lilttle pain control in dentistry sentdentistry and a collaborative look at the effects of opioid...
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CPAIN CONTROL IN
DENTISTRYand a Collaborative Look at the Effects of Opioid Dose Reduction in
Chronic Pain Patients
Jared R. Little DDS
Creighton University School of Dentistry 2007
Jared R. Little DDS PC 2008-2017
Assistant Professor General DentistryOperative Dentistry
Dental AnatomyLab
Clinic
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Prison Life• 90 minute drive for a 7:45am arrival• Check in at guard tower with issued ID• Park and walk in lobby • Present ID for entrance into first “airlock” some days patted down.• Proceed into airlock and allow door to close and lock behind.• Verification called in to the dental clinic that I was expected.• Upon approval inner door is unlocked leading to the inner courtyard of the prison.• Walk to the Health Clinic building and wait for guard to buzz into second airlock• Guard at ths airlock checks id again then buzzes you into the dental clinic waiting
room
Prison Life• Dental clinic approximately 15x30 cinder block room without windows.• Half divided into a locked lab and sterilization area.• 1-2 dentists, a hygienist, 2 assistants.• By 8am six inmates seated on bench. Work is done one by one until done. 1pm six more
until done.• 1 year wait to see the dentist.
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Prison Life
•Typical day:•60 restorations•2 Root Canals•50+ extractions
•ALL DONE WITH NO OPIOID RX
Post Op pain relief
• 800mg Ibuprofen every 8 hours
• 500mg Acetaminophen every 8 hours
• Piggy back
•STUDY?
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Practice Life•Average 20 patients per day plus Hygiene
•GENERAL PRACTICE• 50% Restorative- Fillings, crowns, bridges• 30% Exodontia and replacement• 10% Root Canal Therapy• 10% miscellaneous
•60% Medicaid
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ROOT CANAL THERAPY
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Root Canal Therapy- Post op Pain• General pain from oral procedure• Continuation of the infection for a brief time• Over instrumenting the canal space• Forcing medications through the apex
• Resolution• Ibuprophen and or Tylenol• Amoxicillin or Clindamycin Azithromycin (ZPAK) in presence of active infection• Extreme cases Hydrocodone 5-325 coverage for 48 hours• Medrol dose pack
Follow-up!!!!!that night, 24-48hrs, 1 week, 6 months
ORAL SURGERY
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Dentistry by Dr. Michael Fisher
Dentistry by Dr. Michael Fisher
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Dentistry by Dr. Michael Fisher
Dentistry by Dr. Michael Fisher
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Dentistry by Dr. Michael Fisher
Dentistry by Dr. Michael Fisher
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Dentistry by Dr. Michael Fisher
Dentistry by Dr. Michael Fisher
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Rafael Scaf De Molon Ph.D Brazil
Rafael Scaf De Molon Ph.D Brazil
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Rafael Scaf De Molon Ph.D Brazil
Oral Surgery Post-op Pain• General pain from oral procedure• Continuation of the infection for a brief time• Additional treatments such as alveoloplasty or implant placement
• Resolution• Ibuprophen and or Tylenol• Amoxicillin or Clindamycin Azithromycin (ZPAK) in presence of active infection• Extreme cases Hydrocodone 5-325 coverage for 48 hours
Follow-up!!!!!that night, 24-48hrs, 1 week, 1 month, 6 months, 1 year
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Pain Management Considerations for Dentists
• Dentistry unique• a profession that causes pain as a necessary part of the service we provide our patients. • Large majority of Dentists are self employed business owners providing dental services while
trying to grow their practice.
SOLUTION
SATISFACTION
RECOMMEND
NEED
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SOLUTION
NEED
UNHAPPY
RECOMMENDSOMEONE ELSE
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1. Counsel Patients•HONESTY- what amount of pain might they expect•What amount of relief might they expect from their medications
• “The procedure that we have done is significant and I would expect some moderate pain. If you follow these recommendations I have layed out to you I would expect a reduction in pain enough to function (eat, sleep, work). Do not expect a complete lack of pain.”
Pain Management Considerations for Dentists
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2. Be active with pain management choices.•use non-opioid alternatives for minor procedures•Prescribe minimum amount necessary (responsibly)•Attack the cause of pain (antibiotic Rx)•Check state prescription monitoring programs
Pain Management Considerations for Dentists
Training Experiences Regarding pain Management, Addiction, and Drug Diversion of Dentists Enrolled in the National Dental Practice-Based Research Network McCauley JL, Reyes S, Meyerowitz C, et al. March 4, 2019
• 1/3 of prescriptions issued by dentists are for opioid medications• Levy, Paulozzi, Mack, Jones Trends in opioid analgesic-prescribing rates by specialty: US, 2007-2012. Am J Prev Med. 2015; 49(3):409-413
• 50% of opioids prescribed by dentists remain unused• Maughan, Hersh, Shofer et al. Unused opioid analgesics and drug disposal following outpatient dental surgery: a randomized controlled trial. Drug
Alcohol Depend. 2016; 168:328-334
• Opioid prescribing particularly frequent for adolescents who are at an increased risk of developing misuse.• Gupta, Vujicic, Blatz. Multiple opioid prescriptions among privately insured dental patients in the United States: evidence from claims data. JADA
2018; 149 (7): 619-627
Purpose: conduct a national survey to identify training experiences and resources of dentists regarding pain management, addiction, and prescription opioid drug diversion.
