Hello and welcome. I'm Dr. Donna Rowland, the Psychiatric Mental Health Nurse Practitioner Program Director at UT Austin School of Nursing and the Nursing Expert for SMI Advisors Clinical Expert Team. I'm pleased that you are joining us for today's SMI Advisor webinar, Navigating the Complexities of Opioid Use Disorder, Comorbid Psychiatric Diagnoses, Implications for Older Adults, and Changing DEA Regulations. Next. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Today's webinar has been designated for one AMA PRA Category 1 Credit for Physicians, one Nursing Continuing Professional Development Contact Hour, and one Continuing Pharmacy Education Hour. Credit for participating in today's webinar will be available until January 30, 2024. Slides from the presentation today are available to download in the webinar chat. Select the link to view. Captioning for today's presentation is available. Click show captions at the bottom of your screen to enable this if you wish. Click the arrow and select view full transcript to open captions in a side window. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for Q&A. Now I'd like to introduce you to the faculty for today's webinar, Ms. Melissa Rivera. Melissa is a psychiatric mental health nurse practitioner and the mental health manager at Suvita Health Care in Austin. She has years of emergency room experience and has served as a bilingual staff therapist at the Center for Child Protection. She has extensive experience in treating substance use disorders in both outpatient and inpatient settings. Melissa, thank you so much for leading today's webinar. Thank you, Donna. I'm Melissa Rivera and these are my disclosures. I am a paid promotional speaker for Alchemy and that will not be discussed during our session today. Learning objectives for today's module is for the following. We're identifying the most common comorbid psychiatric diagnoses with opioid use disorder. Ideally understanding the impact on the older adult population and opioid misuse and diversion. And finally, being able to outline the updated Drug Enforcement Agency DEA registration and renewal requirements for all prescribers of controlled substances. Now we're going to take some time to discuss common comorbid psychiatric diagnoses with opioid use disorder. Before we do that, we're going to talk about the aging population. This is the majority of what the data is collected on today, but what exactly does that mean? So when doing the original research for this and identifying various forms of data aggregated, the topic came up about the aging population is not just 65 and up, but subsets within that. So you have from ages 65 to 74 referred to as young old. You have old ages 75 to 84 and then you have the oldest old ages 85 and older. And why is this impactful? It's impactful for various reasons, one of which the baby boomer generation. Those individuals born between 1946 and 1964 currently make up about 22% of the US population. These individuals are currently transitioning into older adulthood, and this is going to make a huge impact on data as we continue to follow that, those trends over time. And this will impact data that we do get for the geriatric population. So what we see here in this table is various, at the top left here, is severe mental illness in the aging population. This is all adults, so ages 18 to 65. Those individuals who have comorbid medical diagnoses with severe mental illness like schizophrenia or mood disorders compared to the general population. You can see here that schizophrenia and mood disorders do trend to higher across the board for all medical conditions when compared to the general population, more so with respiratory diagnoses like asthma, emphysema, and chronic bronchitis ranging between twice as high to three times as high of the general population. The same can be said for hypertension and other cardiovascular diseases. That's the general population, all adults. This bottom table, table two, shows the comparison of severe mental illness and those comorbid diagnoses of physical ailments between adults and the 65 and up aging population. If you notice, for the schizophrenia column on the left, all diagnoses, diabetes, the COPD, asthma, upper respiratory, respiratory diagnoses, and cardiovascular disease range higher for those individuals 65 and older compared to their adult counterparts. Now if you look at the mood disorders on the right of that, you can see that it does also trend higher for individuals that are older than 65. SMI in the aging population. Older adults with SMI are at greater risk of receiving inadequate or inappropriate care, including lower quality of health care, inappropriate prescriptions, and reduced access to needed services. Prevalence of schizophrenia, being around 0.5%, and bipolar disorder, about 0.2%, appear to decrease in older adults. However, the prevalence of major depression ranges anywhere between less than 1% to about 5%. The lower prevalence of schizophrenia in older persons, or the 65 and up population, is most likely due to the remission of psychotic symptoms and premature mortality associated with schizophrenia. Older adults with schizophrenia have about a 20% shorter life expectancy than those of the general public. It would be fair to say