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Introducing eBytes – CE Dojo’s Microlearning Curriculum

CE Dojo announces it’s microlearning course series eBytes. Each microlearning course is a 15 minute vignette on a topic of clinical relevance in a distilled and concentrated manner.

CE Dojo is an nationally approved AGD PACE provider of continuing education. Microlearners can recieved CE credit for individual courses alone or in combination with other microcourses.

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Clonidine Revisted…Again…

We continuously endorse the use of over-the-counter analgesics (non-opiate multi-modal therapy) such as Advil (Ibuprofen), Aleve (Naproxen), and Tylenol (Acetaminophen) – alone or in combination – for most – if not all dental procedures…including surgery. In fact, we train doctors who participate in our state mandated opiate compliance webinar “Strategies For Acute Pain Management In Dentistry” how to move toward an opiate-free practice to ultimately forego their DEA registration.

There are, however, some exceptions. If, for example, you administer any form of sedation or general anesthesia dropping your DEA registration is a non-starter. But even if you don’t, some dentists may feel they need to retain their DEA permit to afford the ability to prescribe sedative agents like a benzodiazepine for their more anxious patients.

Or do you?

I wrote this brief article and published it on LinkedIn almost 5 years ago. With regard to the need to prescribe sedative agents – without a DEA permit – let me reintroduce all of you to Clonidine – again – for the first time!


10 Reasons An Oral & Maxillofacial Surgeon Should Consider Clonidine A More Routine Premedication For Office Anesthesia

While clinicians should be mindful that many of the peri-operative applications of alpha-2 agonists – like Clonidine – remain off label, there are nevertheless many good reasons to consider it’s prospective use on a more routine basis.

David MH Lambert, DDS – LinkedIn July 10, 2017

Clonidine is an imidazoline alpha-2 adrenergic agonist which was originally approved by the FDA in 1974 (Catapres – BI) as an antihypertensive agent. It’s use was initially limited by reports of Clonidine Withdrawal Syndrome – a symptom complex consisting of hypertension, tachycardia, agitation, and insomnia. However, it’s use has been repurposed resulting in unlabeled uses for ADHD, opiate and alcohol withdrawal, smoking cessation, mania and psychosis, and Tourette Syndrome to name a few. In 2010, extended release Clonidine was approved by the FDA for ADHD. It has also been used as a peri-operative adjuvant for anesthesia.

Here are 10 good reasons to consider the administration of Clonidine more routinely as a premedication for office-based anesthesia:

1) Wide margin of safety

Within the context of peri-operative use of Clonidine, there are few reports of activities consistent with syndromic withdrawal. It is safe and effective with a wide margin-of-safety.

2) Produces anxiolysis & sedation

Activation of alpha-2 receptors in the locus caeruleus – a small neuronal nucleus in the upper part of the brainstem which is responsible for wakefulness – results in sedation and anxiolysis. It is, however, devoid of any the addictive potential so commonly demonstrated by other, more commonly utilized agents, i.e. benzodiazepines.

3) Provides analgesia

Descending neural activity from the locus caeruleus decreases nociceptive input and potentially may produce hyperalgesia in combination with NMDA antagonists (i.e. ketamine) while reducing their untoward neurologic sequelae. 

4) Attenuates sympathoadrenal responses

The native activity of alpha-2 adrenergic agonism is sympatholytic resulting in a blunting of central sympathetic outflow – meaning the “fight-flight” system is down regulated.

6) Prevents shivering

Clonidine is the most widely studied alpha agonist for shivering control. It lowers the threshold for vasoconstriction in a linear dose response and is as effective as meperidine in termination.

7) Effective premedication to address “White Coat Syndrome” in normotensive or otherwise well controlled hypertensive patients.

Because Clonidine produces anxiolysis & sedation in addition to it’s native alpha-2 agonist activities, it is an ideal agent to use for patients with situational anxiety who are otherwise normotensive.

8) Provides another site of action in balanced anesthesia

Balanced anesthesia depends upon the administration of multiple agents with activity at differing loci and mechanisms of action. The advantage of this approach is lower overall dosages of all drugs resulting in greater safety and quicker recovery.

9) Prolongs nerve blockade

A plethora of studies have shown that a2 agonists when employed either alone or in combination with local anesthetics or opiate narcotics are highly effective adjuvants in the treatment of short-term pain.

10) Cardio-protective effects

Alpha-2 agonists have demonstrated efficacy in reducing intra-operative myocardial ischemia and post-operative tachycardia. 

