10/2/2017. Treating Pain AADB 10/18/17 DON TEATER MD, MPH TEATER HEALTH SOLUTIONS 1. Disclosure. I have nothing to disclose. TEATER HEALTH SOLUTIONS 2

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1 Treating Pain AADB 10/18/17 DON TEATER MD, MPH TEATER HEALTH SOLUTIONS 1 Disclosure I have nothing to disclose. TEATER HEALTH SOLUTIONS 2 1

2 Ogden Nash Some pains are physical, and some pains are mental, but the one that's both is dental. TEATER HEALTH SOLUTIONS 3 Common quote: Opioids are the most potent medications we have for treatment of pain. ASAM Principles of Addiction Medicine Fifth edition. Chapter 97. TEATER HEALTH SOLUTIONS 4 2

3 Opioid facts The United States has 4.6% of the world s population. We use 80% of the worlds opioids! 1 83% of the world s population has no access to any opioids. 2 TEATER HEALTH SOLUTIONS 5 Opioid increase Drug distribution through the pharmaceutical supply chain was the equivalent of 96 mg of morphine per person in and approximately 640 mg per person in 2015, an increase of >500%. 4, 48 TEATER HEALTH SOLUTIONS 6 3

4 Rates of opioid overdose deaths, sales and treatment admissions, US, Opioid Sales KG/10,000 Opioid Deaths/100,000 Opioid Treatment Admissions/10, Rate Year NationalVital Statistics System, DEA s Automation of Reports and ConsolidatedOrders System, SAMHSA s TEDS TEATER HEALTH SOLUTIONS 7 Dental Opioids and Youth 58 TEATER HEALTH SOLUTIONS 8 4

5 Understanding pain TEATER HEALTH SOLUTIONS 9 Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. International Association for the Treatment of Pain Also cognitive influences. TEATER HEALTH SOLUTIONS 10 5

6 Pain Acute pain: Pain < 3 months Chronic pain: Pain > 3 months TEATER HEALTH SOLUTIONS 11 4 types of pain (acute and chronic) Nociceptive Neuropathic Central Sensitization Opioid withdrawal TEATER HEALTH SOLUTIONS 12 6

7 Central Sensitization Dysfunction of the positive and negative pain feedback systems in the CNS that increase the sensation of pain. TEATER HEALTH SOLUTIONS 13 Pain pathways Nociceptor Spinothalamic nerve Amygdala (fear) Hippocampus (memory) Thalamus Somatosensory nerve (pain) Limbic system (emotion) Prefrontal cortex (rational thinking) 14 7

8 Central sensitization Nociceptor Spinothalamic nerve Amygdala (fear) Hippocampus (memory) Thalamus Somatosensory nerve (pain) Limbic system (emotion) Prefrontal cortex (rational thinking) 15 Central sensitization Inventory Subclinical = 0-29 Mild = Moderate = Severe = Extreme = TEATER HEALTH SOLUTIONS 16 8

9 TMD Central sensitization is much more common in individuals with temporomandibular disorders. 60 TEATER HEALTH SOLUTIONS 17 Acute vs. Chronic Pain Sensory tissue input Affective emotions Cognitive thoughts TEATER HEALTH SOLUTIONS 18 9

10 Opioid withdrawal pain Occurs with reduction in opioid dose for those who have been on opioid therapy even for acute pain treatment. Usually is felt in the area where there is a history of pain. TEATER HEALTH SOLUTIONS 19 Understanding Opioids TEATER HEALTH SOLUTIONS 20 10

11 Poppy plant TEATER HEALTH SOLUTIONS 21 Opioids are the most dangerous drugs Dopamine + Opioid receptors TEATER HEALTH SOLUTIONS 22 11

12 Dopamine TEATER HEALTH SOLUTIONS 23 Opioid receptors Enable us to achieve a goal (short term). 23,24 Decrease pain (minimal effect). Increase motivation. Increase confidence. Increase reward. Reduce depression and anxiety. Increase warmth liking. 25 Liking warm things. Interpersonal bonding. TEATER HEALTH SOLUTIONS 24 12

13 Primary purpose: Dopamine Our primary reward system. This is what we live for. Endorphins and opioid receptors These maximize our ability to achieve the reward TEATER HEALTH SOLUTIONS 25 The Wizard of Oz The Dorothy Reaction TEATER HEALTH SOLUTIONS 26 13

14 Pain Treatment TEATER HEALTH SOLUTIONS 27 Acute pain: treatment Acetaminophen NSAIDS Opioids Topical agents Nonpharmacologic (PT, ice, heat, etc.) Local injections TEATER HEALTH SOLUTIONS 28 14

