Pain Management and Analgesic Meds

Question 1

Pain Management
(4)

Answer 1

— Non-opioid analgesics (acetaminophen and NSAIDs)
— Adjuvants/Co-analgesics (antidepressants, anticonvulsants,
others)
— Opioids
— Focus – acute pain (dental pain)

Question 2

Definitions of Pain
— Definitions vary – no one universally accepted definition for pain
terms

Answer 2

— Subjective experience
— “An unpleasant sensory and emotional experience
associated with, or resembling that associated with, actual
or potential tissue damage” - International Association for the
Study of Pain
◦ Protective reflex
◦ Diagnostic symptom of underlying pathologic condition
– Perception – physical component of pain (pain transmission in body/pathophysiology)
– Nociception – perception of noxious stimuli
– Reaction – psychological component of pain (emotional response)
– Varies greatly among patients

Question 3

Dental Pain
— Affect the — of
the oral cavity
— Due to
— Dental pain is transmitted from
the mouth through the:
(4)
— Nociceptive pain –
— Acute vs. chronic pain (>3 months)

Answer 3

hard and soft tissues
underlying conditions or
dental procedures or both

◦ Trigeminal nerve
◦ Trigeminal ganglia
◦ Thalamus
◦ Somatosensory cortex and limbic
system

stimulation of
nociceptors (pain nerves) from
external stimuli

Question 4

Breakdown of Nociceptive Pain
— Somatic (from teeth, skin, bone, joints, muscle, connective
tissue) – Examples:
(6)
— Visceral (from internal organs)
(2)

Answer 4

◦ Inflammatory (Rheumatoid arthritis)
◦ Mechanical/compression (spine/bone)
◦ Muscle dysfunction (Myofascial pain)
◦ Combinations common
◦ Most dental pain – inflammatory and/or mechanical
– Result of traumatic injury or bacterial infection originating from pulpal
and periapical tissues

◦ Example: appendicitis
◦ Often diffuse and poorly localized

Question 5

Pathophysiology of Neuropathic Pain
— Pain that originates from direct
dysfunction or damage to the
peripheral or central nervous
system.
(2)
— Dysfunction of peripheral nerves
(2)
— Dysfunction of central nervous
system
(1)
— Independent of any ongoing
tissue injury
— Typically described as tingling, stinging,
burning, and/or numb
— Less common type of dental
pain compared to somatic pain
(1)

Answer 5

◦ trauma or disease of neurons
◦ loss of nerve fiber function

◦ focal area
◦ Widespread

◦ reorganization of central
somatosensory processing

◦ Sometimes referred to as
neuropathic orofacial pain (NOP)

Question 6

Chronic or Persistent Pain
— Not well understood
— May be associated with a chronic pathologic process
— Mechanisms
(3)
— Many conditions result in chronic pain
◦ Patients may be taking chronic non-opioid and/or opioid pain medications daily

Answer 6

◦ Peripheral – persistent stimulation of nociceptors
◦ Peripheral-central – abnormal function of peripheral and central
somatosensory system
– Partial or complete loss of descending inhibitory pathways
– Spontaneous firing of regenerated nerve fibers
◦ Central – disease or injury to CNS

Question 7

Pain Classification
— Multiple ways to classify pain:
(3)

Answer 7

◦ Nociceptive vs. Neuropathic
◦ Acute vs. Chronic
◦ Mixed

Question 8

Objective Findings
(3)

Answer 8

— NO OBJECTIVE ASSESSMENT TO
MEASURE PAIN (INTENSITY)
◦ No Laboratory values
◦ No Diagnostic tests
◦ No Radiographic evidence
— May use labs, physical exam, diagnostic tests,
radiographic evidence to identify or
diagnose a condition that causes pain
— Identify risk factors/contributing factors

Question 9

Pain Assessment
(3)

Answer 9

— Numeric pain scale
— Descriptor Scale (verbal
or visual)
— Baker-Wong faces

Question 10

Pain Management Treatment Options
— Common Non-Pharmacotherapy (Dental and
Medical)
(7)

Answer 10

◦ Definitive Dental Treatments: Extractions/Other dental
procedures/treatments
◦ Thermal modalities (ice/heat)
– Ice/cold is often an important for treatment of dental pain
◦ Mouth Guards
◦ Occupational and Physical Therapy
◦ Acupuncture/Accupressure
◦ Others for medical conditions (cognitive-behavioral, splints
therapy, massage, chiropractic etc.)

