Treating Dental Pain in an Opioid-Addicted World
Control Patient Pain Responsibly
Louis F. Rose, DDS, MD
If you’ve been keeping up with your dental journals, it will come as no surprise that our nation is in the thrall of an opioid addiction epidemic. According to a December 2015 CDC report, 47,055 Americans died from drug overdoses in 2014; 40% of those deaths involved opioid analgesics.1 More Americans are killed by drug abuse than by automobiles. Every day in this country, 44 deaths are connected to the abuse of prescription painkillers, most frequently by the drugs oxycodone and hydrocodone, which are often the opioids of choice in a dental office. In the last 15 years, the CDC says we have seen a 200% increase in overdose-related deaths.1 To compound the problem, opioid abuse has become a contributor to the rise of heroin addiction as more patients turn to illicit drugs to satisfy their cravings. I could go on for pages citing these staggering statistics, which are validated by my own experience over my last 40 years of practice.
While dentists do not typically deal with long-term, chronic pain in the same way as physicians, we still contribute to the problem. According to a report by Denisco and colleagues,2 12% of the immediate-release opioid prescriptions written in the United States came from dentists. Noted in an article by Jablow, in 2009, dentists were the largest source of opioid prescriptions given to patients aged 10 to 16, when wisdom teeth are likely to be extracted.3 Far too many teens start on the path to opioid addiction with a pill given to them by the caring dentist who pulled their third molars.
We are all aware that dental pain can be harsh and debilitating. We are naturally inclined to give our patients something to make them feel better, and the request for a potent painkiller is often driven by patient demand and their belief that the stronger a pill, the better it will work. They anticipate suffering after an extraction or other dental surgery and to mollify their anxiety, we acquiesce to their requests for potent pain medication to the point that giving opioids has become a common practice.
In reality, there is no evidence to support routine use of opioids to treat dental pain. Studies show that opioids are not the proper drugs to relieve postoperative dental pain, which is mainly due to inflammation. A Compendium article on pain management explained that opioids act in the central nervous system and do not target the acute inflammatory process.4 In short, opioids create a euphoria that interferes with the perception of pain but they do not address the root cause of it. Postoperative pain management in dentistry can be far more effectively handled by appropriate use of NSAIDS and other drugs specifically geared toward reducing inflammation and/or swelling.4
Moore and Hersh explain some excellent strategies that should be in every dentist’s armamentarium for treating postoperative dental pain,5 with the goal of avoiding opioids whenever possible:
1. Dental surgery can sometimes produce acute postoperative pain, which is typically caused by inflammation and swelling. In cases of significant edema, studies have shown that a short-term regimen of a steroid taken in concert with ibuprofen can successfully lower pain and reduce swelling, particularly when administered prior to surgery.
2. Research shows “when moderate to severe pain is anticipated, a long acting local anesthesia like Marcaine or Vivacaine can delay the onset of pain, reduce the severity, and decrease the need for strong oral analgesics.”5 Used with NSAIDs for the first 2 days, this protocol for pain management is safer than prescribing an opioid. When pain comes later and with less intensity, it requires less medication.
3. Try a combination of NSAIDS and acetaminophen. Because these drugs work on different pathways in the body, they have been clinically shown to be more effective in controlling pain when used together rather than individually. A randomized, placebo-controlled study by Daniels and colleagues concluded that patients who received 400 mg ibuprofen along with 1000 mg acetaminophen reported having less pain that those who got a NSAID/codeine combination.6 If you adapt this protocol as an alternative to an opioid, do not exceed the guidelines of no more than 3,000 mg of acetaminophen per day to avoid potential liver toxicity.
When Opioids Are Unavoidable
There will be times when pain is so severe that it may require an opioid. In those instances, dentists must think twice, act responsibly, and be cautious. Before you write an opioid prescription, consult your state’s Prescription Drug Monitoring Program, which will alert you to the possibility that your patient is an addict by listing other opiates they may be taking and whether they shop pharmacies for painkillers. You can find your state’s program at www.NASCA.org. Limit the amount of pills you prescribe. In most cases, 8 to 10 pills should suffice for 2 to 3 days of pain. It’s unnecessary to write a script for 20 pills, which all too often sit unused in the medicine cabinet where they wind up in the hands of teenagers who pop them for a quick high. When your patient calls you at night at home because the pharmacy won’t fill the prescription, that’s a red flag that the pharmacist suspects an addiction. Bite the bullet and sympathetically refuse.
Finally, when you give out an opioid, always advise your patient not to share the drug with anyone, keep the bottle locked up, and discard the remainder after 10 days.7
As dentists become better informed about the dangers of opioid abuse in dealing with pain management, I am happy to report that our profession is increasingly turning to alternatives. A National Prescription Audit by the FDA showed that between 2003 and 2012, dentists fell from second to fifth place among the most frequent opioid prescribers behind general and family practitioners, internists, and surgeons.7 It should continue to be our goal to be a part of the solution and not part of the problem.
1. CDC Report. Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm. Accessed August 1, 2016.
2. Denisco RC, Kenna GA, O’Neil MG, et al. Prevention of prescription opioid abuse. JADA. 2011;142(7): 800-810.
3. Jablow P. Why dentists write too many scripts. Philadelphia Inquirer; 2016. http://articles.philly.com/ 2016-05-29/news/73429126_1_dentists-opioid-side-effects. Accessed August 1, 2016.
4. 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.
5. Moore PA, Hersh EV. Postoperative pain management in dentistry. Inside Dentistry. 2015;11(4):55-60.
6. Daniels SE, Goulder MA, Aspley S, Reader S. A randomised, five-parallel-group, placebo-controlled trial comparing the efficacy and tolerability of analgesic combinations including a novel single-tablet combination of ibuprofen/paracetamol for postoperative dental pain. Pain. 2011;152(3): 632-642.
7. McCauley JL, Hyer JM, Ramakrishnan VR, et al. Dental opioid prescribing and multiple opioid prescriptions among dental patients: Administrative data from the South Carolina prescription drug monitoring program. J Am Dent Assoc. 2016;147(7):537-544.