Psyched for Mental Health Podcast Ep 3: The Third Wave: Deadly Fentanyl
Substance Use Disorders

Psyched for Mental Health Podcast Ep 3: The Third Wave: Deadly Fentanyl

Welcome to the first episode of Psyched for Mental Health, the official mental health podcast of WebShrink.

James Berry, MD discusses opioid addiction, how and why illicitly made fentanyl is killing hundreds every day across the U.S.

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Episode Transcript:

Dr. Bilotti:

Hello. I’m Dr. Ed Bilotti. And this is Psyched for Mental Health. Empowering you with trustworthy information about modern psychiatry. This podcast is a companion to WebShrink.com: the platform for seekers on providers of mental health.

America’s opioid epidemic is now in a third phase, dominated by the powerful and
dangerous drug Fentanyl, but not the pharmaceutical kind of Fentanyl.
Instead, people are dying of overdoses from illicitly manufactured, fentanyl. The drug
is deadly about 50 times more potent than heroin and a hundred times stronger than
morphine. It can be found in a liquid or a powder form. Illicitly manufactured.
Fentanyl is known by several street names, like a Apache. Dance fever and perhaps
the two most appropriate names, murder eight and poison the drug crept into the
illicit drug market in the United States in the past few years. And it’s often mixed with
other drugs like heroin, cocaine, and methamphetamine and pressed into pills made
to look frighteningly similar to pharmaceutical products.
Needless to say, this is extremely dangerous. Estimates are that around 150 people
are dying daily from overdose. What is it about opiates that makes them so
powerfully addictive that people and even animals will seek them out in spite of their
destructive and deadly effects? People with opiate use disorders will seem to give up
everything just to get more of the drug. Mothers may leave their babies in unsafe
situations to get another dose. It’s been demonstrated over and over that even
laboratory animals will pass up on food and ultimately starve to death, preferring
another dose of opiate to a meal. All of this seems counter to survival, and it makes
me wonder how opiate– the natural forms of which are chemicals that are made
inside of a plant– can they seem to hijack the brain and cause people to do things
that ultimately can lead to their own demise and often do so. My guest is Dr. James
Berry, a board-certified family medicine physician with decades of experience
treating addiction and substance use disorders.

Dr. Berry is a graduate of temple university school of medicine and worked for many
years at the former mercy recovery center, which was once the largest addiction
treatment facility in the state of Maine. Dr. Berry will help us shed some light on
questions, like what is an opiate in the first place? What’s the difference between an
opiate and an opioid? These terms we hear used interchangeably. Why do some
people become addicted and others? What does it look like when someone’s
intoxicated on opiates and what does opiate withdrawal look like? What’s the
difference between drugs like Oxycodone, heroin, and Fentanyl? How are the
disorders treated?

What is Buprenorphine/Naloxone? What’s Methadone. How are they different and
how are they used to treat the disorder? So, let’s get started. Dr. Berry, welcome.
And thank you for joining me.

Dr. Berry:

Thanks for having me, Ed.

Dr. Bilotti:

Can you tell us a little about your background and how you got into the
field of addiction?

Dr. Berry:

I’m trained as a primary care physician. I’ve worked at family practice in
rural Maine for many, many years and got into addiction because when you’re in
rural family practice, the medical field has come to divide it up. But maybe we’re a
team physician. The addiction person left and I kind of fell into it in 1990 and it
gradually consumed more of my life until I became full time in addiction at mercy
recovery center here in Portland. Well, in 2008, I’ve been working full time although
slowing down now as I prepare to retire.

Dr. Bilotti:

Where did you do your medical training?

Dr. Berry:

I did the MD training at Temple University and post-graduate university of
Arkansas and University of Southern California.

Dr. Bilotti:

All right. So today we’re going to be talking about opiates, you know, for
the past couple of years, it’s been somewhat overshadowed by the COVID
pandemic. I would like to discuss with you today, some more details about opiates
and addiction, what they are, what causes it and what can be done to help and what
kind of treatments we can offer people and prevent some of this tragedy that’s really
gone out of control.

Is there a difference between an opiate and an opioid?

Dr. Berry:

The original definition, opiate is pretty narrow. The chemical that’s
isolated from a certain species of poppy plant patches to certain receptors in the
brain’s opioid receptors. And – better living through chemistry – opiates have been
manipulated and made more potent with fewer side effects, more pure to the point
where often they can be synthesized without using the opium from the poppy and
you get the similar chemistry at the end. When you do this, the name changes from
opiate to opioid. However, in practice, these terms are often thrown around
interchangeably and I don’t think we need to worry too much about that distinction.

