Dr. Callan Fockele shares insights on innovative approaches to tackling the opioid crisis, including mobile health teams and the implementation of buprenorphine in emergency medical settings. She also highlights the importance of leveraging lived experiences in shaping effective addiction policies.
Key Takeaways:
- Mobile Health Teams: The impact of mobile health teams in Seattle and how similar initiatives in fire districts could support community needs.
- Buprenorphine in the ER: Protocols being piloted to administer buprenorphine in the field and the emergency department for opioid use disorder treatment.
- Challenges and Solutions: Barriers to linkage care post-overdose, especially for the homeless, and the necessity for integrated support systems.
Guest:
Dr. Callan Fockele; emergency medicine and addiction medicine physician, University of Washington Department of Emergency Medicine, and expert in addiction medicine and population health research.
Resources Mentioned:
- Dr. Callan Fockele
- Organization: University of Washington Department of Emergency Medicine
- Seattle Fire Department’s pilot program for buprenorphine distribution
- 24/7 Telebuprenorphine Hotline
- Health One’s outreach efforts
Quotes:
-“Supporting people with lived experiences is crucial for creating effective addiction policies.” – Dr. Callan Fockele
-“We need to focus on upstream interventions to reduce the high costs of treating substance use disorders in emergency rooms.” – Mark Wright
Listener Challenge:
This week, educate yourself about where and how to obtain naloxone; and consider carrying it to help save lives in your community. Share your pledge on social media using #BEATSWORKINGShow.
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Transcript
The following transcript is not certified. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors. The information contained within this document is for general information purposes only.
[00:00:00] Mark Wright: Dr. Callan Fockele, welcome to the BEATS WORKING podcast. It’s so great to have you here. I’ve really been looking forward to our conversation.
[00:00:07] Dr Callan Fockele: Thank you so much for inviting me.
[00:00:08] Mark Wright: So you are an addiction medicine expert. You work at Harborview Medical Center in Seattle in the emergency department.
[00:00:17] Mark Wright: And I guess we should probably start by saying that if you have not been to Harborview on a Friday or a Saturday night, You have missed out on what is drama., it’s sometimes a little scary. There’s always something happening there. How would you describe working at Harborview Medical Center?
[00:00:34] Dr Callan Fockele: I love it. And actually, um, for childcare reasons these days, I only work overnight. So, the nights are where I enjoy to be at the hospital. I think Harborview is just a really unique place. I’m not originally from Seattle, but having lived here for the last eight years, I know it has a special place in the hearts of many people in the region, largely because I think often when patients are [00:01:00] really sick or injured, they make their way to Harborview.
[00:01:02] Dr Callan Fockele: So I think a lot of folks know people or themselves, who’ve, . Received care there. So, and Harborview is a special place. I think, being the level one trauma center for our region, for Washington, Alaska, Montana, and Idaho, hopefully I got that right. And also the burn center. There’s just a lot of, care that we provide to the region.
[00:01:23] Dr Callan Fockele: And I think what’s really exciting too, is, you know, it says right there on. The wall of our hospital that we serve a particular mission population, and there are lots of populations that are listed there. And one of them are, people with substance use disorders. So I think, the breadth of what we do and the care that we give, is really special.
[00:01:41] Dr Callan Fockele: And I think it’s a real privilege to be an emergency medicine doctor where, I get to take care of whoever walks in the door and don’t have to worry about insurance or other obstacles or barriers that get in the way.
[00:01:52] Mark Wright: Yeah. Harborview, you guys can handle anything. I mean, being that, that regional trauma center, but the reason that I [00:02:00] really wanted to have you on the show, Callan, is that I saw you present at a, at another organization and talk about your work on the front lines of the fentanyl and opioid epidemic that we’re experiencing right now.
[00:02:11] Mark Wright: And I was really struck by Not only your work, but your passion and your commitment, in this area., we’ll get to that in just a little bit, but I, I really love your backstory as a physician. And I think that, most of us kind of get to our professional place in life because in part of what happened to us when we were kids.
[00:02:32] Mark Wright: And I think it’s interesting that You grew up back East. Your grandfather was a coal miner in West Virginia. Is that right?
[00:02:39] Dr Callan Fockele: That’s correct. Yes.
[00:02:40] Mark Wright: And he died from black lung. And you know, it’s just, it’s amazing that we are not that far from that kind of life in this country where people had to go down into the earth and dig coal and died because of it.
[00:02:56] Mark Wright: And we just didn’t protect them., tell, give me a [00:03:00] little, uh, just a nickel tour of your, growing up. Your father also had an infection and sort of was at the receiving end of a medical malpractice and, so take me back to that time those two events really shaped who you are as a physician, didn’t they?
[00:03:14] Dr Callan Fockele: Yeah, well, thank you so much for, inviting that conversation. Yeah. And, yeah, I get a little, emotional thinking about Talking about my grandparents and imagining, a situation which they could see me wearing a white coat today. It’s pretty amazing., yeah, well, so, yeah, I grew up in Virginia, but my father grew up in West Virginia, where my grandfather was a coal miner.
[00:03:36] Dr Callan Fockele: He was a coal miner for a good bit of time since his, teenage years. But he was also a United Mine Worker for, a member of the United Mine Workers. I believe he has his pin for, 50, his 50 year pin. So, it was definitely part of the culture and community for a long time. And I didn’t get to, when I knew him, he was much older.
[00:03:56] Dr Callan Fockele: So I didn’t know his days, being a coal miner, but I heard many [00:04:00] stories from my grandparents and then also my aunts and uncles and my father, of course. And I think what struck me, was really how, um, The environmental and occupational hazards, particularly that are experienced by, the most vulnerable populations in our country can impact their health.
[00:04:19] Dr Callan Fockele: And I saw that. In my daily experience with him when I was around him, um, seeing how he suffered from black lung disease and the complications of that., and, then on the flip side, also got to see how, in his particular situation with the United Mine Workers to be able to advocate for his health.
[00:04:36] Dr Callan Fockele: And also to be able to establish clinics that are dedicated to serving the populations affected by those environmental exposures. And, there was a clinic in his community that was a black lung clinic. And, you know, later on when I was doing my medical training, I got to go back into that community and do some, research and I also got to shadow in that clinic.
