General precautions
a. Even at prescribed doses, opioid analgesics carry the risk of misuse, abuse, opioid use disorder, overdose, and death
b. Importance of the appropriate use of PDMPs [portable digital media interface, i.e. tablets and smartphones] and their use as a clinical decision support tool
c. DSM-5 (R) criteria (or the most recent version) for OUD [opioid use disorders] and the concepts of abuse (taking an opioid to get high) vs. misuse (taking more than prescribed for pain or giving to someone else in pain)
d. The concepts of tolerance and physiological dependence and how they differ from OUD (addiction)
e. Recognition that some opioid analgesics (e.g., Transmucosal Immediate Release Fentanyl products, some ER/LA products) are safe only for opioid-tolerant patients
So where do dentists fit in all of this?
Just as one example, dentists (frequently oral and maxillofacial surgeons) remove over 10 million third molars “wisdom teeth” from 5 million patients in the US at a cost of over $3 Billion and 11 million patient days lost to “standard discomfort or disability”. (4)
Other countries, such as Britain, use opioids far less for wisdom tooth extraction. In fact, a review of randomized, controlled trials of pain associated with the removal of wisdom teeth, concluded that an ibuprofen – acetaminophen combination was, in fact, be more effective for relieving pain, with far less side effects, than opioids, although the authors suggested further studies to confirm this. (7)
In 2006, a survey of dental surgeons found that 74% preferred that patients use ibuprofen after wisdom teeth extraction, but 85% also prescribed an opioid, “just in case” there is breakthrough pain. (8)
A NY Times article, quotes statistics from the Journal of the American Medical Association stating that
dentists and oral surgeons are by far the major prescriber of opioids for people ages 10-19.
The author goes on to say that children who are prescribed any opioids in elementary school have a 1/3 chance of “lifetime illicit use”.
In a report from the CDC, patients (of all ages) who had never taken opioids found that of those prescribe just a 12-day supply, 25% are still taking opioids a year later. (2,3,6)
Why does are these numbers so appalling?
Because the brains of these children and teens are not fully developed, making them particularly susceptible to what may seem very limited doses of opioid pain killers. The human brain doesn’t fully develop until about the age of 25.A recent study of 6,200 high school seniors who did not use illegal drugs, and in fact, had a strong disapproval of illegal drug use, when prescribed opioids at some point prior to graduation, had a 33% risk of future opioid misuse after graduation. (5)
Time to reconsider?
Maybe you are a health care professional who has always done something a certain way. You are not aware of any significant negative effects of opioids on your patients – even the younger ones. That does not mean that you should not consider changing your approach to what you prescribe for patient pain. In light of all the recent research on just how incredibly addictive opioid pain medications can be, especially to your younger patients – it just may be in your patient’s best interests for you to consider the NSAID (Tylenol/Advil) alternative as your first choice for patient pain relief. Note: If you are a more ‘out of the box’ health care professional, and open to new, alternative (but clinically proven) techniques for dealing with pain and pain management, I encourage you to read the article below on EFT-Tapping and the Tapping World Summit that you can watch for free. We (Scott and Bonnie) have both used Tapping for a multitude of issues – including pain – for many years with great success. If we didn’t feel that it would be of great benefit to our audience, we would not be so passionate about introducing you to it and asking you to register to watch the Tapping World Summit. It is free for 10 days (2 speakers per day) and you can learn SO much from all the expert speakers. Scroll down to learn more…
If you treat, work with, or have children –
2. Talk to your kids, or the parents of your young patients, about the risks. Education can be a powerful motivational tool.
3. Educate yourself on the latest guidelines coming from the ADA, AMA, CDC and dental schools where the policy and trend is toward prescribing NSAIDS (Ibuprofen and acetaminophen – Advil and Tylenol) as the first line of treatment for short-term pain. Only if there is breakthrough pain, or it lasts longer than a few days, should something stronger be considered, and even then, only with strict supervision and a repeat of the ‘risk talk’ with your kids or your patient’s parents.
Are you prepared to handle a drug overdose reaction/emergency?
2, https://www.nytimes.com/2017/07/10/opinion/dentists-opioids-addiction-.html
3. https://jamanetwork.com/journals/jama/fullarticle/896134
5. http://pediatrics.aappublications.org/content/early/2015/10/21/peds.2015-1364?utm_source=highwire&utm_medium=email&utm_campaign=Pediatrics_papetoc
6. https://www.cdc.gov/mmwr/volumes/66/wr/mm6610a1.htm
7. http://jada.ada.org/article/S0002-8177(14)60509-2/abstract
8. http://www.jcda.ca/article/e49