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B.16 PHARMACY/PRESCRIPTIONS

PURPOSE

To maintain adequate communication between the Pharmacy and Dental Department.
PROCEDURE

When it is determined by a dentist that a patient will require medication prior to or after treatment, a prescription shall be written on [appropriate form] and transported by [mechanism] to the pharmacy. The pharmacists will notify patients when the prescription is filled.

The prescription shall be written in standard form in the outpatient notes or on the dental progress notes.

Prescriptions shall be written utilizing medications available through the pharmacy and on the formulary.

Prescriptions placed by phone to private pharmacies may occasionally be necessary. It will be the duty of the treating dentist to call the pharmacy chosen by the patient in the event this becomes a necessary course of action. Consultation with the Chief Pharmacist for the use of a DEA number will be the responsibility of the treating dentist.



B.17 DENTAL PAIN MANAGEMENT
PURPOSE.
The purpose of this document is to establish a policy for a Pain Management Program for the [Facility] Dental Program.
BACKGROUND.
Pain is a common part of the dental patient experience. There is a growing body of evidence that unrelieved pain carries with it great physiological and psychological risks, including increased metabolic rate, blood clotting, water retention, impaired immune function, anxiety, depression, loss of hope, and even suicide. Aggressive pain prevention and control can yield both short and long term benefits.
Control of orofacial pain is not only a moral responsibility of the dental provider, but it is also a national priority within the DHHS. One strategy that has been used to assure optimal pain management is to develop formal means within dental programs to evaluate pain management practices and work to continuously improve outcomes.



        1. Each [Facility] Dental Program will develop a pain management policy that will include as a minimum, the following:




  1. Philosophy of Care and Patient’s Rights for pain management and palliative care. If possible, this should be incorporated within the Patient Bill of Rights in each clinic, or if not incorporated, should be posted in a flyer in a conspicuous location in the dental clinic. (Exhibit 1)




  1. An ad-hoc Pain Management Committee with an interdisciplinary approach to pain management utilizing non-pharmaceutical and pharmaceutical therapies should be developed for each [Facility] dental program. This may be a part of the Medical Staff bylaws and include all medical staff, but at a minimum under the auspices of a dental pain management plan, the committee should consist of the dental chief, the clinic pharmacist, the clinic Medical Director, and a patient advocate that may or may not be a staff member (but should not be a medical provider). This committee should meet at least on a quarterly basis to discuss (from a dental perspective) current pain management issues on patients.




  1. A mechanism to document that dental staff review of the efficacy of treatment. This may range from noting the patient’s perceptions of pain management on the dental progress note to a more formal inquiry through a referral to another clinical provider.




  1. Drug formulary appropriate for pain management and treatment of drug side effects. (Exhibit 2)




  1. Identification of non-pharmaceutical and environmental therapies. (Exhibit 3)




  1. Patient educational tools and sources for community resources for referrals. (Exhibit 4)




  1. Identification of resources for assessment and management of addiction. (Exhibit 4)




  1. Quality monitoring tools to evaluate the appropriateness and effectiveness of pain management. These may include: patient satisfaction, drug usage, length of therapy, and impact on quality of life, etc. (Exhibit 5)




  1. Orientation plan for dental and other providers.




        1. Each [Facility] Dental Program will develop policies and procedures that address, as needed depending on services provided, safe medication prescriptions.


DEFINITIONS (IHS).
Pain: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”
Acute Pain: Acute pain is “the normal, predicted physiological response to an adverse chemical, thermal, or mechanical stimulus and is associated with surgery, trauma, and acute illness.” It is generally time-limited and responsive to pharmacotherapy or direct dental intervention. Examples in a dental setting where a patient may experience acute pain include, but are not limited to: severe orofacial trauma, vital tooth fracture, irreversible pulpitis with or without hyperemia, acute apical abscesses, or severe dental caries.

