Buprenorphine In The ED (w/Dr. Dylan Carney)

– What is up Z-Pac? It’s your boy ZDoggMD, today I have a special guest Dr. Dylan Carney, emergency physician, brother from another mother and we’re gonna talk about something that is crazy important which is medication-assisted therapy for opioid dependency. We don’t like to say addiction any more do we, Dylan?

– Yeah that’s fallen out of favor.

– Why, why is that?

– Oh, that’s a great question, I think it just carries a little bit stigma with it, so we use dependency or opioid use disorder nowadays.

– So Dr. Brown’s in the back. There she is. What up?

– What’s up? You guys remember Denise Brown? So Denise Brown did a show with me, she’s from Vituity, and so is Dylan. Vituity’s the company that’s sponsoring the show, they’re just giving us backing to talk about things that really matter, that they’re actually involved in. But it’s not even a commercial for Vituity, it’s us being able to actually talk about stuff meaningfully. And medication-assisted therapy, is crucial because when people show up to the ER with opioid dependency issues, whatever you wanna call it, whatever the PC term is right now, it’s causing lots of suffering, and it’s causing suffering for our frontline staff. Because we have no tools, we just say, “Well okay, go into a rehab program, “that I know you’re not gonna do, “or you’re not gonna be able to afford,” or “I have no tools to treat you aside from “giving you Dilaudid, and telling you to go,” or throwing my hands up and then wondering why we’re seeing more violence in the emergency department. So how did this sort of shape your path, ’cause you’re a Stanford-trained dude, UCSF, all this other hotshot stuff. But you’re struggling with the same issues that anyone on the front lines is struggling with. How did that then lead you to medication assisted therapy? We’ll just call it MAT from now.

– Yeah, absolutely. Well thanks for having me here on the podcast.

– Oh my pleasure.

– I think this topic kind of creeped up on me, and was something I didn’t anticipate finding myself in. But training over the last 10 years and starting my practice of course the opioid crisis has been increasing, and I’m seeing it more and more in the emergency department. And everyone is, no matter where you are. So over 2016 to 2017, we saw about a 30% increase in ED visits for opioid overdoses and opioid-related problems.

– Where are you mainly practicing now?

– I practice right now at MarinHealth.

– Marin, okay gotcha.

– We’re in California.

– We were up there recently, yeah. Okay.

– So when I finished my residency, I did a fellowship in administration and management with Vituity. And during that process we picked kind of like a thesis project to work on.

– So wait, you were training to be an evil administrator.

– Is that what I’m understanding?

– Sort of, yeah, exactly.

– I’m sorry, this interview’s officially over. No no, keep going.

– And at that point, there was a lot more evidence that we should be doing Buprenorphine, or medication-assisted treatment out of the emergency department. And actually it was something that had just started during my chief year in residency at San Francisco General. And so even just that one year of experience, using Buprenorphine in my own practice, I became kind of a relative expert and I just ran with it, and I continued learning more about it. And for my project, decided to work with all of our other emergency department staff at Vituity to train their docs on how to use Buprenorphine to treat opioid use disorder.

– So Buprenorphine is Suboxone, correct?

– More or less, yes.

– More or less. So you’re talking about really, truly doing medication-assisted therapy, which you’re gonna see in comments. So people get very triggered by this idea of giving a drug to treat dependency on a drug. How do you think about that in a sense, in terms of this trade-off between are you then making them dependent on another drug, and as an emergency to physician, how does that work?

– That’s the number one question I get is, “Aren’t you just replacing one drug with another, “or one addiction with another?” But Suboxone or Buprenorphine is not a frequently-abused medication. It’s not euphoric. What it does is it helps treat people’s cravings and stay off of use. Everyone in this area will cite a big study from 2015 out of Yale. Where they did a randomized control trial, and they looked at patients who presented to the emergency department with opioid withdrawal, something we see very frequently. And they randomized them to one of three arms. In the first arm, patients got a referral to treatment. Which is kind of, I’d say, the standard of care. A lot of places, when patients come in with opioid use disorders, you have a list of referral treatment centers, and you say, “Good luck. “Go follow up with this program.”