[00:04:57] Dr Callan Fockele: And it was just a really [00:05:00] amazing experience to be able to see how. The advocacy and lobbying efforts of a population that was most affected by something can really change the arc of a community and really help establish kind of national guidelines for how to support people who are exposed to these kind of environmental Um, and then I also think about my grandmother who, at the time was a coal miner’s wife and she was taking care of a bunch of kids and didn’t have access to clean water 24 7 in the community that they lived in.
[00:05:35] Dr Callan Fockele: And, um, my dad likes to show me this article that was in the newspaper about this, but she like went down to the governor’s office and gave, His office, talking to you and somehow, there was advocacy to actually get running water into their community. So this was not that long ago. This was in the lifetime of my dad.
[00:05:51] Dr Callan Fockele: He was, you know, in his mid sixties now. So, I think about that when I encounter patients who, you know, in our lifetimes are also [00:06:00] maybe don’t have the, same access to the water. The things that we, or I, take for granted in the community in which I live in. So that definitely helped shape my interest in public health, and I was always vacillating between public health and medicine as a future career, and I didn’t have anyone in my family who was I was in healthcare.
[00:06:19] Dr Callan Fockele: So when I grew up, um, my, when I was nine, my, father was in the hospital, for a pretty bad infection. And it, it turned out, that they were worried about necrotizing soft tissue infection, which is kind of a surgical emergency of the restroom to the operating room. And he was in and outta the hospital for months and months and months.
[00:06:38] Dr Callan Fockele: during my early childhood and come to find out, I think about a couple years later, that part of his health complications were associated with gauze that was left in his leg in the initial surgery., so that, the experience of being in the hospital, definitely shaped my experience understanding healthcare.
[00:06:56] Dr Callan Fockele: But I think what really struck me even as a young child [00:07:00] The physicians who were involved never apologized, also, was involved in a lot of litigation over the A lot of my childhood, up until I almost did until I graduated from high school and, just to experience what it was like to be on the receiving end of a mistake, which, you know, all of us are, fallible, physicians, very, very much so.
[00:07:23] Dr Callan Fockele: And, just to, Just to kind of peep behind the curtain to understand the humanity of the clinicians who were taking care of my dad at that time, definitely inspired me to pursue medicine, even though it was something that I didn’t have a lot of familiarity with.
[00:07:36] Mark Wright: Yeah, you were kind of at the intersection of, you know, public health, social justice, individual health. you kind of had a non traditional med school experience, didn’t you? In Berkeley, serving underserved populations there. Tell me about that and how that shaped who you are today.
[00:07:52] Dr Callan Fockele: Yeah, well, I have to say medical school was a blast for me. I,
[00:07:56] Mark Wright: I haven’t, I haven’t heard a doctor say that before.[00:08:00]
[00:08:00] Dr Callan Fockele: yeah, I went to this really cool medical school. It’s called the, University of California, Berkeley slash University of California, San Francisco joint medical program. And what was really cool about that was I got to spend three years in Berkeley doing case based learning. So all of our, Okay.
[00:08:17] Dr Callan Fockele: Preclinical knowledge was attained through our peers, through a curriculum that had to do with cases. So we got to teach each other medicine, and just definitely, of course, interesting to learn the medicine, but also just so interesting to learn from. How you teach, how you learn, how you discuss complicated topics, uh, with people who knew nothing, including ourselves.
[00:08:40] Dr Callan Fockele: So that was very cool. And the additional, like, icing on the cake was, um, we got to take, um, Whatever we wanted at UC Berkeley as graduate students. So, I got to take some environmental health classes and qualitative methods classes. And I got to learn from a bunch of folks who were medical students who had, [00:09:00] my peers were incredible, had all these really diverse backgrounds.
[00:09:04] Dr Callan Fockele: And I got to learn from graduate students who were specialists and had expertise in these very specific things that overlapped my own interests. And it was such a wonderful, Learning environment. And I got to, and to bring it back to West Virginia, I initially went out to California thinking I was going to do something around farm worker unions because that was something I was interested in, as a college student, but I felt my heart being pulled back to Appalachia, and I did some qualitative work around mountaintop removal, coal mining.
[00:09:31] Dr Callan Fockele: in the community where my dad had grown up. And it was just, it felt very full circle to do that. And it was just really neat to, kind of have the, world view and kind of the, the background, that I was so privileged to experience at Berkeley and to bring that, to community I really cared about.
[00:09:51] Mark Wright: So what, was the biggest lesson that you learned when you returned back East and you started studying the impact of, I don’t know if they call it strip mine, coal [00:10:00] mining or whatever, but it’s just decimates the environment, right? They just wipe the top of a mountain off. And, what was the biggest lesson that you learned from that experience?
[00:10:08] Mark Wright: Once you had some, you know, some more training and what was the takeaway for you?
[00:10:13] Dr Callan Fockele: Yeah, well, the class I really enjoyed taking at Berkeley that I brought with me when I went back to West Virginia was a class on community based participatory research and kind of with that mindset of thinking about the people most affected and how they can be integrated into that. Of the work itself.
[00:10:29] Dr Callan Fockele: And I, unfortunately didn’t have the time to really do community-based participatory research while I was in West Virginia. But I think I had those principles or those ideas in mind and when I was there and, I, what the work I was doing was, talking to people who were most affected by, coal mining, in the communities, that, had shrunk over the last 50 years.
[00:10:49] Dr Callan Fockele:, community I was working in, oh, I think was. If I remember correctly, it had a population like the 50, around 50, 000 in the 1950s, and now it’s currently 5, 000, [00:11:00] and the number of coal mining jobs has rapidly decreased. And then, like you mentioned, mountaintop coal mining is a very different type of coal mining that has different types of exposures, not just to the miners themselves, but to the communities.
[00:11:11] Dr Callan Fockele: And so what I was really exploring was just. This paradoxical relationship with coal mining and the community that lives there, this kind of pride and culture that was established as a coal mining town, being able to turn the lights on for a nation at a time of need like during World War II.
[00:11:31] Mark Wright: Yeah.
[00:11:32] Dr Callan Fockele: And also the effects of that, especially now, some of that being, you know, the job security and those kinds of things, but also just where people see the rivers that they used to fish in running green.
