10/27/2019 The Opioid Epidemic 2019waynejones.net/gum/presentations/Opioid_Lecture_5... · The Opioid Epidemic 2019 Steven W. Beadnell, DMD Sunset Oral & Maxillofacial Surgery 15

The Opioid Epidemic 2019

Steven W. Beadnell, DMDSunset Oral & Maxillofacial Surgery

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✓Opioid crisis – nature of the problem

✓Dentist’s role in in the opioid epidemic

✓Identify best practice guidelines for

managing acute dental pain.

✓Discuss Oregon Prescription Drug

Management Program

✓Discuss disposal of prescription drugs

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National Drug Threat Assessment 2017

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National Drug Threat Assessment 2017

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Drug overdose deaths continue to increase in the United States:

✓ From 1999 to 2017, more than 700,000 people have died from a

drug overdose.

✓ Around 68% of the more than 70,200 drug overdose deaths in

2017 involved an opioid.

✓ In 2017, the number of overdose deaths involving opioids

(including prescription opioids and illegal opioids like heroin

and illicitly manufactured fentanyl) was 6 times higher than in

1999.

✓ On average, 130 Americans die every day from an opioid

overdose

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2017 2011

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Fentanyl

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✓ The pattern of drugs involved in drug overdose

deaths has changed in recent years. The rate of drug

overdose deaths involving synthetic opioids other

than methadone (drugs such as fentanyl, fentanyl

analogs, and tramadol) increased 45% from 6.2 per

100,000 in 2016 to 9.0 in 2017.

✓ The rates of drug overdose deaths involving heroin

(4.9 per 100,000), natural and semisynthetic opioids

(4.4), and methadone (1.0) were the same in 2016

and 2017.

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Date of download: 4/14/2019

From: The Burden of Opioid-Related Mortality in the United States

JAMA Netw Open. 2018;1(2):e180217. doi:10.1001/jamanetworkopen.2018.0217

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✓ In 2017, there were 70,237 drug overdose deaths in

the United States.

✓ The age-adjusted rate of drug overdose deaths in

2017 (21.7 per 100,000) was 9.6% higher than the

rate in 2016 (19.8)

✓ The age-adjusted rate of drug overdose deaths

involving synthetic opioids other than methadone

(drugs such as fentanyl, fentanyl analogs, and

tramadol) increased by 45% between 2016 and

2017, from 6.2 to 9.0 per 100,000.

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It’s not just the overdoses creating a $$$ burden

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U. S. Average

21.7100,000

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U. S. Average

21.7100,000

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400

420

440

460

480

500

520

540

2013 2014 2015 2016 2017

Oregon Opioid Deaths

Deaths Linear (Deaths)

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Top states for non-medical use of prescription

drugs among ages 12 and older, 2010-2011.

Source: 2013 National Survey on Drug Use and Health

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1. Opioids are now the leading cause of death for

people under 50.

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people under 50.

2. The rate of overdoses for the teenage

demographic surged 20% in 2015 alone, the vast

majority of which were related to opioids.

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people under 50.




3. With a 10 day supply of opioid painkillers, one in

five people will become long term users. This is

how addictive these pills are!

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https://arstechnica.com/science/2017/03/with-a-10-day-supply-of-opioids-1-in-5-become-long-term-users

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https://www.cdc.gov/mmwr

Characteristics of Initial Prescription Episodes and Likelihood

of Long-Term Opioid Use — United States, 2006–2015

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people under 50.




3. With a 10 day supply of opioid painkillers, one in

five people will become long term uses. This is

how addictive these pills are.

4. Dentists and oral surgeons are now major opioid

prescribers

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How did we get here ?

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❖ Mid-1990’s => Opioid abuse on FDA radar, ignored

Opioid Prescriptions Dispensed by US Retail Pharmacies

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❖ 2000 => American Pain Society + others⚫ Pain is a “patient right” issue

⚫ Vital signs: BP, P, T, RR

◼ Petitioned to get PAIN added as 5th “vital sign”

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❖ 1/1/2001=> Congress declared 2000’s as the decade of

pain control

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PAIN is a four-letter word !

