Ending the Crisis: Mayo Clinic's Guide to Opioid Addiction and Safe Opioid Use

[00:01] Announcer:

Welcome to Principal Center Radio, helping you build capacity for instructional leadership. Here's your host, director of the Principal Center, Dr. Justin Bader. Welcome everyone to Principal Center Radio.

[00:13] SPEAKER_00:

I'm your host, Justin Bader, and I'm honored to welcome to the program Dr. Holly Geyer, MD. She is an addiction medicine specialist at Mayo Clinic in Scottsdale, Arizona, and the physician lead of the MCA Opioid Stewardship Program. And Holly chairs the School Training Overdose Preparedness and Intelligence Task Force, STOP-IT, a 60-member multidisciplinary working group charged with developing a comprehensive and sustainable school opioid overdose preparation plan and toolkit for Arizona schools. She is widely published in high-impact scientific journals and book chapters and maintains an active international lecture schedule. She additionally serves as a physician director of the Mayo Clinic Physician Assistant Fellowship Program.

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And she is the author of the new book, Ending the Crisis, Mayo Clinic's Guide to Opioid Addiction and Safe Opioid Use.

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And now, our feature presentation.

[01:09] SPEAKER_00:

Dr. Geyer, welcome to Principal Center Radio.

[01:11] SPEAKER_01:

Thanks so much for having me, Justin. Pleasure to be here.

[01:14] SPEAKER_00:

Well, I'm honored to speak with you and learn about your work on the front lines of this battle. Tell us a little bit about what's currently going on with the opioid crisis, because we've heard about this for years. We knew there were some things with prescriptions, and now we know there are some things happening with street drugs. We're aware of this issue, but take us into it a little bit.

[01:35] SPEAKER_01:

Right now, we're in the thick of it, Justin. You know, we have heard about this topic for a number of years, and it's because it's undergone evolution. We started with the overprescribing crisis in America, you know, that 1990s to early 2000s, where we as providers were offering opioids without screening patients. without monitoring them. And that got us into the height of the crisis around 2012 when all of a sudden the light bulb comes on in the medical community and we say, my goodness, it's causing complications. We pulled back on prescribing, but the illicit market was waiting.

[02:05]

And that's where we are now, Justin. We are in the opioid overdose crisis as originally heroin followed by the synthetic opioid fentanyl has flooded our market and is leading to upwards of 110,000 deaths annually.

[02:17] SPEAKER_00:

110,000 deaths annually.

[02:21] SPEAKER_01:

About 70% of those are going to be opioids, but not all of them have been tracked. So it's in that range.

[02:27] SPEAKER_00:

And to pick us into a little bit, if you could, what you're seeing among young people, because certainly, you know, we understand that this is an out there problem. But to what extent is it an in here problem that schools are facing with their own students?

[02:41] SPEAKER_01:

I think many of us come with the mindset that, you know, 1980s, 1990s approach that kids will experiment and it's the norm. And oftentimes from our perspective in the addiction field, that's how kids experiment with the world. The problem is it's oftentimes a death sentence. In 2024, when seven out of every 10 illicit fentanyl pills has enough of the illicit opioid fentanyl in it to kill the average American adult, you don't get time to experiment. And the reality is that I think we're entering an era where the drug market has recognized the value of getting kids on this early, and they are now becoming a target.

[03:17] SPEAKER_00:

It seems to me that people who might be taking fentanyl may not even realize it, right? They're not going out and saying, hey, please sell me some fentanyl. It's being laced into other drugs or pills that maybe nobody knows what's in them.

[03:31] SPEAKER_01:

Absolutely. The CDC has recognized that we're now entering what we call the fourth wave of the illicit opioid overdose epidemic. And that's because it's starting to lace other drugs of abuse, methamphetamine, cocaine. We're actually seeing this in almost all drugs of abuse, including the common stuff kids might experiment with, cannabis, even some tobacco products there's been concern with. And so as we look at kids' risk of experimentations going up, The other areas that we've noticed is that stuff you can buy online, right? Muscle relaxants, sleeping agents, things to help you study are widely available on the dark market on Snapchat or other social media sites.

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And kids are buying these without recognizing that they are oftentimes laced with these drugs.

