Pain Management Protocols and Proper Opioid Prescription

Adam Burr, DDS

Dental practitioners must be informed on the dangers of prescribing opioids. Resources are available on alternative pain management techniques. A simple protocol can be developed to maximize safety when prescribing opioids, and real-world solutions can be implemented with patients to promote responsible pain management.

Opioid Use and Abuse in the United States

Throughout the last decade, the magnitude of damage in the United States caused by opioid use and abuse has become all too apparent. Despite many available resources and efforts made on both national and state levels through programs, advocacy groups, and training of healthcare professionals, the devastation from opioid addiction remains prevalent. An estimated 1.7 million Americans currently suffer from opioid use disorder and addiction.¹

There is a divide between the number of opioid-related deaths and other causes of death and how the nation has responded to the opioid crisis in the past. The number of fatalities due to firearms, car accidents, and alcohol are reported as much lower each year in comparison with opioid overdose, yet those other issues have long captured media attention that fuels ideas, debates, proposals, and solutions.²

The rate of death caused by opioid overdose is not only higher than those other causes of death, it is also increasing (Figure 1).³ Undeterred by an increase in awareness campaigns, accessibility of prescription drug monitoring programs (PDMPs), and stringent Drug Enforcement Administration prescription guidelines, deaths from opioid abuse continue to rise each year. Furthermore, there has been a dramatic rise in deaths caused by synthetic opioids, yet a lesser increase in fatalities due to using illicit street drugs such as heroin. On a positive note, deaths from commonly prescribed opioids have stabilized.

How is it that deaths from prescribed opioids are now stable but deaths from overdoses overall continue to increase? In a typical situation, a patient with a legitimate condition may be prescribed an opioid. There is a high likelihood that it will be misused, so a use disorder or addiction may occur. Due to increased awareness and strict prescription guidelines and regulations, the patient will have a difficult time purchasing illegal opioids because they have become much more expensive. At the same time, accessing black market heroin and synthetics can be achieved less expensively because they are not passed through a legitimate supply chain.⁴ The illegal supply of heroin and synthetic opioids is not regulated, and much of the illicit supply in the United States contains dangerous impurities.⁵

For example, in the latest emerging trend, opioid abusers are switching to fentanyl. Originally designed as a pharmaceutical drug, it is now being manufactured illegally. In pure form, fentanyl is 50 to 100 times more potent than heroin.⁶ Due to these factors, an accidental overdose is more likely to occur than with more controlled opioids.

Growing Pains

Young adults aged 18 to 25 years have a higher risk of misusing a legitimate opioid prescription.⁷ Any opioid provided to an adolescent for any reason will increase their chance of abuse in the future, regardless of whether they have ever used illegal drugs previously. In fact, individuals given a legitimate opioid prescription by 12th grade are 33% more likely to misuse opioids after graduation.⁸ Essentially, these are "normal" adolescents who, up until this time, probably have just said no to drugs as they have been taught. They then have wisdom teeth extractions and are sedated with some combination of an opiate. Soon the pain sets in, so they begin to take the prescription opioid that was provided by their dentist or their oral surgeon. It relieves the pain and makes them feel good. However, these prescriptions are incredibly potent for a young person who is not used to such powerful medications. Misuse can easily turn into abuse, and this abuse can quickly escalate into addiction. Many times, they will progress to something stronger, cheaper, and easier to acquire. Although this story is nonspecific, it happens too often, based on the statistics.

The Pain-Free Myth

At some point in time, opioids became the gold standard for pain relief. In the 1980s and 1990s a trend emerged where society felt the right to feel no pain at all. Opioids were extremely effective, but the research at that time stated that they were nonaddictive. An unprecedented pharmaceutical marketing campaign ensued, and the rest is history-the crisis was created. The goal to be 100% pain free still exists today; many patients may expect to feel no pain at all. From the moment a patient presents with severe pain, healthcare professionals may be expected to eliminate it because of the many powerful prescription medication options available.⁹

The Role Dentists Play: Learn, Commit, Heal

Almost one-fourth of a patient's somatosensory and motor neurons are in the lips, face, mouth, teeth, and gums, and each day, dentists routinely perform microsurgery just millimeters away from these extremely sensitive nerves. Patients expect practitioners not only to fix oral disease but to minimize any resulting discomfort. However, practitioners should consider that prescribing for pain relief beyond what may be needed to reasonably resolve it may contribute to the opioid crisis.¹⁰

Because the majority of the dentist's time is spent fixing a problem caused in the teeth, management of resulting symptoms is usually an afterthought and rarely covered in educational courses, even though dentists rank No. 3 overall of healthcare professionals for prescribing opioids.¹¹ Although the dental profession is not entirely responsible for the opioid crisis, it has played a role. Therefore, it is now arguably the responsibility of the profession to commit to being part of the solution. When healthcare professionals are equipped with information regarding how to manage patient pain, they must do so responsibly. Acquiring this knowledge requires extra time and effort, often without compensation. Yet few things are more rewarding for healthcare providers than treating and healing a patient-without causing additional issues such as addiction.

