Dental Section

temp

Prescription Drug Monitoring Program (PDMP)

The PDMP is an online tool available to all prescribers, pharmacists, and patients in Oregon. Once a prescriber is registered with the program, he or she can learn exactly which prescription medications a patient has taken and is taking. The value of this information cannot be overstated. We strongly encourage its regular use as an assessment and management tool. Without question, a query of the PDMP should be completed for each patient prior to prescribing. Prescribers can now delegate “look-up authority” to their support staff. Click here for details.

Concomitant Benzodiazepine and Opioid Use

Most experts advise against concomitant use of benzodiazepines and opioids because of the synergistic effect of those drugs in combination exacerbating respiratory depression. As many as 50% of opioid overdoses have involved sedative hypnotics. In addition, the anterograde amnesia that is inevitable with benzodiazepines can contribute to inadvertent overdose for predisposed individuals. It is strongly recommended that you check for benzodiazepine use by UDS, PDMP query, as well as observing for impairment or sedation. Psychotherapy is often helpful as an adjunct to tapering (see Tapering in this document). Some individuals may require inpatient treatment to successfully discontinue use. Many patients who are dependent on benzodiazepines have a difficult time abstaining from other sedative hypnotic substances (such as alcohol, barbiturates, and carisoprodol), and these drugs have similar risks for overdose when combined with opioids.

Concomitant Marijuana and Opioid Use

Medical and recreational marijuana is legal in Oregon and many other states. It is still illegal, however, under federal law. Marijuana is clearly a mind-altering drug, and though it may provide mild to moderate pain relief, it does have associated risks and side effects, such as altered response times, perceptual changes, and mood changes. In some circumstances, marijuana use may be associated with other illicit or risky drug use.

Some providers do not prescribe chronic opioids when marijuana is used (the patient has to choose which treatment modality to use). Others decide not to include THC in their UDS so as not to create a conflict with their patients. Others believe that marijuana may provide appropriate additional pain relief, particularly CBD (cannabidiol) enhanced varieties.

Disposal

The overprescribing of opioids can lead to the accumulation of unused pills in the medicine cabinet. This is true, especially for acute pain situations, when 30 pills may be prescribed for a time-limited situation and only five pills are taken. Those unneeded medications can pose a risk to children or can inadvertently provide a source of illicit opioids through theft or sharing. The ability to safely dispose of unused medication is an important strategy in the fight to reduce unnecessary opioids in circulation.

Drug take-back programs: The Drug Enforcement Administration promotes national drug-take back day on May 8. Many law enforcement agencies have drug drop boxes in their communities. Some pharmacies may also take unused medications as the laws have been relaxed allowing for medication return in some states. The FDA and DEA have useful hints on their websites for disposal, including how to dispose of unwanted medication safely.

Medication-Assisted Treatment (MAT)

Medication-assisted treatment refers to the use of pharmaceutical agents to treat opioid-use disorder. Generally methadone, buprenorphine, and naltrexone sustained release are used for this purpose. Methadone and buprenorphine have the highest rates of success for opioid-use disorder, an important consideration when weighing the significant risks associated with abuse versus the greater relapse rate associated with non-medication treatment regimens. Remember, those with opioid addiction are living with a potentially fatal chronic disease and deserve prompt and effective treatment.

• Methadone can only be prescribed for addiction treatment in a federally monitored treatment facility. Methadone treatment for chronic pain should be used cautiously, if at all, and only at low doses. Significantly higher daily doses (80–100 mg average) are used when treating opioid-use disorder because the MAT clinic can institute tight medication oversight such as daily nurse monitoring, counseling, UDS, and PDMP query. The use of high-dose methadone in such circumstances does not carry the same degree of risk as it would in a primary-care setting.
• Any physician in an office setting can prescribe buprenorphine, after taking a brief educational course and getting an “X” waiver added to their DEA number.43 Buprenorphine is safer than methadone and generally more convenient to the patient. It is recommended that if you prescribe opioids for chronic pain, you should either become a buprenorphine prescriber or have ready access to that service.
• Medication-assisted treatment should be accompanied by ongoing behavioral supports, and it is strongly recommended that providers of care utilize such expertise as a part of their treatment plan.
• Recognizing opioid-use disorder in your patient should trigger an immediate referral to an effective treatment program or, if you are X waivered, a switch to buprenorphine treatment.
• Injectable naltrexone can be another useful tool for the patient motivated enough to begin treatment after total opioid abstinence. It also can be provided in a practitioner’s office.

