JADA: Dental Pain Management: Opioids, NSAIDs and Other Options


your publisher review in JADA recently
about the efficacy of a combination of ibuprofen and acetaminophen to manage
pain what were your conclusions and what are the clinical significance of that the use of those two drugs to non opioid
drugs ibuprofen which is advil and the sedum in ofin which is tylenol it’s
always been suspected that they might have some additive effects some way that
they actually provide greater analgesia than either one of those drugs alone and
it’s kind of based on an old pharmacologic principle that when you
combine two drugs that have different mechanisms that when you put them
together you can get added benefits but the data was never there until about
four years ago and we’re beginning to see some clinical trials that really
demonstrate that this is pretty remarkable in terms of how much
additional analgesia particularly in our an inflammatory pain model that you get
with that combination and and clinically what’s important it seems to me is we
have always been kind of in this position of either taking tylenol or
taking ibuprofen advil or having to take vicodin or percocet as our analgesic
this actually gives you a position where there’s kind of another level another
step in our kind of continuum of analgesics from mild ones to moderate
ones now we can throw in this combination and the findings are that
this might be opioid sparing in the sense that it doesn’t require that you
use vicodin all of a sudden you have an alternative to having to go to an opioid
wonderful now you mentioned vicodin and percocet do you think that dentist’s are over
prescribing when it comes to those type of opioids. I mean over prescribing is
just a loaded term I think we have a dilemma and it’s a dilemma that we see
in dentistry we see it in doing bunionectomy as we see it when we do
orthopaedic knee surgery and the problem is
we do surgeries on an outpatient basis we prescribe a drug when the patient is
still numb so we don’t haven’t have any idea how much pain they’re going to have
and what we’re prescribing for is how much pain they may or may not have in
three days or two days and the question then becomes how do we know who needs it
and the answer is we don’t know for sure we did a wonderful study where we
instead of looking at what was prescribed we looked at how many of
those opioid pain relievers were what’s actually used by our patients and what
you see is about 15 percent of the patients don’t want to use a vicodin or
percocet they don’t fill it and they don’t use it you see a couple patients
two or three percent who in fact have dry sockets and have extreme the pain
and they need more than we give them but in that middle section there on average
they use a tablets but we don’t know who needs what and our we’re at a loss on
how we can make sure they are not having pain because that really is our first
job is to treat our patients but we also don’t want them to leave 20 tablets
sitting in a medicine cabinet unsecured therein otherwise our problem you also
use the term opioid sparing so are there any strategies involved in using opioids
sparing when it comes to acute management of pain that they should be aware of
well I think what we’re doing now is both in medicine and in dentistry and in
podiatry and all of our surgical fields is we’re trying to think of ways that we
can prevent pain and particularly prevent severe pain and if we can use
mechanisms that keep you from having severe pain then the need to use opioid
analgesics is going to decrease and that it’s been shown in a couple models in
dentistry I think the first one I recall was work using marking maybe fifty years
ago that if in fact after surgery you use a long-acting local anesthetic well
then the patient is numb for six ten hours and doesn’t need to have a
real strong opioid pain reliever additionally in oral surgery that we are
kind of customed to giving steroids corticosteroids like dexamethasone that
prevents swelling and decrease the discomfort postoperatively and most
recently I think we’ve seen use of non-steroidal drugs drugs like naproxen
drugs like ibuprofen and to offer those and give those to patients before they
leave the office before they’re ever in pain to try to get blood levels
established so that you decrease the need for opioids in the in six eight ten
hours after surgery it’s a reasonably good strategy it falls into that
multimodal pain management model that we all talk about these days
so you said decreasing the use of opioids so there’s still a place maybe
for the use of opioids and would it be any strategy somehow to teach the dental
students and dentists how to use opioids in case it’s needed well I think we’re
really moving in that direction to a great extent I mean I think there’s new
curriculums being developed in terms of how we teach opioid prescription writing
and safe prescription writing for our students there are a number of things
that we talked about one is just the basis of is this patient is it
appropriate to give an opioid to this patient do they have a history of abuse
