Good afternoon, everyone, and welcome to today's webinar. I am Felicia Bloom, Manager in the Practice Institute at the American Dental Association. On behalf of the ADA and our collaboration with the Providers Clinical Support System, PCSS, I am very pleased to bring you today's webinar, The Impact of COVID-19 on the Addiction Field, A Call to Dentists. The goal of PCSS is to train healthcare professionals in evidence-based practices for the prevention and treatment of opioid use disorders, particularly in prescribing medications, as well as for the prevention and treatment of substance use disorders. Here are our educational objectives for today's program. Our esteemed presenter today is Wilson Compton, MD, MPE, who is a nationally known expert on the causes and prevention of drug abuse and is the Deputy Director, National Institute on Drug Abuse, NIDA. Before joining NIDA in 2002, Dr. Compton was a tenured faculty member in the Department of Psychiatry and Director of the Master in Psychiatric Epidemiology Program at Washington University in St. Louis, as well as the Medical Director of Addiction Services at the Barnes-Jewish Hospital. Thank you, everyone, for joining us today. It is now my absolute honor to turn everything over to Dr. Compton. Well, thank you so much, Felicia, and welcome to everybody who's listening in today. It's really my pleasure to join the dental field to talk about sort of two key issues. What has been the impact of COVID-19 on addictions in our country? And so I'll be sharing with you information about how the current public health emergency related to the SARS-CoV-2 virus, or COVID-19, has impacted overdoses and other aspects related to substance use disorder in our country. But I'll focus particularly on what can you as dentists do to address these issues, and what can my agency, the National Institute on Drug Abuse, do to help you in your goal to improve health outcomes for the patients that you serve? Now, to begin with, I have brief disclosures, none of which are related to my talk today, but they're here for the record. And so let me get into the presentation itself. When we think about the addiction issues in our country, we are primarily focused on overdose deaths, overdose deaths. And what we've seen is that in 2019, which is the last year that our colleagues at the CDC have full year information and final data, so that there were over 70,000 deaths in 2019. So a significant and a major cause of early mortality and preventable causes of death in our country. The vast majority of these were related to opioids, both prescription and illicit. And we'll go into that in some detail. What's happened since that time? What we've seen is that during the pandemic in 2020, overdose deaths have, to my description, skyrocketed with over a 30% increase based on preliminary information from the National Center for Health Statistics at CDC. Again, most of the overdose deaths are related to opioids, prescription, and illicit. So let's look at this in some other ways. First off, one of the ways to think about this is what parts of the country have been affected by overdose deaths? And these maps from CDC that highlight in a color-coded way, heat maps, as they're so called, I really think illustrates an important point. Every part of our country has been affected by overdose deaths over the last 20 years. We've seen a market increase everywhere you go. That was true in the upper Midwest. That's true in the South. That's true in the West. That's true in the Northeast. That's true in the mid-central regions. So everywhere, we've seen a darkening, in other words, a worsening of overdose deaths during this time period. But I think you, of course, immediately recognize it's not evenly distributed. Some parts of the country have been much harder hit than others. It's well-known that the Appalachian region has been hard hit, and we see that even in the earliest days when those rates were much higher than other parts of the country. And those rates have continued to be high. But now we see areas of the Southeast, like Florida, we see many parts of the Northeast being very severely impacted, and broad regions of the rural Southwest being impacted. I don't know about you, but I, of course, am looking at my particular county and particular area to see what's going on there. I think it's a reminder that drug addiction issues, while they have a national frame, and we pay attention to them in terms of national policies, they are ultimately local phenomenon. Drug use is spread, and the problems related to drug use happen at a very local level, within individuals, within families, within neighborhoods and communities. And so that's the frame that I hope you'll be thinking about. What's going on in your neighborhood? What's going on with your patients that you need to be paying attention to so that you can improve their dental and overall health outcomes? Now, I've described for you sort of the overall sweep in terms of geography and the increases across the last 20 years. But let's look at how this crisis has shifted over time. If I had spoken to you, you know, five or 10 years ago, I would have focused almost entirely on prescription opioids. That's the orange part of this graph, which showed a tremendous increase across the early 2000s. We saw this increase being driven by excess prescribing and availability of prescription medications that were diverted from medical purposes and medical use. For instance, after dental procedures or after many other acute care needs for opioids, diverted into illicit drug use and misuse of these substances. We saw market increases through the 2000s with these prescription opioids. But while that was driven by the excess prescribing and, to my mind, exacerbated by the marketing practices of the pharmaceutical industry, which are well-known at this point, we saw another example of sort of economic drivers of this when we see heroin increasing starting in around 2007 and really increasing, particularly starting in 2010 through about 2016. That's the green line here. The heroin increases, we believe, are driven by how there were changes in the way heroin was sold in the country, that drug dealers figured out that there were ready markets for their products. People who had developed a habit or regular use of prescription opioids might be interested in switching to an illicit substance. Of course, that transition only occurs for a small number of patients, even among those who are misusing or addicted to prescription opiates. Only a small number transition to