[00:11:44] Dr Callan Fockele: So just thinking about how, how you live with both of those things, how you can have pride for a history and also advocate for kind of improved conditions, for the communities most affected. I
[00:11:57] Mark Wright: that dynamic seems like it’s serving you [00:12:00] right now on the front lines of the opioid and fentanyl epidemic in Seattle in terms of you, you really are needing to engage the community to solve this problem here. I’m curious, Callan, how did you wind up in emergency medicine out at the UW? Hmm.
[00:12:14] Mark Wright: Hmm. Hmm.
[00:12:16] Dr Callan Fockele: initially thought I was going to do primary care. So when I was in medical school out in California, I did this longitudinal elective in Fresno. So I spent a year in Fresno doing kind of the basic clinical rotations one does as a medical student. And I was really excited for my primary care rotations.
[00:12:36] Dr Callan Fockele: And I realized, at least in my experience, The experience I was getting at the time was that I always felt like I was telling a lot of people to do things that they didn’t really have any control over. So like, telling people to stop smoking even though they might have untreated mental illness, telling people to stop being farm workers to cause their chronic back pain, um, those kinds of things.
[00:12:56] Dr Callan Fockele: And it just felt, For me, it just felt really frustrating. It’s [00:13:00] like, oh man, there are all these downstream effects of these upstream problems., and, in my primary care clinic shadowing experience, I just didn’t really feel like I could try to tackle them. And, and meanwhile, I was also doing some shadowing shifts in the emergency room.
[00:13:15] Dr Callan Fockele: And, I think that was just, demonstrated like this population. I felt so passionately for the this urban population, the rural population that was taking care in a place like Fresno, but come into the emergency department for like very acute problems that we could put band aids on, you know, like someone might have had a gunshot wound because of the particular zip code that they live in.
[00:13:38] Dr Callan Fockele: And we can do something about that. We can put a chest tube in. We can rush them to the operating room. Someone might be using methamphetamine and might be acutely intoxicated from that. We can help support them through that, process, you know, and it just felt like we could kind of be there, meet people where they are, that harm reduction principle, and that really appealed to me.
[00:13:56] Dr Callan Fockele: And it was also very cool to see like all, kind of these upstream [00:14:00] problems I had seen in the outpatient setting boiled down to like some acute issue and how we use those patient stories to advocate for change. So it For all those reasons, it just got me really excited about emergency medicine. And, when I was looking for places in the country that, had a similar mission, that I felt like what got me excited about emergency medicine, the University of Washington definitely fit that bill.
[00:14:23] Dr Callan Fockele: And, for the reasons I explained, earlier about Harborview, the WAMI, the service to the WAMI region and the, service to the population that might live, you know, a block away. Really appealed to me and I knew that I still wanted to hold these two things, the public health and medicine, in my career and felt like this was the right place to do it.
[00:14:42] Dr Callan Fockele: Yeah,
[00:14:43] Mark Wright: very inspired by a researcher named Lauren Whiteside. You told me that when we spoke a few months ago., in what way and what kind of research is being done in Seattle when it comes to addiction medicine and, and similar disorders?
[00:14:56] Dr Callan Fockele: there’s a lot of research that’s [00:15:00] happening., I can speak to some of the work that’s currently happening in the emergency department, or at least what brought me, to become interested in addiction medicine. So, Lauren Whiteside, was, like a junior faculty member when I, became a resident here, an emergency medicine resident.
[00:15:15] Dr Callan Fockele: She’s an emergency physician, and she had, received some NIH funding to, um, Evaluate opioid use disorder and was doing some her own independent work on that. And then she was also part of a large multi site randomized control trial looking at our implementation trial, I believe, looking at emergency departments starting buprenorphine, which is a medication to treat opioid use disorder.
[00:15:43] Dr Callan Fockele: for patients who come into the emergency department. So, this trial was looking at like, these different ways to implement it and then looking at can it be implemented and what, I think, what the effectiveness of that is., so I got roped in really as a, emergency [00:16:00] medicine resident champion. I, Spoke to her, was really excited about the work she was doing.
[00:16:05] Dr Callan Fockele: I had some clinical situations I had encountered as a young resident that really shaped my feelings of inadequacy in treating addictions in the emergency department. And it was really exciting to me to know that there was this trial that was not in a laboratory somewhere, but actually being implemented.
[00:16:22] Dr Callan Fockele: It could maybe change people’s lives. the lives of the patients that we were serving, and that got me really excited. So I learned more about, her study, and I got to, at the time you had to do a special waiver program to prescribe buprenorphine. So I did the waiver training and could start prescribing.
[00:16:41] Mark Wright: Yeah, let’s talk a little bit more about those drugs so that people have a better framework buprenorphine and methadone How are those drugs used to treat people with substance use disorder?
[00:16:52] Dr Callan Fockele: yeah, so both of those medications are, used in my clinical setting to treat opioid use disorder. I guess to take a step back [00:17:00] about what opioid use disorder is, the DSM,
[00:17:06] Dr Callan Fockele: The manual that tells us how to make these diagnoses has a bunch of criteria, and I think the two ones that we are most familiar with are tolerance and withdrawal. So tolerance, meaning that you need to have more and more of something to have the same effect, and withdrawal, meaning if you abruptly stop something, do you develop symptoms?
[00:17:27] Dr Callan Fockele: And, that can happen, definitely happen with opioids that are prescribed or non prescribed. It can also happen with lots of other medications that we use and other substances, but medications in particular that we use, clinically every day. I can think of like blood pressure, certain blood pressure medications that if you stop them abruptly, You can cause withdrawal in some instances, may need more and more to have the same effect.
[00:17:49] Dr Callan Fockele: So there’s these kind of physiologic things that can happen, based on opioid use and other substances. But really what makes a substance use disorder an opioid use disorder is when, your use [00:18:00] starts impacting kind of the psychosocial things in your life. So those things can be your relationships, your work, your other life, your other, other activities that you enjoy.
[00:18:10] Dr Callan Fockele: Do you start using in risky situations?, do you use more than you would like or for longer periods than you like? So it’s really these, when other kind of these social things, start, being affected by your opioid use, that it becomes an opioid use disorder. So make. To meet the criteria of opioid use disorder, you have to have two or more of those criteria, and they can’t just be the tolerance and withdrawal.
