the  overdoses occur rapidly and if you don't have   someone there with naloxone if an individual  uses too much really high risk for fatality   so the first thing is the distribution of  narcan and making narcan readily available   that's the first step I think  that it's important to note that   and I said this

to a counselor one time I  was very high risk I was still using she   gave me a narcan kit and I went this is great  but if I'm overdosing I can't narcan myself   which then kind of leads into the  next thing which I think we're doing   but we could do a better job which is  minimizing these feelings of guilt and shame   around substance use disorder because  that guilt and shame is what caused me to   use in abandoned houses and alleys and alone  in my car where if I did overdose there was   nobody there to help me I'm talking with the  person who's using drugs I try not to lecture   you

know treat them in a destigmatized way and  try and make them aware that I'm here to help   you know whether that's if they're not ready to  stop using to use safely you know then I teach   them about things like needle exchange use  with somebody so you're not using alone test the drugs if you're you're able to get  fentanyl test strip so you can understand   that you know what you're using recognize  the combinations that you're using could be   more dangerous potentially avoiding the  fear-based messaging where I'm not trying   to explain what the risks are to scare you this  isn't a

scared straight tactic that doesn't work   what I'm trying to do is here's the here's the  realistic possible outcomes of what you're doing   what do you want your outcome to look like  and how can I help you reach that outcome   I think the most important things for  communities to do of course is working with   their health care systems their government  officials to to push and ensure that treatment   is readily available it's important to try and  provide as much treatment as possible and to make   all of the opioid use disorder medications  available to people and that's that's

something   that you know we can we can do if we have  community willingness and provider willingness