opioid use disorders in dental medicine kelly s. barth, do medical university of south carolina...

OPIOID USE DISORDERS IN DENTAL MEDICINE

Kelly S. Barth, DOMedical University of South Carolina

©AMSP 2014

© AMSP 2014 1

“EPIDEMIC” OF Rx OD DEATHS

2

ACCIDENTAL OD DEATHS

3

WHY Rx OPIOIDS?

• Seen as safer than street drugs

• social stigma

• cost

• Wide availability

• Pain

© AMSP 2014 4

14% 18%8%

__________________________________________________________________

WHY DENTISTS?

PCPsIMs Dentists 5

TOP OPIOID PRESCRIBERS

THIS LECTURE WILL REVIEW

• Overview of orofacial pain management

• Recognition of opioid use d/o (OUD)

• Prevention & referral for OUD

© AMSP 2013 6

© AMSP 2014 7

Joe

25 yo student

Wisdom tooth

FH drugs

Alcohol 3x/week

Joanne

38 yo lawyer

Friday distress

Toothache

“Only oxycodone”

Edna

60 yo teacher

One kidney

Tooth extraction

#30 hydrocodone

OROFACIAL PAIN MANAGEMENT

• Definition & classification

• Diagnosis

• Treatment

© AMSP 2013 8

OROFACIAL PAIN

• Unpleasant sensation face or mouth

• Prevalent - 20% US

• Costly – 32 billion/yr© AMSP 2014 9

MouthTeeth GumsMucosaFace Joints

Acute

Chronic

CLASSIFICATION

Location Duration

© AMSP 2013 10

DIAGNOSIS

• Review history

• Exam–Extra/intraoral

–Reproduce pain

• X-rays

© AMSP 2014 11

OnsetLocationDurationCharacterAggravatingRelievingTimingSeverity

TREATMENT

•Pulpotomy = 80% ↓ in pain

•Pulpectomy (root canal) = 75% ↓ in pain

© AMSP 2014 12

SURGERY IS

EFFECTIVE

MEDICATIONS

• Non-steroidal anti-inflammatories (NSAIDs)

• Acetaminophen (Tylenol)

• Combination therapy

• Prophylactic steroids

• Mandibular injections

© AMSP 2014 13

1STLINE =NON-

OPIOIDS

1STLINE =NON-

OPIOIDS

REMEMBER

• Ibuprofen 400mg + acetaminophen 1000mg

• Better pain relief than opioid combo!

• Fewer side effects

• No > 4,000mg acetaminophen/day

© AMSP 2014 14

SOMETIMES OPIOIDS ARE NEEDED

“Opiophobia” “No pain left behind”

Responsible Opioid Pharmacotherapy15

OPIOIDS

• Proteins

• Morphine-like actions

• Stimulate opioid receptors

• Reduce pain

© AMSP 2014 16

OPIOID

OPIOID RECEPTOR LOCATIONS

BRAIN

SPINALCORD

© AMSP 2014 17

GI TRACT

NERVES

Endogenous Opioids

OPIOID CLASSIFICATION

© AMSP 2014 18

OPIOID CLASSIFICATION

© AMSP 2014 19

OPIOIDS WORK WELL FOR ACUTE PAIN

BUT HAVE LIMITATIONS© AMSP 2014 20

OPIOID SIDE EFFECTSSedation

Dizziness

Nausea

Memory

RespirationsItching

Constipation

Tolerance

Withdrawal

© AMSP 2014 21

OPIOID SIDE EFFECTS

© AMSP 2013 22

THIS LECTURE WILL REVIEW

• Overview of orofacial pain management

• Recognition opioid use d/o (OUD)

• Prevention & referral for OUD

© AMSP 2014 23

RECOGNITION OF OUD

• Non-Medical Use

• Opioid Use Disorder

• Physiologic Dependence

© AMSP 2014 24

Terminology

NON-MEDICAL USE (NMU)

Use Rx for + feeling/high–2 million new NMUs/year

–2nd only to THC

–risk in adolescents

–Obtain from family/friend

© AMSP 2013 25

OUD VS. DEPENDENCESymptoms

OUD

Loss of control

in function

Use despite negatives

Compulsive use

Craving

Dependence

Tolerance

Withdrawal

No loss of control

Functioning well

26

≠

Start opioid

Pain

Euphoria

Change source

Tolerance

Doc mg

Tolerance

Pt mg

Use for stress sleep high

Try to

painsleep

w/d

Return to drug

27

How does an OUD start?

Run outearly

RECOGNIZING OUDBehaviors

More clearForging

Steal/borrowing

IV use

Obtained on street

Abuse other drugs

Multiple dose Recurrent Rx loss

Less clearRequest mg

Hoarding

Asking specific Rx

“Doc shopping”

1-2 dose Rx another sx

Psychic effects(Passik & Portenoy 1998)

28

RECOGNIZING OUDSigns

Intoxication Withdrawal

Pain/Distress

Dilated pupils

GI upset/diarrhea

Goosebumps

Euphoria

Constricted pupils

Slurred speech

The “nods”

29

THIS LECTURE WILL REVIEW

• Overview of orofacial pain management

• Recognition opioid use d/o (OUD)

• Prevention & referral for OUD

© AMSP 2014 30

RESPONSIBLE OPIOID RX

1. “Universal Precautions”

2. Use non pharm, non-opioid 1st

3. Don’t Rx > needed

4. Monitor/balance pain, function, & safety (4 A’s)

5. Educate about safe storage & disposal

6. Recognize and refer OUD treatment

© AMSP 2014 31

“UNIVERSAL PRECAUTIONS”

© AMSP 2013 32

Rx Monitoring ProgramsOpioid Tx Agreements

NON-PHARM, NON-OPIOID

• Surgery

• NSAIDs/analgesics

• Steroids

• Mandibular injections

© AMSP 2014 33

DON’T RX > THAN NEEDED

Average dental pain = 24 - 48hrs

Left-over meds = major issue

Rx 2-3 days worth, then re-eval© AMSP 2014 34

PASSIK’S 4A’S PAIN TREATMENT OUTCOMES

• Analgesia (pain relief)

• ADLs (Activities of Daily Living)

• Adverse effects

• Aberrant drug taking behavior

GOAL= Pain Function© AMSP 2014

35

SAFE STORAGE & DISPOSAL

Drug take-back programs The flush list

© AMSP 2014 36

DIAGNOSE AN OUD?

37

THIS DOES NOT WORK… THIS WORKS BETTER . . .

HAVING THE CONVERSATION

• Empathy (pt is suffering)

• Focus = safety & functioning

• Professionally set boundary

• Lifesaving tx available!© AMSP 2014

38

“LOW” RISK PATIENT

Characterized by

Follows plan/stable

function

Side effect concern

Leftover meds

Management

Universal precautions

Routing monitoring

No extra meds!

Safe storage education

© AMSP 2014 39

BEWARE THE LOW RISK PT

© AMSP 2013 40

MODERATE RISK PATIENT

Characterized by Lower risk behaviors

Strong FH

Psych history

Focus on opioids

ManagementUniversal precautions

Non-opioid first!!

Treat psych

Structure/Team© AMSP 2014

41

HIGH RISK PATIENT

Characterized by

In withdrawal

No Rx = urgency

dose > 2x

function

Only opioids

ManagementUniversal precautions

Non-opioid therapy

Max structure

Discuss OUD concern

Refer/Mandate OUD tx!

© AMSP 2014 42

SUMMARY

• Pain & opioid use are prevalent

• Rx opioid epidemic is ongoing

• Responsible opioid Rx = OUD

• Recognize & refer OUD = death

© AMSP 2014 43