heroin, but that's enough for the marketing of heroin to change in many parts of our country. So we see heroin available in suburban and rural areas that didn't used to have a problem. That was the second phase of this, moving from prescription opioids to the heroin situation. The third wave of this, if we think about it in terms of the major components, would be synthetic opioids other than fentanyl, other than methadone. That's primarily fentanyl. Now, fentanyl, of course, is well-known in medical communities as an important medication for surgery, for anesthesia, and it's particularly important in end-of-life care. The fentanyl patches and other ways to administer fentanyl to persons who are suffering from serious pain at the end of life are well-known for providing relief and are an important contributor to end-of-life care. That's not what we're talking about here. The fentanyl that is associated with these increasing overdose deaths is primarily illicit fentanyl, that would be the fentanyl that comes from China or other locations overseas and then shipped to the U.S., and that's been facilitated by a key aspect of fentanyl. It's an extremely potent opioid. So, what does that mean? That means it's something like 80 to 100 times more potent than morphine or 40 to 50 times more potent than heroin. And that potency has two major effects, as far as I can tell. One is it facilitates the smuggling. When you think about it, 50 times more potent means a very small quantity can equal a pretty significant quantity of heroin or certainly an even larger quantity of a prescription medication. So, being able to smuggle smaller quantities facilitates the distribution and the sales of these products. The second aspect of the potency is that the high potency means that even very small amounts can cause a fatal overdose. And that, I believe, is probably the main reason that we're seeing such an increase in overdose deaths related to fentanyl, as fentanyl sales have increased in the illicit drug markets around the country. Now, I may come back to this a little bit, but part of the issue relating to fentanyl is also that it's infiltrated other markets and not just the opiate market as well. Now, as if opioids weren't enough of a problem, what we've seen in the last few years is that this issue related to overdose deaths has been extended to cover polydrug use or multiple other substances. And I highlight for you overdose deaths increasing related to cocaine and methamphetamine underneath the broad category of stimulants, which again have seen market increases since about 2013 or 14. Now, rival the number of deaths related to fentanyl or synthetic opioids. We'll come into this, go into this in some more detail down the road. Particularly important, of course, will be to focus on methamphetamine overdose deaths, which we have seen markedly increased in many parts of the country over the last few years. The West has had endemic problems with methamphetamine now for decades. And we're seeing what's been startling to many of us is to see methamphetamine and methamphetamine overdoses increasing in the north central parts of the country, even parts of the southeast and the northeast, where that is a fairly new phenomenon. And so I think it's an important reminder that what we think of as the drug problems in our area and in our region can shift over time. So we need to be paying attention to what's happening in a local area pretty much always. Now, of course, during the public health emergency related to COVID-19, we've primarily been focusing on mask wearing, vaccination, and how to keep people safe from an infectious disease. What we've noticed, though, is that during the same time, there's been a marked increase in overdose deaths during 2020. So in some ways, this has been a hidden public health emergency continuing and getting worse during the infectious disease issue that we, of course, we've all been so focused on. What might explain some of this? We know that relapse to drug use is exacerbated by stress and difficult life circumstances. That's certainly been true during this pandemic, that the emotional and psychological stress has been significant. Loss of jobs, loss of housing has been a serious issue. We've seen some very practical issues in terms of the difficulty in getting access to treatment at times for persons with a substance use disorder. Homeless individuals and others may face a particular difficulty during this time. A very practical issue when it comes to overdose deaths will be social distancing. We know social distancing is important to reduce the likelihood of infectious disease transmission, but for somebody who's using drugs, using them in an isolated manner by yourself increases the risk of a fatal overdose. Of course, that makes sense because that way there's no one there to potentially provide CPR or provide lifesaving medications in case of an overdose. In addition to all these problems, we've seen a major shift in services during the pandemic. We've seen that telemedicine has been increased markedly. I bet some of you all are using more phone calls to provide advice to patients during the pandemic in ways that you didn't anticipate or expect. Nevertheless, those who need procedures, of course, still need to come to see their clinician. But we have seen virtual support meetings. So even some of the recovery community have adapted to this environment. So there are some interesting shifts. And one of our challenges now is to see which of these shifts should we maintain long-term? What will be beneficial to help patients and improve outcomes in terms of continuing some services through telemedicine and telehealth during this time? I was involved in a study of use of telehealth among providers of buprenorphine, and a couple of things surprised me. One, I wasn't so surprised that a lot of people were availing themselves of these services. But a large percentage began their patients of buprenorphine even using telemedicine as the approach. So essentially what they were doing was remote start on medications for some of their patients. That's quite a novel approach to treating patients where we would expect something as significant as starting a new treatment would be done in person. So learning about that will be a key goal. I was also a bit surprised to see how frequently it's not just internet-supported telemedicine like we're having now for this meeting, but people are using just regular, the phone, whether that's a cell phone or landlines to communicate with patients. So when we think about