Dr. Bilotti:

That is interesting information though. And I, and I agree with you. I think
the terms are often interchanged and thrown around. I’ve heard it called the opiate
epidemic. I’ve heard it called the opioid epidemic and so on. So, I just wanted to
clarify that. So, you’re saying opiates are in its most basic form opiate is natural from
the plant derived from the plant and an opioid is synthetic.

So, many people got started with opioids because of either an injury or a surgery,
some medical condition that led to pain and the pain was treated with prescription
opioids. And then. They noticed that something about this medication that they were
taking for pain also had other effects, like you know, improved mood, made them feel
better, took away some, maybe emotional or psychic pain as well. They didn’t necessarily need it medically, and eventually becoming dependent on it. While other
people will take a dose of a pain medicine and say, oh, I don’t like this. I don’t like
how it makes me feel. I’m not even going to take it. I’ll just use acetaminophen or
something like that for my pain.

Why do some people get addicted, and others don’t? Do we know?

Dr. Berry:

I think we, we do know. And I think the short answer is that it’s a genetic
and it’s the wiring of the brain is the term of what some people are susceptible
addiction, transmitters, chemicals in the addiction, part of the brain, the dopamine
reward pathway that have to be there for the addiction to occur. I think it was you
might’ve read about [in audible] and there’s some others too. About half the people in
the old days around World War II smoked. Then when we found out cigarettes were
bad for us, fewer people started, most people quit – we’re down to around 17%. So,
these 17% are probably represent the people that have addiction propensity.
On the other side, most people couldn’t get addicted to opiates, even if they wanted
to, but the [ inaudible] minority. And that doesn’t mean everyone with the gene gets
addicted. Like most of us, even with a gene for addiction or genes, have a life, have
things that give us satisfaction and keep us interested…

Dr. Bilotti:

So, I, but I think the last, the last thing you said is very interesting,
because what you’re saying is that in addition to the genetic, the underlying genetic
propensity, which is clear and established, there’s also a psychosocial component,
so people who have increased risk of addiction probably also have some other risk
factors. And it’s some kind of interplay between the underlying genetics and the
psychosocial piece, which really makes it not much different from any other mental
illness that we deal with in psychiatry.

So, what does opiate intoxication look like when someone is high on heroin? What,
what is, what is happening physiologically and what are they experiencing?

Dr. Berry:

The person who is starting out on heroin, it triggers the part of the brain or
the dopamine reward pathway. The part that makes us motivated thinks it’s feel good
if pleasure, and then aspects of life that are important, food and going to work,
hobbies, sex, duty– what stimulates it, hijacks that pathway. It makes the person feel
satisfied and good without anything positive, really happening and makes them also
want to repeat the experience, unfortunately over, or maybe fortunately over time,
that feeling gets attenuated and that leads to the high, the good feeling, being
attenuated, and pretty soon, all too soon, the person that’s taking these drugs to
avoid the feeling of withdrawal. Once the brain is adapted and attenuated, it kind of
needs the presence of the opioid be normal.

Dr. Bilotti:

I see. So, the brain is exposed to this and it’s, it feels good, but it’s being
triggered to a degree that’s kind of off the scale. It’s now adapted to having that drug
around. So, if the drug is absent, then the person starts to feel sick.

Dr. Berry:

Yeah. And people who are addicted to heroin, that’s usually what they’ll
tell you. They don’t talk quite as much about the high. There might be a little bit of a
high, but sometimes they take large amounts. I should add that, the reason why
there are these substances there in the first place? They are a poison they’re in the
plant because they’re poisoning what eats the plant, usually insects, sometimes
other animals. So, they’re designed as poisons and the brain sees them the way
they’re designed.

Dr. Bilotti:

That’s fascinating to me. It’s always been fascinating to me, how a plant
can generate a chemical that fits into a receptor in our brains as human beings.
We’re all biological organisms on this planet and we’ve all sort of evolved side by
side and the plants trying to protect itself and survive and so are we…

Dr. Berry:

I have all kinds of stories about this, but I grew up in Ohio on a farm and
there was a lot of wild night shade, but it’s poisonous and the animals don’t eat it. So
cows being, not all that smart,would eat it, but either they call it a “loco weed” and
you could tell, cause the cows would stagger around all over.

Dr. Bilotti:

And then what was it, how toxic was it to the cow would wear off and
then the cow would be okay or…

Dr. Berry:

Yeah, they’d be okay. I don’t know how addictive it was for the cow I was
curious about that.

