Pain and Opioid Use Disorders in Dental Medicine

I.  Introduction

 

A.  Non-medical use and overdose of Rx opioids in US is epidemic

 

1.  15,000 Rx opioid overdoses/year1

 

                a.  >Heroin + cocaine1

 

            b.  Most accidental

 

2. Prescription drugs present a special problem (Slide 4)

 

                        a.  Seen as safe

 

                        b.  Easily obtained

 

                        c.  Inexpensive (or free)2

 

            C.  Dentists prescribe 8% of opioids in the US3 (Slide 5)

 

                        1.  18 million Rx/year; second only to Primary Care Physicians (PCP)3

 

2.  Have opportunity to impact on opioid misuse and overdose deaths

 

3.  Responsibility to prescribe opioids safely

 

D.  This lecture will review (Slide 6):

1.  Overview of oral-facial pain and management

2.  Recognition of opioid use disorders

 

                        3.  Prevention and treatment/referral options for opioid use disorders

E.  Will refer to 3 cases (Slide 7)

1.  Joe

           

                                    a.  25 year-old graduate student

 

                                    b.  Impacted wisdom tooth

 

                                    c.  Strong family history of drug problems (including opioids)

           

d.  Drinks heavily 3 times a week, "like my friends"

2.  Joanne

 

a.  38 year old lawyer, comes in on Friday afternoon

 

b.  Appears in distress, complains of  “terrible toothache”

 

c.  Says “Only oxycodone (Oxycontin) works”

 

3.  Edna

 

                                              a.  60 year old retired teacher with one kidney

 

b.  Presents for uncomplicated tooth extraction

 

c.  Given #30 hydrocodone/acetaminophen (Vicodin)

 

II.  Oral-facial pain (Slide 9)

 

A.  Definition - Unpleasant sensation in face and/or mouth

 

B.  Prevalent - 20% of US in the past 6 months4

 

C.  Costly       

           

            a.  Overall cost of chronic pain = $80 billion/year5

 

            b.  40% associated with orofacial pain5

 

D.  Types orofacial pain are based on (Slide 10):

 

1.  Duration

 

a.  Acute (<3-6 mos generally; for dentists, less than 1 week)

 

            1’  Toothache (odontalgia) (12% of population) 6

 

            2’  Post-tooth extraction or other procedure

 

a’  40% of procedures have acute post-op pain7

 

b’  Average maximal pain duration 24-48 hrs8

 

                        c’  Best predictor = pre-op pain severity/sensitivity8

 

b.  Chronic (>3-6 mos)

 

                        1’  Tempromandibular joint disorder (TMD)

 

                                    a.  Jaw joint pain and dull facial pain

 

                                    b.  In TM joint and muscles of mastication

 

                                    c.  Chronic TMD - up to 12% of US population5

 

                        2’  Burning mouth syndrome

 

                                    a.  Burning, tender, annoying sensation in mouth

 

                                    b.  No apparent mucosal lesion

 

                                    c.  ~ 1% of US population5

 

                        3’  Post-procedural - 10% develop chronic pain9

 

                                    a’  Best predictor = pre-op persistent pain (3 mos)9

 

                                    b’  Second predictor = previous chronic pain9

2.  Location

 

a.  Teeth

 

1’  Odontalgia (tooth ache)

 

2’  3rd molar extraction – prophylactic

 

            a’  5 million people/year10

 

            b’  $3 billion/year10     

 

            c'  3.5 million ~ 20 year olds exposed to opioids/yr10

 

b.  Gums

 

c.  Palate

 

d.  Mucosa

 

e.  Joints– TMD

 

f.  Face - trigeminal neuralgia (shooting pain 5th cranial nerve)

 

            E.  Diagnosis – reproducing pain in office is critical11 (Slide 11)

1.  Review medical history – “OLDCARTS”

2.  Sensitivity

            a.  Sensitivity to temperature?