Question 11

Pain Management Treatment Options
— Pharmacotherapy (Over the Counter [OTC]/Prescription [RX])
◦ In dentistry used as an adjunct to dental treatments (management of post-procedural
pain or when there is not immediate access to definitive dental treatments)
– Analgesics
(1)
– Adjuvant / Co-analgesics (pain modulators)
(2)
– Opioids/opioid-like (e.g. morphine, hydrocodone,
oxycodone/tramadol)
— Mechanisms of action relate to pathophysiology (chemical modulators)

Answer 11

– Non-opioids (Acetaminophen/NSAIDs)

– Anticonvulsants
– Antidepressants

Question 12

Pharmacologic Treatment
— Targeted at symptom relief
— Realistic pain goal:
◦ Target:
◦ May not be able to eliminate until underlying cause
treated/healed
— Still pursuing better treatments to address underlying
mechanisms of pain

Answer 12

reduce pain and improve
function
30%-50% reduction - clinical improvement

Question 13

APAP Drug Interactions
— Few, compared to other pain medications
— Caution in combination with other drugs that cause liver
toxicity
(4)
— Warfarin (but considered safer than NSAIDs)
— More than >3 alcoholic drinks a day increases liver toxicity
risk

Answer 13

◦ Leflunomide (Rheumatoid arthritis medication)
◦ Methotrexate (Rheumatoid arthritis medication)
◦ Carbamazepine (Anti-convulsant)
◦ (Others)

Question 14

APAP Patient Education
(6)

Answer 14

Found in more than 600 different medicines (RX and OTC)
Do not take more than one medicine at a time that contains acetaminophen.
Watch for acetaminophen in OTC cough/cold, allergy, sleep, pain medications
Never take more than the recommended dose of acetaminophen or take it for longer than directed on
the label, unless directed by a healthcare professional to do so.
Caution with alcohol (limit to 1-2 drinks/day)
Pediatrics – follow weight-based guidelines

Question 15

APAP Prescribing Checklist:

Answer 15

q Overall, well tolerated
q Often used in combination with NSAIDs for dental pain
q Precautions/Contraindications
q Allergy to APAP (rare)
qActive liver disease/dysfunction (e.g. active hepatitis)
qInactive hepatitis or treated hepatitis may not not be a contraindications
(check with the patient’s physician for questions about the safety of APAP use)
q > 3 alcoholic drinks/day
q Do not exceed > 4 gm/day in adults (see pediatric weight-based
dosing guidelines)
q Only use one APAP containing product at a time
qCaution use with other drugs that cause liver toxicity

Question 16

NSAID FAMILY
* Non-steroidal Anti-inflammatory Drugs (NSAIDs)
(2)
* Related:
(2)

Answer 16

• Traditional/Non-Selective/Non-Aspirin NSAIDs
• Cox-selective NSAIDs

Aspirin (acetylsalicylic acid - ASA)
Non-Acetylated Salicylates

Question 17

How NSAIDs work in Dental Pain
(4)

Answer 17

— Tissue injury activates
cyclooxygenase II (COX 2)
— COX II converts arachidonic
acid to prostaglandin E2 (PGE2)
◦ resulting in pain and inflammation
◦ alters vascular tone and
permeability, causing edema
— PGE2 sensitizes and lowers
threshold to stimulate
nociceptors which initiates
transmission of pain to CNS
— NSAIDs block COX II

Question 18

COX-2 Inhibitors
(3)

Answer 18

— Only one COX2 inhibitor in the US
◦ celecoxib/Celebrex
— Drug class associated with ↑ incidence of CV thrombotic
events (rofecoxib, valdecoxib – removed from US market)
◦ Celecoxib – associated with higher CV risk >400 mg/day
— More expensive than most nonselective NSAIDs (even
with generic)
◦ reserve for patients with increased GI risk

Question 19

Clinical uses of Nonselective NSAIDs and COX-2 inhibitors
(6)

Answer 19

— Dental pain often includes an inflammatory component
◦ Often considered first line in dental pain for moderate
◦ Preoperative use 24 hours before the appointment decreases
postoperative edema and hastens healing time
◦ Often used in combination with acetaminophen for dental pain
— Mild-moderate pain and inflammation of varied origin
— Used in combination with opioid analgesics for treatment of of
more severe pain
◦ NSAID/COX-2 inhibitor + opioid = synergistic analgesic effect
— Used for treatment of rheumatoid arthritis and other acute/chronic
inflammatory joint conditions
— Treatment of fever
— ASA (low dose) primarily use for cardiovascular event prevention

Question 20

Non-Aspirin NSAID Blackbox Warnings
— GI Risk -
— CV Risk -
— Coronary Artery Bypass Graft (CABG) Surgery -

Answer 20

“NSAIDs cause an increased risk of serious gastrointestinal
adverse events including bleeding, ulceration, and perforation of the
stomach or intestines, which can be fatal.These events can occur at any
time during use and without warning symptoms. Elderly patients are at
greater risk for serious gastrointestinal events.”

