OPIOID USE DISORDERS IN DENTAL MEDICINE Kelly S. Barth, DO Medical University of South Carolina...
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Transcript of 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