Summary

While clinicians should be mindful that many of the peri-operative applications of alpha-2 agonists – like Clonidine – remain off label, there are many good reasons to consider it’s prospective use on a more routine basis. Though it may occasionally produce hypotension and bradycardia in a younger demographic, these patients often possess enough reserve so as to minimize the cardiovascular impact notwithstanding any appropriate intervention to address same. In an older population, the sedative effects of Clonidine – coupled with it’s native sympatholytic effects – make it the perfect pre-medication for management of situational anxiety in otherwise normotensive patients.

I have used Clonidine – safely – on a routine basis as a pre-medication for office based anesthesia for over 10 years mostly in combination with a weight based dosage of alprazolam. Please feel free to inquire more about the technique.

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Study: Naproxen More Effective Than Hydrocodone-Acetaminophen After Dental Surgery

More evidence that NSAIDs with or without acetaminophen are more effective in alleviating pain in the postoperative dental surgery pain model. A recent study from JBR Clinical research demonstrated some unanticipated findings:

“This study is important because the relative efficacy of these two commonly used pain medications has not been directly compared in a validated acute pain model, furthermore, this study is timely because options for reducing the use of opioids to control postoperative pain are highly desired and can provide clinicians with important alternatives when recommending appropriate analgesics.”

Todd Bertoch MD, CEO JBR Clinical Research

We would love to see a fixed OTC combination of naproxen with acetaminophen – much akin to Advil Dual Action – for the future!

David MH Lambert, DDS

Diplomate, ABOMS

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Opiate Crisis To Triple In Next 7 Years

This past February The Stanford- Lancet Commission on the North American Opioid Crisis released their Executive Summary on the state of the opiate crisis. This position paper reviews the past, the present, the future, and proposes remedies.

From 1999 to 2022 The Commission estimates 600,000 deaths in the US and Canada but projects that in between now and 2029 another 1.2 million deaths will occur. This is to say it is anticipated that the opiate crisis will accelerate over 600% of the baseline rate from 1999 to 2022 within the next 7 years.

The Executive Summary reviews the factors involved in the evolution of the opiate crisis and cites 3 broad remedies:

  • Stricter regulation of the pharmaceutical industry
  • Evidence-based public health policies that treat drug addiction as a chronic condition
  • Prioritization of prevention

In my most recent blog post The More Things Change I discussed an interview with Sam Quinones – author of the definitive evolution of the opiate crisis Dreamland and his recent segue The Least Of Us. In The Least Of Us Quinones chronicles the current status of the opiate crisis in the United States, how the drug cartels have shifted production to fentanyl, why fentanyl will continue to substituted in street heroin, cocaine, and methamphetamine, and why deaths will continue to rise.

As has been stated here and elsewhere, the opioid crisis is really 2 separate entities – the prescription and illicit drug crises. It is well established that prescription drug abuse is a gateway into illicit drug abuse and how greater awareness on the part of licensing boards and doctors has led to sharp declines in the prescribing of opiates for pain control. But today, most of the deaths are due to the abuse of illicit fentanyl. And illicit fentanyl – as stated by Quinones – is the cartel’s drug du jour.

While the Stanford – Lancet Commission on the North American Opioid Crisis predicts a massive increase in opioid related deaths over the next 7 years yet it is uncertain, what is their basis? Clearly, if there is this anticipated explosion of death, likewise there must be an anticipated increased fentanyl supply to meet this “demand”. And the increase in supply must be due to an anticipated increase in the importation of illicit fentanyl across our boarders.

Does the Stanford-Lancet Commission know something about our future southern boarder that the rest of us don’t?

If then the Executive Summary is just a veiled acknowledgement of the anticipated future exploitation of failed border policies then in essence what are proposed are platitudes masquerading as remedies. What is really required is little more honest assessment rather than obfuscation.

There was a time when the medical establishment could be relied upon to be accurate, incisive, insightful, and honest. The Lancet has in the past been known for it’s lack of candor. Perhaps it seeks greater credibility with it’s Stanford affiliation. Either way academics will no doubt applaud the Summary. However, until proper action is taken to stem the flow of illicit fentanyl into the US this whole esteemed exercise is little more than virtue signaling.

David MH Lambert, DDS

Diplomate, ABOMS

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The More Things Change…

Sam Quinones is widely credited for his 2015 book Dreamland as the definitive source for the genesis of the opiate crisis in the United States. His most recent book The Least Of Us details how the opiate crisis has now evolved to the more common abuse of fentanyl and it’s analogues apart from heroin at it’s epicenter.