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RESULTS: Researchers reported that 67% of dentists responded that they had prior training in pain management, but fewer than one-half (48%) reported that they had received prior training about identification and assessment of drug abuse and addiction.
Only 25% reported training in identification of prescription drug diversion. With most respondents who stated they had training being recent graduates who had received said training in dental school.
CONCLUSION:Many dentists are not receiving training specific to addiction assessment and identification of drug diversion and that such training is associated with greater risk mitigation in dental practice.
3. EDUCATE PATIENTS•Heart of the real problem
Pain Management Considerations for Dentists
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EDUCATE PATIENTS2009 survey by the Substance Abuse and Mental Health Services Administration or SAMHSA:
• Nearly 600,000 Americans used Oxycontin for nonmedical reasons for the first time in 2008.• More than half said they received the drugs from a friend or relative without buying or stealing them.
West Virginia 2006, more than 60% of all unintentional, fatal overdoses of controlled prescription drugs involved individuals who did not have a prescription for the drug that contributed to their deaths.
Department of Justice- pharmaceutical diversion and abuse is viewed as the greatest drug threat by a growing number of the nation’s law enforcement agencies
Taken from a statement by Roland Goertz M.D. M.B.A., President of American Association of Family Practitioners, August 2011
HOW DOES DENTISTRY MATCH UP TO OTHER SPECIALTIES?
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Trends in Opioid Analgesic-Prescribing Rates by Specialty, U.S., 2007-2012 Levy, Paulozzi, Mack, Jones Trends in opioid
analgesic-prescribing rates by specialty: US, 2007-2012. Am J Prev Med. 2015; 49(3):409-413
2012 US pharmacies and long-term care facilities dispensed 4.2 billion prescriptions, 289 million (6.8%) of which were opioids.
Primary care specialties accounted for nearly half of all dispensed opioid prescriptions
Rate of opioid prescribing rose during 2007-2010 but levelled thereafter as most specialties reduced opioid use.
Greatest increase- Physical medicine/rehabilitation specialists +12%Greatest decrease- ER -8.9% and Dentistry -5.7%
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Functional Correlates of Deliberate Opioid Dose Reduction: Anxiety,
Constipation, Depression, Nausea, Pain, Sleep Quality, Suicidality, and
others.• Jared R. Little DDS Creighton University School of Dentistry• Jonathan Huefner Ph.D. Boys Town National Research Hospital• Kurt V. Gold MD Physiatrist Fitness Research Institute Omaha, NE• Tyler Bean Student Researcher
• In an effort to combat the opioid epidemic, the CDC has recommended limiting morphine equivalent dosing to no more than 90mg per day.
• Our research objectives:1. reduce morphine equivalent dosing in chronic pain patients
previously stable on greater than 90mg per day2. To track multiple factors during the reduction period, and3. To evaluate the functional consequences of this opioid dose
reduction in these patients.
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• Chronic pain patients on a stable opiate regimen in excess of 90mg morphine dose equivalent per day were invited to participate by slowly tapering their daily opiate dose over 8-18 months under physician direction.
• Mean MME (Morphine Dose Equivalent)• Baseline 2018 223.5• 12 month 2019 167.5
25% Reduction
•FACTORS TRACKED DURING MME REDUCTION:
• Self Reported Pain, sleep hours, constipation, exercise, work• Pain Disability• Depression• Anxiety• Sleepiness• Suicidality• Cognitive Function
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GENERAL HEALTH HISTORY FORM
• self reported
• Pain scale of 1-10• Sleep hours• Constipation scale of 1-10• Exercise hours per day recorded• Work hours per day recorded
Pain Disability Index
•7 CATEGORIES
• Family/Home Responsibilities• Recreation• Social Activity• Occupation• Sexual Behavior• Self Care• Life Support Activities
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Pain Disability Index
•7 CATEGORIES
• Family/Home Responsibilities• Recreation• Social Activity• Occupation• Sexual Behavior• Self Care• Life Support Activities
Pain Disability Index
•7 CATEGORIES
• Family/Home Responsibilities• Recreation• Social Activity• Occupation• Sexual Behavior• Self Care• Life Support Activities
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Pain Disability Index
•7 CATEGORIES
• Family/Home Responsibilities• Recreation• Social Activity• Occupation• Sexual Behavior• Self Care• Life Support Activities
Pain Disability Index
•7 CATEGORIES
• Family/Home Responsibilities• Recreation• Social Activity• Occupation• Sexual Behavior• Self Care• Life Support Activities
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Pain Disability Index
•7 CATEGORIES
• Family/Home Responsibilities• Recreation• Social Activity• Occupation• Sexual Behavior• Self Care• Life Support Activities
Pain Disability Index
•7 CATEGORIES
• Family/Home Responsibilities• Recreation• Social Activity• Occupation• Sexual Behavior• Self Care• Life Support Activities
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Pain Disability Index
•7 CATEGORIES
• Family/Home Responsibilities• Recreation• Social Activity• Occupation• Sexual Behavior• Self Care• Life Support Activities
PHQ-9• Frequently used to screen
for depression in patients. • 9-question instrument
given to patients in a primary care setting to screen for the presence and severity of depression.
