PAIN CONTROL IN THE AGE OF ADDICTION

Transcription

1 Useful References 1.MAPS, Mich. Automated Prescription System license PAIN CONTROL IN THE AGE OF ADDICTION John P. Gobetti D.D.S., M.S. Professor Emeritus of Oral Medicine POM Department, School of Dentistry P: Fax: ; 2. Mich. Board of Dentistry Guidelines for the Use of Controlled Substances for the Treatment of Pain. 3." The ADA Practical Guide to Substance Use Disorders and Safe Prescribing" From adacatalog.org 4. Opioid Information From adacatalog.org 5. "Get Dental Pain Relief Safely" brochure for patients W605 From adacatalog.org Definitions Pain- An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Acute Pain - The normal predicted physiologic response to adverse stimulus. Time-limited and responsive to Opioid and other therapies. Chronic Pain - A persistent pain state where cause of Pain cannot be removed or treated. Tolerance - Physiologic state from regular use of a Drug, needing increased dosage for same effect Analgesic Tolerance- The need to increase dose of Opioid for same level of analgesia. N.B. not = Addiction. Addiction - NEUROBEHAVIORAL SYNDROME genetic/ environmental influence resulting in PSYCHOLOGIC dependence for the psychic effects, AKA Drug or Psychologic Dependence. N.B.- Physical dependence and Tolerance are consequences of extended Opioid use and NOT considered Addiction. Physical Dependence- A PHYSIOLOGICAL state of NEURO-ADAPTATION has withdrawal symptoms, Not Addiction. Pseudo-Addiction- Drug-seeking behavior from inadequate pain management, which resolves when Pain is adequately treated. Substance Abuse- Use of any substance for Nontherapeutic purposes. Controlled Substance - Drug, Substance, or the Immediate precursor included in Schedules I - V. Pharmacovigilance - Means Monitoring and Manging Risks, Adverse and side-effects of medications Opioid - natural/semi-synthetic derivatives of opium poppy, or synthetic compounds whose effects are similar on the CNS. Examples - Codeine, Morphine, Hydromorphone, Hydrocodone, Oxycodone, Methadone, Fentanyl, etc. Narcotics - A legal term, not used in medicine because Opioids do not relieve pain by inducing sedation. Pain is subjective symptom, no specific diagnostic tests. Difficult to prevent patients from deceptively acquiring prescriptions for recreational use. 1

2 TWO MAJOR PUBLIC HEALTH CONCERNS 1. Undertreatment of pain 57% of Adults in pain, 40% in constant pain 84% in pain greater than a 4 on 10 point scale 2. Shifting pattern of drug abuse from illicit drugs to prescription medications. Seen as a rise in DIVERSION and NON-MEDICAL use of opioid pain medications DUE TO, UNDERTREATED PAIN 1. Lack of Clinical Guidelines for appropriate pain Treatment and prescribing. 2. Fear of scrutiny by regulatory authorities. 3. Lack of understanding of Regulatory polices and processes. 4. Misunderstanding of Addiction and Dependence. Scope of Drug Abuse Problem USA Figures 36 + MILLION Abuse, 5% of World's Population and 80% of Perscription Opioids Michigan figures 41% increase in Opioid Prescriptions Since 2009, 11 Million scripts, 84 doses per person Deaths have DOUBLED in 4 years More NEW Drug Abusers began abusing pain relievers 2.2 million, than Marijuana 2.1 million or Cocaine 872 K. MAPS PHARMACY DATA Most commonly abused pain medications are, OXYCODONE, ( OXYCONTIN) HYDROCODONE, ( VICODIN) HYDROMORPHONE, ( DILAUDID) MEPHERIDINE, (DEMEROL) FENTANYL CODEINE MAPS DATA MOST DANGEROUS ARE VICODIN, OXYCONTIN WHERE OBTAINED BY ABUSERS Home locations were the most prevalent access idversion of drugs by family, friends, babysitters, Visitors, and youth. MICHIGAN BOARD OF DENTISTRY GUIDELINES FOR THE USE OF CONTROLLED SUBSTANCES FOR THE TREATMENT OF PAIN OBTAIN A COPY FROM THE MICHIGAN BOARD OF DENTISTRY WEB SITE 2

