Fighting Fentanyl Myths with Dr. Ryan Marino
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Hello, everybody. Welcome to Knock Knock High with the Glockenfleckens. I am Dr. Glockenflecken, also known as Will Flannery. I am Lady Glockenflecken, also known as Kristen Flannery.

We've got a great show, great guest, someone we've been trying to get on for a while, Ryan Marino. Know him from back in the med Twitter days. Back in the good old days. Pre-Elon. And a great debunker of misinformation. Yes. He's a toxicologist, addiction specialist, emergency medicine, and does a lot of research

a lot of education around fentanyl and drugs and drug use and abuse and addiction. And he's got his hands full. He does. That is a fraught topic in this country for some reason. But he's done some great advocacy work. So we talked to him a little bit about that and about social media and everything. Yeah. He's got a crazy story involving Tucker Carlson. Yeah. I always complain about...

About people who come after me, which honestly hasn't happened in a while. Knock on wood. But, you know, it's always when you get the ire of a group of people, it's always kind of sucks because it feels like this onslaught of negative attention, of angry emails or whatever. Like nothing I've experienced compares to his story about...

Tucker Carlson and whenever he came after him specifically. And so definitely patient and listen to that story. Before we get to the interview, though, before we start recording, we were reminiscing about my pre-exam routine, which I don't even really... I've blocked out so much of my...

Of all the, like the med school exams and everything. Well, this started in college. So I do remember listening to music before. Yeah. I don't remember like listening to. It was always hip hop or rap or both.

And you'd turn it up real, real loud. Again, listener, please picture the lankiest, whitest white boy you have ever seen. In college, I probably weighed about 170 pounds. And you had like an afro of curly hair. Yeah. Yeah. And you would blast that in your car on the way or whatever. Yeah. You were in the car with me? Sometimes there were like chest pounding. Oh, my God. Yeah.

I'm going to crush this test. I'm trying to remember some... There was some Lil Wayne back in the day. Yeah, Lil Wayne. There was some juvenile. Backed that ass up. 50 Cent. This was... We were talking, you know, early. Yeah. Or mid-2000s. 2008 to... Yeah. Yeah. To 13 or so. It would be 2007, probably. Yeah, 2007. 2007, 2008. The Game. Yeah. Just...

All right. Now it's starting to come back to me. Quality music. Hey, that was good stuff. It was effective. It got me. It really got me pumped up. It got your juices flowing. Yeah. I had a, in, um, in med school, there was a guy who would at the front of the auditorium right before we started taking the test, he would do like 20 pushups. Yeah.

We all made fun of him. I mean, that is also an effective strategy. So maybe he was onto something. Yeah. You got to get like, what does that do? Just gets you going, you know, what's the psychological impact of, look, I was not prepared for, I didn't bring a thesis, but it just there. When you exercise, you, you are, I mean,

I mean, you exercise, you know, you feel more energized, even though your body might be a little more tired. It's like you got the endorphins, you got blood pumping. There's nothing I do now that I need to pump myself up for. Actually, the only thing would be our live shows. I was going to say bedtime with the children. Got to have a pep talk before that. Yeah, but we don't have to like perform. No. Right.

But our live shows, we do a chest bump. Yeah. High five. We kind of punch each other. Like, come on. Let's go. Let's get it done. Yeah. That's mostly for your benefit. I don't need it. You don't need it. But you do. I think you could benefit from it. We do it. You're too laid back before a show.

I just, maybe I have more confidence in us than you do. I'm not so nervous. It's about the energy. No, I have energy. You do have more natural energy than I, like. Yeah. I'm like a, like a rabid squirrel. You have too much, too much of the, like the not, the anxiety, not that you just. Yeah. Like always coming out in different ways. Right. And, and just like, I'm just generally, you know, overstimulated. I just like have a lot of.

nervous energy, but not nervous as in anxious, nervous as in just nerves, right? Like I just have a lot of, I don't listen to rap anymore. I don't listen. Certainly not before we, we, uh, the playlist we played to the, to the crowd before we were performed. I don't think that's because I made that.

That's right. You've never been a rap hip hop fan. Well, sure. I was in college. That's what all the music was in those years. Went through a stage. Yeah. I mean, because that's what was on everywhere. That's on the radio. It's on restaurants. Did you ever have a country stage? No. I was forced into country. I did. Because my sister did.

So you knew the songs. Of course. I lived in rural Texas for 13 years. Yeah. So now it's 20. Yes, I knew the songs. Yeah. Garth Brooks. Brooks and Dunn. Yeah. What else? The other ones. Billy Ray Cyrus. George Strait. George Strait. George Strait. Ooh, big one. Yeah. Oh.

Yeah, he was pretty big, wasn't he? Mm-hmm. Yeah. Yeah, I have deep-set memories of Achy Breaky Heart on the school bus. Was that George Strait? No, that was Billy Ray Cyrus. Oh, yeah. That's right. That's right. That was big. It was a big one. All right. Yeah. Well, anyway.

You have any good pump up music you guys let us know. Yeah. All right. We're getting old. We're tired. We need more strategies. All right. Let's get to our guest again. This is a Ryan Marino physician, emergency physician, toxicologist, addiction specialist, triple board certified. That's a big deal. And a social media personality debunker of misinformation. Here he is. Dr. Ryan Marino.