“NSAIDs may cause an increased risk of serious
cardiovascular thrombotic events, myocardial infarction and stroke, which
can be fatal.This risk may increase with duration of use. Patients with
cardiovascular disease or risk factors for cardiovascular disease may be
at greater risk.”

NSAID use
is contraindicated in the setting of CABG surgery - (short-term) before
and after CABG surgery (aspirin is commonly indicated after CABG
surgery)

Question 21

— ASA/NSAIDs + warfarin

Answer 21

◦ Increased bleeding and INR (consider benefit vs. risk- short-term use may outweigh risks)

Question 22

— ASA/NSAIDs + Blood Pressure Medications
(3)

Answer 22

– + ACE Inhibitors and Angiotensin Receptor Blockers (ARBs)
– + Diuretics
◦ May diminished BP effects but may not be clinically significant (particularly if the patient’s BP is
well controlled)

Question 23

— NSAIDs + High Dose Methotrexate
(2)

Answer 23

◦ Decreased Methotrexate renal clearance/increased toxicity
◦ This interaction is CLINICALLY SIGNFICIANT if methotrexate used in high doses

Question 24

— NSAIDs + Lithium
(2)

Answer 24

◦ Increase serum concentrations of lithium (decrease clearance)
◦ Monitory lithium concentrations and symptoms of toxicity /consider decreasing dose of lithium if
NSAID initiated

— Check with patient’s physician or pharmacist regarding clinical significance if there are
questions

Question 25

Topical NSAID Treatment — Reusable dosing card

Answer 25

— Diclofenac (Voltaren® gel, generics) — Use: FDA approved for treatment of osteoarthritis (OA) * Possible option if patient has contraindications to PO NSAIDs – <5% of the amount absorbed after oral administration, but still carries Black Box warning for systemic ADRs (see below) ◦ Lower extremity dose : 4 gm up to QID, Max dose/joint: 16 g/day ◦ Upper extremity dose: 2 gm up to QID, Max dose/joint 8 g/day ◦ Total body maximum 32 g/day — Potential use for temporomandibular joint pain (off label) — Black Box Warning: GI bleed/ulceration and CV thrombotic events * Avoid in advanced renal disease - no dosing adjustments provided by manufacturer * Contraindicated in perioperative pain in the setting of coronary artery bypass graft surgery — Adverse Effects: pruritus, burning, rash * Still a risk for systemic adverse effects — Avoid oral NSAIDS in combination - no additional efficacy

Question 26

NSAID Prescribing Checklist:

Answer 26

q Often considered first line for dental pain (and in combination with APAP) qOTC doses – more analgesic effects qRX doses – analgesic + anti-inflammatory q Precautions/Contraindications q Allergy to NSAIDs/ASA qPatients with active GI ulcer or multiple GI risk factors: qAge > 65, history of GI ulcers/bleed qConcurrent use of chronic antiplatelets, anticoagulants, corticosteroids, high dose NSAIDs qUncontrolled BP q Severe/advanced HF or exacerbations q Patients with CV disease or multiple CV risk factors q Patients with renal insufficiency/chronic kidney disease q Drug interactions with NSAIDs (warfarin, high dose methotrexate) q Avoid in third trimester pregnancy

Question 27

Adjuvants / Co-analgesics

Answer 27

— Diverse group of drugs with individual characteristics that are useful in the management of pain but aren’t typically considered analgesics — Examples ◦ Anticonvulsants – may decrease neuronal excitability (blocking sodium channels, modulating calcium channels?) ◦ Antidepressants – block reuptake of serotonin or norepinephrine, enhancing pain inhibition ◦ Local anesthetics (example - topical) – block sodium channels ◦ Corticosteroids – strong anti-inflammatory affects ◦ Others — Most anticonvulsants and antidepressants commonly used in chronic, neuropathic pain — Full affects of anticonvulsants and antidepressants for pain management usually take 4-6 weeks — Dentists can prescribe adjuvant pain medications, as appropriate — May wish to consult with patient’s other health care provider(s), if not familiar with selection/dosing