telemedicine, it's both those that have full audiovisual capabilities as well as just the audio connections that can provide a lifeline of clinical support for patients. Now, during this time period, as I've already suggested to you, we've seen a marked increase in deaths, and we'll go into this in a little more detail. While the deaths have increased all across the country, particularly hard hit have been the western regions of the country. In those western regions, we saw, for instance, a 100% increase, nearly 100%, 98% increase in synthetic opioids other than methadone, that is fentanyl-related deaths in these parts of the country. What we believe has happened is that heroin marketing shifted in this part of the country, and so the drug dealers have shifted to synthetic opioids as their primary drug that they're distributing now throughout the entire U.S. The West was the last region where fentanyl extended in terms of the illegal drug markets, and that's been a major change during the COVID pandemic. So let's look at these overall rates during this time period. This is overall overdose deaths in the United States looking overall. What we saw was that there was a peak in November of 2017, and many of us in the public health community were really pleased and excited to see at least a leveling off after, you know, more than 20 years of increases. We saw a 14-month period of slight declines, or certainly one could say a leveling of the increases in overdose deaths, a flattening of the curve, as you may have heard in infectious disease circles. Unfortunately, as fentanyl distribution continued to skyrocket around the country, we started seeing increases across 2019 and into 2020, but particularly during the pandemic period from March of 2020 through the most recent date of February-March of 2021, we've seen about a 30% increase or more. So this is remarkable in terms of the increases. On the left, you see that the overall overdose deaths have increased from February of 2020 to February of 21 by 30%, from 74,000 deaths in a 12-month period to over 96,000 deaths. Natural and semi-synthetic, these are the prescription medications that all of us are so familiar as clinicians. Those have continued to increase as well. Methadone deaths, while a much smaller number, have increased significantly. Cocaine deaths have gone up 20%. But I want to highlight for you particularly psychostimulants, mainly methamphetamine, which have gone up by some 50% during this time period, and the synthetic opioids other than methadone. That's mainly illicit fentanyl, have gone up by more than 50%. At the same time, heroin deaths have begun to diminish, and that's almost certainly due to the fact that the drug markets have shifted from a heroin market to mostly a fentanyl market in terms of illegal and illicit drug sales around the country. One other way to look at this is to just compare COVID deaths to drug overdose deaths. Now, of course, we didn't have any COVID deaths in 2019, but we did have seven to nine persons dying per 100,000. So that's an overall death rate for those between ages 15 and 54. So these are adults in the young to middle-age groups. We saw an increase in overdose deaths between quarter one of 2020 to quarter two and continuing into quarter three, that those rates increased by about 30%, as I've highlighted for you. How does this compare to COVID deaths? I think it may be a surprise to many in the public that the rates of death from overdoses, drug overdoses, is about twice the rate of deaths from COVID in this population ages 15 to 54. So with all the attention we're paying to COVID, I think there's been a hidden epidemic related to drug overdose deaths that deserves attention as well. Now, as I've highlighted for you, there have been changes in the drug marketing, and that's been a major factor here. I highlight for you a book by Sam Quinones called Dreamland that helped illustrate with stories, at least in some parts of the country, about how drug sales shifted to basically a delivery model of telephone ordering and personal delivery services for heroin, that he describes as much like pizza delivery. It's a very disturbing analogy, but one that reminds us that what we think of as principles of sales and marketing apply in illegal drugs, just like they do in the rest of commercial marketplaces. The other key factor, even when it comes to heroin, has been that over time, the cost of heroin dropped across the 1980s and 90s and has remained low. So we have both increased availability and generally lower prices of heroin, at least during the earlier parts of this overdose crisis. Now, fentanyl is the next phase of this economic activity. And as I highlighted for you, the extreme potency of fentanyl facilitates both its smuggling, so its distribution, as well as the lethality of fentanyl products. But one way to think about the potential economic drivers here is this graphic from a few years ago from the Wall Street Journal that reminded us that there's about a thousand fold profit margin. Now, what does that mean? That means in this case, something like $800 worth of precursor chemicals can be put together, maybe not by you and me, but by medicinal chemists that work in illicit, sometimes legal factories in other countries, but often illicit factories as well. But the cost of those products being about $800 can be sold on the street for something like $800,000. That's not a thousand percent, that's a thousand fold increase in the potential profits compared to the cost of these items. That explains why an awful lot of behavior is driven by profits in this market. To some degree, I'm sort of, I was a bit surprised that it's taken them even these number of years for fentanyl to penetrate the heroin or illicit drug markets in the West part of our country, because given these extraordinary profit margins, it doesn't shock me that they would begin to take the place of other substances. One of the most recent concerns though has been that fentanyl is not only sold on the street as a powder and being, taking the place of heroin in illicit markets, but it's also being pressed into pills using pill pressing machines and to mimic both a painkiller medication. So it might be used to create a counterfeit hydrocodone or oxycodone tablets, but it's also being pressed into the form of other medications. For instance, benzodiazepines are sometimes counterfeited with fentanyl containing products. So that's been a major concern that the DEA has alerted us to these huge number of counterfeit tablets that are being distributed