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pain control

❖ 2010+’s => Increasing alarm at increasing opioid

abuse and deaths

HCP = Hydrocodone Containing prescriptions

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pain control

❖ 2001+’s => Increasing alarm at increasing opioid

abuse and deaths

❖ 10/2014 => DEA reclassifies Hydrocodone CIII to CII

in effort to decrease availability of HCPs

HCP = Hydrocodone Containing prescriptions

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Conclusion: The rescheduling of HCPs resulted in a reduction in HCP

prescriptions but was accompanied by increases in the use of codeine-

containing products and tramadol in all settings

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Now the problem has become “HUGE”, but at least we are paying attention

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From: Characteristics of Opioid Prescriptions in 2009

JAMA. 2011;305(13):1299-1301. doi:10.1001/jama.2011.401

Vector One: National (VONA) database from SDI Health

Vector One: National (VONA)

database from SDI Health

❖SDI receives 1.4B Rx per year

❖79.5 M Rx for opioid analgesics

❖Dentists overall was 8.0% of Rx

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❖ 1000 pt & 251 parents

❖ Rx(# of pills):

❖ 1-15 (40-64%)

❖ 16-30 (27-49%)

❖ >30 (4-6%)

❖ Pills left over

❖ 76 -77% after pain abated

❖ 44 - 55% still had pills

❖ 24 - 41% discarded pills

❖ 5 - 14% took for future pain

❖ 1 - 4% someone else took pills

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AAOMS Annual Meeting - Oral Abstracts, October 2017

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AAOMS Annual Meeting - Oral Abstracts, October 2017

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JADA, Volume 147, Issue 7, Pages 537-544 (July 2016)

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The Oregon Opioid Initiative

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Statement on the Use of Opioids in the Treatment of Dental Pain

❖ When considering prescribing opioids, dentists should conduct a medical and dental history to determine current

medications, potential drug interactions and history of substance abuse.

❖ Dentists should follow and continually review Centers for Disease Control and State Licensing Boards

recommendations for safe opioid prescribing.

❖ Dentists should register with and utilize prescription drug monitoring programs (PDMP) to promote the appropriate

use of controlled substances for legitimate medical purposes, while deterring the misuse, abuse and diversion of

these substances.

❖ Dentists should have a discussion with patients regarding their responsibilities for preventing misuse, abuse, storage

and disposal of prescription opioids.

❖ Dentists should consider treatment options that utilize best practices to prevent exacerbation of or relapse of opioid

misuse.

❖ Dentists should consider nonsteroidal anti-inflammatory analgesics as the first-line therapy for acute pain

management.

❖ Dentists should recognize multimodal pain strategies for management for acute postoperative pain as a means for

sparing the need for opioid analgesics.

❖ Dentists should consider coordination with other treating doctors, including pain specialists when prescribing

opioids for management of chronic orofacial pain.

❖ Dentists who are practicing in good faith and who use professional judgment regarding the prescription of opioids

for the treatment of pain should not be held responsible for the willful and deceptive behavior of patients who

successfully obtain opioids for non-dental purposes.

❖ Dental students, residents and practicing dentists are encouraged to seek continuing education in addictive disease

and pain management as related to opioid prescribing.

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https://www.cdc.gov/drugoverdose/prescribing/guideline.html

http://www.nascsa.org/stateprofiles.htm



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Dentists should register with and utilize prescription

drug monitoring programs (PDMP) to promote the

appropriate use of controlled substances for

legitimate medical purposes, while deterring the

misuse, abuse and diversion of these substances.

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Dentists should register with and utilize prescription drug

monitoring programs (PDMP) to promote the appropriate

use of controlled substances for legitimate medical purposes,

while deterring the misuse, abuse and diversion of these

substances.