Opioid Alternatives

Despite many effective alternatives, far too often opioids remain the top choice to manage dental pain. When recommending an opioid alternative to patients, dentists can confidently attest to the effectiveness of comparable options that have been proven to be as effective, if not more effective than opioid treatments.

The metric used to measure the efficacy of pain relief is called the number needed to treat (NNT) (Figure 2). If a medication has an NNT of 1 (best), it is 100% effective at reducing pain by 50% in every patient, which is considered clinically acceptable when determining analgesic efficacy.¹² However, because both dentists and patients may expect 100% pain reduction, there can be a perception problem.

Studies show that naproxen is just as effective at relieving pain as two Percocet^® (oxycodone and acetaminophen) tablets, with a combination of ibuprofen and acetaminophen being the most effective.¹² Another study regarding wisdom teeth extractions and postoperative pain revealed that 325 mg of acetaminophen in combination with 200 mg of ibuprofen provided better pain relief than oral opioids.¹³

Aspirin

Statistics show that 600 mg of aspirin has an NNT of 4.4, which is just as effective as 15 mg of oxycodone at eliminating 50% of pain.^14,15 Aspirin has the following attributes: it is an analgesic that reduces pain, an antipyretic that reduces fever, an anticoagulant that blocks blood clotting, and an anti-inflammatory that reduces the body's natural inflammatory response to tissue damage and pain. Aspirin is contraindicated for patients with an allergy to it and other nonsteroidal anti-inflammatory drugs (NSAIDs); patients with asthma, chronic gastritis, or gout; patients receiving anticoagulants; and patients who are pregnant.¹⁶

Acetaminophen

Acetaminophen is also an analgesic and antipyretic. A 1,000-mg dose has an NNT of 4.6 and is as effective as oxycodone in eliminating pain.^15,17 However, there is a perception among some patients that acetaminophen is not a potent analgesic. This is simply not true based on research, so practitioners should not automatically dismiss acetaminophen as a viable option. Acetaminophen is contraindicated for patients with an allergy to NSAIDs; patients with liver disease, asthma, chronic gastritis, or gout; patients receiving anticoagulants; patients receiving warfarin; and patients who are pregnant. The maximum daily dose of acetaminophen is 3,000 mg.

Naproxen

A 500-mg dose of naproxen sodium has an NNT of 2.7. Studies show that naproxen alone is more effective in relieving pain than oxycodone.¹² Naproxen is an analgesic, an antipyretic, and an anti-inflammatory. Its contraindications are similar to those of aspirin, including patients with an allergy to NSAIDs; patients with asthma, chronic gastritis, or gout; patients receiving anticoagulants; and patients who are pregnant. The maximum dose of naproxen is 1,000 mg.¹⁸

Ibuprofen

Ibuprofen is an analgesic, an antipyretic, and an anti-inflammatory. The NNT of ibuprofen varies based on the dose. Although generally effective in moderate doses, the effect is even greater in higher doses. A 400-mg dose of ibuprofen has an NNT of 2.5, whereas 800 mg holds an NNT of 1.7.¹⁵The contraindications for ibuprofen are similar to those of other NSAIDs, and the maximum daily dose of ibuprofen is 3,200 mg.¹⁹

Winning Combinations

As stated earlier, the combination of ibuprofen and acetaminophen has been repeatedly proven to have the best pain reduction result. It is important to reemphasize that research supports options such as these that are safer and just as effective, or even better than opioids for reducing dental pain. It is the dentist's professional responsibility to change patient expectations by educating them about the many equal alternatives for pain management.

Additional Suggestions for Managing Pain

Take Deliberate Care When Prescribing to Adolescents

When prescribing medication for pain management to adolescents, the dentist must consider that they are at a particularly high risk for developing misuse habits if given an opioid for any reason.^7,8

Long-Acting Anesthetics

After a procedure that is certain to lead to postoperative pain or discomfort, the dentist can consider giving patients a long-lasting anesthetic such as procaine.²⁰ Patients should be informed that the purpose is to allow enough time to fill any prescriptions needed before the anesthetic starts to wear off.

Steroidal Anti-Inflammatories

There are common treatments such as fillings and crowns where pain is a result of inflammation within the nerve in and around the teeth and can become symptomatic afterward. This is especially true for patients who have severe bruxism or attrition. Prescribing a potent steroid such as dexamethasone or a methylprednisolone dose pack for inflammation after treatment is another way to effectively reduce pain. Before steroids are prescribed, the contraindications and drug interactions should be checked. Steroids should not be prescribed for a long duration, but prescribing them for a few days can greatly reduce postprocedure pain.^21-25

Behavioral Management

Setting Patient Expectations

Dentists should have an honest conversation with patients regarding what to expect after any dental procedure. The idea that any postoperative experience will be pain free should not be conveyed, because patients with realistic expectations are less likely to be concerned if the situation gets worse. To mitigate pain, non-opioid options should be offered first. If prescribing an opioid is considered, an informed consent discussion should take place beforehand to review any established opioid prescription policy.

