Rethinking pain management in our dental practices

By Solomon Poyourow DDS, MD, MPH

The overuse of prescription opioids and opiates has become a national crisis. According to the state Department of Public Health, there were 1,925 opioid-related overdose deaths in 2016 in California. What’s more, in 2014, hydrocodone combinations were changed from Schedule III to Schedule II drugs like oxycodone (Percocet, OxyContin) and we lost the privilege to prescribe opioid analgesics, such as hydrocodone (Vicodin, Norco), with refills. Not long after, we started to see best practices for acute pain management emerge that do not rely on opiates and laws seeking to restrict prescribing and require better tracking of opioid prescribing and dispensing. Given these trends, now is a good time for all health care professionals to rethink pain management.

Dentists do a good job managing acute, short-term pain and dentists are not the primary prescribers of opioid analgesics for adults. However, we perform a lot of dental surgeries that result in a lot of opioid prescriptions, and we prescribe the majority of opioid analgesics for children ages 11 to 18. Let’s take a closer look at acute pain management and why it’s time to change our behavior.

Managing postoperative pain

There are various approaches to managing acute pain from dental treatment. I have tried several approaches myself over the years and have my own algorithm for these types of decisions. However, as the number of people experiencing substance use disorders has skyrocketed and there is intense focus on contributing factors, it is more important than ever to look to experts in the field and follow best practices. Gone are the days where I could decide these things without considering the bigger picture. With that as background, here is the stepwise recommendation for acute pain management published in the 2015 ADA Practical Guide to Substance Use Disorders and Safe Prescribing (p 45):

  • Mild pain: Ibuprofen 200-400 mg every four to six hours as needed for pain (p.r.n.)
  • Mild-to-moderate pain: Ibuprofen 400-600 mg every six hours: fixed interval for 24 hrs., then ibuprofen 400 mg q 4-6 hrs. p.r.n. pain
  • Moderate-to-severe pain: Ibuprofen 400-600 mg plus APAP 500 mg every six hours: fixed interval for 24 hrs., then ibuprofen 400 mg plus APAP 500 mg every six hrs. p.r.n. pain
  • Severe pain: Ibuprofen 400-600 mg plus APAP 650 mg hydrocodone 10 mg q six hours: fixed interval for 24-48 hrs., then ibuprofen 400-600 mg plus APAP 500 mg q six hrs. p.r.n. pain

Additional considerations include:

  • Patients should be cautioned to avoid APAP in other medications. Maximum dose for APAP is 3,000 mg/day. To avoid potential APAP toxicity, dentist should consider prescribing a rescue medication containing ibuprofen (Vicoprofen) if patients experience breakthrough pain. Maximum dose of ibuprofen is 2,400 mg/day. Higher maximal dailydoses have been reported for osteoarthritis when prescribed under the direction of a physician.

Future revisions of the guidelines may take into account a finding that was reported in a recent overview of systemic reviews. In “Benefits and Harms Associated with Analgesic Medications Used in the Management of Acute Dental Pain,” published in the April 2018 Journal of the American Dental Assocation, the authors concluded:

When comparing the efficacy of nonsteroidal anti-inflammatory medications with opioids in relation to the magnitude of pain relief, the combination of 400 mg of ibuprofen plus 1,000 mg of acetaminophen was found to be superior to any opioid-containing medication or medication combination studied. In addition, the opioid-containing medications or medication combinations studied were all found to have higher risk of inducing acute adverse events than 400 mg of ibuprofen plus 1,000 mg of acetaminophen. Thus, in general, when considering either benefits or harms, management of acute pain with nonsteroidal medications, with or without acetaminophen, appears to have a therapeutic advantage to opioid-containing medications. Although there are situations in which clinical judgment indicates an opioid-containing medication may be warranted, the data make a compelling case favoring use of nonsteroidal medications, with or without acetaminophen.

Controlled Substances Regulation in California

To assist health care practitioners in their efforts to ensure appropriate prescribing, ordering, administering, furnishing and dispensing of controlled substances, the state of California’s Department of Justice established the Controlled Substance Utilization Review and Evaluation System. CURES, if used consistently by controlled-substance prescribers and dispensers, is an excellent tool for regulatory and law enforcement agencies to reduce the diversion and resultant abuse of Schedule II, Schedule III and Schedule IV controlled substances and for statistical analysis, education and research.

This system makes it possible for controlled-substance prescribers, those who possess an active DEA license and a California health care provider license, to review the database prior to prescribing medications with the potential for abuse. Under California law, all California-licensed prescribers authorized to prescribe controlled substances were required to register to access CURES 2.0 by July 1, 2016. The law requires mandatory use beginning Oct. 2, 2018. Once a provider is registered in the system, the program requires passwords to be changed every 90 days. The system is very easy to use — and fast. It can be utilized in about two minutes.

CURES 2.0 is committed to the reduction of prescription drug abuse and diversion without affecting legitimate health care practice or patient care. Hopefully, this state-mandated program will help prescribers see the true drug history of their patients and alert dispensers before dispensing controlled substances to patients who are seeking them for illegitimate purposes.

Substance use disorders and first exposure

Substance use disorders are not well understood and are often viewed as a moral problem or just a lack of self-control. However, as brain research into these disorders advances, we continue to learn more about the SUD continuum and the contributing biological, physiological and psychological factors. The SUD we know as “addiction” is a concern with the prescription of opiates and opioids and likely the cause of various drug-seeking behaviors we see in the dental office, including exaggeration of pain severity, running out of medication early or frequent dental visits that are apparently unnecessary.

According to the ADA guide, “Addiction is a primary chronic disease of brain reward, motivation, memory, judgment and related circuitry . . . characterized by the inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems in behavior and interpersonal relationship, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission.”

Of particular concern to me as an oral surgeon is research showing an association between exposure to drugs and alcohol early in life with an SUD in later life. Sometimes even a small amount of a substance results in subsequent drug-seeking activity.

Given the current evidence, I prefer a non-narcotic prescription for postsurgical pain in children and young adults. I spend a bit more time on my post-op discussion reassuring parents and patients that their pain will be effectively controlled without narcotics. Most parents welcome the approach and understand that I have their child’s best interests at heart at all stages of treatment, during surgery and afterward.

I encourage other dentists to contemplate their routine prescribing practices, read the available evidence and try a different approach if they tend to prescribe a narcotic to most patients. As each patient is different and requires tailored medical and dental treatment, the same can be said of postoperative pain management.

Related Items

Beginning Oct. 2, all licensees authorized to prescribe, order, administer, furnish or dispense controlled substances in California must, with some exceptions, check a patient’s prescription history in CURES 2.0 before prescribing a Schedule II-IV substance, as CDA first reported in April. One notable exemption to mandatory CURES consultation that applies to dental care and that CDA helped secure is summarized here.

The September 2018 issue of the Update, CDA’s monthly news magazine, focuses entirely on the opioid crisis gripping America and on dentistry’s leadership role in this crisis. Articles include “Rethinking pain management in our dental practices,” by Solomon Poyourow, DDS, MD, MPH, and “End first exposure: Dentistry’s biggest opportunity in the opioid crisis” by Kerry K. Carney, DDS, CDE. Other articles discuss legislative efforts to curb opioid abuse, alternatives to opioids for managing pain and instructions for prescribing controlled substances electronically.