TACKLING THE OPIOID EPIDEMIC: THE DENTAL TEAM'S RESPONSIBILITY ACUTE PAIN MANAGEMENT

Transcription

1 TACKLING THE OPIOID EPIDEMIC: THE DENTAL TEAM'S RESPONSIBILITY ACUTE PAIN MANAGEMENT John E. Lindroth, DDS Associate Professor University of Kentucky College of Dentistry

2 FACULTY DISCLOSURE Neither my wife nor I have had any relevant financial relationships with commercial interests during the past 12 months.

3 EDUCATIONAL NEED/PRACTICE GAP Opioid prescribing practices in Dentistry have contributed to a repository of opiate medication that has created an epidemic of prescription drug abuse in the US. Studies indicate that Dental Practitioners generally overprescribe opiates. There is a need to reevaluate when and how to use opiates to adequately treat acute dental pain.

4 OBJECTIVES Upon completion of this educational activity, you will be able to: Apply evidence-based pain management strategies with appropriate prescribing. Develop a management plan for treating post-operative pain in addicted patients.

5 EXPECTED OUTCOME The Practitioner will have a better understanding of acute dental pain and the appropriate use of opioids in its treatment.

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7 What is PAIN? Acute Pain Chemical

8 Nociceptors

9 Peripheral Mediators of Inflammation Basbaum, et al. Cell, 2009

10 Sensitization (neuroplasticity) Quicker, stronger, faster, spontaneously, wider receptive field Allodynia Light touch is painful Hyperalgesia Pain is exaggerated Inflammatory soup Excitatory chemicals

11 PAIN Trigeminal nucleus

12 What we see as clinicians is pain behavior; what we treat is nociception What we assume is: The amount of pain behavior is proportionate to the suffering, which is proportionate to the pain, which is proportionate to the nociception What we know is: Nociception, suffering, and pain behavior can be independent Jeffery P. Okeson, DMD University of Kentucky Orofacial Pain Center

13 Management of Acute Pain The Dentist s Role Evidence & Strategies

14 Basic Science/Clinical Researchers Pain and anesthesia Minimize acute post-operative pain Reduce analgesic consumption Decrease risk of transitioning into pain chronicity Treat anticipated pain definitively

15 Preventive Management Aggressive management of noxious perioperative stimuli to prevent peripheral/central sensitization Preoperatively Intraoperatively Postoperatively Reduces pain and postoperative analgesic requirements

16 Advocated by ASA Task Force on Acute Pain Mgmt Combing different analgesics that act by different mechanisms at different sites in the peripheral and CNS resulting in synergistic analgesia More effective than single agent therapy Fewer side effects than high dose, single agent Reduces opioid consumption Buvanendran, 2009

17 Analgesics Analgesics classified as: Opioids (narcotics) Non-opioids (non-narcotics) Nonsteroidal anti-inflammatory drugs (NSAIDs) Acetaminophen (APAP) Both classes known to act centrally and peripherally Malmberg, et al. Science, 1992 Graham, et al. Amer J of Therap, 2005

18 Single dose oral analgesics for acute postoperative pain in adults (Review) Moore, et al. The Cochran Lib, individual studies that involved 29,000 dental participants How effective at relieving moderate to severe pain following 3 rd molar surgery Number needed to treat (NNT) to achieve at least 50% pain relief over 4-6 hours following a single dose of analgesic compared with placebo

19 Summary Points No drug produced high levels of pain relief in all participants Best drug = good relief in 70% of participants Worst drug = only 30% relief Period of pain relief varied from 2 to 20 hours 5-15% placebo for dental conditions

20 Dental Pain Naprosyn NNT for at least 50% max pain relief over 4-6 hours compared with placebo, by rank order Ibuprofen 400 Oxycodone 10 Celecoxib 400 Acetaminophen

21 Naprosyn Ibubrofen 400 Oxycodone 10 Percentage of patients achieving at least Acetaminophen 50% max pain relief (dental pain) Celecoxib 400

22 Single dose oral ibuprofen plus paracetamol for acute postoperative pain (Review) Derry, et al. The Cochran Lib, individual studies that involved 1,647 dental participants How effective at relieving moderate to severe pain following 3 rd molar surgery Ibuprofen ( mg) + acetaminophen ( mg) provided effective pain relief for 70% of participants compared with placebo (7%) or ibuprofen alone (52%)

23 Moore, P. A., and Hersh, E. V. JADA 2013;144:8: Copyright 2013 American Dental Association. All rights reserved. Reproduction or republication strictly prohibited without prior written permission of the American Dental Association.