– Yeah, I’ve been there. Not as a patient, or I’d be violating my own HIPAA, but as a clinician…

– Well fair enough. I mean the opioid crisis affects everyone in their own families as well. I can’t name one person who doesn’t have someone in their family or friend group

– Hasn’t been touched by it.

– Who hasn’t been touched by it.

– By the way, in the comments, if you have a family or friend who’s been touched by this, because I tell you, it’s overwhelming actually.

– So arm one was you got a referral to treatment. Arm two is you get a brief counseling intervention referral to treatment. And then arm number 3 was you actually start Buprenorphine in the emergency department and a referral to treatment. And they found that the people who actually got their first dose of Buprenorphine in the emergency department were nearly twice as likely to be retained in treatment 30 days later.

– Wow. So just the act of getting that first dose there was more likely to lead to 30 day… What we’ll call

– Retention.

– “success,” right? Retention.

– Exactly.

– So the other options were just you’re referred, and then tho other one is you’re counseled and referred. And how big was the trial again?

– Ooh, I don’t know how many patients.

– Right, but it was big enough to show a statistical significantly difference there in outcome. So why do you think that is? What’s going on?

– Well the other awesome benefit about Buprenorphine is it’s the best medication we have to treat withdrawal. Withdrawal is a really challenging thing to treat without using an opioid. So you get someone who’s nauseous, they’re vomiting, they feel awful, they have abdominal pain, they’re shaking, in real florid withdrawal because they tried to quit maybe one or two days ago. And they come in for help and you give them some Zofran, maybe you max out your Zofran, you give ’em Tylenol, ibuprofen, IV fluids.

– I’ve been there.

– They’re still barfing and you’re not getting anywhere. They’re in your department for hours and hours, and then maybe sometimes you even admit them because you can’t get them comfortable.

– I’ve had that call, yeah.

– And then sometimes you give up, and you’re like, “Okay, I’ll just give you a small dose of an opioid. “Or maybe I’ll give you one dose of methadone.”

– Yeah, methadone, right.

– Or tell them like, “Why don’t you go home and try to taper it yourself, “instead of quit cold turkey?” Or what you do is you skip the middleman, you just start them on Buprenorphine. And within one hour they can be symptom free. And feel great. And it’s when they leave the department feeling fantastic, and when their symptoms are gone, that they’re like, “Wow, this is a great medication.” And that’s their destination treatment. So that’s what they’re gonna be on. That’s what their provider is gonna start them on as an outpatient.

– Why is Buprenorphine physiologically affecting them this way? In other words, does it also have an antagonistic function to opioid receptors? What’s going on?

– Yeah. It’s like you’re a plant.

– And the truth is, listen, all joking aside, we’ve met five minutes before we did this. But I just heard what his topic was, and I’m like, “We need to talk about this.” So he’s teaching me, and honestly? I’m not an expert in this, so I’m learning along with you guys.

– So when I first learned, it seems very complicated but actually, Buprenorphine is an opioid agonist and an antagonist in one. So what that means is in lower doses, it acts like an opioid. You can actually treat pain with Buprenorphine, there are people who are on Buprenorphine for pain. But in higher doses, there’s a ceiling effect. So unlike morphine, where you give more and more and more, and you get more respiratory suppression and sedation, you have this ceiling effect with Buprenorphine, so that you do not get respiratory suppression and sedation.

– So can you overdose at all on Buprenorphine?

– I’m not gonna say that you absolutely cannot, there are cases of reported overdoses, but they’re usually polysubstance overdoses.

– So something else.

– So it’s mixing with Xanax and alcohol and all this other stuff.

– Which by the way, we’d be remiss if we didn’t say, the co-administration of benzodiazepines, suppressants, and opioids or other drugs is a toxic stew of disaster. So don’t do it. So I was dating this girl in high school, and her dad was the teacher in the band at our high school. And I was a band geek when I was younger. He would be the surrogate father figure ’cause my dad was Indian and didn’t understand the American system at all. And he said, “You’re going to Berkeley as an undergrad, “the one piece of advice I’d give you is, “don’t mix drugs.” He didn’t say “Don’t do drugs.” He’s like, “Don’t mix drugs,” which I think is very good advice.

– Fair enough.