Heroin

There has been a rise in heroin use, heroin overdoses, and heroin treatment admissions in the U.S. over the past decade.44 Opioid dependency does not differentiate between mu agonists, so individuals who develop a substance-use disorder with prescription opioids will find symptomatic relief with any opioid, including heroin. In many parts of the country, heroin is cheaper than pills and is accessible almost everywhere. Therefore, many individuals who cannot stop using pain medications because of dependency or addiction, and whose demand exceeds their supply, turn to heroin use.

Heroin can be smoked, snorted, or injected. It comes in various forms: black tar, gunpowder, and white powder. The potency of the drug varies both regionally as well as temporally, making dosing decisions on the part of the user difficult and dangerous. Overdoses are common, particularly when an addict has reduced his or her tolerance (jail, prison, sobriety based on residential treatment) and then resumes use. Concomitant
use of sedative hypnotics such as alcohol, benzodiazepines, carisoprodol, and sleeping pills increase the risk of overdose.

The most effective treatment for heroin addiction (as well as all opioid substance-use disorder) is medication-assisted treatment (see the MAT section in this document). Since discontinuation of opioids leads to reduced opioid tolerance, relapse is associated with an increased risk of overdose. Risk of relapse and overdose should be an educational component to all opioid treatment.

Bystander naloxone is an essential “downstream” treatment that reduces mortality from opioid overdose. See the Naloxone section (below) in this document.

Individuals with a history of heroin use, past or present, are at high risk of inappropriate use of prescription opioids. Such individuals can safely be treated using buprenorphine or methadone, and primary-care or pain-specialty providers need to be very cautious treating such individuals for pain using opioids.

Naloxone

Naloxone is a pure mu antagonist, and as such, it is an antidote to the effects of opioid intoxication. It reverses respiratory depression that is the cause of death in an opioid overdose. Naloxone has essentially no adverse effects and is remarkably successful in reversing the life-threatening effect of opioids. The incidence of opioid overdose is dose related, but anyone taking opioids is potentially at risk. Therefore, we recommend co-prescribing naloxone for the families and loved ones of all patients prescribed opioids for chronic use.

Naloxone displaces other opioids off the mu receptor sites, but it has a short half-life, having an effect for 30 to 90 minutes. After the drug wears off, the agonists may again reattach to the receptors. Anyone requiring naloxone treatment should be transported to an emergency department for further evaluation since return to the overdose state is possible with the passage of time after the initial naloxone treatment.

Naloxone can be administered parenterally (IV or IM), but it is also effective as a nasal spray. The drug has a very rapid onset of effect when given IV. Its onset of action is more gradual, but still lifesaving, when given via intra-nasal spray. Lay persons can easily be trained to use the intranasal product.

Naloxone is a drug administered by another person to rescue an individual who is overdosing on an opioid. Friends or relatives are often the ones who are present at the time of an overdose and are therefore the individuals who need to receive naloxone training.

Naloxone co-prescribing

Everyone taking opioids on a daily basis should have their friends or loved ones trained in naloxone use. It should be a part of a routine prescribing protocol for prescribers. It communicates your concerns about safety to your patient.

Many states allow lay-person use of naloxone, many insurance companies will pay for the drug, and in Oregon, a simple online training course will suffice to allow dispensing of the drug.

In 2014, 52 people died every day in the United States from prescription-opioid-related overdoses. Cities and states with naloxone distribution programs have seen 37–90% reductions in overdose deaths. Co-prescribing naloxone with medications is an important component of opioid therapy. Patients and their providers commonly underestimate the chance of experiencing an overdose. “Risky drugs, not risky people” is a useful phrase to use when explaining the necessity of naloxone co-prescribing to patients.

Overdose risk factors

As was stated earlier, all individuals taking opioids are at some risk of an overdose. Certain factors will increase that risk:

• Individuals taking sedative-hypnotics (alcohol, benzodiazepines) in addition to opioids are at increased risk. Such individuals may have a partial response to naloxone, since the drug only acts to reverse the opioid component of the overdose.
• Individuals whose opioid tolerance has decreased are at risk. This includes people who leave residential addiction-treatment programs or are released from incarceration.
• Individuals whose dose of opioids is suddenly increased are at risk. For example, a sudden increase in opioid dosing or a new source of herointhat is stronger than the user expected could result in overdose.
• Someone who has previously overdosed is at risk of overdosing again.

