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Join us on this episode as we delve into the complexities of the opioid crisis with David I. Deyhimy, an addiction medicine specialist and founder of MYMATCLINIC. Together, we’ll explore the crisis’ evolution, the challenges faced by responders, and the importance of evidence-based approaches in saving lives.

David I. Deyhimy is an addiction medicine specialist and anesthesiologist dedicated to helping those suffering from drug addiction and preventing overdose deaths from opioids. He is the founder and medical director of MYMATCLINIC (also on Facebook, YouTube, and Instagram @mymatclinic).

He discusses the KevinMD article, “Saving lives with naloxone: perspectives from the frontline.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome David Deyhimy. He’s an addiction medicine specialist and anesthesiologist. Today’s KevinMD article that he co-wrote was titled “Saving lives with naloxone: perspectives from the frontline.” David, welcome to the show.

David Deyhimy: Thank you for having me.

Kevin Pho: Let’s start by briefly sharing your story and journey.

David Deyhimy: Well, I’m an anesthesiologist by training, and got into private practice, and everything was going great. But after a few years I was looking to learn and do some additional things, and I just kind of stumbled upon addiction medicine. I had some understanding of it from my undergraduate degree in psychology. But I was looking for something to do in addition to anesthesia that was going to solve a problem and be meaningful.

And in around 2011 is when I started looking into addiction medicine, and heroin was kind of replacing pills as the number one cause of overdose death in the United States. And at that time there were about 30,000 overdose deaths, and it had recently passed motor vehicle accidents as the number one cause of accidental death.

And here we are in 2024 with close to 110,000 overdose deaths. The last two years it’s the number one cause of death, all cause of death, for 18 to 45 year olds in the United States, by a wide margin. So we are losing this battle against illicit drugs and overdose deaths, and there’s a lot of reasons for that we could talk about if you’re interested.

But this is sort of my passion, the reason why I do what I do. And we have these very, very effective treatments available, but this country isn’t utilizing them nearly as much as they should. Less than one in five people with moderate or severe opioid use disorder is offered any of the three FDA approved medications for treating opioid use disorder, and they’re very effective.

And not enough people are aware of the fact that, for all intents and purposes, the entire illicit drug supply is contaminated with fentanyl from Mexico. So a lot of these overdose deaths are people that weren’t even intending on using opioids. They thought they were taking something else, and they had no tolerance, and they ended up dying very quickly as a result.

So I want to raise awareness for the fact that this is going on, and that people should be carrying the overdose reversal drug naloxone. And now there are higher dose forms of that that will more readily reverse a fentanyl overdose, and that’s part of what the article is about as well.

Kevin Pho: Sure. So let’s talk more about that. It’s titled “Saving lives with naloxone: perspectives from the frontline.” For those who didn’t get a chance to read your article, tell us what it’s about.

David Deyhimy: Well, we have had a drug called Narcan, which is a form of intranasal naloxone, for a long time. And commonly the word naloxone is often mistakenly called Narcan, which is just a pharmaceutical drug, the active ingredient is naloxone. And we can give naloxone in many different ways, intravenously, but the way that lay people tend to carry it and use it is intranasal, and they come in pre-filled nasal injectors, usually two per box.

Now, Narcan is 4 milligrams per nasal injection, and it’s very effective at reversing overdoses caused by drugs like heroin. But now we have fentanyl, illicit fentanyl that is, which is 50 times more potent than heroin. So the speed at which somebody overdoses is much faster, especially if they have no tolerance. And oftentimes it takes much more naloxone to fully reverse the overdose and get them breathing again.

And the article talks about how time is of the essence, because when somebody’s not breathing, they’re experiencing hypoxia to their brain and other vital organs. And sometimes we reverse them but it’s too late, they’ve either had brain damage or they’ve died. So carrying it is the number one most important thing, and having adequate supply and potency is number two.

And there seems to be a lot of resistance to the idea of higher dose naloxone, which will more readily reverse a fentanyl overdose, because it can precipitate withdrawal in people that have tolerance. But my goal as a doctor is to prevent death and to prevent brain injury, and so I want to reverse somebody as quickly as possible.

Kevin Pho: So the naloxone dose that’s commonly available, is that the four milligram dose?

David Deyhimy: Yes. And now there’s an 8 milligram per injector dose, so it’s essentially double. Kloxxado is the name of the brand that’s FDA approved for several years now, and it’s basically double Narcan. And the reason it got FDA approval is because we’re dealing with something that’s 50 times as potent as what we commonly were reversing.

Kevin Pho: And the 4 milligram naloxone, that’s available over the counter, that’s just to be clear.

David Deyhimy: Yeah, recently they got over-the-counter approval for that.

Kevin Pho: OK. So what are some of the arguments against the 8 milligram naloxone? So why isn’t this happening? What are some of the arguments that you’re hearing against that?

