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NARRATOR: Behind every heartbeat is a story we can learn from.




NARRATOR: As we have for over 80 years, Blue Cross and Blue Shield companies are working to use the knowledge we gained from our members to better the health of not just those we insure, but all Americans. Some call it responsibility, we call it a privilege. Second Opinion is funded by Blue Cross Blue Shield.


ANNOUNCER 2: Second Opinion is produced in conjunction with UR Medicine, part of University of Rochester Medical Center, Rochester, New York.




[ Applause ]


DR. SALGO: Welcome to "Second Opinion." Each week, a panel of medical experts joins us here to discuss a real-life case. I'm your host, Dr. Peter Salgo. I want to thank everybody on our panel and our studio audience for being here today. Now, we have some experts today. They are Dr. Aaron Fields, emergency and addiction medicine at the University of Rochester Medical Center; William Moyers from the Hazelden Betty Ford Foundation; primary care physician from the University of Rochester Medical Center, Dr. Lou Papa; and our special guest, Kelly, who is here to share her personal story. Again, thank you all for being here. Lou, everybody here, we all know we're in the middle of an opioid epidemic. It's actually quite tragic. You must see lots of patients in your practice now who have this issue. So, if Kelly came to see you, how would you begin a conversation with her, and what would you do?


DR. PAPA: So, we have to go back, and you have to take off your professional hat here.


KELLY: Okay.


DR. PAPA: And one of the things that comes into people's minds is, "How did this all start?" How did you start using?


KELLY: I have pretty extensive trauma history in my childhood. I started using very young. I was about 14, and I started with dabbling in smoking cigarettes, drinking, smoking marijuana, and whatever prescription pills somebody could steal from their parents. That progressed pretty rapidly. I was snorting heroin by the time I was about 18, IV heroin use by 19. So it kind of -- it kicked off with, I guess, a combination of the childhood trauma and the crowd that I found myself wanting to be around was very much one of drug-based social using, all of that stuff. That's the people I gravitated towards, because we all had kind of similar makeup and background.


DR. PAPA: When did it become obvious to you -- or maybe it wasn't -- or to others around you that there was something else going on, including your own doctor?


KELLY: I mean, it became obvious to me almost immediately. I -- I knew the first time that I did heroin that that was gonna be what either killed me or put me in prison for a long time. That's a pretty common, I think, realization that many people come to pretty early on. My family started to notice the thinness, that I was being sketchy in family situations, that I wasn't around, that things were missing. You know, family started, like, hiding their wallets and purses at Christmas. But no one really knew, I guess, the specifics or how dire of a situation I was in because I kept it as vague as I could.


DR. PAPA: When did it intersect with the healthcare system, and what was that like?


KELLY: I first interacted with my primary care physician, who I adore, after I had gotten clean the first time. So, I had already physically detoxed from the drugs. I was no longer in active withdrawal when I met with my doctor. I had a pediatrician until I was 22.


DR. PAPA: Mm-hmm?


KELLY: And I'm very lucky that I had parents who were as equally supportive. So, you know, my parents were in my first doctor appointments with me. They heard some stuff they probably never wanted to hear their child say. And, you know, my doctor was there for me in any capacity that I needed her to be in, whether it was anxiety medication, whether it was linkages that she could make for outpatient treatment, or something like that. So she was really an invaluable part of my early recovery.


DR. SALGO: Excellent. You're in an emergency department. First of all, Aaron, does it make a difference to you how they got started?