– So back to Buprenorphine, there’s a ceiling, assuming you’re not polysubstance, that’s the advantage. So it can treat withdrawal, and it can treat dependency. And what’s the theory on dependency? What’s the idea there? How is it helping with that? How are you not just substituting methadone for morphine? Another narcotic for another narcotic.

– Well even for the dependency, it really prevents these cravings. These cravings persist for a long time. People who have abstained for years still end up with cravings, and people who are on Buprenorphine or Suboxone for years, when they wean themselves off, they oftentimes find these craving coming back. The partial agonist, the antagonist had another interesting effect, which means that if you’re not in withdrawl to begin with, say you use IV heroin, and you just shot up. And then you go take a bunch of Buprenorphine, it has such a high receptor affinity that it’s gonna kick off all that heroin and put you into withdrawal.

– So let me ask a question then, relating to that. Someone comes in EMS, they’re all out of Narcan, and their respiratory sedation, they’re unconscious, you would normally give Narcan, let’s say it’s all gone, you’re on a desert island. Could you give Buprenorphine? Or would it make it worse?

– That’s an awesome question, I think we’ll start to see some research on that. It’s something that we’ve heard people do in the field. And that if your friend just overdosed, and you guys don’t have Narcan, but you know I’m on Buprenorphine, you can maybe put the sublingual strip in that person’s mouth. And there are reported cases of people being reversed.

– So then you could change the name for that application and get a new patent and call it “Bro-prenorphine.” Like, “Bro, I got you, okay?” That’s really dumb. And also inappropriate.

– And then there’s a though that if we use this to reverse someone, it’s a more gentle reversal than Narcan.

– Yeah, because they’re not going shouting curse words and hurling feces.

– Although if they are doing that, you can give ’em Buprenorphine.

– That makes sense. So you’ve hit ’em with Narcan, they’re jumping out of their skin and screaming bloody murder. At that point you can give ’em a little Buprenorphine.

– Yeah.

– Dude, that’s awesome. So I’m learning a lot here. So let me understand this now. How do you initiate therapy in the emergency department? Do you have to have counseling? Do you have to have a plan for discharge, or can you just give them Buprenorphine? Do you give them a prescription? How do you go about that?

– All great questions. I mean ideally, you do have counseling and all of the other support services. You know adequate treatment of opioid use disorder is not just a single medication, it’s all the treatment, counseling, and case management that comes with it. Unfortunately, Buprenorphine has some special licensing requirements that make it really hard for providers to just prescribe it. So you may have heard about the DEA X Waiver, or the Data 2000 Waiver.

– I’ve heard. Explain it to us.

– So if you have a DA license, you have a license to prescribe narcotics.

– Yeah baby! I’m the candy man.

– But unfortunately you can’t prescribe Buprenorphine.

– That is dumb.

– Yeah.

– Continue.

– So, in order to prescribe Buprenorphine, you need this thing called the DEA X Waiver. And it’s an eight hour course for docs to take, you can take it entirely online, and for free.

– Eight hours though.

– Eight hours, yeah. I’ve heard you can click through it a little bit faster than eight hours. I didn’t say that though.

– Yeah, that was not said.

– And NPs and PAs can do it as well. For them it’s 24 hours. Again, onerous. But I mean I can teach you doc to doc, or doc to NP or PA, within 15 minutes, all you need to know to feel comfortable giving this. And interestingly, and importantly, in a hospital setting or emergency department setting, as a hospitalist or emergency medicine provider, you can administer it without the waiver. Because you’re operating under the license of the hospital.

– That’s important to know.

– So just like residents when they start out can prescribe at a hospital, any ED provider can start this without getting a waiver.

– But can you send them with a prescription, or you can start it with a prescription still, or no?

– So you can do either. So if you have the waiver, then you can send them with their prescription. If you don’t have the waiver, fortunately the half life is like 23 hours. And so you can load them with enough Buprenorphine that their symptoms are gonna be managed until they follow up. And that’s where you really need good linkage with an outpatient treatment program. No you’re not just giving a piece of paper and saying “Good luck.” You are giving them hopefully an appointment tomorrow.

– Dumb, crazy, stupid question from a hospitalist that doesn’t know this stuff. Is it PO-only or IV?

– It is everything.

– Everything.

– Yeah, sublingual, usually.

– Per rectum? ‘Cause that’s how I like my meds. I’m just saying, no judgment.