all around the country. So I do think this is an important concern for patients who may rely on less than reputable sources for their medications. So patients that obtain things over the internet or from neighbors, friends, or sources other than their own pharmacy and pharmacist need to be extremely careful because of this flooding of very dangerous products in the form of counterfeit medications. We've also seen fentanyl being added to methamphetamine and cocaine. So we're seeing overdose deaths from contaminated drug supply well outside the opioid space. And I can't completely understand that. There are some times when people will intentionally mix these two products, but I don't understand why there would be drug dealers would do that on an intentional basis. And I think that's a question, but it certainly means that those that are using these stimulant medications for recreational or for their own intoxication and for whatever other reasons need to be extremely cautious because they are liable to unexpectedly be exposed to fentanyl. And given their lack of tolerance to opioids, they may be particularly vulnerable to overdose impacts. Now let's focus a little bit closer to home in terms of prescription of these agents. And this is a study from a few years ago. So one of the questions is, would this still apply as we've seen a reduction in prescribing? And we don't know the answer to that. But this study was a real eye-opener for me. And I would imagine for you that these were patients who were known to be on medications. They suffered an overdose event and were hospitalized for it. They had a non-fatal opioid overdose during long-term opioid therapy. And this about 2,900 commercially insured patients of those who were on high dosages when they suffered a non-fatal overdose, about two thirds of them remained on high dose opioids even a month or three months after their overdose event. Nearly 20% of them overdosed again within two years. And so both in terms of patients changing what medications and even their prescribers being aware of overdose events and adjusting the prescriptions based on this background was really brought to light by this study. As much as it's the opioids in particular that we're concerned with, the combination of opioids and benzodiazepines is particularly risky for overdose deaths. And about a third to two fifths of patients in these groups were also prescribed benzodiazepines. And almost all of them remained on them in follow-up. So this was a wake-up call to me that clinicians are not modifying the prescriptions they give their patients even in the face of this extremely significant medical event, an overdose. That's one aspect of medical practice that deserves attention. Another is something that is, I think, a very profound finding from our population surveys that we've learned that prescriptions that are misused come both from a patient's own prescription. So that's pretty well-known. We figure some of the patients that we write prescriptions to will take more than what was prescribed, will use it in ways other than what's prescribed. And that's what we mean by misuse. But it turns out that about more than half the time people get their misused opioids from someone else. Their friends and relatives provide them and they in turn got them from their own prescriptions. So this is a good reminder that when we write prescriptions they may not just go to the patient to whom we expect them to go to, but they may be shared with family and friends. And so part of our clinical responsibilities is to minimize that risk of sharing by making sure that prescriptions are written for a smaller number, closer to the number that patients will actually take. And that we work with patients to dispose of unused medications when their time of need, when their need for these has ended. I'd highlight for you that adolescent exposure to opioids is important. You all may be particularly aware of writing for opioid prescriptions to adolescents who have third molar extraction or other dental procedures. And what we found is that legitimate opioid use during high school is associated with misuse after high school. That's one study. In particular, it's the non-medical prescription opioid use among youth that's associated with higher rates of heroin use, or in this case, non-medical prescription opioid use with subsequent heroin initiation. So what does that mean? That means that some of the prescriptions we write that are then diverted to other adolescents may end up causing some of this onset of either prescription opioid misuse or heroin misuse due to the diversion to other people from their prescriptions we write. So is there anything we can do about this? Absolutely. Here's one intervention that colleagues in San Diego conducted a few years ago. The medical examiner in San Diego sent letters to clinicians who had prescribed to decedents that were found to have had their overdose deaths related to prescription medications. The clinicians that received letters were more likely to reduce their prescribing after the intervention compared to those clinicians who didn't get a letter. So being alerted that one of your patients died of an overdose, possibly related to the medications that were prescribed, is a warning sign that seems to shape clinician behavior. Now, this follows some general guidance from our colleagues at CDC on called the Opioid Prescribing Guidance, now five years ago, that were really focused on addressing how to start and how to address the potential need for opioids in new patients who had long-term chronic pain. It was a real focus on when to initiate opioids and also sometimes to focus on continuing them. There was a problem though with these guidelines and in the zeal to implement them, some clinicians said, oh, they took the message as, I should just stop writing prescriptions. Unfortunately, abrupt discontinuation of opioids can itself cause a great deal of morbidity and problems for our patients. Abrupt discontinuation, whether these are illegal or illicit drugs or prescription medications can cause significant harms to our patients and may inspire them to engage in extremely high-risk behavior. That means using street drugs or engaging in other behaviors to address their withdrawal syndromes. So we followed up with a commentary and some outreach by CDC and a number of publications to remind clinicians that when you discover a patient is misusing or is not doing well on the opioids that are being prescribed, it's important to consider tapering those agents in a