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A prescription drug monitoring program (PDMP) is an electronic

database that tracks controlled substance prescriptions in a state.

PDMPs can provide health authorities timely information about

prescribing and patient behaviors that contribute to the epidemic.

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Benefits of PDMP ?

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http://www.orpdmp.com

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http://www.orpdmp.com/



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https://oregon.pmpaware.net/login

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https://oregon.pmpaware.net/login



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Donald H – I&D Perimandibular Abscess

44y/0 WM 2days S/P PO Ext #24-26

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Donald H – I&D Perimandibular Abscess

44y/0 WM 2days S/P PO Ext #24-26

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Narcotic pills last 6 months => 1,299

PDMP Report

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Dentists should have a discussion with patients

regarding their responsibilities for preventing

misuse, abuse, storage and disposal of

prescription opioids.

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DISPOSAL OF MEDICINE, VITAMINS AND OTHER

SUPPLEMENTS PROPERLY CAN HELP:

❖ Prevent unintentional poisoning of children and pets

❖ Prevent misuse by teenagers and adults, even people

you know

❖ Prevent health problems from accidentally taking the

wrong medicine, too much of the same medicine, or a

medicine that is too old to work well

❖ Prevent medicines and supplements from entering

streams and rivers when poured down the drain or

flushed down the toilet

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https://www.dea.gov/sites/default/files/2018-10/Proper%20Disposal%20Flier%20%28October%202018%29.pdf

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DEA National Rx Take Back Day

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DEA National Prescription Drug Take Back Day

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https://archive.epa.gov/region02/capp/web/pdf/ppcpflyer.pdf

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https://archive.epa.gov/region02/capp/web/pdf/ppcpflyer.pdfhttps://archive.epa.gov/region02/capp/web/pdf/ppcpflyer.pdf

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https://archive.epa.gov/region02/capp/web/pdf/ppcpflyer.pdf

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DEA Authorized Drug Dropoff Locations

https://apps.deadiversion.usdoj.gov/pubdispsearch/sp

ring/main?execution=e1s2

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https://apps.deadiversion.usdoj.gov/pubdispsearch/spring/main?execution=e1s2



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https://apps.deadiversion.usdoj.gov/pubdispsearch/

spring/main?execution=e1s2

DEA authorized drug drop off locations

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https://apps.deadiversion.usdoj.gov/pubdispsearch/spring/main?execution=e1s2



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https://www.dea.gov/sites/default/files/2018-10/Proper%20Disposal%20Flier%20%28October%202018%29.pdf

Controlled Substance Public Disposal Locations

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❖Dentists should consider nonsteroidal anti-

inflammatory analgesics as the first-line

therapy for acute pain management.

❖Dentists should recognize multimodal pain

strategies for management for acute

postoperative pain as a means for sparing the

need for opioid analgesics.

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Philosophy of Multimodal Analgesia

Not only just giving 2 or more drugs

which have different mechanism, but:

✓ One drug should be effective at peripheral

sensitization and other at central sensitization.

✓ Combine drugs must be synergistic or additive.

✓ Must be proven by laboratory or clinical data.

✓ Some drugs may act at several points in

nociceptive pathway.

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Administration of two or more analgesics

that act at different mechanisms:

❖Produce additive or synergistic analgesia

(2+2 = 4) (2+2>4)

❖Should be given around the clock (ATC)

Main goal of Multimodal Analgesia is to

reduce the amount of Opioids needed

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❖ Management of acute pain after WT removal

or abdominal or pelvic surgery

❖ Approximately 50,000 patients

❖ NNT = Number Needed to Treat

❖ For at least 50% maximum pain relief over 4-6hrs

compared with placebo

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Acute Pain

NNT for at

least 50%

maximum

pain relief

over 4-6hrs

compared

with placebo

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Ibuprofen 400mg

+ Tylenol 1000mg

Ibuprofen 200mg

+ Tylenol 500mg

Ibuprofen 400mg

Naproxen 500mg

Oxycodone 10mg

+ Tylenol 1000mg

Celecoxib 400mg

Codeine 60mg +

Tylenol 650mg

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Naproxen 500mg

Oxycodone 10mg

+ Tylenol 1000mg

Celecoxib 400mg

Codeine 60mg +

Tylenol 600mg

Ibuprofen 200mg

+ Tylenol 500mg

Ibuprofen 400mg

+ Tylenol 1000mg

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✓ Three clinical trials: Ext Wisdom Teeth 1,647pt