15 Opioids for acute pain Side Effects: Mentally impairing. 8,9 Delay recovery. 10,11 Opioid hyperalgesia. 13,14 Treat depression. 19 Immunosupression. 53 Brain changes. 20 Addiction. 21,22 TEATER HEALTH SOLUTIONS 29 Teens who received a prescription for opioid pain medication by Grade 12 were at 33 percent increased risk of misusing an opioid between ages 19 and 25. Among those with low predicted risk of future opioid use in 12th grade, having an opioid prescription increased their risk of post high school opioid misuse threefold. TEATER HEALTH SOLUTIONS 30 15

16 Percentage of Prescriptions Dispensed for Opioid Analgesics From Outpatient US Retail Pharmacies, TEATER HEALTH SOLUTIONS 31 Acute rx leads to long term use 47 Duration of acute use: 1 day 6% chance of still using that drug a year later. 8 days 13.5%. 31 days 29.9%. TEATER HEALTH SOLUTIONS 32 16

17 Efficacy of pain medications Acute pain 26,27 Percent with 50% pain relief Ibuprofen 200 mg Acetaminophen 500 mg Ibuprofen 400 mg Oxycodone 15 mg Oxy 10 + acet 1000 Ibu acet 500 TEATER HEALTH SOLUTIONS 33 Single Dose Analgesic Efficacy of Tapentadol in Postsurgical Dental Pain: The Results of a Randomized, Double Blind, Placebo Controlled Study. Kleinert, Regina; Lange, Claudia; MD, MSc; Steup, Achim; Black, Peter; Goldberg, Jutta; Desjardins, Paul; DMD, PhD Anesthesia & Analgesia. 107(6): , December DOI: /ane.0b013e ca TEATER HEALTH SOLUTIONS

18 Opioids and acute pain All studies on opioids used for acute pain have shown that the longer they are used, the worse the outcomes! The CDC recommends 3 days or less for acute pain. TEATER HEALTH SOLUTIONS 35 Treatment of chronic pain Behavioral therapy: Cognitive Behavioral Therapy (redirect your thoughts) Mindfulness training (ignore your thoughts) Decatastrophizing this will make your job MUCH easier! TEATER HEALTH SOLUTIONS 36 18

19 When are opioids indicated? Following severe trauma (for a short period) End of life TEATER HEALTH SOLUTIONS 37 Key points Opioids are not very effective pain medications. Opioids do lead to addiction. We must prevent first exposure! We must consider each pill that is prescribed. More pills cause: More damage to the brain Increase risk of addiction and death More chronic pain TEATER HEALTH SOLUTIONS 38 19

20 Recommendations Use ibuprofen and acetaminophen whenever possible for oral treatment of acute pain. Opioids are seldom needed for outpatient treatment of pain. When IV medications are needed, use ketorolac (or ibuprofen) and acetaminophen to decrease (or eliminate) opioid need. Use opioids for their behavioral effects (calming) when absolutely necessary and then for just 1 3 days. The use of opioids should never be automatic! TEATER HEALTH SOLUTIONS 39 Excerpt from: University of Minnesota School of Dentistry Guideline (This is a mandatory guideline) TEATER HEALTH SOLUTIONS 40 20

21 Total Opioid Prescriptions per Quarter Opioid Prescriptions (# of) * ** 1 QTR QTR QTR QTR QTR QTR QTR QTR QTR QTR 2017 Quarters * Protocol introduced to Clinical Affairs Committee ** Protocol Official Policy of Department of OMFS Total Opiod Prescriptions My story: Periodontist and nurse after gum graft. TEATER HEALTH SOLUTIONS 42 21

22 What I hear: If I don t prescribe opioids, word will get out and I will lose business. TEATER HEALTH SOLUTIONS 43 Moore, P. A., & Hersh, E. V. (2013). Combining ibuprofen and acetaminophen for acute pain management after third molar extractions. Journal of the American Dental Association, 144(8), TEATER HEALTH SOLUTIONS 44 22

23 250,000 Number of deaths in the last 20 years from opioids. More than 4 times the number of American deaths in the Vietnam war This is an epidemic. And we are the vector! This epidemic is completely reversible with a change of behavior that will result in better pain management TEATER HEALTH SOLUTIONS 45 To write prescriptions is easy, but to come to an understanding with people is hard. -- Franz Kafka, A Country Doctor TEATER HEALTH SOLUTIONS 46 23