• The total of all 9 responses from the PHQ-9 aims to predict the presence and severity of depression.
0-4 None-minimal 5-9 Mild10-14 Moderate
15- 19 Moderately Severe 20- 27 Severe
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PHQ-9• Frequently used to screen
for depression in patients. • 9-question instrument
given to patients in a primary care setting to screen for the presence and severity of depression.
• The total of all 9 responses from the PHQ-9 aims to predict the presence and severity of depression.
0-4 None-minimal 5-9 Mild10-14 Moderate
15- 19 Moderately Severe 20- 27 Severe
PHQ-9• Frequently used to screen
for depression in patients. • 9-question instrument
given to patients in a primary care setting to screen for the presence and severity of depression.
• The total of all 9 responses from the PHQ-9 aims to predict the presence and severity of depression.
0-4 None-minimal 5-9 Mild10-14 Moderate
15- 19 Moderately Severe 20- 27 Severe
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PHQ-9• Frequently used to screen
for depression in patients. • 9-question instrument
given to patients in a primary care setting to screen for the presence and severity of depression.
• The total of all 9 responses from the PHQ-9 aims to predict the presence and severity of depression.
0-4 None-minimal 5-9 Mild10-14 Moderate
15- 19 Moderately Severe 20- 27 Severe
PHQ-9• Frequently used to screen
for depression in patients. • 9-question instrument
given to patients in a primary care setting to screen for the presence and severity of depression.
• The total of all 9 responses from the PHQ-9 aims to predict the presence and severity of depression.
0-4 None-minimal 5-9 Mild10-14 Moderate
15- 19 Moderately Severe 20- 27 Severe
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PHQ-9• Frequently used to screen
for depression in patients. • 9-question instrument
given to patients in a primary care setting to screen for the presence and severity of depression.
• The total of all 9 responses from the PHQ-9 aims to predict the presence and severity of depression.
0-4 None-minimal 5-9 Mild10-14 Moderate
15- 19 Moderately Severe 20- 27 Severe
PHQ-9• Frequently used to screen
for depression in patients. • 9-question instrument
given to patients in a primary care setting to screen for the presence and severity of depression.
• The total of all 9 responses from the PHQ-9 aims to predict the presence and severity of depression.
0-4 None-minimal 5-9 Mild10-14 Moderate
15- 19 Moderately Severe 20- 27 Severe
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PHQ-9• Frequently used to screen
for depression in patients. • 9-question instrument
given to patients in a primary care setting to screen for the presence and severity of depression.
• The total of all 9 responses from the PHQ-9 aims to predict the presence and severity of depression.
0-4 None-minimal 5-9 Mild10-14 Moderate
15- 19 Moderately Severe 20- 27 Severe
PHQ-9• Frequently used to screen
for depression in patients. • 9-question instrument
given to patients in a primary care setting to screen for the presence and severity of depression.
• The total of all 9 responses from the PHQ-9 aims to predict the presence and severity of depression.
0-4 None-minimal 5-9 Mild10-14 Moderate
15- 19 Moderately Severe 20- 27 Severe
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PHQ-9• Frequently used to screen
for depression in patients. • 9-question instrument
given to patients in a primary care setting to screen for the presence and severity of depression.
• The total of all 9 responses from the PHQ-9 aims to predict the presence and severity of depression.
0-4 None-minimal 5-9 Mild10-14 Moderate
15- 19 Moderately Severe 20- 27 Severe
PHQ-9• Frequently used to screen
for depression in patients. • 9-question instrument
given to patients in a primary care setting to screen for the presence and severity of depression.
• The total of all 9 responses from the PHQ-9 aims to predict the presence and severity of depression.
0-4 None-minimal 5-9 Mild10-14 Moderate
15- 19 Moderately Severe 20- 27 Severe
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PHQ-9• Frequently used to screen
for depression in patients. • 9-question instrument
given to patients in a primary care setting to screen for the presence and severity of depression.
• The total of all 9 responses from the PHQ-9 aims to predict the presence and severity of depression.
