Good afternoon, everyone, and welcome to today's webinar on prescription opioids and older adults. I am Dr. Hanna Elberti, Senior Director of the Center for Dental Practice Policy at the American Dental Association. On behalf of the ADA's Council on Dental Practice and our collaboration with the Providers Clinical Support System, PCSS, I am very pleased to bring you today's webinar titled, The Special Considerations of Pain Management and Opioid Use in Older Adults. Our speaker today has no disclosures. This webinar is aimed at dentists, administrative staff, physicians, social workers, students, and educators, and interprofessional teams. 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. Our presenter today is Dr. Mehran Mehrabi. Dr. Mehrabi is an oral surgeon who practices in Madison, Wisconsin. He is a diplomat of the American Board of Oral and Maxillofacial Surgery. Dr. Mehrabi earned a bachelor of science degree in chemistry at her Sinus College in Pennsylvania, and he graduated from the Boston University School of Dental Medicine. He also graduated from Emory School of Medicine and completed an internship in general surgery. He also held an oral surgery residency there as well. Following graduation, he joined the U.S. Air Force as a staff oral surgeon in the rank of major and included a tour of duty in Iraq. By the end of today's webinar, you'll learn how to describe special considerations for treating older adults by assessing their pain and interpreting their health status. We'll review risk factors for opioid toxicity in older adults and talk about opioid misuse in the older population. Thank you everyone for joining us today. Dr. Mehrabi did want me to remind our audience that this presentation is not intended for minors as it does contain graphic clinical pictures. Any photos that are shared are compliant with HIPAA or consent was provided. I am now pleased to start the presentation with Dr. Mehrabi. So Dr. Mehrabi, as we start this conversation, I'm going to pose a question for you. We know that many referrals are generated to specialists because of competence or confidence gaps for what might actually be perceived as a very simple root canal or extraction, but it is outbalanced by an extensive medical history. What are some factors that you as a specialist consider in your interpretation of health status in older adults or those with an extensive medical history? Good afternoon everyone. I'd like to thank ADA, Dr. Aperte and Felicia and the rest of the ADA team for inviting me. I also would like to thank the audience for taking time for their busy day to look at this presentation. I hope you find this information useful. So when you're trying to look at your patient and trying to make a decision as how sick is too sick, there are two factors you have to consider. There's going to be the procedure factor and there's going to be your patient factor. In the procedure section, you're going to have to look at to see how invasive is the procedure that you're going to perform and what is the provider's knowledge and skills and experience in management of that particular disease. Sometimes you may have a lot of knowledge, but you don't have the right equipment, whether that's going to be the right drill or the right microscope to do the treatment. And even sometimes when you have that, the patient might be so anxious that they may not allow for you to provide the care that you want. So unless you are managing providing intravenous sedations or are able to do so, or may require to have that extra training, that may not be possible in your particular setting. And look in your postoperative care. This procedure is going to produce a lot of bleeding, or this procedure can result in certain type of infection, or are you able to handle the pain management as goes with that particular procedure? Now look at the same area, the bleeding, the infection, the pain, you can look at it from a patient point of view. Is this patient able to tolerate the amounts of bleeding that is required for this procedure? Are they be able to handle the amounts of pain? Is this a patient that, for example, is very much opioid dependent and subsequently may have a problem with their postoperative pain management? Or if the patient is going to be allergic to five, six different antibiotics and trying to manage their post-op infection might be difficult to do afterwards. Looking at patients specifically, you can look at their general appearance. Is this a patient that is going to be wheelchair bound? Is this a patient that is going to be on oxygen? And if so, do they have adequate amounts of oxygen for you to provide the entire care for that particular patient? When we look at the cardiovascular and the respiratory status, we're really trying to avoid medical emergencies for that patient. Given the fact that coronary artery disease and myocardial ischemia tends to be the number cause of death in the United States, that's what we want to focus on. Particularly in elderly women and diabetic, the cardiovascular disease or myocardial ischemia may present atypically. You may not necessarily see that chest pain. Your patient might be more diaphoretic, may look pale to you, may be more short of breath that you normally see them, or they may even have nausea or flu-like symptom, which may not necessarily a gastroenteritis, but may be a signs of myocardial ischemia. From a neurological point of view, you want to get a general assessment to see if this patient is alert and oriented. Can they understand the procedure they're going to go through? Will they be able to have their follow-up care and instructions followed the way you want to? You want to look at them from a hematology, oncology point of view, particularly we care about wound care. The more rapidly patient heals, the less chance of pain and discomfort afterward, the less chance of complication. And of course, if you're going to write them for prescriptions, you want to make sure that medication is metabolized. So if your patient has a history of liver disease or they have liver failure, that might be a factor. Or if the