patient-centered, gradual, careful manner. And dosage changes, particularly rapid reductions can harm patients. That's sort of the short-term message. And so paying attention to how we manage prescriptions is both important in terms of how we start patients on these prescriptions or avoid that where reasonable, as well as how we carefully minimize the use of these and discontinue them in a methodical, careful, patient-centered way. This is just looking at what's happened to retail prescriptions over the last decade. And in this color-coded way, what you see is a marked reduction in prescriptions in most parts of the country. So this is good news. The clinicians have heard the message and we've seen a marked reduction in prescribing. This is about a 60% decline during this time. And while we still see a large number of deaths and complications, this is, I think, good news in terms of clinicians responding and paying attention to their patterns during this time. Now, what are we doing at NIH to address these issues? Well, I want to highlight for you some of what we're doing through our Helping End Addiction Long-Term or HEAL initiative. This is a large-scale research program that has two major themes. The first theme would be, because excess reliance on prescription opioids is part of what got us into this mess, can we do a better job of treating pain without opioids? How can we enhance and improve pain management? So that is the first part of this. What can we do in terms of clinical research and preclinical translational research? And of course, since we're focusing on addiction and on the opioid crisis in particular, improving treatments for opioid misuse, addiction, and overdose are the second major theme. We're very fortunate that Congress has allocated a significant funding for this program, and it's already led to some breakthroughs and some new advances. When it comes to pain management, we're focusing both on preclinical, so early discovery about what explains the transition from acute to chronic pain? Why do some people go from this experience that starts in the periphery with signals coming from injuries to our back, to our hands, to our mouths? But over time, that can translate into a self-perpetuating central pain syndrome. That's a very important set of questions that could have implications for treatment and ways to improve clinical outcomes by focusing on some of the central mechanisms or even using some of our tried and true approaches, things like cognitive behavior therapy and mindfulness training. Those, of course, won't absolutely reduce pain, but they can help people improve their functioning in situations of chronic long-term pain. A second component that I want to highlight for you would relate to implementation or prevention. Now, that's been a broad theme for us in focusing on vulnerable populations on healthcare systems, and particularly focusing on justice systems, where we focus both on adults as well as juvenile justice as where we find individuals who are at very high risk for involvement in drug addiction and having problems related to drug addiction, and so where we might implement effective prevention and treatment interventions to improve their outcomes. Now, when it comes to addressing treatments for substance use disorder and overdose, we have multiple new studies, whether that's testing of new medications or such novel approaches as vaccines that might reduce the reward and reinforcement if drugs are used. These are just some of the approaches. We're even developing the use of transcranial magnetic stimulation or TMS machines. These have come into use for the treatment of depression, of obsessive compulsive disorder. We're seeing them being used for tobacco use disorder at times, and so what role might they play in the opioid crisis and with other forms of addiction? This is a promising area of development right now. I would point out that a key theme, though, in all of this is as we develop new approaches, how do we make sure that they're out there in communities that really need them? I'll highlight for you the healing community study that is testing what happens if we implement naloxone distribution and better access to medications for opioid use disorder and community action campaigns and community education campaigns and all the other approaches that look like they may be effective to address overdoses. What happens when we bundle those together and address the local needs in communities across the country? Well, this study has 67 communities spread across Massachusetts, New York, Ohio, and Kentucky, and half of them are implementing this broad-based approach that pulls together all of these different strategies to reduce overdose. They're doing that right now. Starting next year, the control communities will also start doing the interventions, and we'll look at how big an impact there is between the communities that implement them or on the immediate basis for those that have a delayed implementation. So stay tuned as we look at what happens when we implement today's technology in communities around the country. Will it have the impact that we hope? We have multiple other studies helping to improve the uptake and implementation of these processes. Now, this complex slide reminds us about our COVID-19 efforts at NIH. We've had, as you're well aware, a very successful operation that has led to new vaccines as well as new treatments, and some of these focus on high-risk individuals such as those with substance use disorder as well. I'd say another theme that we've been paying attention to is reducing stigma around addiction. I think that there are ways that you and your practices can focus on this by, do you ask your patients what substances they use, and how do you modify treatment to provide a welcoming environment for patients that may engage in behaviors that are difficult and high-risk in other parts of their life so that their dental care can be taken care of, but perhaps you can refer them for our care for these other issues as well. Now, one of the issues that we focused on is as we're trying to reduce stigma is that the words we use to describe our patients can really make a difference, and so one of the most important messages is to consider using patient-centered language. So I do the best I can not to talk about people as a disease entity, so I don't talk about somebody as an addict, but as a person who suffers from an opioid use disorder or an addiction. Focusing on the person first can reduce the stigma and make it easier to see the person as a whole human