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Preventing Rx Opioid Abuse:The Role of Dentists
Presenters:• John Lindroth, DDS, Associate Professor and Director, Urgent
Care Clinic, University of Kentucky College of Dentistry• Jeffrey P. Okeson, DMD, Professor and Director, Orofacial
Pain Center, University of Kentucky College of Dentistry
Clinical Track
Moderator: J. Kevin Massey, MS, Business and Program Development Specialist, Weitzman Institute, Community Health Center, Inc., and Member, Rx and Heroin Summit National Advisory Board
Disclosures
John Lindroth, DDS; Jeffrey P. Okeson, DMD; and J. Kevin Massey, MS, have disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce healthcare goods and services.
Disclosures
• All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.
• The following planners/managers have the following to disclose:– John J. Dreyzehner, MD, MPH, FACOEM – Ownership interest:
Starfish Health (spouse)– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center
Learning Objectives
1. Explain the dentists’ role in preventing the diversion, misuse and abuse of Rx opioids.
2. Describe efforts to engage dentists in Rx drug abuse prevention.
3. Identify best practice guidelines for managing acute dental pains.
4. Understand best practice guidelines for managing chronic orofacial pains.
“Prescription drugs in the management of acute and chronic orofacial pain”
Breakout Session for DentistsMarch 29, 2016
byJeffrey P Okeson, DMDJohn E Lindroth, DDS
University of Kentucky Orofacial Pain CenterLexington, Kentucky
Dentists get involved with prescription drug use and potential abuse through their efforts in managing their patients’ pain.
Fact:
Therefore, understanding orofacial pain is essential for the dentist.
What isPAIN ?
Thermal
Chemical
MechanicalAcute Pain
Nociceptors
Nociceptors
Peripheral Mediators of Inflammation
StressMemory
PAIN
Emotions
What we see as clinicians is pain behavior; what we treat is nociception
What we assume is:The amount of pain behavior is proportionate to the
suffering, which is proportionate to the pain, which is proportionate to the nociception
What we know is:Nociception, suffering, and pain behavior can be
independent
Jeffery P. Okeson, DMDUniversity of Kentucky Orofacial Pain Center
Management of Acute Pain
The Dentist’s Role
Evidence&
Strategies
Current Practice Patterns
ADA Survey, 2006: prescribing practices after third molar extractions
• 563 oral maxillofacial surgeons (NEng, Wcentral states)• Performed avg 53 3rd molar extractions/mo on 20 year
olds 3.5 million ext/yr (extrapolated in US)• Avg prescription: hydrocodone/acetaminophen x 20 tab
with instruction to take “prn”
Denisco, et al. JADA, 2011
CDCP Utah Study, 2008• 72% of patients prescribed opioids had left over
medication• 71% of those patients with left over opiates –
did not dispose of them
Denisco et al. JADA, 2011
WV Statewide Survey, 2010• 79% General Dentist
• If not opiates NSAIDs (64%), acetaminophen (28%)• If opiates hydrocod/acetamin (73%)
• 3rd molar ext, 10-20 tabs for 2-5 days• 41% of dentist expected patients to have left over
drugs
Denisco, et al. JADA, 2011
Basic Science/Clinical Researchers
Pain and anesthesia• Minimize acute post-operative pain• Reduce analgesic consumption• Decrease risk of transitioning into pain chronicity
Treat anticipated pain definitively
• Aggressive management of noxious perioperative stimuli to prevent peripheral/central sensitization
• Preoperatively• Intraoperatively• Postoperatively
Preventive Management
Reduces pain and postoperative
analgesic requirements
Multimodal Analgesic Approach
Advocated by ASA Task Force on Acute Pain Mgmt
Combing different analgesics that act by different mechanisms at different sites in the peripheral and CNS resulting in synergistic analgesia
More effective than single agent therapy Fewer side effects than high dose, single agent Reduces opioid consumption
Buvanendran, 2009
Single dose oral analgesics for acute postoperative pain in adults (Review)
Moore, et al. The Cochran Lib, 2011Lib, 2011
• 350 individual studies that involved 29,000 dental participants
• How effective at relieving moderate to severe pain following 3rd molar surgery
• Number needed to treat (NNT) to achieve at least 50% pain relief over 4-6 hours following a single dose of analgesic compared with placebo
←←
←
←
←
Oxycodone 10
Ibuprofen 400
Naprosyn
Celecoxib 400
Acetaminophen
Percentage of patientsachieving at least50% max pain relief (dental pain)
←←
←
←
←
Oxycodone 10
Ibubrofen 400
Naprosyn
Celecoxib 400
Acetaminophen
Single dose ibuprofen plus paracetamol for acute postoperative pain (Review)
Derry, et al. The Cochran Lib, 2013
• 3 clinical trials: 1,647 participants with moderate to severe pain after 3rd molar surgery
• 200/500mg or 400/1000mg (ibu/acetamin)• Combination better analgesia than either drug
alone (at same dose)• Effective pain relief for 70% of participants
Moore, P. A., and Hersh, E. V. JADA 2013;144:8:898-908
Copyright © 2013 American Dental Association. All rights reserved. Reproduction or republication strictly prohibited without prior written permission of the American Dental Association.