David Deyhimy: The only argument that I hear repeatedly is that it might put somebody who has tolerance into precipitated withdrawal, which means that when you force the opioid off the receptor with naloxone, it closes the receptor and they wake up, but they feel bad, they feel like they’re in immediate withdrawal.

But precipitated withdrawal is treatable, and death and brain injury is permanent. And it doesn’t necessarily mean that somebody’s going to have precipitated withdrawal, it just might be more likely.

However, like I said, the goal is to reverse somebody’s respiratory depression as fast as possible. And we look at reports and studies all the time where people were given five doses of Narcan to get them breathing again. And that’s a problem for somebody that has one box with two doses in it.

If you’re an EMT or a paramedic and you have a large supply, that’s fine. But 40 percent of overdoses happen with a bystander present and no EMT or paramedic or trained professional present. And that person who’s going to be the first responder needs to reverse that overdose as fast as possible to save this person’s life.

And why there’s any controversy around this still blows my mind. Well, it actually comes down to politics and money, if you want to get down to it. But the goal is to save lives here, and precipitated withdrawal is treatable, it’s not permanent, and death is.

Kevin Pho: Let’s talk about that bystander scenario. So tell us some scenarios where, let’s say there’s a bystander, what should that bystander look out for that would warrant administration of Narcan? So tell me what kind of symptoms they should be looking out for.

David Deyhimy: Reduced consciousness, difficult to arouse, pupils, depressed respiratory rate, less than 10 or eight. And then beyond that you can look for signs of cyanosis, like blue lips. These are all signs of an overdose.

We recommend do a sternal rub to see if they can arouse the person, look at their eyes to see if the pupils are pinpoint, and then carefully look at whether or not they’re breathing at all, or if their respiratory rate is significantly reduced.

Kevin Pho: And if this picture is due to an opioid, and naloxone is administered, what should we look out for to ensure that it is working?

David Deyhimy: You want to wait about two minutes to see that the person is more arousable and that they’re starting to breathe again, or that, if they had a depressed respiratory rate, their respiratory rate is increasing. Two to three minutes is the guideline.

Kevin Pho: OK. So the debate between four milligrams and 8 milligrams. So as a primary care physician, what guidance do you advise me to do? Should I be prescribing 8 milligrams, depending on the situation? What kind of guidance are you giving out?

David Deyhimy: So this is universal guidance. Number one, awareness. You need to raise awareness amongst your patients, because many of our patients have children, or are adolescents or young adults, they fall into that 18 to 45 group. They all need to have awareness that potentially any illicit drug use, the drug you’re using could be contaminated with illicit fentanyl.

The pills that they’re pressing look identical to a Xanax, to an Adderall, to a Percocet, something that somebody might have taken before at a concert or a rave or a party and found to be pleasurable and thought, well, hey, I’ll do this again the next time the opportunity presents itself. But this time it might be counterfeit. So the DEA is seizing incredible amounts of counterfeit pills, and as of last year, 70 percent of them had enough fentanyl in them to kill an opioid naive person.

So number one is awareness. Number two, given this awareness, we should all have the naloxone in our house, in our car, or on our person. If young people are going out to parties and concerts and events, they can easily carry it, it’s very small. And they could be a person that then, if they recognize a potential overdose, they can be acting rather than standing by helplessly waiting for someone else to come, meanwhile brain damage is occurring.

And for people that aren’t overdosing from an opioid, if you use these medications they will not hurt a person at all, they are extremely safe. Whether a person opts for 4 milligrams or 8 milligrams is a personal choice. We dispense it and order it for all of our patients at our OUD treatment clinic, called MYMATCLINIC. Every patient leaves with one every visit, and we allow them to choose, and four out of five of them choose the higher dose version, because they’re aware of how potent the illicit drug supply is.

Kevin Pho: So in addition to awareness, in your ideal world, what would you like to see happen? Would you like to see the 8 milligram dose be available over the counter as well? So if politics weren’t an issue and it were your call in terms of what you want done, what would you like to see happen?

David Deyhimy: I would like there to be massive public service campaigns, where you see billboards driving down the highway and you see commercials on TV funded by the government, raising awareness and what the treatment options are, what the opioid reversal options are. And that it was basically like you have AEDs everywhere now, right, in airports and in schools, so that it’s so readily available all over the place that we could prevent all of these unnecessary deaths.

Kevin Pho: You mentioned politics. This sounds to me like that would be a relatively bipartisan issue. So talk to us about some of the politics that’s kind of confounding this and preventing your ideal situation from happening.

David Deyhimy: This is absolutely a bipartisan issue, because everybody, regardless of what your political affiliations or beliefs are, can potentially be impacted by this. With 110,000 deaths a year, that’s a lot of deaths.

So a lot of it has to do, in our country, with our attitudes towards addiction and drug use. We still hold on to very old ideas, that this is something that people are deciding to do, and that it’s a moral failing, and that if you’re addicted to something you should just stop. When in reality we recognize it medically as a chronic relapsing disorder of the brain.