patient has renal deficiencies that may require dose adjustments, such as if you put the patient on amoxicillin and there are renal insufficiency, you may require to give a lower dose of those medication as you may see elderly. And also we look at vital signs, a very objective, rapid way for tell you to see if your patient is stable or not. Obviously, if your patient has severe tachycardia or hypertensia or their oxygen saturation at room is fairly low or they're tachypneic, that might be a patient that may require more attention and may require more expertise to care for compared to somebody who has stable vital signs. So I talked about cardiovascular and respiratory. And in addition to look at your patient and your skills, keep in mind that we treat patients in team and looking at medical emergency, we want to have that mock medical emergencies to understand that our staff is also able to handle that. So you might be very knowledgeable, you may have the skills, but if you don't have the staff that knows how to handle the emergency, that by itself might be a factor for you to refer the patient to somebody who might be able to handle your sicker patients for you. And along with the medical emergency mock training, you may also do tornado or fire, and then keep in mind with an active shooter in a healthcare setting, our elderly may not be able to run. Of course, that may not necessarily be a factor in a routine daily case that we worry about, but it does become factor if there is an active shooter, which unfortunately we see more often nowadays. And it goes without saying that all elderly tend to be on more medication. By the age of 65, 90% of our patients are in one medication, and up to 30% on five medications. And every time a patient is going to be on a medication, you look at their possibility for adverse effect from that medication versus complication. And adverse effect is something that we expect, such as diarrhea, we take in antibiotic, about 10% of them may cause that. Complication would be something like C. diff with administration of augmenting. Chances are low, 0.01%. It's not something that you're seeing, it tends to be more severe. So when you're trying to make an assessment of whether you're going to put a patient on a medication, just like any other medical decision, you look at the severity of complication multiplied by its prevalence. When you look at the drug interactions, there are three ways of looking at it. We look at drug-drug interactions. Excuse me, there could be a drug-disease interactions or a drug-healing process interactions. And nowadays, with a lot of our patients being on herbal medication, we also worry drug-herbal medication interactions. From 1998 till 2010, there has been a 50% increase on the patient that are taking ginseng, ginkgo, and glucosamine. And that's important factor. These medication that starts with G, remember that they can increase the risk of bleeding on the patient. So if the patient is on these medication, and patient is also taking warfarin, and you're going to perform some sort of a surgical procedure on them, there are going to be a much higher risk of bleeding compared to a patient that is not on herbal medication. So in your medical history taking, it's important not only asking them about the prescribed medication, but also to include herbal medication. Here's a presentation of a friend of mine who I operated on, who was otherwise healthy and had orthognathic jaw surgery. And typically, this is not how my post-operative patient looked like. And what happened in this particular case, my patient was taking NOAD, a medication that taken by bodybuilders to pop up their veins. Well, that causes vasodilation, secondary to the noxious oxide, and subsequently resulted in significantly more bleeding that I expected. The more bleeding results in more edema, which subsequently can result in more pain, but also much more delayed healing, which might be a factor for our patients. When we look at the drug-drug interactions, keep in mind that there are multiple ways of looking at it and how it can be affected. Sometimes drug A can potentiate the effect of drug B. So if a patient is on fentanyl patch and you would write for oxycodone for pain management, you know, you're going to get a better effective pain management, but also keep in mind there's going to be higher risk of respiratory depression and respiratory failure on that patient. Sometimes drug A can inhibit the effect of drug B, exact opposite of that. Your patient is on naloxone or naltrexone as narcotic deterrent medication, and you would prescribe oxycodone. So through a competitive inhibition, you're going to be less effective that particular medication. Sometimes drug A and drug B directly don't interact with each other, but there is going to be an enzymatic activity involved. So if a patient is taking warfarin and you would prescribe metronidazole because you're concerned about an anaerobic infection, maybe from periodontal disease, metronidazole causes inhibition of cytochrome P450 and subsequently increase the concentration of the warfarin, which subsequently increase the INR on that patient, which subsequently can result in increased bleeding on that particular patient. And sometimes the drug side effects of drug A and drug B are very similar and subsequently results in potentiating effect of each other. So if a patient is on amitriptyline, particularly in elderly, and you would prescribe azithromycin for an infection, well, both these drugs can result in increased long QT interval. And if you take them both together, the chances of long QT interval progressing to a ventricular fibrillation and patient expiring is going to be significantly more elevated. Because of all these drug interactions that we worry about, particularly in elderly, which tends to have more medical problems and they take more medication and they have a slower metabolism, Dr. Beers in 1991 developed a list of medications, particularly in elderly, initially in the nursing home, look at the prevalence of those complications, trying to get a sense of which medications are