[00:00:01] Narrator: For more than two decades, we’ve been living through one of the deadliest public health crises in history, the opioid crisis. It began with increased prescribing of opioids in the 1990s. Then came heroin, as growing numbers of people struggling with addiction saw cheaper and more accessible alternatives. In 2013, the crisis entered its third wave, defined by a substantial increase in overdose deaths, involving synthetic opioids, particularly those involving illegally made fentanyl and fentanyl analogs. Across the U.S. and Canada, emergency responders, physicians, families, and community leaders are confronting a crisis that continues to evolve at a rapid pace. Welcome to Countermeasures. This season, we are looking back at historic public health outbreaks and bioterrorism events, from the Black Plague to the 2001 anthrax attacks. We are looking across the span of time to uncover how we have responded to health threats, what we’ve learned, and what we still have to do. Dr. Bonnie Milas is a cardiac anesthesiologist, intensivist, and clinical professor of anesthesiology and critical care medicine at the University of Pennsylvania. Dr. Milas lost both of her sons to accidental fentanyl overdoses within 15 months of each other. Today, she uses her platform to raise awareness about the dangers of accidental opioid overdose and the importance of life-saving measures like naloxone. Through her clinical work, Bonnie has administered fentanyl herself for years and knows firsthand exactly how dangerous it is. She describes watching fentanyl use peak as the crisis evolved.
[00:01:48] Dr. Bonnie Milas: Well, I would say it was probably in the early 2010s, but that it really peaked around 2015. And you have to think about the fact that we went from prescription overdose crisis, and those were with pills. And then subsequently, when those pills no longer were available because we were writing out far fewer prescriptions, than that forced people who had the need to treat their pain or their dependency, they had to switch to the illicit drug supply and that meant switching to heroin. And then of course, the drug dealers got really smart in the sense that rather than waiting for heroin that had to be harvested and grown, that instead it became much cheaper and much more readily available to add fentanyl into the illicit drug supply. And that was really a game changer. By far, that amplified the drug overdose deaths that we saw from 2015 all the way up through 2020, and then into our peaking year of 2022, when we had more people dying from drug overdose than ever before. And that really continues even onto our current day. Where the majority of people that are still dying from drug overdose, it’s due to fentanyl. Fentanyl is a killer.
[00:03:24] Narrator: She also knows exactly how and why fentanyl amplifies overdose deaths.
[00:03:30] Dr. Bonnie Milas: The way in which fentanyl amplified drug overdose deaths is the fact that, and I know this because I deliver fentanyl to patients for heart surgery, is if I give a dose to someone who is uninitiated, never had been exposed to fentanyl before, that it can stop breathing in as little as 90 seconds. That’s how fast it can kill somebody. So there’s really a very limited time from the time the individual uses that substance to the time in which they are at risk of immediate death. And it really forces people who are on the scene, who discover this person is unresponsive and they are barely breathing or not breathing at all. It really forces that responder into the situation where they need to do something immediately on the scene. And I like to say that it forces them into the role of being an immediate responder. And that’s why we need to have things in place whereby anybody can save a life. But the people who are using what that did for them is, they really didn’t have any idea of what concentration of fentanyl was in the substances that they were using. And they really had no idea as to whether it was even present. So it was like rolling the dice. It was like playing Russian Roulette. And that was a very, and still continues to be a very dangerous position to be in for the victim, obviously.
[00:05:21] Narrator: Davis Schneider is a professional baseball player. He lost his brother, Steven, to an accidental overdose in 2020. Steven was a registered nurse who worked to help others.
[00:05:32] Davis Schneider: He was great. My brother, you know, he was like the classic big brother. You know, always kind of pushed me to do better in life, whether that was in school, in sports, being a better person. You know he was really good at everything that he ever did. He was really smart, really nice to people, was really good at sports, played four sports in high school. So I kind of looked up to him in every aspect, and I still do to this day. He really kind of inspires me to just try to be better, work hard and never really leave anything out on the field. He would just always bring me around his friends. You know, I’m friends with his friends to this day. I feel like that was kind of like what made him and our relationship really special was that like he never really not included me in anything. He, you know, he was five years older than me, but he always included me in everything. Very grateful for that. He didn’t really have to. He could have really pushed me aside and be like, oh, you just stay home, but you know he included me in everything and you know I feel like that’s why that was kinda helped me be good at sports too because I was always playing with his friends too and you know they’re always kind of bigger and stronger than me too but I feel like that helped me push me and try to get better and it was always fun playing with those guys too.
[00:06:36] Narrator: Dr. Milas has also experienced the devastating impact of accidental overdose.
