Lilttle Pain Control in Dentistry sentDENTISTRY and a Collaborative Look at the Effects of Opioid Dose Reduction in Chronic Pain Patients Jared R. Little DDS Creighton University School

3/13/2020

1

CPAIN CONTROL IN

DENTISTRYand a Collaborative Look at the Effects of Opioid Dose Reduction in

Chronic Pain Patients

Jared R. Little DDS

Creighton University School of Dentistry 2007

Jared R. Little DDS PC 2008-2017

Assistant Professor General DentistryOperative Dentistry

Dental AnatomyLab

Clinic

1

2

3/13/2020

2

3

4

3/13/2020

3

5

6

3/13/2020

4

7

8

3/13/2020

5

Prison Life• 90 minute drive for a 7:45am arrival• Check in at guard tower with issued ID• Park and walk in lobby • Present ID for entrance into first “airlock” some days patted down.• Proceed into airlock and allow door to close and lock behind.• Verification called in to the dental clinic that I was expected.• Upon approval inner door is unlocked leading to the inner courtyard of the prison.• Walk to the Health Clinic building and wait for guard to buzz into second airlock• Guard at ths airlock checks id again then buzzes you into the dental clinic waiting

room

Prison Life• Dental clinic approximately 15x30 cinder block room without windows.• Half divided into a locked lab and sterilization area.• 1-2 dentists, a hygienist, 2 assistants.• By 8am six inmates seated on bench. Work is done one by one until done. 1pm six more

until done.• 1 year wait to see the dentist.

9

10

3/13/2020

6

Prison Life

•Typical day:•60 restorations•2 Root Canals•50+ extractions

•ALL DONE WITH NO OPIOID RX

Post Op pain relief

• 800mg Ibuprofen every 8 hours

• 500mg Acetaminophen every 8 hours

• Piggy back

•STUDY?

11

12

3/13/2020

7

Practice Life•Average 20 patients per day plus Hygiene

•GENERAL PRACTICE• 50% Restorative- Fillings, crowns, bridges• 30% Exodontia and replacement• 10% Root Canal Therapy• 10% miscellaneous

•60% Medicaid

13

14

3/13/2020

8

15

16

3/13/2020

9

17

18

3/13/2020

10

19

20

3/13/2020

11

21

22

3/13/2020

12

23

24

3/13/2020

13

25

26

3/13/2020

14

ROOT CANAL THERAPY

27

28

3/13/2020

15

29

30

3/13/2020

16

Root Canal Therapy- Post op Pain• General pain from oral procedure• Continuation of the infection for a brief time• Over instrumenting the canal space• Forcing medications through the apex

• Resolution• Ibuprophen and or Tylenol• Amoxicillin or Clindamycin Azithromycin (ZPAK) in presence of active infection• Extreme cases Hydrocodone 5-325 coverage for 48 hours• Medrol dose pack

Follow-up!!!!!that night, 24-48hrs, 1 week, 6 months

ORAL SURGERY

31

32

3/13/2020

17

Dentistry by Dr. Michael Fisher


33

34

3/13/2020

18



35

36

3/13/2020

19



37

38

3/13/2020

20



39

40

3/13/2020

21

Rafael Scaf De Molon Ph.D Brazil


41

42

3/13/2020

22


Oral Surgery Post-op Pain• General pain from oral procedure• Continuation of the infection for a brief time• Additional treatments such as alveoloplasty or implant placement

• Resolution• Ibuprophen and or Tylenol• Amoxicillin or Clindamycin Azithromycin (ZPAK) in presence of active infection• Extreme cases Hydrocodone 5-325 coverage for 48 hours

Follow-up!!!!!that night, 24-48hrs, 1 week, 1 month, 6 months, 1 year

43

44

3/13/2020

23

Pain Management Considerations for Dentists

• Dentistry unique• a profession that causes pain as a necessary part of the service we provide our patients. • Large majority of Dentists are self employed business owners providing dental services while

trying to grow their practice.