inappropriate in the elderly or appropriate with certain conditions or should be used for cautions. For example, if our patients are chronically taking benzodiazepines for sleep or anxiety, we would have to be very cautious about writing for opioids for those particular patients. One factor that is commonly missed in assessing patients' appropriate surgery and looking at their medical history is the social factors, particularly paying attention to see if your elderly patient lives alone. So the college kids that lives alone and the elderly that lives alone tends to be much more concerning, particularly if that elderly has multiple medical problems, particularly if that elderly is going to an anticoagulant. So it's not uncommon for me to ask him, do you live by yourself? And is it possible for your sons or your daughters to come stay with you for one night? Because the first night tends to be, you know, of the more difficult nights and would be always nice to have somebody extra. Also, pay attention to the role of the caregiver that is going to be there as well too. Is this somebody from the family? Is this somebody that is caring or is this somebody that is more distant and don't really care about? They just want to drop off the patient to the next person. Also, sometimes they can be too enthusiastic. Are they too enthusiastically asking for opioid narcotic pain medication? Well, the patient is going to be a fairly minor procedure. Of course, we have to pay attention to HIPAA and respect the patient's privacy. Sometimes our elderly are going to have power attorney of health care, and it's important to either face-to-face or over the phone to talk to the patient, to the person who does have that power attorney. A couple of more other factors in the social history, we also look at drugs and alcohol intake, and sometimes that culture becomes a factor. Here in Wisconsin, drinking beer is not considered an alcohol. Beer is different, and when we say alcohol, we mean hard liquor, which most often tends to be old-fashioned and brandy. Each sort of group may feel that a little bit different based on their culture. Also, just because they are giving you a list of medication, that doesn't necessarily mean they're taking those medication. Unfortunately, nowadays, medication can cost a lot, and it wouldn't be unusual for your patient that is severely antihypertensive, they're severely hypertensive. They might be because they haven't been able to afford to take their medication. Oh, great. Thank you, Dr. Mehrabi. And now that you've taken into consideration the medical and social history, can you explain to us why it's so important that a pain assessment is done? Of course, pain is a part of the healing, but it's kind of more important for us as clinicians. Pain helps us to diagnose the disorder the patient has. Is this a periodontal disease? Is this a pulpal disease? Is this a tooth fracture? And how fast is the patient progressing to get worse? If a patient has mild pain yesterday and very severe pain today, that means that this is something that is progressing very rapidly. And if you do provide a treatment for the patient, we hope that the pain is going to decelerate and decrease. So, it helps to tell you whether your surgical or medical treatment that you're providing is effective toward the patient. It is important to us as clinicians to learn how to describe pain, which can be fairly difficult if you haven't exercised that before. Not only for yourself or documentation to refer back in the future, but also when you describe this to your specialist as you send information to the specialist if the patient does require a referral. When did the pain start? How fast is it growing? Is it radiating to the ear or jaw? Is it pain with function or is it at rest? What sort of treatment has been done in the past? Is it getting, what makes it better? What makes it worse? They tend to be fairly important in describing the pain. Also, keep in mind that the emotional factors can be affecting how the patient is going to describe their pain to you. If a patient is having significant amount of fear, they tend to downplay their pain. If they're anxious, if they're angry, if they're stressed out, they tend to exacerbate that. Also, keep in mind their past experiences and dental memory of the, you know, previous office visit does play a factor of how nervous and anxious they would be and subsequently how they express that amount of pain to you. This is not only present in human, but also you could see in other mammals as well too. So in study of 14 dogs, when they looked at the olfactory pickups of a stranger, strange dog, playmate dog and their owners, majority of the senses were picked up by a pet MRI with of course the sense, but the owners resulted in an elevation of the intake of glucose glycoidate in the basal ganglia and subsequently showed that not only in human but also in animals memory of a pleasant memory or a bad memory tends to stick around and stays in the person and you know make the patients react. So pain assessment is important because you can only improve what you measure and there are a whole variety of systems there to measure pain. One of the simplest one is the Wong-Baker faces pain scales which goes from the score of 0 to 10. We work in the face area and this kind of a fairly easy way of evaluating the patient takes about a few seconds to do, but it is important. You want to record the numbers that the patient tells you as subjective as it might be and to pass that information to the specialist or when you come back and see the patient in four days afterwards you can refer that today to see is your treatment is working for the patient or do we need to change course and go a different direction. Very similar to that we have the visual analog scale where a patient can mark somewhere a scale of 0 to 10 where the patient pain might be and that doesn't obligate them to a specific number. Keep in mind that there are a bunch of other pain questionnaires that can take pages and pages to do. They're primarily written for chronic pain management and probably are