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AMA Update
Facts about fentanyl and how to treat substance use disorder
May 6, 2024
Featured topic and speakers
When is fentanyl awareness day? Is fentanyl an opioid? What is the most effective treatment for opioid use disorder? Fentanyl poisoning: What is fentanyl in? Our guest is Stephen Taylor, MD, MPH, president-elect of the American Society of Addiction Medicine. American Medical Association American Medical Association Chief Experience Officer Todd Unger hosts.
- Get involved in the fight to end the overdose epidemic.
- Access the Opioid Risk Tool (PDF).
- Essentials of Good Pain Care-A Team-Based Approach-Safely Manage Acute and Chronic Pain.
- Using Opioids Safely-Practical Guidance for Pain Management.
- Looking for more opioid CME credit? AMA EdHub login.
- American Society of Addition Medicine opioid use disorder treatment guidelines available.
- The Journal of Addiction Medicine.
- Substance Abuse and Mental Health Services Administration resources and mental health services available.
- Call SAMHSA’s National Helpline: 1-800-662-HELP (4357).
- The AMA is your powerful ally in patient care. Join now.
Speaker
- Stephen Taylor, MD, MPH, president-elect, American Society of Addiction Medicine
Transcript
Unger: Hello and welcome to the AMA Update video and podcast. In recognition of National Fentanyl Awareness Day, today we're talking about the risk that illicit fentanyl continues to pose and what physicians can do about it. Our guest today is Dr. Stephen Taylor, president-elect of the American Society of Addiction Medicine in Jonesboro, Georgia. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Taylor, it's great to have you back.
Dr. Taylor: It's great to be here, Todd. Thanks for having me.
Unger: Over the last few years, we've talked a lot about the overdose epidemic and the increasing role that illicit fentanyl plays in it. Why don't we just start by having you give us a little bit of an overview of the impact that it's having right now?
Dr. Taylor: Well, if you think about the way this epidemic has unfolded over the several years and stages, what we entered into―and I'll start from the pandemic―was a period of time when there was a rapid escalation in the numbers of overdose deaths. And this happened because people's attention was turned to COVID, and people were reacting to the devastation and the trauma that that visited upon us.
And as we saw during that time, the opioid epidemic, which really got a lot less attention during that time, really escalated. Substance use in general escalated, and the numbers of overdose deaths increased to the point where we were setting a new record for numbers of deaths every year during the pandemic, which is what brought us to the point where now we have over 107,000 Americans who died from overdoses, as of the most recent data that's available.
And it's been demonstrated and shown through the CDC and other sources that this increase in the numbers of deaths occurred while the actual numbers of people who were using drugs, and particularly opioids, actually declined prior to the epidemic. Yet the numbers of deaths were increasing. That's because of fentanyl and other high potency synthetic opioids that introduced a much more deadly stage of this epidemic.
Unger: Now, the AMA continues to urge physicians across multiple specialties to begin treating patients with opioid use disorder. But we know it's new territory for a lot of folks which can make it seem daunting. Can you tell us how, for example, say a primary care physician might begin to open their practice to patients with opioid use disorder?
Dr. Taylor: Sure. One of the things that I've always wanted to share with my primary care colleagues is that the treatment of patients with opioid use disorder doesn't have to be in the form of a clinic, where you set up an entire clinic, and you see a whole day's worth of patients who have that diagnosis. That really, in fact, when buprenorphine, one of the medications for treatment of opioid use disorder, was first FDA-approved and first became available for us to use in the office, the intent was specifically so that physicians would be able to use it in their office as part of the normal course of practice to treat patients who have OUD, just as they're treating other patients in their offices. It was never meant to be something that required the setting aside of a whole day to form a whole clinic.
So I would suggest that the way to do this is one patient at a time. Just take on one or two patients who have OUD. There is help available to learn how to utilize the medications for opioid use disorder that are FDA-approved, that are safe and that are effective in treating patients who have OUD. And particularly the two that are FDA approved that any physician can prescribe in his or her office, namely buprenorphine and extended release naltrexone, there's information available on the AMA website, on the ASAM website in particular, that can help physicians get some increased levels of comfort with how to prescribe and manage those medications in patients who have OUD.
It isn't terribly complicated. Physicians are very well capable of educating themselves to get to a comfort level and can prescribe the medications and provide the treatment needed by patients with OUD.
Unger: And Dr. Taylor, this overdose epidemic has been going on for over a decade now, and as you mentioned earlier, continues to kill more than 100,000 Americans each year. Those dying at the greatest rates now are predominantly young people, people who are Black and American Indian and Alaska Native.
What's behind this trend? And can medical societies and physicians do anything to reverse it?
Dr. Taylor: Very important questions. Look, what's behind the trend is this. Two basic facts that we've known for a long time. Number one, addiction is not a drug-specific disease. And this epidemic is not just an epidemic of overdoses, it's an epidemic of addiction and overdoses. And so addiction is not a drug-specific disease.
So when we saw, for example, that opioids led to deaths from people, and then we saw people who went from prescription opioids to using heroin and that led to deaths, well, we then saw a stage in this epidemic in which people began to use stimulants like cocaine and methamphetamine.
But of course, with the introduction of fentanyl and other high potency synthetic opioids, and the further introduction of contaminants and additives like xylazine, we now have a situation in which, just recently, I have heard about a situation in which cocaine that has been obtained from people who had been using cocaine was actually tested, and it was found that a large majority of the cocaine that has been in use is contaminated with fentanyl.
So we need to understand that this is an epidemic of addiction and overdose, not just an overdose epidemic. And when we think about addiction, we need to understand it is not a drug-specific disease.
