Potentially Inappropriate Medication Combination with Opioids among Older Dental Patients: A Retrospective Review of Insurance Claims Data

High prevalence of potential psychotropic drugs interactions among Brazilian dental patients

OBJECTIVE

To determine the prevalence of potential drug-drug interactions involving psychotropics prescribed by dentists, and dispensed by the public healthcare system, as well as to describe the severity and level of evidence of those interactions in the state of Minas Gerais, Brazil.

MATERIALS AND METHODS

We conducted data analysis from pharmaceutical claims in which dental patients received systemic psychotropics in 2017. Data from the Pharmaceutical Management System provided the drug dispensing history of the patients, allowing the identification of those on concomitant medication use. The outcome was the occurrence of potential drug-drug interactions, which were detected according to IBM Micromedex®. Independent variables were the patient's sex, age, and the number of drugs used. Descriptive statistics was performed using SPSS v. 26.

RESULTS

Overall, 1480 individuals were prescribed psychotropic drugs. The prevalence of potential drug-drug interactions was 24.8% (n = 366). The total of 648 interactions was observed and, most of which were of major severity (n = 438, 67.6%). Most interactions occurred in female individuals (n = 235; 64.2%), with 46.0 (±17.3) years-old, concurrently taking 3.7 (±1.9) drugs.

CONCLUSION

A substantial proportion of dental patients presented potential drug-drug interactions, mostly of major severity, which might be life-threatening.

Geroscience: Aging and Oral Health Research

Research in aging has significantly advanced; scientists are now able to identify interventions that slow the biologic aging processes (i.e., the "hallmarks of aging"), thus delaying the onset and progression of multiple diseases, including oral conditions. Presentations given during the 3-part session "Geroscience: Aging and Oral Health Research," held during the 2023 American Association for Dental, Oral, and Craniofacial Research meeting, are summarized in this publication. Speakers' topics spanned the translational research spectrum. Session 1 provided an overview of the geroscience and health span (disease-free and functional health throughout life) concepts. The common molecular mechanisms between oral cancer and aging were discussed, and research was presented that showed periodontal microflora as a potential factor in Alzheimer's disease progression. Session 2 focused on behavioral and social science aspects of aging and their oral health significance. The keynote provided evidence that loneliness and isolation can have major health effects. These social conditions, along with poor oral health, tooth loss, and cognitive decline, could potentially affect healthy eating ability and systemic health in older adults. Research could help elucidate the directions and pathways connecting these seemingly disparate conditions. Session 3 focused on the delivery of oral care in different settings and the many barriers to access care faced by older adults. Research is needed to identify and implement effective technology and strategies to improve access to dental care, including new delivery and financing mechanisms, workforce models, interprofessional provider education and practice, and use of big data from medical-dental integration of electronic health records. Research to improve the "oral health span," reduce oral health disparities, and increase health equity must be tackled at all levels from biologic pathways to social determinants of health and health policies.

Barriers to and facilitators of opioid prescribing by dentists in the United States: A qualitative study

BACKGROUND

Dentists in the United States frequently prescribe opioids for dental-related pain, although evidence shows superior efficacy of nonopioids for pain management. A national sample of US dentists was interviewed to understand the barriers and facilitators to opioid prescribing.

METHODS

Semistructured one-on-one telephone interviews were conducted with dentists sampled from the 6 regions of The National Dental Practice-Based Research Network. Responses were coded into the domains of the Capability, Opportunity and Motivation Model of Behavior. Potential behavior change interventions were identified for targeted themes.

RESULTS

Seventy-three interviews were qualitatively analyzed. Most of those interviewed were general dentists (86.3%) and on average (SD) were in practice for 24.3 (13.0) years. Ten themes were identified within the Capability, Opportunity and Motivation Model of Behavior. Dentists' knowledge of opioid risk, ability to identify substance use disorder behavior, and capability of communicating pain management plans to patients or following clinic policies or state and federal regulations were linked with judicious opioid prescribing. Dentists reported prescribing opioids if they determined clinical necessity or feared negative consequences for refusing to prescribe opioids.

