Episode 137: Dr. Gregory McDonald, Fentanyl Awareness

Gregory McDonald, DO, graduated from the Philadelphia College of Osteopathic Medicine in 1989. He went on to complete a residency in anatomic pathology at the Lankenau Hospital followed by a forensic pathology fellowship at the University of Pennsylvania and the Medical Examiner's office in Philadelphia, Pennsylvania. After completion of this fellowship, he served for 14 years as an assistant medical examiner in Philadelphia, Pennsylvania.

Dr. McDonald currently serves as Dean of the School of Health Sciences and is a professor and chairman of the Department of Forensic Medicine and Pathology at the Philadelphia College of Osteopathic Medicine. His work at PCOM also includes serving as the program director of the Master of Science (MS) in Forensic Medicine program. Dr. McDonald lectures extensively to DO, physician assistant and forensic medicine students as well as providing residents and attending physicians with continuing education programs. He has been the recipient of multiple awards for outstanding teaching.

In addition to his teaching duties at PCOM he has lectured regionally and nationally in subjects including post mortem changes, determination of cause and manner of death, blunt and sharp force injury, asphyxiation and child abuse. Dr. McDonald is also the chief deputy coroner of Montgomery County Pennsylvania.

He has served as the Vice Chairman and Chairman of the American Osteopathic Board of Pathology where he also is the Chairman of the subcommittee on Forensic Pathology. Certified in both anatomic pathology and forensic pathology, he has completed more than 8,000 autopsies and has testified in more than 800 court cases.

Intro Voices  00:04

Where do I go? It only happened. I was singled out the phone calls began about one month ago. What is hazing? Something happened to me when I was I'm worried about my safety. He said he was sorry, can someone help me? Where can I get help? Can someone help me?

 

Karen Ortman  00:30

This is you matter, a podcast for the NYU community developed by the Department of campus safety. Hi, everyone, and welcome back to you matter, a podcast created to teach, inspire, and motivate members of the NYU community who have been victimized in some form or fashion and to identify resources both on and off campus that can help. I am your host Karen Ortman, Associate Vice President of campus safety operations at the Department of campus safety, and a retired law enforcement professional. Today I welcome back a frequent guest of you matter, Dr. Greg McDonald, chief deputy coroner from Montgomery County, Pennsylvania, and the Dean of the School of Health Sciences and Chair of the Department of Forensic Medicine and pathology at the Philadelphia College of Osteopathic Medicine. Dr. McDonald and I are going to discuss in this educational episode, what DEA administrator and Milgram has characterized as the single deadliest drug threat our nation has ever encountered fentanyl. Dr. McDonald, welcome to you matter.

 

Dr. Greg McDonald  01:40

Good morning, Karen. Thank you very much for having me back. It's truly an honor. Appreciate the opportunity.

 

Karen Ortman  01:46

My pleasure. Glad to have you back. Let's begin by sharing with listeners a summary of your background.

 

Dr. Greg McDonald  01:55

Yes, I'm currently the Dean of the School of Health Sciences at the Philadelphia College of Osteopathic Medicine. I'm also the chair of the Department of Forensic Medicine and pathology there. As you had mentioned, I am currently the chief deputy coroner for montgomery county, which is a county just outside Philadelphia. But prior to my current positions, I was a assistant medical examiner for the city of Philadelphia for approximately 16 years. During my time there and up to now I've done. I've completed over 8000 autopsies. And I've testified in court in various civil and criminal investigations over 800 times.

 

Karen Ortman  02:41

Thank you for that. We're here to talk about fentanyl as I said in the introduction. And for me personally, I don't remember hearing about a substance like fentanyl, other than in the late 80s When we started hearing about the crack epidemic. Does this in any way compared to the crack epidemic from your perspective?