AARON: At the end of the day, no, because it all does the same thing in the brain, right? If it's Percocet, if it's methadone, if it's heroin, it hits the same receptors, and it triggers the same pathways, and produces the same physical symptoms. Once they're physically dependent on an opioid, an opioid is an opioid is an opioid. It -- You know, and people will flip from one to the other based on what's available, what's convenient, what can they get. I know a lot of my colleagues in the emergency department will almost get a little aggressively defensive when people come to the emergency department and it seems like they're trying to score medications or score drugs. What some patients don't realize is that while they're there trying to sell a story about their dental pain and why they really need some Dilaudid for it, two doors down, there's somebody having a heart attack who needs my attention. Three doors down, there's somebody who broke their ankle who needs my attention. You know, there's always more patients and other place that attention can be spent, and so rather than recognizing that it's a systems problem, that it's a societal, cultural problem, it gets oftentimes chalked up to, "This person is a bad person, and they're doing something bad." While not all people who are physically dependent on a substance will end up in an emergency department, many do, and if nothing else, treating them as human beings improves the likelihood that they're gonna seek care at a future point. One of the things that kind of set me down this path to working in addiction medicine is that I would see so many recurrent frequent fliers in the emergency department who came in over and over and over again either drunk or intoxicated or in withdrawal or after an overdose, and it just felt like beating my head against a wall. But I started to just try to get to know some of the people, and realized that they had stories of their own and that they were human and that oftentimes there was a reason that they were like this.


DR. SALGO: Now, William, I'm looking at Kelly, and I think all of America is looking at Kelly, and what she's registering on the screen, I'll bet, is not "drug addict." She's not. She looks like your next-door neighbor.


WILLIAM C. MOYERS: Well, addiction does not discriminate. We know that at Hazelden Betty Ford, where I work. I mean, I don't look like an addict and an alcoholic, either. Kelly and I clean up pretty well when we find recovery because we're not using anymore, and we're employed, we're not showing up in the ER, we're paying our taxes, we're being engaged parents. So, a lot of what happens in the emergency room is really reflective of what happens in America, which is that a lot of the population sees addiction as somebody else's problem or affecting people who live under bridges or are a different color or unemployed or don't have faith.


DR. PAPA: Well, it was interesting what she had said with regards to where her supports were -- for her family and her primary care doctor, people who knew her before she was an addict.


KELLY: Right.


AARONl Right.


DR. PAPA: They knew who she was, they knew what she was capable of, they knew that she was hurting, and it wasn't just another person coming into the ED.


AARON: I'm glad you mentioned the hurting part, because I think that's a root cause underlying a lot of the current opioid epidemic. Yes, part of it is the wave of opioids being prescribed. Yes, part of it is increase in illicit heroin coming up from Mexico. Yes, part of it is these new, synthesized Fentanyl analogues. But there is a huge underpinning of untreated, unrecognized, unaddressed mental health and kind of just distress, psychosocial distress, that people have that predisposes them to developing a substance-abuse problem in the first place.


DR. PAPA: It also is distress for the emergency room doctors.


AARON: Sure. Yes.


PAPA: Because part of it is, is when you talked about the heart attack victims, or you talked the broken legs, you know there's an orthopedist you can call. You know -- When they have the heart attack, you know there's a cardiologist you can call. When you have the addict, you're stonewalled.


WILLIAM C. COPE: Where do you send? I mean, once the emergency room doctor or the primary care doctor has had the encounter with the person, oftentimes you don't know where in the community to send a Kelly or a William, because there's not a lot of resources for treatment.


DR. SALGO: But, Kelly, you're on both sides. You've been clean now for how long?


KELLY: Over 3 1/2 years.


DR. SALGO: 3 1/2 years, and what you've done... [APPLAUSE]


KELLY: [ Speaking indistinctly ]


DR. SALGO: Yeah.


KELLY: Thank you.


DR. SALGO: First of all...


KELLY: Thank you. [ Chuckles ]


DR. SALGO: ...congratulations. It's hard.


KELLY: Yeah, it's crazy.


DR. SALGO: But you now are working with folks who are trying to stay clean.




DR. SALGO: And you're taking intake from EDs and trying to find places for them to go?


KELLY: From anywhere, really.


DR. SALGO: So what is this like now from the other side? How do you view all of this?