OK, so as a chronic relapsing disorder of the brain, we can see neurologic changes on fMRI and CT scans for somebody that has an addiction, with regards to dopamine receptors, and a healthy brain. And so it’s not as simple as just stopping, because their brains are not functioning like a normal brain, they’re not weighing risks like a normal brain does. And then there’s the physiological and psychological impact of abruptly stopping.

So that being the case, we should use medications to treat this, just like we treat other chronic relapsing diseases, and you can name any number of them. And we have these effective treatments that greatly improve the outcome, at least for opioid use disorder and for alcohol use disorder, we have very good options.

Number two, countries that have been successful in combating illicit drugs, they’ve come at this with much more of a harm reduction attitude, whereas the United States comes at this much more from a punitive point. And being punitive does nothing to solve the problem. What we need to do is sort of come at this from harm reduction and make treatment available to the people that want it.

And the idea that people simply aren’t going to use drugs, that has never, ever been proven to be the case. Young people in particular are novelty seeking, and they will always try drugs, regardless of whatever national campaign, DARE or what have you. They are not effective.

What is effective is raising awareness and having realistic conversations about the risks, just like you would talk to kids with sex ed training. They’re not going to not have sex. You have to basically teach them about the risks, and then tell them what the options are to keep themselves safe, and then you empower them to make better decisions. And we need to do the same thing in the United States with regards to drugs.

Kevin Pho: So are we seeing the uptake of naloxone vary depending on the part of the country?

David Deyhimy: No, naloxone is surprisingly not controversial, in terms of, everybody can agree that naloxone is a good thing. The controversial part is whether or not higher doses of naloxone are appropriate.

So the argument I told you already was, oh, for people with opioid use disorder you might put them into precipitated withdrawal. In my clinic, the people that have opioid use disorder, they want the stronger stuff. Four out of five of them want Kloxxado over Narcan, because they’re not dumb, and they’d rather have time limited precipitated withdrawal than not be reversed.

OK, the other part that nobody talks about, but I think is really a big deal, is, of those 110,000 deaths, a lot of them are the opioid naive people that we discussed, where they just are trying something now and then. Because these people have no tolerance, they’re going to stop breathing and overdose much more quickly than somebody who has some tolerance.

So to say we should only make four milligrams available totally discounts all those people. And these are the kids of moms and dads who just made one bad decision one time and they ended up dead as a result. They should have the option, these parents, and all of us, not just parents, in terms of what we think we should carry and what we think we should have. And these aren’t the only two options of naloxone, but they’re probably the two most common ones.

Kevin Pho: So what do we have to look forward to, especially from a primary care perspective, when it comes to raising awareness and combating opioid use disorder? So what’s on the horizon?

David Deyhimy: So what we have is, we have very effective treatments for opioid use disorder, and more recently we have these long acting injectable forms of buprenorphine that are incredibly effective for our patient population. So these are known as drugs like Sublocade or Brixadi. It’s much better for these patients to make one decision a month versus having to make good decisions with a controlled substance which they take once or twice a day. So I’m looking forward to more of these tools to have in our armamentarium to treat opioid use disorder.

Also I think important on the horizon is that we need to develop these types of medication assisted treatments for other use disorders or addictions, like methamphetamine is a big one right now, we don’t have any real effective treatments.

Ironically, the deadliest of all the addictions is opioid use disorder, and we have the best treatments, but only one in five people or less are even being offered them. So expanding our existing treatments could be tremendously impactful in reducing the amount of disease we have and the amount of overdoses we have.

And people look at the behaviors of somebody who’s in addiction and they don’t like the behaviors, but the behaviors are symptoms of an untreated disease. And when you treat the disease, the behaviors improve almost immediately. And we could have less homelessness, less crime, less mental illness, by expanding these treatments.

Kevin Pho: We’re talking to David Deyhimy. He’s an addiction medicine specialist and anesthesiologist. Today’s KevinMD article is “Saving lives with naloxone: perspectives from the frontline.” David, we’ll end with some of your take-home messages to the KevinMD audience.

David Deyhimy: OK. Number one, raising awareness, like we talked about. Parents and friends must talk openly about the fact that this is happening, that the illicit drug supply is contaminated.

Number two, carrying the reversal medications, whatever form, but carry a form of reversal medication. But knowing that fentanyl is the primary thing that’s causing more than 80 percent of these deaths, consider carrying higher dose naloxone.

And number three, if you or somebody has opioid use disorder, there are very effective treatments available, and these are increasingly being expanded across the country. You should look for somebody who has a MAT clinic, or MOUD, or medications for opioid use disorder. Find them online. They’re incredibly effective at combating opioid use disorder.

Kevin Pho: David, thank you so much for sharing your perspective and insight, and thanks for coming on the show.

David Deyhimy: Yeah, thank you for having me.