 

Dr. Greg McDonald  03:07

Yes, I would. I think that's a good analogy. In that steep climb of deaths associated with crack back in the 80s parallels in many ways. The increase in fentanyl related deaths. You know, since I've seen it since roughly like 2011 2012 is when I started to see illicit fentanyl being used as a medical student. You know, we were introduced to fentanyl from a legitimate medication. I was in medical school but I started to see the illicit forms of it roughly around 2012 Something like that. Okay, and then it has markedly increased.

 

Karen Ortman  03:56

Let's define fentanyl for listeners. What is fentanyl?

 

Dr. Greg McDonald  04:01

Fentanyl belongs to that class of drugs that are considered opioids. And so it is chemically related to natural opiates like morphine. There's all but it's a synthetic form. It's not opioid. Morphine comes from Opium Wars, your seeds, poppy seeds and they're planted. But fentanyl is produced in the laboratory to synthetic form of this. So it's it's similar to heroin as well. Its chemical nature is similar, it's a little bit different. And that little bit of difference in the chemical nature allows it to be much more potent at lower level lower doses.

 

Karen Ortman  04:47

Is there a medically useful purpose for fentanyl?

 

Dr. Greg McDonald  04:51

Yes, yes, absolutely. I mean it is a very potent pain reliever. So when use in the appropriate context and prescribed in a judicial fashion. It has been used in a number of different ways it can be used by tablets have used as laws and judges. There are what we call a transdermal patch form, that's a patch where you it's kind of like a nicotine patch and you put it on your skin, and that allows for a gradual absorption of the medication into your body. And that typically has been used for people who are suffering from maybe end of life pain from cancer that has metastasized or spread to their lungs, and that can be very painful. So in there are some legitimate uses of fentanyl. But obviously, there has to be used judiciously with a health care provider that is closely monitoring their patient.

 

Karen Ortman  05:58

You mentioned a cancer patient who is near death or end of life being prescribed fentanyl. Under what other medical conditions might one be given fentanyl, by a physician?

 

Dr. Greg McDonald  06:15

Again, it would be for something that where there is significant amount of pain, okay, post surgical, you know, again, I'm not being a type of physician, I typically don't prescribe it myself. Yeah. But it's usually for someone may post operative or something that has a really severe pain that can't be managed by other means.

 

Karen Ortman  06:38

Do you recall, when you first became aware that it was becoming an abused substance?

 

Dr. Greg McDonald  06:46

I would say probably around that time 2012 2013. Again, we started seeing more and more numbers of it. Because I remember when I first saw it, I was wondering, well, was this person legitimately prescribed? Right? Because, you know, that's, that's the first thing we want to try to monitor. But then you find out that more and more cases were coming through our office. And it was obvious that they, they were young people, they were in good health, they had no chronic pain issues. So then you can start to recognize that yes, it probably was illicitly being being given, oftentimes in conjunction with other opiates like heroin, that was being mixed with that, which again, is an extremely deadly combination. And so that's how we start to see it. At least my my experience was, was being mixed with heroin.

 

Karen Ortman  07:46

There are people who actually abuse fentanyl, which presumes that they use it repeatedly and survive each time to equal fentanyl abuse. So they're not using it once and dying. They're using it continually as their drug of choice. How is that possible? If it's so potent, and so deadly?

 

Dr. Greg McDonald  08:15

Well, they many of those individuals have some degree of tolerance to opiate, so maybe their drug of choice prior to fentanyl was something like heroin, or oxycontin or some other type of related opiate, so they have some degree of tolerance to that. And then they start to take the fentanyl and they can gradually increase the levels of fentanyl. That's typically what happens. But again, you're not sure of the concentration of fentanyl that you're buying on the street. And so a small amount to someone who is what I would call opiate naive, someone who has not taken it, they're more likely to die than someone who's longer, who may be using opiates of some form for a number of weeks, months, maybe years.

 

Karen Ortman  09:15

Got it. Let's talk about the impact the fentanyl has on one's body.