KELLY: I'm extremely honored to be involved in the program that I'm in. It's possibly the greatest thing I've been allowed to do with my life. That being said, as someone who has been on the receiving end and is now on the negotiating end of treatment... if anybody is jaded, it can usually be people like me because of the stigmatized care that I received, because of the indifference I was treated with during my medical - You know, I've been revived by EMTs with Narcan, I've been revived by Samaritans. Samaritans gave me more compassionate care than an EMT did. I was not treated, in my humble opinion, ethically or compassionately, you know? And it's difficult, because I think that stigma is one of the, if not the single biggest, barrier to substance use. Even the language -- "Addiction" is extraordinarily stigmatized. The whole point of person-centered care is a person with substance use disorder. You can replace the word "person" with "daughter," "mother," "neighbor," anything.


DR. SALGO: So what should happen? Step one, step two, step three? Walk me through this.


AARON: So, what should happen – If they're coming in by ambulance, and somebody has overdosed, and, for some reason, the ambulance doesn't have access to Narcan, so they're not able to have already given that -- Shouldn't happen in this day and age, but --


DR. SALGO: I was about to say, are there ambulances without Narcan?


AARON: Not really anymore, especially in our area. And so --


DR. SALGO: And for the record, Narcan is a specific narcotic antidote.


AARON: Correct, it's an antagonist that blocks the opioid receptor, so now it's depending on how the person's acting. If they are getting fully thrown into withdrawal, they're often belligerent, combative, don't want to stay, and there's this huge gray zone, medically speaking, of, "Do we have the right to essentially imprison this person? Are we allowed to hold them against their will in the emergency department?" Some take the argument of, they're no longer intoxicated. The opioid has been blocked. They are as sober as they can get. I'm not saying I support this argument, but this is one of the arguments behind not placing such people under a mental health arrest, is that they are no longer intoxicated.


DR. SALGO: So from the ED to the next step can be a bottleneck. Is that where you come in?


KELLY: That's our goal. That's what we're there to do. The biggest disconnect, in my experience so far, has been the discharge plan a patient is given is more of an active compliance than it really is good, patient-centered care.


DR. SALGO: What does that mean?


KELLY: That means that when you discharge someone to a place that is strictly an evaluation agency, which is what we are -- We provide evaluations and linkages for fast treatment. But when you discharge someone to us at 3:00 in the morning with very vague paperwork, and that's the entirety of their discharge plan, with no other linkages for substance use, for mental health, for support, that's an incomplete discharge plan. That person, more often than not, is either gonna not make it to us, or they'll get lost in the cracks, because what can we do at 3:00 in the morning besides provide, you know, peer support and advocacy for them?


DR. SALGO: Well, the object is to get them to you, or someone like you, right?


KELLY: Right.




DR. SALGO: To a facility which provides rehab.


WILLIAM C. COPE: A licensed drug and alcohol facility staffed with, you know, accredited counselors and trained counselors and docs and social workers and so on. But the disconnect between that crisis moment and that treatment opportunity oftentimes is enough that it causes people to start using again, or to not make it to that next step.


DR. SALGO: But now you're clean, if you will. There's no narcotic effect.




DR. SALGO: Out you go on the street in full-blown withdrawal. What's the first thing someone's gonna do?


DR. PAPA: Right, and it would be... The analogy -- Kelly and I were talking before the show. The analogy would be you had a heart attack -- you had a cardiac arrest, and you're being discharged.


KELLY: Mm-hmm.


DR. SALGO: Good luck, then.


DR. PAPA: There's no follow-up with the cardiologist, they haven't told your primary care doctor, they haven't done cardiac rehab, you're not even going to the telemetry unit.


AARON: Usually, right now, the standard is about a four-to-six-hour observation period in the ED, waiting for the Narcan to wear out of their system, primarily to make sure that they're not becoming resedated.


DR. SALGO: Because there are long-acting narcotics...


AARON: Correct.


DR. SALGO: ...which will outlast the Narcan, and if you send them out, they'll arrest you.


AARON: Exactly. So even if I wanted to admit somebody after an acute opioid overdose that was reversed, and the patient wanted to stay, they wouldn't meet what are called admission criteria that are set by the Centers for Medicare and Medicaid, and most insurance companies follow their lead.


DR. SALGO: That's where I wanted to wind up. Is it fair to say, many disconnects here, that's the disconnect? There is no admission criteria for these folks to come on in, and so the crisis continues? Is that fair?