that people who are 65 and older tend to struggle with severe mental illness, but don't show the same rate as those in the adult population. The reason that could be are for a couple of things. One, there is some treatment remission of symptoms that can occur as time with medication. Also, there is a higher, as mentioned here, a higher mortality rate for individuals with severe mental illness, specifically with psychotic symptoms. That can be due to having comorbid medical or physical diagnoses that lead to premature death, but also there is an incidence of about 17.9% of suicide in the aging population. This graph here shows SMI in the aging population. If you look on the far right, you will see two columns, those individuals with no history of a psychiatric disorder and those individuals on the right who do have a history of a psychiatric disorder. We're looking at correlates here of opioid use disorder among these individuals. If you look on the top, it shows how the aging population with any psychiatric diagnoses are more than double in incidence of opioid abuse or misuse. And this would be at the bottom here, lifetime non-medical opioid use. It's also important to note that 4.8% of older adults are living with severe mental illness. This graph also shows differences of race and ethnicity. SMI in the aging population. Outpatient settings do serve the psychiatric population with adults of SMI. Basically, that consists of a more stable, less acute form of their disorder. And that can mean that they have good management with psychiatric medications. They have mental health care management, which could also involve counseling services or other peer services. And they also focus on management of the psychiatric symptoms. Again, this setting is more stable. Comparing that to the assisted living population, there is an incidence of severe mental illness for those individuals, and it increased to about 54%. And this was between the years of 2007 and 2017. That rise from 7.4, 11.4%, that is an increase, a significant increase in that setting. Residents with severe mental illness have multiple chronic illnesses, which is how they tend to qualify dually for Medicare and Medicaid. And this allows for the long-term setting to be subsidized. SMI and Opioid Use Disorder. These here are the rates of non-medical opioid use, which could also be translated as opioid abuse or opioid misuse, in the middle-aged and older adults. You'll notice here bipolar disorder is 20.8% followed by schizophrenia, 19.3%. Both around the 20% range. Most clinicians don't realize how common it is that individuals living with severe mental illness, such as bipolar or schizophrenia, also have a high correlation of opioid use or misuse. Here's another way to look at the data. The right-hand column just shows the prevalence of the same psychiatric disorders of those not misusing opioids. And it's broken down based on specific psychiatric disorders. Again, you see schizophrenia at the 19.3%, bipolar disorder at 20.8%. The impact on older adult population and opioid misuse and diversion. Opioid use in the aging population. There are various forms of opioid use. The majority of the data did show opioid use disorder as created by the diagnostic criteria of the DSM-5 text revision. Also included was problematic opioid use. This was forms of opioid nonmedical use resulting in social, medical, or psychological consequences. They were subclinical in that they did not meet the criteria for opioid use disorder as outlined in the DSM-5 text revision. Prevalence of opioid use disorder among older adults tripled between the years 2013 to 2018. Problematic opioid use in 2014 was 2% of individuals aged 50 and older. This was compared to the 1.1% that was in 2002. This shows the trend that there is an increase in problematic opioid use. The rise in problematic opioid misuse does correlate with the increase in individuals aged 55 and up seeking treatment for opioid use disorder. Not only are problematic use and diagnoses of opioid use disorder increasing, but so are the older adults in this age group who are seeking care. That's potentially a good thing. We want our individuals who are struggling with opioid use and misuse to seek care. But it is increasing the trend here. So in 2005, the age group made up about 14.1% of substance use disorder admissions in the United States. This was compared to the 5.9% that was in 2005. Opioid use disorder in the aging population, along with comorbidities. Opioid use disorder had about two to three times more medical and psychiatric comorbid diagnoses compared to those in the older age group. This was compared to the 5.9% that was in 2005. Opioid use disorder had about two to three times more medical and psychiatric comorbid diagnoses compared to those individuals without an opioid use disorder diagnosis. If you look here, the most common physical diagnoses on the left-hand column are cardiovascular and respiratory disorders. There are some additional disorders listed here as well that was outlined in the literature. On the right-hand column here, the most common psychiatric diagnoses were major depressive disorder, followed by PTSD and anxiety disorders, then bipolar disorder. Again, this is looking at that correlation between those individuals