Dr. Bilotti:

So, all the talk lately is about fentanyl. Fentanyl seems to be the drug that
is most pervasive on the streets. Can you just distinguish a little bit about fentanyl? I
understand that it’s a lot more potent than heroin.

Dr. Berry:

So, Fentanyl came onto the streets around 2015, 2016, and we saw an
immediate spike in deaths. We get, most of our, these street drugs from Mexico. It
was heroin in the old days and fentanyl was about 50 times more potent. So that
pretty much replaced heroin. So, what we saw three or four years ago, less heroin.
Now, I think I saw one urine test that might’ve been heroin last week: it’s the first time
I’ve seen it for many months — it’s all fentanyl, fentanyl, fentanyl…

Dr. Bilotti:

And it’s far more dangerous…

Dr. Berry:

Well, it’s far more potent and that makes it easier to ship and sell and
make also makes it more dangerous, it has to be mixed properly, to get a safe dose.
And even if it’s mixed properly, you get someone who is not tolerant to it and not
used to it and takes what might be a normal dose for an addict might put someone in
an overdose situation if they’re not used to it.

Dr. Bilotti:

So, if people are abstinent from using the drug for a, for a period of time,
the brain then normalizes back to the way it would have responded before it had
adapted to being exposed to the opiates. And so, if they go back now, they’re
released from prison. They go back to the street, and they think well, this is how much I used to use in order to get high. So, they go and use that, but now that’s
enough to potentially kill them.

Dr. Berry:

Yeah, and that same thing for people getting out of treatment facilities,
particularly of the residential facilities. The same thing happens, even though they’re
cautioned that that might happen, but their brain is, we say naive to the opiates.

Dr. Bilotti:

Wow. So, the increased presence of fentanyl may account for some of
the rise in overdose deaths; it probably does…

Dr. Berry:

It accounts for nearly all the rise in overdose deaths. There is nearly
always as fentanyl present and about half the time there was another drug present
too, either stimulants or benzos. And it’s a combination effect with fentanyl that also
has a role.

Dr. Bilotti:

So, you mentioned treatment programs. Can you say a little about what
treatment for opiate addiction looks like? What are the best ways to treat this
disorder?

Dr. Berry:

Okay. So if we look at the ways we treat addiction in general, whether it’s
cigarettes or stimulants or opioids, treatment falls into several categories, one is
medication and then there are behavioral or counseling based treatments and then
more socially based treatment. A lot of addiction is related to being in a social
network. And the best example of that are support groups, alcoholics anonymous,
narcotics anonymous, which provide some counseling function as well, but they’re
primarily a social treatment and probably the fourth layer of treatment is if all else
fails, residential based treatment. We probably prefer to have the person in the
community when we’re treating them for what I already mentioned, that when you get
out of treatment, there’s a kind of a risky period of readjustment to the community.
Medication for opioids for almost all, or at least the vast majority of people, needs to
be part of the treatment at least for a time.

So, the medications used are opioids themselves, but in the United States,
methadone and buprenorphine, or by the brand name Suboxone. And the problem is
that if you were on opioids, these very potent opioids, and there’s a lot of adaptation;
the brain, as we mentioned, you’re on for any length of time, that is becomes harder
and harder to reverse by just stopping the opioid. It’s necessary to keep those
receptors occupied, use these other modalities too, but you need to use a drug as
well, prescription drugs.

Dr. Bilotti:

So, then what’s the difference between methadone, which has been
around for decades, right? I think since the fifties?

Dr. Berry:

Oh, goodness, 50 years…

Dr. Bilotti:

What’s the difference between that and Suboxone and buprenorphine-
naloxone, Suboxone brand name is a combination, buprenorphine and Naloxone –
and methadone. How are they different?

Dr. Berry:

So, methadone, as you mentioned, that has been around the longest and
has been fairly successful, but the main problem with it was that it was not all that
safe, and people were able to overdose on that. People would take methadone
home. Someone else would get into it and overdose on it. Suboxone or
buprenorphine, which has been out on the shelves of hospitals and pharmacies for a
long time, it was looked at in the late eighties and early nineties, as an alternative.
And has the advantages of being even longer acting, being safer and harder to
overdose on, being a much more effective blocker of the opiate receptor. So
relatively lower doses could be given to block that receptor. So, of people took other
opioids, they would not get an effect from them. It can be given once a day and is
very hard to overdose on. So, it’s been an easier, safer drug. People generally don’t
take it to get high. They don’t get over sedated from it and stay on it for a long period
of time and function quite normally. Which not to say that you need don’t need to
access these other modes of treatment, you do, because there’s other life
dysfunctions that go on besides once you’ve taken the drug for a long time, that need
to be fixed.

