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Given the Current Epidemic of Opioid Abuse, What Is Your Prescribing Regimen When Managing Patient Pain?
Raymond A. Dionne, DDS, MS, PhD | Mark Donaldson, ACPR, PHARMD, FASHP, FACHE | Jason H. Goodchild, DMD
Raymond A. Dionne, DDS, MS, PhD: The management of acute orofacial pain has been critically reevaluated due to the opioid abuse epidemic. It is no longer considered optimal to routinely prescribe an opioid combination to treat moderate to moderately severe pain, such as the pain that occurs after simple extractions, endodontic treatment, or periodontal surgery. Opioids should now be considered the last choice for acute pain, not the default prescription.1 For procedures likely to result in mild pain, over-the-counter formulations of aspirin, acetaminophen, or a nonsteroidal anti-inflammatory drug (NSAID) provide adequate pain relief and fewer side effects with no risk of an opioid overdose. The management of severe pain following a surgical procedure may require an opioid for a few days, but the number of pills should be minimal, refills should be avoided (unless the veracity of the request can be confirmed by clinical examination), and precautions should be taken to dispose of the unused medications in a responsible manner. The clinical indications for considering the use of an opioid for postoperative pain were recently reviewed.2
The inflammatory etiology for most postprocedural pain provides a strong rationale for administering NSAIDs prior to the procedure or in the immediate postoperative period to minimize the inflammatory cascade that drives the cardinal signs of inflammation: pain, edema, and limitation of function. Prostanoid production at the site of tissue injury by the constitutive form of cyclooxygenase (COX) is largely blocked by dual COX-1/COX-2 inhibitors such as ibuprofen. The expression of COX-2 in the first few hours after tissue injury adds to the inflammatory cascade, but is also inhibited by a dual COX-1/COX-2 inhibitor. Effective inhibition of the prostanoid pathway and minimization of nociceptive input into the CNS with a long-acting local anesthetic are additive and block the development of hyperalgesia at 24 to 48 hours when acute pain peaks.3 Pain can be further inhibited by continued administration of an NSAID during the first few days following a surgical procedure and supplemented with acetaminophen for additive analgesia. Opioid administration should only be considered for pain of severe intensity and only when a preventive non-opioid regimen fails to provide adequate relief. Routinely prescribing an opioid for all patients does not provide any benefit if it isn't needed; however, it does expose patients to the potential for adverse events and opioid misuse. Overprescribing opioids also contributes to the burden of unused pills that may be diverted for misuse or sold illicitly.
A pain prevention paradigm based on the large body of evidence that has resulted from well-controlled clinical trials in the oral surgery model provides a basis for the patient education that is needed to assure patients that they are receiving the optimal treatment to minimize postoperative pain without opioid analgesia. Furthermore, they are avoiding the risks of overdose among their families while helping to decrease the societal burden of opioid addiction, overdose deaths, and the financial cost of the opioid epidemic, which is now estimated to have exceeded $1 trillion in the United States alone.
Mark Donaldson, ACPR, PHARMD, FASHP, FACHE:At the end of 2017, due to the high rates of abuse, overdose, and death, the opioid crisis in the United States was declared a public health emergency.4 In the previous year, the total number of opioid prescriptions in the United States approximated 215 million with an annual opioid prescribing rate of 66.5 prescriptions per 100 people.5,6 In 2015, opioid overdoses resulted in 33,091 deaths, and more than 300,000 deaths have occurred since 2000.7,8 Because dentists follow primary care physicians as the second-largest group of prescribers of immediate-release opioids, they have been identified as having an important role in opioid abuse prevention efforts.9,10
What do opioid abuse prevention efforts look like? The knee-jerk reaction is often to simply stop prescribing opioid-containing analgesics. A recent infographic presented by the American Dental Association's Health Policy Institute details a downward trend in opioid prescribing by dentists beginning in 1998 and continuing to 2012 (dentists were responsible for 15.5% of all US opioid prescriptions in 1998, which dropped to 6.4% by 2012).11 Unfortunately, this same data showed that from 2010 to 2015, opioid prescription rates increased for all age groups except among patients aged 19 to 25 years, and that the most egregious rise in opioid prescribing occurred among patients aged 11 to 18 years. Clearly, a sustainable reduction in opioid prescribing will not occur without a commensurate solution.