 

b.  Sensitivity to percussion/chewing?

3.  Extraoral exam – facial swelling, large lymph nodes, etc

4.  Intraoral exam – tooth pulp tests, palpation, percussion, etc

5.  Evaluate and correlate X-rays

 

III. Treatments for acute oral-facial pain (Slide 12)

           

            A.  Opioids have limitations: are not necessarily first line (described below)

 

            B.  Dental treatments

           

                        1.  Pulpotomy

                       

                                    a.  Removing neurons/receptors in the pulp chamber

 

                                    b.  80% ↓ in pain11

 

                        2. Pulpectomy  (root canal)

 

                                    a.  Removing material in pulp chamber and root canal

 

                                    b.  75% ↓ in pain11

 

            C. Non-opioid medications are first line pharmacotherapy (Slide 13)

            1.  Non-steroidal anti-inflammatories (NSAIDs)

                                               

                                    a.  Ibuprofen (Motrin)

 

                                                1'  400mg - 800mg + long-acting anesthetic pre-proc.12

 

                                                2'  400-600mg TID = effect of opioids for many12

 

                                    b. Ketorolac (Toradol - IV NSAID) 30mg IV pre-operatively

 

                        2.  Analgesics

 

                                    a.  Acetaminophen (Tylenol) 1000mg once pre-procedure12

 

b.  Effective for 3rd molar extractions(with ibuprofen, see below)

 

            3.  Combination therapy13

 

                        a.  Ibuprofen 400mg + acetaminophen 1000mg13

 

                        b.  >pain relief than opioid combo and less side effects13

 

                        c.  Do not exceed 4,000mg acetaminophen/day

 

            4.  Pre-emptive glucocorticoids (steroids) - anti-inflammatory

 

                        a.  Dexamethasone 4-8mg IV

 

                        b.  Dexamethasone 10mg PO

           

            5.  Mandibular injections - 3rd molar extractions14,15

 

a.  Long acting anesthetic (bupivacaine) at end of procedure

 

b.  50% pain vs placebo

 

IV.  Treatments for chronic oral-facial pain

 

A.  Tempomandibular Disorders (TMD)

 

            1.  Patient education & self-care (e.g.: adequate sleep, hydration)

 

            2.  Occlusal splints if bruxism (protects if grind teeth)

 

            3.  Psychosocial interventions (e.g. biofeedback, behavioral therapy)

 

            4.  +/- physical therapy for TMD (mixed results)

 

            5.  Naproxen (Aleve) 250-500mg BID x 10-14 days

 

            6.  Muscle tenderness present:

 

                        a.  Muscle relaxer

 

                        b.  Cyclobenzaprine (Flexeril) 10mg at bed x2-3 wks16

 

            7.  If above fail:

 

                        a.  Low dose 1st generation (tricyclic) antidepressant

 

                        b.  Amitryptiline (Elavil) 25mg at bed x 3-4 mos17

 

            8.  Little to no role for opioids or benzodiazepines

 

B.  Trigeminal neuralgia

 

            1.  Anticonvulsants18- turn down signal to pain nerve (block Na channels)

 

            2.  Carbamazepine (Tegretol) 300-400mg 2x/day

           

                        3.  Oxcarbamazepine (Trileptal) 600mg 2x/day

V.  Opioids- they do have a role in dentistry (Slide 15)

A.  Definition of opioids (Slide 16)

1.  All neuropeptides (natural and synthetic) with morphine-like actions

 

2.  Stimulate opioid receptors in brain → reduce pain;

 

3.  Other receptor locations à side effects (Slide 17)

 

            B.  Classification of opioids

 

                        1.  Endogenous opioids (Slide 18)

 

                                    a.  Body's natural way to decrease pain

 

                                    b.  Enkephalins, endorphins, dynorphins (similar proteins)

 

                                    c.  These automatically ↑ in pain and ↓ discomfort

           