Dr. Bilotti:

Right, as a psychiatrist, I do a lot of work with co-occurring disorders, so
a mental health disorder and a substance use disorder occurring at the same time,
and it’s infinitely clear to me that they are intimately related and not always, usually
not even separate things. So, what you’re saying then is we give a prescription
medication to bind to those receptors so that other, opiates like fentanyl and heroin,
et cetera. In other words, the buprenorphine holds on more tightly to the receptor
than say fentanyl, is that correct?

Dr. Berry:

Yes. In fact, it holds on so tightly, that if we give it to people on Fentanyl,
it kicks the fentanyl off and actually throws people into withdrawal for a few days
we’ve had to learn how to wrestle with that over the last couple of years.

Dr. Bilotti:

So, you give them the prescription, but then also the other modalities
such as well, addressing any co-occurring depression, anxiety, or other mental
health disorder, treating that possibly with other medication or psychotherapy or
both. And that whole combination sets up a program for maximizing the chances of a
successful recovery.

Before we go on to talk about harm reduction. I just want to bring up the subject of
treating an overdose. So, there’s, there’s a lot of talk past couple of years about
making Naloxone available to the police or to the public to be able to administer in
the event of a potentially lethal overdose. Can you tell us about how Naloxone works
and what that would look like?

Dr. Berry:

So, Naloxone is an opiate blocker. So, it’s similar to the blocking effect we
talked about other buprenorphine except it’s very quick and kicks the fentanyl or
other opioids off the receptor. So, this instantly throws them into, gets rid of the opioid, throws them into withdrawal. Unfortunately, it’s rather short acting. So preferably the patient needs medical attention. At that point, it’s been very effective.

We don’t think of overdose as such a lethal phenomenon as we used to. It used to it
seem like every other overdose the person passed away. But now most people, if I
take a history, they’ll say, “Oh I’ve had Naloxone once or twice…”

Dr. Bilotti:

Really speaks to the power of this addiction that someone who’s been
through that even more than once would continue to go back and use again. And at
that point, it’s certainly is not a choice. For someone to just will themselves to never
pick up and use again, it’s not always an option. And that’s why a lot of these other
modalities need to be implemented. Right?

Dr. Berry:

It is a motivation for treatment. I’ve seen people who will come into
treatment after having overdosed and that scared them, but it’s not enough because
as you say, the urge to use even overrides the desire to stay alive.

Dr. Bilotti:

In spite of all of these modalities and treatments that we have, some
people are going to use substances and we’re not going to be able to completely
stop. It seems like people always will be seeking out some kind of mind altering
substance. And so given the fact that a percentage of people have this propensity to
become addicted, the concept of harm reduction comes about as a way of, if you’re
not going to be able to stop using, at least we can minimize the risk and the harm
caused by it. So can you tell us, you know, you’re taking on.

Dr. Berry:

The best example of harm reduction is the use of rescue Naloxone. So
that’s one of many examples. Another example we think of is the use of a seatbelt
[…] you’re not decreasing reckless driving or alcohol-related driving or anything, but
you are preventing deaths.

Harm reduction is something that there are, there are so many aspects, so many
opportunities to intervene, and I’m not going to run through a list because I won’t get
to talk about them all. The needle exchanges. Safe injection sites, housing first;
there’s a lot of addiction has been aggravated by homelessness and inadequate,
safe places to live, and then downside, what you’ve got to watch for is harm
reduction initiatives that are related to decreasing the availability of the drug. You
have to be very careful because that can backfire. And I think one thing we were all
trying to do is reduce the amount of stigma around seeking treatment, and around
the disease in general. And that’s actually part of harm reduction as well as a part of
treatment. There’s a lot of patients that they get on into treatment and particularly
they get along to Suboxone and they say, well, that’s just another failure trading one
addiction for another. And they go into pharmacies and they get stigmatized right
there in the pharmacy. I’m always talking to the pharmacists and this one I thought I
had everything nailed down and he goes in and gets the third degree from the
pharmacist, turned out to be a pharmacy assistant; the regular pharmacist was on
lunch break, so they pulled someone from the upfront register, who wasn’t trained at
all on being nice to people and not stigmatizing people.

Dr. Bilotti:

Well Dr. Jim Berry, thank you so much for joining me today. This was a
very insightful discussion. Good luck with your semi-retirement. I hope you’re able to
make the most of that. but if you’re like most of us though, you’re probably still
working too hard.

References

Psyched for Mental Health Podcast Ep 2: Harm Reduction