DR. PAPA: Well, I'll tell you what they did that made no sense at all. We had an opioid crisis that was partly created by the medical community.


DR. SALGO: Mm-hmm?


DR. PAPA: And the first thing they did was, "Dr. Papa, you can't prescribe opioids more then seven days." Right? Came down where I have to go through multiple steps to prescribe somebody, yet didn't do anything to improve access for treatment.


KELLY: Mm-hmm.


DR. SALGO: Mm-hmm.


DR. PAPA: So it was all about, "Shut it down," which contributed to the heroin epidemic.


KELLY: That's exactly what happens. When you say, "Well, sorry, once your seven days of your Oxycodone are up, figure it out."


DR. SALGO: We're gonna pause for just a minute. You know, every day, we hear about medical innovations that make an impact and hold promise for improving our healthcare. Take a look at this.


DR. STONER: Carotid arteries are responsible for most of the blood flow to the brain, and a blockage in the carotid artery can be one of the leading causes of stroke. When a blockage gets severe enough that it either causes symptoms or it's beginning to restrict blood flow to the brain, your doctor may recommend seeing a surgeon about fixing the blood flow in the carotid artery. Carotid stenting delivered from the groin artery has been around, really, for probably almost 20 years, but it never caught on because the complication rate was higher than that of surgery. The surgeon had to deliver a stent from a location remote from the carotid artery, go up through the blockage, pass the blockage, and, intuitively, that actually makes sense that that would be a problem, because when that stent goes by the blockage in the carotid artery, it can break a piece off. TCAR is an acronym. It stands for "TransCarotid Arterial Revascularization." It represents an evolved or new technology to treat blockages in the carotid artery. It's an elegant procedure wherein a surgeon places a catheter in the neck artery through a very small incision just above the collarbone. A separate catheter is placed in the vein, which is the low-pressure system in the leg, the femoral vein. By hooking these two catheters up, the surgeon can temporarily reverse the blood flow, usually just lasting three or four minutes in time, allows us to safely place a stent without the risk of breaking off components of the blockage in the neck artery and causing a stroke. If the patient has a blockage and it breaks loose during the procedure, it simply is reversed. It goes out of the body, trapped in a filter, and the blood is returned back into the body. The blockage is essentially sucked out of the body during the case. As we evolved our experience with this technology, we drove this to a more and more aggressive molding of the carotid artery to sort of get the shape and the flow characteristics that we want before the stent is placed, so it's completely even changed not just the delivery of the stent, but the way we now think about what's called pretreatment of the carotid artery -- kind of molding it and getting it shaped the way we want it to look to provide the best flow characteristics for the patient when we're done. I think that this will push carotid surgery to a larger group of people as well -- people who were not candidates before -- so we can reduce the risk of stroke. And I think, as we study this procedure, which appears to be as safe or safer than surgery, we'll learn more about the role of this surgery to prophylactically reduce the risk of stroke in patients.





DR. SALGO: And we're back. You know, before we went to break, we were talking about the barriers that exist between getting acute treatment, which is Narcan or whatever you need, and then chronic treatment, or into some sort of treatment facility. But it begs the question, William -- Is there effective treatment? And if so, what does that treatment look like?


WILLIAM C. COPE: Well, I think that treatment looks like Kelly, and it looks like me. I'm a multiple treatment guy. I was in treatment four times over five years between 1989 and 1994. And I can't speak for you, but you've shared some of your own experience, so we're what effective treatment looks like. The thing, Peter, is, is that there is no one-size shoe fits all anymore. There are many pathways to recovery, more so now than there were five years ago, more so than there were, certainly, when I found recovery in 1994. What worked for me might not be what works for Kelly. What worked for Kelly might not be what works for somebody with co-occurring. The opioid epidemic certainly has resulted in the use of innovative medicines, like Suboxone -- we were talking about it, buprenorphine -- and other substances. We have to recognize in this country that there are many ways to find recovery. What matters is matching that pathway to recovery with the individual needs of the patient.


