lessons learned a decade of experience addressing the
TRANSCRIPT
Lessons Learned –
A Decade of Experience
Addressing the Opioid Crisis
Tuesday, October 15, 2019
Bon Secours Mercy Health
Emergency Department
Referral Model in Action:
Addressing Dental Access,
Opioid Prevention and Pain
Management
M. Frank Beck, DDS, FAAHD, MAGD, FIOCI, DSCDAGeneral Practice Dental Residency
Program Director, Mercy Health
Regional Chief Opioid Officer
NEOMED, Associate Professor, Internal Medicine
OSU, Adjunct Assistant Professor,
Division of Pediatric Dentistry and Community Health
The University of Pittsburgh, Adjunct Professor,
Dept. of Dental Public Health, College of Dental Medicine
Nickola Ceglia LISW-S, ACSW
Instructor/SBIRT Trainer, Mercy Health
Former Executive Director of Trumbull County Mental Health and Recovery Board
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• Understand the development, operational approach
and rationale for implementing the Definitive Care
Concept
• Recognize evidence-based approaches to pain
management including pre-operative, peri-operative
and post-operative approaches
• Recognize the benefits of creating tools to improve
identification of at-risk patients, encourage early
treatment referrals, establish acute withdrawal
protocols and provide more efficient access to available
PDMP databases
Training Objectives
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INTRODUCTION
Limited access to dental care results in increased utilization of hospital Emergency Departments (ED) for dental services
Treatment of patients requiring dental care in the ED generally consists of writing two prescriptions and the recommendation that the patient follow up with a dentist.
SIGNIFICANCE
Patients seeking dental care in EDs receive only symptomatic relief and re-enter the system in the future presenting with more fulminant pathology.
These follow up visits require the utilization of even more resources and in some instances hospital admissions.
DISCUSSION
NEDC accounted for 3 of the TOP 20 diagnoses for Level I
& II ED visits
Utilization of the ED for dental problems was higher for
uninsured (47.11%) and Medicaid (25.18%) patients.
DEFINITIVE DENTAL CARE MODEL
2008 developed and implemented
NEDC 7:00am – 4:00pm
NEDC 4:00pm – 7:00am
DEFINITIVE DENTAL CARE OUTCOMES
Immediate and definitive relief of pain elimination of infection
Interrupts progression of pathology
Eliminates exacerbation of other systemic morbidities
Eliminates unnecessary use of narcotics
2007 – 2008 ED date demonstrating higher utilization in the evening and night time hours
Data suggests the possibility that establishing definitive Dental Care linkages with ED may result in improvements to the present delivery model
SUMMARY
NEDC accounted for THE #1 Level I & II ED visits in 2008 and 2013-2014
NEDC accounted for 3 of the TOP 20 Level I & II visits
Utilization of the ED for dental problems is higher for uninsured and Medicaid patients
Attempt to provide definitive care for the patient in contrast to traditionally rendered symptomatic care
This significantly decreases the number of unnecessary dental visits to our Emergency Dept.
Designated block scheduling is utilized
Patient compliance is ensured by only providing a limited number of pain pills sufficient until the subsequent DCC appointment
• Initiationo Peripheral pain receptor – nociceptor
▪ NSAIAs
• Transmissiono Nerve fibers and spinal cord
▪ Local anesthesia
• Integrationo CNS/ Brain – pain perception and pain reaction
▪ Opioids
• Modulationo Pain inhibitory pathways in brain and spinal cord
▪ TCA’s
Pain Management Strategies
NNT
The medication with the lowest NNT will be
the most efficacious
Oral pain medications
NNT of 1.5 = excellent
NNT of 2.0 = good
NNT of 2.5 = fair
NNT Comparison of Orally
Administered Analgesics
Analgesic NNT
Ibuprofen 400 mg/APAP 1000 mg 1.5
Ibuprofen 200 mg/APAP 500 mg 1.6
Ketoprofen 100 mg 1.6
Ibuprofen 600 mg/800 mg 1.7
Analgesic NNT
Ketorolac 1.8
Oxycodone 5 mg/ APAP 500 mg* 2.2
Aspirin 1200 mg 2.4
Ibuprofen 400 mg 2.5
Analgesic NNT
Oxycodone 10 mg/APAP 650 mg 2.7
(2 Percocet)
Oxycodone 10 mg/1000 mg* 2.7
Naproxen 40 mg/440 mg 2.7 (2.3)
Naproxen 500 mg/550 mg 2.7
SourcesThe Oxford Pain Group League table for
analgesic efficacy
Cochrane Database of Systematic
Reviews
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A new study compared opioids and over-the-counter painkillers in ERs. Opioids didn’t do so well.
