OPIOID USE DISORDERS IN DENTAL MEDICINE Kelly S. Barth, DO Medical University of South Carolina ©AMSP 2014 © AMSP 20141

“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 20144

14% 18% 8% __________________________________________________________________ WHY DENTISTS? PCPs IMsDentists 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 20136

© AMSP 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 20138

OROFACIAL PAIN Unpleasant sensation face or mouth Prevalent - 20% US Costly – 32 billion/yr © AMSP 20149

Mouth Teeth Gums Mucosa Face Joints Acute Chronic CLASSIFICATION LocationDuration © AMSP

DIAGNOSIS Review history Exam –Extra/intraoral –Reproduce pain X-rays © AMSP Onset Location Duration Character Aggravating Relieving Timing Severity

TREATMENT Pulpotomy = 80% ↓ in pain Pulpectomy (root canal) = 75% ↓ in pain © AMSP SURGERY IS EFFECTIVE

MEDICATIONS Non-steroidal anti-inflammatories (NSAIDs) Acetaminophen (Tylenol) Combination therapy Prophylactic steroids Mandibular injections © AMSP ST LINE = NON- OPIOIDS 1ST LINE = NON- OPIOIDS

REMEMBER Ibuprofen 400mg + acetaminophen 1000mg Better pain relief than opioid combo! Fewer side effects No > 4,000mg acetaminophen/day © AMSP

SOMETIMES OPIOIDS ARE NEEDED “Opiophobia”“No pain left behind” Responsible Opioid Pharmacotherapy 15

OPIOIDS Proteins Morphine-like actions Stimulate opioid receptors Reduce pain © AMSP OPIOID

OPIOID RECEPTOR LOCATIONS BRAIN SPINAL CORD © AMSP GI TRACT NERVES

Endogenous Opioids OPIOID CLASSIFICATION © AMSP

OPIOID CLASSIFICATION Opiate Opium Morphine Codeine Semi- synthetic Heroin Hydrocodone Oxycodone Synthetic Fentanyl Methadone Tramadol © AMSP

OPIOIDS WORK WELL FOR ACUTE PAIN BUT HAVE LIMITATIONS © AMSP

OPIOID SIDE EFFECTS Sedation Dizziness Nausea  Memory  Respirations Itching Constipation Tolerance Withdrawal © AMSP

OPIOID SIDE EFFECTS © AMSP

THIS LECTURE WILL REVIEW Overview of orofacial pain management Recognition opioid use d/o (OUD) Prevention & referral for OUD © AMSP

RECOGNITION OF OUD Non-Medical Use Opioid Use Disorder Physiologic Dependence © AMSP Terminology

NON-MEDICAL USE (NMU) Use Rx for + feeling/high –2 million new NMUs/year –2 nd only to THC –  risk in adolescents –Obtain from family/friend © AMSP

OUD VS. DEPENDENCE Symptoms 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   pain  sleep w/d Return to drug 27 How does an OUD start? Run out early

RECOGNIZING OUD Behaviors More clear Forging Steal/borrowing IV use Obtained on street Abuse other drugs Multiple dose  Recurrent Rx loss Less clear Request  mg Hoarding Asking specific Rx “Doc shopping” 1-2 dose  Rx another sx Psychic effects (Passik & Portenoy 1998) 28

RECOGNIZING OUD Signs IntoxicationWithdrawal 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

RESPONSIBLE OPIOID RX 1.“Universal Precautions” 2.Use non pharm, non-opioid 1 st 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

“UNIVERSAL PRECAUTIONS” © AMSP Rx Monitoring ProgramsOpioid Tx Agreements

NON-PHARM, NON-OPIOID Surgery NSAIDs/analgesics Steroids Mandibular injections © AMSP

DON’T RX > THAN NEEDED Average dental pain = hrs Left-over meds = major issue Rx 2-3 days worth, then re-eval © AMSP

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

SAFE STORAGE & DISPOSAL Drug take-back programs The flush list © AMSP

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

“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

BEWARE THE LOW RISK PT © AMSP

MODERATE RISK PATIENT Characterized by Lower risk behaviors Strong FH Psych history Focus on opioids Management Universal precautions Non-opioid first!! Treat psych Structure/Team © AMSP

HIGH RISK PATIENT Characterized by In withdrawal No Rx = urgency  dose > 2x  function Only opioids Management Universal precautions Non-opioid therapy Max structure Discuss OUD concern Refer/Mandate OUD tx! © AMSP

SUMMARY Pain & opioid use are prevalent Rx opioid epidemic is ongoing Responsible opioid Rx =  OUD Recognize & refer OUD =  death © AMSP