2.  Opiates - term usually reserved for: (Slide 19)

 

            a.  Natural chemicals found in the opium poppy

 

            b.  Structure (slide)

 

c.  E.g. opium, morphine, codeine

 

d.  Are effective pain Rx but can

 

            1'  →euphoria

 

            2'  Tolerance (resistance to drug) can develop quickly

 

3.  Semi-synthetic opioids (Slide 19)

 

            a.  Modifications of natural opiates that stimulate opioid receptor

 

            b. Invented in search of safer/less likely misused alternatives

           

c.  Structure (slide)

 

d.  E.g. heroin, hydrocodone (Vicodin), oxycodone (Percocet)

 

4.  Synthetic opioids (not involve natural opiates) (Slide 19)

 

            a.  Man-made chemicals that stimulate opioid receptor

 

            b.  Structure (slide)

 

            c.  Eg.fentanyl (Duragesic), methadone, tramadol (Ultram)

 

            C. All work by stimulating opioid receptors

 

1.  All ↓ pain

 

2.  All have similar dangers/side effects (Slide 21)

 

            a.  Sedation: contribute to death in overdose

 

            b.  ↓ respirations: contribute to death in overdose

 

            c.  Dizziness

 

            d.  Nausea/vomiting

 

                                    e.  Memory/cognitive impairment

 

            f.  Constipation: can be severe and hard to Rx

 

            g.  Itching

 

                                    h.  Tolerance (need ↑ drug to get effect)

 

                                    i.  Dependence

 

            D.  Non-Medical Use

 

                        1. Use for feeling/high

 

                        2.  12 million NMUs/year (2 million new/year)

 

                        3.  2nd only to marijuana

 

                        4.  á risk in adolescents

 

                        5.  Obtain from family/friend

           

            E.  Opioid use disorder → take drug despite problems (Slide 26)

 

                        1.  Defined in 5th edition of Dx Manual (DSM-5)

 

                        2.  Reflects 2+ of 11 possible repeated problems in same 12 mo

 

                                    a'  Failure to fulfill major role obligations

 

                                    b'  Social, work, recreational activities given up

 

c'  Tolerance - need  ↑ dose to get high

 

d'  Withdrawal - opposite of acute effects, discussed later

 

e'  Take larger amounts or longer period than intended

 

f'  Persistent desire to quit or unsuccessful quitting

 

g'  Much time spent to obtain/use/recover from drug

 

h'  Craving, strong desire, urge to use substance

 

i'  Continued use despite negative consequences

 

j'  Use despite physical or psychological problems

 

k'  Use in situations which it is physically hazardous

 

            F.  Physical dependence on Rx opioids ≠ use disorder (Slide 26)

 

                        1.  Withdrawal when stop

 

                        2.  Functioning well

 

VI.  Opioid use disorders (OUD) - What can dentists do to avoid them in patients?

 

            A. Anyone can develop an OUD

 

                        1.  Including dentists, physicians, health care professionals

 

                        2.  Process might involve (Slide 27):

 

                                    a.  Start the drug → relief of pain (i.e., negative reinforcement)

 

                                    b.  Tolerance develops → increase the dose

 

                                    c.  Doc gives 1+ month Rx and refills

 

                                    d.  Patient ↑ dose on own

 

                                    e.  Starts to use drug to sleep/feel better/↓stress

 

                                    f.  When ↓ or stop drug has rebound in pain, insomnia, etc

 

                                    g.  Goes back to drug; ↑’s dose; gets drugs elsewhere

 

                                    h.  Now has dependence

 

            B.  Recognizing possible OUD - Risk factors

 

                        1.  Aberrant drug-taking behaviors (ADTBs) (Slide 28)

           

                                    a.  Asking for specific medications

 

                                    b.  Running out of medications early/taking more than Rx

 

                                    c.  Crushing/snorting medication

 

                        2.  Personal/family history of any substance use Dx (SUD)

 

                        3.  History of involvement with law (inc DUI)

 