24 Don Teater MD Teater Health Solutions teaterhs.com TEATER HEALTH SOLUTIONS 47 References: 1. Solanki DR, Koyyalagunta D, Shah R V, Silverman SM, Manchikanti L. Monitoring opioid adherence in chronic pain patients: assessment of risk of substance misuse. Pain Physician. 2011;14(2):E119-E Seya M-J, Gelders SF a M, Achara OU, Milani B, Scholten WK. A first comparison between the consumption of and the need for opioid analgesics at country, regional, and global levels. J Pain Palliat Care Pharmacother. 2011;25(1):6-18. doi: / NIDA. Safe Prescribing for Pain Paulozzi LJ, Baldwin G. CDC Grand Rounds: Prescription Drug Overdoses a U.S. Epidemic. MMWR. 2012;61(1): Murray C. The state of US health, : burden of diseases, injuries, and risk factors. JAMA. 2013;310(6): doi: /jama Birnbaum HG, White AG, Schiller M, Waldman T, Cleveland JM, Roland CL. Societal Costs of Prescription Opioid Abuse, Dependence, and Misuse in the United States. Pain Med. 2011;12: Paulozzi LJ, Jones CM, Mack KA, Rudd RA. Vital signs: overdoses of prescription opioid pain relievers---united States, MMWR Morb Mortal Wkly Rep. 2011;60(43): Cherrier MM, Amory JK, Ersek M, Risler L, Shen DD. Comparative cognitive and subjective side effects of immediaterelease oxycodone in healthy middle-aged and older adults. J Pain. 2009;10(10): doi: /j.jpain Gooch CM, Rakitin BC, Cooper ZD, Comer SD, Balsam PD. Oxycodone lengthens reproductions of suprasecond time intervals in human research volunteers. Behav Pharmacol. 2011;22(4): doi: /fbp.0b013e328348d8b Thiele RH, Rea KM, Turrentine FE, et al. Standardization of Care: Impact of an Enhanced Recovery Protocol on Length of Stay, Complications, and Direct Costs after Colorectal Surgery. J Am Coll Surg. 2015;220(4): doi: /j.jamcollsurg Woller S a., Hook M a. Opioid administration following spinal cord injury: Implications for pain and locomotor recovery. Exp Neurol. 2013;247: doi: /j.expneurol White J a, Tao X, Talreja M, Tower J, Bernacki E. The effect of opioid use on workers compensation claim cost in the State of Michigan. J Occup Environ Med. 2012;54(8): doi: /jom.0b013e b. TEATER HEALTH SOLUTIONS 48 24

