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In this thought-provoking podcast episode, we invite guest Casey Grover, an emergency physician, to explore the ethical dilemmas surrounding the treatment of substance use disorders in the criminal justice system. Join us as we examine two compelling case studies that shed light on the harmful consequences of inadequate treatment. Casey shares insights into the violation of ethical principles and the urgent need for change. We discuss the life-saving potential of buprenorphine as a proven treatment for opioid use disorder and its impact on reducing overdose deaths. Discover the ethical responsibilities of health care providers and the transformative impact that proper treatment can have on incarcerated individuals. Join us as we advocate for a shift towards compassionate and equitable care for patients with substance use disorders in the criminal justice system.

Casey Grover is an emergency physician.

He shares his story and discusses his KevinMD article, “Not treating addiction in criminal justice settings violates the 4 ethical principles in medicine.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Get CME for this episode by clicking on the CME link in the show notes. Today we welcome Casey Grover. He is an emergency physician and an addiction medicine specialist. His KevinMD article that he co-wrote is titled “Not treating addiction in criminal justice settings violates the 4 ethical principles in medicine.” Casey, welcome to the show.

Casey Grover: Thank you. I’m very grateful to be here, and I’m grateful that you published my article on your site.

Kevin Pho: So we’ll get into your article in a little bit. First off, briefly share your story and journey to where you are today.

Casey Grover: Thank you, yes. I did my residency at the Stanford-Kaiser program in Palo Alto, in the San Francisco Bay Area, and graduated in 2013. I’ve been toiling away in the emergency department where I work here in Monterey, California, for about 10 years. Shortly after I graduated residency, we had a very young child, 19 months old, die of an opioid overdose, and my co-author and colleague Dr. Reb Close and I started our county’s opioid safety coalition.

Initially it was trying to reduce opioid use and overdose, and as America has changed, we are now much more addiction treatment advocates. We both sat for our addiction medicine boards and passed, and now both of us practice addiction medicine in addition to emergency medicine. Most recently, I put together a podcast for acute care providers on addiction, just because I felt like I got so little training in addiction during my training, and we see so much addiction throughout medicine, particularly in the emergency department.

Kevin Pho: Tell us some stories about what exactly you’re seeing in the emergency department when it comes to opioid cases.

Casey Grover: Oh, it’s absolutely tragic. This is really funny to say, but as an addiction medicine doctor, I miss heroin. It was so much easier to treat. I have a large number of patients on buprenorphine; people might know the name Suboxone or Subutex. When we started, people were predominantly on prescription opioids or heroin. They’re both short-acting opioids, and transitioning from short-acting full-agonist opioids to buprenorphine was relatively easy.

Unfortunately, as fentanyl has completely saturated the market, most of my patients, whether they want to or not, are using fentanyl. And fentanyl, unfortunately, when it’s used heavily, is lipophilic, and it ends up staying in the body for days, kind of the way cannabis and THC do. So we have some patients who test positive for fentanyl over a week after their last use, and it makes starting buprenorphine very challenging. So it’s been much harder to get people on buprenorphine, which is an exceptionally lifesaving treatment for opioid use disorder.

We’re also seeing addiction change. I had a patient last night in the emergency department who was using methamphetamine and couldn’t figure out why she wasn’t feeling right, and a urine drug screen showed that her methamphetamine had been laced with fentanyl. So we’re really seeing addiction change. We just detected bromazolam, that’s a designer benzo, in our drug supply. We’re starting to see isotonitazene, that’s another novel opioid, in our drug supply. We’re starting to see hints of xylazine in our drug supply. It’s almost like every month we’re having to change what we’re doing, because the drug supply is changing, and we’re having to adapt to what our patients are seeing and feeling.

Kevin Pho: So as an emergency physician, where does the role of addiction treatment come in, in terms of buprenorphine and introducing that? Because I can imagine how busy you guys are in the emergency department. How does that enter into that conversation and treatment plan?

Casey Grover: Well, for years, forgive me, I told patients with addiction, “I’m sorry, we don’t treat you.” And that was OK at the time. I remember as a resident we had a gentleman who came in who clearly had a problem with prescription opioids, and we quite frankly told him to get lost and not come back, and that was considered OK at the time. And I’ll never forget, my first year at my hospital, a dad brought his son into the ER for a problem with cocaine, and I grabbed one of the mental health nurses, and we went in together and said, “Sorry, we don’t do addiction.”