Question 28

Perioperative Use of Gabapentinoids

Answer 28

— Limited evidence in dental procedures but may decrease pain and amount of opioid medications — No anti-inflammatory property benefits vs. using NSAIDs pre-procedure/post procedure — Single dose or 2-3 dose peri-operatively — Gabapentin regimens vary (examples) ◦ Single dose of 300-600mg 1-2 hrs pre-op OR ◦ 300 - 600 mg 1-2 hrs pre-op + 300 mg q 6 hrs X 3 doses — Pregabalin regimens vary (examples) ◦ Single dose of 150-300 mg 1-2 hrs pre-op OR ◦ 150-300 mg 1-2 hrs pre-op + 150 mg daily X2 doses — Growing concerns about gabapentionoid abuse, particularly in combination with opioids/other CNS depressants ◦ Limit use to short-term/small quantities

Question 29

Use of Carbamazepine/Oxcarbazepine in Trigeminal Neuralgia

Answer 29

— Often felt in the jaw, teeth or gums ◦ May result in misdiagnosis and unnecessary dental procedures — Carbamazepine (most evidence – Level A) ◦ 200-1200 mg/d in 2-3 doses/day ◦ titrate by 100 mg every other day until sufficient pain relief is attained or until intolerable side effects prevent further upward titration. ◦ ADRs: sedation, dizziness, nausea, vomiting, diplopia, memory problems, ataxia, elevation of hepatic enzymes, and hyponatremia, leucopenia, aplastic anemia, allergic rash, systemic lupus erythematosus, hepatotoxicity, and Stevens-Johnson syndrome (SJS) ◦ Drug interactions: CYP450 (macrolide antibiotics, tramadol, tapentadol, calcium channel blockers) — Oxcarbazepine (Level B) ◦ 300-1800 mg/d in 2 doses/day ◦ increased as tolerated in 300 mg increments every third day until pain relief occurs ◦ improved side effect profile and fewer drug interactions than with carbamazepine

Question 30

Opioid Black Box Warnings

Answer 30

— Addiction, misuse and abuse can lead to overdose and death — Alcohol use with extended-release formulations (Kadian, Oxymorphone ER, Zohydro) result in increased plasma levels and potentially fatal overdoses — Crushing, dissolving or chewing of long-acting products can cause the delivery of a potentially fatal dose — Risk of medication errors with the oral solution - dosing errors due to confusion between mg and mL, and other opioid solutions of different concentrations, can result in accidental overdose and death — Opioid analgesic Risk Evaluation and Mitigation Strategy (REMS) for all opioids which includes an education program for health care providers, Medication Guides provided to patients and emphasis on education and safe use — Life threatening respiratory depression — Life threatening neonatal opioid withdrawal syndrome with prolonged use during pregnancy — Accidental ingestion of even one dose, especially by children, can result in a fatal overdose — Risks from concomitant use with benzodiazepines or other CNS depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing of morphine and benzodiazepines or other CNS depressants for use in patients for whom alternative treatment options are inadequate. Limit dosages and durations to the minimum required. Follow patients for signs and symptoms of respiratory depression and sedation.

Question 31

Centrally Acting Opioid-Like Agents — Tramadol (Ultram)

Answer 31

◦ MOA – μ-opioid activity (30%) – inhibition of NE and 5HT reuptake (70%) — Considered less abuse potential (C-IV) — CYP2D6 and CYP3A4 interactions — Common side effects ◦ dizziness, nausea, constipation, headache, sedation — Increased seizure risk — Increased risk of serotonin syndrome with other serotonergic drugs — Most effective for mild-moderate (not severe) pain — Do not use in pediatric patients (variable metabolism) ◦ < 12 years of age or < 18 years following tonsillectomy/adenoidectomy surger

Question 32

Centrally Acting Opioid-Like Agents — Tapentadol (Nucynta)

Answer 32

◦ MOA – μ-opioid activity – inhibition of NE — C-II controlled substance — Fewer drug interactions compared to tramadol — Common side effects ◦ nausea, dizziness, vomiting, constipation and somnolence — Increased seizure risk — Indicated for moderate to severe pain — Expensive! — Do NOT consume alcohol with Nucynta ER — Safety and efficacy in pediatric patients less < 18 years have not been established

Question 33

Opioid Agonists/Antagonists — Opioid Partial Agonists/Antagonists (nalbuphine and pentazocine) ◦ Don’t use with other opioids because it can precipitate withdrawal — Pure Antagonists ◦ Naloxone (6) ◦ Naltrexone (3)