24 Preoperative Analgesic Strategy Prescribe NSAIDs / acetaminophen one hour before the procedure for preemptive analgesia Lower postoperative pain/swelling Decrease opiate consumption Near 70% success rate Corderre, et al. Pain, Vol 2, 1993 Ong, et al. Pain Medicine, 2010 Katz, et al. Clin Pain Mgmt, 2008

25 Intraoperatively One for the road As post-op pain is anticipated, consider giving an injection of a long-acting bupivacaine before dismissing patient

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27 Continue the NSAID/acetaminophen that was initiated preoperatively

28 Administration of analgesics should be clock regulated not PRN Prevents delays in receiving medication Provides timely and effective pain relief Dependent on time and less on symptoms Savage. Prin. Of Addiction Med, 4 th ed

29 Post-operative Pain Relief Take the following medication exactly as scheduled for the next days. Ibuprofen 200 mg (2, 2 3, 4 tablets) +PLUS+ Acetaminophen ES 500 mg (1, 1 2 tablets) 3 A total of tablets with food and 20 oz water at: am, pm, pm, and pm for Pain Relief 3

30 Arthritis Advisory Committee and Drug Safety & Risk Management Committee (Feb 2014) All NSAIDs risk of CHF, HTN, and Stroke Ibuprofen exaggerated platelet activation ( thromboxane formation) Celebrex platelet deposition and disaggregation (prostacyclin synthesis) Naproxen only slight platelet activation (cardioprotective like ASA) Everybody has their own dose-response curve (genotype and metabolism)

31 Post-operative Pain Relief Take the following medication exactly as scheduled for the next days. 2 tablet Naproxen 220 mg +PLUS+ 1 tablet Acetaminophen ER 650 mg Take together two times a day 8 8 am, pm, pm, and pm 3 for Pain Relief

32 Management of pain may require the use of opiates to achieve adequate pain control

33 Post-operative Pain Relief Take the following medication exactly as scheduled for the next days. Ibuprofen 200 mg (2, 3, 4 tablets) +PLUS+ Acetaminophen ES 500 mg (1, 2 tablets) 4 A total of tablets with food and 20 oz water at: am, pm, pm, and pm 1-2 opiates for breakthrough pain 5 One opiate at bedtime

34 Post-operative Pain Relief Take the following medication exactly as scheduled for the next days. 2 tablet Naproxen 220 mg +PLUS+ 1 tablet Acetaminophen ER 650 mg Take together two times a day 8 8 am, pm, pm, and pm Take 1-2 opioid between these doses 5 Take one opioid at bedtime

35 Acute Pain Management with Preexisting Opioid Dependency Physically dependent on opioid (prescribed for pain or for addiction or dependent on street opioids) must have their baseline opioid requirements met plus additional opioids for acute pain treatment Aggressively treat the pain - don t under treat Makes subsequent pain management more difficult Wesson, et al. J Pain Symptom Manage, 1993

36 Recommendations Verify with patient s provider or program Multimodal approach Provide a different opioid short-acting Usually higher doses, shorter intervals Clock regulated Avoid pentazocine (displaces maintenance opioid) W/D Alford, et al. Ann Intern Med, 2006

37 Treatment of Acute Pain in Patient Receiving Buprenorphine Physicians Clinical Support System (PCSS), 2005 USDHHS, Clinical Guideline, TIP 40, pp EPERC, Fast Facts #221, 2009 Consult with prescribing physician or program Mild Moderate Acute Pain Continue Buprenorphine and use short-acting opioid agonist with high mu affinity (morphine, fentanyl, hydromorphone) Avoid hydrocodone or codeine

38 Consider treating with buprenorphine alone to a maximum of 32 mg sublingual/day in divided doses every 6-8 hours Moderate Severe Acute Pain d/c buprenorphine, initiate high dose opioid analgesic, or convert to methadone Following surgery, provide adequate opioid analgesia clock regulated Before restarting buprenorphine, patient opioid-free for hours to avoid W/D Patient s physician will initiate buprenorphine

39 Thank you