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Changing Opioid Prescribing Patterns for Post-Extraction Dental Pain

May 9, 2017
Dentists are the second highest prescribers of opioids. However patient preference and public awareness of the opioid abuse crisis have turned the tide on prescribing immediate-release opioids after dental extractions, which have declined in recent years.

Over the past 20 years, an increase in prescribing of opioid pain medications has contributed to the heightened rate of unintentional drug overdose deaths.1 Dentistry, in particular, has been directly affected by the national crisis of opioid abuse. While primary care physicians prescribe the majority of opioids, dentists prescribe them at a higher rate than do primary care physicians and are the second highest prescribers of opioids.2

According to a survey of over 1,500 oral surgery patients or their parents, more than 7 in 10 respondents indicated they would opt for a non-opioid medication to treat postsurgical pain from third molar (wisdom tooth) extraction if given the choice. Despite the desire for an alternative, 70% of respondents reported an opioid was prescribed post-extraction. These findings are being presented at the 2017 Annual Meeting of the American College of Oral and Maxillofacial Surgeons (ACOMS).3

“It’s evident that opioids continue to be the cornerstone of pain management following third molar extraction, despite their association with unwanted side effects and the risk for abuse or addiction,” said Pedro Franco, DDS, one of the study investigators. “This research shows us that an overwhelming majority of patients—many of whom are likely exposed to opioids for the first time following an oral surgery procedure—would prefer a non-opioid option. I am hopeful that these findings will encourage clinicians and patients alike to be more proactive in their pain management discussions, especially as it relates to the availability of opioid alternatives.”

X-ray of wisdom teeth.

This study brings up an interesting, but perhaps misleading point. Yes, immediate-release opioids are often prescribed for management of post-extraction dental pain. However, there has been an overall drop in opioid prescriptions by dentists, largely due to a combination of continuing education requirements and increased awareness of the risks of opioid abuse.4

In fact, a dental visit may serve as an optimal point of intervention for screening and educating patients regarding the risks associated with prescription opioid misuse and diversion. Although most dentists receive training related to prescribing opioids, there is a gap in the assessment and identification of prescription opioid misuse and diversion. There is also a gap in the recommended risk mitigation strategies, including screening for prescription drug abuse, consistent patient education, and the use of a Prescription Drug Monitoring Program, or PDMP, prior to prescribing opioids.5

Why Use Opioids After Tooth Extraction?

The strategy of combining 2 analgesic agents having distinct mechanisms or sites of action (eg, combining a peripherally-acting analgesic with a centrally-acting analgesic) has been long advocated.6 Combinations of acetaminophen with hydrocodone (Vicodin, Lorcet, etc.) are the most frequently prescribed drugs in the United States.7 Analgesic formulations containing an opioid and a peripherally-active analgesic consistently provide greater pain relief than do the component agents when administered alone.8

But, including an opioid as part of an analgesic combination increases the risk of adverse reactions (ie, nausea, vomiting, psychomotor impairment, etc.) and carries the risk of drug misuse and abuse in some patients.9 In dentistry, the additive effects of ibuprofen-APAP combination seem to be effective for pain control of post-extraction pain in most patients. This combination has the potential to provide profound pain relief while minimizing adverse effects.10

The decision to prescribe any pain medication must be made by the doctor, with full disclosure of its potential dangers to the patient. While most dental post-operative pain can be treated effectively without opioids, it is imperative that the prescribing decision be made by the doctor, with appropriate input from the patient.

The survey findings, which was conducted by Nielsen’s Harris Poll Online using a nationwide electronic survey and sponsored by Pacira Pharmacueticals, highlights an opportunity to bridge the gap in surgeon/patient communication. At least 90% of patients and parents indicated wanting the opportunity to discuss a personal pain management plan with their surgeon in advance of their procedure, and many (up to 71%) reported feeling concerned about the potential for opioid-related adverse effects. Despite this, only approximately 40% discussed these concerns with their surgeon, noted the survey results.3

The survey results require further unbiased study. While the authors claim that the research shows “…an overwhelming majority of patients…would prefer a non-opioid option…”, a final, definitive statement regarding patient preferences and trends requires comprehensive research. Many patients, due to the media coverage of opioid misuse, certainly will request non-opioid options if given the option. Others, however, will insist that opioids are necessary for achieving comfort during their recovery.

The dentist, in concert with the patient, must make the ultimate prescription decision. An ethical, compassionate decision necessitates a thorough presentation of all the positive and negative attributes of each available medication.

It must be noted that Pacira Pharmaceuticals publishes these survey results alongside its sponsorship of webinars for dentists, urging them to incorporate Pacira’s drug, Exparel (bupivacaine), into their practice’s pain management strategies.

Last updated on: April 10, 2018
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