Rx16 clinical tues_330_1_lindroth_2okeson

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