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Strategies in the Dental Office for Safer Management of Patients at Risk for
Opioid-Seeking Behavior
ADA & PCSS-O 19 June 2013
Theresa E. Madden DDS MS PhD FACD www.finetunegums.com 304 West Bay Drive NW
Olympia, WA 98502 800-223-GUMS
PCSS-O Prescribers’ Clinical Support System for Opioid Therapies is a three year
grant funded by Substance Abuse and Mental Health Services Administration (SAMHSA),Center for Substance Abuse Treatment (CSAT). It is a collaborative project led by American Academy of Addiction Psychiatry (AAAP) with: American Dental Association (ADA), American Medical Association (AMA), American Osteopathic Academy of Addiction Medicine (AOAAM), American Psychiatric Association (APA), American Society for Pain Management Nursing (ASPMN), and International Nurses Society on Addictions (IntNSA). These organizations are providing training and education on the safe and effective prescribing of opioid medications in the treatment of pain and/or opioid addiction.
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Disclosures
None No conflict of interest Individual consultant to PCSS-O My opinions do not necessarily represent
those of PCSS-O, ADA, SAMHSA, AAAP
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Assumptions Previous learning scientific basis of additive disorders acute and chronic pain management
Epidemic proportions of opioid misuse Devastating consequences for families & society Lack of training in dental schools or CDE Reject archaic prejudices against those afflicted
Goals of Training
Save lives Prevent diversion Improve pain management Reduce practice disruption Reduce dentist, staff frustration, fear Improve clinical practice Increase recovery Protect recovering patients
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My Commitment to Follow-up with Audience
[email protected] Available for consultation Assistance with office forms Personalized assistance with
writing treatment contracts
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Case #1, “Stephanie”
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44 year old Caucasian female
Chief Complaints: 1.“My fiance says you are the doctor who
can fix my mouth.” 2.Ill-fitting maxillary removable partial
denture prosthesis 3.Pain
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Treatment Plan Options?
IDEAL OHI root planing single implant #19 maxillary All-on-4 hybrid implant supported fixed bridge
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Immediate Implant Placement
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Titanium Bar
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Problem List Multiple long-standing abscesses Ill-fitting maxillary removable partial denture Poor oral hygiene Request for opioids Discrepancies in history
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Treatment Contract
Pain Management Section
“Stephanie has shared with me the fact that she has a high tolerance to opioid pain medications, that Vicodin is not acceptable to her and that at times, she has needed to take Dilaudid and Percocet.” 19
Pain Management Section (cont)
“Therefore, in order for me to accept Stepanie as a patient, she will have to agree to remain under the care of a physician trained in Pain Management and the safe use of Opioid medications.”
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Pain Management Section (cont)
“There are two such physicians in Olympia, that I recommend, if Stephanie is not already under the care of such a specialist. In addition, Providence medical centers provides such services. To my knowledge after extensive research, there are no physicians with this specialized training West of Olympia.”
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Treatment Contract
Dr. Madden’s usual pain control strategies
Enhance placebo effect and 24/7 availability post-op Sinus augmentation using horizontal approach (Caldwell-
Luk procedure), “All-on-4” full arch extractions with immediate implant placement. IV sedation drugs:
Fentanyl, Versed (I don’t use propofol) Ampicillin Solu-medrol or decadron (profound 36 hour pain-relief)
Periodontal surgeries, extraction of non-impacted hopeless teeth
• 75 mg ketoprofen q 6 h (if non-allergic, non-anticoagulated) • may supplement with Tylenol up to max daily dose 23
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How Can Dentists Assess Risk for Opioid Misuse?