[00:18:33] Dr Callan Fockele: Um, yeah, so
[00:18:36] Mark Wright: so when you prescribe these drugs, it’s I don’t want to get too technical because I’m not able to get too technical but, as I understand it, these drugs, attach to some of the receptors that the narcotic normally would attach to, and it sort of soothes the system or, or makes the system feel okay?
[00:18:57] Mark Wright: And not needing the drug?, is that how they work?
[00:18:59] Dr Callan Fockele: Oh [00:19:00] my gosh, yeah, you like hit the nail on the head. You could definitely talk about this. You could come talk to patients about this. Um, yeah, the way these, receptors work, if you could imagine kind of an X, Y, diagram, and,, Opioids, like full opioid agonists mean like opioids that bind fully to those receptors on the y axis kind of bind fully to the receptor and have a full opioid effect.
[00:19:24] Dr Callan Fockele:, and then shorter acting opioids like say Heroin back in the days where heroin was still readily available., they’re short acting, so they bind fully to those, opioid receptors, have a full effect on that y axis, but be short acting. So on the x axis of time, there’d be a peak and a trough. With fentanyl, We know that like the amount of time that fentanyl actually has an impact is much shorter.
[00:19:48] Dr Callan Fockele: So it’s like even peakier. So it like peaks and then troughs like very much more narrow. So if you can imagine that on that XY graph, the way other, the [00:20:00] medications we treat opioids It can also be mapped out. So, for example, with methadone, it has a full opioid effect. So it binds fully, just like heroin and fentanyl does, but it lasts for a long period of time.
[00:20:13] Dr Callan Fockele: So instead of having those peaks and troughs, plateaus, um, it kind of, modulates so they kind of smooths that out. So if you can imagine like someone who’s using heroin, maybe has to be like re dosed like every couple hours or so, just because of how short acting it is with Fentanyl., I’ve talked to patients sometimes it can be like every two hours they need to ose because of how peaky it is.
[00:20:35] Dr Callan Fockele:, but with methadone, you have that full opioid effect and last for a long period of time, so you don’t have to have that. Um, so a medication like methadone binds fully to those opioid receptors and can help with cravings and withdrawal. Remember like those symptoms that are needed for the diagnosis of opioid use disorder, in super high doses, like with, like any other full opioid.
[00:20:58] Dr Callan Fockele: Agonists like heroin, fentanyl, [00:21:00] methadone, in really high doses, it can cause some of the negative side effects like sedation, respiratory depression, especially when combined with other sedating medications. So, for those reasons, and some other reasons, based on the pharmacology of methadone, often folks need to kind of be started on lower doses of methadone and build up over time.
[00:21:18] Dr Callan Fockele:, and, So that’s kind of the physiologic reasons why methadone is a little bit difficult to get on. And then there’s all these like bureaucratic, legislative, like actually federally mandated reasons why there are lots of obstacles and barriers for patients to actually get started on methadone because methadone can only be dispensed from an opioid treatment program.
[00:21:38] Dr Callan Fockele: It’s not like Um, and it’s really tightly regulated and there are lots of, rules that one has to follow, so that can make it difficult for folks to get on, and then I’ll just quickly mention buprenorphine, um, which is my favorite medication of all time, but it’s a partial opioid agonist and [00:22:00] you can remember that X, Y graph again, buprenorphine kind of binds, kind of halfway up that.
[00:22:06] Dr Callan Fockele: halfway up that graph. It binds that receptor in a different way than those full opioid agonists. And by binding in a different way, there’s actually a sealing effect. So, and what that means is that it helps with cravings and withdrawal, like the treatment of opioid use disorder, but it doesn’t have some of those negative side effects like respiratory depression and sedation and can be safer with other sedating medications.
[00:22:29] Dr Callan Fockele: So, buprenorphine is something that’s also not as tightly regulated. So folks. Like an outpatient clinic in the emergency department can dispense it, meaning like giving someone that medicine in front of them and also prescribe them long prescriptions for it. There are some complications that Fentanyl has created for us and starting folks on both methadone and buprenorphine.
[00:22:54] Dr Callan Fockele: So that the landscape has definitely changed. But, buprenorphine in particular, [00:23:00] in my clinical setting in the emergency department is our go to, and there’s some really exciting and novel things that are happening with buprenorphine to help get, that medication out to people.
[00:23:08] Mark Wright: Well, let’s talk about the barriers a little bit later in our discussion, but I wanted to talk about fentanyl. Since you just raised that, I spent a little time on the DEA website last night and correct me if I’m wrong., this is what was posted there. Fentanyl is now the leading cause of death for Americans between the ages of 18 and 45.
[00:23:26] Mark Wright: And in the calendar year of 2023, the DEA seized More than 77 million fentanyl pills and nearly 12, 000 pounds of powdered fentanyl. That’s enough fentanyl to kill the entire U. S. population. That was seized in one year The testing of fentanyl now is showing that it’s even more potent. And some of the DEA testing labs are showing that 7 in 10 pills that they test contain potentially deadly doses of fentanyl., and that’s an increase from four out of 10, just two years earlier. In your mind, Callan, I [00:24:00] guess we know that fentanyl is scary, but when you start to look at some of these stats, it’s unbelievable what this drug is capable of doing and you see the receiving end of it, just, I would just love your perspective on fentanyl right now.
[00:24:16] Mark Wright: And, what do we need to know as just average everyday citizens when it comes to this drug?
[00:24:20] Dr Callan Fockele: Yeah, and those are, terrifying statistics, and I think I would add to that, As we’re rattling off numbers as I think in 2023, which is the number that the year that you had mentioned the seizure data, I think more than 100, 000 people died of drug overdoses in the US, I believe. And in King County, so where we’re currently sitting, where Seattle is, there were 1300 people who died last year from overdose.
[00:24:46] Dr Callan Fockele: So, we definitely, like, thinking about the upstream and downstream effects of things, we definitely see these patients, in the emergency department. all the time and first responders see them out in the field. So patients who have died from [00:25:00] overdose and overdose survivors. So if you think about like the folks who are dying from overdose, there’s a much larger population of people who survive overdose and thinking about how to best serve them.
