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

2. “EPIDEMIC” OF Rx OD DEATHS 2

3. ACCIDENTAL OD DEATHS 3

4. WHY Rx OPIOIDS? Seen as safer than street drugs  social stigma  cost Wide availability Pain © AMSP 20144

5. 14% 18% 8% __________________________________________________________________ WHY DENTISTS? PCPs IMsDentists 5 TOP OPIOID PRESCRIBERS

6. THIS LECTURE WILL REVIEW Overview of orofacial pain management Recognition of opioid use d/o (OUD) Prevention & referral for OUD © AMSP 20136

7. © AMSP 20147 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

8. OROFACIAL PAIN MANAGEMENT Definition & classification Diagnosis Treatment © AMSP 20138

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

10. Mouth Teeth Gums Mucosa Face Joints Acute Chronic CLASSIFICATION LocationDuration © AMSP 201310

11. DIAGNOSIS Review history Exam –Extra/intraoral –Reproduce pain X-rays © AMSP 201411 Onset Location Duration Character Aggravating Relieving Timing Severity

12. TREATMENT Pulpotomy = 80% ↓ in pain Pulpectomy (root canal) = 75% ↓ in pain © AMSP 201412 SURGERY IS EFFECTIVE

13. MEDICATIONS Non-steroidal anti-inflammatories (NSAIDs) Acetaminophen (Tylenol) Combination therapy Prophylactic steroids Mandibular injections © AMSP 201413 1ST LINE = NON- OPIOIDS 1ST LINE = NON- OPIOIDS

14. REMEMBER Ibuprofen 400mg + acetaminophen 1000mg Better pain relief than opioid combo! Fewer side effects No > 4,000mg acetaminophen/day © AMSP 201414

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

16. OPIOIDS Proteins Morphine-like actions Stimulate opioid receptors Reduce pain © AMSP 201416 OPIOID

17. OPIOID RECEPTOR LOCATIONS BRAIN SPINAL CORD © AMSP 2014 17 GI TRACT NERVES

18. Endogenous Opioids OPIOID CLASSIFICATION © AMSP 201418

19. OPIOID CLASSIFICATION Opiate Opium Morphine Codeine Semi- synthetic Heroin Hydrocodone Oxycodone Synthetic Fentanyl Methadone Tramadol © AMSP 201419

20. OPIOIDS WORK WELL FOR ACUTE PAIN BUT HAVE LIMITATIONS © AMSP 201420

21. OPIOID SIDE EFFECTS Sedation Dizziness Nausea  Memory  Respirations Itching Constipation Tolerance Withdrawal © AMSP 2014 21

22. OPIOID SIDE EFFECTS © AMSP 201322

23. THIS LECTURE WILL REVIEW Overview of orofacial pain management Recognition opioid use d/o (OUD) Prevention & referral for OUD © AMSP 201423

24. RECOGNITION OF OUD Non-Medical Use Opioid Use Disorder Physiologic Dependence © AMSP 201424 Terminology

25. 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 201325

26. 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 ≠

27. 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

28. 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

29. RECOGNIZING OUD Signs IntoxicationWithdrawal Pain/Distress Dilated pupils GI upset/diarrhea Goosebumps Euphoria Constricted pupils Slurred speech The “nods” 29

30. THIS LECTURE WILL REVIEW Overview of orofacial pain management Recognition opioid use d/o (OUD) Prevention & referral for OUD © AMSP 201430

31. 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 201431

32. “UNIVERSAL PRECAUTIONS” © AMSP 201332 Rx Monitoring ProgramsOpioid Tx Agreements

33. NON-PHARM, NON-OPIOID Surgery NSAIDs/analgesics Steroids Mandibular injections © AMSP 201433

34. DON’T RX > THAN NEEDED Average dental pain = 24 - 48hrs Left-over meds = major issue Rx 2-3 days worth, then re-eval © AMSP 201434

35. 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

36. SAFE STORAGE & DISPOSAL Drug take-back programs The flush list © AMSP 201436

37. DIAGNOSE AN OUD? 37 THIS DOES NOT WORK… THIS WORKS BETTER...

38. HAVING THE CONVERSATION Empathy (pt is suffering) Focus = safety & functioning Professionally set boundary Lifesaving tx available! © AMSP 2014 38

39. “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 201439

40. BEWARE THE LOW RISK PT © AMSP 201340

41. 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 2014 41

42. 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 201442

43. SUMMARY Pain & opioid use are prevalent Rx opioid epidemic is ongoing Responsible opioid Rx =  OUD Recognize & refer OUD =  death © AMSP 201443