Hey, Kristen. What's up? I've been grossing you out about these little guys, Demodex mites, for months now. Yes, you have. Thank you for that. Well, good news. I have more facts to share with you. Oh, great. Yeah. These mites have likely lived with us for millions of years.

Passed down through close contact, especially between moms and babies. That's very special. They're born. They live, crawl around and die on your eyelids and in your lash follicles. Lovely. The entire life cycle from egg to adult lasts about two to three weeks. That whole time, they live right there on your eyelid. That's making me itchy. Okay.

It is fun to gross you out, but we do all have these. All right. It's really common. It causes a disease when there's an overgrowth of these mites called Demodex blepharitis. It causes the eyelids to get red, itchy, irritated. You get this crustiness to the eyelids. But I have really good news. This is actually really good news. Okay. We have a prescription eye drop for this. Okay. That is great.

That does make me feel better. Visit MitesLoveLids for more information about demodex blepharitis and ways we can treat it. Again, that's M-I-T-E-S-L-O-V-E-L-I-D-S dot com to learn more. All right. Finally, we are here with Dr. Ryan Marino. Ryan, it's a shame that it's taken us so long to talk to each other in this way because we've been following each other on social media for quite a while.

Yeah, it's been a long time. I'm excited to be here, though. Yeah. So my first question for you is just a really generic question. I just want to get your gut reaction. Is social media worth it? Oh, my gut reaction is... As a healthcare professional? No. No.

See, sometimes I feel like my answer goes back and forth. Yeah. Like lately, I feel like it just makes me angry. It just makes me mad. Yeah. But sometimes I feel like there's good, still good in the world. I think it depends on what you're talking about. If you're just consuming social media, stop that right away. Just stop it. But if you are talking about, you know, what Ryan is...

putting out there on social media. I think that's absolutely worth it. He's doing a lot of good. The tricky part, though, is that you don't get to hear about or see a lot of the good that comes of the education that you are providing the general public. So that's a bummer. And so I have to first commend you because I feel like over the years, I have spent less and less time trying to...

really engage with the misinformation stuff and trying to debunk it. I still do it sometimes with iStuff specifically, but I've just gotten so tired over the years. You are still going strong. And I feel like every- Listen, he's triple board certified. This man has endurance. It's amazing. Exactly. That's the thing. Maybe it's the Red Bull. I don't know. I don't know.

But honestly, what keeps you going with all this stuff? I don't know. That's a really good question. And so, I mean, my gut answer to any question about social media is probably no. But obviously, I mean, I'm there. I still learn a lot there. I'm thankful for other people that are there. So, yeah, I think there is a possibility for good. And every one little thing, I mean...

I don't know a specific example off the top of my head. I'll give you an example. I'll give you, because this is, here's one thing that's like, if, because obviously this is in your wheelhouse of, you know, drug use and all the myths that come up with fentanyl and everything, and we'll get into all that stuff, but

Here's one example where if I heard this, I would just like want to turn off social media like for months on end. It's when people start thinking that dogs are getting addicted to methamphetamines by eating poop from people, unhoused, homeless people. I'm sorry, what? So talk about this because this is a good place to start. Yeah, that's a real thing. And unfortunately, not just a one-time thing either.

But I think it was a couple of years ago, some other social media character tried putting out there that dogs in San Francisco were getting addicted to methamphetamine because homeless people were pooping on the street and dogs were eating it. And that was like picked up as a national news story. First of all, this has happened multiple times. You've heard this type of thing. Yes.

That is a popular rumor, whether it's from like dogs or children. And the dogs getting sick, getting addicted, overdosing is always that's when people

you know, there's something there. Um, when like the fentanyl touch stories lose traction, they'll start saying that dogs are overdosing. Oh, they change dogs. Yeah. Cause that's when, when I, when I first started seeing your stuff, um, it was a lot of the, the, the fentanyl craze, which I think, I mean, is that, do you, do you feel it changing over time or is it still the same storylines with,

with fentanyl that's a good question are there patterns yeah i think for the most part things have improved uh but like that the touch and exposure myth still seems really pervasive with like law enforcement and the news seems to still love picking picking those stories up so does law law enforcement believes this to be true typically

It's actually included in a lot of training and like instructional materials in law enforcement. I'm sure you must wonder this all the time, but how? How does it get in there? I mean, did they not do they not consult any medical professionals about like how how is it that misinformation gets into official legal enforcement training, law enforcement training?

Um, that's a great question. It came from the DEA, but I mean that the DEA has even corrected themselves. So I don't know why it's still being taught, still being considered true. It's like all you have to do is, I mean, turn on the news for one of these stories and you'll hear a dozen reasons why this doesn't happen. Well, it's this, the old thing that it's, it's, um,

It's easier to promote a false idea and get it to train, gain traction versus the work is like 10 times, a hundred times harder to, to get that idea out of, of public. I would just hope that there were systems in place to like for in the general public. Sure. Right. But like,

Our law enforcement, I would hope they had, like, better information and procedures for that. So that's disappointing. But then do you feel like, Ryan, that it's...