Opioid Prescription Policy

It is strongly recommended that dentists implement an opioid prescription policy into their practice (Figure 3). A solid, patient-geared document is useful in preconditioning pain management expectations, specifically toward opioids. A policy is not a legal document, nor is it designed to fulfill obligations for informed consent, but it is helpful when setting expectations and managing pain, specifically with prescribing opioids. It can be presented directly in the front office, examination rooms, or operatories where patients can clearly access and review it.

When prescribing an opioid, the healthcare professional should be sure that the patient has read the opioid prescription policy to clearly understand what to expect afterward if a refill is needed. Preconditioning patients' expectations to individual practice standards for prescribing opioids for pain management will greatly reduce unreasonable expectations-and because the conversation has already taken place about what to expect postoperatively, patients will more readily accept that they may be in discomfort while their body heals after treatment.

When Opioids Are Considered

Sometimes an opioid is the right answer for postoperative pain. When prescribing an opioid is considered, the healthcare professional should pay close attention to the patient's medical history, review any personal or family history of misuse, abuse, or addiction, and comply with individual state regulations and requirements for informed consent.

Interactions With Other Medications/Mental Disorders

Patients with other comorbidities, such as depression, anxiety, and posttraumatic stress disorder, are more likely to abuse opioids if provided a prescription. In addition, prescribing an opioid concurrently with other medications, such as benzodiazepines, will increase the central nervous system (CNS)-depressing actions of those medications and can lead to overdose.^26,27Dentists should also discuss alcohol consumption with the patient (also a CNS depressant), as well as whether naloxone should be provided. Naloxone is an opioid receptor antagonist that reverses the binding of the opioid to its receptors, reversing the symptoms of overdose. Dentists who consider prescribing an opioid should be very familiar with what naloxone is and how to prescribe it; they should also discuss with the patient, family members, or loved ones when it should be used.²⁸

Legal Considerations

Practitioners who choose to create an opioid policy should always verify state laws to ensure compliance. PDMP requirements should be checked for informed consent, limitations on duration for each prescription, and any continuing education requirements. After checking the state's PDMP, the practitioner can decide which type of opioid(s) to prescribe based on the level of expected pain, individual health, and other medications. Dentists should prescribe for the shortest amount of time possible and be familiar with any individual state prohibitions in regard to duration; many states prohibit prescriptions lasting longer than 7 days. Extended or long-acting formulations should be avoided. Research has shown that patients who take long-acting or extended-release versions of opioids are more likely to overdose.²⁹ Because there is risk of losing a prescription pad or having it stolen, practitioners may also be required to switch to an electronic prescription pad when prescribing opioids.

Morphine Milligram Equivalent Dose

Generally, opioids have some comparison or ratio of potency to morphine, so many states require practitioners to calculate the morphine milligram equivalent dose (MME) of each prescription beforehand. According to the Centers for Disease Control and Prevention, the MME should be less than 50 to reduce the risk of abuse.²⁹

Calculating the MME

To calculate the MME of a prescription, the highest dose possible should be assumed. For example, if a patient is prescribed one or two Vicodin^® (325/5 acetaminophen and hydrocodone) pills every 6 to 8 hours for pain, the most that patient could take is two Vicodin pills every 6 hours, for a total of eight pills per day: Multiply eight by 5 for a total of 40 mg of hydrocodone in 1 day. Then multiply that total amount by the MME conversion factor (1 for hydrocodone), which would equal 40 MME for 1 day.²⁹

Real-World Solutions

Case 1

A 25-year-old male patient presented to the author's practice with severe pain through the submandibular region extending into the temporomandibular region due to multiple decayed teeth and apical lesions. His medical history was negative-he had no known allergies and was not receiving any medications at the time. He had been scheduled back for treatment but was in such severe pain that he could not sleep or function. The author had to determine what to safely prescribe for pain until the patient was able to begin treatment. The author looked him up on the state's PDMP to enable a more educated decision on how to prescribe for this patient. It was discovered that he had not had any prescriptions recently filled, had not been to any other pharmacies, and had not had any other prescribers in the previous 6 months. The author wrote a prescription for him that day for tramadol and acetaminophen (Ultracet^®), one of the author's defaults for moderate to severe pain in combination with ibuprofen.