0-4 None-minimal 5-9 Mild10-14 Moderate
15- 19 Moderately Severe 20- 27 Severe
GAD-7• self-reported questionnaire for
screening and severity measuring of generalized anxiety disorder (GAD)
• seven items, which measure severity of various signs of GAD according to reported response categories with assigned points
• Assessment is indicated by the total score, which is made up by adding together the scores for the scale all seven items
0-5 None 6-10 Mild11-15 Moderate16-21 Severe
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GAD-7• self-reported questionnaire for
screening and severity measuring of generalized anxiety disorder (GAD)
• seven items, which measure severity of various signs of GAD according to reported response categories with assigned points
• Assessment is indicated by the total score, which is made up by adding together the scores for the scale all seven items
0-5 None 6-10 Mild11-15 Moderate16-21 Severe
GAD-7• self-reported questionnaire for
screening and severity measuring of generalized anxiety disorder (GAD)
• seven items, which measure severity of various signs of GAD according to reported response categories with assigned points
• Assessment is indicated by the total score, which is made up by adding together the scores for the scale all seven items
0-5 None 6-10 Mild11-15 Moderate16-21 Severe
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GAD-7• self-reported questionnaire for
screening and severity measuring of generalized anxiety disorder (GAD)
• seven items, which measure severity of various signs of GAD according to reported response categories with assigned points
• Assessment is indicated by the total score, which is made up by adding together the scores for the scale all seven items
0-5 None 6-10 Mild11-15 Moderate16-21 Severe
GAD-7• self-reported questionnaire for
screening and severity measuring of generalized anxiety disorder (GAD)
• seven items, which measure severity of various signs of GAD according to reported response categories with assigned points
• Assessment is indicated by the total score, which is made up by adding together the scores for the scale all seven items
0-5 None 6-10 Mild11-15 Moderate16-21 Severe
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GAD-7• self-reported questionnaire for
screening and severity measuring of generalized anxiety disorder (GAD)
• seven items, which measure severity of various signs of GAD according to reported response categories with assigned points
• Assessment is indicated by the total score, which is made up by adding together the scores for the scale all seven items
0-5 None 6-10 Mild11-15 Moderate16-21 Severe
GAD-7• self-reported questionnaire for
screening and severity measuring of generalized anxiety disorder (GAD)
• seven items, which measure severity of various signs of GAD according to reported response categories with assigned points
• Assessment is indicated by the total score, which is made up by adding together the scores for the scale all seven items
0-5 None 6-10 Mild11-15 Moderate16-21 Severe
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GAD-7• self-reported questionnaire for
screening and severity measuring of generalized anxiety disorder (GAD)
• seven items, which measure severity of various signs of GAD according to reported response categories with assigned points
• Assessment is indicated by the total score, which is made up by adding together the scores for the scale all seven items
0-5 None 6-10 Mild11-15 Moderate16-21 Severe
GAD-7• self-reported questionnaire for
screening and severity measuring of generalized anxiety disorder (GAD)
• seven items, which measure severity of various signs of GAD according to reported response categories with assigned points
• Assessment is indicated by the total score, which is made up by adding together the scores for the scale all seven items
0-5 None 6-10 Mild11-15 Moderate16-21 Severe
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GAD-7• self-reported questionnaire for
screening and severity measuring of generalized anxiety disorder (GAD)
• seven items, which measure severity of various signs of GAD according to reported response categories with assigned points
• Assessment is indicated by the total score, which is made up by adding together the scores for the scale all seven items
0-5 None 6-10 Mild11-15 Moderate16-21 Severe
12
Epworth Sleepiness Scale• measure daytime sleepiness• The questionnaire asks the subject to rate
his or her probability of falling asleep on a scale of increasing probability from 0 to 3 for eight different situations that most people engage in during their daily lives, though not necessarily every day.
• The scores for the eight questions are added together to obtain a single number.
• 0-5 Low Normal • 6-10 High Normal• 11-12 Mild Excessive• 13-15 Moderate Excessive • 16-24 Severe Excessive
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Epworth Sleepiness Scale• measure daytime sleepiness• The questionnaire asks the subject to rate
his or her probability of falling asleep on a scale of increasing probability from 0 to 3 for eight different situations that most people engage in during their daily lives, though not necessarily every day.
• The scores for the eight questions are added together to obtain a single number.
• 0-5 Low Normal • 6-10 High Normal• 11-12 Mild Excessive• 13-15 Moderate Excessive • 16-24 Severe Excessive
Epworth Sleepiness Scale• measure daytime sleepiness• The questionnaire asks the subject to rate
his or her probability of falling asleep on a scale of increasing probability from 0 to 3 for eight different situations that most people engage in during their daily lives, though not necessarily every day.
• The scores for the eight questions are added together to obtain a single number.
• 0-5 Low Normal • 6-10 High Normal• 11-12 Mild Excessive• 13-15 Moderate Excessive • 16-24 Severe Excessive
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Epworth Sleepiness Scale• measure daytime sleepiness• The questionnaire asks the subject to rate
his or her probability of falling asleep on a scale of increasing probability from 0 to 3 for eight different situations that most people engage in during their daily lives, though not necessarily every day.
• The scores for the eight questions are added together to obtain a single number.
• 0-5 Low Normal • 6-10 High Normal• 11-12 Mild Excessive• 13-15 Moderate Excessive • 16-24 Severe Excessive
Epworth Sleepiness Scale• measure daytime sleepiness• The questionnaire asks the subject to rate
his or her probability of falling asleep on a scale of increasing probability from 0 to 3 for eight different situations that most people engage in during their daily lives, though not necessarily every day.
• The scores for the eight questions are added together to obtain a single number.
• 0-5 Low Normal • 6-10 High Normal• 11-12 Mild Excessive• 13-15 Moderate Excessive • 16-24 Severe Excessive
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Epworth Sleepiness Scale• measure daytime sleepiness• The questionnaire asks the subject to rate
his or her probability of falling asleep on a scale of increasing probability from 0 to 3 for eight different situations that most people engage in during their daily lives, though not necessarily every day.