being who has specific needs as just one of the ways that we can address what terms to use and avoid when talking about addiction. Now, when we talk about what we can offer dentists in particular, I'd highlight for you some of the material on the website of the National Institute on Drug Use, where there are science-to-medicine approaches, a safe opioid prescribing for dental pain, a dental screening and brief intervention and referral-to-treatment course. These are some of the resources we have on our website, and I encourage you to take a look at them. I'd highlight for you that the American Dental Association and NIDA have partnered, both in terms of now a few years ago, highlighting the role of the oral health community in addressing the opioid overdose epidemic and continuing to see how dentists can play a role in addressing this crisis. Our Centers of Excellence in Pain Education act as hubs for the development of materials, and I encourage you to take a look at this, and if there's some places where you'd like to see us invest, let us know what might be helpful to you. Now, as I highlight for you what some of the approaches are, we think in terms of screening of problems as a key theme. We have materials on our web that can be useful both for clinicians and for patients, so you can encourage your patients that may have an issue to take the brief screener for tobacco, alcohol, and other drugs. It's really a very short questionnaire that helps provide an overall risk assessment, both those who don't have a problem here, if that's important to understand, as well as those who might be at risk for having a use disorder related to tobacco, alcohol, and other drugs where providing direct treatment or referral to treatment would be indicated. The Tobacco, Alcohol, Prescription, Medication, and Other Substances tool is another important tool. This is a questionnaire or a screener that you might consider. It's really two components. One is a very brief screener. It primarily asks, have you ever used each of the substances? Because if you really never used a substance, we don't need to ask further information about it. But for those that report some use of tobacco, alcohol, prescription medications, or other substances, we'll go on to determine what's your likelihood of having a significant problem related to these substances, where we need to refer you for treatment or provide care for you directly. When we think about screening a brief intervention for adolescents, this is another tool available on our website. Again, this is divided into both a patient self-administered, as well as a clinical tool. And it follows this same approach. So it initially asks about frequency of abuse of alcohol, tobacco, marijuana. So this is primarily for adolescents. But if any of them are positive, then you'll ask the same kind of questions for less common drugs. At the end of this, there'll be a risk profile and recommended actions, which could be to complete a full assessment, to make a diagnosis, or it could be to continue their positive life choices and continue to avoid use of substances. Now, there are multiple resources that I can recommend for you, whether these are the treatment resources available through our colleagues at the Substance Abuse and Mental Health Administration. We do have some information on the NIDA website, particularly that focuses on research findings on effective treatment approaches for drug misuse and drug addiction. And in particular, I'd encourage you to pay attention to an infographic on medications for opioid overdose, withdrawal, and addiction. So information that might be helpful to address some of the myths and misinformation about use of buprenorphine or methadone as the most common substitute medications for persons with an opioid use disorder, or the use of extended-release naltrexone, a long-acting opioid blocking medication that has also been shown to be effective in treating opioid use disorder. And our information about these products can be very helpful in guiding patients and clinicians. Now, I've highlighted for you NIDAMED, which is where many of these resources are located. Please take a look at this in terms of screening tools. We're constantly updating this material to include the latest trends, treatment resources. There are some CME programs, and there will be resources specifically for dentists and other health professionals. I invite you and your colleagues to partner with us to improve the dental page. So if you see some gaps there, let us know, and we'll be happy to take your advice into consideration as we're always looking for ways to improve our outreach. I think I've gotten through a lot of material in the last 40, 45 minutes to focus with you on how the overdose epidemic, our addiction crisis in our country, has accelerated during 2020 and indeed into 2021, at least the early months where we have data, during the COVID public health emergency. Now, this may be due to both changes in the sales of fentanyl to many parts of the country that didn't have fentanyl before, as well as some of the direct effects of the COVID crisis in terms of social isolation, lack of access to treatment, and other problems that may have led to increased overdose deaths. As I've highlighted, it's that the synthetic opioids other than methadone, that is fentanyl and fentanyl-related compounds that have been an increasing and a particularly serious concern. I hope you'll agree with me that science offers solutions to these problems. We can offer both shorter term in terms of greater access to continue to today's treatments, because some of them can be very effective if implemented fully, but also we are always investing in tomorrow's treatments and tomorrow's prevention approaches so that we make sure that we build better approaches to deal with these chronic complex conditions known as opioid use disorder, stimulant use disorder, and other addictive conditions. Dentists have a very important role to play both in addressing prescription opioid exposure, and I hope you paid attention when I talked about the importance of minimizing adolescent opioid exposure. So, I'm particularly excited about some of the research that has shown that opioid sparing approaches are just as effective for many dental procedures as providing opioid following a dental procedure. There will be patients though who need them, so are there other ways to intervene? And also, when you discover patients that have an issue related to tobacco use or alcohol use or opioid misuse, what can you do as a clinician