David Casarett on a solution that may help a family who is grieving after the loss of a loved one who has been in hospice ~
“This is something . . . in a hospice setting falls to family members to deal with. It’s one of these things that as you’re dealing with the loss of a loved one, as you’re dealing with all of the other things that you have to manage after somebody dies, also being faced with the problem of getting rid of dangerous medications. That’s one thing we actually could fix. We could make that better. We can’t take away their grief and their sense of loss. We can’t help them with all the other management and logistic issues they need to deal with, but we can, at least, help them to take care of these dangerous drugs that are sitting around in the house.”
David Casarett: The trick for us is giving those patients exactly what they need but no more.
Brian Wilson: The opioid crisis is an epidemic with many faces. To a member of the law enforcement
community, opioids are dangerous substances to be managed and controlled. To the parent who’s lost a child to addiction opioids are a gateway drug that can lead to a lifetime of loss and regret. But to those in pain management, opioids are necessary tools to help hurting patients at a time when little else can. Dr. David Casarett is the Chief Medical Officer at DisposeRx. As a professional with years of experience helping his patients manage pain, he brings a unique perspective to our conversation about the opioid crisis, and we start at the beginning.
Downstream Effects of Increased Opioid Prescribing
David Casarett: Many of us back in the ’90s, early 2000s saw pain as the fifth vital sign, as a problem we had to solve, and became much more aggressive at prescribing pain medications, including opioids. Many of those prescriptions were legitimate for real needs and patients who were suffering, but some of them weren’t. Gradually, the tide began to turn and there was an influx of opioids to people who didn’t necessarily need them and a black market. Many of those patients, when that supply of drugs became unavailable, or less available, or more expensive turned to other forms of opioids including black tar heroin that was imported from Mexico. I wouldn’t say all this started because of physicians, especially since many of those physicians like myself were really trying to do right by our patients, but I think we are seeing many of the downstream effects of increased opioid prescribing 10, 15 years ago, which we’re now dealing with today.
Brian Wilson: You are described to me as a palliative physician. What is that exactly? And, tell me a little bit about your credentials and what you bring to this particular story.
David Casarett on Palliative Care
David Casarett: Sure. So palliative care is a specialty of medicine and of nursing and social work, and other disciplines, by the way, it’s not just physicians, focused on improving quality of life for patients with serious illness. We help with pain and symptom management for patients with cancer. We help with decision making under difficult circumstances for patients, say with heart failure. We provide emotional and spiritual support, meaning our team does, our nurses, our chaplains, our social workers. We really try to improve decision making and improve quality of life for patient who are going through a rough period of time, patients and their families, I should add.
Brian Wilson: And often they’re in hospices. What happens there at the end, let’s say, of the journey? Either you get better, or in some cases, the pain management was used to support you through the end of life and now you’ve passed on. So what happens now to all those drugs that were prescribed?
Hospice Care – Disposition of Leftover Medications
David Casarett: Well, that’s a good question. And just to be clear, most palliative care physicians actually work with what we think of as being upstream of hospice, so I work in a hospital, and many of my colleagues work in clinics. We take care of patients before they enroll in hospice. But there are also, by the way, opportunities to be much more careful about medications. But, I think you’re right where the most urgent problem, at least in my view, arises when patients enroll in hospice. Some patients graduate from hospice, as we say. They outlive the hospice prognosis and they leave hospice, but most don’t, and will spend anywhere from a few days to a few months on hospice, and will die leaving behind to their families an average of 10 prescriptions for medications, which often translates into at least dozens, sometimes hundreds of pills. Maybe those pills are for controlled substances like benzodiazepines like Valium or opioids like morphine. Figuring out what to do with those medications and how to handle them safely is what led me to begin talking with John Holaday initially, a couple of years ago as DisposeRx was getting off the ground. We talked about ways in which palliative care providers and hospice, which provide opioids and other controlled substances to patients appropriately to make them more comfortable, can also be part of the solution in helping to dispose of those medications safely.
Brian Wilson: It seems to me, many times when you have something that comes out of nowhere very quickly, as this epidemic apparently did, it takes a while for legislators to get a grip on what they’re doing and what needs to happen. From a law enforcement standpoint, what are the problems that are emerging as a result of this opioid epidemic?