• The scores for the eight questions are added together to obtain a single number.
• 0-5 Low Normal • 6-10 High Normal• 11-12 Mild Excessive• 13-15 Moderate Excessive • 16-24 Severe Excessive
Epworth Sleepiness Scale• measure daytime sleepiness• The questionnaire asks the subject to rate
his or her probability of falling asleep on a scale of increasing probability from 0 to 3 for eight different situations that most people engage in during their daily lives, though not necessarily every day.
• The scores for the eight questions are added together to obtain a single number.
• 0-5 Low Normal • 6-10 High Normal• 11-12 Mild Excessive• 13-15 Moderate Excessive • 16-24 Severe Excessive
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Epworth Sleepiness Scale• measure daytime sleepiness• The questionnaire asks the subject to rate
his or her probability of falling asleep on a scale of increasing probability from 0 to 3 for eight different situations that most people engage in during their daily lives, though not necessarily every day.
• The scores for the eight questions are added together to obtain a single number.
• 0-5 Low Normal • 6-10 High Normal• 11-12 Mild Excessive• 13-15 Moderate Excessive • 16-24 Severe Excessive
Epworth Sleepiness Scale• measure daytime sleepiness• The questionnaire asks the subject to rate
his or her probability of falling asleep on a scale of increasing probability from 0 to 3 for eight different situations that most people engage in during their daily lives, though not necessarily every day.
• The scores for the eight questions are added together to obtain a single number.
• 0-5 Low Normal • 6-10 High Normal• 11-12 Mild Excessive• 13-15 Moderate Excessive • 16-24 Severe Excessive
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Epworth Sleepiness Scale• measure daytime sleepiness• The questionnaire asks the subject to rate
his or her probability of falling asleep on a scale of increasing probability from 0 to 3 for eight different situations that most people engage in during their daily lives, though not necessarily every day.
• The scores for the eight questions are added together to obtain a single number.
• 0-5 Low Normal • 6-10 High Normal• 11-12 Mild Excessive• 13-15 Moderate Excessive • 16-24 Severe Excessive
Epworth Sleepiness Scale• measure daytime sleepiness• The questionnaire asks the subject to rate
his or her probability of falling asleep on a scale of increasing probability from 0 to 3 for eight different situations that most people engage in during their daily lives, though not necessarily every day.
• The scores for the eight questions are added together to obtain a single number.
• 0-5 Low Normal • 6-10 High Normal• 11-12 Mild Excessive• 13-15 Moderate Excessive • 16-24 Severe Excessive
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SBQ-R• self-report questionnaire designed to
identify risk factors for suicide• unlike some other tools commonly
used for suicidality assessment, it asks about future anticipation of suicidal thoughts or behaviors as well as past and present ones and includes a question about lifetime suicidal ideation, plans to commit suicide, and actual attempts
• A total score of 7 and higher in the general population and a total score of 8 and higher in patients with psychiatric disorders indicates significant risk of suicidal behavior
SBQ-R• self-report questionnaire designed to
identify risk factors for suicide• unlike some other tools commonly
used for suicidality assessment, it asks about future anticipation of suicidal thoughts or behaviors as well as past and present ones and includes a question about lifetime suicidal ideation, plans to commit suicide, and actual attempts
• A total score of 7 and higher in the general population and a total score of 8 and higher in patients with psychiatric disorders indicates significant risk of suicidal behavior
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SBQ-R• self-report questionnaire designed to
identify risk factors for suicide• unlike some other tools commonly
used for suicidality assessment, it asks about future anticipation of suicidal thoughts or behaviors as well as past and present ones and includes a question about lifetime suicidal ideation, plans to commit suicide, and actual attempts
• A total score of 7 and higher in the general population and a total score of 8 and higher in patients with psychiatric disorders indicates significant risk of suicidal behavior
SBQ-R• self-report questionnaire designed to
identify risk factors for suicide• unlike some other tools commonly
used for suicidality assessment, it asks about future anticipation of suicidal thoughts or behaviors as well as past and present ones and includes a question about lifetime suicidal ideation, plans to commit suicide, and actual attempts
• A total score of 7 and higher in the general population and a total score of 8 and higher in patients with psychiatric disorders indicates significant risk of suicidal behavior
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SBQ-R• self-report questionnaire designed to
identify risk factors for suicide• unlike some other tools commonly
used for suicidality assessment, it asks about future anticipation of suicidal thoughts or behaviors as well as past and present ones and includes a question about lifetime suicidal ideation, plans to commit suicide, and actual attempts
• A total score of 7 and higher in the general population and a total score of 8 and higher in patients with psychiatric disorders indicates significant risk of suicidal behavior
SBQ-R• self-report questionnaire designed to
identify risk factors for suicide• unlike some other tools commonly
used for suicidality assessment, it asks about future anticipation of suicidal thoughts or behaviors as well as past and present ones and includes a question about lifetime suicidal ideation, plans to commit suicide, and actual attempts
• A total score of 7 and higher in the general population and a total score of 8 and higher in patients with psychiatric disorders indicates significant risk of suicidal behavior
1
1
2
2
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SBQ-R• self-report questionnaire designed to
identify risk factors for suicide• unlike some other tools commonly
used for suicidality assessment, it asks about future anticipation of suicidal thoughts or behaviors as well as past and present ones and includes a question about lifetime suicidal ideation, plans to commit suicide, and actual attempts
• A total score of 7 and higher in the general population and a total score of 8 and higher in patients with psychiatric disorders indicates significant risk of suicidal behavior
1
1
2
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Trails Making• a neuropsychological test of visual
attention and task switching.• It consists of two parts in which the
subject is instructed to connect a set of 25 dots as quickly as possible while still maintaining accuracy.
