Special Series, Part Three: Effective Alternative Treatments to Opioids
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Dr. Jose Lança is an M.D., PhD., and Assistant Professor at the Faculty of Dentistry, Department of Pharmacology and Toxicology at the University of Toronto. In this third and final interview in our series, Dr. Lança delivers important insights on treating patients within the current opioid crisis and provides evidence-based, alternative treatments for pain management. Effective alternatives to opioids and other pain management resources in dentistry
Watch Dr. Lança’s presentation, Opioids: The Good, The Bad, and The Ugly Read/download the transcript of the conversation (PDF) Full Conversation (14.33″)We always want to hear your thoughts and questions. Leave a comment about this post in the box below or send us your feedback by email or call us at 1-855-716-2747. Until next time! CDA Oasis Team |
Thank you for your presentation.
I have a couple of questions. Firstly, the dose response curve for NSAIDS + ASA are given but they don’t compare it with opioids. That leaves the obvious question of how do these relate?
The second question I have relates to the definition of efficacy. The presenter compares UK and NA methods of pain control, but this ignores cultural issues around what adequate pain control is. We are causing acute pain, it will end and the patient will go on to forget the post-operative course. The safest thing would be to provide no analgesia; however, we are expected to act in a humane way and alleviate our patient’s pain. I suspect this is greatly influenced by cultural expectations. The presenter says that British patients have the same pain that North American patients have, and that is probably true; however, I doubt that they have the same expectations of treatment. I don’t think that can be casually ignored.
The comparison between ER physicians, Family Medicine specialists and dentists is a red herring. We all treat pain but that is about where the similarity stops. Dentists are causing acute pain in surgery. We generally know our patients, their medical, social and dental histories. We are more equipped to treat our patient’s pain in a holistic way than an ER doctor who is mostly concerned about whether the patient is going to die in their ER and probably has little to no knowledge of their history. Comparisons like these detract from the seriousness of the presentation.
I do prescribe opioids from time to time as they are effective and relatively safe. I don’t hand them out without thought or insight. The implication of all the anti-opioid talk these days is that any opioid use is bad and creates a social blight. Opioids are neither good nor bad. They are a tool. Used in the right hands with care and forethought they are one of the great gifts of medical science. Don’t throw out the baby with the bathwater.
Not everyone who has had their pain treated with opioids has gone on to overdose. I suspect the current crisis we are enduring has more to do with social and mental health issues and the introduction of fentanyl-like drugs to the illicit drug supply than the prescribing practices of physicians and dentists.
My personal opinion is that I am getting a little tired of our professional organizations constantly telling us we are creating a problem that we actually have no control over.
Thank you for your comments.
Regarding your first question, additional discussion was included in my previous CDA Oasis presentation entitled “Opioids – The good, the bad and the ugly”. More importantly, addition of codeine (60 mg every) to a combination of acetaminophen and ibuprofen failed to improve analgesia (Best AD, 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 Oct;75(10):2063-2069).
Your second question relates to “the definition of efficacy”. Actually, it is not related to the definition of efficacy, but rather to pain management and patient expectation regarding experiencing pain. It is true that cultural factors condition the perception of pain intensity and expectations of analgesia. It is the responsibility of the healthcare professional to explain to patients the complexity of the medical or dental procedure, analgesia and expectation of pain. These apply to patients in the UK as well as in North America.
The comparison of opioid prescribing between dentists, and physicians – e.g., Emergency Medicine, Family Medicine, Orthopedic Surgery, General Surgery, Osteopathic Surgery, Obstetrics and Gynecology – is a valid and relevant comparison. It is not a personal opinion. Two studies are particularly relevant in this regard:
1. Rigoni GC. Drug utilization for immediate- and modified release opioids in the USA. Division of Surveillance, Research & Communication Support. Office of Drug Safety – FDA. 2003. http://www.fda.gov/ohrms/DOCKETS/ac/03/slides3978S1_05_Rigoni.ppt Accessed February 2017.
2. Denisco RC, et al. Prevention of prescription opioid abuse: The role of the dentist. JADA 2011;142(7):800-810.
Finally, unnecessary prescription, use and abuse of opioids in pain management has contributed, and unfortunately continues to contribute, to an opioid epidemic that according to Health Canada has caused more than 9,000 people deaths in Canada between January 2016 and June 2018 related to opioids (https://www.canada.ca/en/health-canada/services/substance-use/problematic-prescription-drug-use/opioids/data-surveillance-research/harms-deaths.html).
Each and everyone, including the pharmaceutical industry, public, educators, and healthcare professionals have the responsibility, and ethical and professional obligation to address and manage this crisis.