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