• The test can provide information about visual search speed, scanning, speed of processing, mental flexibility, as well as executive functioning
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TIME N Mean Std. Dev Std. Error Mean
MME (Morphine Dose Equivalent)Baseline 78 223.481 169.3987 19.180612 months 78 167.526 133.2202 15.0842
non-opioid adjuvant Baseline 78 5.4 2.665 0.30212 months 78 5.91 3.244 0.367
Hours of good sleep Baseline 78 4.69 1.417 0.1612 months 77 4.61 1.289 0.147
Daily work hoursBaseline 78 5.397 6.8681 0.777712 months 78 5.179 7.3881 0.8365
Disability: FamilyBaseline 78 6.03 2.74 0.3112 months 78 5.9 2.84 0.322
Disability: RecreationBaseline 78 6.55 2.818 0.31912 months 78 6.69 2.732 0.309
Disability: SocialBaseline 78 5.74 3.156 0.35712 months 78 5.92 2.997 0.339
Disability: WorkBaseline 77 6.61 3.253 0.37112 months 78 6.59 3.18 0.36
Disability: SexBaseline 73 5.89 3.828 0.44812 months 74 5.95 3.565 0.414
Disability: Self careBaseline 78 3.86 3.214 0.36412 months 78 3.82 2.846 0.322
Disability: Life supportBaseline 77 2.88 2.842 0.32412 months 77 2.69 2.446 0.279
DepressionBaseline 78 7.41 5.612 0.63512 months 78 8.44 6.303 0.714
AnxietyBaseline 77 5.74 5.384 0.61412 months 78 6.76 6.133 0.694
SleepinessBaseline 78 5.67 4.788 0.54212 months 78 5.79 5.544 0.628
Suicidality: Ever thought/attmpt.Baseline 78 1.74 1.122 0.12712 months 78 1.68 1.122 0.127
Suicidality: Ideation during last yr.Baseline 78 1.31 0.744 0.08412 months 78 1.4 0.827 0.094
Suicidality: Ever told anyoneBaseline 78 1.22 0.573 0.06512 months 78 1.22 0.526 0.06
Suicidality: Likely to attemptBaseline 78 0.79 1.024 0.11612 months 78 0.85 1.163 0.132
Trails test A+B combinedBaseline 78 76.954 38.0056 4.303312 months 78 77.062 39.8416 4.5112
TIME N Mean Std. Dev Std. Error Mean
MME (Morphine Dose Equivalent)Baseline 78 223.481 169.3987 19.180612 months 78 167.526 133.2202 15.0842
non-opioid adjuvant Baseline 78 5.4 2.665 0.30212 months 78 5.91 3.244 0.367
Hours of good sleep Baseline 78 4.69 1.417 0.1612 months 77 4.61 1.289 0.147
Daily work hoursBaseline 78 5.397 6.8681 0.777712 months 78 5.179 7.3881 0.8365
Disability: FamilyBaseline 78 6.03 2.74 0.3112 months 78 5.9 2.84 0.322
Disability: RecreationBaseline 78 6.55 2.818 0.31912 months 78 6.69 2.732 0.309
Disability: SocialBaseline 78 5.74 3.156 0.35712 months 78 5.92 2.997 0.339
Disability: WorkBaseline 77 6.61 3.253 0.37112 months 78 6.59 3.18 0.36
Disability: SexBaseline 73 5.89 3.828 0.44812 months 74 5.95 3.565 0.414
Disability: Self careBaseline 78 3.86 3.214 0.36412 months 78 3.82 2.846 0.322
Disability: Life supportBaseline 77 2.88 2.842 0.32412 months 77 2.69 2.446 0.279
DepressionBaseline 78 7.41 5.612 0.63512 months 78 8.44 6.303 0.714
AnxietyBaseline 77 5.74 5.384 0.61412 months 78 6.76 6.133 0.694
SleepinessBaseline 78 5.67 4.788 0.54212 months 78 5.79 5.544 0.628
Suicidality: Ever thought/attmpt.Baseline 78 1.74 1.122 0.12712 months 78 1.68 1.122 0.127
Suicidality: Ideation during last yr.Baseline 78 1.31 0.744 0.08412 months 78 1.4 0.827 0.094
Suicidality: Ever told anyoneBaseline 78 1.22 0.573 0.06512 months 78 1.22 0.526 0.06
Suicidality: Likely to attemptBaseline 78 0.79 1.024 0.11612 months 78 0.85 1.163 0.132
Trails test A+B combinedBaseline 78 76.954 38.0056 4.303312 months 78 77.062 39.8416 4.5112
Small changes in various factors noted but no statistically significant changes…
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TIME N Mean Std. Dev Std. Error Mean
MME (Morphine Dose Equivalent)Baseline 78 223.481 169.3987 19.180612 months 78 167.526 133.2202 15.0842
non-opioid adjuvant Baseline 78 5.4 2.665 0.30212 months 78 5.91 3.244 0.367
Hours of good sleep Baseline 78 4.69 1.417 0.1612 months 77 4.61 1.289 0.147
Daily work hoursBaseline 78 5.397 6.8681 0.777712 months 78 5.179 7.3881 0.8365
