1. Pain Management in the Midst of an Opioid Crisis
Alan Murray, LSCSW, LCSW Executive Director Heart of America Professional Network (913)

2. Heart of America Professional Network
The mission of Heart of America Professional Network is to ensure public safety by assessing for and assisting with the rehabilitation of impaired healthcare professionals by providing advocacy, consultation, referral and monitoring services
Kansas Dental Board
Kansas Board of Optometry
Kansas Board of Healing Arts
Kansas Board of Nursing (KNAP)

3. History of Opium Use in Pain Management
Opium, found in the pod of the poppy plant, contains both codeine and morphine known as opiates
Its analgesic and euphoric qualities have been noted and utilized by civilizations since 3400 B.C.
Sumerians referred to it as “Hul Gil”…the “Joy Plant”
Arabs, Greeks and Romans used it as a sedative
Its use was prohibited during the Inquisition
The frequent use of morphine led to “Soldiers Disease” during the Civil War
Beginning in 1898 with the introduction of Heroin, synthetic opioids have played an increasing role in Acute and Chronic Pain Management
In the 1990’s, untreated pain became a major public health concern
Driven by pharmaceutical marketing, opioid prescribing increased dramatically

4. “Pain is whatever the experiencing patient says it is and exists whenever he/she says it does” Justified Prescription Opioids without findings, diagnosis or treatment plans

6. Your Brain on Opioids

8. The Opioid Epidemic in America
The United States accounts for 5% of the world’s population but consumes 80% of all opioids, including 99% of all Hydrocodone
In 2012, 259 million prescriptions were written for opioids, which is more than enough to give every American adult their own bottle of pills
430 million doses of opioids are taken non-medically each year
Of the 20.5 million Americans 12 or older that had a substance use disorder in 2015, 2 million had a substance used disorder involving prescription pain relievers- nearly 4X the number than those with a substance use disorder involving heroin
Drug overdose is the leading cause of accidental death in the US, with 52,404 lethal drug overdoses in 2015
Opioid addiction is driving this epidemic, with 20,101 overdose deaths related to prescription paing relievers, and 12, 990 overdose related to heroin in 2015

9. On an Average Day in the U.S.
More than 650,000 opioid prescriptions are dispensed
3,900 people initiate nonmedical use of prescription opioids
580 people initiate heroin use
78 people die from an opioid-related overdose

11. The Crisis in Kansas
Poisoning is the second leading cause of injury deaths in Kansas. Poisoning death rates, which include drug poisonings, surpassed motor vehicle traffic-related death rates in 2013.
Prescription drugs, illicit drugs, and over-the-counter medications were the underlying cause of death for almost 90% of all poisoning deaths.
In 2015 the drug poisoning death rate was 11.8 deaths per 100,000 persons
Among these drug poisoning deaths, 67% were unintentional and 15% were suicide or intentional self-harm
Males had rates 1.3 times higher than females
Decedents aged years had the highest age-specific drug-poisoning death rate of all selected age categories

17. The Role of Dentist in the Opioid Crisis
Dentists prescribe between One and 1.5 Billion doses of IR opioids annually
Dentist account for approximately 12% of all opioid prescriptions
Over 40% of dental patients are prescribed opioids following tooth extraction
The rate among adolescents is curiously higher at 61%
Average prescription is for 20 tablets of hydrocodone/APAP
96% of prescribers instruct to “take as needed”
Patients given opioids following dental surgery reported 54% of prescription left over following cessation of pain
52 Million opioid doses taken non-medically can be traced to dental practices
Dentist are leading prescriber to young people (10-19 years of age)
Adolescent non-medical users of prescription opioids-27% obtained from dentist

19. Legal Guidelines Being Established by Dental Boards
Continuing Education on Pain Management
Continuing Education on Substance Abuse and Addiction
Continuing Education on Identifying Patients At Risk for Substance Abuse Disorders
Counseling Patients about Side Effects and Addictive Nature of Opioids
Counseling Patients about Proper Storage and Disposal of Opioids
Appropriate Prescribing Guidelines regarding Quantities and Duration of Opioids
Use of Opioid Alternatives
Use of Prescription Drug Monitoring Programs
Partial Filling of Prescriptions

20. The Dentist Role in Pain Management
The American Dental Association’s Core Competencies of graduating dental students include the abilities to prevent, diagnose and manage pain

22. Pharmacological Control of Dental Pain
Initiation of impulse; NSAIDS, APAP
Propagation of Impulse
Local Anesthetics
Perception of Painful Stimuli Opioids

25. Scope of Prescription Writing Authority
A prescription must be issued in good faith for a legitimate dental purpose And
By a practitioner in the usual course of professional practice
Doctor/Patient Relationship
Scope of Practice
Patient of Record
Examination
Documented Findings
Diagnosis and Treatment Plan