ineffective or unsuitable in a dental chair to be used for acute pain management. Okay, can you share some of your thought process when considering a prescription for opioids and the specific risk factors for opioid toxicity associated with older adults including comorbidities, cognitive and physiologic changes as we age? Dentists have been involved with pain and pain management since the early days of anesthesia. Pain management is a center part of a dentistry as a business. If you look at globally there are various steps where we can interfere to minimize the amount of pain for the patients. I like to bring your attention particularly toward their accelerated healing. If our patients heal quite faster they're subsequently going to have a shorter recovery, less pain, less need for analgesics, particularly opioid analgesics, and this is where science and innovation can be very beneficial. We know that there is, for example, platelet drive growth factor within the platelets and we try to incorporate platelet-rich plasma or LPRF which kind of acting like a tissue group. For some of you who have not seen the movie Old by M. Nutt Shamlott, I would recommend you see that and you understand what I mean. If you can within seconds make the gum tissue look like the patient had surgery four months ago, then there won't be any need for any pain management. And I do think that, you know, we have the ability for that innovation. If we can come up with a vaccine in three months for COVID, I think that can be done. But nothing is going to take over the good surgical skills. If the provider has good skills, they are going to always provide a less traumatic surgery, so intraoperatively patient would be less traumatized and postoperatively things can move forward in a more predictable measured manner, versus if we are trying to be haphazard treatments where we don't really understand our patients or the procedure that is being provided, you may end up with such more disastrous results. And in that regards, postoperative instruction is also very important for the patient. We don't want to forget about that. Here's a presentation of a patient that had performed biopsy, and I failed to communicate well with the patients on how to take care of themselves afterwards. And subsequently, we ended up with a much bigger ulcerative lesions with much more amounts of pain, requiring much more extensive pain management afterward, which could have been all prevented more or better if I would have spent a little bit more time describing to the patient on how to take care of themselves afterwards. So we want to describe to the patient a brief summary of what is involved in the recovery course, what medication you're going to give them and how they should take it, and look at their chronic medication. If you stop the medication for the procedure, if the patient was stopped their Coumadin or their Eliquis, Ralto, etc., and they need to go back on, this is the time that you would need to talk to them about it, how they should proceed as far as their diet and activity, and of course their wound care, you know, when should they start rinsing with salt water and so forth. And something that is very important is the patient should know what to report and how to report to the provider. There needs to be an access to the aftercare provider in case there is significant amounts of bleeding, if the pain management is not working, or if the patient is starting to develop an allergic reaction. Keep in mind when we are dealing with elderly, the person that is going to be there with our patient is not necessarily going to be the person that is going to be taking care of the patient, so there is going to be possibility for transfer of the care. Writing information can be helpful, providing phone number in the notes of the post-operative instructions can be helpful, and giving a phone call afterwards when the patient's settled can be beneficial because, you know, it might be a son taking care of the patient and that son drops the patient off at the nursing home, so it would be good to get the nurses in charge to tell them what has been done, what sort of dressing the patient have, and how they should take their medications afterwards. So, if I'm trying to look at my patient and trying to make a decision what am I going to write for pain medication, there are going to be basically two important factors for me to look at. I'm going to look at the patient's medical history, I'm going to look at, you know, medications they are taking, I may call and talk to their primary care providers, look at the electronic prescription drug monitoring program, but something extremely important, unlike our young adolescents who have never had surgeries before and don't know what would work for them, our elderly have quite high number of surgeries in the past, so you can kind of go through that and see, excuse me, what they have taken in the past and what works. At the same time, you can get a sense of what's the patient's pain tolerance. If a patient has taken just Tylenol for a history of pancreatic cancer or shoulder replacement, chances are they're going to be fine with Tylenol for dentistry, and also you have to look at your invasiveness of the procedure. If a patient is going solely through a restorative treatment, I don't think necessarily need to be very aggressive as far as providing significantly strong analgesics afterwards, whereas if you are providing a much more invasive procedure, then certainly you can kind of go in more detail to that. Now, here are some examples. On the right side, you see a fibroma can be easily removed. This patient may recall minimal amount of analgesics afterwards. This procedure tends to be fairly painless, versus the procedure on the left side, you're seeing a patient who had a fairly traumatic experience, and that patient is going to have significantly more amount of pain. Keep in mind, the amount of pain does not always go with the severity of the disease the patient had. Here's a patient who had a very mild pain after developing an ulceration over their growth after two years. This