[00:06:41] Dr. Bonnie Milas: The fact that fentanyl made it so immediately important to have somebody available to respond, what really brought that moment home for me was the fact that I had lost both of my adult sons to drug overdose. And in both cases, it did involve fentanyl. In particular, my younger son was in the city of Philadelphia. He made the critical mistake of buying and using in the city. And what that meant for him is he used overnight. Certainly, there was very little chance of him being discovered. But also the fact that, and we learned this from his toxicology report that we got back, that the only opioid that was present in his bloodstream was fentanyl, and it was 100 percent pure fentanyl. So unfortunately, he really didn’t have a chance of surviving. And that is what really kind of brought it home to me, that we really needed to have something immediately available. And we really need it to focus on injury prevention.
[00:07:57] Davis Schneider: COVID was kind of a tough time for everyone. Everyone was kind experiencing it at the same time for the first time. Everyone was kinda going through stuff. So my brother dealt with some mental stuff for sure. You know, and he kind of turned to drugs at that point. So, and I didn’t know that at the time. He didn’t really share it with me or my family. I feel like he didn’t wanna like admit it to our family. So he kind turned to the drugs and had an accidental overdose and during 2020 in November. And you know, that was six years ago, almost. But yeah, it was tough for me and my family and it still is. Every single day, you just get reminded of it, whether you’re walking down the street or you’re talking to your family or something like that. Me and my family are still kind of pushed through. I wish I knew what he was kind of going through. I feel like with him, Steven, he didn’t really want to admit that he was going through something, at least to me, just because he was that classic, strong big brother. I feel like he didn t want to admit he was kinda going through some stuff. I wish he did, and I wish more people could speak out of what they’re kind of going through and, you know, tell someone and get the help that they need, but kind of kept it to himself. And you should never really keep something to yourself because you’re always trying to get help and stuff like that. So I’m looking back at it. I wish I kind of either chimed in or helped or knew a little bit more, but everything’s always hindsight.
[00:09:18] Narrator: During the fentanyl crisis and prior waves of the opioid crisis, certain communities and populations were particularly vulnerable.
[00:09:26] Dr. Bonnie Milas: The specific populations that were really most at risk were the inner city population who were known to use substances or were substance dependent, and particularly in areas where there’s a great deal of income disparity, that that was the group that was really hardest hit. I think that the public health departments, county health departments. Those individuals who do outreach work, they were really critical and they were quick to recognize that these are the people that we really need to save. And education went out to those groups. And we also were able to put the medication in their hands so that they could really save each other. The other groups that were particularly hard hit, especially during the COVID years, were those individuals that were somewhat cloistered or in remote areas such as the Alaskans and the Native Americans, that they were also disproportionately really affected by fentanyl and the drug overdose crisis. We’ve really seen a number of improvements since the mid-2010s with the fentanyl surge. Public education has really taken off. There are many state-wide or county-wide programs that are immediately available. There are states that have opioid dashboards and you can go onto those websites and find not only treatment programs, but also where can I get naloxone product? How can I have it even mailed to my home for free? There are online education programs. There are a number of substance abuse programs that have expanded their access to care. That’s really expanded over the years. Medication assisted treatment, MAT, with either Suboxone or Methadone. So it’s not just the access to Naloxone that has decreased overdose deaths, but there are so much more available than what was available in the mid-2010s.
[00:11:54] Narrator: While awareness of and access to naloxone has grown, there is still a lack of awareness about the risks of illicit fentanyl and other opioids, as well as stigma that continues to be a barrier.
[00:12:05] Dr. Bonnie Milas: I would say that the biggest barrier to getting naloxone and overdose education really out there in the public was changing the mindset of the public. And when I talk about changing the mindset, I like to think of it in two different areas, whether it’s in the home or whether it is in a public space. So in the home, I’m talking about friends and family. When I go out and try to teach people, the thing I hear frequently is, well, I don’t live with somebody who abuses substances or my kids would never touch drugs. Well, I like to tell them that you really don’t have any control of what comes into your home, first of all. Yes, you may have a teenager or someone in the home who you thought would never even use a substance that they wouldn’t know necessarily what it is, but I like to teach people that any given day your teenager or anyone in the home might be having an emotional event that they feel stressed and that the bottom line is they could use something that might be given to them by someone else. And for a teenager, it might be the kid who’s sitting across from them in homeroom. And that is the most likely place where they are going to pick up a substance that they don’t know exactly what it is. But, you know, to the parent, wouldn’t you like to have something in the home that you could immediately respond to your child who’s just about to take their very last breath? I think that would be critical. We do lots of things to protect our family members. You know, we buy fire extinguishers. We put plastic plugs and electrical outlets. You know there’s all types of things that we do. Wouldn’t you want to have this life-saving drug immediately available as you’re waiting for 911 or the EMS squad to arrive?
[00:14:19] Narrator: Davis has also seen how hard it can be for men in particular to open up about what they’re struggling with and how that silence feeds the stigma.