who did have an opioid use disorder in the aging 65 and up population. Opioid pharmacokinetics in older adults. I think it's important that we understand the physiological changes associated with the aging population as this will help us better understand those risks and adverse side effects that come with opioids in this population. Breaking it up by organ activity and systems, kidney function. Renal clearance does tend to decline as we age about 1% annually after the age of 50. Therefore, there is a decreased opioid clearance. This can lead to increased toxicity and those adverse drug reactions. Now, speaking about hepatic function, when talking about the metabolic activity of the liver, as we age, our liver size does tend to decrease. This is due primarily as a result of the metabolic activity of the liver. Now, speaking about the metabolic activity of the liver, as we age, our liver size does tend to decrease. This is due primarily as a result of decreased blood flow to that area, and therefore, it decreases the first pass metabolism associated with our healthy liver function. This, when regards to opioids, can increase the bioavailability of opioid metabolites in the system. Again, the concern here is that we are at higher risk of respiratory depression as the opioid is not being able to be cleared from our system. Continuing on different organ activity as we age, body fat does tend to increase in percentage for the aging population. This can delay elimination of those agents that are lipophilic, such as fentanyl and methadone, both of which do accumulate in subcutaneous tissue. Therefore, more body fat percentage results in an increased storage of those particular opioids. Total body water tends to decrease in volume as we age as well. This can lead to increase in concentration of those metabolites which are water-soluble. And neurotransmitters. Neurotransmitters lead to reduced therapeutic index as they do change. So dopamine, glutamine, and serotonin changes, neurotransmitter changes over time as we age tend to have a reduced therapeutic index. And this can impact the way that the receptor sites activate or utilize medications. And this can lead to adverse effects associated with opioid use disorders in older adults. A higher likelihood of adverse reactions. Again, the primary concern that we're worried about in the aging population or in general with opioids is a decreased respiratory drive leading to... Continuing on opioid pharmacokinetics in older adults, there is a correlation between increased pain sensitivity and advanced age. It's important because it's more likely that aging population will burn through similar metabolites like morphine quickly, leading to poor pain management. And right here, I did identify that there is a prevalence of older adult patients diagnosed and being treated for chronic pain. Initial peak opioid plasma concentrations with single bolus and maintenance concentrations with chronic use may be somewhat higher in the elderly as well. And the density of new opioid receptors decrease with age, while the affinity of the new opioid receptor site increases. What this means is that there are less opioid receptors with age. However, the remaining receptors become more responsive or sensitive to substances that interact with them. Opioid prescriptions in the aging population. Between 2015 and 2016, an average of about 19.3% of the elderly population filled at least one opioid prescription. In the same time span, 2015 to 2016, 7.1% of those individuals considered 65 and up had four or more opioid prescriptions, opioid fills or refills. This graph here on the left does identify the data across various races, ethnicities, and between genders. However, no notable statistical difference was found in the rate of any use or frequency of use between elderly men or elderly women. Let's talk some more about opioid prescriptions. So chronic pain diagnoses makes up for a large number of individuals over the age of 65. About 45% to 85% of the elderly population has a form of a chronic pain diagnoses. This puts individuals in that age group at a higher prevalence of receiving a strong opioid as a prescription. If you look on the right here, there are outlined lists of weak opioids, strong opioids, and other opioids. Under the strong opioid as identified here, morphine, fentanyl, oxycodone are all identified as strong opioids. So this prevalence of receiving a strong opioid prescription would be in this range. Those individuals with a chronic pain diagnosis and being 65 and up, they are the fastest rate of increased opioid prescribing. This particular age group is more likely to receive an opioid prescription than any other age group. Initiation of strong opioids without a trial of simple analgesics or weak opioids account for a third of the outpatient aging population. And a weak opioid would be outlined here as tramadol, but not listed could also be a Tylenol-3 or alternative. Instead of receiving those trials or a simple analgesic, they were more likely to receive one of these listed strong opioids, such as fentanyl, morphine, hydromorphone, morphine. It's also important to note that since the rates are highest with this population, the aging population, they tend to have more access to supply of