patient ended up to have a squamous cell carcinoma, but very amount of pain. So, pain and severity of disease, they don't necessarily go together. In patients who have dental extraction, dental extraction tends to be traumatic. They tend to heal via secondary intention, and they tend to be more painful, and they require much more aggressive treatment compared to, for example, a soft tissue biopsy. And dental implants. Generally speaking, dental implants is a measured procedure and do not cause significant amount of pain and discomfort. There is really no age limit on the placement of the dental implant. We want to use some common sense. Certainly, we want to look at their medical history to see when it's appropriate, but sometimes if there is a complication, the patient may develop past pain swelling at the site of the implant placement. They may require simply have the implant removed, not necessarily require a significant amount of analgesics. Sometimes the easiest answer is the best answer. If you see a patient who has an incorrect placement of restorative in their mouth and their complaint of pain and bleeding in that area, rather than discussing what pain medication you want to write for that patient, just go ahead and change their fillings, and that might be a much easier procedure. More invasive the procedure within the bone, it's going to cause more pain and may require more aggressive treatment. But not all invasive surgeries are going to be requiring more severe pain. Here's a patient who is elderly, has fairly large lesions between teeth number 19 to 21, sounds big, looks painful, but it's mostly soft tissue. And this particular patient did fine by just taking Tylenol afterwards and providing phone number for the patient as far as access to care if Tylenol does not work. So most often patient wants to know that they're not being abandoned afterwards. Here's another example of patient that was referred to me for implant tooth number 10, which obviously probably, you know, is not the right treatment. This patient and more than likely this patient looking at maxilla and mandible will require full mouth extraction, but don't be committed that necessarily that you have to do all your treatment in one visit. By separating the number of the visit, it would minimize the amount of pain the patient may have, shorten the procedure, and subsequently it may result in the decreased need for writing for analgesic pain medications afterwards. Sometimes we preemptively give medication to the patient to minimize the amount of post-operative pain, and certainly that works well by using steroids, IV steroids, or giving them enzoids. The anxiolytics and opioid analgesics may cause a problem, interfere with getting a consent, unless they're obtained on a different day on a patient. One thing that you may hear from more from teenagers than elderly is something called pineapple tea with the active ingredient to be brolyamine has been shown to decrease the amount of post-operative pain in the patients because of its anti-inflammatory effect, which is a little bit much simpler and less toxic compared to what they use early 1900, where they use a combination of gene sugar, water, cocaine, heroin, and therazine, which I can imagine would be much more unpredictable. So our armamentarium for pain management, we have our acetaminophen, nortelano, our NSAIDs. We want to be a little bit cautious about use of selective COX-2 inhibitors in patients with a history of coronary artery disease or MI. We have our opioid analgesics. Preoperative steroids can be helpful. Diphenhydramine or Benadryl can be a little bit problematic in our elderly, as it can result in acute delirium in those patients we would try to avoid. Long-acting anesthesia, including the liposomal preparation, can be also fairly beneficial by providing acute pain relief without significant systemic side effects. Not all opioids are the same. We look at opioids through their morphine milliequivalent. This gives you a sense of what are the chances for the respiratory depression and what are the chances of addictions and dependence on that particular opioid. So, for example, hydrocodone has a morphine milliequivalent of one versus codeine or tramadol have a significantly lower morphine milliequivalent and oxycodone significantly higher. And what that means is that hydrocodone and oxycodone are not the same. If you have to write for oxycodone, you should write for significantly lower number of quantity compared to hydrocodone. And be aware that our patient tends to be on chronic pain medications nowadays quite a bit. And it's important to look for drug interaction between the two. And also be aware if a patient is, for example, on one NSAID and you put them on another NSAID, you're going to increase the risk of renal toxicity and increase risk of renal nephritis. So, pay attention if a patient is taking Celebrex, for example, for arthritis and you write them for Motrin, you can increase the risk of toxicity in those patients. And if you want to write for acetaminophen and ibuprofen, it's important to know what are some contraindications to write of these medications. We know that acetaminophen is metabolized by the liver. So, if our patient has any form of liver failure, they may result in increased liver toxicity. Acetaminophen by itself is hepatotoxic through a free radical intermediate. Medications such as phenytoin, which is used for seizure. Tegretol, which is used for seizure isoniazid, which is a TB medication, can increase the concentration of acetaminophen through the enzymatic activity. Although rare, patients can be allergic to acetaminophen. But the most important one to know is that the patient may already be taking other medications that are containing Tylenol in them. So, we want to make sure we don't exceed the 3000 daily limit. Patients who we may want to prescribe Motrin, obviously, if they're allergic to Motrin, we want to avoid that. Some of the other absolute contraindications would be pregnancy, because of the premature closure of PDA. If a patient's taking lithium methotrexate, which has a low