DR. SALGO: You know, isn't part of the problem, though, where the blame is ascribed? Nobody blames a diabetic for being diabetic.


DR. PAPA: No, and it's interesting to me how, you know, you talk about this more and more, it's really no different than any other disease. So when you said, you know, "We really gotta tailor it," we know that about every disease, right? Not every case of breast cancer is gonna be treated in the same way. And no one ever gets beat up if their breast cancer -- Nobody points the finger at them since the breast cancer comes back.


DR. SALGO: Right.


DR. PAPA: Or if you had another heart attack. It's exactly right.


AARON: On this topic, one of the things that often people... Every time I say this, people tell me, "Oh, this needs to be out there more."


DR. SALGO: So bring it out here more.


AARON: North of 90% of people who, at any point in their life meet criteria for substance use disorder, primarily for alcohol use disorder -- More than 90% of those will go into remission, sustained remission, on their own without formalized treatment, without any intervention. Think about every person that you went to college with...


DR. PAPA: Right.


AARON: ...who went out and partied each weekend.


KELLY: Mm-hmm.


AARON: Guarantee you those people all meet criteria for alcohol use disorder.


DR. PAPA: Mm-hmm.


AARON: But because of the environment they're in, the people they're surrounded by, it becomes accepted. It's a social norm.


KELLY; Right.


AARON: And usually, people age out of that. As they get older, as they take on more life responsibilities, those behaviors stop because people realize it's no longer conducive "for the life that I want to lead." It becomes a problem, truly, for that person when, despite those negative impacts on their life, they're not able to control the behaviors.


DR. SALGO: Let me ask this, then, because I can hear -- I know the folks at home are saying this. "Alcohol's one thing, heroin's another."


DR. PAPA: No, no.


KELLY: It's not.


DR. SALGO: You say that's not true.


KELLY: It's not.


DR. PAPA: True.


DR. SALGO: Why not?


KELLY: I mean, a drug is a drug is a drug. Anything that impacts and changes either the development or the cognitive ability of a person is a drug. It's a chemical. It changes your makeup genetically, or however. I'm not a doctor.


DR. PAPA: And tobacco.


WILLIAM C. COPE: And guess what? We've had an epidemic of one way, shape, or form around all substances since the Continental Congress in the late 1700s was trying to come up with public policy around the sale of rum. I mean, the reality is, is that there's no silver lining with the opioid epidemic, but it has helped to level the playing field in how we as a society, we as a community, deal with this issue.


DR. SALGO: You know, alcohol will kill you...


KELLY: Yeah.


DR. SALGO: ...just as surely as heroin will.


KELLY: Maybe not as quick.


DR. SALGO: Maybe, but society doesn't look at them the same. I think that's what you were getting at.


KELLY: You can't pull out bags of heroin and needles at a party like you can --


DR. PAPA: [ Chuckles ]


KELLY: It's the truth.




AARON: Depends on the party.


DR. SALGO: Not at the parties I go to.


KELLY: No, I mean, I tried, and it doesn't work.


DR. PAPA: And, plus, the alcohol's legal.


KELLY: Right.


DR. PAPA: Because it's a legal thing, it's accepted.


KELLY: Because somebody's making some money somewhere.


DR. PAPA: I just wish there was a sense of fairness in terms of disease treatment, right? Because, even now, there's not the same degree of research and resources, because whether it's -- For me, whether it's legal or not doesn't make a difference. If I have a patient that needs treatment, how do I get them in? It really is where the rubber hits the road.


DR. SALGO: What's on the horizon? What's coming down the road, if anything, that's gonna make this better?


KELLY: Peer support.


WILLIAM C. COPE: Peer support.


AARON: Peer support has been a huge, growing movement.


DR. SALGO: What does that mean? What is peer support?