 

Dr. Greg McDonald  09:24

Fentanyl has a predilection for certain receptors, particularly in the brain and in the lungs as well. So it does provide feelings of obviously pain relief. That's what it was originally designed for. But you also get feelings of euphoria. You're feeling very good. But you start to have someone's pure computer feel sleepy, and then that sleepiness can progress to a coma, and then that coma may progress to death. As I mentioned that it does, there are receptors that can result in a marked amount of fluid building up in the lungs. And this respiratory depression is typically what is the underlying mechanism for people who die of fentanyl deaths. And that's what I see at autopsies, I see lungs that are really filled with fluid, and it's in normal adult lung would say may weigh 300 350 grams. But if someone's using fentanyl, and you have a lot of fluid building up in the lungs, that may that long may now weigh 789 100 grams. So and you can almost oftentimes you can see this fluid bubbling up through the nose and mouth of people, when you find them, unresponsive or deceased. And that's a real strong indicator. They're doing some kind of opiate, oftentimes fentanyl,

 

Karen Ortman  11:04

at autopsy, however, fluid in the lungs could be an indicator or something else. So what what else is present? That makes it clear to you that it's a fentanyl death.

 

Dr. Greg McDonald  11:20

Well, there's not always a clear indication just from the autopsy. That's why I need to obtain toxicology specimens, such as blood and urine and things like that, and send that forward for confirmation to a lab. Now, some of the things that I might find in fentanyl deaths, but it's also similar to other drug abuse, you may see needle puncture sites track marks, you may see complications and skin infections resulting from injecting with dirty needles for instance, or infections on the heart, we may see one of the another effect that fentanyl has something that we call urinary retention. So oftentimes the bladder is very filled with your end because people can't urinate with that. So there's a few things that we tend to look for, but it's not necessarily specific for fentanyl. Sometimes you can see similar findings in heroin or oxycontin deaths as well,

 

Karen Ortman  12:27

are their outward signs of abuse.

 

Dr. Greg McDonald  12:30

You can look at them and you can see that maybe they're having signs and symptoms of opiate disorder. And those signs would be pupils become can become constricted. They may appears some Linden may be nodding off sleeping, they may have brown degrees of euphoria at times. So those are some of the symptoms that you could see with fentanyl. But you may see that with other other

 

Karen Ortman  13:00

substances. Yeah. We spoke about fentanyl being used in a legal manner in a medically acceptable manner. And then there's the illicitly produced fentanyl. What is the difference between the two? In terms of their chemical makeup, if anything?

 

Dr. Greg McDonald  13:27

Good question. You know fentanyl is fentanyl. Whether it is in the legal sense or illegal sense. However, and this is something that we're really, when I say we it's forensic pathologist toxicologist law enforcement people are really challenged now. We're seeing a lot of what we would call fentanyl analogues that are is where you have the chemical structure, fentanyl, but they may change it slightly. And that can be a challenge to pick to detect that in a laboratory setting. Law enforcement are struggling with that as well. And now that we're seeing a variety of different lab, illicit clandestine laboratories throughout the world, producing these fentanyl and producing the analogues to fentanyl, some of those analogs can be even more potent than the parent fentanyl would be.

 

Karen Ortman  14:30

What do you do about this?

 

Dr. Greg McDonald  14:34

That's a good question. If there is a case that say if I were to I won't call this week and if I were to do a case where I suspect that an opiate happened week the toxicology comes back and it's negative. We can hold on to we could retain that blood specimen you know and refrigerate it and hold on to it. And then maybe a month from now. When the toxicology lab paper get actually get some samples of an illicit analog, they run their tests, they can get a kind of a signature of what that specific federal law, federal analog may be. And then we can read maybe retest the blood and and find it then. So, you know, and kudos to the forensic toxicologist out there, very small, very smart people. And they're not easily fooled. And they're becoming more and more adept at being able to recognize these fentanyl analog variations that we're starting to see.

 

Karen Ortman  15:41

What are the signs and symptoms of a fentanyl overdose?