[00:25:09] Dr Callan Fockele:, I think when I think about fentanyl, I think about the Go back to how fentanyl is different from other opioids., I think you gave some, striking examples of just the potency of the pills that are being manufactured and distributed, and the amount of seizures. I think some of the things that I also think about are, well, three things in particular, actually.
[00:25:29] Dr Callan Fockele: So one being that it’s super short acting, and I mentioned this before, and this is important to note, because I think with folks who are previously using Short, but longer acting opioids like oxycodone or oxycontin, those kinds of things. The folks wouldn’t have to doze so often, and, just to feel well.
[00:25:51] Dr Callan Fockele:, so if we can think of another XY graph, um, like often I think something that I think the public may already know, but I think something to [00:26:00] emphasize is that, this kind of euphoria that, that’s happening. Yeah, like I think that like the feeling of high being high, often wears off very quickly.
[00:26:08] Dr Callan Fockele: So patients who are using opioids, like there may be some euphoria associated with their use initially, but as soon as their use becomes disordered, like all those things that I was talking about, they’re really just using opioids to like get back to feeling well and not feeling withdrawal anymore.
[00:26:22] Dr Callan Fockele: So if you could imagine a patient who’s using fentanyl and it’s wearing off in their bloodstream so quickly that they have to redose so quickly and every time they use the. Drug supply is toxic, and may be a A fatal dose, it’s like playing Russian roulette. Like every time they redose, it can be a very dangerous situation if they’re not, using in kind of safe ways, like using test doses, using with someone else, having naloxone available to them, having safer use supplies, like kind of all the harm reduction, So, so that’s one thing is that short acting, two is that, it’s super potent.
[00:26:58] Dr Callan Fockele: I don’t want to belabor this, but I [00:27:00] think you talked about this. It’s just much more potent in smaller doses. And then the third thing is that it’s lipophilic, which is a fancy word, and I’m not a fancy, doctor, but like the, it’s just like, it hangs out in our fatty tissue and muscle very strongly.
[00:27:14] Dr Callan Fockele: And why that’s important is that, It sticks around for a long period of time and, even though it’s short acting in the blood, it sticks around in our fatty tissue and muscle and that actually makes it complicated to get started on the medication buprenorphine., because buprenorphine, in a different, in addition to like all its amazing attributes, is it’s super potent and super strong.
[00:27:32] Dr Callan Fockele: So it binds to those opioid receptors and actually knocks off other opioids. So, the way that we Often ask patients to get started on buprenorphine is to actually abstain or to not use any opioids for a prolonged period of time and Historically with heroin that would be like 8 to 12 hours with fentanyl We’ve been asking patients more like 24 to 36 hours if you’ve ever encountered someone who’s experiencing opioid withdrawal.
[00:27:55] Dr Callan Fockele: That’s a incredible ask to try to support that person [00:28:00] through that process, especially if they’re DEALING WITH ANY OTHER TYPE OF SOCIAL DYNAMIC LIKE THEY’RE EXPERIENCING HOMELESSNESS, DON’T HAVE ACCESS TO CLEAN WATER, THOSE KINDS OF THINGS. So, and I just bring that up because, when we think about the innovations of how we get people started on a medication like buprenorphine, we really have to think about the pharmacology of fentanyl and how it’s really changed the game.
[00:28:17] Mark Wright: Yeah. Boy, that’s scary that the fact that it’s short acting, the fact that it’s potentially deadly on every dose that you don’t know what you’re getting. That just seems like a recipe for complete disaster. I want to ask more about Naloxone, Callan. That, that seems like it’s been a game changer.
[00:28:34] Mark Wright: That’s the drug that can reverse an overdose. Does it work with fentanyl the way it does with other, other sort of opiates?
[00:28:42] Dr Callan Fockele: It does, it does. Yeah, they’re, so again, fentanyl is a full opioid agonist, just like those other opioids we talked about. And naloxone displaces, it’s super strong and potent, and it binds those opioid receptors and knocks off fentanyl in addition to other opioids. And I think there’s been a lot of conversation about, oh, I don’t know if naloxone [00:29:00] is as effective with fentanyl and, I think there have been some pharmaceutical companies that, have been creating like larger doses of naloxone, and even like injectable naloxone or diversions of naloxone that last for long periods of time.
[00:29:13] Dr Callan Fockele: And I don’t think the evidence demonstrates that naloxone is ineffective towards fentanyl. Instead, I think what we have to think about is, how, like the mechanics of actually how the naloxone works. So, again, this is a little bit beyond my pay grade, but when we think about, like, how the different, ways of administering naloxone and their onset of action.
[00:29:34] Dr Callan Fockele: So, it’s incredible how much intranasal And actually, if you listeners are in the state of Washington, you can actually get free naloxone. If you Google that, in order to access free naloxone, just have it around with you. Like when you’re walking around in your community, make sure, if you go to a party that you have it with you.
[00:29:54] Dr Callan Fockele:, and that is really, like you mentioned, change the game and being able to support people. Save people’s lives, like actually save their [00:30:00] lives. And, but intranasal naloxone and when squirted up the nose is just like any type of nasal spray, it kind of sits in the nose and then it kind of dissolves over time.
[00:30:08] Dr Callan Fockele: So it’s onset of action is a little delayed compared to, injectable naloxone. So there is like intramuscular naloxone, kind of like an EpiPen that goes into the muscle and then dissolves there., versus, IV or intravenous naloxone, which is often administered by paramedics. So, the onset of action is different in those situations.
[00:30:27] Dr Callan Fockele: It’s much quicker with IV compared to IM compared to intranasal. So, I think sometimes, and in the community, my hypothesis is that patients aren’t breathing., they’re having intranasal naloxone administered to them. It’s taking long the normal, but it feels like forever time to take effect and people are administering more of it in that time period, which is totally fine.
[00:30:50] Dr Callan Fockele: Like, better more than less., most important thing is to be able to do rescue breaths for folks because that is what’s going to kill someone is actually not getting the breath that they need., [00:31:00] and calling 9 1 1 for additional help and support because there could be something else going on or You know, they could have another substance that won’t respond to naloxone, but, I would want the takeaway to be that naloxone is still extremely effective.