Here at CE Dojo and in the past as Old Well Consulting, we have painstakingly chronicled the association of opiate abuse and early adolescent exposure to prescription opiates both here on this blog and in our popular webinar Strategies For Acute Pain Management In Dentistry. Unfortunately, Dentistry has been identified in many studies as one of the most frequent prescribers of opiates to this vulnerable age demographic.

Even more unfortunately, I have my own suspicions why Dentistry is being identified. Sam Quinones was recently interviewed by Drug Free NJ about his most recent book but I honestly was startled by a comment he made. When discussing how adolescents and young adults are particularly at risk for opiate addiction the indications for prescription opiate use was raised. Quinones stated at roughly 59 minutes into the webinar…unequivocally that athletic injuries – and wisdom tooth removal (M3) – were the usual culprits.

Did I say “wisdom tooth removal”? I had a hunch…but the 900 lb gorilla in the room just beat his chest.

And you know who this really points to, right? You got it – oral and maxillofacial surgeons (OMS).

I am just the messenger, but I think we (OMS) all need to take very critical stock of what has been stated. M3 removal is part of the core of procedures routinely performed on a daily basis by OMS and it is a strong revenue source for practices all across the country. While there has been much research into evidence based support of elective M3 removal, the question becomes which public health concern (morbidity from delayed M3 removal versus prospective opiate addiction) takes precedence?

I have thought about Mr Quinones statements for over a month now – how can these seemingly competing sets of concerns be best addressed? Here’s what I have concluded:

  • Limiting opiate exposure and use in favor of over-the-counter (OTC) analgesics is obviously key.
  • Using less potent opioids (hydrocodone vs oxycodone) would be supportive.
  • Consider use of liposomal bupivicaine (Exparel) for extended pain control
  • Timing surgery to optimize ease of removal would really seem to be the most important factor to decrease post-operative discomfort and maximize the effectiveness of OTC analgesics.
  • Earlier than ideal surgery to accommodate a referral is frankly unethical and should be discouraged
    • Example – an orthodontist who is uncomfortable with management of serial extractions will need to push removal of M3 necessitating much earlier surgery in addition to lower incisor gingival grafting due to arch expansion.
  • Providing a small quantity of prescription opioid analgesics under direct parental supervision for “rescue” would seem appropriate in some circumstances.

It is up to us (OMS) to be good stewards of responsible opiate prescribing to one of our more common and most vulnerable patient demographics. If we do not take the lead, others will do so for us. Recent events in North Carolina regarding office-based general anesthesia are case-in-point. Continuing “cookie cutter” approaches to patient management should be replaced by individualized care. Referring general practitioners can further help their patients by differentiating and acknowledging preventive versus medically necessary care, and supporting specialty recommendations to defer care to optimize post-operative management in favor of OTC analgesics.

David MH Lambert, DDS

Diplomate, American Board of Oral & Maxillofacial Surgery


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Opiate Epidemic Disproportionately Worsening in High School Age Demographic

A pre-print citation in medRxiv is demonstrating a near 100% increase in opiate related deaths in the high school age demographic (ages 14-18) from 2019 to 2020 alone.  Illicitly manufactured fentanyl once again appears to be the usual suspect.  This study calculated drug overdose deaths by 5 year age groups over the 11 year period from 2010 to 2021 but also compared racial and regional differences . 

American Indian or Alaska Native (AIAN) adolescents, Latinx adolescents, and adolescents in the West census region within the high school age demographic were disproportionately affected, overdose death rates 2.15, 1.31, and 1.68 times the national average in 2021, respectively.  Fatalities involving fentanyl tripled from 2019 to 2020 representing over 3/4 of adolescent overdose deaths in 2021.

These findings again reinforce the premise that adolescents are particularly susceptible to opiate addiction.  While these finding implicate illicitly manufactured fentanyl as the most common cause of death, it cannot be emphasized enough the need for clinicians to reduce exposure to prescription opiates as gateway drugs to street opiates.

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Epic Carelink

In my brief tenure as an academic oral & maxillofacial surgeon and through advanced graduate studies in clinical informatics at Oregon Health & Sciences University, I gained a real working knowledge of the benefits of the EPIC electronic health record (EHR).  

EHR implementation gained heavy momentum during the Obama presidency as the result of the HITECH act which provided among many things financial incentives for health care entities to adopt meaningful use activities.   Meaningful use activities were a set of criteria which brought forth gradual EHR adoption and was promoted through Medicare/Medicaid reimbursement incentives.  The goal of these activities was to make patient data more accessible to doctors and patients themselves, to improve the exchange of information between institutions, to improve insurance integration within health care systems, and to hopefully help decrease the cost of care among many others.