Paul Moore and colleagues wrote an excellent editorial in the Journal of the American Dental Association, which asked oral healthcare practitioners, "if NSAIDs are at least as effective as acetaminophen-opioid pain relievers and have lower incidences of adverse effects, why do we prescribe acetaminophen-opioid pain relievers for patients?"12These authors recognized that although a prescription for an opioid combination analgesic may still be needed after outpatient surgery for certain patients and procedures and should remain an essential part of a dentist's therapeutic options, there may be more effective strategies for postoperative pain management that do not require opioid combination analgesics, such as the use of an NSAID with acetaminophen.
Lastly, the concept of preemptive analgesia (eg, giving patients an NSAID, such as 400 mg of celecoxib, prior to the procedure) could be considered for more difficult cases to help mitigate pain before it is triggered.13 All of these strategies have shown documented success without adding to the current opioid epidemic.
Jason H. Goodchild, DMD: In the midst of the recent focus on the "US opioid epidemic," it would seem reasonable for oral healthcare providers to respond by eliminating the practice of writing opioid prescriptions following dental treatment. It is likely that some oral healthcare providers have adopted a no-opioid prescription policy in their practices, while others are approaching the crisis in a more measured way. Careful and judicious prescribing must be a first-line approach as well as offering non-opioid analgesic therapy utilizing NSAIDs.
Numerous studies support the use of NSAIDs as viable alternatives to opioid therapy following dental surgery. A systematic review by Aminoshariae and colleagues recommended NSAIDs as the drugs of choice to address endodontic pain, and a study by Best and colleagues demonstrated that the addition of an opioid to an NSAID regimen did not improve analgesia following third molar surgery.14,15
If there are no contraindications to the use of an NSAID (eg, allergy, renal artery stenosis), a protocol utilizing ibuprofen and acetaminophen is recommended. In a previous article, Donaldson and I described a non-opioid regimen using a "1-2-4-24" mnemonic to help improve oral healthcare providers' prescribing practices.16,17 This strategy describes the administration of a single oral, intramuscular, or submucosal dose of 4 to 8 mg of dexamethasone either pre- or perioperatively, followed by two drugs in four doses for 24 hours. The two drugs are ibuprofen (600 mg) and acetaminophen (1,000 mg), which are taken together every 6 hours (four doses) for the first 24 hours.
The success of this regimen relies on patient compliance. If the patient is still experiencing pain after the first 24 hours of strict compliance, he or she can continue the 2-4-24 regimen or switch to a pro re nata dosing schedule. If, despite excellent compliance, the patient still needs routine medication after 2 days to alleviate postoperative pain, follow-up and reexamination by the oral healthcare provider is encouraged to rule out other confounders such as infection.
Raymond A. Dionne, DDS, MS, PhD, is a research professor at the Brody School of Medicine at East Carolina University, Greenville, North Carolina.
Mark Donaldson, ACPR,PHARMD, FASHP, FACHE, is a clinical professor in the School of Pharmacy at the University of Montana, Missoula, Montana, and a clinical associate professor in the School of Dentistry at the Oregon Health & Sciences University.
Jason H. Goodchild, DMD, is the director of clinical affairs at Premier Dental Products Company, Plymouth Meeting, Pennsylvania, and an associate clinical professor in the Department of Diagnostic Sciences at the Creighton University School of Dentistry, Omaha, Nebraska.
