Roundtable
Q: Do dentists prescribe too many opioid-containing drugs?
Dr. Hersh
Across all the major newspapers in the United States, interviews with leading experts from health-related fields focus on the scope of the prescription opioid abuse problem and question what are we doing about it on the educational side, and what’s going on in the trenches of clinical practice.1 Are we, as dentists, prescribing too many opioid-containing drugs? The simple answer is “yes we are,” and this is supported with clinical research.2 To put this into perspective, it is important to realize that family-care physicians, emergency-department doctors, and orthopedic surgeons contribute to the problem as much as and, in some cases, more than we do.3,4 This still does not get us “off the hook.”
So, why are we doing this? As pointed out in a recent publication, dentists who were trained in the 1970s and early 1980s were educated at a time when acetaminophen combined with codeine (Tylenol® with codeine #3), hydrocodone (Vicodin®), or oxycodone (Percocet®) were the “go to” drugs for postoperative pain control.5 By the mid 1980s, double-blind, randomized, placebo-controlled clinical trials had been published, clearly demonstrating that nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen 400 mg or flurbiprofen 100 mg were just as efficacious as, if not superior to, optimal doses of opioid combination drugs in patients who received dental impaction surgery.6,7 However, because most of these studies were performed to obtain US Food and Drug Administration approval for a general acute pain indication rather than solely for acute postsurgical dental pain, these manuscripts appeared in clinical pharmacology and medical journals not typically read by dental practitioners.
While the current dental literature is now ripe with publications reinforcing the favorable efficacy and tolerability of NSAIDs compared to opioids,8-10 some clinicians either overlook these reports or underestimate the risks. Because the US Drug Enforcement Administration (DEA) classified some opioid-containing drugs as schedule II (highest abuse potential of marketed drugs), patients and dentists perceive them to have more analgesic efficacy strength than other medications.5 This makes dentists in all specialties more likely to prescribe them and patients to have increased expectations for obtaining better pain relief compared to ibuprofen and naproxen, which can be also purchased over-the-counter.
The fact that acetaminophen plus hydrocodone is now a DEA schedule II drug (similar to acetaminophen plus oxycodone) may also add to the problem. Dental practitioners who normally would prescribe or recommend an NSAID postsurgically and only call in the above two drugs for breakthrough pain can no longer do so in many states. This leaves acetaminophen with codeine (Tylenol with codeine #3) or acetaminophen with tramadol hydrochloride (Ultracet®) as the potential call-in opioids. Codeine and tramadol, unfortunately, have some unusual pharmacokinetics in about 10% of the population. These patients are unable to convert these drugs to their active demethylated metabolites—morphine and O-desmethyltramadol—rendering these opioids less effective or ineffective compared with higher metabolizers of these drugs.11 Typical acute opioid side effects of drowsiness, nausea, and constipation may still appear in these individuals.
The state and federal governments have been deeply sensitized to the growing problem of prescription opioid abuse, overdosage, and transition to heroin (which becomes cheaper on the streets). The fact that prescription-drug monitoring programs are now law in almost every state validates this observation. It is up to experts in the field of acute dental pain to educate our students and practitioners on strategies that can be used to reduce the number of opioids we prescribe. If we, as a profession, do not take action, then the bureaucrats will make these decisions for us.
Dr. Dionne
The current national epidemic in opioid overdoses clearly indicates that the widespread availability of opioids is contributing to the initiation of drug abuse and subsequent development of tolerance and dependence. While the therapeutic use of opioids for severe pain that cannot be managed sufficiently by other analgesics alone is appropriate and usually results in a favorable balance between therapeutic benefits and adverse events, their illicit use is contributing to approximately three deaths per hour in the United States. Social attitudes throughout the decades regarding marijuana and alcohol use may have helped propel the nonmedical use of opioids. However, due to the wide variability in potency, dose, and proportion of the opioid drug in formulations that are sold illicitly, the respiratory depressant effects of opioids result in significant morbidity and mortality. Based on the gateway theory of drug abuse, the initiation of drug abuse is typically related to the initial exposure of a drug class, a genetic susceptibility to drug abuse, and the reinforcing properties of the drug. The administration of an opioid analgesic drug combination containing oxycodone or hydrocodone to patients at risk for opioid misuse, especially adolescents, may be sufficient to expose individuals to the euphoric effects of opioids and can serve as the first step in the transition from drug exposure to opioid abuse. Prescribing opioid combinations for acute pain in vulnerable populations may represent an irrational clinical practice, as other drugs and therapeutic strategies are generally more effective and have little risk for precipitating opioid abuse.