Synergy between paracetamol and NSAIDs in experimental pain
Miranda, et al. Pain, 2006
Combinations, rank of potencies:1. Naproxen/ paracetamol2. Diclofenac/paracetamol3. Ibuprofen/paracetamol4. Meloxicam/paracetamol5. Piroxicam/paracetamol6. Ketoprofen/paracetamol
Preoperative Analgesic Strategy
Prescribe NSAIDs / acetaminophen one hour before the procedure for
preemptive analgesia
• Lower postoperative pain/swelling• Decrease opiate consumption• Near 70% success rate
Corderre, et al. Pain, Vol 2, 1993Ong, et al. Pain Medicine, 2010Katz, et al. Clin Pain Mgmt, 2008
Intraoperatively
One for the road…• As post-op pain is anticipated, consider
giving an injection of a long-acting bupivacaine before dismissing patient
Administration of analgesics should be clock regulated – not PRN
• Prevents delays inreceiving medication
• Provides timely &effective pain relief
• Dependent on timeand less on symptoms
Post-operative Pain Relief
Take the following medication exactlyas scheduled for the next ___ days.
1 tablet Naproxen 220 mg+PLUS+
1 tablet Acetaminophen ER 650 mg
Take together two times a day
__ am, __ pm, __ pm, and __ pm
3
8 8
Management of pain may require the use of opiates to achieve
adequate pain control
Post-operative Pain ReliefTake the following medication exactlyas scheduled for the next ___ days.
1 tablet Naproxen 220 mg+PLUS+
1 tablet Acetaminophen ER 650 mg
Take together two times a day
__ am, __ pm, __ pm, and __ pm
Take 1-2 opioidbetween
these doses
Take one opioidat bedtime
5
8 8
Prescription Monitoring Programs
Most states have or are developing prescription monitoring programs for controlled substance
Several states are working on electronic versions of their monitoring programs
States with Monitoring Programs
WA
ORMT
ID WY
ND
SDMN
IANE
WI MI
CO KS MOIL INUTNV
CA
AZ NM OK
TXAK
ARLA
TNKY
MS AL GASC
NC
OHVA
PANY
MEVT N
H
NJ
MD
RI
DC
DE
HI
VW
FL
PR
C-II onlyC-II, IIIC-II, III, IVC-II, III, IV,V (Selective scheduled drugs, used
for disciplinary purposes only.)
CT
Goals of Prescription Monitoring Programs
Designed to be:• a source of information
for practitioners and pharmacists
• an investigative tool for law enforcement
GOALS
Decrease doctor shopping
KentuckyAllSchedulePrescriptionElectronicReporting
An electronic data monitoring system
KASPERKASPER is Kentucky’s Prescription Monitoring Program (PMP). KASPER tracks Schedule II – V controlled substance prescriptions dispensed within the state as reported by pharmacies and other dispensers.
Enhanced KASPER (eKASPER) is the real-time web accessed database that provides a tool to help address the misuse, abuse and diversion of controlled pharmaceutical substances.
Goals of KASPER• KASPER was designed as a tool to help
address prescription drug abuse and diversion by providing:– A source of information for health care
professionals– An investigative tool for law enforcement and
regulatory agencies• KASPER was not designed to:
– Prevent people from obtaining prescription drugs– Decrease the number of doses dispensed
There are significant differences in the processing of the acute pain and chronic pain.
acutepain
chronicpain
Therefore there are significant differences in the management of these pains.
The normal processing ofnociception to pain
Tissue injury
It’s notpain here.
It’s notpain here.
It’s notpain here.
It’s onlypain here.