[00:31:13] Dr Callan Fockele: Carry it and use it.
[00:31:15] Mark Wright: Yeah. Most of us will never experience what it’s like to treat someone who’s overdosed., can you describe a typical scenario that ER docs at Harborview see on a daily basis? And, I think the more graphic the better. I mean, obviously not inappropriately graphic, but I, would love for you to paint us that picture because this is something that, that you all see over and over and over, right?
[00:31:39] Dr Callan Fockele: I think at any time there are often a handful of patients who are overdose survivors, here in our emergency department. And I think, I think the details are often, kind of lost when, once they come into the emergency department compared to in the, in the field where our emergency medical services see them.
[00:31:56] Dr Callan Fockele: I think, the stories I hear though are patients [00:32:00] who’ve, experienced an overdose. Um, hopefully there was someone around them who, um, saw them and can alert, patients. Someone to call 9 1 1 and hopefully have Naloxone or Narcan available and can start administering, Narcan and, providing rescue breaths.
[00:32:16] Dr Callan Fockele:, by the time of emergency medical services, arrive and in our community that typically includes law enforcement, basically life support providers, including firefighters or emergency medic who are trained in as emergency medical technicians. And, . Paramedics, which are advanced life support providers, and those folks, advanced life support providers and paramedics often come with the patients, having issues still with breathing and having other complications.
[00:32:41] Dr Callan Fockele:, so there’s like a whole group, it’s a huge crowd that ends up showing up to, um, these situations. Um, and basically what they focus on is kind of the things, um, that are reversible and that we can help support people when they’re really sick. So, um, Protecting their airway, um, making sure that they can [00:33:00] breathe correctly and making sure that they have a pulse and the support that we give in a patient after overdose is often figuring out if they need more naloxone to give those rescue breaths.
[00:33:09] Dr Callan Fockele: So that’s really what that’s like. And I think after what I’ve heard from first responders is that after a person is reversed, um, it’s often a very, um,
[00:33:22] Dr Callan Fockele: Surprising, shocking, terrifying experience because as far as that person knows they were just going to sleep and they wake up and there’s 30 people around them often yelling at them that they almost died, a bunch of people in uniform, they don’t know what’s happening. It can be really scary and there was probably a period of time where there wasn’t enough oxygen going to their brain.
[00:33:41] Dr Callan Fockele: So, um, It’s a very, um, chilling experience, I think, for patients, um, after they’ve gone through that and, um, when the naloxone starts kicking in. So if you can imagine if a person had been, you know, not breathing for a while, might have gotten multiple doses of intranasal naloxone, might [00:34:00] have gotten intramuscular naloxone from our firefighters.
[00:34:03] Dr Callan Fockele: They might have gotten IV naloxone from the paramedics. Once all that hits, which, you know, Could happen minutes after a patient wakes up, they’re suddenly in terrible withdrawal. So that naloxone, in addition to saving their life, just displaced all their opioids. And now they’re feeling maybe the worst withdrawal they’ve ever experienced.
[00:34:21] Dr Callan Fockele: So, um, and they’re surrounded by a bunch of folks in uniform who are possibly Trying to, trying to console them, but maybe it’s appearing like they’re yelling at them. It’s really disorienting. And I, my impression and for first responders and also patients with lived experience is that, um, that’s kind of a fight or flight period of time.
[00:34:42] Dr Callan Fockele: Like, do you stick around or do you get out of there and like, try to take care of feeling better? Um, Potentially using the same substances that led to your overdose in the first place. So it’s a very high risk period of time. And patients after overdose, we know from the data is that there’s anywhere between [00:35:00] their rate of mortality.
[00:35:01] Dr Callan Fockele: So their chance of dying of the people who survived a non fatal overdose. The number or the percentage of folks who die at a year from all causes is anywhere between 5 and 15%. And that is. Maybe twice that of those who, suffer from a severe heart attack, at the higher limits, so it’s, It’s incredible and thinking about like all the things we do for people with like such high risk Situations someone who’s having a severe heart attack, you know, we go lights and sirens run to the emergency department There are activations happening that cath lab is getting started the cardiologist is running in and doing procedures and they stay in the hospital and do all these things and For some patients who are overdose survivors there’s very little that’s done for them We’re trying to improve that process But the things that we’re thinking about is how do we help with withdrawal symptoms quickly get people started on medications that have the chance of?
[00:35:52] Dr Callan Fockele: Reducing their mortality by 50 percent that means the number needed to treat is two so I have two patients who I started on a [00:36:00] medication like buprenorphine or methadone., I could potentially save one person’s life. There’s like not a medication that’s as effective that I prescribe in the emergency department as methadone and buprenorphine.
[00:36:10] Dr Callan Fockele: So I think just like thinking about how can we help these patients after overdose get the medications that they need that could potentially save their lives.
[00:36:18] Mark Wright: Yeah, let’s go down that road a little bit more. It, it seems like that person who just overdoses, who is at the ER, it seems like that person should be, offered a safe place to go, a place to enter treatment, but it seems like a lot of times what happens is maybe they get buprenorphine and then they just walk right back out.
[00:36:42] Mark Wright: They may not even have a home. Talk about the system, Callan, right now. What’s happening systemically to get those people the treatment that they need and where are the gaps? Where do we need to, to pay attention to, to doing more?
[00:36:55] Dr Callan Fockele: I really appreciate that question because I think about the care [00:37:00] cascade for those patients, those overdose survivors often. And I think we can think about like, you know, the moment in which they wake up from their overdose to potentially discharge and what that looks like for them, at least in the emergency department setting.
[00:37:13] Dr Callan Fockele: And, there are some really exciting things that are happening., at, each step. And I think there are more, more can and should be done, and will be done., but, one step of this is that patient who wakes up after overdose, after they’ve received all that naloxone and is in terrible withdrawal.
[00:37:28] Dr Callan Fockele: Like I mentioned, buprenorphine is actually the perfect medication to help treat their symptoms and get them started on, long term treatment, if that’s what that person chooses., we know at the highest risk period for folks after overdose is that 48 hours after overdose., and Turns out buprenorphine can stick around in someone’s system when it’s given in high doses for 48 hours.