– Probably.

– And then the other question is someone here, Thuong Trinh, is saying “Suboxone crazy price. “$3,000 per 300 month cost.” I think he means per month, maybe? How expensive is it?

– So that may be their formulation, because it’s generic. And you can get sublingual film that’s generic and cheap.

– Oh, got it.

– And it’s covered by almost every payer.

– Sublocade. Got it, yeah. Okay, right. And what about people–

– So sublocade, that comment, that actually refers to another concept, which is that if a person’s opioid receptors are blocked by Buprenorphine, then it’s protective. So I give a patient a ton of Buprenorphine and send them on their way, say they say, “Screw this appointment, “I’m not gonna go into treatment right now. “I’m gonna go shoot up.” You’ve kinda blocked their receptors. For the next 24 hours.

– Oh snap. You’re like their wing man that’s actually trying to get the girl.

– Exactly.

– And totally blocking. Okay, let me rewind for a second. It seems to me like this drug, apart from the obvious harm-reduction, can be used in a variety of circumstances in the emergency department to prevent death and suffering. Why isn’t it used more? What are the blockades against this apart from cost and the the things we talked about? ‘Cause you don’t need to have all that training if you’re an emergency department provider.

– And I would say not just ED, but inpatient too. I mean, this affects our inpatient colleagues just as much. You admit someone for cellulitis, they then tell you that they’re on opioids, they then go into withdrawal. These patients AMA at a 30% rate. So 30% of these patients who start withdrawing end up AMAing from your inpatient service.

– By the way, I gotta say that’s great dispo for me. 30% discharge rate? That’s barely any paperwork.

– Fair enough. Or you start them on their treatment and then they don’t bounce back. So you save yourself that reaction.

– That’s good too. So again, preventing bounce backs, hospitalists, other docs in the hospital can do it, emergency department providers can do it. And again you learned about all this through your fellowship at Vituity, this administrative fellowship? That’s how you got pointed down this?

– Yeah, in a combination from the administrative fellowship and then getting to work with a lot of people in the community. I mean Yale and Highland, have been doing a lot of the research and kind of pioneering this.

– Highland in Oakland?

– Yeah.

– Yeah, great place. My buddy did his training there as well. And again guys, again, this is not to pitch the sponsor of this show, but I’m gonna pitch the sponsor of this show. This is why we work with companies like this. I told you, I promised you guys I was never gonna work with shitty, stupid companies again. And again, I’m not even supposed to curse on sponsored shows, but I’m just being real here. These guys are awesome, their leadership is awesome, their doctors are awesome, I run into them on the street and they’re like, “Oh we saw your show with Denise.” We love working with these guys, they’re doing the right thing, and these are the kind of organizations and bright spots we should promote. It you’re saving lives, if you’re teaching people about Buprenorphine… So what else around that topic, before we take some comments, would you wanna make sure we knew that I’m not asking?

– I mean it really is a lot easier than you think. You asked why we’re not doing it more often, why not everyone’s doing it? You know, two years ago when I started working on this project with all of our sites we surveyed everyone and there were about nine sites doing this in our group of emergency departments. And then we asked them again a year later, “Are you guys using Buprenorphine? “Are you starting a program?” And that quadrupled in one year.

– Oh wow.

– And so there’s more and more interest in doing this. A big component is education. And then I think the other big component there was this big study a while back, that showed it takes 17 years for evidence to become standard of care.

– Sounds right. That’s actually conservative.

– Yeah. And so it’s the translation of that evidence, that really excites me. How do we get a bunch of docs who maybe trained one year ago or 25 years ago, how do we teach them something new? How do we show them all this evidence, and how do we translate that into practice?

– I’m gonna give you a hug. Because that’s the whole point of what we try to do here on this show. So in this episode, we might reach more people in a single episode than 10 years of conferences.

– Exactly.

– See now they’re gonna wanna go out, and they’re gonna learn how to do this, and whether you’re teaching them, or someone else is teaching them, it will transform care in a catalyzed amount of time. So I’m a big believer in this platform for that purpose. So thank you for bringing that wisdom to us.

– Absolutely.