opioids. This does put them at a higher risk for diversion. Oftentimes, due to concerns of polypharmacy, a lot of patients in this age group have access to quite a few medications. So individuals that care for them, live amongst them, they are more, they do have access to these opioids, and therefore, it wouldn't be hard to imagine how they're at a higher risk for potential diversion. This graph shows opioid prescriptions over time in the aging population. So again, we're talking 65 and up from 2005 to 2017. You can see that the data trend shows an increase of opioid prescribing in this population, which continues to steadily rise throughout the years. Specific opioids prescribed in aging population over time. This graph shows a data breakdown based on the three subsets we discussed earlier regarding the aging population. You have the 65 to 74-year-olds, the young-old, the 75 to 84-year-olds old, and the 85-plus oldest old. The 85-plus is in green, 75 to 84, blue, 65 to 74, red. It's important to note here that while morphine doesn't show a whole lot of change over time, per se, oxycodone did. There was a big rise there between 2005 and 2017. Same can be said for fentanyl. The highest increase rate, though, was in the 85-plus group. Now, buprenorphine, there was a slight increase, but it still remains low. Interestingly enough, when you look at the tremadol between 2005 to 2017, while there is some increase, then after around 2011, you see it begin to plateau and even slightly decrease. That further backs up what was previously mentioned about weaker analgesics or weaker opioids being prescribed less often than those stronger opioids. Specific opioids prescribed in the aging population over time. The study did reveal significant variations in opioid prescriptions among older patients. The oldest olds, that's the 85 and older, showed the highest rate of increase in opioid prescriptions over the last decade. The aging population may experience more side effects and adverse effects to opioids, and that is again reminding you all the reasons we identified about the pharmacokinetics as our bodies age regarding our renal function, hepatic function, our lipid percentage, body water volume, etc. Due to increased prescribing of opioids in the aging population, there is a high prevalence of chronic use. Therefore, it's important to monitor this patient throughout the course of treatment. Important to critically evaluate the need for initiation of and continuation of any opioid prescription. Now, speaking of buprenorphine regarding safety for older adults. Buprenorphine is an opioid used in the treatment of opioid use disorder and chronic pain, as it does carry similar risks such as any opioid. However, buprenorphine is actually preferred in the aging population due to its unique routes of administration, which bypass the GI tract. By doing so, it reduces the risk of changes in drug bioavailability and absorption. This minimizes direct contact with opioid receptors in the GI tract, decreasing the incidence of GI-related adverse drug reactions compared to other opioids. Transdermal and buprenorphine allows a complete avoidance and bypassing of the GI opioid receptors. Therefore, it demonstrates lower rates of constipation, which is a common side effect for opioids. Buprenorphine levels show minimal increases in renal impairment, and there's no notable rise in buprenorphine-related adverse effects as a result. The drug's Phase II metabolism makes clinical implications for hepatic dysfunction minimal. That's important, again, as talking about our older population regarding renal function, hepatic function, and how over time those can become less effective for clearance of opioids. In this case, buprenorphine shows to have little impairment with those subgroups. Updated DEA registration and renewal requirements for prescribers of controlled substances. Medication Access and Training Expansion, MATE, Act of 2021. It outlined new training requirements for buprenorphine prescribers. All providers now only need eight hours of training to prescribe buprenorphine. This is compared to the previous requirement differential between physician and advanced practice provider hour requirements. Now it's all providers with prescriptive authority, eight hours, all providers in general. Department of Health and Human Services must award grants to professional organizations and education programs for integrating substance use disorder training into curricula. Now, Mainstreaming Addiction Treatment, MATE, Act of 2021, eradicated the data waiver requirement. Impact of this showed that there was an increase in the number of potential prescribers. This went from 130,000 to 1.8 million. Significant. France saw an increase in the use of MOUD by 95% and a decrease in overdose deaths by 79% following the removal of additional licensing requirements. It's fair to say by increasing access to providers, it improved outcomes for patients. MATE training requirements require one of the following. Either a total of eight hours of training from approved organizations of opioid or other substance use disorders when renewing or newly applying for a DEA license. Example the PCSS modules. Award certification in addiction medicine or addiction psychiatry from the American Board of