COMMENTARY

Understanding Opioids: Part 2

Elinore F. McCance-Katz, MD, PhD; Jeffrey N. Baldwin, PharmD; Ann Marie Schreier, PhD, RN; William T. Kane, DDS, MBA

Disclosures

January 16, 2013

In This Article

And, Finally, Dentists

Dr. McCance-Katz: Thank you, Dr. Baldwin. Dr. Kane, can you comment on dental practice and the prescribing of opioids? How are dentists taught about analgesia for dental pain? What are the options for relief of dental pain? Given that dentists do prescribe opioid pain medications, do they receive training on recognition and treatment of misuse and addiction?

Dr. Kane: In regard to how dentists learn about analgesia and pain control, my personal experience goes back to the late 1970s when I was at the University of Missouri School of Dentistry. Pain control and analgesia were initially addressed during the second-year didactic courses like anesthesia, oral surgery, periodontics, endodontics, and pharmacology. In the third-year dental curriculum, a course in therapeutics is offered and the students begin their clinical training. There is significant exposure to "practical prescribing" from part time instructors in the various clinical areas. For example, generous prescribing was encouraged to manage pain following dental procedures such as extractions (eg, "Write them a prescription for Tylenol® #3, #20 and for #25 if it is Friday." Whether this occurs in dental education today I cannot say with certainty; however, based on my experience speaking with recent graduates, it appears that what is taught today is very similar to my training. Individuals who participate in general practice residencies or various specialty training programs receive additional practical training in prescribing.

I received no training regarding addiction or substance abuse treatment during dental school. When I began practicing in a small, rural town, I observed the types of analgesics that were being given to patients by the oral surgeons in my area because they would include this information in letters to me regarding treatment of patients I referred to them. This is where I developed my own comfort zone in prescribing. I took note of the type and amount of analgesic medicines being prescribed to address dental postoperative pain. For example, oral surgeons in my area prescribed Fiorinal® #3 or Synalgos®-DC for full mouth extractions or third molar extractions. I concluded that this level of analgesia would be effective for single extractions or endodontic procedures that I undertook in my own practice.

On a personal note, I became involved with self-medicating in late 1983 and sought treatment for chemical dependency in January 1984. My drug of choice was an opioid, meperidine. On my first day in treatment, I met a patient who had been in recovery for one and a half years and had to have a root canal. For analgesia, she was given nitrous oxide during the procedure and postoperatively received a prescription for oxycodone, which may have been the catalyst to the start of her relapse. This made an incredible impression on me, and this event marks the point at which my interest began in the management of dental patients with active addiction and in recovery.

I recently presented a continuing education course in San Francisco at the ADA's Annual Session on this very subject. Additionally, I have published peer-reviewed articles on this topic. It seems as though there is need for this type of continuing education, particularly for those dentists in practice for some time who need to revisit the topics of dental pain, analgesia, and potential for development of substance use disorders.

In 2009 and 2010, I participated in the Tufts Healthcare Institute Program on Opioid Risk Management. This experience changed my outlook on the provision of appropriate analgesia. The project brought together leaders from academics, government, law enforcement, as well as practicing dentists to address proper prescribing of opioid analgesia and how dentistry might actually be playing a part in the prescription drug epidemic. When Dr. Paul Moore from the University of Pittsburgh asked, "What do you think happens to the unused pills in the prescription bottle?" I gained several important insights regarding the potential of well-meaning dentists to contribute to opioid pain medication misuse and abuse.

Prior to this meeting, I did not know how much dentistry contributed to opioid diversion and nonmedical use of opioids. As a result of this meeting, an article was published in the Journal of the American Dental Association on opioid diversion.[1] This was around the time that a white paper was released from the White House about the "Prescription Drug Epidemic."[2] The ADA was also asked to participate with the AAAP in the aforementioned PCSS-O project, providing webinar and online training, a mentoring program, and a list-serve discussion that focuses on safe and effective use of opioids in treatment. The participation of the ADA in this project will help to educate dentists on all of these issues. I am beginning to see continuing education courses on appropriate prescribing within the field of dental medicine, and I think we are going to see more of this in dentistry.