[04:15] SPEAKER_00:

Holly, thank you for the update there on what's going on with opioids and fentanyl in particular. I think one of the things that comes to mind for educators who've been around a while is the DARE program. And for anyone who's not aware, DARE was a big push, maybe in the, what was it, the 80s, the 90s, to make schools make kids aware of the dangers of drugs. And after some rigorous evaluation, what we learned was, it didn't work. What we ended up doing with the DARE program was, in a lot of cases, getting kids curious so they would experiment when the intent was the opposite. So I think we're pretty shy as a profession now about speaking up about these issues because we know there is the potential to do it badly.

[04:59]

Your research has focused on how to do it right. How can adults and educators in particular play a helpful role in battling this crisis without making things worse?

[05:10] SPEAKER_01:

What a great question, Justin. And it's one we absolutely have to address if we're going to get this right. My first comment about DARE is that you're right. It was back in kind of that 1980s to 1990s. I went through it too. And I remember the day when, you know, the cop would come and he'd tell you, don't smoke.

[05:26]

It'll really give you a little bit of a buzz and you'll be socially accepted and it'll be fun to use initially, but it'll make your breath smell bad. And then you get to go outside and see a fire truck and hug a dog. What oftentimes when we look back at the D.A.R.E.

[05:41]

program was incorporated was perhaps not necessarily selling the harms of engagement. And concurrently, because it was the first time many of these kids would have been exposed to the topic, it piqued curiosity. Two things have been mitigated since that era. Number one, kids have direct access to the Internet. And this is everywhere. The topic is everywhere.

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Their friends all know about it. So the ingenuity of it as a concept, I think has been dulled. And number two, we've recognized, like I said, that there are other ways to get this communication out. The Montana Meth Project is one of the best examples in the nation of a communication campaign that had powerful, profound impact. It showed horror stories on television at prime time of people overdosing or the secondary consequences of drugs. And when we sold the negative effects, the light bulb was going on in people's minds.

[06:33]

As our stop it committee is looking at developing curriculum, we have recognized that we really need to level set with kids. One pill can kill for the DEA. You may not get people back. We need naloxone widely available to help with overdose reversals. And so there's a lot of communication that's going to focus on the aftermath response, the fact that this is now an endemic problem, and that there are preventative mechanisms to avoid the inevitable harms if you go down the road of use.

[07:05] SPEAKER_00:

Well, yeah, let me ask Holly about naloxone because I think we're hearing about that. Maybe it is in some schools, but a lot of people may be uncertain about exactly what naloxone is for and why we might want to think about it. Take us into that a bit.

[07:19] SPEAKER_01:

Absolutely. Naloxone is one of the most amazing drugs ever invented. It's got virtually no side effect profile when admitted to someone who's not experiencing an overdose. And to those that are, it has the opportunity to revive them from what's oftentimes an inevitable death, literally within seconds. The drug is easy to administer in most cases. There's an intranasal version and you just put it up the nose and squirt it and watch for a response.

[07:45]

This is a drug that we're looking to get widely available within schools, Justin, but unfortunately we're just not there due to policies and then misunderstandings of the drug itself.

[07:54] SPEAKER_00:

So it's my understanding there is no harm in giving naloxone to someone who doesn't need it. So like if we have a student who inexplicably behaves strangely and then passes out in the nurse's office, we may not have time for them to get to the hospital. Is it appropriate in that situation if we suspect opioids to administer naloxone? And granted, we're not in a medical consultation here, but just for general information.

[08:18] SPEAKER_01:

100% Justin. This drug is so easy to administer. It takes almost no level of training for the average person. And so when in doubt, give it.

[08:27] SPEAKER_00:

It reminds me almost of an EpiPen, right? Like we've all had EpiPen training. We know about EpiPens and only some students have EpiPens, but this is a little bit different, right? It doesn't have to be prescribed for the individual, right?

[08:40] SPEAKER_01:

Absolutely. And EpiPens come with a negative safety profile if administered to the wrong person who's got underlying medical conditions. Naloxone doesn't work that way. If independent of your baseline medical problems, if you give it and it's not an overdose, you will still do well.

[08:55] SPEAKER_00:

Now, how do schools get Naloxone? And is there any kind of training process or like what steps do they need to take to have it on hand?