3 MAJOR POINTS FROM GUIDELINES 1. People/Patients MUST have appropriate and effective pain relief. 2. Inadequate pain control from lack of knowledge about pain management, and misunderstanding of addiction. 3. Fear of investigation/sanctions by Federal, State and local regulatory agencies. MAJOR GUIDELINE POINTS CONTINUED 5. Pain must be assessed and treated promptly. 6. Dose quantity and frequency adjusted to the intensity and duration of the pain. 7. Validity of prescribing based on treatment of the patient and DOCUMENTATION OF TREATMENT, not the quantity, etc. 4. Dentists MUST be diligent to prevent DIVERTSION of drugs for ILLEGITMATE purposes. GENERAL GUIDELINES USED BY THE BOARD OF DENTISTRY These guidelines are used to EVALUATE YOUR use of controlled Substances for pain control. EVALUATION OF THE PATIENT 1. Appropriate Med./Dent. History. 2. Nature and intensity of the pain. N.B. - Other regulatory agencies use them State of Michigan Attorney General U.S. Attorney General 3. Current and past treatments for the pain. 4. Underlying or coexisting diseases/ conditions Evaluation of Patient Continued, 5. Effect of pain on Physical/Psychological health 6. History of Substance/Chemical Abuse? 7. Records MUST document recognized dental indications for use of Controlled Substances. TREATMENT PLAN 1. Objectives used to determine treatment of pain success, ie. Pain Relief, Improved oral-facial, Physical and Psychological function. 2. Indicate further diagnostic evaluation or treatments planned. 3

4 INFORMED CONSENT 1. Discuss Risk/Benefit of use of Controlled Substances. 2. If patient is high risk for medication abuse and/or has a history of substance abuse, a. Written Agreement outlining Patient Responsibilities. b. Number and Frequency of Refills. c. Discontinuance of Drug Therapy -any violations of Agreement. PERODIC REVIEW 1. Should review course of treatment and any new information about the etiology of the pain. 2. If treatment goals not achieved should reevaluate appropriateness of continued treatment. CONSULTATION 1. Dentist should be willing to refer patient for additional evaluation and treatment to achieve treatment goals. 2. Patients with history of substance abuse or with comorbid psychiatric disorder may require extra care, monitoring, documentation, and consultation with/or referral to expert in management of such patients. REQUIRED DENTAL/MEDICAL RECORDS Dentist should keep accurate and complete records To include; 1.Medical History and Dental Examination. 2. Diagnostic,Radiographic, Therapeutic, and Laboratory results. 3. Evaluations and Consultations. 4. Treatment Objectives RECORDS CONTINUED, 5. Discussion of Risks/Benefits. 6. Treatments. 7. Medications: Date, Type, Dosage and Quantity prescribed. 8. Instructions and Agreements. 9. Periodic Reviews N.B. All records should be current and in S.O.A.P. format Subjective,Objective,Assessment,Plan COMPLIANCE WITH CONTROLLED SUBSTANCES LAWS AND REGULATIONS Must be licensed in State and Comply with Federal/ State regulations. Dentists are ENCOURAGED to use MAPS, Michigan Automated prescription System Better Now, Easier Access and Use 4

5 WHAT S BEEN OCCURRING Regular course of treatment dentist guided by Professional Standards, not limited to; 1. Consistency in the doctor-patient relationship. 2. Frequency of prescriptions for the same drug. 3. Quantities beyond those normally prescribed for the drug. 4. Unusual dosages. Recent Cases of aberrant behavior regarding Prescription drugs. Excessive drugs, 500 Vicodin-ES per month Prescriptions for people, non-patients of record. Diversion of drugs by dentist, spouse, staff Ordering from wholesale drug supply for personal use/sale. COMPREHENSIVE PAIN HISTORY DENTISTS AND ALL OFFICE STAFF MUST BE VIGILANT PREVENTING MISUSE OR ABUSE OR DIVERSION OF PAIN MEDICATIONS 1. Location of Pain 2. Character of Pain; shooting, sharp.etc. 3. Highest pain level; How and When pain started. 5. Exacerbating and relieving factors. 6. Effect on sleep/mood. 7. Patient s expectations of Pain control. 8. Patient s expectations of Pain Medications. PAIN MEASUREMENT SCALES The 0-10 measurement scale provides some guidance of a patient s pain intensity. BUT The best method is to ask and listen to how they describe the pain and it s effect on them. Some patient s UNDER REPORT PAIN because, 1. They do not like the way they feel on pain medications due to dull cognitive abilities. 2. Not want to be complainers. HAVE A PAIN PLAN Opioid Analgesics are LIGITIMATE, USEFUL, EFFECTIVE agents for pain control BUT not always Indicated or Appropriate. Decision to use Opoids based on each unique case and Risk/Benefit analysis. MUST have TRANSPARENT DOCUMENTATION of the reason for their use. 3. Not want to be seen as drug seekers. 5