Answer 33

– Blocks all opioid receptors – Produces rapid reversal of opioid effects – Increases patient's pain – Treatment of respiratory depression cause by opioid overdose – Precipitates opioid withdrawal symptoms but saves lives – Dose: IV, IM, SubQ: Initial: 0.4 to 2 mg; may need to repeat doses every 2 to 3 minutes – Nasal spray also available (see subsequent slides) – Similar actions to naloxone but longer duration of action – Treatment option for alcoholics and opioid dependence – Dose: Initial: oral 25 mg; if no withdrawal signs occur, administer 50 mg/day thereafter – Alternative regimens may include higher doses on the weekends or 150 mg 3 times a day – IM: 380 mg once every 4 weeks

Question 34

Uses of Opioids in Dentistry — Pain from (3) — Post Procedural Management — Other potential dental conditions causing pain including temporomandibular disorders (TMDs) and masticatory muscle disorder — Should be considered “last line” for all indications

Answer 34

◦ Abscesses/Infection/Inflammation ◦ Trauma ◦ Surgery/Procedures

Question 35

Managing Acute Dental Pain – Putting It All Together — Limited evidence of best regimen - — Current practice often includes multimodal analgesic combinations ◦ Most effective combinations and doses not well studied — Growing concerns over opioid abuse – The US consumes 99% of the world’s ---combinations – No research on effectiveness of hydrocodone in dental pain — Many patients’ first experience with an opioid coincides with a dental procedure, such as the extraction of wisdom teeth ◦ Among prescribers of opioids for adolescents, dentists are proportionately the most prevalent prescribers (~--%) ◦ In children/ adolescents < 18 yrs old – misuse often occurs from misuse of own previous prescriptions – use of prescribed opioid pain medication before high school graduation is associated with a --% increase in risk of later opioid misuse – misuse of opioids in adolescence - strong predictor of later onset of heroin use

Answer 35

best practice is based on anecdotal reports, case studies, systematic reviews, a few randomized controlled clinical trial, and the opinions of experts. hydrocodone/acetaminophen 31 33

Question 36

American Dental Association Pharmacologic Management of Acute Dental Pain Guidelines — Key Pharmacologic Options .

Answer 36

◦ NSAIDs – Ibuprofen or Naproxen ◦ Acetaminophen ◦ Opioids – Hydrocodone – Oxycodone ◦ Supplemental local anesthetics – Bupivacaine + Epinephrine by block or infiltration injection – Articaine + Epinephrine by infiltration injection

Question 37

Comparison of Hydrocodone and Oxycodone

Answer 37

— Both semi-synthetic opioids — Both are Schedule II controlled substances — Oxycodone is more potent (takes less mg for similar effects) — No significant evidence on a populations level of major differences in efficacy or tolerability at equianalgesic doses — Noted interpatient variability with efficacy and tolerability ◦ Discussing previous patient experiences with using hydrocodone or oxycodone may contribute to decision-making — Mostly similar adverse events ◦ Some studies show hydrocodone is more likely to cause GI ADRs, especially constipation ◦ Some studies show oxycodone is more likely to cause sedation, grogginess, fatigue, etc. — Both have short-acting and long-acting formations ◦ long-acting formations should NOT typically be used for dental pain — Both are available as combination products with acetaminophen ◦ using separate tablets rather than combination tablet may be less confusing to patients and minimize risk of exceeding maximum acetaminophen dosing if planning to continue acetaminophen use with NSAID

Question 38

Other Strategies/Considerations for Management

Answer 38

— START pre-procedure NSAID 24 hrs prior - unless contraindication ◦ Decreases postoperative edema and hastens healing time ◦ Example ibuprofen 400-600 mg qid X4 — Consider scheduled doses of NSAID +/- acetaminophen the first 24-72 hours (depending on procedure) then prn — The ADA panel suggests against adding oral, submucosal, or intramuscular corticosteroids to standard analgesic therapy for management of post-op dental pain ◦ Recommendations did not address IV administration or post-op complications such as trismus, facial swelling or infection) ◦ Perioperative IV steroids (e.g., dexamethasone) may decrease swelling and discomfort after third molar extractions — If opioid prescribed, the ADA panel recommends to use at lowest effective dose, fewest tablets, and the shortest duration, which rarely exceeds 3 days

Question 39

Good Practice Statements – Panel Advises/Recommends

Answer 39

— Counsel patients on expectations ◦ some pain, analgesics should make their pain manageable ◦ discuss with patient their past experiences, preferences and values regarding pain management (shared decision making) — Avoid routine use of “just-in-case” opioid prescriptions for breakthrough pain — If opioids are used, counsel patients regarding appropriate storage and disposal — Review the state’s prescription drug monitoring program to determine the co-prescribing of other controlled substances

Question 40

ADA Panel Includes the 2020 FDA Drug Safety Communication

Answer 40

— For all patients who are prescribed opioid pain relievers, health care professionals should discuss the availability of naloxone, and consider prescribing it: ◦ Patients who are at increased risk of opioid overdose: – using benzodiazepines or other medicines that depress the central nervous system – history of opioid use disorder (OUD) – who have experienced a previous opioid overdose ◦ Consider prescribing naloxone if: – Patient has household members, including children, or other close contacts at risk for accidental ingestion or opioid overdose.

