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patient population. • Low dose NSAIDs may be used for the shortest possible duration but diclofenac should be avoided due to increased incidence of hepatotoxicity. • If opioid therapy is necessary, consider non-acetaminophen containing opioid medications, such as tramadol, at the lowest effective dose with prolonged dosing intervals. The metabolism of codeine to morphine (active metabolite) is impaired in liver dysfunction, so it should be avoided. • Chlorhexidine gluconate without alcohol should be utilized rather than formulations with alcohol (if indicated). o Severe liver disease (Child-Pugh class C, decompensated cirrhosis with ascites or esophageal varices) • Acetaminophen is the analgesic of choice in this patient population, but the total acetaminophen intake (from all sources) should be limited to 1 gram daily. • NSAIDs should be avoided. 9 • Opioid therapy should be avoided due to risk of adverse effects (sedation, respiratory depression) in these patients at high risk of hepatic encephalopathy. If opioid therapy is necessary, use the lowest effective dose with prolonged dosing intervals. Codeine should be avoided. • Chlorhexidine gluconate without alcohol should be utilized rather than formulations with alcohol (if indicated). o If concurrent ethanol abuse (diagnosed alcohol use disorder, CAGE questionnaire score ≥2, AUDIT questionnaire score ≥8)54 • Dentists should consider brief intervention and referral to treatment for patients with substance use disorders. • Acetaminophen should be avoided (from all sources). • Chlorhexidine gluconate without alcohol should be utilized rather than formulations with alcohol (if indicated). Abstinence-Based Treatment for Opioid Use Disorder 38 o Opioid medications for pain management should be avoided as patients considered “opioidnaïve” are at higher risk for opioid overdose at smaller doses of opioid medications and could contribute to relapse of substance use. o Chlorhexidine gluconate without alcohol should be utilized (if indicated). Chronic Pain Patients 18,31,38 o Dentists should consider consulting with patient’s chronic opioid prescriber prior to prescribing opioid medications; often patients in these programs have a contract preventing the use of opioid medications from other sources, and opioid prescriptions could violate this contract. o If opioid therapy is necessary for adequate pain control, higher doses of opioids or more frequent dosing intervals may be necessary for acute pain management o The risk of adverse effects from opioids, such as respiratory depression and death, likely outweigh any analgesic efficacy at doses ≥ 50 MMEs (morphine milligram equivalents) per day3. Therefore, opioid therapy should be avoided for patients taking ≥50 MMEs per day of chronic opioid prescriptions. Medication-Assisted Treatment for Opioid Use Disorder 38 o Dentists should consider consulting with patient’s medication-assisted treatment provider prior to prescription of opioid medications; often patients in these programs have a contracts preventing the use of opioid medications from other sources and opioid prescriptions could violate this contract. o If medication assisted treatment is opioid antagonist, opioid use should be avoided due to reduced efficacy. Opioid antagonists include: • buprenorphine/naloxone (Bunavail®, Suboxone®, Zubsolv®) • bupropion/naltrexone (Contrave®) • naltrexone (ReVia®, Vivitrol®) • naloxone (Narcan®) 10 o Opioid agonists used for