Because I've felt this and like you start talking about things like for me, it's talking about the health insurance stuff and even some stuff in ophthalmology. Other people seem to care a little bit less about that. But it just it seems like you're not getting anywhere on social media and you just end up in arguments. You just end up like, how do you how do you feel about that in terms of of all this advocacy? Just talking about that.

uh, myth busting about drugs, about fentanyl. Like, what do you, do you feel like you're making progress? Do you feel like it's helpful?

Yeah, I mean, I think it's really easy to get bogged down into that, like, individual arguments. And that is kind of what social media prioritizes, like, bickering and fighting and that kind of stuff, especially some of the different platforms. But so, I mean, I think if you're able to avoid that, which it can be really hard to do, then there's more to it. But yeah, that happens a lot. And...

A lot of people's minds are made up. Like you'll, you'll never change their mind no matter what. And so then you got to start focusing on other like areas of actual advocacy. I feel like, like what you've been doing, you've done a lot of, you've done obviously at your background, doing a lot of work in addiction medicine. Tell us about, you know, some of the, some of the ways outside of social media you've helped kind of bring,

you know, knowledge to, to accurate knowledge, you know, fighting misinformation outside of social media.

Yeah. So the reason I got into social media in the first place was just because I was having trouble with the work that I was doing. And so like addiction and substance use, I mean, those topics are like near and dear to me. That's why I kind of pivoted into that career trajectory. But like the first thing, the reason I got onto Twitter back in 2017 was because I couldn't even get my own colleagues to give out free Narcan kits that I

had funded, had placed in the emergency department. We were seeing in Western Pennsylvania, I mean, the same patients would come in multiple times in one ED shift for overdoses and people still didn't want to give them Narcan, which was kind of ridiculous. And then just realizing that it's because people have all of these misinformed beliefs about things like that. And then

Kind of went from there. Does this just stem from just the feelings around the opioid epidemic when it started and the villainization of opioids? I don't think it's just opioids because this, I mean, goes into pretty much every drug. I think the topic of like drug use and addiction are just so...

they're what people believe and what's taught is so inaccurate and based in kind of these like stigmatized ideas and stereotypes. And I mean, even like our laws and the practice of medicine, it's been over 100 years since they banned doctors from treating addiction medically. And we've had some not loopholes, but like ways around that with things like methadone and buprenorphine and

But that law is still on the books like you you cannot treat someone's addiction with off label medications or use controlled substances like that. And so I think that that is probably the biggest part because it's really any drug topic. There's someone who has a really strong opinion about it and someone who's really wrong. And they're usually the same person. That's a good point.

I feel like that's a life lesson for the children. Yeah, people are...

People who are really wrong are also very, very loud. Yeah, exactly. So speaking of that, actually, I want to congratulate you on this. I think this is a couple of years ago now, but congratulations on being the wokest man in medicine. Oh, thank you. I just like, do you have a plaque on your wall? Is it, is, did you receive anything from the Tucker Carlson, you know, whenever you found out about your achievement? Yeah.

They did not send me anything, unfortunately. That's too bad. They should at least send you a sash. They did send hundreds of online trolls my way. Tell that story. Someone did get me a hat that says that. It was two years ago now.

2023? I don't know. It was Christmas Eve and Tucker Carlson ran a segment about me and called me the wokest man in medicine, which was supposed to be an insult. But honestly, it's my proudest accomplishment. And what was the story of my CV? It should. It should honestly go and certainly in your media reel if you're trying to anything. But what was what was that in reaction to?

Why? How did you gain? What was the criteria? Because I had something to do with fentanyl and vaccines that I make fun of. Overdoses or something was what he was trying to say. I don't know. There was like pictures of me that he showed from my personal Instagram. Oh, God. Someone did a lot of investigation into me for that and then decided that I was the wokest man in medicine. So.

Interesting. And then what was the reaction like online after that? I can't even imagine this because this was, I'm sure, on Twitter, right? You got, this is pre-Elon. Yes. I guess so. This was before he took over and ruined it. I don't know. I think so. 2023. 2023. I think that was 2024 when, maybe it's been like two years now that he took over. I don't know.

But anyway, so it was on Twitter you got all over across social media that people were coming after you. Yeah. And in real life, I mean, I would say that was pretty terrible for like a lot of months. So what way? Like emails, people, you know, emails, letters. I mean, people wanted me to lose my job, all of that stuff. Yeah.

The one reason I would say no is my gut reaction to social media is probably from that whole experience. You could end up on a Tucker Carlson show. That's got to be one of the worst things to get your face on, something like that, where people are extremely opinionated about this topic. Yeah.

I'm curious how for something like that that bleeds into your real life. Like I'm sure you said people are trying to get you fired. I'm sure you had like, you know, negative reviews. You know, that's always been like a thorn in the side of practicing physicians is whenever you start seeing those pop up. Did people call your employer? Yes. Calls, letters, reviews, calls.

My online scores, there's a lot of interesting comments. I mean, most of them are all from the same day. Yeah. When you're subjected to that kind of abuse that bleeds into your real life...

Did you have to have a conversation with your, I don't know how much you can go into it about, I mean, this was a couple of years ago now, so I'm sure it's all kind of hopefully settled out. But, uh, did you have to go in for a meeting with like the administrator or something and to talk about this stuff or how did that work? Yeah. I mean, people were really, uh,

fired up, I guess. I don't know what the word would be because these are like people who are out of state, don't think medicine is real, don't think science is real. But for some reason, I mean, a corporation running a health care system is going to take this as a very serious complaint, even though this is not their customer ideologically or geographically. Fear for your safety at all during all of this?