SOLUTION

SATISFACTION

RECOMMEND

NEED

45

46

3/13/2020

24

SOLUTION

NEED

UNHAPPY

RECOMMENDSOMEONE ELSE

47

48

3/13/2020

25

1. Counsel Patients•HONESTY- what amount of pain might they expect•What amount of relief might they expect from their medications

• “The procedure that we have done is significant and I would expect some moderate pain. If you follow these recommendations I have layed out to you I would expect a reduction in pain enough to function (eat, sleep, work). Do not expect a complete lack of pain.”


49

50

3/13/2020

26

2. Be active with pain management choices.•use non-opioid alternatives for minor procedures•Prescribe minimum amount necessary (responsibly)•Attack the cause of pain (antibiotic Rx)•Check state prescription monitoring programs


Training Experiences Regarding pain Management, Addiction, and Drug Diversion of Dentists Enrolled in the National Dental Practice-Based Research Network McCauley JL, Reyes S, Meyerowitz C, et al. March 4, 2019

• 1/3 of prescriptions issued by dentists are for opioid medications• Levy, Paulozzi, Mack, Jones Trends in opioid analgesic-prescribing rates by specialty: US, 2007-2012. Am J Prev Med. 2015; 49(3):409-413

• 50% of opioids prescribed by dentists remain unused• Maughan, Hersh, Shofer et al. Unused opioid analgesics and drug disposal following outpatient dental surgery: a randomized controlled trial. Drug

Alcohol Depend. 2016; 168:328-334

• Opioid prescribing particularly frequent for adolescents who are at an increased risk of developing misuse.• Gupta, Vujicic, Blatz. Multiple opioid prescriptions among privately insured dental patients in the United States: evidence from claims data. JADA

2018; 149 (7): 619-627

Purpose: conduct a national survey to identify training experiences and resources of dentists regarding pain management, addiction, and prescription opioid drug diversion.

51

52

3/13/2020

27

RESULTS: Researchers reported that 67% of dentists responded that they had prior training in pain management, but fewer than one-half (48%) reported that they had received prior training about identification and assessment of drug abuse and addiction.

Only 25% reported training in identification of prescription drug diversion. With most respondents who stated they had training being recent graduates who had received said training in dental school.

CONCLUSION:Many dentists are not receiving training specific to addiction assessment and identification of drug diversion and that such training is associated with greater risk mitigation in dental practice.

3. EDUCATE PATIENTS•Heart of the real problem


53

54

3/13/2020

28

EDUCATE PATIENTS2009 survey by the Substance Abuse and Mental Health Services Administration or SAMHSA:

• Nearly 600,000 Americans used Oxycontin for nonmedical reasons for the first time in 2008.• More than half said they received the drugs from a friend or relative without buying or stealing them.

West Virginia 2006, more than 60% of all unintentional, fatal overdoses of controlled prescription drugs involved individuals who did not have a prescription for the drug that contributed to their deaths.

Department of Justice- pharmaceutical diversion and abuse is viewed as the greatest drug threat by a growing number of the nation’s law enforcement agencies

Taken from a statement by Roland Goertz M.D. M.B.A., President of American Association of Family Practitioners, August 2011

HOW DOES DENTISTRY MATCH UP TO OTHER SPECIALTIES?

55

56

3/13/2020

29

Trends in Opioid Analgesic-Prescribing Rates by Specialty, U.S., 2007-2012 Levy, Paulozzi, Mack, Jones Trends in opioid

analgesic-prescribing rates by specialty: US, 2007-2012. Am J Prev Med. 2015; 49(3):409-413

2012 US pharmacies and long-term care facilities dispensed 4.2 billion prescriptions, 289 million (6.8%) of which were opioids.

Primary care specialties accounted for nearly half of all dispensed opioid prescriptions

Rate of opioid prescribing rose during 2007-2010 but levelled thereafter as most specialties reduced opioid use.

Greatest increase- Physical medicine/rehabilitation specialists +12%Greatest decrease- ER -8.9% and Dentistry -5.7%

57

58

3/13/2020

30

Functional Correlates of Deliberate Opioid Dose Reduction: Anxiety,

Constipation, Depression, Nausea, Pain, Sleep Quality, Suicidality, and

others.• Jared R. Little DDS Creighton University School of Dentistry• Jonathan Huefner Ph.D. Boys Town National Research Hospital• Kurt V. Gold MD Physiatrist Fitness Research Institute Omaha, NE• Tyler Bean Student Researcher

• In an effort to combat the opioid epidemic, the CDC has recommended limiting morphine equivalent dosing to no more than 90mg per day.