[09:01] SPEAKER_01:

That's an excellent question. We've done a 50-state review as a part of Stop It, and we're in the process of actually publishing this information. But in essence, what we've recognized is that every state seems to have diverse laws on this topic. Across the United States, I think it's only 15 states that haven't addressed it in statute at all. And of the remaining two-thirds, I've seen one of everything. I've seen laws where there's free funding for it on behalf of the states.

[09:27]

There are states where you have to buy it yourself, which on average is about $45 for a two-pack these days. You can actually get this drug over the counter and go to your local CVS or Walgreens, or there's also distribution programs that come down through state opioid settlement funds, oftentimes through either Department of Health or the Attorney General's office in a state. So it's worth just reaching out to those two entities if you're a school administrator to see what might be free already.

[09:51] SPEAKER_00:

And school nurses may also have information on naloxone from their own sources, right?

[09:55] SPEAKER_01:

Absolutely. The National Association of School Nurses does have some resources. I encourage everyone to visit their website. It's excellent. And there may be links there that could be helpful for funding as well.

[10:06] SPEAKER_00:

Let's talk a little bit more about your book. If we could, you've written a guide called Ending the Crisis Mayo Clinic's Guide to Opioid Addiction and Safe Opioid Use. What prompted you to take on that project and write that book?

[10:18] SPEAKER_01:

I would say it's a constellation of a variety of factors in my life. My parents had started a drug treatment program when I was a kid, and I grew up in an environment hearing the stories. And, you know, it was a different epidemic back then. I'm not going to date myself online, but, you know, it was a prescription crisis. And what I recognized is that people coming through our program came from all walks of life. These are people who were businessmen.

[10:40]

We had state senators' kids, and we had people who grew up on the streets. Really, opioids proved to be the equal opportunity destroyers. And as I entered the world of medicine and started understanding neurobiology that derived it and how it truly is a medical condition that can be diagnosed and viewed on standard imaging technologies that we have for other conditions like strokes. The light bulb went on, you know, how are we understanding opioids as a society? That was the nidus for this book. I've treated little old ladies who are dying of cancer, riddled from top to bottom, who swear on their life they will not take an opioid in their final days, despite the uncontrolled pain because they don't want to become addicted.

[11:18]

That's a misunderstanding. And on the other hand, I've had 20-year-olds playing Candy Crush in their coat cart, just sitting there with 12 out of 10 pain, crying. We are a society that turns to a pill for everything. And what this book does is talk through the average listener or reader. on what are opioids, why they're available, what is pain, what's the difference between acute pain and chronic pain, how to use opioids safely, and then how to navigate all their consequences or complications, including addiction and overdose. There is a heavy, heavy section on the role of friends and family to help people with this condition, as well as resources nationally.

[11:56]

There is standard of care for opiate addiction, but it's only offered in about 10 to 20% of all cases. So if a reader is interested in this topic, I would encourage them to focus on that section. Thank you.

[12:06] SPEAKER_00:

Yeah, I'm glad you mentioned that completely avoiding all opioids is not necessarily what we're going for. They do have a use. They do have value to society.

[12:16] SPEAKER_01:

Absolutely. In our book, we go into great detail to talk about the role of opioids. And one thing I would want to stress to all of our reading audience is that opioids are not the enemy. Our misunderstanding and our misuse of them is. And when they are used in the right patient, for the right indication, at the right dose, for the right length of treatment, via the right route, They are one of nature's greatest miracles. When used outside those settings, they kill.

[12:42]

And so offering that education. And by the way, Justin, this is the only book on the market addressing this topic. I mean, we're 25 plus years into this crisis. We don't have a book till now. It's beyond me. But I collaborated with our Mayo Clinic Opioid Stewardship Program, which is a multidisciplinary group of at least 40 members coming from all subspecialties and backgrounds to help bring the best information of this field together into one resource.

[13:06] SPEAKER_00:

There are a number of different fronts that we need to think about. One is the kind of last chance opportunity to save someone from an overdose with naloxone that we can obtain, that we can keep on hand in schools and train staff and maybe even students to administer in a potential emergency. There's also the appropriate use and the oversight side that I'm sure your clinic and your work focuses a great deal on. And then there's the street drug side and dealing with laced drugs and with fentanyl appearing in places where we would rather it not be. How can parents best think about this issue? Because I have kids who are in middle school.