therapeutic index, or glucose 6-phosphate dehydrogenase deficiency, which can result in acute hemolysis on those patients. Some of the contraindications are kind of more of a less important, or shall I say a relative, would be asthma, hypertension, or coronary artery disease, or ACE inhibitors. When we do use ibuprofen, particularly, we like to use that as a schedule. Tell the patient to take it every six hours, to allow it to build it in their system, to get rapidly to a steady state concentration. Keep in mind that when we do talk about early, because of the decreased metabolism, they may achieve the steadiest state concentration on a lower dose, and faster. So, you may not necessarily have to give the same amount of medication to them. Also, keep in mind that ibuprofen not only helps with pain, but also helps to decrease inflammation, but that would require a higher dose. And decreased inflammation is important, because that reduces the amount of tissue destructions down the line afterwards. So, overall, we're going to look at three levels for pain management in order for me to decide what I'm going to write my patients. Most of the patients can be well-managed by taking acetaminophen and NSAIDs. These are the patients that are going to have, you know, less than five out of ten pain. For majority of the third molar surgeries, which tends to be much more invasive procedure, I may go to a level two. I will write in the NSAIDs and acetaminophen as scheduled, and may introduce the short-acting opioids for limited purpose, maybe a few pills here and there in case the pain is severe. And very rarely do we see a patient that is going to have such a significant severe pain that may require to have opioid on schedule, in addition of taking acetaminophen and ibuprofen as well. So, Mehran, if possible, can you just use the next few minutes to go over some key points about opioids? And because this conversation is specific to older adults, can you give us some key findings with opioid use in older adults? Okay. So, in regard to the use of opioids in elderly, you know, dentists are not the number one as far as the writing prescriptions. It tends to be more coming from family physicians and internists, particularly as it relates to the dental matters. Our emergency rooms are not really equipped for management of dental pain, and all the doctors in the ER having the armamentarium is writing prescriptions. Also, rural dentists, because of the lack of specialty care in order for them to kind of provide some sort of a band-aid help until the patient can travel to a larger city to see specialists, they may have no choice but to write for opioid pain medication. So, these combinations have resulted in increased amounts of opioids that are prescribed. Unfortunately, nowadays we have as many as 50,000 who have passed away from the opioid and 40% of those were true prescription medication. It's not only produced a devastating problem for the patient and their family, but also causes significant amount of cost for the healthcare as well as decrease in the productivity of the patient and as well as their family. But we are improving, we're getting better. In 1990s, we spent about 15.5% of our prescriptions in opioids. By 2012, that number has decreased to 6.4. This improvement primarily is due to patient and dentist education limitation on the number of the prescription opioid we write and decrease in the number of the leftovers and the use of electronic prescription drug monitoring program. But the first step in understanding of solving a problem is knowing that there is a problem. So, when we look at elderly, of course, that when they come to your office, you know, be concerned about a patient who is at altered mental status or elderly can be more prone to dementia. The most common type of dementia is Alzheimer. But the patient can also be developing very rapidly. And if a patient is developing very rapidly, this might be a signs of opioid toxicity, which is a part of a delirium. Delirium tends to be acute, secondary to either an acute illness or a drug toxicity. They're reversible. And opioid toxicity will fall one of these categories. So, normally when we think of elderly, this is what, I'm sorry, normally when we think of somebody who has drug abuse or substance use disorder, this is what we think of. However, be aware that elderly can very well be in the category of people who may abuse drug. I remember, you know, way back in my early in my residency, I had a patient who had a facial fractures look like very similar to that young lady over there. And when I went to do a physical examination, he had a swollen foot, secondary to the heroin injections to her foot. So, we don't normally think of these patients as being a substance use disorder patient, but they could very well be secondary to maybe previous prescriptions they got or issues in life. And one thing interesting to note is that unlike our younger population who get most of their opioids from dealers, our elderly tends to get majority of those medication through healthcare providers, maybe because of to do with Medicare and having health insurance, maybe because the prescriber may not be as attentive to kind of to look at substance use disorder in the early as they might be with the younger person. And not only they can be drug abuser, they can also be drug dealers. They may use the leftover medications to sell to supplement their income, or they may unconsciously leave the medication unsecure and somebody else who comes to their home may take that medication and try to sell them. So, generally speaking, the substance use disorder tends to decrease as we age, but there's recently has been a substantial increase in the substance use disorder in elderly to as many as 1 million. This has been an increase from 3.4 to 7%. This is study from July. So, you can see that the problem is not over. And certainly ease of access is one of the most important factor along some of the other medical changes that goes toward the brain. Great. Thank you, Mehran. So, from this presentation, what would be the key points that you want