Hello, my name is Derrick Glynn. I'm here to talk to you about fentanyl, the emerging threats, and harm reduction strategies for substance use disorder. I have no financial relationships with any commercial interests related to the content of this presentation, and I will not be discussing off-label use during this presentation. Substance Use Access and Training Expansion Act, which was enacted in June 2023, requires a one-time eight-hour training in evaluation, treatment, and management of substance use disorder for all new providers applying for a DEA license. This content can be applied toward this requirement. Objectives. We're going to summarize the impact of fentanyl in opiate epidemic. We're going to examine the emerging threats in the United States related to opioids. We're going to categorize harm reduction strategies. Now, driven by the opiate epidemic, overdose deaths has now risen five-folds in the past two decades. For every one prescription of illicit opioid overdose deaths in 2015, there were 18 people who had substance use disorder involved, 62 people who had substance use disorder involving prescription opioids, 377 people who misused prescription opioids in the past year, and there were 2,000 people who used prescription opioids in the past year. So this is a huge, tremendous problem, and overdose has driven the opioid epidemic even more. Now, when we talk about overdose deaths, we need to categorize and turn it into three ways of opioid overdose deaths. Now, the first rise came in probably the early 90s. It was James Clear, who coined that pain is the fifth bottle sign, and it really caused providers that prescribed opioids to really overprescribe to mitigate patient's pain. The wave two kind of happened in the early 2000s, and that was risen more by the heroin overdose deaths. And wave three, we're dealing with synthetic and illicit opioid, fentanyl. So fentanyl is still very much involved in the overdose deaths. Now, nationally, overdose deaths by the numbers of all ages, synthetic opioid overdose deaths by other than methadone primary fentanyl, you can see it's over close to 80-something thousand. Psychostimulate with abused potential primary methamphetamine is rising. Now, more stimulus such as cocaine and prescription opioids. Heroin is kind of slowing down in antidepressants. So you can see that now the rise for the abused potential is the methamphetamine is really starting to rise. Now, more than 107,000 drug overdose deaths have occurred between July 2021 and June 2022. That's 64% involved in synthetic opioids like fentanyl. Now, drug overdose deaths in the United States topped, like we said, over 170,000 for the first time. In fact, you have a more chance to overdose death and one, the odds ratio are one in 96 to die from overdose death than one in 103 with a motor vehicle accident. So the odds ratio are much higher for overdose deaths. Now, fentanyl is a synthetic opioid that is up to 50 times stronger than heroin and a hundred times stronger than morphine. So very powerful drug. There are two types of fentanyl I want to discuss in this presentation. That's pharmaceutical and illicit manufactured. Now, pharmaceutical oftentimes you use for treating pain. In anesthesia we use for intraoperative and acute pain and for advanced cancer pain. However, illicit manufactured fentanyl is available in different forms such as liquid and powder. Now, illicit drugs do not come with an ingredient list. Many contain multiple other things that are used to in combination with fentanyl. So we really don't know what illicit drugs, what it is combination with. And so that's a major concern in terms of overdose and harm to patients that are substance use abuser. Now, illicit manufactured fentanyl comes in powder form. It's usually mixed with drugs like heroin, cocaine, methamphetamine, and made into pills that are made to resemble other prescription opioids. Fentanyl laced drugs are extremely dangerous. People may be unaware that their drugs are laced with fentanyl. The liquid form of fentanyl is found in nasal sprays, eye drops, and dropped onto paper or small candies. And that brings us to the DEA, the federation, feds issued a warning about rainbow fentanyl. Apparently this, this fentanyl, colored fentanyl has been found in several places in the United States. This fentanyl, colored fentanyl has been found in seas in over 21 states. Now this, this fentanyl kind of appeals to the young population. They're deliberately targeting youth. Now there's an emerging threat with youth in communities of color as it pertains to, uh, fentanyl. So definitely be aware of, uh, this colored coated, uh, fentanyl that is very attractive to, to youth. Now the street names for illicit manufactured fentanyl include Apache, Dance Fever, Friend, Goodfellas, Jackpot, Murder Eight, Tango, and Cash. It's very important that we are aware of these names that, uh, the genre of names that people call fentanyl. So we are aware. And the Biden-Harris administration designated fentanyl laced with xylosine, an emerging threat in the United States. What is xylosine? Xylosine is a alpha-2 agonist drug similar to, um, clonidine. It stimulates the presynaptic alpha-2 adrenal receptors, thereby decreasing noradrenaline, releasing both central and peripheral synaptic nerve terminals. But it's not used in humans. It's used commonly in veterinary medicine and to sedate, to sedate and provide pain control for animals, mainly horses. It is, the more you are, the more you use, the stronger the effects will be. So the reason why they lace it with fentanyl, because it creates a stronger effect for the fentanyl. Um, the effects of pain control, sleepiness, sedation, lower decrease in body temperature, lower heart rate, blood pressure, decrease in breathing. When to suspect xylosine, drug effects feel longer, lower heart rate or dizziness, not responding to naloxone. Tips on xylosine. Start slow, start low and go slow. May stay in your system for hours and can build up and over time. So be careful. If you take clonidine and suspect xylosine is in your fentanyl, consider decreasing your dose or monitoring your blood pressure. People with xylosine may be at increased risk for wounds. Even in non-injectable locations, keep an eye on your skin and tend to wounds early. Again, the xylosine impact impacts