[00:14:28] Davis Schneider: I think so. I think our society is getting a little bit better with that. People are kind of realizing it doesn’t have to be that way. But for sure, when it comes to men and that stigma, it definitely is a little more with men. And I try to kind of make sure I’m telling people that I know that I’m trying to go through stuff or something like that, tell my sisters, tell family. So I’m not trying to be better with it. But it definitely gives a little stigma in this world when it comes to that, when it comes to men.
[00:14:55] Narrator: While progress has been made, the opioid crisis is still evolving.
[00:15:00] Dr. Bonnie Milas: So things that we have seen in the illicit drug supply that has changed from a positive standpoint, the fentanyl concentration that we’re currently seeing is somewhat lower than it had been in our peak years. The other thing that we’ve seen is the animal tranquilizers that have been added by the drug dealers. Really, these are cheap drugs like xylazine. That was added in. Now, what we had seen with xylazine was really horrible necrotic skin wounds, which led to amputations of arms or legs. And it’s been a relief to see that xylazine is not currently being seen in our drug supply. That’s really kind of faded away. What has replaced it is another animal tranquilizer, medetomidine. With medetomidine, what we’re seeing is worsened withdrawal symptoms, and sometimes that requires hospitalization. You know, the fact that we’re seeing slightly lower concentrations of fentanyl is positive. The negative things that we are currently seeing in the illicit drug supply is fentanyl is being replaced with even more potent fentanyl analogs. With a very potent fentanyl analog, it may require repeated doses of naloxone in order to reverse someone’s drug overdose. That’s really a negative change that we’re seeing. In addition, I think it’s very disappointing, although we are seeing overdose deaths decline. I think the public thinks that the overdose crisis is over. COVID subsided, overdose deaths are decreasing. But the overdose crisis is far from over. We are still losing more people due to drug overdose than we are either due to suicide or motor vehicle accidents. It still is the leading cause of accidental death in the United States. So the overdose crisis is not over and the fentanyl analogs remain to be the main cause why people are dying due to drug overdose.
[00:17:20] Narrator: Dr. Milas is clear that the crisis is far from over, but she’s just as clear that individual actions still matter, even against something this large. Davis has seen that firsthand since he started using his platform to talk about his brother.
[00:17:36] Davis Schneider: So many people have reached out to me, and it’s kind of really hit home to me. They just reached out and shared their experience too with either themselves or a loved one, and I feel like that’s all that really, not, I wouldn’t say matters, but like it kind of made a difference. I feel already that people can read my family’s story and my brother’s story and kind of reflect on it, and they had that same experience, and they’re not going through this alone and there’s people out there that’s going through the same thing and I feel like that’s all that really matters is people kind of sharing experiences and making sure they’re not going through it alone. One thing to take away probably, there’s no such thing as rock bottom, I feel you can always try to get up from where you’re at. And I feel having family and friends and loved ones, I think that helps a lot, but you only need one person in your life to kind of make a difference for you and if you have that one person then that’s what you really need. There’s always room for growth and to get back to a better place. And I wish I knew sooner with my brother, but I can help one person or someone can help one person each single day, then that’s all that really matters.
[00:18:45] Narrator: Davis’s philosophy is simple. You only need to help one person to make a difference. Dr. Milas leaves us with something just as simple and just as urgent.
[00:18:55] Dr. Bonnie Milas: The one thing that I would like to impress upon everybody who’s listening is that when it comes to drug overdose, there are no second chances. There are no do-overs. You cannot rewind the tape. You can’t go back. Please have a naloxone product immediately available in the home. Know how to use it. It’s pretty straightforward and to please, no basic CPR, you will not regret it. And otherwise, you know, particularly to family members is to let your loved ones know that you love them, that you are always there for them. And from your own personal standpoint, from your own personal perspective, to know that you’ve done your very best, and again. To not have any regrets.
[00:19:56] Narrator: The third wave of this crisis has a shape now. We can trace it. From prescription pills to heroin to fentanyl. And now, to whatever comes stitched into the supply next. But underneath the data, this episode has really been about two families who live through the parts statistics can’t capture. The moment before, you know, and everything after. Dr. Milas asks for something concrete. Naloxone in the home. CPR basics. No regrets. Davis asks for something just as concrete and just as achievable. Check in on the people around you and don’t assume anyone is fine just because they say they are. Neither of them is asking you to solve an epidemic. They’re asking you to be ready for one person, one day. The opioid crisis isn’t over. It’s evolving. And it will take the combined effort of all of us to combat it. Thank you for listening to Countermeasures. If you enjoy the show, please consider leaving us a rating or review. Thank you to our guests for taking the time to share their insights. If you found this episode insightful, please share it with colleagues and friends. And don’t forget to subscribe so you don’t miss future conversations. Davis Schneider is a paid spokesperson of Emergent. The views he expressed in this podcast are his own.