Medical Specialties, American Board of Addiction Medicine, or the American Osteopathic Association. Graduation within five years from a medical school, APRN program, or PA school in the United States. The program, though, must include at least eight hours of opioid or other substance use disorder curriculum. Training can occur in one session or as a cumulative of sessions which equal eight hours of training. CE training can include in-person lecture settings, professional organization seminars, virtual training, etc., if it's provided by an approved organization. Previous training on managing opioid use disorder or other substance use disorder may be used to fulfill these requirements. Also, the past completion of a data waiver training will satisfy the new training requirements. For more information, go to www.aprn.org. And here are the free modules provided by the APNA for an eight-hour curriculum to meet the requirements. And these are the following training objectives of that course. To review the addiction, identification, and evidence-based treatments. To discuss the pharmacology of opioids as it relates to treatment of opioid use disorder patients. To describe the fundamentals of office-based opioid treatment, including the treatment of the comorbid patient. To explain the process of buprenorphine induction as well as stabilization and maintenance. To discuss other approved antagonist and agonist medications to treat OUD. To discuss basic office protocols, including medical record documentation and confidentiality. And finally, to utilize evidence-based resources to ensure providers have the confidence to prescribe buprenorphine for patients with OUD. These are those modules provided by the APNA, and they are free. Conclusions. There are limited studies on the aging population with opioid use or misuse. However, the data does suggest that older adults receiving treatment for opioid use disorder respond just as well, if not better, than their younger counterparts with the same diagnoses. Minimal data surrounding treatment options for older adults with problematic opioid use, which does not meet the DSM-5 text revision criteria for opioid use disorder. Current recommendations for this subset is to consider employing prevention strategies and implementing safe opioid prescribing practices. Remain updated on evidence about medications for opioid use disorder treatment. Thank you for your time today. Thank you for such an interesting and important presentation, Melissa. Before we shift into Q&A, I would like to take a moment and let you know that SMI Advisor is accessible from your mobile device. Next slide. Use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts as a consult. Download the app now at smiadvisor.org slash app. And now we'll shift into some Q&A. Okay, let me see. There is a comment. Thank you. Very informative. We'll start with that. I wanted to say, just back on the PCSS modules, I wanted to say that that stands for providers clinical support system. And Melissa did mention that AP&A provides those modules for free. And I wanted to let you know that they provide those for free for their members and also for their non-members. So anyone can access them that way. All right, so we'll take this first question. Does any of the research of those individuals onset of opioid use and when they started exhibiting symptoms of SMI? Did the opioid use start at a younger age and continue or start at a later age? And that question came in when you were talking about those with opioid use disorder had two or three times more physical and mental health comorbidities. Great question. Thank you. The data did not specifically outline in that way. That would be a really interesting area for further research. But from what the data showed, it didn't identify age of onset for opioid use or in regards to the mental health or mental illness onset of symptoms. So we can look more into that. Hopefully somebody will also consider doing research in that area. Great. And if we can find any more data on that, we will post it on the discussion board that is affiliated with this webinar and we'll show you how to access that as we wrap things up. Okay. Next question. Is there still a risk of dependence if prescribed the weak opioids? Risk of dependence with weak opioids. The data did not specifically outline a difference between the weak or stronger opioid prescriptions. But if you're looking for specific data, we can get that for you. If I'm to speculate, I imagine that there would be a risk for dependence in either, specifically with this population of individuals 65 and up. So I think that there very likely could be with use, chronic use, just as any opioid would lead that. Whether or not it would lead to misuse or abuse, I don't know about that. I know that wasn't part of your question, but that's kind of where my mind goes regarding dependence. So physical dependence, I would likely guess yes, but we can get you some more information on that. Yes, we will follow up on anything that we need to get more research data on for you. Thank you, Melissa. There is another comment. Thank you. I learned a lot and I had a lot of questions about this over the years. All right. There are many more questions coming in and trying to get them