One area in particular that I am interested in is how dentistry manages patients with chronic pain issues taking large amounts of opioid medications who may have substantial tolerance to opioids but require pain management following a dental procedure. I think most dentists tend to misunderstand this subgroup of patients and often undertreat their acute pain issues. Often, patients taking large amounts of opioids for chronic pain issues will present in a dental office complaining of extreme acute pain. I feel most dentists do not understand that this subgroup of patients has pain that may be in excess of what many patients experience (potentially hyperalgesia related to sensitivity to painful stimuli induced by chronic opioid use) or will have pain following dental procedures that will not be addressed by their standing opioid doses. I was not trained to recognize this as a dental student, and I thought these patients were merely being dramatic or were drug seeking. I think this is a common view with practicing dentists.

For example, in the past, I told a patient prescribed methadone for chronic pain that the methadone dose should cover any postoperative pain, and I did not prescribe any opioid analgesics. Thus, I had underestimated and undertreated the pain experienced by this patient both pre- and postoperatively. If these patients are being treated by a pain management physician, a telephone consult is in order. I now know these patients often require higher doses of an opioid analgesic than I would have thought and would be comfortable prescribing without a consultation with their physician. These types of increasingly common clinical situations should be addressed in continuing education as well as in training in undergraduate dental schools and specialty programs.

Currently, I am seeing several patients in my practice taking buprenorphine/naloxone, and of course this requires a different approach to their analgesia needs. I have found that buprenorphine/naloxone dose splitting and increasing of the dose if necessary has been successful in patients undergoing dental procedures that can be associated with pain. I think this approach is best to use whenever possible because it does not require discontinuation and reinduction onto buprenorphine/naloxone. Of course, the prescribing of an opioid (which, for patients being treated with buprenorphine/naloxone for opioid addiction, may have caused problems previously) will require discontinuation of buprenorphine/naloxone and subsequent restarting of the medication. This process can place a patient with opioid dependence at risk for relapse. In addition to using the dose-splitting approach, I also like to consult with the prescribing physician. In that way, the physician is in the loop and we can support decisions that each of us make. I often receive calls from my fellow dentists looking for information about this subject. Additionally, I get calls about prescribing opioids for dental patients in abstinence-based recovery as well. This can be a slippery slope, and I generally recommend a physician consultation with comanagement similar to that in patients taking warfarin.

I think that dentists in practice as well as those still in undergraduate dental schools and certainly those in specialty programs need more information and educational efforts on treating patients in both active disease (addiction) as well as in the various forms of recovery. I tell my fellow dentists that regardless of whether the patient is in recovery, we should use our clinical judgment and determine how long the patient will need a narcotic pain medication. This is usually 2-3 days following a dental procedure. Dentists should then have the patient use a nonsteroidal anti-inflammatory drug (NSAID) for continued pain. If pain persists after 48-72 hours, there could be some further complication that may need to be addressed such as recurrent infection, a dry socket, or something similar. I also think dentists underestimate the power of NSAIDs and do not consider the potential use of pentazocine/naloxone for postoperative pain relief.

Pentazocine/naloxone is indicated for moderate to severe pain (which is the same indication as for oxycodone) and is a Schedule IV drug, indicating less abuse liability than hydrocodone or oxycodone. A single 50-mg pentazocine dose is equivalent to approximately codeine 60 mg, and the addition of naloxone does not impede analgesia but does reduce the risk for injected abuse. (When injected by an opioid-dependent person, it will produce severe opiate withdrawal). Opiate withdrawal is not life-threatening but is very uncomfortable, so the addition of naloxone 0.5 mg (similar to the approach with buprenorphine/naloxone for treatment of opioid addiction) reduces abuse and increases safety. This approach can be particularly helpful for patients recently abstinent from methamphetamine or opioids and who may need significant dental work as a result of the abuse of these drugs. Ongoing, regular education on effective approaches to dental analgesia should help to change dental practice in this area.

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