analgesia, sedation, amnesia, the central nervous system, respiratory system, respiratory decrease, skin disorders, ulcers and tissue necrosis, cardiovascular, hypotension, bradycardia, tachycardia, basal constriction, metabolic endocrine, hyperglycemia. As you can see, the ulcerations that xylosine produces, very staggering. Xylotoxicity diagnosis and treatment. Signs and symptoms of intoxication. Again, physical, hypotension, bradycardia, meiosis, hyperglycemia, sedation, behavior, CNS depression similar to opiate intoxication appear high. Signs and symptoms of overdose. Again, hypotension, hypertension, bradycardia, hypoglycemia, sedation, respiratory depression, behavior that has CNS depression similar to opiate overdose and uptension. Provider response. Physical, IV fluids, manage hyperglycemia with insulin as needed. If bradycardia is severe, consider atropine. Continue to monitor him. Support care. Avoid any kind of CNS depression. Provider response. Naloxone, multiple doses may be necessary. Manage hyperglycemia with insulin. Oxygen. They might need intubation if indication, if there's severe respiratory depression. Monitor K Mag replaced as needed for the electrolyte imbalances. Again, naloxone has a short half-life and multiple doses over 48 hours may be necessary. And naloxone is just going to reverse the fentanyl. But we should remember, yes, naloxone should be given with xylosine, but since it's often combined with other opioids, expect it recommended given naloxone in the case of suspected xylosine overdose, because it's usually laced with fentanyl. So the xylosine, the naloxone is going to reverse the fentanyl. However, naloxone cannot reverse the effects of xylosine such as a shallow breath. So you got to call 9-1-1. Harm reduction. And we talked about harm reduction in multiple things. Protection, hard hats, seat belts, in terms of airbags, needles, but understanding that when we're talking about substance abuse disorder, it is a chronic condition and that we're going to have extremes of highs and lows and that we must understand that in order to be most effective and most impactful, we have to really adhere and address harm reduction. Examples of harm reduction in other areas, sunscreen, seat belt, speed limits, birth control, cigarette filters. With substance use disorder, there's other forms such as what public messages campaign, social marketing, say no to drugs, anti-stigma campaigns. Really, when you stigmatize people that have substance use disorder, you decrease their chance of being and seeking treatment. Education of prescribers. Prescriber education, that's the whole wave that we face with that first wave with overprescription of opioids. Really addressing what is required of a patient that is in pain control. And there's multiple modal ways to attack that. And understanding multiple modal ways to address pain management, such as regional opioid sparing techniques for patients that might be in pain or have an opioid epidemic or opioid overuse disorder. Tracking and monitoring. Prescription drug monitoring programs, that's very important. If a patient is going to a primary care provider, understand that they must look at various states have prescription drug monitoring programs that allow you to look at if a patient is seeking or going from state to state trying to obtain medication. So this is important for providers to really incorporate prescription drug monitoring program in their practice. What are some harm reduction strategies? Well, full access to naloxone. Now naloxone is FDA approved. Good Samaritan laws are very important because when we see or we might come upon a person that may be unconscious, that we are able to help them. There's many syringe swap services. So we have for a safer syringe or that one that you can exchange a dirty syringe for a clean syringe. Safer drug consumer consumption services. So really the FDA is really the key to making sure that we have safe drugs in the consumer services. Other strategies, post overdose services, such as behavior treatment or opioid treatment facilities. And definitely medication for opioid use disorder, MOD, that's very key to access for people that have substance use disorder to have access to this life-saving medication, which will decrease craving and decrease the use of opioids. So these are strategies that we must implore for harm reduction. What are some other harm reduction strategies? Well, fentanyl test strips and naloxone. Well, fentanyl test strips are important because we want to decrease the amount of illicit drugs in fentanyl. If your drug is laced with something else, it could definitely cause one to overdose death. So fentanyl test strips are a harm reduction strategy that we must implore to reduce overdose. And of course, naloxone is something that now that it's over the counter, that somebody that has, that is using substance use, has a substance use disorder, this should be readily available. If your family member or somebody that you know has a substance use disorder, we should readily have a naloxone available and accessible to us. Now fentanyl test strips, they're accessible, easy to use, they're inexpensive. They strip the immunoassay paper into drug, can detect fentanyl and fentanyl analog injection liquid or powder. So you would test your drugs. It's a way of making sure that your drug is pure. Average cost is about one to three dollars. It takes minutes. And you can see from this right here, one red line is positive for fentanyl. Two red line is negative for fentanyl. Use caution. So this is a way that somebody that has a substance use disorder, they can be intentional in assessing their drugs to make sure that it's pure. It's not laced with zolazine or methamphetamine or any other drug. And this, although we want them to stop using drugs completely, this is a mechanism that is a harm reduction strategy for them. Now there are four types of naloxone. You can inject it into muscular, nasal spray, intranasal, auto injection and Narcan nasal spray. So the FDA has approved for over-the-counter Narcan naloxone. So this is usually given in four milligrams. It's usually two doses that are inside of the box. So one can use Narcan as a reversal agent for that. And those are my references. Thank you.

fentanyl

opioid epidemic

harm reduction

overdose deaths

substance use disorder

naloxone