Avoiding Opioid Overdose & Addiction PDF

AVOIDING OPIOID OVERDOSE & ADDICTION MARCUS A. CRAYTON, DDS HOWARD UNIVERSITY HOSPITAL ORAL & MAXILLOFACIAL SURGERY PGY-3 EFFECT OF OPIOIDS ON THE BODY OPIOID ANTAGONISTS MEDICATIONS FOR OPIOID USE DISORDER BUPRENORPHINE MU-OPIOID RESPONSE WHY COMBINATION? BUPRENORPHINE AND NALOXONE ...

AVOIDING OPIOID OVERDOSE & ADDICTION MARCUS A. CRAYTON, DDS HOWARD UNIVERSITY HOSPITAL ORAL & MAXILLOFACIAL SURGERY PGY-3 EFFECT OF OPIOIDS ON THE BODY OPIOID ANTAGONISTS MEDICATIONS FOR OPIOID USE DISORDER BUPRENORPHINE MU-OPIOID RESPONSE WHY COMBINATION? BUPRENORPHINE AND NALOXONE NALOXONE AAOMS RECOMMENDATIONS A NSAID can be administered pre-emptively and use be the first line treatment unless contraindicated. A perioperative corticosteroid can limit swelling and decrease postoperative discomfort after 3rd molar extractions. Long acting local anesthetic may delay onset & severity of pain. Avoid starting treatment with a long acting or extended releasing opioid. Ibuprofen and acetaminophen taking together work synergistically to rival opioids.  AAOMS RECOMMENDATIONS When indicated for acute breakthrough pain, consider short acting opioid analgesics. You can use your local states prescription drug monitoring program if one suspects abuse. All instruction for patient analgesia and analgesic prescriptions should be documented. Inform patients to never exceed 3000-4000mg of Acetaminophen a day & 3200mg of ibuprofen a day. Avoid prescribing acetaminophen with codeine for pain to pediatric patients (< 12 y.o) Always important to educate patients on the expectations of postoperative pain management and anticipated levels of relief. Discuss storage and disposal with patient PDMP IMPROVES PATIENT SAFETY View close to real-time, electronic access at the point-of-care to prescription histories of their patients, including prescriptions from other states. Identify patients who are obtaining opioids from multiple providers. Review the average MME/day for their patients. Identify patients who are being prescribed concurrent medications that may increase risk of overdose—such as benzodiazepines and opioids. Identify possible diversion, substance use disorder, or needed care coordination. View PDMP data directly from CRISP’s Unified Landing Page (ULP) or through an Electronic Health Record (EHR) system. Increase confidence in safely prescribing and dispensing PRESCRIPTION WRITING EXAMPLE DEA DRUG SCHEDULING Schedule I - drugs, substances, or chemicals are defined as drugs with no currently accepted medical use and a high potential for abuse. Some examples of Schedule I drugs are: heroin, lysergic acid diethylamide (LSD), marijuana (cannabis), 3,4-methylenedioxymethamphetamine (ecstasy), methaqualone, and peyote. Schedule II - drugs, substances, or chemicals are defined as drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence. These drugs are also considered dangerous. Some examples of Schedule II drugs are combination products with less than 15 milligrams of hydrocodone per dosage unit (Vicodin), cocaine, methamphetamine, methadone, hydromorphone (Dilaudid), meperidine (Demerol), oxycodone (OxyContin), fentanyl, Dexedrine, Adderall, and Ritalin. DEA DRUG SCHEDULING Schedule III - drugs, substances, or chemicals are defined as drugs with a moderate to low potential for physical and psychological dependence. Schedule III drugs abuse potential is less than Schedule I and Schedule II drugs but more than Schedule IV. Some examples of Schedule III drugs are products containing less than 90 milligrams of codeine per dosage unit (Tylenol with codeine), ketamine, anabolic steroids, testosterone. Schedule IV - drugs, substances, or chemicals are defined as drugs with a low potential for abuse and low risk of dependence. Some examples of Schedule IV drugs are Xanax, Soma, Darvon, Darvocet, Valium, Ativan, Ambien, Tramadol. DEA DRUG SCHEDULING Schedule V - drugs, substances, or chemicals are defined as drugs with lower potential for abuse than Schedule IV and consist of preparations containing limited quantities of certain narcotics. Schedule V drugs are generally used for antidiarrheal, antitussive, and analgesic purposes. Some examples of Schedule V drugs are cough preparations with less than 200 milligrams of codeine or per 100 milliliters (Robitussin AC), Lyrica. EXAMPLE OF WRITING A CONTROLLED SUBSTANCE SIGNS OF ADDICTION Excessive use. Function abilities at home or work are compromised. Decline in interpersonal relationships. Psychological impairment. Much time is devoted to drug use or obtaining drugs. DOCTOR SHOPPING Substance user will seek prescription opioids to abuse through “doctor shopping” Signs of drug seeking behavior include Contacting the dentist by phone after regular office hours or during weekends. Demanding immediate action, often aggressive. Not following through for recall visits. Claiming to be out of town or requesting early refills or stolen medications. Claiming to be allergic to all drugs except controlled substances Often will request a particular medication (Percocet or Vicodin) AVOID CODEINE IN CHILDREN Codeine is converted by the liver into morphine There is genetic variability in how quickly an individual’s body breaks down the drug. It provides inadequate relief for some patient while having too strong an effect on others. Children are often ultra rapid metabolizers and may experience severely slowed breathing rates or even die after taking standard doses of codeine. IMPORTANT POINTS TO UNDERSTAND Oxycodone is twice as strong as morphine Codeine - weakest opioid Gabapentin and oxycodone combo is dangerous Opioid plus Benadryl - caution Ambien, Ativan—do not take codeine, hydrocodone with these Tramadol is about the same strength as codeine Tramadol acts as a SSRI (i.e. it acts like Prozac or Lexopro) Do not prescribe tramadol to suicidal patient IMPORTANT POINTS TO UNDERSTAND Schedule 2 narcotic - Oxycodone & Hydrocodone Schedule 4 narcotic - Tramadol NSAIDs cause ‘Renal Artery Constriction’, for a patients who are on diuretic already --- makes it worse Steroid and NSAID combo- contraindicated Prescribe Tylenol, tramadol while on Medrol dose pack—AVOID NSAID WHILE ON STEROID—IT IS DANGEROUS