I guess to some degree, I think more so just the way that people try to like weaponize everything at their disposal, like to try to ruin my life, to try to get me fired because they don't don't like what I say about fentanyl, that kind of thing, which is really bizarre because there's nothing you can do back. But you can't even get fake health grades reviews taken down, that kind of thing. And so I think.

In terms of social media and advocacy, you really have to have good support because without that, why would anyone want to do this? Yeah. It certainly takes courage. I mean, I've never been subjected to that kind of ire. No, you have. Actually, there have been a couple times. You have, yeah. I've waded into some...

like scope of practice stuff, which is a big hot topic, hot topic, hot button issue. That's what I'm trying to say. Hot button issue within the medical field. That's gotten me into a bit of trouble, but nothing where I felt like, you know, did you feel like you, like there's a chance you might lose your job after go on leave or something? Was it, did it get that far? I mean, it has at different points. Yeah. The, the,

Tucker Carlson, I mean, is obviously a well-connected person. And you have to imagine that kind of corporate America and Fox News viewers have a large area of overlap. Right. But in the end, you're...

you're talking about evidence-based medicine. You're talking about facts. You're talking, I mean, if, and if people just don't like to hear the truth about some of these things from an actually board certified medical doctor, which is unfortunate. And so you've got to, I don't know. I feel like you just have to take solace in the fact that, you know, you're correct about,

And and in the end, as long as you have the truth on your side and evidence on your side, like you're not doing anything wrong. Yeah, you're not doing anything wrong. And and you hope over time people will come to that conclusion. But I don't know. I have less and less hope that. Well, this makes me curious. Like, it's not just this issue. It's what you just said of people don't trust, you know.

medicine anymore people don't trust doctors like like faith in our institutions is eroding and that includes the institution of health care and science and um so what are you guys gonna do about that how do we fix this that's a good question let's take a break and then we'll come back and try to answer how we get people to trust medicine again okay

All right. We're back with Dr. Ryan Marino. Ryan, I'll let you go first because I am not totally sure. What do we do about this?

Well, so I guess I never answered your question, too, about what I do like outside of social media for advocacy. And I think that's one way that you can go about this. So, I mean, I mentioned like I give out Narcan, but I have worked with local, state, national politicians, gone and done education for them, for different groups. I mean, handing out supplies and stuff. At the end of the day, the thing that...

I feel has made the most difference in this issue. And I mean, like I wrote a paper that was used to change a law that

But the thing I think that's had the most impact is actually through social media. And so maybe I come across annoying to some people, whatever. I think that is how you connect to people. That's how you kind of rebuild trust is like, why am I spending my time worrying about this kind of thing? And there's more people out there who are actually open to that.

are receptive to like learning um and and want kind of better information it's just the problem is the ones who are the loudest uh and suck up all the air are the ones who are negative and closed-minded and and all of those things yeah it's it's one of those things i i totally agree with you on the impact social media can have and not just getting your message out but but

finding the people that feel the same way that can actually then turn to, to, to, you know, in-person advocacy outside of social media, getting laws changed. You, you, I know you had, um, actually shortly after the Tucker Carlson thing, you, uh, you had the removal of the X waiver on buprenorphine prescribing, which I don't know if you know. What's an X waiver and what is. Tell us what that is. I think that's a huge. Yeah. Yeah.

Buprenorphine. It was perfect, yeah. All right. I had an attending that just called it bup. Bup. So that's easier to say. That's much easier. That was a huge deal. And so that's like an example of turning the social media presence and all the things you've been talking about for so long and your expertise sharing that on social media, but turning it into real change in the real world. So talk to us about that experience. And what is an ex-waiver? Yeah.

Yeah. So this goes back to that like silly law that you can't treat addiction medically. And so bup is one of the two medicines or three, I guess now that's approved for like opioid addiction with methadone and naltrexone.

And people are probably more familiar with bup as like Suboxone being the brand name for one of the forms. But you had to do a special training, which was eight hours of additional. Usually it was

in person, they moved to like in person and hybrid. And then with COVID went all remote, but eight hours of additional training for physicians and 24 hours of additional training for, um, advanced practice providers to get a special license to be able to prescribe that. Uh, and so bup is technically like a opioid drug, but it's,

Not the same as any other opioids, which don't have this restriction in the fact that it has much less addictive potential and like almost no overdose potential. Um, so it was this kind of arbitrary extra hurdle that just prevented people from prescribing this medication that saves people's lives. Um,

And in finally, a couple of years ago, they got rid of that requirement. And so anyone with a DEA license can now prescribe that. And it is it's kind of ridiculous just because if you had a DEA license, you could prescribe any amount of NDAs.

any other opioid that people could get addicted to could overdose on. I mean, I, as a ER doctor can prescribe like chemotherapeutic drugs, um, all of these things that I have no business and should not be prescribing do not have restrictions. But once again, because addiction is treated so differently, so weirdly, um, that was the one place where they put this, this extra hurdle. Hmm.

