Opioids: The Good, The Bad and The Ugly…
My meetings with Dr. Jose Lança, from the University of Toronto’s Faculty of Dentistry and the Faculty of Medicine, are always so valuable in presenting and delivering extremely useful clinical information that supports every day clinical practice. This interview looks at the opioids crisis that is plaguing North American societies and the role of dentists in it.
Chiraz Guessaier, CDA Oasis Manager
Highlights
Opioids bind to opioid receptors in the brain. Upon binding to these receptors, opioids have various effects including:
- Analgesia
- Sedation/sleepiness
- Mood changes – dysphoria, euphoria
- Tolerance/addiction
- Cough suppression
- Miosis
- Endocrine effects
- Dermatologic effects – itching, sweating
- GI motility – constipation
- Urinary retention
- Respiratory/cardiovascular effects
- Coma/death
Repeated administration of opioids lead to a tolerance to the analgesic propertes which increases the need to increase the dosage of the medication. At the same time, the negative effects such as constipation will not disappear even at lower dosages. Tolerance begins with the first dose and usually becomes clinically relevant after 2-3 weeks of repeated exposure.
The treatment of opioid addiction can be managed pharmacologically and non-pharmacologically. Opioid antagonists have high affinity for opioid receptors. Naloxone (Narcan) is one example and has a very high onset of action which leads to a quick reversal. Naltrexan (Trexan) is similar to naloxone; however, it has a longer onset of action and a longer half life. This medication is indicated for chronic opioid or alcohol dependence.
Pain management using opioids has both risks and benefits and they must be weighed against one another. The WHO’s Pain Management Ladder is a useful tool to help determine the correct pain medication(s) to use. There is a marked difference in prescription patterns of opioid medications amongst different countries.
Studies have shown that NSAIDs should be the drug of choice for pain of endodontic origin. If this is not suitable, NSAIDs in combination with acetaminophen should be employed. Only in situations where the latter is ineffective should NSAIDs in combination with a centrally acting drug be used. Steroids can be used in irreversible pulpitis.