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Questions & Answers: Where Do Opioids fit in the Management of Acute Post-Surgical Pain?

Chris LeeCairnsDrs. Chris Lee and Brian Cairns return to answer questions about the management of acute post-surgical pain and when and how should opioids be used in such situations.






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Click here to watch the Case Conference: Where Do Opioids fit in the Management of Acute Post-Surgical Pain?

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What is the ideal analgesic regimen for acute surgical procedures in the oral cavity, in particular 3rd molar extraction?

  • The go to is ibuprofen: 600mg every 6 hours if the patient can tolerate ibuprofen. 

When do you advise combining acetaminophen with ibuprofen, what dose to use, how long to treat post op, and when to consider using opioids?

  • An alternative dose would be 500mg naproxen (Aleve) (2 tablets) every 12 hours. 
  • Otherwise alternate 600mg ibuprofen with 1000mg acetaminophen.
  • The recommendation is to have continuous therapy for 3-7 days post-op.

What is the maximum daily dose of ibuprofen (2400 vs 3200) that a patient can take, and is there a “ceiling effect” with NSAIDs?

Generally, there is no evidence of benefit of going beyond 2400mg a day, because of the ceiling effect of using an NSAID.

What is the place of opioids in post-surgical acute pain management and what is the rationale for their use?

  • Opioids are third-line medications, if you cannot use an NSAID, the next alternative is acetaminophen. ANd, if you cannot use acetaminophen, that’s when opioids become an option. 
  • It is important to acknowledge the patient’s pain and try to evaluate the patient’s situation and prescribe the best therapy for pain management. However, it is important to watch out for patients who are asking for refill for other reasons. 

Do you routinely pre-medicate with NSAIDs as part of your analgesic regimen?

  • There is a good evidence of using pre-medication or at least immediate post-op while the effect of local anesthestic is still in action. 

Do practitioners tell patients to return unused doses to the pharmacy for destruction?

  • Yes, practitioners as well as pharmacists should advise patients to return unused doses to their pharmacist who will dispose of any excess medication appropriately. 

Are there any effective and proven methods by which I can screen patient for the potential of misuse or abuse of opioids?

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  1. Dr. John Burgess July 14, 2015

    I have found in working together with oral surgeons, endodontists and with experience in my own practice that ibuprofen is very much more effective than Tylenol 3 or 4. Several studies have pointed this out with large patient numbers (although I cannot find the specific references for them (over 10 years ago…).
    Most oral surgeons I work with inject Dexamethasone post op to reduce swelling and post-op inflammation.
    I have been using Ibuprofen 4-600 mg q6h for a few days, starting prior to the surgery to increase blood levels. Dexamethasone 4 mg q 12 hours is given to those who are suspected of having more profound discomfort (proportional to the amount of bone removal and tissue reflection) Surgical protocols with microscope reduce the need for as much bone and tissue retraction/removal while providing great vision. Most often taking all of these into account, opioids are rarely needed. When gross bone or significant tissue trauma are required then opioids are brought into the mix. However, even then there are very few times(even with full mouth clearance, that I require opioids (perhaps 5 times a year) Incorporation of oral Dexamethasone to complement Ibuprofen completely changed my post-op protocol, eliminated pain, and eliminated constipation or addictive personalities making impossible requests in my practice.
    My determination to use opioids is usually made prior to releasing the patient, after determining how much surgical trauma was necessary. As I mentioned, microscopy has significantly reduced this along with gentle and conservative flap reflection techniques.

  2. Tom Shackleton July 14, 2015

    Excellent information! Thanks for the update

  3. Dr. Larry Gaum July 14, 2015

    I must disagree with the choice the doctors have made as to ibuprofen’s being number one on the list. These are my reasons:

    #1 Mega doses of Ibuprofens have been known to cause severe, irreversible kidney damage. In my estimation, 2400mgs., daily is to be considered a mega dose. Taking it for 4-5 days or longer equates to 12,000mgs. This is unconscionable. Just because this is taught in dental school at Dalhousie does not make it correct. It is certainly something that I do not teach in my hands-on seminars across Canada and the USA.
    As well, dosages of this magnitude play havoc with the patient’s stomach. Most cannot tolerate the medication with dosages of this quantity.
    #2 A far better choice is a combination of drugs and medications such as: Acetaminophen (300mgs.) + Codeine(30mgs) + ibuprofen (200mgs). All are synergistic and compliment and accentuate each other within safe levels. The use of multiple drugs in combination, which serve to provide the most efficient actions in each one and compliment each other, is a far better procedure than using one mega dose of one drug.
    #3 Narcotics,(codeine,oxycodon)have been proven to be most effective with acute pain emanating from traumatized bone, periosteum and mucosa, as we witness in the removal of impacted 3rd molars.
    Dr. Larry Gaum
    Oral/Maxillofacial surgeon

    1. JCDA Oasis July 16, 2015

      Thank you for leaving your feedback. Considering ibuprofen the number 1 on the list is not particular to Dalhousie University.

      It is important to note that several papers recommended NSAIDS as first line and NOT in combination with codeine. The following (https://www.cda-adc.ca/jcda/vol-68/issue-8/476.pdf) is a paper by Dr. Dan Haas indicating first line is an NSAID or Acetaminophen. As well, the section on “Drugs in Dentistry” in the CPS (the medication reference used by pharmacists and clinicians alike) suggests the same, as does Yagiela’s textbook “Pharmacology and Therapeutics for Dentistry” which is used by most dental schools in North America.

      The World Health Organization analgesic ladder suggests the same.

      Further, another Systematic Review by the Cochrane Database 2010, April 14(4): CD008099 by Derry et al suggests that 60mg of codeine is less effective for pain control than 600mg of ibuprofen or 1000mg acetaminophen.

      Using an NSAID acutely (for 3-7 days, for post procedure analgesia) will not cause liver or kidney damage (see Becker et al Anesth Prog 57:67-79 2010). and 2400mg is certainly not a whopping dose.

      CDA Oasis Team, on Behalf of Drs. Chris Lee and Brian Cairns.

      1. Larry Gaum July 21, 2015

        Let me clarify once and for all.

        As a teacher, having taught pharmacology at U of T for 20 plus years, but also a practicing oral surgeon for 40 plus years, my humble observations are as follows:

        The use of drugs in combination, wherein each drug combined has been established and calculated to provide the most efficient action as well as symergise with other combined drugs, in my clinical opinion, is the most ideal and the best analgesic for post operative oral surgical procedures. To suggest that an effective narcotic, such as codeine has no rightful place in post op analgesics, is incorrect and misleading.

        In your suggestion to read certain articles, you may check codeine and the oxycodons, and observe their recommendations for moderate to severe pain. And furthermore, if you have a patient who just had 4 bony impacted 3rd molars removed, where tooth, periosteum, and bone were cut and traumatized, that took 1-2 hours of surgery, and you hand him/ her a Rx for ibuprofen, you best have good running shoes and athletic feet.

  4. Pat Duronio July 14, 2015

    Look up Maxigesic. It is available in England and Australia. It is a combination of acetaminophen and ibuprofen in one tablet. Their research has shown that 1000 mg. of Tylenol taken at the same time as 400 to 600 mg. of ibuprofen is the most effective regimen for acute 3rd molar extraction pain even surpassing any opioid regimen. They potentiate one another and one is metabolized in the liver and the other in the kidneys. This regimen is every 6 hours on the clock for 2 to 3 days only. I have not prescribed opioids to healthy individuals in 3 years since hearing the above from Dr. Baker at the University of Iowa. I wish Maxigesic was available in Canada.


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