organized. Let's see. Next. Does the overuse present itself differently than it does for a younger population? Sorry, I thought I hit the unmute button, but I was still muted. Do you mind repeating that question one more time? Sure. I guess, does the overuse in the older adult population present itself differently than it does for a younger population? I guess they mean symptomatic-wise. Okay, that's what I was wondering, whether it means presentation-wise. That's a great question. I'm not sure that I read anything specifically. I just think with regards to diagnostic criteria, the circumstances might be different, right? When you talk about chronic pain, that was a big piece in the research was the chronic pain diagnoses. Whether that's anecdotal or not, a lot of times individuals with chronic pain, when someone is older, it's more accepted. It's more acceptable, whereas somebody who's younger and complains of chronic pain, that might raise some more alarms for somebody to investigate. How it presents, I think it probably presents similarly, but how attuned we are as clinicians to somebody's dependence or maybe misuse, it might be a little different. I think that's part of the reason why attuning ourselves to the circumstances of the aging population because, yes, as we age, the body does tend to break down. We have some aches and pains. With a lifetime of experiences under that individual's belt, they may have some physical traumas that add to physical chronic pain. It seems more accepted culturally compared to those individuals who are younger, but I don't know if actual symptomology looks all that different. I just think it's viewed a little differently by the clinician who's doing the evaluations. Something you said during the presentation, that even though I believe it was around 20% of older adults have an OED diagnosis, that we as clinicians don't think about that. It's on the forefront of our minds to assess for symptoms of opioid use disorder in the older adults much of the time. Right. Actually, as an aside, not that anybody asked this, but I think it's really interesting, I'm currently working with the older population. I specialize, most of my work is with individuals 65 and up. Currently, my oldest patient just turned 102. Obviously, they're not all that old. All that to say is when I first joined this practice, it was really interesting that the primary care providers were pretty convinced that this population does not struggle with opioid use disorders or even misuse. It was pretty shocking to me. I don't think it's for lack of evaluation or assessment. I think more so it has to do with it's just more accepted that an older individual is going to be in pain and we have to treat it. We have to treat the pain. It's not viewed as abuse or misuse because the face of somebody who carries that diagnosis might look different in our minds than what it is for the older adult. Right. Let's see. Do you know of any outreach models that specifically target older adults like naloxone or fentanyl test strips? Naloxone or fentanyl test strips? Is that what you said? Sorry, I couldn't really hear that. Yes, those were a couple of examples. The question is, do you know, are there any outreach models that specifically target older adults? For example, naloxone or fentanyl test strips. I guess they probably mean providing those for free or having those. I see. Not that I'm aware of, not that it's specifically catered to the aging population, but I do know that there are various programs out there with outreach for individuals who struggle with opioid use disorder or even otherwise. There is a huge public service push, I think, for educating the community at large, those who do struggle and even those who do not, with access to resources, even like the intranasal naloxone that you don't necessarily even need a prescription for, depending on what state you're in. I think that, generally speaking, does exist, but out specifically for the aging population, not that I'm aware of. That doesn't mean that it doesn't exist. It's just not something that I came across. Thanks. Yes, the naloxone, free distribution of naloxone, even without a prescription. I believe that every state at this point has some version of that. I know here in Texas, any provider or any adult, frankly, can walk into a pharmacy and be dispensed two of those at a time without a prescription. So there's like a standing pharmacist prescription to be able to give those out. Of course, there are other programs that you can find online that will send you in the mail those same supplies, which are very important to have on hand, not just for patient care, but for anyone that's in your home or your office that might be in an overdose situation. So I'm glad you brought up the naloxone, Melissa. Thank you. Okay. The next question, what is the dose range of buprenorphine in older adults? Is it different? That's a great question. So outright, no. As far as I'm aware, unless they've changed some protocols, the dosing range is not significantly different than it would be for any adult in general. Now, the reason I say that is if we kind of refer back to one of the slides that I mentioned, that because of the route, it avoids the GI route. So it's bucal or sublingual, and it doesn't