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Not validated in non-chronic pain or dental
patients 27
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Known Risk Factors for Substance Use Disorders
Under 45 years of age Personal or family history
DUI Incarceration
Mental health problems Pre-adolescent sexual abuse
Reverse Side
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Health History Questionaire
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Have you ever had periodontal treatment? ________ Are you having mouth or face pain now?__________ Have you ever had a serious head or neck injury?___ Has it been hard for the dentist to get you numb?___ If you usually take antibiotics for your dental visits, could you tell us why? ________________________ On a scale of 1 to 10, how physically and/or emotionally comfortable are you in a dental office? __________________________________________
Health History Questionaire
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Please provide your medication & supplement list here, electronically or on a separate paper: Prescribed_______________________________________ Not prescribed____________________________________ “Over-the-counter”________________________________ “Natural/herbal” supplements________________________ Pain medications Bisphosphonates ever (Fosamax)?_____________ Steroids in the past 2 years?____________ _______ How many alcoholic drinks do you average per occasion? ○ >12 ○ 7-10 ○ 3-6 ○ 1-2 How many in the last 24 hours (1 standard drink= 12 oz regular 4-5% beer, 6 oz of wine or 1.5 oz of liquor) Do you completely abstain from alcohol? _____________
Health History Questionaire
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Height:________________Weight:____________ Are you happy with your present weight?_______ Are you on a special diet?_________________ Ever taken diet pills (fen-phen, dexedrine etc)?___ Do you take antidepressant medications?_ _ Do you ever need a tranquilizer to sleep or relax?__ How many cups of caffeinated beverages do you consume per day?____Do they contain sugar?____
Health History Questionaire
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Do you smoke or chew tobacco?__________ How much tobacco per day and for how many years?_______________________________ Would you like to quit?______________________ Do others in your household smoke?____________
Health History Questionaire Yes No ADHD Yes No Anaphylaxis Yes No Anemia Yes No Angina Yes No Anxiety Yes No Arthritis Yes No Artificial Heart Valve Yes No Artificial Joint Yes No Asthma Yes No Bipolar Depression
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Health History Questionaire Yes No Chest Pains Yes No Chronic Pain Condition Yes No Cold Sores/Apthous Ulcers Yes No Congenital Heart Disorder Yes No Congestive Heart Disease Yes No Contact Lenses Yes No Crohn’s Disease Yes No Depression Yes No Diabetes (circle type I or II) Yes No Drug/Alcohol Treatment Yes No Eating Disorder
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Health History Questionaire Yes No Lung Disease Yes No Lupus Yes No Mitral Valve Prolapse Yes No Memory Loss Yes No Multiple Sclerosis Yes No Obsessive Compulsive Disorder Yes No Organ Transplant Yes No Osteopenia Yes No Osteoporosis
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Health History Questionaire Yes No Psychiatric Care Yes No Radiation Treatments Yes No Recent Weight Loss or Gain Yes No Recovering from alcohol/drug disorder Yes No Renal Dialysis Yes No Rheumatic Fever Yes No Rheumatoid Arthritis Yes No Sarcoidosis Yes No Scarlet Fever Yes No Schizophrenia
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Health History Questionaire Yes No Sleep Apnea Yes No Spina Bifida Yes No Spinal Problems Yes No Stomach/Intestinal Disease Yes No Stomach Ulcers Yes No Stroke Yes No Swelling of Limbs Yes No TMJ pain or jaw locking Yes No Thyroid Disease Yes No Tuberculosis Yes No Tumors or Growths Yes No Victim of Abuse (circle childhood, teens, adulthood) Yes No Vision Loss
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Verbal Interview
Objective questioning about drug tolerance Use Motivational Interviewing Microskills
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Suggested Questions (tolerance)
How many pills does it take per day to relieve your pain?
What about when you first took this medication?
Did it take less pills then to relieve your pain than it takes now?
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Suggested Questions (craving)
Some patients experience craving for these medications and this seems to be genetic in many cases.
Have you or anyone in your family experienced any kind of craving for these pills. By that I mean, wanting to take them even when not in pain?
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Open-Ended Questions
Probe widely for information Help uncover the pt/client’s
priorities and values Avoid socially desirable responses Draw people out
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Key MI Skills
Open-ended questions Reflective listening Affirmations Summarize Elicit self-motivational
statements
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Major References and Additional Resources on
Motivational Interviewing Miller WR & Rollnick S. Motivational
Interviewing (second edition). New York: Guilford, 2002.
SAMHSA/CSAT Treatment Improvement Protocol on Motivational Interviewing (#35) http://text.nlm.nih.gov
www.motivationalinterview.org
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MI: Theoretical Underpinnings
Warmth, genuine empathy, and unconditional positive regard are necessary to foster therapeutic gain (Rogers, 1961)
Ambivalence about decisions is resolved by
conscious or unconscious weighing of pros and cons of change vs. not changing (Ajzen, 1980)
Meet patients/clients where they are
(Prochaska, 1983)
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How Does Behavior Change?
Behavior A Behavior B
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Benefits of Changing
Costs of Changing
Benefits of not
changing
Costs of not
changing
“finding the personal price” Sobell, 2006
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Meta-Analysis of MI - 72
(Hettema et al., Annual Rev Clin Psych, 2005)
72 studies considered: -Alcohol - 31 -Illicit drugs - 14 -Smoking - 6 -HIV risk - 5 -Treatment adherence - 5 -Water purification - 4 -Diet/exercise - 4 -Gambling - 1 -Eating Disorder - 1 -Relationship - 1
72 studies considered: -MI vs. other tx - 25 -MI vs. usual tx - 6 -MI vs. no tx/placebo - 21 -MI + other tx - 7 -MI + usual tx - 5 -Mixed designs - 6 -Within-group only - 2
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Transtheoretical Model “Stages of Change”
Determination (Preparation)
Relapse*
Precontemplation*
Contemplation*
Maintenance
Action Termination
(Exit) *No firm commitment to change yet
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1 – 10 Scale
1 = hate flossing 10 = love flossing
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1 – 10 Scale
1 = shot by firing squad, run over by a train, 10 = can’t wait to rise in the morning to start flossing
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“Layers” of Motivational Interviewing
Implement MI Principles
Address Barriers to the Next Stage of Change
Use Microskills
Engage in Active Listening with the Patient/Client
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Determination
Relapse
Precontemplation
Contemplation
Maintenance
Action
Termination
NO FIRM COMITMENT TO CHANGE
FIRM COMMITMENT TO CHANGE
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Goals by Stage
Relapse Precont Cont.