The old dogma that provided a rationale for prescribing an opioid combination, eg, Tylenol with codeine #3 or Percocet, was based on a need to provide greater analgesic effect than what was produced by aspirin or acetaminophen use alone. The introduction of NSAIDs in the 1970s and the development of the oral-surgery model of acute pain demonstrated that a single-entity NSAID is usually more effective than opioid-containing combinations, is better tolerated by ambulatory patients, and results in less edema following oral surgery. In the 1980s, it was found that administration of an NSAID prior to the onset of acute inflammation reduces postoperative pain and attenuates the development of hyperalgesia contributing to pain at 24 to 72 hours following dental surgery. A more effective therapeutic approach that minimizes the need to prescribe opioids for acute dental pain is a preventive strategy.12 This is based on the proven clinical efficacy of administering an NSAID prior to pain onset to suppress the local release of prostanoids at the site of tissue injury, thereby minimizing the development of peripheral sensitization. For hyperalgesia, by-the-clock administration of an NSAID to maintain pain suppression for the first 24 to 72 hours can be used. When employed with a long-acting local anesthetic, the postoperative nociceptive barrage over the first 4 to 8 hours following tissue injury is further minimized and results in an additive preventive analgesic effect. In those patients who do not report adequate pain relief, acetaminophen can also be administered postoperatively by-the-clock as an adjunct to the additive analgesic effects of the NSAID and the local anesthetic. If a rescue analgesic is needed, Ultracet can be prescribed to avoid the greater respiratory depression and abuse potential of other opioids. (See cced.cdeworld.com/courses/5009 for dosing recommendations.)
The old dogma is to prescribe opioid combinations to virtually all patients expected to have postoperative pain following a dental procedure. Use of a preventive/additive/adaptive approach to the pain paradigm predicts greater efficacy, fewer adverse events, and less exposure to opioids that contribute to the initiation of drug abuse in a finite number of dental patients. The relevant question is not whether dentists are prescribing too many opioids but rather: why are they prescribing any opioids?
Dr. Moore
The faculty members and residents of the University of Pittsburgh’s Department of Dental Anesthesiology recently evaluated the use of opioid pain medications following third-molar extraction surgery. By using a structured telephone interview process, our goal was to determine the patients’ actual consumption of prescribed opioid analgesics.13 The patients had each been provided a prescription for about 20 tablets of acetaminophen/hydrocodone (Vicodin, Norco®, etc.) to manage postoperative pain. When contacted 7 days after surgery, we found that 10% of the patients did not fill the prescription or did not use any of the tablets. About 5% required more than the initial prescription of 20 tablets because of a “dry socket” or an infection. On average, the interviewed patients used only eight tablets during the course of 7 days.
The dilemma for surgeons is, of course, trying to determine which of their patients won’t need opioid analgesics and which patients may require all 20 tablets. So when I am asked if oral surgeons overprescribe opioids analgesics following third-molar extractions, the answer is clearly no. After all, our primary responsibility as oral-health practitioners is to provide compassionate care for our patients, including proper management of their postsurgical pain. A prescription for 20 Vicodin tablets is likely to be adequate for most patients.
So how do we prevent unused opioid analgesics from being diverted for nonmedical use and abuse? Part of the solution is to provide an opioid-sparing multimodal pain-management approach. Many perioperative therapeutic strategies can limit postoperative pain and reduce the need for opioid analgesics such as Vicodin or Percocet.8 Providing ice packs has been a traditional method to control postoperative swelling. The use of a long-acting local anesthetic such as bupivacaine hydrochloride (Marcaine®) can delay the onset of acute pain following surgery. The intravenous administration of a corticosteroid such as dexamethasone minimizes trismus and postoperative pain. Similarly, preemptive NSAIDs such as naproxen, ibuprofen, and ketorolac can decrease the severity of pain when local anesthesia wears off. Initiating postoperative pain control with an NSAID alone or in combination with acetaminophen has been found to be a very effective nonopioid alternative.9 These therapies, either alone or in combination, have been found to be effective in delaying the onset and minimizing the severity of postoperative pain.
