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Misuse of opioid pain medication in dentistry: Fact or fiction?

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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.

References

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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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3 Comments

  1. Brian Barrett November 29, 2013

    As with all things great and wise the smart people will already know this and this others won’t read the article. The overprescription of narcotics may be due to the fact that no one likes to get the post op phone calls and complaints and with a dozen dilaudid no one is going to call until they are all gone. No doubt VERY effective pain control – risk benefit – rather them have a little discomfort – Have extracted everything from impacted 8’s to 3’s – probably a couple thousand tough surgicals in nearly 40 years and have never prescribed anything sronger than tylenol 3.

    Reply
  2. Richard Anderson December 3, 2013

    I try to prescribe the amount of opioid commensurate with the anticipated need. However , I find the number ’20’ far too often rolls off my pen’s tip. Think of the numbers of patients and their contacts that we, as a profession, can affect by not over-prescribing.

    Reply
  3. I find that most dentists are divided into two camps on this issue: 1) those that freely prescribe opiate pain medication, sometimes in quantities that are inappropriately large, and sometimes in cases where they are not clinically necessary; and 2) those that are seemingly afraid to prescribe any medication, often suggesting patients use over the counter medication in does that are too low to be effective.

    I feel that both empirical and clinical anecdotal evidence tend to support the notion that NSAID medication is generally more effective for the management of post operative pain following dental extractions in the prolonged post operative period.

    That being said, there is a strong emotional component to pain, yet this is something that is rarely acknowledged. I am of the opinion that narcotic pain medication is effective in controlling the sharp pain of the immediate post operative period, and especially effective in managing the emotional component of pain.

    In contrast to the common practice of prescribing ibuprofen and adding an opiate later, I tend to support the idea of prescribing an opiate in sufficiently high dose for a very short duration (first day or two), and transitioning to NSAID in a high enough dose for antiinflammatory effect. If using ibuprofen, this is generally 600mg QID or 800mg TID. Over the counter doses of ibuprofen generally provide analgesic action but are generally insufficient to provide antiinflammatory action.

    I am speaking in regards to a procedure associated with significant trauma. Simple extractions can often be managed with very little medication and without narcotics.

    In this, as in all dental scenarios, I think providers really need to use clinical judgement and modify clinical protocols and medication regimens accordingly. Too often, dentists rely on some standard generic protocol.

    Consider the atraumatic extraction of tooth #27 hat has moderate periodontal involvement,using elevator and forceps. I don’t think that a pile of narcotic medicaiton (or any for that matter) is indicated.

    However, consider a patient undergoing full mouth extraction in preparation for a complete immediate denture… or a complex and invasive extraction with fracture of the cortical plate. I don’t think that having the patient suffer with over the counter Advil at too low a dose (or worse Tylenol with almost no antiinflammatory action) is appropriate either.

    In the latter cases, should narcotic medication be denied just because it may have the concurrent effect of euphoria? Has one also considered the dysphoria created by the procedure?

    Reply

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