25 References: 13. Edlund MJ, Martin BC, Russo JE, Devries A, Braden JB, Sullivan MD. The Role of Opioid Prescription in Incident Opioid Abuse and Dependence Among Individuals With Chronic Noncancer Pain. Clin J Pain. 2014;30(7): Chu LF, Clark DJ, Angst MS. Opioid tolerance and hyperalgesia in chronic pain patients after one month of oral morphine therapy: a preliminary prospective study. J Pain. 2006;7(1): doi: /j.jpain Webster BS, Verma SK, Gatchel RJ. Relationship between early opioid prescribing for acute occupational low back pain and disability duration, medical costs, subsequent surgery and late opioid use. Spine (Phila Pa 1976). 2007;32(19): doi: /brs.0b013e318145a Miller M, Stu ÃT, Azrael D. Opioid Analgesics and the Risk of Fractures in Older Adults with Arthritis. J Am Geriatr Soc. 2011;59: doi: /j x. 17. Ray WA, Chung CP, Murray KT, et al. Prescription of Long-Acting Opioids and Mortality in Patients With Chronic Noncancer Pain. JAMA. 2016;315(22):2415. doi: /jama Solomon DH, Rassen J a, Glynn RJ, Lee J, Levin R, Schneeweiss S. The comparative safety of analgesics in older adults with arthritis. Arch Intern Med. 2010;170(22): doi: /archinternmed Tenore PL. Psychotherapeutic benefits of opioid agonist therapy. J Addict Dis. 2008;27(3): doi: / Younger JW, Chu LF, D Arcy NT, Trott KE, Jastrzab LE, Mackey SC. Prescription opioid analgesics rapidly change the human brain. Pain. 2011;152(8): doi: /j.pain Martell B, O Connor P, Kerns R, et al. Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med. 2007;146(2): Accessed August 9, Odgers CL, Caspi A, Nagin DS, et al. Is it important to prevent early exposure to drugs and alcohol among adolescents? Psychol Sci. 2008;19(10): doi: /j x. 23. Polunina AG, Bryun E a. Neuropsychological Functions of μ- and δ-opioid Systems. ISRN Addict. 2013;2013:1-13. doi: /2013/ Inagaki TK, Ray LA, Irwin MR, Way BM, Eisenberger NI. Opioids and social bonding: Naltrexone reduces feelings of social connection. Soc Cogn Affect Neurosci. 2016;epub ahead:1-8. doi: /scan/nsw Schweiger D, Stemmler G, Burgdorf C, Wacker J. Opioid receptor blockade and warmth-liking: Effects on interpersonal trust and frontal asymmetry. Soc Cogn Affect Neurosci. 2014;9(10): doi: /scan/nst Teater D. Evidence for the Efficacy of Pain Medications. Itasca, Illinois; TEATER HEALTH SOLUTIONS 49 References: 27. Moore RA, Derry S, McQuay HJ, Wiffen PJ. Single dose oral analgesics for acute postoperative pain in adults. Cochrane Database Syst Rev. 2011;9(9):CD doi: / cd pub Holdgate A, Pollock T. Nonsteroidal anti-inflammatory drugs ( NSAIDs ) versus opioids for acute renal colic. Cochrane Database Syst Rev. 2004;(1):Art. No.: CD doi: / cd pub Kleinert R, Lange C, Steup A, Black P, Goldberg J, Desjardins P. Single dose analgesic efficacy of tapentadol in postsurgical dental pain: The results of a randomized, double-blind, placebo-controlled study. Anesth Analg. 2008;107(6): doi: /ane.0b013e ca. 30. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain United States, MMWR. 2016;65. doi: /jama Eriksen J, Sjøgren P, Bruera E, Ekholm O, Rasmussen NK. Critical issues on opioids in chronic non-cancer pain: an epidemiological study. Pain. 2006;125(1-2): doi: /j.pain Afilalo M, Etropolski MS, Kuperwasser B, et al. Efficacy and Safety of Tapentadol Extended Release Compared with Oxycodone Controlled Release for the Management of Moderate to Severe Chronic Pain Related to Osteoarthritis of the Knee: A Randomized, Double-Blind, Placebo- and Active-Controlled Phase III. Clin Drug Investig. 2010;30(8): doi:1 [pii]\n / Cherkin DC, Sherman KJ, Balderson BH, et al. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain. JAMA. 2016;315(12):1240. doi: /jama Krumova EK, Bennemann P, Kindler D, Schwarzer A, Zenz M, Maier C. Low pain intensity after opioid withdrawal as a first step of a comprehensive pain rehabilitation program predicts long-term nonuse of opioids in chronic noncancer pain. Clin J Pain. 2013;29(9): doi: /ajp.0b013e31827c7cf Darchuk KM, Townsend CO, Rome JD, Bruce BK, Hooten WM. Longitudinal treatment outcomes for geriatric patients with chronic non-cancer pain at an interdisciplinary pain rehabilitation program. Pain Med. 2010;11(9): doi: /j x. 36. da Costa B, Nüesch E, Aws R, et al. Oral or transdermal opioids for osteoarthritis of the knee or hip ( Review ) Oral or transdermal opioids for osteoarthritis of the knee or hip. Cochrane Database Syst Rev. 2014;(9). doi: / cd pub3.copyright. 37. Franklin GM. Opioids for chronic noncancer pain: a position paper of the American Academy of Neurology. Neurology. 2014;83(14): doi: /wnl TEATER HEALTH SOLUTIONS 50 25