So part of the problem that we are seeing is that even though many different populations of people may use different drugs and have different patterns of use, when we have a situation in which drugs as varied as cannabis and cocaine and methamphetamine, and even benzodiazepine pills, are all being contaminated with fentanyl, then we have a situation in which we're going to see overdose deaths among a wider variety of populations.
The other thing to remember, the other fact that's important here is that addiction is a disease of pediatric onset. So you mentioned the fact that there's adolescent populations that are being affected. Well, that is not hard to understand. Addiction is a disease that starts in adolescence. And we have to understand that it was inevitable.
Once we had a situation in which large numbers of people in our population were succumbing to overdoses from the drugs to which they had become addicted, it was inevitable that we were going to start to see this among adolescents, because it's in fact that population in which addiction starts.
So we need to make sure that we target young people and improve what was already a problematic infrastructure and a lacking infrastructure in terms of providing treatment for adolescents with substance use disorder. We need to work on improving that as a part of our strategy to address this crisis.
Unger: Well, the introduction of fentanyl into that array of drugs that you talked about, plus additives like xylazine, really creating a very complex and scary situation.
Dr. Taylor: It absolutely is. And it's also creating a more challenging situation for those of us involved in the treatment of those patients. The whole process now of initiating, for example, a patient onto buprenorphine, has to be updated. We all know in this area in which we practice in terms of practicing medicine, we all know that we constantly have to update our knowledge base and update the way we practice.
Well, that is driven home even more by the fact that we are facing an epidemic that is ever changing. And so now the process of initiating a patient on buprenorphine, for example―again, one of the treatments for OUD―that process has to be updated. It has to be changed. We don't do it the same way as we did when we were primarily seeing people with prescription opioid addiction, or even addiction to primarily heroin.
But again, that information is also readily available in the sources that I've referred to earlier. And it should not be seen by physicians as a barrier or as a reason why they're not going to be able to take care of these patients. The physicians are well capable of providing the care that these patients need, and it is something that I strongly encourage my colleagues throughout the house of medicine to get involved in.
Unger: Now, Dr. Taylor, the changes that you're talking about, I have a feeling that advocacy plays a big role in trying to change the situation. And AMA and the American Society of Addiction Medicine continue to advocate together on this particular issue, both at the state and federal levels. Tell us a little bit more about the partnership between our organizations and the ways that we work together.
Dr. Taylor: Well, there are a number of ways, as you mentioned, both at the state and at the federal level. For example, every state has a state medical society. And as president-elect of the American Society of Addiction Medicine, I'm well aware that we in ASAM have state chapters throughout the country. And very often, our members who are members of ASAM state chapters are also members of our state medical societies, and all of which are part of the AMA. And we all work together in our advocacy efforts at the state level.
The other very important way that I have been able to enjoy working with my AMA colleagues is in the AMA House of Delegates. I happen to be not only ASAM's president-elect, but I am also the chair of ASAM's delegation to the AMA House of Delegates, and I consider that a great honor and a great privilege because we are actively involved in working together on numerous policy initiatives, numerous resolutions in which the AMA and ASAM team up.
We educate each other. We prepare each other to bring forth the best resolutions and bring to bear the best science so that we work together to advocate for policies that will enhance the care of patients with substance use disorder, that will try to break down the barriers, break down the stigma, increase access to care. We work together incredibly well, I believe, in our efforts between ASAM and the AMA. And it's something that I'm very proud to be a part of.
Unger: Well, given the challenging nature of the situation, exactly what you point out―the importance of the house of medicine, so to speak, the policy that comes out of the House of Delegates, so critical right now as they have a huge impact on the advocacy for both our organizations.
In addition to the advocacy you mentioned before about resources, the AMA has a wealth of resources on this particular issue. It includes our Annual Overdose Epidemic Report, courses in the AMA Ed Hub that help physicians meet their DEA requirements. This is so important. It's ready-made to help you get that done. Dr. Taylor, where else can physicians go to learn more about this?
Dr. Taylor: So thanks for mentioning those specific parts of the AMA website. Also on our website, ASAM, the American Society of Addiction Medicine, we have information, we have courses that physicians can take that can provide continuing credit that will also help with learning how to take care of patients with substance use disorder, and specifically, with opioid use disorder.
There's also information on SAMHSA's website. There's a tremendous amount of information available that physicians can utilize and can access easily to learn what they need to learn to take care of these patients.
Unger: Dr. Taylor, you can't help but open the paper up and see a story about the devastating impact of fentanyl on communities and people across the country. Given how challenging the situation is, is there a good reason for hope, staying positive at this point?
Dr. Taylor: The biggest reason for hope―and there obviously is certainly a great reason for hope. The biggest reason is because, remember, addiction is a treatable disease, OK? And we are learning more constantly about how to provide treatment for this very treatable disease.
We also are learning more all the time about how to reduce harm. So, naloxone is becoming increasingly available. And we are utilizing it to reverse overdoses. We are advancing policies like overdose prevention sites in increasing parts of the country so that we can keep people alive long enough so that we can get people the treatment that they need for addiction disease and hopefully, then, prevent people from dying from overdoses.
There are so many places and so many ways that we are working hard to address not only this specific epidemic, but the ongoing challenge of substance use disorder and the social determinants of health that contribute to substance use disorder. There's absolutely lots of reason for hope.
Unger: Dr. Taylor, thank you so much for joining us and for those words of encouragement and all your perspective. Fentanyl Awareness Day is an important moment for us to take stock of our work to end the overdose epidemic. And while much progress has been made, there's still a lot to do. To support the AMA's efforts in this area, I encourage you to become an AMA member at ama-assn.org/join.
That wraps up today's episode, and we'll be back soon with another AMA update. Be sure to subscribe for all our new episodes, and find videos, podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
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