 

Dr. Greg McDonald  15:49

Typically, the person will be very sleepy, sambal entwickelte sondland. They may. One of the things that we oftentimes hear from family members whose has a loved one who ultimately passed away, they say that they heard them snoring very loudly. Right? That is when I hear if I'm reviewing and a report and investigative report. And it's noted in there that the family member, maybe they see their loved one come home, they look like they're intoxicated, they just look sleepy, they go to bed, and then their family members hear them snoring very loudly, and they check on them in the morning. And unfortunately, they've deceased overnight. It's that loud snoring that is an indicator of pulmonary edema, the fluid building up in the lungs. So we see that quite frequently. Other things if you're observing your person, they may be nodding off. Again, their pupils will be constricted. They may have slurred speech they may have stem may be staggering. If they're walking it, it may look like they're intoxicated from something like alcohol or something as well. So it can mimic a lot of other types of substance abuse.

 

Karen Ortman  17:10

And it could mimic a heroin overdose or any other opioid overdose. What should one do if they see someone who appears to be overdosing in the process of

 

Dr. Greg McDonald  17:29

Well, first thing obviously call 911. That's that would be the first thing. You check them if they're you may have to render CPR, chest compressions for them. Now, if there is a high index of suspicion, get the Narcan we prior to her death Naloxone that is being widely distributed is much more easily available to lay people, first responders, police officers, EMS day they have access to it. But we're seeing it being more in a good in a good way more ubiquitously distributed, and it's a safe medication. If you give it to someone, they don't have an opiate, you know, it's not going to do them damage. So if you can have Naloxone, it's can be given a couple different ways probably one of the best ways it's a nasal spray that you give to someone so that even if they're unconscious, it's not like you have to swallow anything or anything like that. So and it is very effective. It is only effective again for opiates. It wouldn't work for, you know cocaine or methamphetamine or something like that. But it really it can produce profound reversal of the negative effect of the opiates and fentanyl.

 

Karen Ortman  19:02

Let's say there's somebody who purchases an illicit pill that's not from a prescription or from their doctor or pharmacy. Is there a way to test for the presence of fentanyl in that substance?

 

Dr. Greg McDonald  19:18

Even in a really good top notch state of the art forensic toxicology lab, it can be a challenge picking up some of these analog so if you have a kind of a quick street method of doing it, that might not pick up. Fentanyl.

 

Karen Ortman  19:39

How long does fentanyl stay in your system?

 

Dr. Greg McDonald  19:42

It can again depends on obviously the B amount. It can be a few hours that it's worth it can be before it gets broken down into its metabolites, but it can be there for a significant time again And depending on the route of administration, if it is being given through one of those transdermal patches, then you're slowly over a period of time being given a smaller amount of fentanyl, as opposed to someone who may be injecting it, obviously, intravenously, then your levels are gonna go up pretty quickly, and they may go down a little bit more rapidly as well. But obviously, something like in intravenous injections certainly carries much more risks, then something like a transdermal patch,

 

Karen Ortman  20:39

how addictive is fentanyl?

 

Dr. Greg McDonald  20:43

It's like other any other opiate, it is very addictive. It is. And the problem is it will produce very distinct withdrawal symptoms, like any other opiate would, those symptoms can be vomiting, nausea, and sometimes you know, it can be really result in respiratory depression, in certain cases, they may need to have medical intervention for them. So anyone who is withdrawing from opiates, in can, depending on the severity of it, and what have you, they may best be served by being in a medical institution to hospital setting where they can be monitored during the withdrawal can be monitored.