                        4.  Regular contact with SUD friends

 

                        5.  Risk-taking or thrill seeking behavior

 

            C.  Recognizing possible OUD - Exam findings (Slide 29)

           

                        1.  Opioid Intoxication  

 

                                    a. The "nods"

                       

                                    b.  Euphoria

 

                                    c.  Pupils constricted

 

                                    d.  Slurred speech

           

                        2.  Exam signs of Opioid withdrawal

 

                                    a.  Dilated pupils

 

                                    b.  GI upset/diarrhea

 

                                    c.  Goosebumps

 

                                    d.  Total body/bone pain, appear uncomfortable

 

                        3.  Evaluate for “pseudoaddiction

                                   

                                    a.  "Drug-seeking behavior"

                                   

                                    b.  Prompted by unrelieved pain

 

                                    c.  Diagnosis: cautiously med and re-eval             

 

            D.  Responsible opioid prescribing practices (Slide 31)

 

1.  "Universal precautions"

 

            a.  Clinicians are not good at predicting who will have problems! 

 

            b.  Standard Opioid Treatment Agreements

 

                        1'  Document signed by provider and pt

 

                        2'  Discuss expectations for both provider and pt

 

                                    a'  Urine drug testing

 

                                    b'  Refill policy

 

                                    c'  Consequences for breach of agreement

 

                                    d'  Risk of physical dependence

 

                                    e'  Obtaining medications from one provider

 

                                    f'  Education about safe storage

           

            c.  Prescription Drug Monitoring Programs (PDMPs)

 

                        1'  Statewide databases (37 US States)

 

                        2'  Pharmacist-entered registry of controlled substance Rx

 

                                    a'  Opioids, Benzodiazepines, Stimulants, Barbs

 

                                    b'  Limitations: lag time; mistakes

 

                        3'  Searchable with pt name and date of birth

 

                        4'  Give clinicians ability to screen for "doctor shopping"

 

                                    a'  Rx from multiple providers

 

                                    b'  Rx for substances not reported to provider

 

2.  Use non-pharmacology  when possible

 

3.  Non-opioid pain relievers as 1st line Rx (previously reviewed)

 

4.  Use optimal meds before procedure (previously reviewed)

 

5. Don’t Rx > needed : but is common mistake10

 

a.  85% prescribe #20 hydrocodone for 3rd molar ext

 

b.  40% expect patients to have left-over medication

 

c.  Unknown if they advise about safe disposal of meds

 

d.  Best to Rx enough for 2-3 days, then re-evaluate

 

6.  If need Rx opioids, balance pain relief with safety

 

a.  Analgesia (pain relief)

 

            1'  Pt to measure pain on 1(mild) -10(severe) scale

 

            2'  Ck if pain medicine helps with pain?

 

            3'  Plan ahead about duration of pain relief needed

 

b.  Ask ADLs (Activities of Daily Living) = functioning

 

            1'  "What is your day like?"

 

            2'  Functioning at home and work 

 

            3'  "How long are you in/out of bed?"

 

c.  Adverse effects (side effects) need be considered

 

d.  Aberrant behavior may indicate problems with opioid Rx

 

            1'  Lost prescriptions in past?

 

            2'  Hx of taking >prescribed?

 

            3'  Taking with other meds to increase effect?

 

e.  Goal = â pain, áfunction

 

f.  Re-evaluate - If not functioning well, increase structure

 

            1'  More frequent (weekly) appointments      

 

            2'  Short(er) supply of medications

 

            3'  Refer/mandate OUD Rx if needed to ensure safe pain tx

 

7.  Educate about safe storage/disposal

 

a.  Drug "take-back" programs (slide)

 

            1'  Local or federal programs (ref below)

 

            2'  They will "take back" unused medications

 

            3'  May not take back controlled substances

 

b.  To flush or not to flush? 