Chronic Pain: “A pain state which is persistent (more a month) and in which the cause of the pain cannot be removed or otherwise treated.” Chronic pain may be associated with a long-term, incurable, or intractable medical conditions or diseases, or, in a dental setting, a chronic periodontal or pulpal infection, rampant tooth decay, or dentinal hypersensitivity (not all inclusive).
Palliative Care: “An interdisciplinary approach to the study and care of patients with active, progressive, far advanced disease for whom the prognosis is limited and the focus of care is quality of life” (medical definition). In a dental setting, palliative care is offered to patients for whom the tooth condition is not easily diagnosed (e.g., cracked tooth syndrome), the condition may be reversible (e.g., pulpitis), or time to complete care is a limiting factor (e.g., walk-in patients). Examples of palliative care offered in a dental setting include the placement of a temporary or intermediate restorative material (pulpitis), root canal access (pulpitis), emergency extraction (acute infection, fractured root, etc.), or the prescribing of appropriate pharmacotherapies (for chronic infections or for pain relief).
Physical Dependence: “Physical dependence on a controlled substance is a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. Physical dependence is expected with extended use of opioids and, by itself, does not equate with addiction.” In a dental setting, many of our patients may be on long-term pain management plans through their primary health care provider, and this may affect the efficacy of dental analgesic/anesthesia therapies.
Addiction: “A primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.” In a dental setting, it is important to not single-handedly make a diagnosis of “addiction” without first consulting the patient’s primary health care provider; some patients returning unexpectedly for additional analgesics or stronger medications may in fact be suffering from tolerance (see below) or pseudo-addiction (see below).
Tolerance: “Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time. This may include the need to increase the dose of an opioid to achieve the same level of analgesia. Such tolerance may or may not be evident during opioid treatment and does not equate with addiction.”
Pseudoaddiction: “Pattern of drug-seeking behavior of pain patients who are receiving inadequate pain management that can be mistaken for addiction.” This is a primary consideration of all dental providers, as often dental providers attribute a patient seeking additional analgesics to addiction.
Substance Abuse: “Substance abuse is a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances. It may include the use of any substance(s) for non-therapeutic purposes or use of medication for purposes other than those for which it is prescribed.” Signs of substance abuse in a dental setting may be demonstrated either through controlled analgesics or illegal drugs, and the dental care provider must recognize the signs of substance abuse and collaborate with other clinic health providers, mental health professionals, pharmacists, or substance abuse counselors if they perceive a problem (methamphetamine use, for example, creates the clinical “meth mouth” appearance, and other illicit drugs also have definitive clinical manifestations in the mouth).


PROCEDURE
The [Facility] Dental Program will promote and provide a standardized approach to the patient with pain that emphasizes a non-judgmental, multi-modal and individualized treatment plan. Such plans should increase access to known therapies, improve continuity of care, maximize communication and education for the relief of acute and chronic pain in all stages of a person’s life. Specifically, each dental program will consider the following guidelines in developing their pain management programs:


  1. Initial assessment and regular reassessment of pain. Pain screening and evaluation will be part of all dental patient encounters. When patient screening indicates the presence of pain, the patient’s self-report of the level of pain will be assessed (scale of 1-10 on the Dental Medical History Form). When pain is identified, the patient can be treated within the clinic or referred for treatment, depending on the professional judgment of the dental provider. The scope of treatment in a dental setting is based on a variety of factors - the setting, the services available, time available, staffing available. At a minimum, the dental provider should assess pain intensity and quality (for example, pain character, frequency, location, duration), based on both patient self-reporting and clinical measurements. An addiction history and/or assessment will be performed as indicated. Addiction is not a contraindication to treatment for pain, but can be a co-occurring condition that warrants medical attention. The potential for diversion of controlled substances will not preclude their use but instead will mandate responsible and responsive health care. When assessing pain, the dental provider may perform a variety of clinical tests such as electric pulp testing (EPT), cold response (Endo-Ice), percussion sensitivity, palpation of the affected region, or, in some cases, access with a dental handpiece.




  1. Patient involvement in care decisions in order to facilitate effective management of the pain. Patient and provider must enter into a therapeutic alliance with mutual consent when pain is identified. Once a pattern of pain has been co-documented by the patient and provider, the standardized process for assessment and interdisciplinary treatment will be implemented and followed with documented evaluations for outcomes of relief of pain and improvement of functions.




  1. Education of patients, and families when appropriate, regarding risks and benefits and limitations of chosen pain relief modalities. Education of patients and families about their roles in effective pain management as well as side effects of pain treatment.




  1. Discussion about community and traditional beliefs and practices regarding pain, medication, and disability should be sought and respected by health care providers and administrators.




  1. Education of relevant practitioners in pain assessment and management.


RESPONSIBILITIES


  1. [Facility] Dental Chief – will provide guidelines to [Facility] dental programs, and provide orientation to new dental staff.




  1. Clinic Dental Chief – will post pain policies in the clinic, train dental staff, and implement policies and procedures in collaboration with each clinic’s policies and the [Facility] dental policies.