It’s really interesting. You look at America: One in seven Americans will develop a substance use disorder or addiction at some point in their lives, and yet less than one in 10 gets access to treatment. So we stigmatize patients, we judge them, we don’t offer them help, and we wonder why they don’t get better. And so I think emergency physicians and first responders have kind of a chip on their shoulder: Why don’t these patients get better? Why do they keep coming back? Why is there such recidivism?

And what’s incredible is, if you actually offer them treatment, they get better. I have a colleague who’s been in addiction medicine for 30 years here in the Monterey area, and I asked him, “What percent of your patients are in long-term recovery?” I estimated he would say 5 percent, 10 percent. He said, “I don’t know, two-thirds.” And I about fell out of my chair. Now, he has a very different population, and I now have an addiction clinic myself, and probably about 50 of my patients are doing really well.

So I think for me, it started with, “I’ve got to do something for this person. They keep coming back. I don’t get it.” I spend a lot of time with patients with addiction. In fact, on KevinMD.com I actually published two articles with one of my patients who had addiction. He was my co-author; they were his stories. Unfortunately, he has since passed from an overdose. But we needed to do something.

And it’s really incredible now. When I walk in the room and I’m like, “Hey, Dr. Grover here, emergency medicine, addiction,” patients really feel that they have something that can give them hope. I was working the other night, and there was a 17-year-old using fentanyl, and I walked in the room and introduced myself, and the mom burst into tears. She’s like, “I didn’t know there were addiction doctors that could treat my teenager.” It’s really very empowering to give people respect, offer them treatment, and give them and their families hope.

So, long-winded answer, but I think the take-home would be: We didn’t do much for a very long time with addiction, and we didn’t see any improvement in those patients. As we’re doing better to offer addiction treatment, we are now seeing positive outcomes. And I’m very pleased to say that in my region, in our Central Coast of California area, we have seven emergency departments, and all seven have a drug and alcohol counselor in them.

Kevin Pho: And you talk more about this in your KevinMD article that you co-wrote with Dr. Close, “Not treating addiction in criminal justice settings violates the 4 ethical principles in medicine.” Now tell us, how did your article come together?

Casey Grover: Pure anger, I’ll be honest. We had a case, and I wrote about it in the article. It’s the second case, where a person with opioid use disorder had a fatal overdose after being forced to withdraw in jail. And it’s really funny. I think I was very naive as an emergency medicine resident. We had a patient come in who seemed intoxicated, and my response was, “Well, he can’t be drunk. He’s in jail.” And my attending laughed and reminded me that you can get essentially any drug you want in jail, including alcohol.

It’s a really tragic thing. I just published on my podcast this morning an article looking at the diversion, or spread to the market, of buprenorphine. What they found is that when people divert buprenorphine, it’s largely to people who want to be treated for opioid use disorder and either don’t have access to treatment or don’t want to seek treatment in a traditional setting because of stigma and judgment. So the authors of this paper actually hypothesized that if you make buprenorphine more available, the diversion will go down, and I suspect that’s probably true in a criminal justice setting.

I don’t know about you, but I was always taught that when you identify a patient who has a problem with opioids, you cut them off. Unfortunately, that just really precipitates withdrawal. So in this case, this poor person was clearly dependent on opioids, went into the criminal justice setting, and basically white-knuckled it: vomiting, diarrhea, body aches, chills, feeling horrible, intense drug cravings. And then promptly after leaving jail, with their tolerance decreased from whatever time period of not using, they go and try to seek relief and get back to their drug use. And this is a mom who’s left kids motherless, because she died of an overdose.

I contrast this with patients that I see who come out of the criminal justice setting in a different area where they have access to buprenorphine, and they’re so busy working that I have to do phone appointments with them. They’re like, “Hey, Doc, I can’t make my clinic appointment. I’ve got to work,” because they’re doing well. And that’s the first case I highlight with Dr. Close in this paper: This guy was doing really well.

It just breaks my heart that we have such a lifesaving treatment. I love this statistic: The number needed to treat to save a life for a patient with opiate use disorder, by treating them with buprenorphine, is 1.4. I can’t think of a number needed to treat that good for almost anything. The number needed to treat to save a life for a proton pump inhibitor for an upper GI bleed is infinity, meaning there isn’t a mortality benefit. And yet buprenorphine has a number needed to treat for mortality of 1.4. Why are we not using this more widely? And I actually put this in my article: When France really deregulated buprenorphine in the 1980s, their opioid overdose mortality dropped by 80 percent.