 

            1'  Most opioids are on “OK to flush" list

 

            2'  FDA: risk improper use> risk to environment

                                                3'  Dispose of all other meds in household trash

                                                            a'  Mix with kitty litter or used coffee grounds

                                                            b'  Place in plastic bag & discard in household trash

                                                            c'  Take name, ID info off pill bottles

                        8.  Recognize and refer for OUD treatment

 

D.  Screening for and recognizing OUDs (discussed previously)

 

1.  Awareness of physiologic response to opioids

 

            a.  Medical use opioids usually tolerance: not a Dx

 

            b.  High Rx dose can withdrawal if stopped quickly: not a Dx

 

            c.  Relief of pain by Rx is rewarding

 

                        1’  That risk of seeking out drug

 

                        2’  That risk OUD as discussed above

           

VI.  Lifesaving treatment is available for opioid use disorders (Slide 37 - 38)

 

            A.  How to have the conversation

 

                        1.  Empathy, not guile

 

                        2.  Focus on safety and functioning

 

                        3.  Believe they are suffering

 

            B.  Avoid "kicking patient out"

 

            C.  "Bad news = you may have addiction; Good news= treatment available"

 

                        1.  Can avoid withdrawal

 

                        2.  Can help with pain

 

VI.  Clinical examples

 

            A.  Low risk patient – (Edna: 60 year old teacher for tooth extraction)

 

1.  Use characterized by: 

 

a.  Stable use pattern

 

b.  Improved function

 

c.  Concerned about side effects

 

d.  Follows treatment plan

 

e.  Has leftover meds

 

                        2.  Management:  Routine monitoring, no extra meds, safe storage

 

            C.  Moderate risk patient (Joe: grad student for wisdom tooth extraction)

 

1.  Use sometimes characterized by:

 

            a.  Irregular aberrant behaviors (lost first Rx)

 

            b.  Strong family history of substance abuse

 

            c.  Psychiatric co-morbidities sub-optimally managed

 

            d.  Preoccupied with opioids

 

2.  Management:

 

a.  Decentralize opioids

 

b.  Mandate management of co-morbid psychiatric issues

 

c.  Structure (frequent visits, pill counts)

 

d.  Interdisciplinary team

 

D.  High risk (Joanne: 38 year old/Friday PM/demanded oxycodone)

 

1.  Use can be characterized by any of the following:

 

            a.  Active use disorder with opioids or other substances

 

            b.  Possible current withdrawal (the “emergent” appointment)

 

            c.  Recent termination with previous prescriber

 

            d.  Rapid unsanctioned dose ↑, without relief

 

            e.  Breach of treatment agreement/Loss of control

 

f.  Poor or declining functioning

 

g.  Unconcerned with adverse effects

 

h.  Will not consider anything other than opioids

 

2.  Management

 

a.  Maximum structure, Above plus:

 

            b.  Non-opioid therapy, if possible

 

c.  Short supplies, frequent visits, UDSs, pill counts

 

d.  Mandate active treatment in psych/sub treatment

 

1’  Trust but verify

 

2’  Confirmation & coordinate with provider

 

           

VII.  What you can do now

 

A.  Rational use of opioids

 

B.  Educate patients on safe disposal of medications

 

C.  Screen, recognize and refer opioid use disorders 

 

V.  Summary

A.  Pain is prevalent in dental medicine

 

B.  We are in the midst of a prescription opioid epidemic

C.  Dentists are among top prescribers of opioids

D.  Dentists can prevent and recognize opioid use disorders

E.  Good, life-saving treatment is available for opioid use disorders

 

VI.  Resources

 

A.  Safe opioid disposal

 

(www.cdc.gov/HomeandRecreationalSafety/Poisoning/preventiontips.htm)

 

B.  Screening tools for opioid misuse (www.painedu.org)

 

C.  SC Prescription Drug Monitoring Program (www.dhec.sc.gov/scripts)

 

D.  Suboxone providers (www.suboxone.com)

 

 


 

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