CONCLUSIONS

Dentists' opioid decision making is influenced by a range of real-world practice experiences and patient and clinic factors. Education and training that target dentists' knowledge gaps and changes in dentists' practice environment can encourage effective communication of pain management strategies with patients and prescribing of nonopioids as first-line analgesics while conserving opioid use.

PRACTICAL IMPLICATIONS

Identified knowledge gaps in dentistry can be targets for education, clinical guidelines, and policy interventions to ensure safe and appropriate prescribing of opioids.

Opioids and older adults: Increasing trends in opioid usage in a dental population compared to a National Database (NHANES)

Aim

To examine self‐reported opioid prevalence at a dental school clinic for patients ≥65 years old as compared to national data, comparing gender, ethnicity/race and older adult age groupings.

Methods and results

Self‐reported prescription opioid medication use was extracted from the medical record for dental patients ≥65 years old who visited the school's general dental clinic (GDC) in 2012 or 2017. This data was compared to the National Health and Nutrition Examination Survey (NHANES) data for 2011–2012 and 2017–18. There was a significant increase in prevalence of opioid use in adults ≥65 between 2012 (4.5%) and 2017 (6.5%) and for ages 65–79 (from 4.7% to 6.3%) and ≥80 (3.4% to 7.9%), women (4.8% to 7.0%), and African Americans (4.7% to 8.4%) in the GDC. Older adults at the GDC reported less opioid use than the NHANES national average for both periods no matter the gender or the age with variable results for race/ethnicity.

Conclusion

The prevalence of older adults taking opioids in our general dental school clinic population increased significantly in 2017 as compared to 2012 but was lower than the national average for the respective periods. Awareness of existing opioid usage in older adult patients and its higher adverse risk potential is critical when prescribing analgesics for dental pain for this age group.

Risk of fall-related injury and all-cause hospitalization of select concomitant central nervous system medication prescribing in older adult persistent opioid users: A case-time-control analysis

BACKGROUND

Concomitant use of central nervous system (CNS) medications frequently occurs in older adults with persistent opioid use. The risks of adverse outcomes associated with combinations of opioids, sedative hypnotics, or skeletal muscle relaxants have not been sufficiently described in this population.

OBJECTIVE

To compare the overall and incremental risk of (1) fall-related injury and (2) all-cause hospitalization associated with sedative hypnotics and skeletal muscle relaxants among older persistent opioid users.

METHODS

A case-time-control study was conducted using administrative claims of adults ages ≥66 years with a history of persistent (≥90 days) opioid use. Cases included those with first (1) emergency department, hospital, or outpatient visit for a fall-related injury, or (2) all-cause hospitalization. Exposure to CNS medications prior to the case event versus earlier periods, and the risk associated with CNS drug class combinations and sequence of use, was estimated using conditional logistic regression, adjusted for time trends and time-varying covariates.

RESULTS

Among 140,101 older persistent opioid users, 20,723 experienced fall-related injury and 39,444 were hospitalized during follow-up. Skeletal muscle relaxant use was associated with an increased risk of fall-related injury (Odds ratio [OR] 1.28) and all-cause hospitalization (OR 1.11). Statistically significant associations were observed for the joint effects of interactions involving skeletal muscle relaxants on fall-related injury (with opioid: OR 1.25; with sedative hypnotic: OR 1.24), and interactions involving opioids on all-cause hospitalization (with sedative hypnotic: OR 1.10; with skeletal muscle relaxant: OR 1.17). The addition of a skeletal muscle relaxant to an opioid regimen was associated with a 25% increased risk of fall-related injury. Additions of other CNS medications did not have apparent incremental effects on the risk of all-cause hospitalization.

CONCLUSION

The excess risks of fall-related injury and hospitalization associated with various combinations of CNS medications among older persistent opioid users should be considered in therapeutic decision making. Further research is needed to confirm these findings.