Disability: FamilyBaseline 78 6.03 2.74 0.3112 months 78 5.9 2.84 0.322
Disability: RecreationBaseline 78 6.55 2.818 0.31912 months 78 6.69 2.732 0.309
Disability: SocialBaseline 78 5.74 3.156 0.35712 months 78 5.92 2.997 0.339
Disability: WorkBaseline 77 6.61 3.253 0.37112 months 78 6.59 3.18 0.36
Disability: SexBaseline 73 5.89 3.828 0.44812 months 74 5.95 3.565 0.414
Disability: Self careBaseline 78 3.86 3.214 0.36412 months 78 3.82 2.846 0.322
Disability: Life supportBaseline 77 2.88 2.842 0.32412 months 77 2.69 2.446 0.279
DepressionBaseline 78 7.41 5.612 0.63512 months 78 8.44 6.303 0.714
AnxietyBaseline 77 5.74 5.384 0.61412 months 78 6.76 6.133 0.694
SleepinessBaseline 78 5.67 4.788 0.54212 months 78 5.79 5.544 0.628
Suicidality: Ever thought/attmpt.Baseline 78 1.74 1.122 0.12712 months 78 1.68 1.122 0.127
Suicidality: Ideation during last yr.Baseline 78 1.31 0.744 0.08412 months 78 1.4 0.827 0.094
Suicidality: Ever told anyoneBaseline 78 1.22 0.573 0.06512 months 78 1.22 0.526 0.06
Suicidality: Likely to attemptBaseline 78 0.79 1.024 0.11612 months 78 0.85 1.163 0.132
Trails test A+B combinedBaseline 78 76.954 38.0056 4.303312 months 78 77.062 39.8416 4.5112
Small changes in various factors noted but no statistically significant changes…
With one exception
TIME N Mean Std. Dev Std. Error Mean
MME (Morphine Dose Equivalent)Baseline 78 223.481 169.3987 19.180612 months 78 167.526 133.2202 15.0842
non-opioid adjuvant Baseline 78 5.4 2.665 0.30212 months 78 5.91 3.244 0.367
Hours of good sleep Baseline 78 4.69 1.417 0.1612 months 77 4.61 1.289 0.147
Daily work hoursBaseline 78 5.397 6.8681 0.777712 months 78 5.179 7.3881 0.8365
Disability: FamilyBaseline 78 6.03 2.74 0.3112 months 78 5.9 2.84 0.322
Disability: RecreationBaseline 78 6.55 2.818 0.31912 months 78 6.69 2.732 0.309
Disability: SocialBaseline 78 5.74 3.156 0.35712 months 78 5.92 2.997 0.339
Disability: WorkBaseline 77 6.61 3.253 0.37112 months 78 6.59 3.18 0.36
Disability: SexBaseline 73 5.89 3.828 0.44812 months 74 5.95 3.565 0.414
Disability: Self careBaseline 78 3.86 3.214 0.36412 months 78 3.82 2.846 0.322
Disability: Life supportBaseline 77 2.88 2.842 0.32412 months 77 2.69 2.446 0.279
DepressionBaseline 78 7.41 5.612 0.63512 months 78 8.44 6.303 0.714
AnxietyBaseline 77 5.74 5.384 0.61412 months 78 6.76 6.133 0.694
SleepinessBaseline 78 5.67 4.788 0.54212 months 78 5.79 5.544 0.628
Suicidality: Ever thought/attmpt.Baseline 78 1.74 1.122 0.12712 months 78 1.68 1.122 0.127
Suicidality: Ideation during last yr.Baseline 78 1.31 0.744 0.08412 months 78 1.4 0.827 0.094
Suicidality: Ever told anyoneBaseline 78 1.22 0.573 0.06512 months 78 1.22 0.526 0.06
Suicidality: Likely to attemptBaseline 78 0.79 1.024 0.11612 months 78 0.85 1.163 0.132
Trails test A+B combinedBaseline 78 76.954 38.0056 4.303312 months 78 77.062 39.8416 4.5112
Small changes in various factors noted but no statistically significant changes…
With one exception
Morphine Milligram
Equivalents
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TIME N Mean Std. Dev Std. Error Mean
MME (Morphine Dose Equivalent)Baseline 78 223.481 169.3987 19.180612 months 78 167.526 133.2202 15.0842
non-opioid adjuvant Baseline 78 5.4 2.665 0.30212 months 78 5.91 3.244 0.367
Hours of good sleep Baseline 78 4.69 1.417 0.1612 months 77 4.61 1.289 0.147
Daily work hoursBaseline 78 5.397 6.8681 0.777712 months 78 5.179 7.3881 0.8365
Disability: FamilyBaseline 78 6.03 2.74 0.3112 months 78 5.9 2.84 0.322
Disability: RecreationBaseline 78 6.55 2.818 0.31912 months 78 6.69 2.732 0.309
Disability: SocialBaseline 78 5.74 3.156 0.35712 months 78 5.92 2.997 0.339
Disability: WorkBaseline 77 6.61 3.253 0.37112 months 78 6.59 3.18 0.36
Disability: SexBaseline 73 5.89 3.828 0.44812 months 74 5.95 3.565 0.414