Updated by German Lopez@germanrlopez [email protected] Nov 9, 2017, 9:30am EST
Patients Unable to Take NSAID’s• 5 mg oxycodone + 500 mg APAP (OTC)
• In 2013 the FDA mandated pharmaceutical companies to limit the APAP dose in combinations to 325 mg or less
• According to NNT best combination• 5 mg oxycodone + 500 mg APAP (NNT = 2.2)
• Combination no longer commercially available
Opioids and acute painAll studies on opioids used for acute pain
have shown that the longer they are
used, the worse the outcomes!
The CDC recommends 3 days or less for
acute pain.
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• Opioids are not very effective pain
medications
• Opioids do lead to addiction
• We must avoid the first exposure (age 18)
• Use opioids for their behavioral effects
(calming) when absolutely necessary and
for only 1-3 days
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PRE-OPERATIVE
Start an NSAID 24 hours prior to procedure
600 mg ibuprofen q.i.d.
400 mg celecoxib
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PRE-OPERATIVEConsider prescribing a corticosteroid for your patient• If pain and/or swelling develop or persist post-op, it is reasonable to
consider prescribing a corticosteroid (assuming swelling is not due to infection)
• Edema from surgery usually peaks at 48-72 hours
• Note that corticosteroids can be prescribed preemptively when severe pain and significant swelling are anticipated post-operatively
• Rx Dexamethasone 4 mg, 4 tabs
• Rx take two tabs stat in the AM, then one tab next day, and a final tab on the 3rd day
• This dose can be halved for younger or older patients
• If preferred, it is not necessary to take a loading dose of the steroid
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PERIOPERATIVE• Use bupivacaine during or at the end of
procedure
• Must be given as a block
• Exparel
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Set Expectations
“Some discomfort is normal… in fact, you can use it as a
barometer of your post-op healing progress.”
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NNTs“We know, without question, the most effective ways to manage your post-op course, and more importantly, we have
a rank order of the effectiveness of pain medications known as NNTs.”
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Opioids
“Occasionally opioids are used to alter perception and reaction to your
discomfort…unfortunately, they are not therapeutic and must be used along with the non-opioids to achieve adequate pain relief.”
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Adverse Affects“We are careful about opioids because
they have been shown to be ineffective in managing post-op pain…are highly
addictive, will cause you harm and could even result in overdose if
used incorrectly or abused.”
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Preoperative/Perioperative Pain Management
“All studies show that post-op pain is best managed preoperatively and
perioperatively…fortunately, we began your pain management course preoperatively and just gave you a perioperative long-acting local
anesthetic to prolong your comfort leveland minimize your post-op pain.”
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What is SBIRT? – Acronym for: Screening: quick validated screen to
determine severity of substance use.
Brief Intervention: collaborative conversation that increases patient motivation for change
Referral to Treatment: directly links patients with appropriate services.
evidence based
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SBIRT as a vital sign Routine screening for other potential medical
problems (e.g. cancer, diabetes, high blood pressure)
Why not for alcohol and drug use?
Adding a validated screening tool to medical history/annual review
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Primary Goal of SBIRT
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To identify those who are at moderate or high risk for psychosocial or health care problems related to their substance use choices.