26 References: 38. Balague F, Mannion AF, Pellise F, Cedraschi C. Non-specific low back pain. Lancet. 2012;379(9814): doi: /s (11) Artus M, van der Windt DA, Jordan KP, Hay EM. Low back pain symptoms show a similar pattern of improvement following a wide range of primary care treatments: A systematic review of randomized clinical trials. Rheumatology. 2010;49(12): doi: /rheumatology/keq Cherkin DC, Sherman KJ, Balderson BH, et al. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain. JAMA. 2016;315(12):1240. doi: /jama Webster BS, Verma SK, Gatchel RJ. Relationship between early opioid prescribing for acute occupational low back pain and disability duration, medical costs, subsequent surgery and late opioid use. Spine (Phila Pa 1976). 2007;32(19): doi: /brs.0b013e318145a Franklin GM, Stover BD, Turner J a, Fulton-Kehoe D, Wickizer TM. Early opioid prescription and subsequent disability among workers with back injuries: the Disability Risk Identification Study Cohort. Spine (Phila Pa 1976). 2008;33(2): doi: /brs.0b013e c. 43. Edlund MJ, Martin BC, Russo JE, Devries A, Braden JB, Sullivan MD. The Role of Opioid Prescription in Incident Opioid Abuse and Dependence Among Individuals With Chronic Noncancer Pain. Clin J Pain. 2014;30(7): Lee D, Armaghani S, Archer KR, et al. Preoperative Opioid Use as a Predictor of Adverse Postoperative Self-Reported Outcomes in Patients Undergoing Spine Surgery. J Bone Jt Surg. 2014;96(11):e89-e89. doi: /jbjs.m Shaheed CA, Maher CG, Williams KA, Day R, Mclachlan AJ. Efficacy, Tolerability, and Dose-Dependent Effects of Opioid Analgesics for Low Back Pain A Systematic Review and Meta-analysis. JAMA Intern Med. 2016;176(7): doi: /jamainternmed Eriksen J, Sjøgren P, Bruera E, Ekholm O, Rasmussen NK. Critical issues on opioids in chronic non-cancer pain: an epidemiological study. Pain. 2006;125(1-2): doi: /j.pain TEATER HEALTH SOLUTIONS 51 References: 47. Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use United States, MMWR Morb Mortal Wkly Rep 2017;66: DOI: Guy, G. P., Zhang, K., Bohm, M. K., Losby, J., Lewis, B., Young, R., Dowell, D. (2017). Vital Signs: Changes in Opioid Prescribing in the United States, MMWR. Morbidity and Mortality Weekly Report, 66(26), Juch, J. N. S., Maas, E. T., Ostelo, R. W. J. G., Groeneweg, J. G., Kallewaard, J.-W., Koes, B. W., van Tulder, M. W. (2017). Effect of Radiofrequency Denervation on Pain Intensity Among Patients With Chronic Low Back Pain. JAMA, 318(1), Shaw, W. S., Hartvigsen, J., Woiszwillo, M. J., Linton, S. J., & Reme, S. E. (2016). Psychological Distress in Acute Low Back Pain: A Review of Measurement Scales and Levels of Distress Reported in the First 2 Months After Pain Onset. Archives of Physical Medicine and Rehabilitation, 97(9), Derry, C., Derry, S., & Moore, R. (2013). Single dose oral ibuprofen plus paracetamol ( acetaminophen ) for acute postoperative pain ( Review ). Cochrane Database of Systemic Reviews, (6) Thiele, R. H., Rea, K. M., Turrentine, F. E., Friel, C. M., Hassinger, T. E., Goudreau, B. J., McMurry, T. L. (2015). Standardization of Care: Impact of an Enhanced Recovery Protocol on Length of Stay, Complications, and Direct Costs after Colorectal Surgery. Journal of the American College of Surgeons, 220(4), Vallejo, R., de Leon-Casasola, O., & Benyamin, R. (2004). Opioid therapy and immunosuppression: a review. American Journal of Therapeutics, 11(5), Retrieved from Kurmis AP, Kurmis TP, O Brien JX, Dalen T. The Effect of Nonsteroidal Anti-Inflammatory Drug Administration on Acute Phase Fracture-Healing: A Review. J Bone Jt Surg. 2012;94: doi: /jbjs.j Daniell, H. W. (2008). Opioid endocrinopathy in women consuming prescribed sustained-action opioids for control of nonmalignant pain. The Journal of Pain : Official Journal of the American Pain Society, 9(1), TEATER HEALTH SOLUTIONS 52 26

27 References: 56. Rolita, L., Spegman, A., Tang, X., & Cronstein, B. N. (2013). Greater number of narcotic analgesic prescriptions for osteoarthritis is associated with falls and fractures in elderly adults. Journal of the American Geriatrics Society, 61(3), Bot, A. G. J., Bekkers, S., Arnstein, P. M., Smith, R. M., & Ring, D. (2014). Opioid use after fracture surgery correlates with pain intensity and satisfaction with pain relief. Clinical Orthopaedics and Related Research, 472(8), Baker, J. A., Avorn, J., Levin, R., & Bateman, B. T. (2016). Opioid Prescribing After Surgical Extraction of Teeth in Medicaid Patients, JAMA, 315(15), Volkow, N., McLellan, T., Cotto, J., Karithanom, M., & Weiss, S. (2011). Characteristics of Opioid Prescriptions in JAMA, 305(13), Campi, L. B., Jordani, P. C., Tenan, H. L., Camparis, C. M., & Gonçalves, D. A. G. (2017). Painful temporomandibular disorders and central sensitization: implications for management a pilot study. International Journal of Oral and Maxillofacial Surgery, 46(1), TEATER HEALTH SOLUTIONS 53 27