– And one thing I wanted to ask you about too was how does this relate? ‘Cause we’re talking in our five minute pre-show, we were talking about caregiver wellness. So the nurse practitioners, the PAs, the doctors, the rad techs, everybody else who’s touching patients on the front lines, how does this affect them when we’re quote-unquote “burning out?” Okay, one second. I talk about moral injury a lot, right? This idea that we are forced to do things that are morally repugnant. It’s morally repugnant to me that we would put a patient out on the street with no capacity to help themselves when we know they have a fatal illness which is opioid dependency, and we do nothing. We’re hamstrung, we’re powerless, and we’re afraid. And to some extent we created this epidemic, co-created it by handing this stuff out, because pharma told us this was the thing to do to treat pain, and we’re worried we’re gonna get sued, and think of the conflict, right? So how does this affect that sort of wellness component of what we’re trying to do?

– Absolutely. We walk a lot in wellness, there’s I think the Stanford Model that has three arms and one of them I think is efficiency of practice. And I think of that as you know, I went into emergency medicine because I like to be able to treat everything, I think of myself as having this quiver of solutions for everything. But up until this, I didn’t really have a great solution for opioid use disorder and opioid dependency. So these patients come in, and like I mentioned earlier, they’re vomiting, they feel awful, I’m trying my best with all of my non-opioid pain medications to get them comfortable, and I’m just not succeeding. And now suddenly, we have this medication that we can use that not only makes them feel better immediately, but it actually improves mortality, it improves retention in treatment, it reduces healthcare costs, ’cause these patients stop bouncing back as much. So when I go to work and I have solutions for all my patients, that’s a shift that I feel like I won at. Whereas if I go to work and I just don’t have solutions, and I can’t fix anyone’s problems, that’s where I feel burnt out.

– God I love this man so much. That’s the heart of it. Finding solutions. I’m tired of complaining, I’m tired of feeling hurt, I’m tired of feeling burned out, I’m tired of feeling powerless. Learned helplessness is so terrible. Here you are, young kid, fresh-faced, goes out and says, “I’ll have a solution. “Let’s start pushing it. “It’s there in front of us. “Why should we wait the 17 years “for it to become practice,” right? Alright, at this point, I’m gonna say bye to people who wanna check out, and if we end up sharing this clip as a smaller clip, we might cut it right here. So thank you, hit share on this one. Spread the word about medication-assisted therapy for opioid use disorder. Now we’re gonna take questions. So Dr. Brown, was there anything that popped out at you, or should I start peekin’ ’em? Yell at me, holla at a boy.

– [Denise] So, how long can you take this? What’s the kind of duration? Would it be safe to take it for five years? Would it be safe to take it for 10 years?

– So what’s the duration of safety for using this? Do you have to use it for life?

– You can. So, it’s safe to take for life. And this is where we hand off to the addiction specialists. ‘Cause I think that is a patient-specific answer. There are some people who are really motivated to taper off of it, there are some people who use it for a year. I had a patient the other day who developed dependence within 30 days after her knee replacement, and came in because she tried to quit her meds cold turkey. And that might’ve been a patient who really only wants to be on it for a little bit of time, because her dependence was new, it just developed in the last 30 days. Although I’ve also seen people who have been on Buprenorphine for a year or two, they tapered themself off, and then relapsed and came back into the emergency department to restart.

– Okay, so I’m gonna read this comment because it’s provocative in this sense. So Richard Wan says, “If Suboxone strips work, “why doesn’t Alcoholics Anonymous adopt “a shot of whiskey a day to prevent alcohol abuse? “This is about money. “Money for the docs that are specializing in it,” except you don’t get paid, “and money for the manufacturers who make this stuff. “I’ve never seen any definitive proof that “opioid maintenance works long term.” Okay, I’m gonna answer one part of this, and then you can take the second. The reason that AA doesn’t give a shot of alcohol for alcohol dependency is two-fold. Number one, alcohol is actually a direct liver toxin and will kill you over time, whereas this is actually reasonably safe, alright? Except for constipation and those sort of things that you get with opioids. The second thing is that alcoholics cannot drink a shot of whiskey without going down the rabbit hole of drinking a whole bottle of whiskey. Buprenorphine has that ceiling, so you’re not gonna go down this rabbit hole and end up in trouble with that, it just is not physiologically likely or possible. Now, your thoughts on this?