Disability: Self careBaseline 78 3.86 3.214 0.36412 months 78 3.82 2.846 0.322
Disability: Life supportBaseline 77 2.88 2.842 0.32412 months 77 2.69 2.446 0.279
DepressionBaseline 78 7.41 5.612 0.63512 months 78 8.44 6.303 0.714
AnxietyBaseline 77 5.74 5.384 0.61412 months 78 6.76 6.133 0.694
SleepinessBaseline 78 5.67 4.788 0.54212 months 78 5.79 5.544 0.628
Suicidality: Ever thought/attmpt.Baseline 78 1.74 1.122 0.12712 months 78 1.68 1.122 0.127
Suicidality: Ideation during last yr.Baseline 78 1.31 0.744 0.08412 months 78 1.4 0.827 0.094
Suicidality: Ever told anyoneBaseline 78 1.22 0.573 0.06512 months 78 1.22 0.526 0.06
Suicidality: Likely to attemptBaseline 78 0.79 1.024 0.11612 months 78 0.85 1.163 0.132
Trails test A+B combinedBaseline 78 76.954 38.0056 4.303312 months 78 77.062 39.8416 4.5112
Small changes in various factors noted but no statistically significant changes…
With one exception
Morphine Milligram
Equivalents
From 223.5To 167.5
TIME N Mean Std. Dev Std. Error Mean
MME (Morphine Dose Equivalent)Baseline 78 223.481 169.3987 19.180612 months 78 167.526 133.2202 15.0842
non-opioid adjuvant Baseline 78 5.4 2.665 0.30212 months 78 5.91 3.244 0.367
Hours of good sleep Baseline 78 4.69 1.417 0.1612 months 77 4.61 1.289 0.147
Daily work hoursBaseline 78 5.397 6.8681 0.777712 months 78 5.179 7.3881 0.8365
Disability: FamilyBaseline 78 6.03 2.74 0.3112 months 78 5.9 2.84 0.322
Disability: RecreationBaseline 78 6.55 2.818 0.31912 months 78 6.69 2.732 0.309
Disability: SocialBaseline 78 5.74 3.156 0.35712 months 78 5.92 2.997 0.339
Disability: WorkBaseline 77 6.61 3.253 0.37112 months 78 6.59 3.18 0.36
Disability: SexBaseline 73 5.89 3.828 0.44812 months 74 5.95 3.565 0.414
Disability: Self careBaseline 78 3.86 3.214 0.36412 months 78 3.82 2.846 0.322
Disability: Life supportBaseline 77 2.88 2.842 0.32412 months 77 2.69 2.446 0.279
DepressionBaseline 78 7.41 5.612 0.63512 months 78 8.44 6.303 0.714
AnxietyBaseline 77 5.74 5.384 0.61412 months 78 6.76 6.133 0.694
SleepinessBaseline 78 5.67 4.788 0.54212 months 78 5.79 5.544 0.628
Suicidality: Ever thought/attmpt.Baseline 78 1.74 1.122 0.12712 months 78 1.68 1.122 0.127
Suicidality: Ideation during last yr.Baseline 78 1.31 0.744 0.08412 months 78 1.4 0.827 0.094
Suicidality: Ever told anyoneBaseline 78 1.22 0.573 0.06512 months 78 1.22 0.526 0.06
Suicidality: Likely to attemptBaseline 78 0.79 1.024 0.11612 months 78 0.85 1.163 0.132
Trails test A+B combinedBaseline 78 76.954 38.0056 4.303312 months 78 77.062 39.8416 4.5112
Small changes in various factors noted but no statistically significant changes…
With one exception
Morphine Milligram
Equivalents
From 223.5To 167.5
25%
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Functional Correlates of DelibarateOpioid Dose Reduction: Anxiety,
Constipation, Depression, Nausea, Pain, Sleep Quality, Suicidality, and
others.
• Results:• Baseline opioid dose correlated at statistically significant levels with self reported pain level,
exercise, hours of sleep, disability measures including family activities, recreation, social, self care, and life support-related activities, anxiety, and depression.
• However there were no significant changes in any of these values with the 25% overall opiate dose reduction in these patients.
Functional Correlates of Deliberate Opioid Dose Reduction: Anxiety,
Constipation, Depression, Nausea, Pain, Sleep Quality, Suicidality, and
others.
• Conclusions:• Opiate dose reduction did not increase measures of pain, anxiety, depression, social disability,
family involvement, recreation, sleep quality, self care, or cognative testing performance. • Continued monitoring of these factors while assisting with further reduction in opiate daily dose
and evaluation of trends appears appropriate.
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