to help guide them to changing their lives and to getting a treatment that can be so can be life-saving? Now, with that, I'm very glad to turn it back over to our moderator, and I'm happy to entertain some questions now. I really appreciate your time and engagement this last 45 minutes. Thank you, Dr. Compton, for that incredibly important presentation. It's now time for our Q&A period, audience, so if you haven't already, please type your questions into the Q&A box and we will get started. So, Dr. Compton, how do you envision the dentist helping to curb the opioid epidemic, especially in light of COVID-19? Well, I think as I've highlighted for you, one is to pay attention to the prescribing that you're doing. So, that'll be a first step, is minimizing unnecessary prescribing of opioids. So, that means two things. One, when a procedure doesn't require opioids, not using them, taking advantage of other approaches that can have adequate or just as good control of pain as prescription of opioids. I would also say that the second issue is when opioids are prescribed, minimizing the number of tablets, perhaps asking the pharmacist to only fill half of a prescription, that way maybe they don't have to come back for a full refill, which can't always be done and they need to come in person and you want to minimize the unnecessary inconvenience to our patients, but a pharmacy doesn't have to fill a whole prescription. They can just fill a handful of tablets and a patient can come back in just to their pharmacy at that point. That's a very practical way. I would also encourage you to focus on encouraging your patients and mentioning to them what are they going to do with leftover medications, particularly of parents of teenagers, how are parents going to be partly responsible for the disposal of excess or leftover medications. Those are just some of the ways the dentist can be involved today when it comes to the prescriptions, but I'd also say you have a more subtle and a longer-term role that you will identify patients that have problems with alcohol, tobacco, opioids, and other substances, and so when you do, making sure that you're aware of your local resources you can refer patients to is a key next step. Thank you. Great advice. Here's another question, Dr. Compton. Can dental providers get fentanyl testing strips to have at their offices for patients to take? If so, how do they get them? Well, I think that's a wonderful question. We see a lot of interest in the fentanyl test strips as a potential way that patients can test their own drug supply for the presence of fentanyl. Now, it's really, it's kind of, it's intriguing to me because fentanyl test strips are approved by the FDA for testing of biological specimens, so they're designed and approved for testing urine for the presence of fentanyl. They really weren't designed or maximized for testing of the drug supply, but they're being used in many locations around the country by persons who are very concerned about their, the cocaine that they want to use, the methamphetamine, or the purported heroin that they may be going to administer to themselves, and they want to know if there's fentanyl in it, and so they've been using them successfully. We are seeing some evidence of changes in behavior by some individuals based on knowledge of having fentanyl in their products. In terms of how dentists may get involved in this, you can certainly, they are able to be purchased through online services. If you simply try to purchase them, you can find access to them quite readily. They're not an illegal product, and they are sold in commercial marketplaces. There has been some relaxation of government rules, and so both SAMHSA and CDC have allowed their grantees, mostly at a state level, but sometimes local and other public health entities, to use their funds to purchase fentanyl test strips, so it may be that your local officials within your state, public health officials, or state drug abuse officials may have some guidance for how you in your particular area can gain access to them. I've not heard of dentists distributing them, and I'll be very curious. If any of you all are doing that, please send me an email about that so I can learn how it's working for you. This is an area where we want to understand practices as they're evolving so we can learn from you and from others what works well, what doesn't work so well, where are their benefits, where might there be areas where we could improve practices. Okay, great. Thank you so much, and I know, Dr. Compton, you cited the most recent data that's currently available, but what would you say is the single most important research development dentists should know about at NIDA? I think that's a terrific question, and I would encourage you, it's not always NIDA-based research, but it is from NIH. I would have you pay attention to some of the opioid sparing approaches. I've been really surprised looking at some of what our general surgeon and some of our dental colleagues have been doing in terms of alternatives to opioids for following procedures, things that I would assume you had to use opioids for. It turns out pain control is just as good and maybe even better without opioids. Now, that's not going to be true for all patients, but of course we need to be thinking about liver function and kidney function and gastrointestinal tracts. If you're going to consider acetaminophen, ibuprofen, or other NSAIDs, we need to be thinking about their potential side effects, and so these decisions, there's a reason why these are prescription medications, is it takes somebody with the education and background to be able to weigh these different components in making decisions, but I actually think those opioid sparing studies are really worth paying attention to because they open my eye to where we can make progress and really have very good outcomes for our patients. Thank you. I don't know if you can say we have a question, Dr. Compton, but there was a question about overdose deaths, and typically on average, how many overdoses before a death? I know that would vary patient by patient, situation by situation, but is there a sort of parameter there that you as an expert think would be helpful to the audience? I don't know the answer to that. I do know that a major risk factor for a fatal overdose death is a previous non-fatal overdose death. It's one of the most prominent risk factors, but I really don't have a good handle on the national numbers in terms of all non-fatal overdoses. We're pretty good at counting fatalities, and