 

Karen Ortman  21:34

For someone who does not have an opioid habit, what is the smallest amount of fentanyl that can kill

 

Dr. Greg McDonald  21:44

and almost any mount? Alright, again, I can't give you a specific digital signs of a pin, pinhead, it possibly viewer as we say opiate naive, and you've never taken it and you take it. And again, we also depends on the route of administration as well. Obviously, if it's intravenous, that's going to reach the concrete directly into the bloodstream. And that's the effects are going to be much more manifest very quickly, as opposed to if you're taking a pill containing it or something like that. But there's no necessary lethal level of it. Even a very small amount can kill you. And that's why I typically do not when I'm filling out the death certificates, I don't say fentanyl overdose. I usually say adverse effects of fentanyl, because it's just what may be a therapeutic level of fentanyl for someone who's been on you know, hospice for cancer or something like that. What's therapeutic for them may be lethal for someone who's opiate naive. So common terminology, we tend to say overdoses. But if you really want to look at it narrowed down. Many of these are not true overdoses directly taking the role could be small amount of it, but it's for that person,

 

Karen Ortman  23:09

after consuming fentanyl, or the effects felt immediately.

 

Dr. Greg McDonald  23:16

Once again, it depends on the route of administration. If you're injecting it, yes. If you're taking it, you probably this one of the safest ways is the transdermal patches that I mentioned, then it's going to be more more slow and more measured. symptomology slower. So again, it but if you're taking intravenously, or if you're snorting it, some people have done that as well, then the effects are pretty rapid, to the point where I've even had people who, you know, again, very tragic, they die while they still have a needle in their arm and a tourniquet still on their arm. That's how devastating this can be. No.

 

Karen Ortman  24:06

Are there mental, as well as physical side effects of fentanyl abuse.

 

Dr. Greg McDonald  24:13

There are, again withdrawal if you have withdrawal from it and oftentimes results in depression and you know, the opposite because when you're using it, it gives you a feeling of euphoria. So if you're not using it or withdrawing from it, then you can have the opposite effects, depression, certainly other mental health issues, anxiety and things like that. So and again, that depends on how long the person has been using it. You know, how abrupt their their withdrawal of the medications has been, et cetera?

 

Karen Ortman  24:48

We've been speaking about fentanyl and heroin and the the how commonplace it is to mix the two. Can you speak to To the effects of fentanyl, when mixed with sedatives and other depressants or hallucinogens, methamphetamine, cocaine

 

Dr. Greg McDonald  25:16

when you're eating fentanyl and associated with other sedatives, as you mentioned, other drugs out there, they're relatively safe handled themselves, typically the benzodiazepines, Xanax and things like that they're relatively safe taken appropriately. But if you combine that with a, you know, other depressant, fentanyl bandit can have certainly notorious effects and can have an additive effect to the fentanyl. Same thing with alcohol, Alcohol is a depressant and certain levels can be a respiratory depressant as well. So that can add to it. So if I were signing out a death certificate of someone who had a blood alcohol level of, let's say, even point 1.2, and they had fentanyl, I would probably contribute the alcohol to their death as well. And I will put that in the death certificate. Other drugs on the other end of that spectrum stimulants such as methamphetamine, cocaine, they work in a different way. But they are still very, very lethal. So you can have person can die of cocaine or methamphetamine. But you add fentanyl to it, then, you know, you're you're really playing Russian roulette in that regard. And we are we are starting to see that people have been using and again, this isn't real New Years ago, they will be using cocaine and heroin together. Yeah. Because the heroin when we kind of my understanding is the heroin would make the cocaine high, not as jagged, not as aggressive. So I suspected that similar symptomatology would be attributable to fentanyl and cocaine are fentanyl and methamphetamine as well. So, again, you know, any one of those drugs in those results are potentially lethal. If you see them together, then I I would typically if I'm filling out the death certificate, I may say mixed drug intoxication are vers effects of and I would list drug cocaine, fentanyl, methamphetamine, what have you, because at autopsy, it may be a challenge to determine which drug was the most lethal? Oftentimes, it's the combination of

 

Karen Ortman  27:44

how do you recommend that parents discuss fentanyl with kids?