6 CONTROL OF PAIN Knowledge of all your Pharmaceuticals Complete list of all Patient s Medications and Drugs; Prescribed, Herbal, Vitamins, O.T.C.s AND Recreational Know ingredients of all the drugs, Acetaminophen brand names and products Electronic Resources Epocrates,com Drugstore.com CLINICAL USE OF ANALGESICS Dentistry is OUTPATIENT Patients must return to Daily Routine/Activities Drugs that DEPRESS PSYCHOMOTOR FUNCTION increase Patient Injury Risk from Hazardous activities EVALUATE PROCEDURE/PATIENT BEFORE PRESCRIBING ACUTE PAIN IS TRANSIENT USUALLY HOURS Can be managed with either Peripherally or Centrally Acting Pain Medications If longer Recheck the Treatment or Diagnosis Then progresses to less intense Pain, Edema, and Inflammation which Can and Should be managed with NSAIDs Extent of Surgical Procedure Simple vs.surgical extraction Psychological/Emotional evaluation of Patient Patient s Reported Past Experiences with Analgesics N.B. Patient s Planned Activity After the Procedure for hours HAVE A PAIN MEDICATION REFERENCE LIST NAME- Brand and Generic Use O.T.C.s first Onset Duration Dose and Type, Liquids act faster Toxic Levels MOST IMPORTANT Side-effects Contraindications Drug interactions Drug- Disease Interactions Rescue Doses COST ***Good Rx *** START WITH THE PROPRONIC ACIDS NSAIDs MOST EFFECTIVE ONES IBUPROFEN - MOTRIN, ADVIL NAPROXEN - NAPROSYN NAPROXEN SODIUM - ALEVE KETOPROFEN - ORUDIS ALL HAVE OTCs FOR USE 6

7 WHEN NEEDED USE COMBINATIONS FOR BEST EFFECT EXAMPLE; TYLENOL #3 WITH CODEINE ACETAMINOPHEN 300mg. CODEINE 30 mg. C III schedule NOW ADD IBUPROFEN 400 mg. CAN EVEN USE AS A RESCUE DOSE BECAUSE TOXIC LEVELS ARE and should not be exceeded ACETAMINOPHEN 4,000 mg., (3,000 mg.) IBUPROFEN 3,200 mg., (2,400 mg.) UNDERUSED BUT EXCELLENT ADDITIONS TO ANALGESICS 1. STEROIDS- MEDROL DOSEPACK 4mg (21) METHYLPREDNISOLONE EVEN A SINGLE PREOPERATIVE DOSE 4 mg of DEXAMETHASONE significantly reduces post-procedure pain. 2. SKELETAL MUSCLE RELAXANT- FLEXERIL 5-10 mgs, tid, CYCLOBENZAPRINE HYDROCHLORIDE 3. SEDATIVE/ANTIANXITY, PRE AND POST OPIOID ANALGESICS Derivatives of OPIATE family Stimulate C.N.S. Opiate Receptors Usually combined with; Aspirin, Acetaminophen, or Ibuprofen for synergistic effect. GREATEST CONCERN - POTENTIAL FOR ABUSE Other Concerns - G.I. Upset, Constipation, Sedation, Respiratory Depression POTENTIAL ADVERSE EFFECTS OF OPIOIDS PHYSICAL; Sedation, Constipation, urinary Hesitancy, Dry Mouth,Nausea/Vomiting, Itching, Sweating hypogonadism. BEHAVIORAL EFFECTS; Mood Changes, Impaired function of daily activities, Drug Craving/Seeking. ABUSE OF OPIOIDS; Euphoria, Garrulousness, Increased Motor Activity, and MAGNIFICATION OF PLEASURE COMBINE DRUGS Continued HYDROCODONE, C II, 2.5, 5, 7.5, 10 mg. with Acetaminophen 300, 325 mg Aspirin 500mg. Ibuprofen 200mg. Various Strengths and Combinations are available for use. Hydrocodone the most prescribed Drug and Pain Medication U.S.A. MORE IMPORTANT THAN THE DRUG YOUR KNOWLEDGE OF THE DRUG LOOK UP EACH DRUG, ALL DRUGS, YOU USE HAVE A DRUG SHEET WITH FOLLOWING INFORMATION Name - Generic/Brand Category/Schedule Drug Class Mechanism of Action Therapeutic Effect Use Pharmacokinetics Indications/Dosages Side Effects/ Adverse Reactions Precautions/Containdications 7