• Our research objectives:1. reduce morphine equivalent dosing in chronic pain patients

previously stable on greater than 90mg per day2. To track multiple factors during the reduction period, and3. To evaluate the functional consequences of this opioid dose

reduction in these patients.

59

60

3/13/2020

31

• Chronic pain patients on a stable opiate regimen in excess of 90mg morphine dose equivalent per day were invited to participate by slowly tapering their daily opiate dose over 8-18 months under physician direction.

• Mean MME (Morphine Dose Equivalent)• Baseline 2018 223.5• 12 month 2019 167.5

25% Reduction

•FACTORS TRACKED DURING MME REDUCTION:

• Self Reported Pain, sleep hours, constipation, exercise, work• Pain Disability• Depression• Anxiety• Sleepiness• Suicidality• Cognitive Function

61

62

3/13/2020

32

GENERAL HEALTH HISTORY FORM

• self reported

• Pain scale of 1-10• Sleep hours• Constipation scale of 1-10• Exercise hours per day recorded• Work hours per day recorded

Pain Disability Index

•7 CATEGORIES

• Family/Home Responsibilities• Recreation• Social Activity• Occupation• Sexual Behavior• Self Care• Life Support Activities

63

64

3/13/2020

33


•7 CATEGORIES



•7 CATEGORIES


65

66

3/13/2020

34


•7 CATEGORIES



•7 CATEGORIES


67

68

3/13/2020

35


•7 CATEGORIES



•7 CATEGORIES


69

70

3/13/2020

36


•7 CATEGORIES


PHQ-9• Frequently used to screen

for depression in patients. • 9-question instrument

given to patients in a primary care setting to screen for the presence and severity of depression.

• The total of all 9 responses from the PHQ-9 aims to predict the presence and severity of depression.

0-4 None-minimal 5-9 Mild10-14 Moderate

15- 19 Moderately Severe 20- 27 Severe

71

72

3/13/2020

37













73

74

3/13/2020

38













75

76

3/13/2020

39













77

78

3/13/2020

40













79

80

3/13/2020

41













81

82

3/13/2020

42







GAD-7• self-reported questionnaire for

screening and severity measuring of generalized anxiety disorder (GAD)

• seven items, which measure severity of various signs of GAD according to reported response categories with assigned points

• Assessment is indicated by the total score, which is made up by adding together the scores for the scale all seven items

0-5 None 6-10 Mild11-15 Moderate16-21 Severe

83

84

3/13/2020

43











85

86

3/13/2020

44











87

88

3/13/2020

45











89

90

3/13/2020

46











12

91

92

3/13/2020

47






12

Epworth Sleepiness Scale• measure daytime sleepiness• The questionnaire asks the subject to rate

his or her probability of falling asleep on a scale of increasing probability from 0 to 3 for eight different situations that most people engage in during their daily lives, though not necessarily every day.

• The scores for the eight questions are added together to obtain a single number.

• 0-5 Low Normal • 6-10 High Normal• 11-12 Mild Excessive• 13-15 Moderate Excessive • 16-24 Severe Excessive

93

94

3/13/2020

48









95

96

3/13/2020

49









97

98

3/13/2020

50









99

100

3/13/2020

51









101

102

3/13/2020

52









103

104

3/13/2020

53

SBQ-R• self-report questionnaire designed to

identify risk factors for suicide• unlike some other tools commonly

used for suicidality assessment, it asks about future anticipation of suicidal thoughts or behaviors as well as past and present ones and includes a question about lifetime suicidal ideation, plans to commit suicide, and actual attempts

• A total score of 7 and higher in the general population and a total score of 8 and higher in patients with psychiatric disorders indicates significant risk of suicidal behavior





105

106

3/13/2020

54









107

108

3/13/2020

55









1

1

2

2

109

110

3/13/2020

56





1

1

2

26

Trails Making• a neuropsychological test of visual

attention and task switching.• It consists of two parts in which the

subject is instructed to connect a set of 25 dots as quickly as possible while still maintaining accuracy.