Pain
Functional Neuroanatomy of the Human Brain
- reflex pain (fast pain) -protection
The Primitive Reptilian Brain
the spinal cord
the medullary structures
The Mammalian Brain
the spinal cord
the limbic structuresthe medullary structures
- pain / pleasure center -(emotions, behavior,instincts and drives)
the spinal cord
The Primate Brain
the limbic structures
the medullary structures
the cortex
- motivational response -(reason, meaning, consequence)
Interactions at the higher centers
The hypothalamus-pituitary-adrenal axis(stress center for the brain)
the hypothalamus
Interactions at the higher centers
The emotional centers of the brain(anger, fear, anxiety, depression, etc.)
the hypothalamus
the limbic structures
Interactions at the higher centers
the limbic structures
The memory center of the brain(experiences are stored)
the hypothalamus
the hippocampus
Interactions at the higher centers
the limbic structures
the hippocampus
the hypothalamus
the amygdala
Controls the individual’s behavior(future emotional and physical actions)
Interactions at the higher centers
• Stress• Emotions• Sleep• Pain• Addiction
Therefore,all of these brain areas
are involved with:
Interactions at the higher centers
So how does this relate to the management of acute
and chronic pain?
Therefore,all of these brain areas
are involved with:
PainThe etiology of
Acute vs Chronic Pain
Peripheralnociceptive input
Acute Pain
Dorsal hornchanges
Central sensitization
Behavior
Emotions
Stress
Memory
Neuroplasticity
This representspermanent changes in
processing pain.
Addiction
The differences between acute and chronic pain
Acute pain Chronic pain
Time
Axis I(Physical ) Suffering
and Pain BehaviorAxis II
(Emotional)
physical tissue injury
higher centerinfluences
This leads to increased liability
of addiction
Treatment considerations for managing acute and chronic pain
Acute pain Chronic pain
Time
Axis I(Physical ) Suffering
and Pain BehaviorAxis II
(Emotional)
physical tissue injury
higher centerinfluences
Dr. Lindroth has reviewed these.Let’s now review management of chronic pain.
This leads to increased liability
of addiction
Generally,chronic pain can be consider pain that lasts longer than normal healing time.
Expect some pain. Continued pain? Why?
PainWith chronic pain it is difficult to separate
contributions of nociception, stress,
behavior and addiction.
Central sensitization
Neuroplasticity
Behavior
Emotions
Stress
Memory
Addiction
PainQuestion?
Why are you prescribing an opioid?
Central sensitization
Behavior
Emotions
Stress
Memory
Neuroplasticity
Addiction
The University of Kentucky Orofacial Pain Center
The patient’s average duration of pain is 4 years.
We evaluate 500-600 new patients a year.
We only have 12 patients chronically using opioids.
Managing chronic orofacial pain is complicated and multifactorial.
Jeffrey P Okeson, DMD, ABOP, Program DirectorIsabel Moreno Hay, DDS, PhD, ABOPReny de Leeuw, DDS, PhD, ABOPCharles Carlson, PhD, ABPP, Director of Behavioral Med and ResearchJohn Lindroth, DDS, ABOPElizangela Bertoli, DDS, MSCraig Miller, DMD MS AAOMCristiana Perez, DDS, MS, ABOP, ABPDIquebal Hasan, DDS, MSAnne Harrison, PT, PhDGarrett Naze, PT6 Dental Residents3 Clinical Psychology Residents
University of Kentucky Orofacial Pain Center
- The Faculty and Staff -
- The Faculty and Staff -Jeffrey P Okeson, DMD, ABOP, Program DirectorIsabel Moreno Hay, DDS, PhD, ABOPReny de Leeuw, DDS, PhD, ABOPCharles Carlson, PhD, ABPP, Director of Behavioral Med and ResearchJohn Lindroth, DDS, ABOPElizangela Bertoli, DDS, MSCraig Miller, DMD MS AAOMCristiana Perez, DDS, MS, ABOP, ABPDIquebal Hasan, DDS, MSAnne Harrison, PT, PhDGarrett Naze, PT6 Dental Residents3 Clinical Psychology Residents
2 Full-time staff
A Multiprofessional TeamDentistry
PsychologyPhysical Therapy
Graduate training programs in all three disciplines.