✓ Ibuprofen/Tylenol

✓ 200/500mg or 400/1000mg

✓ Combination better analgesia than either drug

alone (at same dose)

✓ Effective pain relief for 69-70% of patients

2013

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JADA 2013;144(8):898-908.

+

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JADA 2013;144(8):898-908.

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A reasonable approach to acute dental pain

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https://apps.state.or.us/Forms/Served/le9402.pdf

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http://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/SUBSTANCEUSE/OPIOIDS/Docum

ents/oregon-recommended-opioid-guidelines-dentists.pdf

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Prescribe NSAIDs/Acetaminophen one hour before the procedure

❖Lower postoperative pain/swelling

❖Decrease opiate consumption

❖No consensus on benefit

❖Makes sense to do it in most cases

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Ibuprofen❖The analgesic ceiling effect of nonsteroidal

anti-inflammatory drugs (NSAIDs) is well

studied. Although ibuprofen is commonly

used in dosages as high as 800 mg for acute

pain, the analgesic ceiling is only 400

mg/dose, to about 1200 mg/day. However,

2400 mg daily can relieve inflammation

without providing additional pain relief.

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Comparison of 400 mg vs 600 mg of ibuprofen vs

placebo in patients with postoperative dental pain

Seymour RA, Ward-Booth P, Kelly PJ. Evaluation of different doses of soluble ibuprofen and

ibuprofen tablets in postoperative dental pain. Br J Oral Maxillofac Surg. 1996;34:110-114.

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Ibuprofen

❖ The literature clearly demonstrates that for

pain relief the commonly prescribed doses of

600 mg or 800 mg of ibuprofen every 6 to 8

hours should be replaced with a maximum dose

of 400 mg every 8 hours.

❖ Dosages over 1200 mg daily offer no additional

pain relief and are known to cause cardiac and

gastrointestinal toxicities.

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NN

Black Box Warning by FDA in 2005

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Black Box Warning by FDA in 2005

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Coexisting medical conditions to consider before recommending NSIADs

CARDIOVASCULAR RISKS✓Patients with cardiovascular (CV) disease are at

increased risk for cardiovascular events

(myocardial infarction, stroke) when taking a non-

aspirin NSAID such as ibuprofen or naproxen

sodium.

✓For patients on an aspirin heart therapy regimen,

ibuprofen may interfere with the cardioprotective

benefit of aspirin.

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CARDIOVASCULAR RISKSRecent FDA NSAID label updates with respect to CV risks:

✓ For any patients taking a non-aspirin NSAID—including

ibuprofen or naproxen sodium—the risk of heart attack, heart

failure, and stroke increases.

✓ Patients are now urged to ask their healthcare professional

before using OTC NSAIDs if they have had a stroke in the past.

✓ Patients are also encouraged to stop use and ask a healthcare

professional if they have symptoms of heart problems or stroke,

including chest pain, trouble breathing, weakness in one part or

side of the body, slurred speech, or leg swelling.

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GASTRITIS OR ULCERS

Patients over age 60 and patients with

existing GI risks who take ibuprofen or

any other NSAID are at higher risk of

developing serious GI toxicities such as

an ulcer or bleeding.

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Be part of the solution !

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Documents

10/27/2019 The Opioid Epidemic 2019waynejones.net/gum/presentations/Opioid_Lecture_5... · The Opioid Epidemic 2019 Steven W. Beadnell, DMD Sunset Oral & Maxillofacial Surgery 15