 

Dr. Greg McDonald  27:51

I think the best thing in Ghent not to scare them too much. But to make them wary of that. And the warning is that fentanyl can come in a variety of different forms riding on this pill form, when the last few weeks, has been hitting the press where they have seen a lot of pills that are multicolored, almost looking like candy. And so So I think the best thing to do was Halloween coming up and things like that. I'm hoping that we don't see a surge of fentanyl issues and children from these things. But you never know. And I think it's important to educate your children that you're taking drug even if you're taking something that may appear to be relatively innocuous, like you're smoking marijuana or something like that. You don't know what may be present in there. Right? Because you're not dealing with you know, a big pharmaceutical company here. There's not a great deal of quality control, and is illicit medication. So you may be smoking what you think is marijuana but there may be some fentanyl laced in there. You may be taking a pill that you think is ecstasy, but there may be fentanyl in intersperse with that. So, again, just telling your children that it could be lethal and your first dose may be your last dose. And so to try to quote experiment can be really fake. It'll

 

Karen Ortman  29:32

choose now. According to the CDC, fentanyl took the lives of 107,375 people from January 2021 through January 2022. Do you see this epidemic changing course? Do you envision another side Ever since will be introduced to take its place. Do you think we will ever get ahead of these illicit substances? Killing people? Well,

 

Dr. Greg McDonald  30:12

you know, again, that that is kind of a law enforcement issue as well. I know they're doing their best they can to keep ahead of all these different analogs. But not not to sound negative here, but I think it'd be an extremely big challenge for because again, when you have these a listed labs, these clandestine labs being able to produce it, it's different than growing poppy seeds, right, so you're growing poppy seed that can only grow in certain parts of the country of the world, right and a certain climate. But if you're making this these clandestine labs, they can be anywhere. You know, they could be in Alaska, they could be in Singapore, they could be just about anywhere. So and as they become better and better at making it, it becomes cheaper and cheaper, I see the distribution being expanding. I'm hoping I'm wrong, I truly am. Because you know, this is really, you know, almost every day I work, I have some drug related deaths, and more and more of them are opiates, more and more of the more Sentinel. So I would really like to be put out of a job, quite frankly, regarding that, unfortunately, I guess maybe law enforcement have a different take on it. But I don't see an end to this anytime in your future.

 

Karen Ortman  31:46

Not when there's so much money to be made.

 

Dr. Greg McDonald  31:48

Correct. Yeah. And there's the real issue. No, that doesn't take a great deal of money to make them take great deal of knowledge to a certain extent to make this either so.

 

Karen Ortman  32:03

And the earning potential is great. Exactly. For those who wish to engage in this behavior. I think it's so tragic, just the number of people that have been lost to this epidemic. So to the degree that we can educate listeners, I'm grateful for you. coming today, and and willing to share all of your knowledge, is there anything that we have not spoken about that you would like to share?

 

Dr. Greg McDonald  32:35

I think, you know, the DEA has some very, very good resources the CDC does, as far as treatments and how to, you know, seek treatment seek rehabilitation, there can also give you some leads as to where you can get Naloxone Narcan out some of the easier, you know how the best way to go about getting it. And just, you know, I think it's important to for schools to not to shy away from this to head hit it head on and address it. And again, it's it's terrible, it's problematic. But I have given lectures to schools showing the the certainly the lethal effects of it. And I think it begins and tome It begins in the schools. And there are a lot of good resources out there on the internet, National Institutes of Health, as well as NIH has some good resources.

 

Karen Ortman  33:33

Thank you so much, Dr. McDonald for joining me today. I really appreciate it.

 

Dr. Greg McDonald  33:38

My pleasure, Karen. As always, it's always a pleasure. And thank you and I want to thank your listeners for having me on here today.

 

Karen Ortman  33:48

My pleasure. Thank you once again to my guest, Dr. McDonald and to all of our listeners for joining us for today's episode of You matter if any information presented was triggering or disturbing. Please feel free to contact the wellness exchange at 212-443-9999 or NYU is Department of campus safety and their victim services unit at 212-998-2222. Please share like and subscribe to you matter on Apple podcasts, Google podcasts, Spotify, Stitcher, or tune in