University of Kentucky Orofacial Pain Center
- The types of patients seen -(The primary diagnoses from > 6400 consecutive patients)
Muscle pain disorders 44%(42% of which was cervical origin)
Neuropathic pain disorders 13%
TM Joint pain disorders 24%
Primary Headache 7%(77.2% report headache as a symptom)
Other (sinus, ear, toothache, etc.) 22%
University of Kentucky Orofacial Pain Center
- The types of patients seen -(The primary diagnoses from > 6400 consecutive patients)
Muscle pain disorders 44%(42% of which was cervical origin)
Neuropathic pain disorders 13%
TM Joint pain disorders 24%
Primary Headache 7%(77.2% report headache as a symptom)
Other (sinus, ear, toothache, etc.) 22%
Opioids are certainly not the primary management strategies for any of these chronic pain conditions.
University of Kentucky Orofacial Pain Center
- The types of patients seen -(The primary diagnoses from > 6400 consecutive patients)
Muscle pain disorders 44%(42% of which was cervical origin)
Neuropathic pain disorders 13%
TM Joint pain disorders 24%
Primary Headache 7%(77.2% report headache as a symptom)
Other (sinus, ear, toothache, etc.) 22%
University of Kentucky Orofacial Pain Center
Opioids are not the primary management considerations for neuropathic pain.
Antiepileptic drugs (anticonvulsants): i.e. gabapentin, pregabalin, Tricyclic Antidepressants: i.e. amitriptyline, desipramine,
Antidepressants (SSRI and SNRI) i.e. duloxetine (Cymbalta) milnacipran (Savella)
Neuropathic pain disorders 13%
University of Kentucky Orofacial Pain Center
Opioids are not the primary management considerations for neuropathic pain.
Antiepileptic drugs (anticonvulsants): i.e. gabapentin, pregabalin, Tricyclic Antidepressants: i.e. amitriptyline, desipramine,
Neuropathic pain disorders 13%
University of Kentucky Orofacial Pain Center
Non-medication considerations:Behavioral interventionsPsychologic managementsPhysical therapy modalitiesTopical medications
Before you write an opioid prescription for a chronic pain patient you should ask the following questions:
1. Have all alternative analgesics and non analgesics medications been tried?
2. Have you reviewed a Prescription Monitoring Program report for the patient? (ex. KASPER)
3. Are there other healthcare providers ready and available to support your efforts with this patient?
4. Have you discussed the risks and benefits of long-term opioid use?
5. Have you discussed treatment goals of the therapy?6. Have you provided a written agreement that thoroughly
explains your and the patient’s responsibilities?
The Significant Components of an Opioid Agreement
1. Total control of all pain medications.2. Regular visits for evaluation:
• Pain control, adverse side effects• Physical assessment• Psychologic assessment (depression)• Cognitive assessment
3. Prescriptions are only provided during regular visits.4. Regular use of a Prescription Monitoring Program.5. Agreement for mandatory random urinalysis and pill
counts.6. If the patient fails to comply in any area, he/she will be
dismissed from the program and either the medications will be tapered down until gone or the individual will be referred to a rehabilitation facility.
The Significant Components of an Opioid Agreement
Select extended-release and/or long-acting opioids
Short acting opioids are indicated for acute pain control. hydrocodone (ex. Lortab), oxycodone (ex. Roxicodone)
Long-acting opioids are generally indicated for chronic pain management. methadone oxycodone (OxyContin) morphine sulfate (MS Contin)
Summary
When should you prescribe opioid medications?
Is it acute nociceptive pain or chronic pain with central mechanisms that greatly complicate treatment.
When should you prescribe opioid medications?
May consider: NSAIDs Short acting opioids Short period of time
Acute pain
Summary
When should you prescribe opioid medications?
First management considerations are not opioids.Consider other options:
NSAIDs, Antiepileptic, Tricyclics, Antidepressants, Behavioral training, Counseling, Physical Therapy, etc.
Chronic pain
Can you identify a clinical reason for the pain?
(diagnosis?)
Summary
“Prescription drugs in the management of acute and chronic orofacial pain”
byJeffrey P Okeson, DMDJohn E Lindroth, DDS
University of Kentucky Orofacial Pain CenterLexington, Kentucky
Thank you.Any questions?
Preventing Rx Opioid Abuse:The Role of Dentists
Presenters:• John Lindroth, DDS, Associate Professor and Director, Urgent
Care Clinic, University of Kentucky College of Dentistry• Jeffrey P. Okeson, DMD, Professor and Director, Orofacial
Pain Center, University of Kentucky College of Dentistry
Clinical Track
Moderator: J. Kevin Massey, MS, Business and Program Development Specialist, Weitzman Institute, Community Health Center, Inc., and Member, Rx and Heroin Summit National Advisory Board