References
1. Dionne RA, Gordon SM, Moore PA. Prescribing opioid analgesics for acute dental pain: time to change clinical practices in response to evidence and misperceptions. Compend Contin Educ Dent. 2016;37(6):372-378
2. Dionne RA, Warburton G, Khan A. When are opiods indicated for postoperative analgesia in dental practice? Compend Contin Educ Dent. 2018;39(3):142-145.
3. Gordon SM, Brahim JS, Dubner R, et al. Attenuation of pain in a randomized trial by suppression of peripheral nociceptive activity in the immediate postoperative period. Anesth Analg. 2002;95(5):1351-1357.
4. US Department of Health and Human Services. HHS acting secretary declares public health-emergency-address national opioid crisis. HHS.gov Website. https://www.hhs.gov/about/news/
2017/10/26/hhs-acting-secretary-declares-public-health-emergency-address-national-opioid-crisis.html Published October 26, 2017. Accessed February 17, 2018.
5. US Centers for Disease Control and Prevention. US prescribing rate maps. CDC Website.
https://www.cdc.gov/drugoverdose/maps/rxrate-maps.html. Updated July 31, 2017. Accessed February 17, 2018.
6. US Centers for Disease Control and Prevention. Annual surveillance report of drug-related risks and outcomes. United States, 2017. CDC Website. https://www.cdc.gov/drugoverdose/pdf/pubs/2017-cdc-drug-surveillance-report.pdf. Accessed February 17, 2018.
7. US Department of Health and Human Services. About the U.S. opioid epidemic. HHS.gov Website. https://www.hhs.gov/opioids/about-the-epidemic/index.html. Accessed February 17, 2018.
8. The White House. President Donald J. Trump is taking action on drug addiction and the opioid crisis. https://www.whitehouse.gov/the-press-office/2017/
10/26/president-donald-j-trump-taking-action-drug-addiction-and-opioid-crisis. Published October 26, 2017. Accessed February 17, 2018.
9. Denisco RC, Kenna GA, O'Neil MG, et al. Prevention of prescription opioid abuse: the role of the dentist. J Am Dent Assoc. 2011;142(7):800-810.
10. Oakley M, O'Donnell J, Moore PA, et al. The rise in prescription drug abuse: raising awareness in the dental community. Compend Contin Educ Dent. 2011;32(6):14-16,18-22.
11. American Dental Association. HPI Infographic chronicles dental opioid prescription rates. ADA News Website. https://editions.mydigitalpublication.com/publication/?i=473109&p=26#{%22page%22:%2226%22,%22issue_id%22:473109} Published February 5, 2018. Accessed March 23, 2018.
12. Moore PA, Dionne RA, Cooper SA, et al. Why do we prescribe Vicodin? J Am Dent Assoc. 2016;147(7):530-533.
13. Al-Sukhun J, Al-Sukhun S, Penttilä H, Ashammakhi N, Al-Sukhun R. Preemptive analgesic effect of low doses of celecoxib is superior to low doses of traditional nonsteroidal anti-inflammatory drugs. J Craniofac Surg. 2012 Mar;23(2):526-529.
14. Aminoshariae A, Kulild JC, Donaldson M, et al. Evidence-based recommendations for analgesic efficacy to treat pain of endodontic origin: A systematic review of randomized controlled trials. J Am Dent Assoc 2016;147(10):826-839.
15. Best AD, De Silva RK, Thomson WM, et al. Efficacy of codeine when added to paracetamol (acetaminophen) and ibuprofen for relief of postoperative pain after surgical removal of impacted third molars: a double-blinded randomized control trial. J Oral Maxillofac Surg. 2017;75(10):2063-2069.
16. Goodchild JH, Donaldson M. Treating nociceptive orofacial pain. Inside Dentistry 2017;13(10):61-70.
17. Brignardello-Petersen R. Submucosal dexamethasone reduces pain, swelling, and trismus after impacted third-molar extraction. J Am Dent Assoc. 2017;148(5):e64.