Question 41

Key Drug Interactions with Opioids

Answer 41

— Avoid Combination CNS depressants: ◦ Alcohol ◦ Benzodiazepines/ Anxiolytics (examples: alprazolam, diazepam, lorazepam) ◦ Sedative-hypnotics (examples: eszopiclone, zaleplon, zolpidem) ◦ Anticonvulsants (including gabapentinoids) ◦ Muscle relaxants — Caution in offering opioids to patients taking gabapentinoids and central nervous system active medications or additional opioids to patients already taking opioids for other medical reasons — Consider length of therapy and individual risk to patient (co- morbidities)

Question 42

Prescription Drug Collection Boxes — Medication Take-Back Option preferred (Recommended by FDA, DEA and EPA)

Answer 42

◦ DEA-registered permanent collection sites ◦ Remove all personal information ◦ Locate at site or event at pharmacies, law enforcement facilities, community sites – DEA or National Associations of Boards of Pharmacy, website to locate permanent disposal boxes – Google Maps – type in “drug (or medication) disposal near me" – DEA – National Prescription Drug Take Back Events

Question 43

Proper Disposal of Opioids

Answer 43

— When preferred options are not available/create barriers — Remove or scratch out personal information from bottles — FDA recommends mixing with unpalatable substances and placing in a non-descript container in the trash: ◦ Coffee grounds ◦ Kitty litter ◦ Dirt ◦ Packets from pharmacy (biodegradable gel) — Some long-acting opioid/others recommended to be flushed due to dangers ◦ Morphine ER, Oxycontin, Fentanyl patches, etc. ◦ See “FDA flush list”

Question 44

Consideration for Prescribing Opioids – Controlled Substances

Answer 44

— Most opioids: C-11 ◦ Follow Federal and State Laws — Tramadol: C-IV — Tylenol w/ Codeine tablets: C-111 — Opioid containing cough suppressants: C-V — Pregabalin: CV — Caution: do not provide larger quantities than needed due to abuse, misuse, and/or sharing (most states have quantity limits for opioids for acute pain) — If patient calls requesting additional pain medications after initial quantity, have patient return for assessment and look for other causes of pain — E-prescribing required for controlled substances in Missouri and Kansas ◦ Missouri - annual waiver and exceptions/Kansas biannual waiver and exceptions — Practitioners issuing electronic prescriptions for controlled substances must use a software application that meets all Drug Enforcement Administration (DEA) requirements

Question 45

State Prescription Drug Monitoring Programs (PDMPs) — Purpose: reduce prescription drug misuse, abuse and diversion while ensuring patients have access to safe, effective treatment ◦ usually reports outpatient Rx — Requirements for providers vary depending on state — Missouri law does not mandate checking PDMP before prescribing a controlled substance to a patient except for MO HealthNet participants. Kansas law also required checking for KS Medicaid participants ◦ Must have individual DEA and MO BNDD numbers — In states not requiring checking the PDMP it is recommended to monitor state’s PDMP to identify concerns BEFORE writing a prescription ◦ See this information at the point of contact with the patient ◦ Check for other opioids and benzodiazepines (other controlled substances CII-IV) ◦ Identify patient at higher risk for adverse drug reactions or accidental overdoses ◦ Potentially able to identify and minimize or avoiding adverse drug reactions or accidental overdose — Communicate with other prescribers and/or pharmacist — Missouri – activated December 13, 2023 – transferred from the St. Louis County PDMP — Kansas – K-TRACS (Kansas Tracking and Reporting of Controlled Substances) — States do not necessarily share information with each other (some state laws prohibit it