Further resources

• Videos demonstrating use of naloxone: http://tinyurl.com/oregonoverdose
• Oregon naloxone law: http://tinyurl.com/oregonODlaw
• Oregon training materials: http://tinyurl.com/naloxonetrainer
• Prescribing information and guidelines: http://www.prescribetoprevent.org
• San Francisco Health Department provider guide to prescribing naloxone:
  http://www.sfhealthnetwork.org/wp-content/uploads/26a-Detailing_Provider_final.pdf
• San Francisco Health Department brochure for patients:
  http://www.sfhealthnetwork.org/wp-content/uploads/27-Detailing_Patient_final.pdf

Sleeping Pills (Z Drugs and Others)

The Z drugs—zolpidem, zaleplon, eszopiclone—are indicated for the short-term treatment of insomnia. These medications are not benzodiazepines, but they do act on the same receptors and though they have a somewhat different risk profile (reduced seizure risk with withdrawal, for example) they share many of the adverse effects of benzodiazepines such as drowsiness, memory impairment, reduced coordination, depression, and sleep disturbances. Benzodiazepines are also commonly prescribed for insomnia, namely temazepam and lorazepam. As noted, there are many adverse effects associated with use, with little long-term efficacy.

There is an increase in all of these effects with elderly and pediatric patients. Using any of the Z drugs, benzodiazepines, alcohol, or opiates in any combination increases the risks of impairment and overdose. It is easy to become dependent on these medications, and it can be difficult to return to normal unaided sleep when discontinuing use. There are safer medical alternatives as well as non-pharmacological options that can be explored.

When considering prescribing these medications for insomnia:

• Avoid combinations of Z drugs, benzodiazepines, opioids, or stimulants
• Use the lowest dose possible:
  • Avoid prescribing these for children and adolescents
  • Use cautiously and at the lowest doses in the elderly
• Prescribe for only short intervals (7–10 days)
• Consider alternatives:
  • Trazodone
  • Amitriptyline
  • Melatonin

Tramadol and Tapentadol

These are opiate-like analgesics used to treat moderate to severe pain. In addition to binding to mu opioid receptors, tramadol weakly inhibits norepinephrine and serotonin reuptake and tapentadol inhibits norepinephrine reuptake. Many of the risks associated with opioids are true for tramadol and tapentadol. Tramadol is now a Schedule IV drug and has been shown to increase the risk of precipitating a seizure. Both of these medications can cause physical and psychological dependency.

We recommend that tramadol be treated as other true opioids when evaluating risks and benefits of
opioid treatment.

Carisoprodol

Carisoprodol is a muscle relaxant with properties and risks similar to benzodiazepines including similar habit-forming properties. This medication should be used cautiously, if at all, especially in combination with opioids. It has been removed from the market in a number of countries worldwide, and the EU recommends it not be used for the treatment of low back pain. In patients experiencing severe pain from spasticity, consider alternatives such as tizanidine or baclofen.

Meperidine

Meperidine is a narcotic analgesic with sedative properties and is not recommended for outpatient treatment of acute or chronic pain. Additionally, meperidine is included in the 2015 AGS Beers Criteria as a potentially inappropriate medication to be avoided in patients 65 years and older because of potentially higher risk for delirium (neurotoxic metabolite), and lack of analgesia when taken orally. Furthermore, the American Pain Society does not recommend its use as an analgesic.

Long-Acting Opioids

Long-acting opiates consist of ER/LA formulations such as oxycodone, morphine ER, fentanyl patches, and methadone, among others.

Long-acting opiates carry the same risks as short-acting formulations. However, the risks of addiction, abuse, misuse, overdose and death are much greater, especially in opiate-naïve patients. For this reason, the use of long-acting opiates should be reserved for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative modalities (both pharmacologic and non-pharmacologic) have been maximally tried and subsequently failed.

Methadone

Methadone has unique metabolic properties making it particularly dangerous to prescribe outside of a closely managed methadone clinic. Overdoses are greatly increased with methadone compared to other opioids. Most guidelines recommend dosing at fewer than 30 mg/day or not at all.

You will notice in the table below, as the dose of methadone increases, the potency of the drug in relation to other opioids increases in an exponential fashion. This table can assist in making safe medication switches from methadone to other opioids and vice versa.

