Opioid abuse continues to dominate the national conversation. In 2015, 12.5 million people misused prescription opioids, with 15,281 deaths, according to the Department of Health and Human Services. The medical establishment is now investigating how to manage these often needed prescriptions without exposing patients to risks. Dentistry is no exception, though many questions remain.
“We don’t yet have guidelines relating to best practices when it comes to the number of pills, the dose of the medication, or the strength of the medication,” said Mark Bicket, MD, an assistant professor of anesthesiology and critical care at the Johns Hopkins University School of Medicine micro motors australia. “In general, the principle of using the lowest dose appropriate for the patient applies, and that extends into deciding if opioids are appropriate for treating pain or not.”
For example, opioids often are prescribed after third molar extractions. Yet a 2016 study found that only 46% of these pills actually were taken properly, resulting in more than 100 million pills left over and available for misuse and abuse by these patients and others. This dangerous surplus is the result of the challenges in predicting how much pain patients will feel and how much medication they will need to mitigate it.
“Dentists, like most caring people, don’t want patients to have significant pain that they could help control. It’s also difficult for us right now to determine how much pain someone will have after a procedure,” Bicket said. “Pain is a pretty personal experience, or I guess I should say it is a unique experience, that depends on some personal characteristics as well as what type of procedure that you had done.”Is Brushing With Toothpaste Enough? for more information.
Earlier this year, the ADA released an official statement on the use of opioids in treating dental pain. According to the ADA, dentists should consider nonsteroidal anti-inflammatory analgesics as the first line of therapy for acute pain management, along with multimodal pain strategies. When opioids are necessary for chronic orofacial pain, the ADA advises, dentists should coordinate with other treating doctors including pain specialists.
“Many people’s pain after dental procedures can be effectively controlled by Tylenol or acetaminophen, as well as nonsteroidal anti-inflammatory drugs like ibuprofen, or Aleve, that you can get commonly over the counter,” Bicket said. “You can write prescriptions for stronger doses of these drugs as well.”
When dentists do need to prescribe opioids, Bicket said, they should remember that patients who are prescribed longer courses of treatment have a greater risk of developing an addiction than those prescribed shorter courses. Dentists also need to talk about these risks with their patients, he added, including any previous use of opioids.
“I think one of the important things to recommend is that prescribers check with patients about their risk for opioids misuse, if they have a history themselves or a family history of drug misuse,” Bicket said. “Also, dentists should look at their patients’ past prescriptions for opioid medications through a prescription monitoring program Dental Chair.”
When opioids are prescribed, patients need to store them securely so others in the household don’t use them either intentionally or unintentionally, Bicket said, noting that dentists should ask their patients if they have lockable cabinets or drawers or other options at home for such storage. Also, dentists should reach out to their patients during the course of the prescription to see how it is going, for the patient’s benefit as well as their own.