To identify those who have a substance use disorder and need higher levels of care
Two Levels of Screening
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Pre-screen: For Everyone/Universal
One or two questions to help filter individuals
that will be most likely to “screen positive” on
a full screen.
“How many times in the past year have
you had…”
…5 or more drinks in a day (men)
…4 or more drinks in a day
(women)
“How many times in the past year have
you used a recreational drug or
prescription medication for nonmedical
reasons?”
Time saving measure when time is limited.
A “positive” pre-screen indicates the need to
administer the full screening tool.
Full Screen: After Positive Pre-Screen
The full screening tool provides information about the patient’s level of substance use risk and the appropriate next steps:
Brief Intervention or
Referral to Treatment
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Score Zone Action
0 - 7 I – Low Risk Positive reinforcement
8 - 15 II - Risky Brief intervention
16 - 19 III - Harmful
Brief intervention or
referral to specialized
treatment
20+ IV - SevereReferral to specialized
treatment
AUDIT(10) Interpretation
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DAST(10) InterpretationScore Zone Action0 - 2, plus no daily use of
any substance, no weekly
use of opioids, cocaine or
meth; no injection drug
use in the past 3 months;
not currently in substance
abuse treatment
I – Low RiskBrief Education: monitor
and reassess at next visit
3 - 5 II - Risky Brief Intervention
6 – 8 II - Harmful
Brief intervention or
referral to specialized
treatment
9+ IV - SevereReferral to specialized
treatment
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Dependent Use Referral to Treatment
Harmful Use Brief Intervention/possible
Referral to Treatment
At-Risk Use Brief Intervention
Low Risk No intervention
Screening Informs the SBIRT Process
What Are Brief Interventions
Brief motivational
and awareness-raising interventions
given to at-risk or harmful
substance users.
Goal is to help patients decide to
lower their risk for alcohol-related
problems.
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Brief Intervention Steps
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1. Raise the Subject
2. Provide Feedback
3. Enhance Motivation
4. Negotiate a Plan
A Strong Referral to Appropriate
Treatment Provider is Key
When your patient is ready:
• Know your local resources
• Make a plan with the patient
• You should actively participate in the referral process
• Decide how you will communicate with the provider
• Confirm your follow up plan with the patient
• Decide on ongoing follow up support strategies that you
will use
• Direct warm handoff
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How would I know (and what should I do) when a patient has a drug problem?
The ADA encourages dentists to seek continuing education in Screening, Brief
Intervention, and Referral to Treatment (SBIRT) for patients who may be at risk
for substance abuse and/or be prone to addiction.
SBIRT is an evidence-based practice used to identify, reduce, and prevent
problematic use, abuse, and dependence on alcohol and illicit drugs. It is
comprised of three basic components.
Screening – Specialized techniques for identifying risky substance use
behaviors.
Brief Intervention – Specialized techniques for motivating at-risk
individuals to change their behavior.
Referral to Treatment – Specialized techniques for referring these
patients for appropriate diagnosis and treatment (e.g., support line,
addiction counselor, treatment facility, etc.)
SBIRT is based on an Institute of Medicine recommendation* that called for
community-based screening for health risk behaviors.
ADA Practical Guide to Substance Use Disorders and Safe PrescribingSAMHSA.gov/sbirt
Humility of Mary Health Partners
Emergency Physicians Monthly
You’re Suing Me for What?
On May 13, 2015, the Supreme Court of West Virginia ruled that patients who become addicted to prescription medications can
sue doctors and pharmacies for
addiction-related damages. This ruling may
have significant implications for prescribers of
medications with the potential for addiction,
including emergency physicians.
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Resources
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www.samhsa.gov/sbirt
www.motivationalinterviewing.org
https://addiction.surgeongeneral.gov/sites/default/files/S
potlight-on-Opioids_09192018.pdf
https://youtu.be/KlaCo3zw1PM (Clinic Workflow)
https://youtu.be/MaxHuf17A44 (Brief Intervention “Jill”)
https://youtu.be/b-ilxvHZJDc (Brief Intervention “Steve”)