Ultimately, the author prescribed 500 mg of amoxicillin for his infection, Ultracet for the pain, and ketorolac to be used in combination with the Ultracet. Ketorolac is a potent NSAID that can be used to help reduce moderate to severe pain.^30,31When prescribing ketorolac, the author generally prescribes 10 mg and has the patient take two pills immediately and then one pill every 12 hours thereafter as needed for pain. This was an effective alternative to prescribing an opioid and simply hoping the patient would return for treatment.

Case 2

A 39-year-old female patient presented with stage III, grade C periodontal disease and recurrent decay around all dental restorations. In addition to having bipolar disorder and depression, she had a strong history of substance abuse and addiction. She had been working with an American Society of Addiction Medicine (ASAM)-certified physician regarding her addiction. After a lengthy discussion with her and her loved ones, the author's practice determined that there was no way to effectively restore her teeth given her history, so full-mouth extractions and fixed implants were discussed.

The patient was receiving Suboxone^® prescribed by her treating physician, but she also sought other opioids in between her Suboxone dosages. Suboxone is a combination of buprenorphine and naloxone. Buprenorphine is a partial antagonist and agonist for opioid receptors, meaning that it binds to receptors and introduces actions that the patient may feel with opioids, but it does not provide the same high and craving issues after use. Used in conjunction with naloxone, it will reduce any overdose effects caused by the introduction of an opioid.³²

Patients receiving Suboxone should not be prescribed another opioid under any circumstance without first clearing it with their physician and then having the patient go through a detoxification period to taper off the Suboxone. There was a legitimate reason to consider an opioid for this patient, but that was not a decision that the dentist should make alone. Ultimately, there must be a discussion with the physician.

If the dentist is performing extractions and placing implants in this type of case, a consultation should take place between the dentist and the physician. If an oral surgeon is involved, then the dentist, oral surgeon, and physician should discuss how to handle postoperative pain. The challenge is that if patients receiving Suboxone are given opioids, they will likely misuse that opioid because of a history of misuse and addiction. They will have severe withdrawal symptoms, leading to a negative patient outcome.

Ultimately, the physician informed the patient as to how long she was going to be off Suboxone before surgery. An opioid was then prescribed by the oral surgeon, and the patient was then scheduled to see her physician 1 week postoperatively, which was imperative to assess the opioid use and reestablish her use of Suboxone.

Case 3

A 37-year-old female patient presented with a non-restorable tooth No. 30. The crown failed and had been separated from the root canal-treated tooth. There was a chronic apical lesion in the area, as well as gross decay. The patient had a positive history for substance abuse and a history of Crohn's and liver disease. Her husband was deployed with the military overseas, and her life was generally highly stressful. Due to her history of substance abuse, she was working with an ASAM-certified physician.

The patient was being prescribed Suboxone and clonazepam. Receiving a benzodiazepine (clonazepam) is a contraindication to receiving an opioid because they are both CNS depressants. However, she needed treatment on tooth No. 30, and there would be moderate pain after removing the chronic apical lesion. Because of her medical condition, she was unable to take NSAIDs or acetaminophen; that restriction is what had originally caused her opioid use.

The patient was forthcoming about her substance use disorder. She was very concerned about the postoperative pain from the scheduled tooth extraction because she did not want to take any additional medications. A conference call was scheduled between the author, the surgeon, and the treating physician to discuss all the relevant factors. Ultimately, the physician tapered her off Suboxone, and the oral surgeon prescribed Percocet.

The patient then misused the prescription and 2 days later requested a second prescription. The surgeon consulted with the physician and agreed to write the second prescription.

In the end, the patient did reinitiate her Suboxone treatment. Although her old habits resurfaced by using the Percocet prescription beyond what she was supposed to use, misuse does not necessarily equal abuse or addiction. It simply means that she used the prescription outside of the prescribed doses. Fortunately, she did not fall back into addiction and is doing well.

Safeguarding Patients and the Dental Practice

Patients and families of patients who suffer from the use and abuse of opioids know that opioids continue to create pain for society as a whole. Healthcare providers can put safeguards in place for patients. The goal is to understand alternatives to opioids and present realistic expectations to patients about how to manage their pain to reduce the risk of becoming a statistic.

It is hoped that some of these solutions will better safeguard the dental practice as well. It is imperative for dentists to lower patient expectations for 100% pain-free treatments. In addition, implementing an opioid policy will facilitate conversation about whether opioids are the right option.

Finally, it is important to remember that dentists should be sure their prescribing aligns with individual state regulatory demands to minimize any uninformed prescribing practices in the office. This is especially important if independent contractors, such as oral surgeons, are working in the practice and treating patients of record.

Conclusion

In conclusion, almost everything healthcare providers do to heal patients has the potential to cause pain. Unfortunately, dentists cannot control individual physiology that communicates pain, but they can help by learning how to safely manage it.

About the Author

Adam Burr, DDS
Private Practice
Salt Lake City, Utah

References

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