              1. The Dental Clinic Chief is responsible for the overall implementation and monitoring of the Pain Management/Palliative Care Program. Annual performance improvement reports documenting the on-going data collection and assessment process with impact of data analysis on improved outcomes will be prepared as part of each clinic’s reports to the [Facility] dental chief.




              1. The Dental Clinic Chief is responsible for the formation of an interdisciplinary pain management/palliative care team that will develop the required [Facility] policy/procedures. The interdisciplinary team, at a minimum, will include a Medical Director of the facility, the pharmacist, the dental chief, and a patient advocate appointed by the clinic dental chief (may be a non-medical staff member).


REFERENCES. Public Law 94-437; Health Care Improvement Act; Joint Commission of Accreditation of Healthcare Organizations Home Care/Hospice/Hospital/Ambulatory Care Standards; Patient Self Determination Act 1990; CFR 21-Food and Drugs – Volume 9, Part 1306 – Prescriptions; Model Guidelines for the Use of Controlled Substances for the Treatment of Pain; Federation of State Medical Boards of the U.S., Inc. 1998; American Academy of Pain Management; American Pain Society; American Society of Addiction Medicine, 2001; Billings Area Pain Management/Palliative Medicine Program, Chronic Pain Management Strategies, both available at www.ihs.gov.


(This item is optional. All policies may be updated and authorized on the Title page, or on each individual policy)
EFFECTIVE DATE. This policy is effective upon date of signature of the [Facility] dental chief, and shall remain in effect until cancelled or superseded.
SSU Dental Chief: ______________________________________ Date: _____________
Reviewed by:

(1) SSU Clinical Director: ____________________________ Date: _____________


(2) SSU Chief Pharmacist: ____________________________ Date: _____________
(3) SSU CEO: ______________________________________ Date: _____________
(4) AAAHC Representative: ___________________________ Date: _____________
EXHIBITS.

Exhibit 1 – philosophy of care/bill of rights

Regarding dental pain management
This patient Bill of Rights may be used in conjunction with each clinic’s published Bill of Rights, and should be posted in the dental clinic.
*************** YOUR RIGHTS AS A PATIENT ***************
1. You have the right to appropriate assessment and management of orofacial pain.
2. You have the right to be treated as an individual with respect, concern, and dignity.
3. You have the right to uphold your cultural, psychosocial, spiritual, and ethical beliefs as these pertain to your state of health, your perception of your illness or injury, and to the health care provided, including medications prescribed by your dental provider.
4. You have the right to understand the nature of your illness, prognosis, the effects of the treatment, including full and prompt disclosure of adverse or unexpected outcomes to treatment, to ask for a second medical opinion concerning your state of illness and the type of treatment that is required and the risks involved. This means that you have the right to understand why medication is being prescribed for you.
5. You have the right to make a decision concerning your condition after you have been given the following under the informed consent clause (approval to do certain procedures/treatments):
a. Complete information on the nature of your illness, treatments, alternatives, and the risks involved;

b. The effects of the treatments/procedures as they may restrict you from normal activity;


c. The name and qualification of the clinical provider performing the treatment;
6. You have the right to refuse treatment to the extent permitted by law, and to be informed of the risks involved in so doing.
7. You have the right to confidentiality, privacy, and security of your medical record and all other individually identifiable health information, including medications prescribed for your dental condition. You, or your legally designated representative, have the right to access information contained in your medical record, within limits of the law.
8. You have the right to know certain policies and protocols exist that apply to the identification of perceived painkiller addiction or tolerance, and that the dental provider may request additional resources from other providers to better be able to manage your orofacial pain.

9. You have the right to have your designee (you guardian, next of kin, or legally authorized responsible person) exercise, to the extent permitted by law, your rights if you have been judged incompetent in accordance with law, have been found by your physician to be medically incapable of understanding the proposed treatment or procedure or make a treatment decision, are unable to communicate your wishes regarding treatment, or are a non-emancipated minor.



*************** YOUR RESPONSIBILITIES ***************
In addition to your rights, you have certain responsibilities as a patient to contribute to your oral health care at the clinic. These responsibilities include:
1. Provide accurate and complete information about present complaints, past medical history, any medications you are or were taking, and other health matters as requested by the clinical provider, to the best of your knowledge.
2. Be compliant with the care plan and treatment recommended by the clinical provider, and agreed upon by you at the time of treatment.
3. Be responsible for your actions if you refuse treatment or are non-compliant with your care plan.
4. Make and keep your appointments.
5. Be ultimately responsible for your own health by taking necessary preventive steps, complying with medical treatment, and participating fully in your treatment plan.
6. Tell the dentist or dental staff if you have concerns about the management of your dental pain so that effective changes can be made if possible.
This dental facility is committed to providing you and your family with quality oral health care in a relaxed, respectful, and professional atmosphere. We believe that you and your health care provider are equal partners in your health care and that a favorable outcome can best be achieved by you fully participating in all aspects of your health care.