Answer 45

— Purpose: reduce prescription drug misuse, abuse and diversion while ensuring patients have access to safe, effective treatment ◦ usually reports outpatient Rx — Requirements for providers vary depending on state — Missouri law does not mandate checking PDMP before prescribing a controlled substance to a patient except for MO HealthNet participants. Kansas law also required checking for KS Medicaid participants ◦ Must have individual DEA and MO BNDD numbers — In states not requiring checking the PDMP it is recommended to monitor state’s PDMP to identify concerns BEFORE writing a prescription ◦ See this information at the point of contact with the patient ◦ Check for other opioids and benzodiazepines (other controlled substances CII-IV) ◦ Identify patient at higher risk for adverse drug reactions or accidental overdoses ◦ Potentially able to identify and minimize or avoiding adverse drug reactions or accidental overdose — Communicate with other prescribers and/or pharmacist — Missouri – activated December 13, 2023 – transferred from the St. Louis County PDMP — Kansas – K-TRACS (Kansas Tracking and Reporting of Controlled Substances) — States do not necessarily share information with each other (some state laws prohibit it)

Question 46

Using PDMPs (3)

Answer 46

— Centers for Disease Control Opioid Guidelines - Do not dismiss patients from care — Activity report ◦ Not punitive for prescriber ◦ Reports the prescriber’s controlled-prescription prescribing ◦ Impacts on patients’ overall morphine mg equivalents (MMEs) — Dentists - sign up to access PDMP in MO or their state ◦ May appoint a staff member to be a delegate

Question 47

Opioid Overdoses: in practice or in the community

Answer 47

— Identify possible opioid overdoses — Activate EMS — Administer naloxone ◦ Available over-the-counter (OTC) naloxone (Narcan) nasal spray ◦ Statewide standing order for retail pharmacies or free naloxone through community-based organizations still option – Good Samaritan Laws: Immunity from criminal prosecution, disciplinary actions from a professional licensing board, and civil liability for an individual who, acting in good faith and with reasonable care, administers an opioid antagonist to an individual whom he or she believes is suffering an opioid-related drug overdose ◦ Prescription insurance coverage? ◦ Expanding access and education important!

Question 48

Naloxone Education Basics

Answer 48

Ø Suspect overdose (person unresponsive) – CALL 911 Ø If must leave temporarily put in recovery position (on side) Ø Indication for naloxone rescue: signs of overdose § slowed, shallow breathing/not breathing § labored exhale “death rattle” from throat § body is limp § pale and/or clammy skin § fingernails or lips turn § Lighter skinned: purple or blue § Darker skinned – grayish or ashen § not responsive § excessively sleepy and cannot be aroused with a loud voice or sternal rub § pinpoint pupils § vomiting or making gurgling noises § slowed or stopped heartbeat Ø Administer naloxone as directed/ how to administer, depending on formulation – most common nasal spray Ø Position patients on their side after naloxone administration (recovery position), if breathing § they may vomit Ø If not breathing perform rescue breathing or if no pulse, CPR as indicated (may vomit)

Question 49

Naloxone Education Basics

Answer 49

Ø Most patients respond to naloxone with a return to spontaneous breathing Ø Administer naloxone every 2-3 minutes: Ø If a patient’s symptoms return or if the patient doesn’t respond or achieve the desired response (i.e., adequate spontaneous breathing), and emergency medical help has not yet arrived Ø When giving additional doses of Narcan nasal spray, alternate nostrils Ø Long-acting/potent opioids may require more than 2 doses and repeated doses (EMS should have additional supply – important to transport to Emergency Department ASAP) Ø Continue rescue breaths (or CPR, if needed) Ø Do not leave Ø If naloxone is given to a patient who is not opioid-dependent or is not opioid-intoxicated, it has no clinical effects Ø Important to call 911 first ◦ duration of most opioids is longer than that of naloxone — Naloxone use may precipitate withdrawal, but most patients remain confused and are usually not combative

Question 50

Patient Education — Realistic Goals — Opioids are usually safe to use when prescribed for short periods of time under care of medical professional when other treatments aren’t options (contraindications) or aren’t controlling the pain ◦ Abuse and misuse are a dangerous and a growing problem in the US ◦ Avoid combining other CNS depressants such as alcohol, most sleep medications and some anxiety medications (benzodiazepines) — Monitoring ◦ Pain improvement (if not improved or worsening have patient return for follow up appointment) ◦ Side Effects – Education on using laxative for constipation (stool softener and fiber may not be effective) ◦ Educate on non-opioid and non-pharmacological treatment

Answer 50

— Realistic Goals — Opioids are usually safe to use when prescribed for short periods of time under care of medical professional when other treatments aren’t options (contraindications) or aren’t controlling the pain ◦ Abuse and misuse are a dangerous and a growing problem in the US ◦ Avoid combining other CNS depressants such as alcohol, most sleep medications and some anxiety medications (benzodiazepines) — Monitoring ◦ Pain improvement (if not improved or worsening have patient return for follow up appointment) ◦ Side Effects – Education on using laxative for constipation (stool softener and fiber may not be effective) ◦ Educate on non-opioid and non-pharmacological treatments

Question 51

Patient Education: Answer these questions for patients (5)

Answer 51

1. What is the goal of this prescription? 2. When and how should I take this? (be specific and stress using scheduled non-opioid when applicable) 3. How long should I take this drug? 4. Are there any risks for me from this medication? 5. What do I do with any extra medication?

