. . . for our health

Mark Remiker, MA: Peggy O'Halloran, MPH: Michael Grasmick, PhD; Frederick Curro, MD; Paul Smith, MD

Wisconsin Research and Education Network and the University of Wisconsin Department of Family Medicine

Acute pain treatment by physicians and dentists: Results from a WREN/PEARL collaborative

survey

WREN

• Wisconsin Research and Education Network

• Founded in 1987

• 130 Clinics

• 20 Healthcare organizations

• 37 communities

PEARL

• Practitioners Engaged in Applied Research and Learning

• NIH-sponsored network of private-practice dentists

• Launched in 2005 at NYU College of Dentistry

• Over 200 Practitioner-Investigators in 32 states

• 16 studies are ongoing or completed, with almost 6,000 subjects enrolled

Background & Significance

• common both in dentistry and primary care

• very little literature on prevalence in primary care

• physician attitudes poorly described in literature

• no literature to support the anecdotal link of attitudes to prescriptions given and adequacy of pain relief

Acute Pain:

Collaborative Aim

Describe the attitudes and practices related to the treatment of acute pain and any differences between primary care clinicians and dentists through electronic survey.

- Descriptive analysis

- Hypothesis generation

Survey Group

• Members– Simple online registration

– Respond to at least 80%

– Responses inform WAFP board how you feel about the issue in question

• Surveys– Address issues important to primary care

– 12 or less a year

– Take approximately 5 minutes

Methods: the sample

Table 1: Sample demographics

WRENDoctors

PEARLDentists

Both

N 79 145 224

Age (SD) 47.4 (9.8) 50.25 (10.03) 49.3 (10.04)

Years Practicing (SD)

17.3 (10.1) 20.96 (9.6) 19.48 (9.8)

Sex (M/F) 37/31 103/42 140/73

Method: Survey 2 (general attitudes)

- How often do you use the following treatment options for acute orofacial pain?

– Education

– Medication

– Referrals

- Drugs commonly prescribed? – NSAIDS

– Opioids

– Muscle relaxants

- Attitudes toward prescribing opioids

Methods: Survey 1 (Scenarios)

Scenario 1 (TRAUMA)A 25 year old male with no known medication allergies slipped on the

ice while carrying a package and fell hitting his face on the curb about 12 hours ago. He did not lose consciousness, but he has facial bruises, swelling and broke off part of an incisor. He put the ice on the injury when he got home last night because of the pain. He took Ibuprofen 600mg every 6 hours and it “helps some,” but he woke up twice last night because of the pain. He has an angular fracture with no pulpal exposure and approximately 1/3 of the incisal edge is gone. You do not suspect any bone fractures.

– Scenario 1: TRAUMA

– Prescription: Ibuprofen 600 mg/6 hours

– Effective: SOME

Methods: Survey 1 (Scenarios)

Scenario 2 (SINUSITUS)A 23 year old woman with no known medication allergies presents with

right maxillary tooth pain, a two week history of gradual improving upper respiratory symptoms, but worsening facial pressure and pain for the past 10 days. She took some Claritin D 24 hours which did not help much. You make a clinical diagnosis of right maxillary sinusitis.

– Scenario 2: SINUSITUS

– Prescription: Ibuprofen 600 mg/6 hours

– Effective: NO

Methods: Survey 1 (Scenarios)

Scenario 3 (ABSCESS)A 43 year old female with no known medication allergies has had a right

lower mandibular pain intermittently for 2 weeks. She has developed swelling and increasing pain the last 3 days inadequately controlled with acetaminophen 500 mg every 4 hours. She woke up 4 times last night and is in obvious distress. You make a diagnosis of tooth abscess.

– Scenario 3: ABSCESS

– Prescription: acetaminophen 50 mg/4 hours

– Effective: NO

Methods: Survey 1 (Scenarios)

Post-scenario questions– Any non-medication treatments?

– Would you recommend a medication?

• Name

• Dose

• Instructions

• Prescription?

– Medication 2?

Preliminary Results

Correlation Matrix

Age Years Practicing

Trauma Sinusitis Abscess Total

Age x

Years Practicing

0.89* x

Trauma 0.01 -0.04 x

Sinusitis -0.01 0.001 0.21* x

Abscess -0.07 -0.07 0.33* 0.05 x

Total 0.00 -0.02 0.72* 0.67* 0.61* x

* = p < 0.000

Preliminary Results

Med Recommendation: Trauma

Doctor Dentist Total

No 13 34 47

Yes 65 108 173

Total 78 142 220

Pearson Chi2 = 1.59p = 0.21

Scenario 1: Trauma

First Med Recommendation

Acetaminophen NSAID Opioids Antibiotic Other0

10

20

30

40

50

60

DentistDoctor

– Scenario 1: TRAUMA– Prescription: Ibuprofen 600 mg/6 hours– Effective: SOME

Preliminary Results

Med Recommendation: Sinusitis

Doctor Dentist Total

No 4 51 55

Yes 72 87 159

Total 76 138 214

Pearson chi2 = 25.78p < 0.00

Scenario 2: Sinusitis

First Med Recommendation

Acetaminophen NSAID Opioids Antibiotic Other0

10

20

30

40

50

60

70

80

90

DentistDoctor

– Scenario 2: SINUSITUS– Prescription: Ibuprofen 600 mg/6 hours– Effective: NO

Preliminary Results

Med Recommendation: Abscess

Doctor Dentist Total

No 2 4 6

Yes 73 135 208

Total 75 139 214

Pearson chi2 = 0.008p = 0.93

Scenario 3: Abscess

First Med Recommendation

Acetaminophen NSAID Opioids Antibiotic Other0

10

20

30

40

50

60

70

80

90

DentistDoctor

– Scenario 3: ABSCESS– Prescription: acetaminophen 50 mg/4 hours– Effective: NO

Preliminary Results

Prescribing opioids across scenarios

No Yes Total

Doctor 41 35 76

Dentist 103 36 139

Total 144 71 215

Pearson chi2 = 9.028p = 0.003

Summary of preliminary findings

• Individuals who prescribe more for one ailment are likely to prescribe more for others.

• Dentists less likely than doctors to prescribe for sinus infection

• Dentists more likely than doctors to avoid prescribing opioids

Limitations

- Sample size

- Sex ratio

- Exploratory analyses

- Attitudes only, not behaviors

- Analyses do not speak to a effectiveness

Future Directions

1. Analyze the rest of survey 1 and the entire 2nd survey

2. What methods are most effective?

3. What are the patients attitudes?

Thank you

- Questions? Comments? Did anyone generate any Hypotheses?

- WREN/PEARL survey takers

- PEARL group: Van P. Thompson, Don Vena, Frederick Naftolin, Matthew Buchholz

- WREN group: Hannah Louks

- National Institute of Health