so we can count on the death certificates as giving us an estimate of overdose deaths. I'll use words like estimates because death certificates are not always accurate, and they're based on the skills of the coroner or medical examiner in terms of what they code and write down on the death certificate, but we do have records of all decedents in our country and national records. I don't have national records in terms of non-fatal overdoses, which will show up in multiple places. One of the issues is people may experience an overdose and never seek health care. They may have been resuscitated by one of their family members, or it may have been something where they turned blue, they weren't breathing very well, but it wasn't fatal, and they woke up, fortunately. The accurate classification will depend on how we define a non-fatal overdose test, but it's a great question, and you piqued my curiosity, and I'm going to see if I can answer it down the road. Thank you. Another question that's popped in, Dr. Compton, you mentioned magnetic stim as a treatment adjunct. Since depression may often be a part of this problem in chronic pain management, what about ketamine as an adjunct, and forgive me if I mispronounced. I also would pronounce that as ketamine. Ketamine, thank you. In the illicit drug markets, it's also often referred to as special K. It's been very interesting to see ketamine treatment being one of the newest and most novel approaches to treating chronic depression that doesn't respond to other treatments. It's administered in a very controlled manner, only under clinical supervision, but it turns out that treatments of a few treatments with escatamine, it's a particular enantiomer of ketamine, can produce relief of depression in a number of patients who otherwise have extraordinary difficulties. Now, I mentioned transcranial magnetic stimulation when I was thinking of, can we apply that in the addiction space? And we are seeing people test that in research paradigms. We've seen early success already in the area of tobacco control, where FDA has authorized use of TMS approaches for persons who don't respond to other treatments for their tobacco addiction. But will that be useful for cocaine use disorder, or methamphetamine, or opioid use disorder? There's some early evidence to suggest that it might be. The question is what targets? It's not just that this is applied to the whole brain, but which pathways? I'm particularly interested in those that go from our frontal lobes to the midbrain. Those pathways are important in judgment and decision-making, and an awful lot of clinical neuroscience work has suggested that diminished strengths of those pathways is seen in many persons with substance use disorders. So, can we strengthen them and change the kind of decision making that people make every day when they're trying to be clean and sober? People have to make a decision. Am I going to use today? Well, all of us recognize that temptation is around us everywhere we go in our lives, and finding the strength to say no, whether that's to something as innocent or minimal as a pastry that we see in a window of a shop, to something as potentially directly life-threatening as whether a relapse on cocaine, methamphetamine, or opioids is something that our patients struggle with. If we can find ways to change that decision-making with such novel techniques as transcranial magnetic stimulation, that's a very exciting opportunity. To what extent does alcohol abuse factor into opioid use? Well, I highlighted for you, at least indirectly, that methamphetamine overlaps with opioids in important ways. I didn't actually show you the data, but while we see deaths increasing for methamphetamine, there have been deaths increasing both in those where the death certificate said there was both methamphetamine and opioids. But even in those where the death certificate doesn't identify a role for opioids, we still saw an increase in deaths related to methamphetamine. Alcohol is similar. People can overdose on alcohol. Anybody that's worked in an emergency room will recognize that you see people come in with alcohol poisoning on a very frequent basis, particularly young individuals who may drink really large amounts are at risk from direct overdoses related to alcohol. The combination of alcohol and opioids, just like the combination with benzodiazepines, appears particularly lethal. So they both may suppress respiratory drive. And so we can understand why the combination might be more dangerous than either one by itself. That's one way I think about this. It's so typical that persons with an opioid use disorder have other substance use problems. Alcohol, tobacco, cannabis, these very, very frequently accompany opioid use disorders. So one of the most important things is if you identify patients who are using cigarettes or other tobacco, those are the patients to ask about alcohol consumption and to be sure to ask about other substances. When you identify problems related to alcohol and tobacco, very carefully probe about other substances. The overlap is so significant in misuse and problems related to them. Thank you. And why don't we take one more question before we wrap up. To close out, Dr. Compton, how can dentists partner with NIDA to ensure mutual collaboration? Well, you can reach out directly to me. You can certainly look on our website at our materials that are for dentists. And if you see gaps or problems, shoot us an email and we'll respond. Great. Thank you. Well, audience, that's all the time we have today. If you have a question about the webinar topic that was not answered, please email dentalpractice at ADA.org. I want to sincerely thank our speaker, Dr. Wilson Compton, and to all of you, our attendees, for joining us on today's webinar. For additional resources and support during this challenging time, please visit the ADA at ADA.org forward slash wellness and the PCSS website at PCSSnow.org. Here is some information on PCSS's mentoring program. We also want to share their discussion forum. These are the organizations that are part of the PCSS coalition. You may find PCSS online here. It's thanks to the strength of 163,000 plus ADA members that helps us successfully advocate for you and bring you essential resources like today's webinar. Don't miss a single development. Join or renew today. This now concludes our program. Thank you so much and have a great afternoon.

webinar

Dr. Wilson Compton

COVID-19 impact

dentists

overdose deaths

opioids

substance misuse

treatment referral

NIDA resources