us to leave with? So, here's the key point to this. So, it's important to understand that even if you do the right thing, writing the pain medication who actually has pain, and writing that correctly, that patient can still develop abuse, addiction, and devastating lifelasting problems for themselves as far as their family. So, because of the complex medical history, we're not going to be able to just forget about this and avoid this. Sometimes, you have no choice but to use narcotic pain medication. But opioid analgesic should not be the first line of therapy. It should be reserved for severe pain for a short period of time with limited purpose. As we always say with elderly and pharmacology, we want to go slow and low. So, the lowest dose possible and start on the lowest medication potency and efficacy, so you don't have to overdose your patient. We look at the drug-drug interaction. We talked about use criteria, particularly paying attention to prescribing opioids for patients who are on benzodiazepine. An increase that, you know, as we get older, the number of medications tends to increase. And if I can emphasize one last thing, treat the patient as a team. We, you know, we don't treat patients alone. You have hygienists, you have your assistant, front desk staff, they all can give you input in your patient management. Ask the primary care provider and medical specialist for their input if you're not sure how to proceed. And your specialist, they have gone through the same thing, so kind of may have a little bit more experience in that particular field. So, don't hesitate to give them a call, send them an email presenting the case to them to say, how would you manage this patient's pain? And they can be, I'm sure, more than happy to provide you with some support. All right, great. Thank you so far for everything with this presentation. We do have an opportunity now to answer a few questions. And looking through the Q&A, we have individuals on this call from all parts of healthcare, which is wonderful. But I think a great question that might be on a lot of people's minds is, for patients who cannot tolerate NSAIDs and for whom Tylenol is not sufficient pain management, what would you prescribe? You know, it is rare. It's probably more rare than you would think. So, we want to look at first step to get is what experience the patient has had in the past. Unfortunately, patients have some misunderstanding regarding pain medication and pain management. For example, it's not unusual for us to hear from a patient indicating that, I'm allergic to ibuprofen. And when you get a little bit further, they say that, you know, well, my mother can't take ibuprofen. And subsequently, I'm allergic and I cannot take that medication. We know that there is no correlation between the two. So, you know, just it's important to kind of dig in a little bit deeper into that. The second thing you want to see is what sort of side effects the patient gets. If a patient indicates, for example, I cannot take NSAIDs because I'm worried about, you know, stomach bleed, then you want to kind of dig into that, you know, well, I was just had stomach pain once, so I thought I had ulcer versus somebody who has actually been scoped and they saw an ulcer, then their hemoglobin went down to seven. Those two scenarios are very much different than each other. Another thing to point out is that patients may come to you to say that, you know, when I was in my 30s, I took a lot of ibuprofen and subsequently ibuprofen does not work for me. I can tell you for 100% certainty that there is no such thing as tolerance to ibuprofen and tolenol, meaning that taking the same dose, you're going to get the same results. You're not going to have a decrease in the results if the patient has taken it before. Now, granted, if you take ibuprofen for a long time, you have to monitor the renal function to make sure the patient is not going to have interstitial nephritis, but the efficacy of the treatment does not decrease over time. So, pay attention a little bit into, you know, why the patient indicates tolenol and ibuprofen does not work, because in reality, those populations are low. And if the patient does indicate that it doesn't work, you know, unfortunately, right now, we don't have a lot of choices. You know, we have many, many choices for diabetic medication, for hypertensive medication, but our choices are very limited, you know, when it comes to pain medication. My hope is that, you know, within the next five years, we're going to come with a newer mechanism action for medication that we can use. You know, you can think of some sort of alternative therapy to see if that would help, but it's going to be use of a long-acting local anesthesia for the patients, a different category of NSAID if you would like. And if those are not possible, you know, your next, you know, sets of options could be codeine or tramadol. Both of them can have some trouble, so it's important to investigate whether the patient has taken those medications before. Tramadol also may come in ultraset or with a combination of tolenol, even at the therapeutic dose can cause seizure, which is, you know, can be concerning. Also, patients who take SSRI, such as Zoloft, Prozac, Apaxil, can have serotonin syndrome by prescription of tramadol, so you're going to have to be careful with that as well too. If you do have to write for the prescription for the opioid, understand what you're trying to achieve and limit the number of medication and put the patient on more recalls. Don't just send a patient with a high number of prescriptions and say, all right, I'll see you in two weeks. You know, maybe you want to have the patient come back in three days, give them a limited number, and have them come back and see, you know, how they're doing. So, the sooner we get the patient off that medication, the better you're going to be off. Okay, great. Thank you, Dr. Mehrabi. There was also a question or perhaps more of a comment about discussion with older adults and the prescription for narcotics, and I just wanted to highlight that one of our ADA team