Clinical Correlations/Opioid Epidemic

What are the five causes of the current opioid epidemic?

1. Pain as the fifth vital sign

2. Unrealistic patient expectations regarding chronic pain management

3. Very bad statistics (0.03%)

4. Marketing of oxycontin and duragesic in the 1990s

5. Neuroexcitatory effects of oxycodone, oxymorphone, and hydromorphone

Past research said that __% of opioid users developed dependency.

0.03% (not true!)

What is misuse?

use of a medication (prescribed for a medical purpose) other than as directed or as indicated, whether willfully or unintentionally and whether or not harm results

What is physical dependence?

a state of adaptation that is manifested by a drug-class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug or administration of an antagonist

What is tolerance?

a state of adaptation in which exposure to a drug induces changes that result in the diminished effects of one or more drugs in the body over time

What is abuse?

any use of an illegal drug or the intentional self-administration of a medication for a nonmedical purpose such as altering one's state of consciousness (for example, "getting high")

What is addiction?

a primary, chronic, neurobiological disease, with genetic, psychosocial and environmental factors influencing its development and manifestations; it is characterized by behaviors that include impaired control over drug use, compulsive use, continued use despite harm and craving or a combination of these

How did COVID cause a significant rise opioid use?

disruptions in treatment and support systems

isolation

social determinants of health cause greater vulnerability

Post-pandemic opioid use issues include

trauma era

follow up with those who regressed

access to recovery

In NC in 2022, there were ____ overdose deaths per 100,000 residents.

38.5

Post-surgical patients receiving opiates for pain control are particularly vulnerable to dependence due to

Excessive post-procedural prescribing of opioids

Gaps in follow-up

Inadequate disposal of unused excess suppl

___% of opioid naive patients develop dependence.

5-15%

What groups are at higher risk of overdose?

Diagnosed mental health condition

Substance use disorder

Which procedures account for the highest proportions of US dental opioid prescriptions?

extractions (65.2%)

What are the classifications for the controlled substance drug schedules?

Schedule I = highest potential for abuse with no accepted medical use

Schedule II = high potential for abuse with some accepted medical use

↓

Schedule V = lowest potential for abuse

Most opioids are schedule

II - III

What is the NC STOP Act 2017?

limits supply of opioids doctors can prescribe to 5-7 day supply, with follow up necessary for refills

required E-prescriptions

mandatory use of PDMP and document

What is the NC HOPE Act 2018?

increase penalties for healthcare workers who steal patient drugs

increase law enforcement on drug distribution in communities

What are the types of orofacial pain?

nociceptive (tissue injury, inflammation)

neuropathic (lesion or nervous system dysfunction)

nociplastic (hypersensitivity, altered nociceptive pain with MSK involvement)

What are some pharmacological approaches to acute dental pain and patient considerations?

pre-conditioning (focus on function)

appropriateness and individualization of prescribing

non-narcotic alternatives and efficacy

develop a practice policy/protocol addressing risk mitigation measures

What is the DIPM?

Dental Impaction Pain Model

post surgicaldental pain generally may be moderate to severe but typically resolves in 1-2 days after the extraction

How does presurgical NSAID use delay the onset of postoperative pain?

Reach therapeutic blood levels of the NSAID before the surgical trauma generates various prostaglandins

NSAIDs inhibit prostaglandin synthesis but do not attenuate the response to prostaglandins once they have been formed

Mild acute orofacial pain can be treated with

ibuprofen 200-400 mg PO every 4-6hours PRN

Mild to moderate acute orofacial pain can be treated with

ibuprofen 400-600 mg PO every 6hours x 24 hours, then every 4-6hours PRN

Moderate to severe acute orofacial pain can be treated with

Ibuprofen 600 mg + APAP 650 mg every 6 hours x 24 hours, then every 4-6 hours PRN

"2-4-24 Regimen"

Severe acute orofacial pain can be treated with

opioids

What is the maximum daily dose of ibuprofen?

1200 mg/day (OTC)

3200 mg/day (prescription)

What is the max acetaminophen in tablets now?

325 mg

What is NNT?

number of patients that need to be treated in order to have an impact on one person

you want the number as close to 1 as possible

What is the benefit of acetaminophen in combo with NSAIDs?

avoid dose ceiling effect

What is the acetaminophen max daily dose?

4000 mg

Which opioid receptor is associated with dependence?

delta

Which opioid receptor is associated with respiratory depression and euphoria?

mu

Which opioid receptor is associated with dysphoria?

kappa

What is the drug of choice for nociceptive pain?

anti-inflammatories

NOT opioids

What are the cons of tramadol?

Limited therapeutic advantage alone

increased risk of serotonin syndrome

can cause seizures at 300 mg

300 mg of tramadol can cause

seizures

What is cold/heat therapy? What is the benefit?

first 1-2 days, ice packs 15 mins on, 10 mins off

next 2-3 days, heat packs 20 minute cycles for swelling

rotation reduces skin irritation and expands blood vessels

True or False: NSAIDs increase risk of GI bleeding in the presence of SSRIs.

TRUE!

True or False: Avoid prescribing opioids and benzodiazepines concurrently whenever possible.

TRUE!

The goal of risk mitigation is

make opioid prescribing safer while maintaining access to opioid analgesics for those patients who are benefitting from them

What are some key risk mitigation strategies?

1. assess patient history

2. use PDMP

3. optimal patient communication practices and expectations

4. appropriate storage and disposal

5. consideration for naloxone co-prescribing when appropriate

What is the PDMP?

Prescription Drug Monitoring Program

Used to effectively track patient's controlled substance uses across different health facilities (in the same state)

What is the difference between acute, subacute, and chronic pain?

acute < 1 month

subacute 1 - 3 months

chronic > 3 months