Well, that must feel good that your advocacy work was, I'm assuming, fairly integral to getting that change. It went to the White House. Yeah. Yeah, that was exciting. Unfortunately, not much has really changed since that policy changed, but it was a good thing. So I'm happy. That's disappointing.

You had to dress up in a suit, which I know is hard for emergency physicians. So you had to dress up and then you don't start seeing the effects of it. But why do you think that is? I mean, I think it'll just take time. People are still hesitant to prescribe now that they're allowed to because for the past 20 plus years, everyone was told that this drug was effective.

special required additional training was too complicated. It's really like one of the easiest things I do. It's easier to prescribe, I think, than like ibuprofen. So even I could do it? Even an ophthalmologist? Yeah. Like,

I mean, I absolutely never, I absolutely won't, but, uh, it's, it's very much outside of, I'm maybe one of the last types of physicians who should probably be prescribing it. I don't know, but maybe I'm wrong. But, um, but anyway, that's, that's awesome. At least people have the ability to do it. I'm curious this, how does this work? How does that medication where I want to get an

You know, I'm sure Kristen's not going to like care about like the mechanism of action of these medications, but I'm actually curious. Like, how does it, you said it doesn't have abuse potential. So how is it, is it acting on a different receptor? I vaguely remember this from med school, but not really.

So it, I guess technically like everything has abuse potential. I mean, ibuprofen, Benadryl can be abused even. But yeah, when it comes to bup, it acts on the same receptors, but it's a partial agonist at your mu opioid receptors. And so it won't give you respiratory depression in adults, at least no matter how much you take.

And there's much less of that like rush euphoria feeling people get. It doesn't work as well for pain a lot of the time. It does it. But it takes away like the craving of pain.

that people will have that drives them to, to abuse. And one of the cool things about it is if people have it in their system, because it has a much higher affinity for those receptors, even if someone went out and like the worst day of their life or got peer pressured really hard, uh, and used again, um, they're, uh,

Much less likely to a overdose, but even have that like reward effect where you kind of reset the cycle of wanting to use again. And so it is pretty cool. So give me give me three things that you're constantly you feel like you're constantly talking about trying to correct the misinformation of like three things that tomorrow like you could just get rid of that misinformation completely.

you could, you would do it. Like you had a magic, a magic misinformation genie who like used to snap of their fingers. Like all of a sudden that thing goes away. What would it be for you? Three things. Oh, three things. You get, you get three things.

There's probably three things just with fentanyl. I mean, like right now, the Senate is about to pass a bill that's scheduling every fentanyl analog as a schedule one, which is completely illegal.

And so, I mean, the misinformation around fentanyl is really problematic. That, I think, would probably be like number one, two, and three. Talk to us about that, the schedule one thing. I didn't quite follow that.

So fentanyl. Yeah. One of the things I think people forget or aren't aware of is it is a medicine, even though it's driving all of these overdose deaths and is very dangerous for people in street drugs. It's the exact same chemical compound as like an invaluable medicine.

is probably, I mean, I don't have the actual numbers, but if I had to guess, probably like top five most used medicines in the entire world just because of how useful it is for treatment of pain, for sedation, for ventilated patients, for critical illness, all of this stuff. And I will have people... Even in, by the way, even in, real quick, even in cataract surgery, like we give it for just a small amount. You've had fentanyl. Oh, yeah.

Oh, yeah. Because I've had lots of surgeries and stuff. Well, and during the cardiac arrest, you were out for a couple days. That's what they were using. I'm sure I got all kinds of medications. You kept trying to wake up. You were a problematic patient. Anyway. You needed more fentanyl. Man, I wonder how much I got. I don't know. Anyway, go ahead. Oh.

But yeah, I think people don't realize that. And I'll have people in the emergency department with like broken bones, horrible injuries, that kind of stuff, turning down the fentanyl that we're trying to give them to treat their pain because they're scared it's going to get them addicted, going to have them overdose. And I mean, you had a bunch of fentanyl and you're not addicted. So there's a good example.

But yeah, I think that's one of the big problems. And then that bill, fentanyl analogs. So, I mean, I think some of these have gotten a pretty good amount of attention in our like overdose epidemic, the things like car fentanyl that show up in the, in the drug supply and are a hundred thousand times stronger than, than morphine or whatever it's quoted as. And we'll, we'll cause like overdoses.

overdose clusters, outbreaks of overdoses in certain areas, but we've largely seen those kind of disappear. People seem to just want fentanyl. And so this law is going to make anything that's chemically related to fentanyl be illegal, which will also prevent research into

treatments uh into how these compounds work and so one of the things that they're banning is actually an antagonist at your opioid receptors so it's potentially like a narcan um that could maybe even be like more specific for fentanyl or maybe it works better for for certain situations that kind of thing um and that's going to be illegal uh and those the like

illicit drugs that get sold on the street, if you are some drug dealer and you have a

a idea in your mind that you can mess with the chemical structure to get around the laws. There's a law going back to the eighties that doing that kind of stuff is already a crime. So this adds nothing. If you like sell a drug that isn't, isn't scheduled and it makes someone overdose that that's already a crime. This is just going to impede research and add criminal charges to people who get arrested. And so the big problem is,

is that we use the criminal justice system to treat addiction in this country. And we don't use things like bup that actually work. And it's just going to take time to get people to change their thought process. Well, yeah. And I mean, no one asked for this advice, totally unsolicited, but just... It's like we have a podcast. You get to give unsolicited advice all the time. I solicit it. But applying my psychology background for one moment and my communications background,

Um, here's what I think allows, well, one thing that people that are spreading misinformation and people that are making laws like this, like things that are happening in that area, they are, they are being, the tactics they are using are more effective than the tactics that healthcare is using. So facts are facts and that's true.