[00:37:48] Dr Callan Fockele: So the like theoretical Benefit is there that like, if we can get people this medication, we can at least give them the chance to be stabilized and potentially reduce their risk of [00:38:00] having another overdose or death within that 48 hour window. So, there’s been work done and, led by, Michael, Sarah, who’s, Seattle, medical director, And our folks with the Health 99 team with Health One with our mobile integrated health run by John Ehrenfeld and Raleigh DeHoog.
[00:38:21] Dr Callan Fockele: He’s the amazing case manager who works there. There’s an emergency medicine resident named Kira Gressman who’s been leading this effort. So there’s like a whole team that’s really trying to work on, Getting medications like buprenorphine out into the field for the patients at their time of need, because what we’re seeing is when folks make it to the emergency department, even if that’s 20 or 30 minutes later, the naloxone has worn off and they’re sleepy again, and they’re not, they’re, Physiologically not able to take the, get that buprenorphine and not go and withdraw.
[00:38:50] Dr Callan Fockele: So there’s that like short time window in which someone’s gotten the naloxone, experienced withdrawal, and can get the buprenorphine to help with their symptoms. And that window is often in the field. [00:39:00] So really targeting folks in the field and how we can get that medication to them., and, so Seattle Medic One is currently Piloting, getting buprenorphine out in the field.
[00:39:09] Dr Callan Fockele: And we’re hoping to expand that with basic life support providers, including firefighters and EMTs eventually too. But that’s kind of on the horizon., when we make it to the emergency department, if they make it to a place like Harborview during business hours, we have, the care, care navigator, who’s amazing, who can kind of help set up with appointments and.
[00:39:28] Dr Callan Fockele: Try to get people to the next step. But this is difficult outside of business hours, which then again, the emergency department is open 24 7. We take care of patients all the time at 2 a. m. on Saturday. So how we’ve been thinking about how do we improve our protocols? So that patients who come into the emergency department either after receiving buprenorphine in the field or maybe come in for an unrelated concern, how to get them started on buprenorphine quickly and high enough doses to actually help with their symptoms because we’re seeing now that [00:40:00] folks actually need higher doses of buprenorphine in the era of fentanyl to really help address their symptoms and longer prescriptions.
[00:40:06] Dr Callan Fockele: Something that we, as a Department of Emergency Medicine at the University of Washington, have also helped create through the help of Public Health Seattle King County is a 24 7 telepuberorphine hotline. So for folks. So, um, for those of us who, either come into the emergency department and leave without a prescription or need a bridge prescription or are out in the community and interested in starting, they can call, this hotline, 24 7 and be connected to an emergency physician who can make a diagnosis of opioid use disorder and prescribe buprenorphine, and we typically prescribe two weeks and try to get people linked to care.
[00:40:40] Dr Callan Fockele: and then I think the last little bit of the linkage to care piece, Well, I guess just to go back to buprenorphine too, I think it’s important for anyone listening, if there is anyone listening, is that, thinking about long acting injectable buprenorphine. So there’s a medication, there are different formulations, but the one I use most often is a month long injectable buprenorphine, [00:41:00] which patients who’ve gotten loaded on buprenorphine, in the pre hospital setting may get to the ED would actually be perfect candidates for this long acting injectable medication, and it’s covered by Medicaid.
[00:41:10] Dr Callan Fockele:, so, And if patients are going to be discharged, it could potentially be covered. So we’re thinking through what the process to, like, increasing availability of that for patients would be. And then the last part about linkage to care is that this is really where the rubber meets the road. I think about how do we get patients, to care?
[00:41:25] Dr Callan Fockele: Make it to that next appointment. And we’ve done a lot of work, even if, like, setting up, led by Dr Lauren Whiteside, actually, and others here at Harborview, creating a bridge clinic, essentially, folks can follow up in the next 2 to 3 days. To continue on buprenorphine, but it’s still extremely difficult for them.
[00:41:45] Dr Callan Fockele:, and what we’ve noticed now that we’ve done some quality improvement work related to the patients who have received pre hospital buprenorphine is that, there’s a lot of loss to follow up., and. It just also happens that the population that we’ve encountered are also [00:42:00] experiencing homelessness, and often don’t have working phone numbers and often have Medicaid.
[00:42:04] Dr Callan Fockele: So it’s this, like, difficult situation in which, if we discharge someone from the emergency department, we may never see them again. So how do we provide all the care that they need, potentially for the next month? In that encounter in order to reduce their mortality because we have access to them.
[00:42:20] Dr Callan Fockele: It’s just whether or not we’ll give it. And then how do we figure out all those upstream things to link people to care? I know there are like some innovations that are happening across the country, especially with pre hospital buprenorphine of potentially putting folks. up for a place for like a short period of time, whether or not that’s like a motel or a tiny, tiny home for short periods of time in order to find them in order to get them linked to kind of to the next step of support or whatever that looks like for that individual using of course harm reduction principles.
[00:42:52] Dr Callan Fockele: But what we’re seeing is just if we can’t discharge someone to an address or a place where we can find them again, we can’t find [00:43:00] them.
[00:43:00] Mark Wright: Yeah. I think what is striking me right now is that, you know, statistically, Americans spend more than any country in the world on health care and our health outcomes. are way down the list. And I’m thinking what you’re talking about is exactly one of the reasons why. The most expensive setting to give care is the emergency room.
[00:43:21] Mark Wright: You could not create a more expensive way to treat human beings with health problems. This is what we’re doing on a daily basis. Thousands and thousands and thousands of people with substance use disorder across the country are ending up in the ER, the most expensive setting in health care, to get treated for something that could be treated, with a mobile clinic that could be treated in a community health center.
[00:43:45] Mark Wright: And it just is, it’s, We’re just so bad at connecting the dots. If we spent a little bit of money upstream, helping these people, we could save millions and millions of dollars at the other [00:44:00] end., I don’t know. I’m just kind of, kind of venting a little bit, but, we’re just about coming up on time, Kalen.
[00:44:05] Mark Wright: I’d love to ask you. If you were in city government in Seattle, knowing what you know about this problem, what’s one or two things that you would really push for at, at the city level to try to move the needle?