Question 52

Cannabinoids

Answer 52

— > 100 cannabinoids in cannabis - two of the main active cannabinoids of cannabis are delta-9-tetraydrocannabinol (THC) and cannabidiol (CBD) — Hemp-derived - CBD (< 0.3% tetrahydrocannabinol [THC] dry weight) vs. Marijuana – derived products — Quality and variability of products complicate and contribute to concern ◦ 2021 CDC Health Advisory: CBD product labeling may underestimate the concentration of THC by not reporting delta-8 THC concentrations, which may result in psychoactive and other adverse effects ◦ May not contain claimed ingredients or may be contaminated with other ingredients, including small amounts of THC or toxins — Complicated by federal and state laws

Question 53

Cannabinoids in Dental Pain

Answer 53

— A PAUCITY OF LITERATURE AVAILABLE related to clinical benefits — Any role in therapeutic use is in its infancy — Insufficient evidence exists to support a tangible clinical benefit of cannabinoids in managing orofacial pain ◦ further research is recommended to investigate the benefits of cannabinoids’ use. — CAUTION: Use of cannabis and THC can enhance sedative, psychomotor, respiratory and other effects of CNS depressants such as opioids, benzodiazepines and alcohol — Potential for CYP450 (liver enzyme) drug interactions with other medications

Question 54

Marijuana smokers

Answer 54

— Associated with poor quality of oral health — Higher rate/increased risk: ◦ Tooth decay ◦ Missing teeth ◦ Plaque and greater severity of gingivitis than non-users ◦ Xerostomia – higher rate than tobacco smokers ◦ Leukoplakia ◦ Mouth and neck cancers – “cannabis stomatitis” – risk to develop into malignant neoplasia — Immunosuppressant properties - higher prevalence of oral candidiasis compared to non-users

Question 55

Summary of Recommended Pharmacologic Options for Dental Pain Management

Answer 55

— NSAIDs ◦ Ibuprofen* (400 mg q 6 hrs) or Naproxen* (440 mg q 12 hrs) – Consider starting pre-op for extractions/procedures – Other NSAIDs possible options (similar efficacy/safety) — Acetaminophen* (650-1000 mg q 6 hrs) ◦ In combination with NSAID or when NSAID contraindicated — Opioids (for inadequate post-op pain control with non-opioids in adolescents and adults) ◦ Hydrocodone 5-7.5 mg q 6 hrs ◦ Oxycodone 5 mg q 6 hrs — Supplemental local anesthetics ◦ Bupivacaine + Epinephrine by block or infiltration injection ◦ Articaine + Epinephrine by infiltration injection * See weight-based dosing guidelines for children < 12 yrs old

Question 56

Dental Pain Prescribing Checklist

Answer 56

q Screen patients to determine current conditions, allergies, medications, potential drug interactions, disease state cautions and contraindications and history of substance abuse qIf patient using opioids for chronic pain/other indications, coordinate with prescribing provider q Use non-opioid analgesics (NSAID +/- Acetaminophen) as foundation of pain management unless contraindicated qAvoid multiple APAP//NSAID containing products qConsider scheduled doses the first 24-72 hours then prn q If prescribing opioid: qCheck Prescription Drug Monitoring Program (PDMP) qUse lowest dose/shortest duration Use in combinations with non-opioids (NSAID/APAP) qAvoid in patients in recovery for substance abuse (work with substance abuse provider) qMay be one of limited options in patients with contraindications to NSAIDs and APAP

Question 57

Dental Pain Prescribing Checklist, continued

Answer 57

q Opioid Precautions/Contraindications qCodeine and tramadol are contraindicated in children younger than 12 and should be avoided/used with extreme caution in ages 12-17, due to variability in metabolism qAvoid prescribing opioids in combination with benzodiazepines, sedative-hypnotics, or anxiolytics. q Caution in elderly and patients with renal and hepatic insufficiency q Screen for drug interactions (cumulative CNS depression) q Educate patients about use, adverse effects qOpioids: abuse risks and appropriate disposal qMaximum dose of APAP (4,000 mg)