But that's kind of where health care stops. They're like, that should be enough. That's their self-evident. That should be enough. If that doesn't convince you, I don't know what will. Well, you know what will is appealing to people's emotions and telling stories, connecting it to their real lives, lives of people like the people they know, the people they love and appealing to that. And we do have a negativity bias, which allows, you know,

scary, negative, fear-based stories to have more impact than positive stories. But you can use that to your advantage too. You can flip that on its head and say, I mean, you know what the scariest thing is to me is losing someone I love or, you know, bad things happening to someone I love. And that's what people are playing on when they generate these fears. But the same is true, you know, we could be doing that in healthcare as well of if you don't

don't do these things. I mean, the anti-vax movement is a good example, right? Like if you don't do these things, your loved ones are in danger or, you know, whatever it is, whatever your message is, if you find a way to tie it back to emotions and storytelling and personal connections, that is going to go, it's just neuroscience that is going to have a larger impact on people than all the facts in the world. And, and using the facts to supplement is great because

Because then it's not manipulation. It's just true. But you can't rely on facts alone. And I think your example about the anti-vaxxers, I mean, is good because a lot of this misinformation, it seems like everyone who believes one thing believes like all of these things. And if you, I mean, scratch the surface of the like fentanyl truthers, they also are anti-vaxxers and all of that stuff.

And at the end of the day, a lot of that seems to boil down to this like very American belief in like the individual and like personal liberty and American exceptionalism, whatever. Like I don't need a vaccine because I have an immune system. My child's going to be stronger. Like if you're worried, get yours, that kind of thing. And it is really hard to reach them because you do have to kind of

make those appeals that are not as objective as you want to be. Yeah. I mean, you have to meet people where they are and then you can,

lead them to so try to scare the hell out of them about measles if that's what it takes i mean it's a scary disease it's pretty scary all on its own what's happening right now so and i there has been a vaccine spike in texas but you know yeah well we had the first death of a child right um that we've had in more than 20 i think since 2015 isn't it

I'm not sure how long ago it was, but it was a long time ago. One too many. One too many. And unfortunately, it's still the classic thing where people won't care until it affects them personally. Right. So you have to figure out how do I make this relevant to people personally. And social media is great for that too because one of the words is media and you

that's a great tool for storytelling. You know, that's a great tool for appealing to emotions that people have and fears that they have and, and, you know, bringing them along on a journey to start where they are and get them to where the truth is. And Ryan, you said something interesting though, when you're talking about patients coming in to the emergency department, I would assume that because of what we always see about fentanyl, all these lies about fentanyl,

as opposed to the truth, that people would be afraid of dying from receiving any fentanyl. But it's more people are afraid that they're going to get addicted to fentanyl. Is there a difference there, do you see? Yeah, it is. People are less scared of having an overdose, I think, because if they're in the hospital, that's actually a good question. I haven't really thought about it.

Super hard about that. Yeah, we saw like the same thing. I mean, after Michael Jackson, people wouldn't want propofol to like get their their hip put back in kind of thing. They were they were really scared that it was going to but not that it was going to kill that. I don't really know what people are scared of. That's a good point. But it's not.

And I know that I know, you know, this and I know this, but to let all the listeners know, you know, it's not just getting an exposure once is going to set off an addiction to something like that's that's right. That's typically how that are there some things where that works? Is that like a nugget of truth where that comes from? So yes and no. For the most part, no. And I mean, addiction is still not.

greatly understood, I would say. But it is it's more than just like one exposure to a drug. And so someone like having a beer or getting fentanyl in the hospital is not going to end up addicted. I'm sure there are like stories out there where someone says that, but there's probably details that are being omitted. And so, I mean,

like whole social, cultural, economic, all of those things factor in way more than even just the drug itself. And I mean, we know that some people have genetic predispositions to addiction. Some people can be addicted to like any substance. And so maybe it was the pain medicine they were getting and then they get over that, but then get into alcohol, that kind of thing. So yeah,

Yeah, it's not the one time dose. And for people, I mean, I think having like that conversation would be better if people told me they don't want fentanyl because like their father was addicted to Percocet or something. That would be a much easier way to start conversations and be able to help people with those kind of fears. But usually what comes out is just like fentanyl has become

the boogeyman by the media, that President Trump said fentanyl was bad, that kind of thing. Right. Well, I don't know if you're still the wokest man in medicine. I don't know if someone's taken the title from you at this point, but I just want to congratulate you on your accomplishments. And I have to address the elephant in the room here. What? Is that you guys...

Your doppelgangers. Oh, yeah. Oh, the curly hair and the beard. And the beard and the face shape. I mean, there's a lot. That's true. I think I'm like more than a foot shorter than you, though. Oh, well, most people are. Let's take one more break and then we'll come back. I have a little activity for us. All right. A little game to play and then we'll wrap up. So I'll be right back.