members did post in our chat that we have available two new resources. One is a guideline on having that discussion with a patient when you have decided that a narcotic is appropriate for short-term pain management, but more importantly, there is a checklist that you can use with your patient to make sure that they're understanding of proper storage and risks associated with that. Now, I believe we may have time here for one more question, and the questions are wonderful. I wish we could have a part two to this. It would be, I've seen some dentists recommending Ploradol as pain medication over ibuprofen. Is there any difference? Big time. Absolutely. Especially in elderly that we are talking. The risk of renal toxicity with Ploradol is significantly much more elevated. The risk of peptic ulcer is going to be significantly more elevated. So, I'd be very cautious about writing Ploradol for the elderly. You know, one thing that I think that the dentists are in disadvantage is we don't have easy access to the lab or other labs for our patient. So, you know, Ploradol is a wonderful medication as long as you can monitor the patient's kidney functions. So, you know, renal failures is four categories, stage one through four. So, we look at the GFR or very closely related to that cleatherine clearance to get a sense of that. And what happens, you know, if you put the patient on even a week of Ploradol, they can, they can cause significant amount of renal damage and subsequently put the patient in renal failure. So, even in my younger patient, when I do write for Ploradol after third molar surgery, I only write it for, for 10 tablets. And if I feel that I need to continue to write for more, I usually send them to the hospital to get a creatinine level before continuing on that medication. So, although the good point is that, you know, if a patient is not able to take one NSAID, that doesn't mean they cannot take the others. Or if one NSAID doesn't work, that doesn't mean they cannot take, you know, other NSAID with a better efficacy. But Ploradol tends to be much more stronger with a higher side effect that can be a factor. Now, Ploradol does come through intranasal fashion, which can, for those of you who are not able to do IV placement, it might help you for a rapid release of pain in the clinic. Say, for example, you have a patient, you've performed an IND, your local anesthesia is not working, your patient is crying a lot of pain, saying it really hurts. This is where that medication can be really helpful. So, keep in mind, if a medication is taken sublingual, transbuccal, or intranasal, it has a reduced first bypass effect, which means that it doesn't get metabolized by the liver as you would do with the oral, and subsequently it's going to have more potent results. And this is where it can be very beneficial because you can get a rapid release of pain. You just want to make sure that patient doesn't have a contraindication to take Ploradol. Okay, Mehran, I think we have time for one more question. And this one would be in regard to, let's say you have a patient, and over the age of 65, they're in your chair, you've decided the diagnosis is pulpitis, you've treated accordingly, but you know that you have to manage some post-op pain, and you've decided on a prescription. How can you assess if this patient is at a higher or lower risk of developing substance abuse? The CDC has provided some good guidelines that can help with that. So, there are three factors that I would suggest to look at. You're going to look at the patient's factors themselves. You know, we can ask the patients, and they most often they tend to be honest with their providers. You know, have you used narcotic pain medication in the past? Have you taken illegal drugs in the past? Any history of alcohol abuse in the past? Yeah, and we look at their family history. You know, it is well known for patients or people who have a family history of alcohol abuse, they're going to be at higher risk of alcohol abuse themselves. And same thing goes with the drug abuse. So, if my patient's parents, sisters, brothers have a higher risk of or had a history of alcohol abuse, I tend to be more cautious with them. We also want to look at the history of psychiatric disorders, bipolar, depression, anxiety. And I understand that, you know, 25% of the U.S. population has some form of anxiety or depression. But unfortunately, psychiatric factor, particularly the bipolar or CD, for example, schizophrenia, that puts them at higher risk of drug abuse simply because of their mental health status. Okay. Well, I just want to say that's unfortunately all the time we have today. And I know you had enough content to do three of these. But if we did not answer your question, we will do the best we can to address them as quickly as possible. Additionally, if you have a question about today's topic, please email dentalpracticeatada.org. And I want to sincerely thank our speaker, Dr. Mehran Mehrabi, and all of you, our attendees, for joining our webinar today. For additional resources and support on the topic of opioids and wellness, please visit the ADA at ADA.org forward slash wellness and the providers clinical support system at PCSSnow.org. Here is the information on the PCSS mentoring program. We also wanted to share information on the PCSS discussion forum. PCSS is a collaborative effort led by the American Academy of Addiction Psychiatry in partnership with these organizations. You may find PCSS online here. And the ADA is a CERP recognized provider. Track your credits and learn more about upcoming events in one spot at ADA.org forward slash myADA. It's 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. Funding for this initiative was made possible in part by a grant from the Substance Abuse and Mental Health Services Administration. And this now concludes our program. On behalf of the ADA and PCSS, thank you and have a great day.

Prescription Opioids and Older Adults

Dr. Mehran Mehrabi

pain management

opioid use

older adults

evidence-based practices

substance abuse

safe prescribing practices

grant funding