So I think the solution to opioid use disorder, and not a comprehensive solution, but a really simple, easy-to-implement way to really reduce mortality from opioids in the U.S., is really to get physicians comfortable with and prescribing buprenorphine. And not every patient wants buprenorphine; some prefer methadone, some want withdrawal management. But in my hospital, we have so many physicians who just didn’t train with it and aren’t comfortable with it, and actually we’re doing some grand rounds later this month to really try to increase the comfort physicians have with buprenorphine.

Kevin Pho: So give us a sense, in the incarceration setting, how common is it that buprenorphine is available in a jail?

Casey Grover: Yeah, and I have to be clear: In Monterey County, we have the jail staff, and we work with them regularly. Dr. Close actually now goes to the jail on a regular basis and is trying to effect positive change. In some ways it’s like anything: Change takes time, and people’s minds may not be as open to change as we would like. But yeah, here in Monterey County we’re trying to start a jail buprenorphine program that is robust, where anyone who needs it can get access to it. We’ve started small, and Dr. Close is working really hard. Essentially, what it looks like is when people get brought into a jail or prison, if they have an opioid use disorder, they are offered treatment with buprenorphine.

And again, unfortunately, I talk to loads of nurses who work in the criminal justice setting who talk about how buprenorphine is relentlessly diverted through the prison and jail systems. Coming back to this article that I just posted on my podcast that is a review of buprenorphine diversion, it’s largely because people want it to treat themselves, to not withdraw. And when it’s inequitably distributed, people will take advantage of those inequities to make a quick buck, or in jail or prison, it’s trading for goods or whatever it is.

But I guess my thought would be that in an ideal world, if you have an addiction, as you enter the criminal justice setting, as you’re a captive audience, we should treat it. And that might be with alcohol. If we gave every person who came through emergency departments in America who had a problem with alcohol oral naltrexone, or acamprosate, or gabapentin for alcohol use disorder, we could reduce drinking in literally millions of Americans, and we don’t. So in my practice, if you come into the ER to see me for an alcohol use disorder, you’re going home with a medication for alcohol use disorder to reduce your intake. I’ve tried to educate my colleagues, and I actually have a lecture on my podcast, a plea to treat alcohol use disorder the way we do opiate use disorder.

I think people have really gotten behind buprenorphine for opiate use disorder. There’s a great organization here in California called the California Bridge Program, which is basically designed to make addiction care on demand in the emergency department, and they have very simple and easy-to-read treatment guidelines for emergency physicians, nurse practitioners, PAs, and nurses. It’s great, but we can do so much more.

And I think it’s really because we don’t do that much education on addiction. Dr. Close and I both attended medical school at UCLA. We both did residencies in emergency medicine; she did hers at UCLA, and I did mine at Stanford. Between the two of us, in those 15 years of education, we got one hour of training on addiction, and ironically, it was on gambling addiction. I don’t know how it was for you, but you learned the nuances of alcohol-related liver disease, variceal bleeding, and alcohol-related gastritis, but you never learned to go one step back and say, “How do we reduce the alcohol use?” And I guess that’s what I’m trying to synthesize together, now that I have two specialties.

Kevin Pho: So would you say that’s the biggest obstacle? Is it the lack of education? Is it a money issue? Also, is there the misperception that buprenorphine is being diverted? What would you say is the biggest obstacle?

Casey Grover: I think it’s actually all of those. The biggest one is that physicians are busy, and it takes time to sit down and connect with a patient when you’re busy. I’ll give you an example. I go in, I see a patient; they’ve got asthma. In fact, I did this last night. The patient has asthma, and they’re actively smoking cigarettes. It’s really easy to give them a dose of prednisone, check a chest X-ray, check a COVID swab, give a little albuterol, “Feeling great, off you go.” It takes more time to sit down and do a smoking cessation discussion. And last night, I will be totally honest, I was slammed, and I didn’t have time to do it. So as much as I try to be kind of a warrior on this, I didn’t have time last night. To sit down and talk to people about Chantix, and how Nicorette gum actually works, and how to chew it properly, takes time.

And what I’m hoping to do, with my group here and my colleagues on the Central Coast of California, is make doing the right thing easy. I think what we find as physicians is that if it’s hard work, we’ll just skip that step and focus on the next patient, to make sure we see as many people as we can and help as many people. But if it’s easy, we can do it. And I think for me, it’s just, “Hey, would you be interested in naltrexone?” “Sure.” “Let me tell you what it does.” It probably takes me 30 seconds to explain it. The number needed to treat for naltrexone to reduce drinking depends on the study, but it’s probably about 1 out of 10. I probably see 10 patients with alcohol use disorder in just three or four shifts in the ER. So I think, again, it’s how do we make it easy but also effective.