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All right, Ryan, last thing. We're going to play a game. It's called ER or RR.

So emergency room. I know you guys don't like the term emergency room. It's an emergency department. But for this purposes, we're calling it an emergency room. ER or RR, rest and relaxation. Oh, okay. So should you go to the ER or just a little bit of RR? Okay. All right. So we're going to rapid fire. We're going to just run through these. All right. I'm going to give you a scenario and you're going to answer. You spill hot coffee on your hand and the skin turns red but doesn't blister. ER or RR?

R.R. You're eating a drumstick and a small bone gets stuck in your throat. You can breathe and talk, but swallowing hurts. E.R. That's what I was going to say, too. I was like, get the bone out of my throat.

And that could probably go somewhere you don't want it to go eventually. Right. That's probably a big deal. There's all sorts of things down that tube. All right, here you go. You're putting some furniture together with a drill. The drill slips and it cuts your hand. You've been bleeding for 10 minutes even after applying pressure to the wound. ER. Yeah, you probably need some sutures in that thing. Your finger gets slammed in a car door. It's throbbing, swollen, and starting to turn purple, but you can move it a little bit.

ER. That's a tough one. Yeah, go to the ER just in case. I would probably R&R that one. I was going to say that has happened to me before and my parents did not take me to the emergency room. So I don't know what that says. That might be a judgment call right there. I mean, if in doubt, I mean, you know, if you don't know anything about medicine, you know, maybe... Put some ice on it. See how it goes. I don't know. Yeah, ER is never the wrong answer. Right. Yeah, exactly. You eat

You eat week-old leftovers from the fridge. Later on, you feel nauseous and then develop explosive diarrhea. RR. What if the explosive diarrhea lasts for more than three days? ER. The one thing, though, is if you need to be on a toilet, you do not want to go to the hospital. Right. Because it is the worst place to need a toilet.

Yeah. That's a good point. Yeah. They're all shared and they're all disgusting.

Oh, God. Okay. That's wonderful. Oh, what a conundrum. If you're in the hospital, you need to toilet, go find an ophthalmology department. There you go. Well, you won't. You're in a hospital. Toilets are, well, that's, you know, occasionally. Sometimes they're not in like the gross hospital part. They're in like the cleaner, much nicer, like radiology. Somewhere near the library. That's right. Exactly. Yeah.

All right. Just look for the windows. Yeah, that's right. All right. You fall off your bike. Your knee is swollen and you really can't put any weight on it with you can't really bear weight without significant pain. You are non weight bearing is a bad sign, right? Yeah. Yeah. All right. Here's one that's mainly kind of for me, too. You just bought a new can of pepper spray for self-defense while trying to unlock it. You accidentally spray yourself in the face.

And your eyes burn. You should probably just go to the ER. Yeah, I think that's probably a good idea. Unless you have an eyewash shower. Yes. For pepper spray, by the way. Yeah, there's a trick, right? Soap and water. Soap and water, okay. Yeah, just rinse those eyes, soap and water. Anything like oil-based or soap specifically? Yeah, because it's oil-based, and so you want to just, you got to use soap to. You got to use some other kind of oil to get it out. Yeah, exactly. What if you have like coconut oil?

Like I used to take my makeup off with coconut oil. Would that work? I mean, it probably is not going to help to try, but it's not going to help to try or hurt. I mean, sorry. It doesn't hurt to try like coconut oils. Fine. Yeah. They probably would. It just seems like it would hurt to put soap in your eye. So, but I guess you got pepper spray in there anyway. So what's the difference? Yes. How do you feel? How are you with eyeball stuff? You're good. How's your slit lamp skills?

So good. Couldn't even tell you where the slit lamp is. Well, that's not unusual. That's pretty unusual. I find all of my ruptured globes on ultrasound. Yeah, I know. You're going to go there. We won't go there because we only have so much time on this podcast. But that's actually pretty common. It's not how we diagnose open globes, but it's...

Whatever gets you to the right answer, I think is okay. I saw, I think it was Ted Cruz, maybe. One of the people who's trying to get DEI taken out of everything removed either all of the web pages or grants or papers that had POC in it because they thought it was person of color. But it removed a lot of point of care. Oh, no. So...

I thought you would appreciate that. That's great. We're in the upside down, right? Point of care ultrasound. That's what explains this. Well, that's what's going on with the doge stuff. I know. Right? It's like just...

Sure. You can think, and in a lot of areas, I'm sure there is some government waste, things that can be scaled back. But just to take a hatchet to it and just full scale, just cut out departments. It's like they don't realize that words and acronyms can have multiple meanings. These things exist for a reason, and they're indiscriminately just...

Anyway, that's a whole other topic. Yeah. At least they're getting rid of point-of-care ultrasound. Thank goodness. Absolutely. All right. Our last one. You're at a Christmas potluck and you eat Uncle Jerry's dish that he didn't mention contained peanuts. You're allergic. He's like, I don't need to hear any more. That's it. Don't want to mess with that. Do you have any... Have you ever been to the...

Did you as a patient ever have to go to the emergency department? That's a good question.