Exhibit 2 – dental pain pharmaceutical protocol
The following is the analgesic protocol for the [Facility] Dental Program. This protocol is only a recommendation, as it is the responsibility of the treating dentist to use his or her professional experience and the specific patient experience to determine the best course of therapy for that patient; it is inaccurate to assume that each and every patient should receive the same analgesics for the same dental condition. Each clinic is encouraged to devise a pain management plan customized to their clinical setting and patient population.
Procedure Most common analgesic prescribed Other analgesic modalities
Simple extraction Ibuprofen, 600mg, 20-30 tabs Tylenol #3, Vicodin 5/500

(ADA Code 7140) Acetominophen, 325mg, <30


Surgical extraction Ibuprofen, 600mg, 20-30 tabs + Vicodin 5/500

(ADA Code 7210) Tylenol #3, 12-20 tabs Acetominophen, 325mg, <30


Restorations-multiple Ibuprofen, 600 mg, 10-20 tabs Acetominophen, 325, 10-20

(ADA Codes 2100)


Pulpitis-reversible Ibuprofen, 600 mg, 10-20 tabs + Acetominophen, 325, 10-20

Dental therapy (IRM, Fl-, desensitizer)


Pulpitis-irreversible Ibuprofen, 600mg, 20-30 tabs + Vicodin 5/500

Or Abscess Tylenol #3, 12-20 tabs Acetominophen, 325mg, <30


TMJD Ibuprofen, 600mg, 20-30 tabs or more Steroid therapy (through

+ Dental therapy (splint, manipulation) medical department)


Tooth fracture Ibuprofen, 600mg, 20-30 tabs or more + Vicodin 5/500

Tylenol #3, 12-20 tabs + Acetominophen, 325mg, <30

Dental therapy (extraction, restoration)
Endodontic therapy Tylenol #3, 12-20 tabs Vicodin 5/500

(ADA Codes 3200) Acetominophen, 325mg, <30



Other potential pharmaceutical therapies for the relief of orofacial pain include Darvocet N-50 and N-100, Ultram 50-100 mg, and Percocet (for multiple extractions or large abscesses; however, as a Schedule II controlled substance, Percocet should rarely be used in a dental setting).
Again, the above guidelines are only recommendations, as each provider has the autonomy to prescribe appropriate pharmaceutical therapies based on the level of pain, etc.

Exhibit 3 – non-pharmaceutical dental therapies
The following non-pharmaceutical dental therapies are available from [Facility] Dental Clinics for pain management (most actually include a pharmaceutical component, but do require a pharmacy prescription alone, although the dentist may combine “pharmaceutical” and “non-pharmaceutical” therapies for effective pain management):


      1. Endodontic access – where pulpitis exists, the dentist has deemed the tooth salvageable, and the patient desires to save the tooth, the dentist may access the tooth pulp and remove the major dental nerves to the tooth, usually under local anesthesia. Limiting factors for this treatment option include time (usually more than 15 minutes is required to perform this procedure), diagnosis (irreversible pulpitis or necrosis/abscess), patient desires (to save tooth), medical condition (if a patient requires SBE prophylaxis prior to dental work, this procedure may not be done on a walk-in basis), staffing (a dental assistant and dentist must be present), and informed consent (the patient, if over age 18, or if under 18, the parent or LEGAL guardian must consent to the treatment).




      1. Intermediate Restorative Material (IRM) – where pulpitis exists, but the dentist is unable to determine if it is reversible or irreversible, an IRM may be placed on the tooth with or without local anesthesia. Limiting factors for this treatment option include time (usually more than 10 minutes is required), diagnosis (reversible pulpitis), patient desires (to save tooth), medical condition (if anesthesia is to be done, and the patient requires SBE prophylaxis), staffing (a dentist must be present to diagnose the condition), availability of the material (IRM), and informed consent (see above).