Law Enforcement Challenges Emerging From Opioid Epidemic
David Casarett: Many people in law enforcement did see this coming. They may not have been able to convince other people of the urgency of what they saw, but certainly law enforcement in some of the hardest hit areas, in the Rustbelt, in the Appalachian south in the United States, and also to some degree on the west coast, those law enforcement professionals saw this influx of black tar heroin and saw inappropriate uses of prescribing, and really only now are beginning to be heard. Definitely hats off to many people in law enforcement who knew what was going on and really did they’re best to connect the dots. Some of us now are just beginning to catch on.
Naloxone – A Double Edge Sword?
I think some of the challenges right now are at a really high level for law enforcement is trying to figure out how to both respond to the epidemic and particularly some of the overdoes are now becoming routine, unfortunately, in many of our communities including some hotspots, unfortunately, where I live in North Carolina, but also, trying to take a preventive stance as well. For instance, some of the efforts now to make naloxone widely available. I have friends who work in law enforcement who tell me that they’re torn when they arrive at the scene of a drug overdose. They’re now equipped to administer naloxone to hopefully reverse an overdose and bring somebody back, but they have the sense that many people are beginning to count on this. And this is becoming a safety net that’s in someways enabling certainly risk behavior and overdoses, and whether that’s true of not, I don’t know, but I think many law enforcement professionals I know really feel torn. They feel like they have to save this person’s life, but knowing that when they do, they have this feeling that by doing that, they’re giving that person and the people around them, essentially, permission to risk an overdose again, and also them contributing to the-
Brian Wilson: Wow.
Curbing the Opioid Epidemic
David Casarett: Widespread use of naloxone certainly solves that. But, does it curb the epidemic as a whole? No, it doesn’t. For that you need really aggressive education and prevention, and good drug treatment programs, as well as what we’re talking about now, efforts to try to keep some of unused medications out of the hands of, not just people who could abuse them, but kids who might use them by mistake, which is one of my big fears in taking care of hospice patients, that leftover medications would get into the hands of, not of somebody who necessarily has an intention of abusing them, although, that’s certainly a risk, but a kid who lives in the house accidentally taking a bottle of morphine. That’s something that keeps me up at night.
Brian Wilson: Of course, you can’t take the drug and become addicted to it if it’s not available to you. I mean, if you need it for pain management that’s one thing, but the problem is many times it’s sitting in the medicine cabinet. But if you can somehow find a way to solve that problem, so it’s not sitting in your medicine cabinet, it can’t be abused and then lead people down this road to ruin.
DisposeRx – Solution for Patients to Dispose of Leftover Medications
David Casarett: Or families down the road to ruin. Many people begin down that road to addiction getting left over medications from a friend or a family member. Speaking as a physician, I don’t want deny my patients, and I would want to argue that my colleagues should deny their patients pain medications if they need it, but the trick for us is giving those patient exactly what they need, but no more. I think it’s certainly easy to say, well, reduce the amount of pills we prescribe, and that’s fair, but in some states those limits are so strict and so severe that physicians are finding they can’t actually prescribe enough and patients need to keep coming back. I think one elegant solution is a process like DisposeRx that allows people to take as much as they need and then dispose of that when they’re done, so they don’t feel tempted, a week, a month, a year later, to dip into the medicine cabinet if they’re feeling tired, or anxious, or need something to lift their mood, and so it doesn’t tempt other people to use or misuse in that case those prescription medications.
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Brian Wilson: Put a human face on this for me, if you could. Give me some example of a story that you’ve heard of a family that has gone through the crisis that you describe.