[13:48]

Many parents wonder, am I talking about this with my kids too early, too late? Am I even helping by talking with my kids? Am I making them curious? Am I making this better? Am I making this worse? What's some of your top advice for parents?

[14:01] SPEAKER_01:

First thing I would say to every parent is it is out there and your kids know about it. If they are in junior high or above, this is always one of the things that's coming up on a regular basis inside schools, whether or not you're aware they're talking about it. So not addressing it causes more harm. The data shows that if a parent discusses the dangers of drug use with their kid, that kid is 50% less likely to engage in drug use. Start early, right? So kids need to know, and our target age group for the Stop It Subcommittee will be grade 6 through grade 12.

[14:34]

But keep in mind as a parent that these drugs are now starting to look like sweet tarts. They have additives for colors and flavors. Start talking even before the age group I mentioned about the dangers of picking up things off the ground and putting them in your mouth, right? You can't tell what a pill is. Nothing goes in the mouth. As you're looking at those older age groups have discussions about the dangers of fentanyl, and there's a number of online resources.

[14:57]

The first one I would recommend is the Drug Enforcement Agency One Pill Can Kill campaign. Great information on there for adults. There's a lot of other stuff out there. So Song for Charlie is another one. Sold Out Youth Foundation. A couple other national ones.

[15:12]

If you Google the term curriculum on opioids and fentanyl, it'll come up. So I would be prepared. We're hoping schools are integrating this curriculum in. Our national survey across the United States suggests it's in a small minority of schools where it's actually mandated by state law, but hopefully times will change.

[15:30] SPEAKER_00:

Let's talk a little bit more, Holly, about the STOP-IT subcommittee. And again, just a tremendous acronym for School Training, Overdose Preparedness, and Intelligence Task Force. What does that committee do?

[15:40] SPEAKER_01:

I'm glad you remembered the acronym, Justin. I get that wrong more times than not. Gotta write it down on my hand here. So the STOP-IT subcommittee was really a grassroots effort in the state of Arizona to bring curriculum and opioid preparedness material into Arizona schools. There had been a law that was passed a couple years ago that requires schools to have policies and procedures on the topic of naloxone administration. And what we saw is that schools were oftentimes interpreting that law as, my policy is to call EMS.

[16:08]

My policy is to call 911 and not stock the drug. And that was raising a lot of problems in schools. We had at least a couple hundred overdoses in the last one year within kids under age 18. Schools need to be prepared. Right now, Arizona is the state where 59% of all fentanyl is trafficked through to the United States. So we're sitting at the epicenter.

[16:31]

Our training task force was really the beginning of a variety of providers across the state representing different medical professions, along with a couple government agencies. that together approached the Department of Education to be a collaborator on a task force, and we were granted that. Now we're 60 plus members. We have diverse backgrounds from education to government to community liaisons and social work to multiple medical fields that have built out what we hope to be a comprehensive toolkit that schools can adapt. If we did it here in Arizona, Justin, we can do it anywhere. And we just realized this last week that the Department of Health, as well as our access or state Medicaid department, is willing to supply all of the naloxone.

[17:14]

It comes through Medicaid dollars, which many states will have access to to disperse for opioid-related efforts. So schools can check into that. So really, I would highlight in this conversation, stop it can be done anywhere. We hope to publish on our methodology because other states will have volunteers just like us, willing to get in there, get dirty, and bring policies, procedures to schools as samples, build out a toolkit, and find the lock zone for schools to have.

[17:40] SPEAKER_00:

So an alarming problem, but not something where we're powerless. It's exciting to have, as you said, really kind of a wonder drug that can stop an overdose in its tracks that doesn't have side effects, not even to the level that an EpiPen has, and that often we can get for free and have on hand. If you could kind of wave your magic wand and have a wishlist of actions that school administrators would take, I expect naloxone would be on that list. What else might you add to that list for school administrators?

[18:10] SPEAKER_01:

Actually, yes, Justin, that would be on the list. It is not top of the list. The first thing I want is for every school and school district in the respective state to look up state laws as to what is and isn't permitted on campus. Speak with our legal team. If you are allowed to have naloxone, First thing I would do is identify whether or not your respective school district permits it and then start developing policies and procedures on it. Sample policies and procedures are available on the National Association of School Nurses website.