      1. Extraction – where pulpitis, necrosis/abscess, or severe periodontal disease is diagnosed, the dentist may extract the affected tooth to manage the patient’s pain. However, limiting factors for this treatment option include time (usually more than 15 minutes is required to extract a tooth), patient desires (to remove tooth), medical condition (see above), staffing (a dentist and dental assistant must be present), and informed consent (see above). In most [Facility] dental clinics, extractions are not usually the treatment of choice for dental walk-ins due to the time constraint.




      1. Anesthesia – one short-term pain management is through the delivery of anesthesia to the affected site, although this is usually used in conjunction with another treatment modality.




      1. Temporo-mandibular joint manipulation – if pain is present in the TMJ, the dentist may either physically manipulate the TMJ or massage gently available muscles of mastication (temporalis, masseter, etc.). This may be combined with pharmaceutical therapy or may in itself relieve the patient’s pain.




      1. Occlusal adjustment – if pain is present due to bruxism or occlusal trauma, the dentist may adjust the occlusion with a dental handpiece for effective pain management.




      1. Denture adjustment – if pain is present in the edentulous patient, the dentist or dental assistant may adjust the patient’s denture, and the dentist may cauterize the ulcerated region of tissue affected by the ill-fitting denture (silver nitrate stick, etc.).




      1. Other – the dentist, through his or her experience, may choose other non-pharmaceutical therapies that effectively manage pain.


Exhibit 4 – community resources ([Facility] Dental program)
Resources that may be available to assist patients with addiction problems:
NAME OF FACILITY CONTACT phone

Substance Abuse Programs:

Other Tribal Resources:
State and Local Resources:

Exhibit 5 – Quality Assurance Tool – Survey
Each clinic is encouraged to periodically monitor patient satisfaction regarding dental policies on pain management. What follows is an example of a simple pain management survey that can be used or modified in order to assess current dental policies. The steps in quality assurance are: (1) identify a problem or issue (pain management); (2) assess the issue (through this survey); (3) discuss the survey and make recommendations for changes (through the Pain Management Committee at the clinic level); (4) implement the recommended changes (in policy or protocol); (5) re-assess the issue (through a follow-up survey instrument); (6) report re-assessment and make further recommendations for changes (through the Pain Management Committee); and so on – the point is that quality assurance in pain management is a continuous process for the dental team.


Instructions to patient: At your last dental visit, we provided you with pain medication or other therapies to relieve your pain. This short survey is designed to help us improve on how we treat pain in the dental office. Your honest and candid responses will help us review our existing policies on pain management for all of our valued patients.

1. At your last dental visit, what type of pain management therapy did the dentist perform? Please check ALL that apply.

□ Pain medication (that you received from the pharmacy)

Temporary filling was placed

□ Tooth was pulled

□ A root canal was started

□ The dentist gave me anesthesia (a shot)

□ The dentist adjusted my teeth or denture

□ Nothing – the dentist did not attempt to relieve my pain


2. When you came into the dental office LAST TIME, how much pain did you have (on a scale from 1-10, with 10 being the highest)? ___ (write a number here)
3. When you left the dental office LAST TIME, how much pain did you have (on a scale from 1-10, with 10 being the highest)? ___ (write a number here)
4. Two to three days after your LAST dental visit, how much pain did you have (on a scale from 1-10, with 10 being the highest)? ___ (write a number here)
5. For the same tooth problem that you had last time, how much pain do you have TODAY (on a scale from 1-10, with 10 being the highest)? ___ (write a number here)

6. Based on your previous experiences with dental pain, how do you think the dental clinic/dentist managed your pain at your LAST VISIT? (Check only one box)

□ Very good, pain was managed

□ Good


□ Okay, about average

□ Not good

□ Poor, pain was not managed
7. What suggestions do you have for the dentist/dental staff regarding dental pain for patients at this clinic? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Answer these questions if you received a prescription for pain medicine at your last dental visit.
8. If you received pain medication at your LAST VISIT, was it enough to handle your pain (were enough pills given)? ___ YES ___ NO ___ NOT SURE
9. If you received pain medication at your LAST VISIT, was it strong enough to handle your pain? ___ YES ___ NO ___ NOT SURE
10. What suggestions do you have regarding the strength and amount of pain medication prescribed by the dentist to patients with dental pain? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Thank you for your participation in this survey. The results from this patient survey will be discussed with our Pain Management Committee, who may make recommendations for improving our pain management plan in the dental office. This survey will NOT affect the quality of care you receive in the dental office and is anonymous. If you wish to specifically discuss this survey or your own pain with your dental provider, however, you are welcome to talk with your dentist about this issue.



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