I don't think you've ever been since I've known you. I don't think I have. It's amazing considering how clumsy you are. I know. You would think that you would have. But I'm also very anxious. Yeah, you're also very. So it keeps me away from a lot of danger. Okay. All right. Yeah. Wow. But I've been. I've had to take a kid. I've had, you know, when I was a kid, my brother had to go. He cut the tip of his finger off. I got on a tall ladder the other day, Ryan. You wouldn't have been very proud of me. Oh.

How tall was that? I was probably like a good six feet in the air, seven feet. I don't know. I mean, it's tall, high enough where, you know, it would have been a disaster if I had fallen. But aren't you six feet in the air all the time? No, my feet, the bottom of my feet were six feet. I mean, you gotta specify.

I just like, there's ever since I've been doing all this like comedy for like, and, and making videos about all these specialties, I learn about all these different specialties. And I, I, I know the things that like,

just that they hate. Yeah. Or that they keep, they always tell patients not to do, you know, whatever it is. And that's one of the things in emergency medicine. Yeah. Stay off the ladders. And like ortho. It's like, oh yeah. Like the, the middle-aged male homeowner. Yeah. Which is, you know, which is me, but luckily for you, you are deathly afraid of,

I really don't like heights. I'm not. It's a. See? Fear keeps you from doing stupid stuff. It's protecting me. If you put a trampoline under the ladder in case you fall, you could hit two things. Yeah. Yep. But just more bouncy. So it's better. Yeah. I like it. Just be sure you don't have any pads around the springs. Any other safety tips you want to give our audience?

Always have a trampoline under your ladder. Yeah. That's a good one. Yeah. That's the main one. Definitely seek medical care if you have any flashes or floaters. Okay. Well, I have a lot of floaters and you tell me that it's fine. And I say that to Ryan because he's a bit nearsighted. Oh, how nearsighted? Can you guess? Yeah. He's got to be like a minus nine, minus eight.

Minus seven. Seven, okay. I can see I'm missing a chunk of my face. Yeah, it's because your lenses, your nearsighted lenses minimize your face. Yes, for people just listening, he's not actually missing a chunk of his face. Yeah, that's right. It's an optical illusion from the glass of the lens. Yeah. Well, you're in the right place. You could pop on that ultrasound and really go to town if you ever have any flashes of light. So...

just to let you know and as you know i know all right so let's tell people where they can find you ryan uh you're on blue sky primarily now yeah um i mean i guess i i'm on blue sky uh

Yeah, that's a good one. And where can people find like good, accurate information about fentanyl? Give people like a resource for some of the things that you do around addiction around. I mean, I think there's a lot of good resources out there. The things that I would say people should look for are probably like harm reduction groups. And I think that harm reduction is probably.

which is like a very contentious point. Um, but that is probably the biggest like advocacy, um, area and push. And the reason that our overdose deaths are finally declining. Um, that's, that's where I would look. Yeah. Awesome. Well, um, thank you so much for joining us. Thanks for having me talk to you. All right. We'll see you later, man. We should get you on blue sky. I'm there.

Oh, you are? I'm not like checking it super often. That's the thing that I need to get going on. You used to have to have an invite to join it. Yeah? Yeah. I've been there a long time. Like we've had accounts for a long time. Yeah. It has gotten better. It was pretty rough initially. It's gotten better. More people that I like to follow on Twitter are now on Blue Sky. And it's...

For me, it's like you see the things that you actually want to see versus X, which I get fed a whole bunch of stuff that there's no interest in. The algorithm sucks. It's awful on X. I think the algorithm has its own agenda. That has pushed me away from that website a lot. I wonder if that's intentional.

Like, are they trying to get rid of the people that are not into what they're peddling? I don't know. Maybe. Anyway, Blue Sky. Instagram, too. There's several old med Twitter people on Instagram these days. Everybody kind of got dispersed. Yeah. We got to converge. Ryan Marino's a great follow. Really smart, and he's funny, too. Yeah. He's got some really good comebacks and quips. Yeah.

When dealing with all these misinformation peddlers. Right. These fentanyl scare accounts. Yeah. So anyway, check them out. Ryan Marino on Blue Sky. Let us know what you guys thought of the episode. If you have any suggestions for guests or any topics you want us to talk about.

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Although, I watched the Oscars last night. And I feel like I need to get in my dramatic mode. Oh, okay. Like, to learn about our number guys. Program disclaimer notes. Maybe I should start drawing up some tiers to make it look real dramatic. Sure. Do whatever you want here. Go to glockenflecken.com or reach out to us.

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Yeah, 100%. Everybody loves Jonathan. Everybody wants a Jonathan as part of their healthcare team. Yeah, who wouldn't? Well, I can't give you Jonathan. Well, that's too bad. I can give you Microsoft Dragon Copilot. Okay, well, that might be even better. This is your AI assistant for clinical workflow. It's incredible. It helps to streamline documentation, which is one of the hardest parts of being a physician these days. Yeah. It allows you to automatically convert conversations into specialty-specific documents.

notes. That's pretty cool. It really is. You can customize commands and templates and it also helps you to summarize notes and evidence and just makes your job so much easier by taking away some of that administrative burden. Yeah. To learn more about how Microsoft Dragon Copilot can work for you, visit aka.ms slash knock knock high. Again, that's aka.ms slash knock

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