[00:44:20] Dr Callan Fockele: Oh, yeah, I think the things that come to mind are bolstering services that exist that are just unable to provide the care that they want to provide because they don’t have sufficient support. So I guess what I’m trying to say is, things I would probably focus on would be. Supporting organizations and groups that do amazing work, but are unable to really fulfill their mission or what they would hope to be able to fulfill because they don’t have the means to do that.
[00:44:55] Dr Callan Fockele: And the means could be people, Or finances or kind of [00:45:00] infrastructure to do that. And I think the two, I’ll just kind of do two shout outs, I think, to two groups if that’s okay., I would love to just, I think, highlight their work and also say, if other folks out there would be interested Supporting them.
[00:45:17] Dr Callan Fockele: Um, one is a group that I had mentioned before is the HealthONE group. So the, and there are groups like this throughout our county, but, mobile integrated health is a kind of community paramedicine group that. Is there to, was initially targeted to help address the needs of, kind of high utilizers of the 911 system.
[00:45:38] Dr Callan Fockele: So, um, particularly vulnerable patients, but they’ve kind of migrated transitioned into being able to, address kind of the overdose or they’ve been called to address the overdose crisis, and have a special team that’s dedicated to, meeting patients after overdose, trying to get. Get them on medications if that’s what they want and connecting them to care.
[00:45:58] Dr Callan Fockele: They do incredible work and, [00:46:00] and the patients who we’ve seen, we’ve gotten that pre hospital buprenorphine I was talking about, I can tell you so many stories of like how they’ve tracked down that patient and gotten them to, the next place in order for them to get care and how, how positively those patients have felt and experienced that love that, that, Health 99 and HealthONE team has given them.
[00:46:19] Dr Callan Fockele: Um, And I also think like, wow, they’re only in service a couple days a week, and, it’s, There are very few people on the staff. And yet we have, you know, 1, 300 overdoses last year and those are those who have died. So if you can magnify that by like the number of overdoses that they experience every day, like it’s just a teeny tiny fraction that they actually get to address.
[00:46:44] Dr Callan Fockele: So I think being able to bolster something that seems to be really effective, Could we just make that stronger? And kind of like a little, segue on that is that, I also, um, have encountered our mobile health team, that’s run through Public Health Seattle, King County, [00:47:00] that are really on the streets serving and caring for people and, some of the most compassionate ways I’ve ever seen and experienced.
[00:47:06] Dr Callan Fockele:, one of the nurse practitioners, is incredible and she works in the emergency department too. And, I think it’s also really important to have, um, you know, people who have dreamed of, could we, uh, create, like, programs like that, programs like HealthONE, Health99, like the mobile health team, and have them in each fire district so that we could, um, help support kind of the needs of the communities that are there, because I think it’s also really important to have, you folks who know that community, you know, the people who hang out there are part of that community being the ones that serve them.
[00:47:36] Dr Callan Fockele: And it would just be really, really, really cool. I think to have kind of a infrastructure in which there is these kinds of services that were really, transplanted and, or, you know, had roots into those communities. Um, and then the second one, just because I get a number two is that I recently encountered the recovery navigator program.
[00:47:53] Dr Callan Fockele:, so peer support specialists,, I mean, it gives me chills just thinking about the work that they do because, they, they have [00:48:00] the lived in living experience of knowing all these issues with the infrastructure and the bureaucracy and the systems and they come and meet people where they are.
[00:48:08] Dr Callan Fockele: Literally wherever they are, whether or not that’s on the street, whether it’s in the emergency department, and they advocate for them on their behalf. And I recently had an encounter with a patient where, we, if clinic was closing, we need to figure out what to do with them. And they were still, in high need, lots of, um, lots of needs, needing a lot of support and the recovery navigators, um, This person and brought them to the next stop and continue to advocate for them.
[00:48:32] Dr Callan Fockele: So I think, especially raising up people with live and living experience in these conversations and paying them a living wage and more than a living wage for what they’re doing and to be able to encourage them to be part of these larger conversations about how we can improve policy. So I think those would be my tip.
[00:48:54] Mark Wright: Just one last question, Callan, and that is, you know, our mission is to redeem work, and that is to show that work can be [00:49:00] really honorable. And, uh, you know, if everybody shows up the right way, it really strikes me that your work is just doing so much good in our community.
[00:49:08] Mark Wright: What would you say the secret to your success has been when it comes to work? Taking what you care about in life, what you’re passionate for, and then combining that with your abilities, you know, in terms of doing the work., can you just give me some, thought on that?
[00:49:21] Dr Callan Fockele: Well, that’s extremely kind. Thank you for that. I think. I think throughout my career, my very short career so far, I feel like I have often been told not to do something because it really didn’t fit within the boundaries of checking a box of whatever it was to go up a ladder of whatever the next step was.
[00:49:39] Dr Callan Fockele: And, I think I had other people, including my husband, Ken in my life, who was saying, you know, you should, you know, You know, you’re going to do the thing that you feel passionately about. And I think having someone in my corner has really been the, the, allowed me to say, you know what, I’m going to forget, like what all these other people are saying, and that this is a bad idea.
[00:49:59] Dr Callan Fockele: I’m going to do the [00:50:00] thing that I feel like, is the right thing to do, but it’s just like, like the thing that will continue to light my fire, because the, our careers are long, right? We have to work for a good bit of time in the future and doing something that we care about and, lights our fire and gives us, a reason to, give up in the morning and also hope.
[00:50:16] Dr Callan Fockele: I, I think, I, I guess maybe just a last thought is that I think with the opioid crisis in particular, um, there’s a lot to be, those numbers are, damning, right? Like we feel terrible reading off those numbers of how many overdose deaths or fentanyl has been seized. But I think what gives me hope is that there’s just so much good work that’s happening from all those organizations I mentioned, from the innovations that are happening, the like coloring outside the lines of what has historically been done in the past.
[00:50:43] Dr Callan Fockele: And it just gives me a lot of hope for the future. And I think that’s what continues to bring me into work.
[00:50:50] Mark Wright: Callan Fockele, thank you so much for what you’re doing to redeem work and also for what you’re doing to make our community a better place. Here’s to a long career for you in, in doing such [00:51:00] amazing work. Thanks. This has been such a pleasure. Appreciate it.
[00:51:03] Dr Callan Fockele: Thank you for having me.