KELLY: So, I am a -- I'm a state-certified peer support and advocate, so someone in my position who has the first-hand, lived experience and not necessarily higher education or clinical, but I've taken many hours of courses on ethics, on providing good support, on recovery coaching, all of the things that I need to do – what I do in my personal life, professionally, and be of service to the recovery community. The science shows that people attempting either abstinence or any sort of recovery, who have the support and advocacy of a trained peer, have a way higher success rating. The threshold is much higher for success for those people. Peer supports in hospitals as part of an overdose intervention team or a treatment team, those are -- they're so, so important, and that is my biggest issue, is that peers are not -- 'cause we're not professional. I don't have a degree, and so --


DR. PAPA: Isn't that similar to AA? I mean, that's essentially a peer-to-peer, and that's been one of the most successful.


KELLY: AA was built on a peer model. It is -- It is peer-to-peer.


WILLIAM C. MOYERS: In fact, we talk about the fact that addiction is an illness of isolation.


KELLY: Yeah.


WILLIAM C. MOYERS: And the antidote to it is community.


DR. SALGO: If this is as big a national problem as it seems to be, and we're looking to turn this thing around, let's just go around the horn if you will -- Baseball term, by the way, Lou. I know you don't like sports that much.


DR. PAPA: Didn't know a horn was involved in baseball.


DR. SALGO: And what's one suggestion you've got to turn this all around?


WILLIAM C. COPE: We're talking about a medical issue, and you've got two people who are not docs. You've got two people who've been there and done that, who are recovering. To have a program and an audience -- I can promise you that this program will result in people finding hope and then getting to help. So what we need, if I could suggest one thing, is more of this. We need more people standing up and speaking out and sharing their own experiences.




DR. PAPA: I think there has to be serious consideration in dollars that are behind treatment. Access, training for physicians, because a lot of physicians are very uncomfortable with this -- They don't have this as part of their training -- to create that connect-the-dot.


DR. SALGO: Mm-hmm.


DR. PAPA: And better research on how do you get -- because there's a lot of resistance to peer-to-peer, interestingly enough. But, basically, put your money where your mouth is. If you really think this is a crisis, don't just cut off the supply. You know, treat the entire condition.


DR. SALGO: Kelly?


KELLY: So, probably my number-one suggestion, just based on, again, like, my personal experience and that of someone on a more clinical path now, is just, like, across-the-board compassion training for EMTs and ED people, because I've had some pretty horrific encounters with EMTs in person, as the receiver, on social media -- people who are proudly ambulance drivers and EMTs just saying pretty derogatory, awful things about "junkies." And, like, that word doesn't offend me. However, stigmatized language and not using it does much more for the provider of care than it does for the receiver. It doesn't bother me what term you use to call me. For the person providing it, would you feel more comfortable treating a junkie or a person with substance use disorder? So, you know, taking a course on ethical, compassionate, and informed treatment, person-centered care, smart care, anything like that for anyone who is going to have their hands on treatment at all, I think... It's just, that's the dream.


DR. SALGO: Aaron, you get the last word.


AARON: Love, you know?


KELLY: Mm-hmm.


AARON: Love for yourself. Love for the other. Love for the disadvantaged. Love for the person who is down and out. My grandmother used to always say, "There but for the grace of God go I." I'm not a religious person, but I say this at least once or twice a day.


DR. SALGO: Well, thank you very much. It's been a great discussion, and I want to thank all of you for being here. Kelly, thank you so much for sharing. This can't be easy, to share this kind of experience, and I just want to tell you how much we appreciate...


KELLY: Yeah.


DR. SALGO: ...your being here. I want to thank our panel, of course, as a group. I want to thank our studio audience for being here. I want to thank our audience at home for watching. Now, you'll find more "Second Opinions" and more patient stories online at, and you can find us anytime on social media. I'm Dr. Peter Salgo, and I'll see you next time for another "Second Opinion."


 [ Applause ]


NARRATOR: Behind every heartbeat is a story we can learn from.




NARRATOR: As we have for over 80 years, Blue Cross and Blue Shield companies are working to use the knowledge we gained from our members to better the health of not just those we insure, but all Americans. Some call it responsibility, we call it a privilege. Second Opinion is funded by Blue Cross Blue Shield.


ANNOUNCER 2: Second Opinion is produced in conjunction with UR Medicine, part of University of Rochester Medical Center, Rochester, New York.