• The test can provide information about visual search speed, scanning, speed of processing, mental flexibility, as well as executive functioning

111

112

3/13/2020

57

113

114

3/13/2020

58

115

116

3/13/2020

59

117

118

3/13/2020

60

119

120

3/13/2020

61

TIME N Mean Std. Dev Std. Error Mean

MME (Morphine Dose Equivalent)Baseline 78 223.481 169.3987 19.180612 months 78 167.526 133.2202 15.0842

non-opioid adjuvant Baseline 78 5.4 2.665 0.30212 months 78 5.91 3.244 0.367

Hours of good sleep Baseline 78 4.69 1.417 0.1612 months 77 4.61 1.289 0.147

Daily work hoursBaseline 78 5.397 6.8681 0.777712 months 78 5.179 7.3881 0.8365

Disability: FamilyBaseline 78 6.03 2.74 0.3112 months 78 5.9 2.84 0.322

Disability: RecreationBaseline 78 6.55 2.818 0.31912 months 78 6.69 2.732 0.309

Disability: SocialBaseline 78 5.74 3.156 0.35712 months 78 5.92 2.997 0.339

Disability: WorkBaseline 77 6.61 3.253 0.37112 months 78 6.59 3.18 0.36

Disability: SexBaseline 73 5.89 3.828 0.44812 months 74 5.95 3.565 0.414

Disability: Self careBaseline 78 3.86 3.214 0.36412 months 78 3.82 2.846 0.322

Disability: Life supportBaseline 77 2.88 2.842 0.32412 months 77 2.69 2.446 0.279

DepressionBaseline 78 7.41 5.612 0.63512 months 78 8.44 6.303 0.714

AnxietyBaseline 77 5.74 5.384 0.61412 months 78 6.76 6.133 0.694

SleepinessBaseline 78 5.67 4.788 0.54212 months 78 5.79 5.544 0.628

Suicidality: Ever thought/attmpt.Baseline 78 1.74 1.122 0.12712 months 78 1.68 1.122 0.127

Suicidality: Ideation during last yr.Baseline 78 1.31 0.744 0.08412 months 78 1.4 0.827 0.094

Suicidality: Ever told anyoneBaseline 78 1.22 0.573 0.06512 months 78 1.22 0.526 0.06

Suicidality: Likely to attemptBaseline 78 0.79 1.024 0.11612 months 78 0.85 1.163 0.132

Trails test A+B combinedBaseline 78 76.954 38.0056 4.303312 months 78 77.062 39.8416 4.5112





















Small changes in various factors noted but no statistically significant changes…

121

122

3/13/2020

62






















With one exception






















With one exception

Morphine Milligram

Equivalents

123

124

3/13/2020

63






















With one exception

Morphine Milligram

Equivalents

From 223.5To 167.5






















With one exception

Morphine Milligram

Equivalents

From 223.5To 167.5

25%

125

126

3/13/2020

64

Functional Correlates of DelibarateOpioid Dose Reduction: Anxiety,


others.

• Results:• Baseline opioid dose correlated at statistically significant levels with self reported pain level,

exercise, hours of sleep, disability measures including family activities, recreation, social, self care, and life support-related activities, anxiety, and depression.

• However there were no significant changes in any of these values with the 25% overall opiate dose reduction in these patients.

Functional Correlates of Deliberate Opioid Dose Reduction: Anxiety,


others.

• Conclusions:• Opiate dose reduction did not increase measures of pain, anxiety, depression, social disability,

family involvement, recreation, sleep quality, self care, or cognative testing performance. • Continued monitoring of these factors while assisting with further reduction in opiate daily dose

and evaluation of trends appears appropriate.

127

128

Documents

Lilttle Pain Control in Dentistry sentDENTISTRY and a Collaborative Look at the Effects of Opioid Dose Reduction in Chronic Pain Patients Jared R. Little DDS Creighton University School