necessarily have the same absorption issues that maybe other opioids would. So in that way, it's been able to moderate for some of the differences that can occur with an individual that's 18 and up or 18 to 64 compared to those individuals 65 and up. So if we're talking about an actual standardized protocol difference, not that I'm aware of. But also that's part of the reason why, because it's kind of avoiding those systems, the hepatic, the GI tract, the renal issues that can sometimes be associated with orally ingested opioids. Thank you. We're getting some good and tough questions. Here's the next one. Did any of the studies review older military veterans' opioid use as an overt symptom of their underlying issues? Oh, that's a great question. I did not see. So there wasn't anything specifically identifying somebody's veteran status. Now, I did see some studies conducted by the VA with regards to their population, the aging population, but it was very minimal. The majority of the information that was gathered was regarding their adult, so 18 to 64-year-olds. And so it wasn't super relevant to this particular presentation. But I do think that's a really great question. I'm sure the government is doing some form of research on that topic, and if not, then we should definitely encourage it. But as far as I know, I did not see any major difference for the aging population in regards to their opioid use. Yeah, that's a great question, and now I'm super curious. I will go poking around, and if I can find something, that's going to land itself on the discussion board as well. So we'll have some homework, but that's fine. Yes, you guys are coming with really great questions. Yeah, the next question, is there any evidence-based practice you are willing to recommend for treating older adults with co-occurring mental health and substance abuse issues? So I know you talked in your presentation about MOUD, or the Medications for Opioid Use Disorder, and I'm not sure if the question is asking beyond that. Are there any other treatments that you would recommend? Okay, the way I'm interpreting that question is if maybe there's any other additional recommendations for non-medication intervention, I'm guessing? Probably so. If they want to clarify further, oh yes, okay, they did just clarify further, yes, beyond medication-assisted treatment. Yes, so it's hard because it doesn't necessarily distinguish. I have two little subsets here, and we didn't really discuss this in this particular presentation, but for the older adult in general, the aging population, there are some therapeutic interventions that tend to work better in that age group, like narrative therapy, cognitive behavioral therapy for sure, and solution-focused therapy. Then there are, on the other hand, those therapeutic modalities which are more effective for individuals who struggle with an opioid use disorder or substance use disorder in general. And those might include also cognitive behavioral therapy, peer support therapy. There is some discussion regarding some kind of protocol with AA model, although that's not everybody's cup of tea regarding the way that there's a Christian religious focus. And that's okay, there are other non-religious focused options as well. They're just a little harder to come by. But I think what we can take away from that is that there is a peer support and accountability piece to it. So treatment centers kind of offer that as well, right? So you'll have individual therapy, group therapy, and then I think there's also diet exercise that is integrated into those programs. If we're talking overlap, cognitive behavioral therapy tends to be the thing that carries through in both age group and opioid use disorder. But I do think that if you're treating an opioid use disorder, that is going to be incredibly difficult to parse out without additional support, right? So some type of engagement in individual therapy, group therapy would be the ideal. And that's where most of the data is supporting of that. Sorry, there's a really long way to answer your question as I was thinking through the question as I was answering it. So I apologize. Yeah, I think that's important too. It's important also to recognize that medication-assisted treatment or medications for opioid use disorder, the two different acronyms, they're not supposed to be a standalone. The recommendation is that you do this and you're also providing some sort of therapy or some other intervention. All right, so let's take a couple more questions. This is a super interesting one. Why did our government make it illegal for Amazon to sell fentanyl test strips? And why is Narcan regularly available but not the test strips to avoid the overdose in the first place? Could it be that the lawmakers have their hands in the companies producing Narcan? I have no idea. I'm going to be completely honest. I have no idea, but I love that that's even being brought up because it is important to note. I think that's a piece that we don't necessarily always talk about in these types of settings is how important policy is, right? And the way that we impact policy. We just kind of wait for things to come downstream and then we either utilize them or don't. And that's a great point. Why is it that, on the one hand, we