I think the other thing is that there’s shame and stigma. How many patients lie to their doctor about their alcohol intake? Probably most of them. One of my patients, who I’ve really tried to be open with, just got admitted for a relapse that she hid from me. I haven’t had a chance to see her in person, because we’ve been doing telemedicine visits, because she’s a busy person and a mom. She didn’t want to admit that there was a problem. And I’ve really tried to create an open environment with her where she can feel safe, and even then, people don’t want to admit they have a problem, because there’s so much societal stigma around it.

Kevin Pho: How much education would a typical physician need to be comfortable prescribing buprenorphine?

Casey Grover: So the traditional training was eight hours, back when we had the so-called X waiver. The answer is it’s probably about an hour. We’re going to do a grand rounds for the physicians at my hospital next week, and one of our local gurus in addiction medicine, who has been doing addiction medicine longer than I’ve been alive, I think, is planning to talk kind of doc to doc: “This is how you do it.”

My experience with buprenorphine is that once a person’s on it, it’s pretty easy to maintain, kind of like lisinopril. You just refill it every month, as long as they’re doing well. It’s the initiation that can be difficult. For that reason, a lot of times folks get sent into the emergency department, because of the way buprenorphine works: If it’s taken at the wrong time, it can actually increase withdrawal symptoms, in what’s called precipitated withdrawal. So that’s really the big learning curve, but that’s something that my specialty has actually gotten relatively good at, simply because we’ve been the epicenter of opioid overdoses in the last 20 years.

Kevin Pho: Now, if we were to make change across the country in the jail setting, though, does this need to come from grassroots physicians like yourself? Should there be policy changes? How can we make changes in the incarceration setting across the country?

Casey Grover: I think it really comes down to anything that makes a positive change. People always ask me, “Gosh, you work in the ER. What’s the worst thing you do? Is it gunshots? Is it bleeding?” And I say it’s telling a parent. There are no words to watch a mother sob while telling her, or to watch a father sob while telling him, “Your kid is dead.” I have goosebumps right now as we’re talking about it. And so whatever I can do to say that a young person doesn’t have to die, I’m in.

Now, that being said, we’ve worked with our local sheriff, who’s wonderful and super supportive, and she’s at the top of the organization, working top-down to make it happen, and even then it takes time. So we’ve been working with our local lawmakers, and we’ve been working grassroots. My colleague Dr. Close just said, “Hey, jail, here I come,” and was able to go in on Fridays and see patients. So I think, for me, watching Americans die of addiction is an all-hands-on-deck moment. About 450,000 Americans die from tobacco every year, about 100,000 Americans die from alcohol every year, and about 110,000 Americans die from other drugs every year. We’ve got to do something.

Kevin Pho: So you alluded to this earlier. Tell us a success story that you and Dr. Close saw in the ER, based on the successful implementation of addiction treatment in jail.

Casey Grover: Let me read you a text message I got just the other day. Let me see if I can find it. Here we go. “Hello, I hope you are happy, healthy, and thriving. I wanted to touch base with you and let you know that my friend’s son that you helped with the Suboxone will have a year of sobriety in June of 2022. Thank you so much for helping him get his life back.”

This is a young individual who had not necessarily been justice-involved yet, but a person with substance use, and that’s the direction people tend to go. He came in to the ER, we got him on Suboxone, and here he is a year later, doing well.

Kevin Pho: We’re talking to Casey Grover. He’s an emergency physician. He co-wrote the KevinMD article “Not treating addiction in criminal justice settings violates the 4 ethical principles in medicine.” Casey, tell us some of the take-home messages that you want to leave with the KevinMD audience.

Casey Grover: Absolutely. I think the first thing is that stigma and shame keep people away from us as physicians and medical providers. One of the best things you can do is to avoid judgmental language. Don’t call it a dirty urine; call it an abnormal urine drug screen. Don’t call them addicts. Don’t call them alcoholics. They’re people first. It’s a patient with alcohol use disorder; it’s a patient with opioid use disorder.

And then educate yourself. You can make the most incredible changes in people’s lives. The federal government has also made changes here: In order to renew your DEA, you’ll have to do eight hours of training on addiction. So, to circle back to your original point about how we can effect positive change, the federal government has deregulated buprenorphine. Any physician can now prescribe it, including for opiate use disorder, and we’re all going to be getting some more education about it.

Kevin Pho: Casey, thank you so much for sharing those stories and sharing your time and insight.

Casey Grover: Thank you so much.