[18:39]

You're welcome to reach out to me for the stop it committee. We have also developed some there that are freeware for others to use. The next step after that is to begin stocking it. It's not expensive. Our recommendations are that for every 300 students in a school building, there be two vials of naloxone available. So, you know, that could be upwards of six to 10 vials in every school, depending on your size.

[19:01]

Keep them with your AEDs. Keep them unlocked. You need everyone to have access to this drug. In your policies, make sure that you're not requiring anyone to have formal training unless state law otherwise defines it before the naloxone can be delivered because it's really easy to give. If you can lick a lollipop, you can shove this little aerosolizer up someone's nose and push a button. I promise.

[19:24]

And then ultimately have an after action review process, right? The kid used that drug for a reason, either by accident, follow that trail for the illicit substance, right? Or they have a substance use disorder and there are great treatments available.

[19:37] SPEAKER_00:

Great advice. And I love the idea of keeping naloxone in the AED boxes that are now everywhere. They're impossible to miss. People are probably running into them quite often and literally bumping into them in the hallways because we now have them in so many places, which is a very good thing. And certainly there's room in those boxes for naloxone. And interesting that you mentioned checking the policies.

[19:59]

So are you suggesting that there are policies in place that might make it challenging, like that might need to be changed in order to stock naloxone on campus?

[20:08] SPEAKER_01:

Yes, there are. Unfortunately, I won't list states today, but there are some states that actually restrict naloxone availability to very certain populations that may be permitted to carry it, and many other states don't address it in statute. So again, speaking with the legal team is going to be key. My experience, because this is such a widespread issue that so many states are trying to address, is that there will be openness to getting naloxone into schools. I think a lot of the hesitancy that we've seen is at the school administrator level and the That's the barrier we're trying to break in this conversation.

[20:40] SPEAKER_00:

Yeah, certainly if there is a policy issue, this seems like a bipartisan matter, right? And if we have a state law that needs to be changed, we should be able to get bipartisan support for changing that law and for preventing overdoses and for saving kids' lives. And does your group do anything on the legal advocacy side as far as state legislation?

[21:01] SPEAKER_01:

We were very, very keen to ensure that we had legal representation on our subcommittee from the Attorney General's office to assist with interpretation of these laws. And so I would encourage any group that's starting up a stop it version to do the same thing. Our state laws weren't being interpreted well. And so that was one barrier we needed to cross. Another that we're attempting to address right now is who is allowed to report an overdose? Our emergency medical services hypothetically should be contacted every time an overdose occurs on school.

[21:30]

But the tracking mechanism of whether or not that overdose was on school is very poorly delineated and oftentimes a box that EMS should be checking is not being checked. We need to know what's happening in our schools, its frequency and prevalence. And so with that, we're working on potentially looking at a change in our state law to require school nurses to report back up during these situations.

[21:50] SPEAKER_00:

Well, Holly, to bring this home a little bit, could you give us some of the numbers, some of the statistics about what's going on with the opioid crisis currently?

[21:59] SPEAKER_01:

Thanks, Justin. Yeah, it's not a pretty picture. We have seen some improvements, we think, from preliminary data in 2024 that overdose deaths perhaps are going down, likely due to the widespread availability of naloxone. But I will tell you that not only are adults impacted, and by the way, this drug class has reduced our average American life expectancy by a couple of years. That's huge when we think of all the improvements we've made for decades in the American landscape. We're also seeing this impacting our kids now, too.

[22:30]

In fact, we're losing an entire class of high schoolers weekly to opioid related deaths or overdose deaths. So it's not a trajectory we want to put kids on. The American Medical Association had published a report a couple of years ago that showed between three to 19% of people who touch the drug class of opioids will develop long term dependency. And that remodeling of the brain that's so much more likely to occur in kids than adults makes them much more susceptible for getting on that trajectory to an overdose later in life. Right now, opioids are the number one cause of death in adults under age 45. So this is not a path that we can afford to put them on.

[23:07] SPEAKER_00:

So talk to your school nurse and your leadership in your organization and definitely check out Holly's book, Ending the Crisis, Guide to Opioid Addiction and Safe Opioid Use. Dr. Holly Geyer, thank you so much for joining us on Principal Center Radio.

[23:24] SPEAKER_01:

Such a privilege to be with you, Justin. Thank you.

[23:26] SPEAKER_00:

Keep up the good work.

[23:28] Announcer:

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