have access to certain medical – and it's actually expensive sometimes. Even if you do go to a pharmacy to try and get Narcan over the counter, it can be expensive. So it's still kind of reducing access in a way. But now Amazon doesn't even sell test strips. I didn't know about that, actually. So it is an interesting thought exercise, but also I would love to know where that's coming from. Yeah, and then there's just a further comment on that. Not to mention, addicts usually use alone. And how do you Narcan yourself? So that's a good point. All right, one last question we'll take. Any thoughts on why clinicians would go directly to prescribing opioids before trying the weaker analgesics for older adults? Because I think you said it was one-third. Yes, it's a third. So there's a couple of things regarding that. I think that part of it could be that because of the – I don't know if you remember, I mentioned that there's more sensitivity to pain as we age. There's less of them, less opioid receptor sites. And of those opioid receptor sites that do remain, they tend to be more sensitive. So in our training and in the medical system in general, I think that for a long time pain was viewed or still is viewed as the fifth vital sign, right? And so when we have our older patients that struggle with pain and then more or less burn through those medications because the way that that particular – they're more sensitive. They're more sensitive to pain. Therefore, their pain is not managed as well when they do get access to an opioid. Instead of increasing frequency of maybe a lower dose of a medication, you want to just make sure that you're managing somebody's pain. And so that's where our focus really remains on. It's just kind of like, okay, well, we need to make this – ameliorate this now. And we tend to see those elderly patients more. That particular individual is more likely to have time and downtime to be uncomfortable and to call and to reach out and to say, this is bothering me. Or we'll see that those individuals end up in the ER, right? So then there's higher utilization of emergency services. And it all kind of runs downstream, right? So based on your practice, the goal is to keep your patient out of the ER. And if they tend to keep going because they're not having their pain managed well, well, that kind of falls down onto the outpatient provider to do that, to manage that. And so I think that's probably where that comes from. That's a guess. But I think that part of it has to do with the fact that as we age, we're more sensitive to pain. We have more sensitivity. And the coverage of opioids in general, we just want to make sure that we're taking care of it with less tablets, if you will. And that usually tends to lead to higher potency meds. Thank you. All right. And there's a couple more questions, but we're at time. So I'm going to read one comment. And then the other question that we didn't get to, if you give us a couple days, we will post on the discussion board your question and answer. Last comment, Ventura County Substance Use Division said that test strips are coming from 211. They're going to provide free fentanyl testing strips to individuals in Ventura County offered in packs of five. Individuals can request one package at a time. That's really great. And hopefully that is going to be something that other places are picking up. Okay. So I've got a few more slides before we wrap up and we'll tell you how to get credit and all of that. So. Thank you so much again, Melissa, for this amazing presentation. So this slide will show you how to get to that discussion board that I mentioned that is specific to. To our webinar. And so you'll have the slides to be able to remind you how to do that. Let's see. So SMI Advisor offers more evidence-based guidance on comorbid substance use disorders such as this resource, Implementation of Integrated Medication-Assisted Treatment for Opioid Use Disorder in a Serious Mental Illness Service Setting. This implementation guide is designed to provide guidance to administrative, clinical, and or medical leaders of organizations and programs serving people with serious mental illness on how to implement Integrated Medication-Assisted Treatment services for clients who have co-occurring opioid use disorder and or alcohol use disorder. Access the guide by clicking on the link in the chat or by downloading the slides. To claim credit for participating in today's webinar, you need to meet the requisite attendance threshold for your profession. After the webinar ends, please click continue to complete the program evaluation. The system then verifies your attendance for credit claim. This may take up to one hour and can vary based on local, regional, and national web traffic and usage of the Zoom platform. And lastly, please join us on December 14th as Stephen Michio and Maureen Bailey present Building Success, Embedding Peers on Mobile Teams. Again, this free webinar will be held on Thursday, December 14th from 3 to 4 p.m. Eastern time. Thank you all so much for joining us and until next time, take good care.

webinar

Melissa Rivera

opioid use disorder

comorbid psychiatric diagnoses

aging population

pharmacokinetics

opioid prescriptions

DEA

prescribers

evidence-based practices