Putting a Human Face on the Opioid Crisis
David Casarett: Unfortunately, I don’t have to reach into my professional world, just in my daily life it’s all too clear. One of our neighbors, they had a kid in his teens, star student, went to college for a couple of years, took some time-off to travel the world, planned to go back to an ivy league institution, and they noticed over the course of a couple of months when he got back, was just gradually becoming more withdrawn, less successful, changed his group of friends, couldn’t get a handle on what was going on or what had happened to him, had always been self-sufficient, self-starter, straight A student. They didn’t worry about him. They figured he was just going through a phase until they found him dead one morning of an overdose in the living room, and he had had this fairly long history addiction to opiod painkillers initially, which he had apparently gotten from his father’s medicine cabinet. And then, graduated from that to illicitly obtained oxycodone and other drugs, from that to heroin that he had been injecting, all without their knowledge. This is a solid, upper middle class, professional family. And it’s a wakeup call, I think for everybody in the community, to their credit, if this could happen to them, it could happen to anybody, and probably was happening to other people who just didn’t realize it. This isn’t something that just happens to somebody across town on the other side of the tracks. This is something that is invading living rooms, families all across the country. Nobody is safe from it.
Brian Wilson: I mean, if you’re a parent, for example, listening to this, and it all seemed like it happened very quickly, what are the signs that might exhibit themselves that maybe you have a problem that needs some pretty quick intervention? Because, sadly, it sounds like there’s not a lot of time to react here.
Identifying Opioid Addiction
David Casarett: Sometimes there is, sometimes there isn’t. In this case, there probably was, in retrospect, but it was something that the family didn’t detect. I think, again, I’m not an addiction expert, so take my advice with a grain of salt. But, in general, addiction manifests itself as a change in behavior, a change in social relationships, often behaviors that interfere with social relationships or with work. Sometimes, that’s clearly tied to drug abuse and sometimes it’s not. Those people I know who work in addiction research say that sometimes the best safeguard is to have a high index of suspicion, and to be upfront, and communicative, and ask family members what’s going on, what the problem is. Say you’ve noticed some changes and engage in an open, honest, and as much as you can, nonjudgmental approach to figuring out what’s going on.
Brian Wilson: I guess I’m wondering is if perhaps the problem is bigger than we realize, and that when these things happen, sometimes they’re not identified as such because many families don’t want to have the stigma of say, oh, my son died from a drug overdose.
Raising Awareness of the Opioid Epidemic
David Casarett: I think that was certainly true early on. I think, again, this is my guess, I’m not a forensic pathologist, but my guess is that everyone or many people in the United States have become much more aware of this being a problem. Early on, that has certainly been an issue. I think many episodes of drug overdoses were not identified or were identified using different terms and were not identifiable as a pattern in existing databases. But, I think we’ve got to the point now where it may not be the first thought on a coroner’s mind, but it probably would be the second, or at least the third. I think we’re much more alert to that. I think families, you’re right though, still associated this with a lot of stigma. I know of other families who have been very assertive at saying exactly what happened to their son or daughter, and talking about why it happened, and using their tragedy as a way to educate a community. It’s unimaginably difficult to do under those circumstances, but I really admire families who, not only manage to get through that horrendous circumstance of losing a son or daughter, but also use that as an opportunity to teach others, to prevent others from going the same road.
Finding Solutions in the Stories
Some of the stories that I’ve been paying much more attention to are stories that help us to problem solve. Those are stories, in fact, one woman I was just talking to a couple of weeks ago whose mother died in hospice, who came to her mother’s house and found, literally, an entire closet full of medications, including many medications that were opioids, which her mother who died of cancer, didn’t want to take, but also didn’t want to throw out, and so had enough opioids in the form of oxycodone morphine probably to take care of a couple of dozen patient with terminal cancer. My friend, was faced with the challenge of how do you get rid of all these medications, and really didn’t have any guidance, didn’t have any suggestions from the hospice or the physician. And that’s just one story that I know of.
This is something, that I think, often, in a hospice setting falls to family members to deal with. It’s one of these things that as you’re dealing with the loss of a loved one, as you’re dealing with all of the other things that you have to manage after somebody dies, also being faced with the problem of getting rid of dangerous medications. That’s one thing we actually could fix. We could make that better. We can’t take away their grief and their sense of loss. We can’t help them with all the other management and logistic issues they need to deal with, but we can, at least, help them to take care of these dangerous drugs that are sitting around in the house.
Announcer: Thank you for listening to Opioids: Hidden Dangers, New Hope. Subscribe today where you get your podcast or visit opioids-hiddendangers-newhope.com for more information. This presentation is underwritten by DisposeRx.