Gabapentin

Gabapentin and pregabalin have a role in the treatment of neuropathic pain, but also have potential for misuse and abuse. These agents are perceived on the street as a substitute for most common illicit drugs. Overdoses have been fatal because of CNS depression, especially when combined with opioids, alcohol, or other CNS depressants.

Gabapentin and pregabalin are structurally related to GABA. They reduce the release of excitatory neurotransmitters as well as increase the effects of the dopaminergic reward system. This is responsible for the sedative and dissociative/psychedelic effects that can occur at higher doses. Pregabalin is a Schedule V controlled substance in the U.S. It may have a higher addiction potential than gabapentin resulting from its rapid absorption, faster onset of action, and a greater affinity for binding sites. The bioavailability of pregabalin does not change with higher doses, but bioavailability of gabapentin decreases by nearly 50% when the dose is increased from 900 mg/day to 3,600 mg/day. As a result, gabapentin doses greater than 1,800 mg/day don’t appear to provide additional neuropathic pain relief.

Gabapentin may help attenuate withdrawal symptoms from alcohol or opioids, and abusers will often “bridge” with gabapentin until they can obtain a supply of illicit drugs. However, it is important to note that individuals may also experience withdrawal symptoms from gabapentin itself. Consider alternatives such as tricyclics (TCAs) for neuropathic pain as an alternative to high-dose gabapentin.

Value Identification

Prior to engaging in potentially challenging conversations, it is advisable to spend time reflecting on the core values and principles that you are upholding in the difficult conversation. For example, it may be in the service of practicing safe medicine, being in alignment with your colleagues, the medical board and/or community, state, and national safe opioid prescribing guidelines. When you are in alignment with your values and the healthcare team believes that the change is in the patient’s best interest, the difficult conversations are often more manageable and rewarding.

Realistic Expectations

When asking a patient to do something they may be afraid to do or that they do not want to do, they may leave the appointment highly distressed, very angry, and/or inconsolably sad. It is common for providers and the healthcare team to feel that if a patient leaves in such a highly agitated way, this indicates that the outcome of the appointment was a failure. Reconsider this belief. When a provider or healthcare team member asks a patient to make a change that is guided by core principles and values and a belief that it is in the patient’s best interest to make the change, then the state the patient is leaving in can be considered a natural part of the patient’s therapeutic process, and a positive step toward the individual’s overall health and well-being.

Willingness to feel Uncomfortable

Difficult conversations often bring about discomfort for patients, their families, providers, and healthcare team members. When we model our willingness to be uncomfortable to our patients, it helps the process. Consider saying to yourself before engaging in such a conversation, “I am willing to be uncomfortable having this conversation because it is in the service of my value of safety and best-practice medicine.” It can be helpful to notice your own sympathetic nervous system activation (e.g., rapid, shallow breathing; clenching fists or jaw), and then engage in an activity to activate your parasympathetic nervous system (e.g., slowing down your exhale and softening your hands or jaw). Just as these situations can be highly triggering for our patients, they can be highly triggering for providers and the healthcare team, as well. These conversations go much more smoothly when providers or healthcare team members can identify which types of patients and situations trigger them the most and develop an intervention strategy to notice the trigger and proceed calmly and effectively with delivering effective patient care.

Relationship as a Resource

It is important not to underestimate the relationship between the patient and the provider or healthcare team as a resource. Most patients genuinely care for their providers and/or healthcare team and want to work collaboratively with them. Often, genuinely communicating with patients that you will stick by their side through the changes can be one of the most powerful tools. Patients often fear their providers or healthcare team will abandon them, ask them to make changes too quickly, not listen to their fears, and or “fire” them from their practice. Proactively quashing such fears and acknowledging that the fear is real to them will go a long way toward reducing those fears.

Belief and Confidence

Expressing the belief in the patient’s ability to make the change is one of the most valuable tools for creating positive clinical outcomes such as removing or reducing opioids. You may think the patient knows this; however, it is highly advisable to overtly tell the patient, even over multiple appointments, and even if it feels redundant or if you don’t completely believe that your patient will be able to make such changes. Believing the patient can change is critical to the success of the process. Over time, as you see your patient making such changes and actually increasing functioning and quality of life, you will be more confident in your patient’s abilities and it will be easier to relay your belief in them.

Resources

Difficult Conversations: Real life examples, Helpful Hints, and Tools – https://www.oregonpainguidance.org/clinical-tools

Motivational Interviewing Resources – http://www.motivationalinterviewing.org