The EPIC EHR system is by far the #1 EHR in the USA, if not the world.  Health care providers within an EPIC care system have unlimited access to patient health care information on a number of different platforms (desktop, mobile) both local and remote.  And anybody these days who has an a relationship with a major healthcare entity as a patient should be well award of the benefits of the patient access portal MyChart.  EPIC even has a dental EHR named “Wisdom”.

But what most dental providers do not realize is that they too can have access to a local or regional health care entity’s EPIC EHR through a resource called EPIC CareLink.  While you cannot add information to the EHR, the benefit is that you can easily lookup a patients entire EHR without having to request records, etc.  Further, if communication is desired between your patients medical providers, you are provided the credentials to exchange information electronically in the EPIC platform through EPIC Mail.

Dental providers should take the opportunity to partake of this highly useful capability.  It’s fast, it’s convenient, and it’s free.  Simply look for CareLink with your nearest neighboring health care institution and fill out the application.  For example, here in North Carolina I could apply for CareLink access through University of North Carolina Healthcare or Duke Healthcare – both are EPIC institutions.  If you are a licensed health care provider, you have a legitimate opportunity to request access.

EPIC CareLink will help you improve the care you provide your patients.  Period. Do it. 

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US Opioid Fatalities Reach Grim Milestone…

Recent CDC reports over 100,000 opiate related deaths (all sources) from April 2020 to April 2021, up 29% from the same prior period; North Carolina saw a 36.9% with Florida falling below the national average with a 26.2% increase in opiate related deaths.

Most opiate related deaths are attributed to illicit opiate abuse and have been on the rise during the COVID pandemic characterized as “deaths of despair”.  However, the lacing of heroin with fentanyl plays a significant role in these deaths with up to 2/3 of all deaths due to illicit heroin use containing fentanyl.

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NC Practitioner Compliance With CSRS

The home/welcome page of the NC Board of Dental Examiners has an interesting post copied from the NC Medical Board’s website. Not too unexpectedly, CSRS is flagging registrants who have been prescribing controlled substances but not reviewing a patient’s CSRS profile. In this post it states:

Administrators of the state-run North Carolina Controlled Substances Reporting System (NC CSRS) recently sent letters to some licensees who may not be checking patient prescription histories as required before prescribing certain medicines.

State law requires that prescribers review a patient’s 12-month prescription history in the NCCSRS before prescribing a Schedule II or Schedule III opioid. The requirement went into effect July 7. The full text of the law that mandates NC CSRS use can be read here. The NC DHHS letters inform prescribers that information about their possible noncompliance has been shared with the appropriate licensing board, which has prompted multiple licensees who believe they have been inappropriately flagged as noncompliant to reach out to NCMB. NCDHHS has provided a report to NCMB and the information is under review. No determinations have been made about how to use the reported information. NCMB is committed to working with NCDHHS to improve this process and will update licensees when it determines what action, if any, to take in response to data provided.

Licensees who believe they have been inappropriately flagged as noncompliant should email NCCSRS at csrs.utilization@dhhs.nc.gov. Please note that the email address included in the NCDHHS letters mailed to prescribers includes a typo that causes messages to bounce back as undeliverable. Learn more about mandatory use of NC CSRS, including exemptions to the requirement, at www.ncmedboard.org/nccsrs.

by NC Medical Board

Dentistry is way far behind other health care domains (medicine, pharmacy, etc) when it comes to adopting a true electronic health record and e-prescribing. Frankly there is no real motivation to do so beyond e-prescribing as compared to the medical domain due to ties with reimbursement. But what most dentists do not appreciate is that much of healthcare now exists in the digital realm and information is exchanged.  This means now we all leave a real digital footprint is – especially when it comes to prescribing controlled substances.  

Though we appreciate inquiries made through CSRS enables practitioners to find out about their patients, we might not appreciate that regulatory entities could gather the same information about us.  In fact, the reporting that can be made through reporting systems like CSRS can be quite robust including the ability to rank providers activities and to find outliers.  This could mean that practitioners whose controlled substance prescribing activities do not fall within certain criteria might otherwise be flagged for further inquiry.

We believe the message is very clear for NC dentists – CSRS will probably be providing similar information to the NCBDE.  So, bring yourself into compliance, and do so now.

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AMA Reports Decreased Opiate Prescribing…Increased Deaths

Consistent with other reports we have made the American Medical Association has released a report showing a 44% decrease in opiate prescribing over the past 10 years with a 6.9% decrease from 2019-2020 alone.  However, at the same time, “deaths of despair” continue to rise as a worsening drug overdose and death epidemic from illicit opiates laced with fentanyl continues to rage in the United States.