Misuse of opioid pain medication in dentistry: Fact or fiction?
Derived from the Chronic Orofacial Pain Workshop of the Network for Canadian Oral Health Research, IMHA, Canadian Institutes of Health Research, Montreal, November 2013
Gilles Lavigne, DMD, PhD, FRCD, Professor, Faculté de médecine dentaire, Université de Montreal
Mary Lynch, MD FRCPC,Professor Anesthesiology Psychiatry Pharmacology,Dalhousie University,
To understand the misuse of prescription opioid analgesics (POA), it is critical to examine the definitions used in the research. The Canadian Alcohol and Drug Use Monitoring Survey (CADUMS) is an ongoing national survey that examines alcohol and drug use in Canadians 15 years of age and older. CADUMS defines the nonmedical use of prescription opioids (NMPOU) as including individuals who acknowledge using their pain relievers more than they were supposed to, obtaining the medication from a family member or friend, or obtaining the medication over the Internet, from a pharmacist without a prescription, or from any other source without a prescription. In 2009 CADUMS also included an item asking whether the prescription opioid had been used “to get high.” In 2009, the prevalence of any use of POA in Canada was 19.2%, with 4.8% of people acknowledging NMPOU and 0.4% indicating that they used the POA to get high (Lynch and Fischer). There was no association between the amount of POA dispensed in a province and misuse or use to get high (Shield, Jones et al.).
Many teenagers are first exposed to opioids (e.g., codeine, hydrocodone, oxycodone) following third molar surgery (Denisco, Kenna et al.). It is important to manage the pain after dental surgery in order to facilitate comfort and healing and to prevent chronic pain. However, given that these medications are attractive to a minority of people who may misuse them, it is also important to prescribe opioids in a safe and structured manner.
After third molar surgery, non-steroidal analgesics (ibuprofen, acetaminophen) are prescribed, and in most cases, a large dose of ibuprofen (i.e., 800 or 600 mg every 4 h) is sufficient (Moore, Nahouraii et al.) If you suspect that your patient needs a stronger pain medication (i.e., opioid), you can provide this as a second prescription. Pharmacists are our partners in reducing the risks of misuse and addiction, and they can exert some control. Parental support in the postoperative period is also essential. In addition, make sure that adolescents are informed about the medication you have prescribed.
Preemptive analgesia, or giving non-steroidal analgesics in the hours before impacted molar or periodontal surgery or root canal treatment, is also a proven method to reduce postoperative pain, and lower doses or pills are used (Chiu and Cheung, Bauer, Duarte et al.)
Avoid leftover opioid pills. After third molar surgery, it is common to prescribe 20 strong painkiller pills (Mutlu, Abubaker et al. 2013). We should prescribe the minimum number required to control the pain.
We also need to instruct our patients not to give their painkiller pills to friends or to resell these medications, as these are dangerous and illegal practices.
As clinicians, we also need to develop strategies to identify patients at risk for drug misuse behavior. In the absence of simple screening tools for dental clinics, we must use our common sense and assess the risks on a case-to-case basis. Make sure they get effective pain control. We need to balance risk of misuse with the risk of developing chronic pain.
- Bauer, H. C., F. L. Duarte, A. C. Horliana, I. P. Tortamano, F. E. Perez, J. L. Simone and W. A. Jorge (2013). “Assessment of preemptive analgesia with ibuprofen coadministered or not with dexamethasone in third molar surgery: a randomized double-blind controlled clinical trial.” Oral Maxillofac Surg 17(3): 165-171.
- Chiu, W. K. and L. K. Cheung (2005). “Efficacy of preoperative oral rofecoxib in pain control for third molar surgery.” Oral Surg Oral Med Oral Pathol Oral Radiol Endod 99(6): e47-53.
- Denisco, R. C., G. A. Kenna, M. G. O’Neil, R. J. Kulich, P. A. Moore, W. T. Kane, N. R. Mehta, E. V. Hersh and N. P. Katz (2011). “Prevention of prescription opioid abuse: the role of the dentist.” J Am Dent Assoc 142(7): 800-810.
- Lynch, M. E. and B. Fischer (2011). “Prescription opioid abuse, what is the real problem and how do we fix it? .” Can Fam Physician 57: 1241-1242.
- Moore, P. A., H. S. Nahouraii, J. G. Zovko and S. R. Wisniewski (2006). “Dental therapeutic practice patterns in the U.S. II. Analgesics, corticosteroids, and antibiotics.” Gen Dent 54(3): 201-207; quiz 208, 221-202.
- Mutlu, I., A. O. Abubaker and D. M. Laskin (2013). “Narcotic prescribing habits and other methods of pain control by oral and maxillofacial surgeons after impacted third molar removal.” J Oral Maxillofac Surg 71(9): 1500-1503.
- Shield, K. D., W. Jones, J. Rehm and B. Fischer (2013). “Use and non-medical use of prescription opioid analgesics in the general population of Canada and correlations with dispensing levels in 2009.” Pain Res Manage 18: 69-74.
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