– In terms of the financial aspect, it’s a generic medication and there’s no billing difference, it’s just an ED visit. It doesn’t matter whether or not I treat it with Buprenorphine or I treat it with something else. What was the second component of the question?

– The second component was “I’ve never seen evidence that it works long term.”

– Oh, the evidence. Well there’s a big meta analysis that looked at every trial of medication-assisted treatment. So every randomized control trial. And there were at least 20. And all of them showed a reduction in mortality. When you compare patients that are on MAT to patients who are not. And I’ll qualify that and say 15 of those studies at least were methadone. So there have been a lot of questions about methadone here, because the concept of MAT is giving a medication to treat symptoms of withdrawl and cravings. And so there are three medications we use for MAT. There is methadone, there’s Buprenorphine, and then there’s Naltrexone. Naltrexone is a long-acting, kind of Narcan opioid-blocker. And so I know that methadone conjures up a lot of fear in some people’s minds. I mean we see a lot of overdoses.

– Going to the methadone clinic, overdose, long-acting.

– And that has a different set of regulations federally. And for a lot of reasons, we can’t necessarily start someone on methadone. But the honest truth is that the outcomes are great on methadone as well. Mortality improves on methadone.

– Real quick, Robbie Westerman said, “I never got high on my Suboxone, it gave me a life.” Robbie, weigh in, are you still on maintenance, or were you able to get off? Because I think one of the questions that I think I have always is, “What’s the root cause of opioid dependency?” Is it some deep unconscious need, emptiness, void, that’s psychological that can be dealt with over years with therapy? Is it a physical receptor, genetic tendency, or is it a mix of those things? What’s your instinct on this?

– I mean, I think it’s a mix of everything. Your biology, your genetics, your environment. Kinda like everything else, similar biology, yeah.

– This “Hungry Ghost” theory some people have put out, so when you take one piece off, you go, “Okay, let’s satisfy the receptor piece, “now let’s dig into the therapy.”

– I was gonna say, some people start because they had a knee replacement and that was their first use of an opioid, other people start because they were having a really hard time in their life and they turned to using. And then some of these people have an easier time stopping, and other people have a harder time stopping. So I think it’s a case-by-case scenario.

– Tanya, thank you for the stars. Dr. Brown, you had a comment.

– Well I think Vanessa Medina has talked a couple of times about something that’s recurring here on some of the comments, and that is “How do we address the stigma?” So we’re trying to address a medical issue, a crisis of epic proportions. But then there’s still somehow this stigma attached to Suboxone, or to Buprenorphine. What should we be doing about that?

– This’s a great question, because I can tell you in the comments I see the stigma. So how do you think about that?

– It’s constant, it’s not gonna change overnight. I think this is just where we have to keep leading, keep being the positive change agents, keep talking to everyone about this. Talk openly about it. You know when you approach a patient without judgment, and just ask them openly, they answer openly, and you learn a whole lot more. And we should talk to our colleagues this way, and I think also I try to connect with my colleagues, when I do sense a little bit of stigma, whether that be another provider, or a nurse. Like we said earlier, it’s touched everyone’s family or their friends somehow. So it’s something we can all relate to.

– I think personally, and this is my own philosophy, I think moralizing about this stuff is not productive. And I think again, holding accountability is important, but I think moralizing about it doesn’t help because we are largely driven by these unconscious things that happen. And so anything we can do from a system standpoint to nudge individuals in the right direction, in a harm-reduction direction, in a direction that is better for their family. Forget about them. Let’s say you think they’re a piece of crap for being a weak person who’s addicted. And there are people who think this. I disagree with them strongly. But think about their families. If there’s a way you can protect their families from the addiction, the sequelae of that addiction, then wouldn’t you wanna do it? And if it’s a chronic… We have diabetics on Metformin for life. We have diabetics on insulin for life. Why can’t we have somebody who suffers with this disease on it for life if they’re productive members of society, they’re doing okay, it doesn’t have a lot of downside except for cost. And I bet the cost will come down the more you destigmatize it.

– And even if you can’t put your stigma away, there is so much evidence; you can’t ignore the evidence that it improves outcomes, it improves mortality, it really achieves that IJ triple aim, quadruple aim reducing costs, helps me in my efficiency of practice.