26. The 2 Major Questions
How Much?
and
To Whom?

27. Stepwise Guidelines for Acute Postoperative Pain Management in Dentistry Moore, PA, Hersh, EV. Combination Ibuprofen and Acetaminophen for Acute Pain Management after Third Molar Extractions. JADA 2013; 144(8):
Mild
Ibuprofen ( mg) every 4-6 hours as needed for pain
Mild to Moderate
Ibuprofen ( mg) every 6 hours; fixed intervals for first 24 hours, then 400mg every 4-6 hours as needed for pain
Moderate to Severe
Ibuprofen ( mg) with APAP 500mg every 6 hours; fixed intervals for first 24 hours, then Ibuprofen 400mg with APAP 500mg every 6 hours as needed for pain
Severe
Ibuprofen ( mg) with APAP 650mg with Hydrocodone 10mg every 6 hours; fixed intervals for hours, then Ibuprofen ( mg) with APAP 500mg every 6 hours as needed for pain

28. NSAIDs Contraindicated
Mild
APAP ( mg) every 6 hours as needed
Moderate
APAP 650mg/HC regular intervals every 6 hours for 24 hours, then APAP ( mg) every 6 hours as needed
Severe
APAP 650mg/OC 10 mg regular intervals every 6 hours for 48 hours, then APAP ( mg) every 6 hours as needed

29. Alternatives to Opioids “PLAN”
Pre-emptive use of NSAIDS
Long Acting Local Anesthetics
APAP + NSAIDS
NSAIDS First

31. What About Mary? 42 Year Old Caucasian Female
Registered Nurse working in hospital setting
Suffers from chronic back pain
Recently moved into area from out of state
Has no primary care physician currently
Allergic to NSAIDS
Currently taking Oxycodone 10mg every 6 hours as needed for chronic back pain
Presents with cracked molar requiring extraction

32. Patients at Highest Risk
Substance abuse histories or current use
Already on Opioids
History of DUI or substance-related arrest
Cigarette Smokers
Victims of Sexual Abuse
Depression
Anxiety

33. Women
Women are more likely to have chronic pain, be prescribed prescription pain relievers, be given higher doses, and use them for longer time periods than men.
Women may become dependent on prescription pain relievers more quickly then men.
48,000 women died of prescription pain reliever overdoses between and 2010
Prescription pain reliever overdose deaths among women increased more than 400% from 1999 to 2010, compared to 237% among men
Heroin overdose deaths among women have tripled in the last few years. From 2010 through 2013, f e heroin overdoses increased from 0.4 to 1.2 per 100,000

34. Adolescents
In 2015, 276,000 adolescents were current nonmedical users of pain relievers, with 122,000 having an addiction to prescription pain relievers
In 2015, an estimated 21,000 adolescents had used heroin in the past year, and an estimated 5,000 were current heroin uses. Additionally, an estimated 6,000 adolescents had a heroin use disorder in 2014
People often share their unused pain relievers, unaware of the dangers of nonmedical opioid use. Most adolescents who misuse prescription pain relievers are given them for free by a friend or relative
The prescribing rates for prescription opioids among adolescents and young adults nearly doubled from 1994 to 2007

36. Cultures of Substance Use Disorder, Drug Misuse, and Drug Diversion
The Sharing Culture
The Income-Driven Culture
The Substance Abuse Culture
The Addiction Culture
Combinations of Cultures

37. Motivational Interviewing
Open-ended Questions
Affirmations
Reflections
Summaries

38. Motivational Interviewing Demonstration

39. Assessing Risk Factors
Record Review and communication with the patients other health care providers
Screening Tools and Questionnaires
Opioid Risk Screen
Quick Screen (NIDA)
Screener and Opioid Assessment for Patients with Pain (SOAPP-R)
Pain Medication Questionnaire (PMQ)
Prescription Drug Monitoring Programs (PDMP)
KTRACS

40. Behavioral Characteristics of Drug Seeking Patients
Requesting specific opioids
From out of town/area
Refuse treatment/request meds
Request early refills
Lost or stolen prescriptions
Make up pain
Often irritable, hyperactive, malnourished, unkempt, non- compliant or appear impaired or sedated

41. Doctor Shopping

42. What About Mary? 42 Year Old Caucasian Female
Registered Nurse working in hospital setting
Suffers from chronic back pain
Recently moved into area from out of state
Has no primary care physician currently
Allergic to NSAIDS
Currently taking Oxycodone 10mg every 6 hours as needed for chronic back pain
Presents with cracked molar requiring extraction

43. Preventing Doctor Shopping
Question their choice of practitioner
Require photo ID
Confirm telephone and address
Utilize PDMP (KTRACS)
Provide complete examination and document findings
Utilize NSAIDS
Limit quantity of Opioids prescribed

44. Office Ready-Access List for Dental Practitioners
Law Enforcement & Regulatory Agencies
Specialist
Local Police Department
State Drug Task Force
DEA
State Board of Pharmacy
State Dental Board
Addiction Specialist
Pain Specialist
Community Pharmacist
Substance Abuse Counselor
Local Addiction Treatment Centers
Drug Information/Poison Center
Local Hospital or Emergency Room

45. Reduce Prescription Drug Abuse by following Accepted Standards
Prescribe for legitimate dental purposes only
Prescribe only for patients of record
Review Medical History before prescribing
Periodically update pain management training
Counsel and follow-up with patients regarding proper compliance, storage and disposal
Consider non-opioids, pre-emptive medications
Train Office staff
Consistently utilize Prescription Drug Monitoring Program (PDMP)
Never prescribe without proper patient treatment records
Safeguard prescription pads
Learn to identify high-risk substance abuse patient
Limit quantity prescribed, numeric and textual

46. Questions/Comments