Determ. Action Maint
} }
Build commitment to change
Create, implement, and refine plan for change
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For Ambivalence - DEARS
Develop discrepancy - Compare positives and negatives of behavior, and positives and negatives of changing, in light of goals; elicit self-motivational statements
Empathize with ambivalence and pain of engaging in behavior that hinders goals
Avoid arguments - don't push for change, avoid labeling
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For Ambivalence - DEARS (continued)
Roll with Resistance • Change strategies in response to resistance • Acknowledge reluctance and ambivalence as
understandable • Reframe statements to create new momentum • Engage pt/client in problem solving
Support Self-efficacy • Bolster responsibility and ability to succeed • Foster hope with menus of options
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For Ambivalence – Dr. Madden’s advice
Change the Subject
Come back to it at a later visit if they don’t bring it up eventually
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Determination
Relapse
Precontemplation
Contemplation
Maintenance
Action
Termination
NO FIRM COMITMENT TO CHANGE
FIRM COMMITMENT TO CHANGE
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Goals by Stage Relapse Precont Cont.
Determ. Action Maint
} }
Build commitment to change
Create, implement, and refine plan for change
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Addressing barriers in your practice
Case #2 Greg
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“George” 54 year old Caucasian businessman, “hard-hit” by
recession in 2009 Specific request for Percocet 10/325 Wife works for referring dentist Photocopied my prescription Withheld consent to pain-relieving surgery Demanded bone grafting on tooth w/ poor prognosis Never paid his bill
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Case #3 “Danny”
65 year old Native American male On periodontal maintenance since 1991 in this
practice (I purchased in 2009) Has obtained from us, opioids after every hygiene visit I had previously lent him my personal copy of the
cookbook, “Foods of the Americas” He recently accepted my recommendation for 4
quadrants of scaling and root planing
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Danny
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Danny Victoria (RDH) alerted me to his opioid request Asked for his pharmacy of choice Phoned pharmacist while he was in hygienist chair 120 vicodin since January 2013 Discovered primary care physician prescriber Phoned her to discover he has signed a pain
management contract Her nurse faxed it to me while he was still
undergoing Victoria’s hygiene treatment 67
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Danny’s Narcotic Medication Contract
#3 “I will not obtain prescriptions for narcotic medications from another doctor, without notification to my provider at Shelton Family Medicine. Mason General Hospital Emergency Department also has a copy of my narcotic contract on file.”
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Dr. Madden’s Actions
“Danny, you will have to ask your provider at Shelton Family Medicine if you need more vicodin. That’s the way this in handled these days”
A hand written note tucked in a sealed envelope in his tooth brush goody bag.
He showed up for the next root planing visit!!! 70
What Dr. Madden Learned
Previous PSCC-O Webinar We are clinicians We are not police or judges We don’t need to “fire patients” We should set safe limits and promise to
continue treating our patients
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Case 4, “Valerie”
49 year old African-American female On periodontal recall in this practice since 2010 Refused necessary periodontal surgery Requests opioids after every hygiene visit Multiple treatment planning discussions Dental school financials presented Finally one quadrant surgery completed
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Valerie’s pain management
Methadone Pain clinic does not respond to multiple
written and phone consultation requests
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Example Letter to
Pain Specialist
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Letter to Pain Specialist
“The reason I am writing is that she always requests prescriptions for opioids at each of her appointments. Opioids are not usually necessary for the services we are providing. Rarely do other patients need to take Advil and/or Tylenol for the non-surgical visits. In addition, most of my surgical patients avoid post-operative pain by taking 75 mg Ketoprofen plus 2 extra-strength Tylenol. ”
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Letter to Pain Specialist
“Since you provide pain management services for Veleda, I am writing to request a phone discussion on how we can safely handle this patient. I would feel more comfortable if you would be the sole prescriber of the opioids and I keep you closely informed of her appointments and procedures.”
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Opioid Medication Contract Items You understand that opioid medications have the
potential to induce craving, addiction, nausea, lack of concentration, death from overdose. They are the most commonly abused and diverted drug in the US.
You agree to return any unused pills for proper disposal and record keeping.
You will not flush pills or put then in the trash, as this harms the environment.
You will not give or sell your unused pills even to a family member. 77
Staff Training “Ketoprofen is in the same class of drug as
ibuprofen, only 10 times more potent.” Avoid inferring that opioids are stronger than NSAIDs If asked, emphasize adverse effects of opioids
• No driving • Difficulty concentrating • Nausea • Craving, tolerance, dependence • Diversion • Don’t mix with alcohol 78
Future Research & Recommendations
Validate ORT in dental practices with acute pain patients (NDPBRN)?
Buprenorphine-premedication prior to surgery? Standardize a dental opioid contract/consent form Dental practice guidelines for referring to pain and
addiction specialists • Overcome fear and resistance • Reduce opioid misuse originating from dental practices
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“Layers” of MI
Implement MI Principles
Address Barriers to the Next Stage of Change
Use Microskills
Engage in Active Listening with the Patient/Client
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Thank you
800-BAD-GUMS
www.finetunegums.com