– Oh, go ‘head.

– So I’ve got another one from Matt Slassman, “What’s the potential pre-hospital application? “All the paramedics are getting fried “by repeat overdose patients. “We’re slinging Narcan like crazy. “Is this something we could look at seeing in the field in the future?” And I think when we talk about burn out, we talk about moral injury, we’ve gotta include all those first responder, paramedic guys who are really seeing this up close and very personal at times.

– I gotta talk to you guys direct for a second. The pre-hospital people send me the most impassioned messages of anybody. They are suffering, you guys. And remember, these are guys that get paid a lot of times minimum wage to do the kind of work that would give a tough burly dude, stereotypical masculine person PTSD for the rest of their life. And so this question is very valid. Can we improve the conditions and perceived power and efficacy of our front line pre-hospital staff with this solution.

– I mean they have been the most eager colleagues I’ve seen. For every case that I see, they see many more. Because they’re seeing patients that decline transport, they’re seeing cases that expire in the field and don’t come in. They see a lot more than we do, and they have been leading the way. Whether that is distributing Narcan, and don’t quote me on this, but I believe there are some EMS systems that are trialing initiation of Buprenorphine suboxone in the field.

– Oh wow. So, good. So we’re starting to look at it, we’re starting to study it.

– Absolutely.

– Other thoughts or questions? This has been an insanely helpful discussion for me, because I get asked these questions a lot, and I keep telling people, “Look, I understand the vagaries of it, “but I need to talk to an expert,” and now we have an expert. And I really wanna thank you Dylan. This was super helpful. If it influences five people in this audience, and there have been like 500 people watching live. Five people in this audience to go out, learn more about it, implement it in their own emergency department, hospital, whatever. Pre-hospital, paramedic on their rig, or it starts a new trial, we’ve done good I think. ‘Cause I’m actually a believer in this approach, and until we figure out the root cause of addiction, and figure out how to target that, we have to treat it the way we do, which is like this, with medication-assisted therapy.

– Absolutely. And the field has developed some awesome toolkits and protocols. Two years ago it was an entirely different scene, developing the protocols was a little bit more challenging. Now we have them, if anybody wants to learn more, feel free to email me. I’ll give this guy my email address, you can put it in the show notes, and I’ll be able to share information. We also published a white paper with Vituity on how to start MAT out of the ED. So we can get that to you guys if you’re interested in that.

– Ping us. So we’ll be make sure to have contact information available in the show notes, potentially in the description and in the stuff when we repost it here, on YouTube, on the podcast if you’re listening. And elsewhere. Denise, you had a follow up from?

– [Denise] I just wanted to give a special shout out to Robbie Westerman. I think your comments have been incredibly insightful. It’s kind of like a hair club for men thing. This is a guy–

– I’m also the president!

– Who has basically gone from a user of this medication and a homeless guy, to now almost finishing his nursing practitioner degree.

– [Dylan] Oh wow.

– And I just think that is pretty flippin’ spectacular. So I just wanted to say congratulations, and we’re all very proud of you.

– [Dylan] That’s great.

– I have goosebumps, dude. And that’s unusual for me. Because I’ve had my goosebumpectomy. Had a total parasympathectomy. So this is like a violation of the laws of nature. Robbie, congratulations.

– Absolutely.

– Thank you for weighing in, thank you for being so honest and vulnerable too in your own experience, because there’s so much stigma, and the truth is now you’re gonna go on to this amazing life, and you go from homeless to having a life and I think that’s the most powerful statement that can be made. We can’t make statements like that, ’cause we’re third parties to this. So thank you again Dylan. What an honor, man.

– Thanks a lot. Thanks for having me, man.

– Will you come back on the show in the future?

– Absolutely. Whatever you want.

– And I wanna shout out to Denise Brown and Vituity for making this possible. This is the kind of partnership we want to keep having, you guys. And I wanna thank my supporters, who support us with $5 a month, doing this thing. They make all this stuff possible. I have all this cool gear ’cause of them, and also this sweater. I used their money to buy a sweater.

– Nice.

– ‘Cause I need one. I’m cold, people. Alright guys, I love you, stay safe out there, share this video. And we out. Peace!

– Next time.