Principles of safe and responsible prescribing have been repeatedly advocated in recent years.14 At the University of Pittsburgh, we teach our dental students to counsel patients about the possible side effects and the abuse potential of opioid analgesics. This is essential, particularly for adolescent patients who may have never taken an opioid analgesic. Some state dental societies are recommending written informed consent documents when prescribing opioids to minors. Providing patients with information regarding pain expectations is also important. Prescription Drug Monitoring Programs (state-operated electronic databases for monitoring the prescriptions of controlled substances our patients receive) can be accessed when available to prevent “doctor shopping” behaviors. The number of tablets of opioid pain medications to be dispensed should be limited, usually to a 2- or 3-day supply. Recommendations to properly secure and dispose of unused opioid pain medications should also be provided to patients.
For 30 years, I have taught the initial didactic course in pharmacology and therapeutics that introduces the concept of therapeutic index and risk/benefit ratios. As our profession and our society have grown more complex, we have broadened our definition of risk beyond the specific adverse effects our patients might encounter, such as nausea, vomiting, constipation, drug interactions, and respiratory difficulties. With the current opioid epidemic facing our nation, our responsibilities have expanded to address the life-threatening environment of opioid abuse and addiction. Our assessment of risk has broadened to include the potential of diversion of our unused prescription opioids to friends and family members, a diversion that may contribute to our nation’s opioid abuse and overdose epidemic.
Elliot V. Hersh, DMD, MS, PhD
Professor, Pharmacology, University of Pennsylvania School of Dental Medicine, Philadelphia, PA
Raymond A. Dionne, DDS, PhD
Professor, Brody School of Medicine, Department of Pharmacology and Toxicology, School of Dental Medicine, Department of Foundational Sciences, East Carolina University, Greenville, NC
Paul A. Moore, DMD, PhD, MPH
Professor, Pharmacology, Dental Anesthesiology and Dental Public Health, School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA
References
1. Jablow P. Opioid fight starts with a dental chair. Philadelphia Inquirer. May 29, 2016:G1, G6.
2. Maughan BC, Hersh EV, Shofer FS, et al. Unused opioid analgesics and drug disposal following outpatient dental surgery: a randomized controlled trial. Drug Alcohol Depend. 2016;168:328-334.
3. Levy B, Paulozzi L, Mack KA, Jones CM. Trends in opioid analgesic-prescribing rates by specialty, U.S., 2007-2012. Am J Prev Med. 2015;49(3):409-413.
4. Ringwalt C, Gugelmann H, Garrettson M, et al. Differential prescribing of opioid analgesics according to physician specialty for Medicaid patients with chronic noncancer pain diagnoses. Pain Res Manag. 2014;19(4):179-185.
5. Moore PA, Dionne RA, Cooper SA, Hersh EV. Why do we prescribe Vicodin? J Am Dent Assoc. 2016;147(7):530-533.
6. Cooper SA, Engel J, Ladov M, et al. Analgesic efficacy of an ibuprofen-codeine combination. Pharmacotherapy. 1982;2(3):162-167.
7. Dionne RA. Suppression of dental pain by preoperative administration of flurbiprofen. Amer J Med. 1986;80(3A):41-49.
8. Hersh EV, Kane WT, O’Neil MG, et al. Prescribing recommendations for the treatment of acute pain in dentistry. Compend Contin Educ Dent. 2011;32(3):22, 24-30.
9. Moore PA, Hersh EV. Combining ibuprofen and acetaminophen for acute pain management after third-molar extractions: translating clinical research to dental practice. J Am Dent Assoc. 2013;144(8):898-908.
10. Aminoshariae A, Kulild JC, Donaldson M, Hersh EV. Evidence-based recommendations for analgesic efficacy to treat pain of endodontic origin: a systematic review of randomized controlled trials. J Am Dent Assoc. 2016;147(10):826-839.
11. Hersh EV, Pinto A, Moore PA. Adverse drug interactions involving common prescription and over-the-counter analgesic agents. Clin Ther. 2007;29(suppl):2477-2497.
12. Dionne RA, Gordon SM. Changing paradigms for acute dental pain: prevention is better than PRN. J Calif Dent Assoc. 2015;43(11):655-662.
13. Welland B, Wach A, Kanar B, et al. Use of opioid pain relievers following extraction of third molars. Compend Cont Educ Dent. 2015;36(2):2-9.
14. Moore PA, Hersh EV. Principles of pain management in dentistry. In: O’Neil, ed. The ADA Practical Guide to Substance Use Disorders and Safe Prescribing. Hoboken, NJ: Wiley; 2015.