are they pregnant are they on drugs that may have caused drug interactions that’s
kind of the medicine part probably you know more about that than I do but on
the other hand we like to think about how we could instruct patients counsel
patients on how to go about using this prescription we’re offering that
instruction for me and what I teach is mrs. Jones this is prescription for an
opioid you may not have to fill this at all I’m giving it to you so that you
have it on hand in case you do need it but 60% of my patients
going to ever require an opioid to manage the pain the pain is never that
severe so that kind of counseling on what to expect postoperatively becomes
an important part of what we do and then and then we get there instructions that
we’re now talking about don’t share this drug with anybody make sure you keep it
secured lock and keys so that nobody else is using that drug and make sure you
dispose of it properly after 7-10 days after you no longer need it so opioid
drug abuse still exists obviously so is there a place for dentists and even ADA
in the health of combating this type of drug abuse that exists in this country
and elsewhere well I think we’re all really alert to the kind of increased
use of opioids misuse of opioids overdose deaths in the United States
have dramatically increased and I think all of us physicians dentists patients
law enforcement regulatories even the President of the United States
at this point are all interested in how they can jointly collaborate and
cooperate to try to decrease this misuse of opioids in honesty in the last couple
years is really an indication that prescribing has decreased that the
problem is not so much prescription drugs as it has been but now it’s moving
in to illicit drugs such as heroin and fentanyl and the overdose deaths are
being reported for that that kind of use rather than misuse of a prescription
drug in the July issue of Jada you and your co-authors have written a
commentary about the vicodin verses and the inflammatory drugs do you want to
make any comments on that for the audience well I mean we’ve been arguing
for a long time about the fact that in inflammatory pain in post-operative
dental pain the nonsteroidals invariably are more effective than the opioids
particularly the way we prescribed opioids one tablet four to
six hour kind of prescribing of vicodin the nonsteroidals really work better and
particularly the combination of a non-steroidal with acetaminophen
it’s just shows extreme efficacy compared to vicodin but there’s a lot of
reasons why we prescribed vicodin sometimes it’s just the patient’s demand
it of us that’s probably not a good reason to to write a prescription for an
opioid but we recognize pain management is the holy grail of good care of
compassionate care what a patient knows is whether they hurt or not at the end
of the day and so we’re pretty sensitive to making sure that we do everything we
can for our individual patient to make sure they’re not in pain the problem is
what happens if this is the patient who doesn’t need more than one tab or two
tab or three tab then you get this unused part that you really need to
instruct your patients that you need to secure it and dispose of it properly
but there are contraindications for nonsteroidals
ibuprofen as wellness acetaminophen and so and so forth where maybe opioids may
be the alternative a choice I would never suggest that we don’t need to have
opioids as part of our armamentarium our management tools most of the side
effects and contraindications for nonsteroidals are long-term use not
short-term use and so to a great extent well most of our patients are going to
do well on a on a non-steroidal but I think there are times when the pain is
really severe when you’re talking about a dry socket when you’re talking about a
very acute odontogenic infection the nonsteroidals
may not be able to cover that and that you may need to go to an opioid pain
reliever it had a reasonably good dose to be able to manage that pain with an
oral analgesic you would add anything there is one
thing that makes us unique and I think you really need to stop and think about
the fact that most of our prescribing not most but a great deal of our
prescribing has to do with taking out wisdom teeth well now we’re talking
about young adults we’re talking about adolescence and if you look think about
your own experience in your own kids the first time they ever saw a vicodin was
probably after they had their wisdom teeth taken out think about that it only
occurred to me four or five months ago this is really why we are sometimes in
the cross hairs with the media because not that we prescribe a lot we in fact
don’t prescribe a great number of a great amount of these agents but we’re
the first and you know if somebody is going to get in trouble with alcohol or
tobacco or anything it’s that first experience that can really be problem
and I i lecture very heavily that we have a special opportunity and
responsibility but particularly an opportunity to stop and say to this
eighteen year old who’s just had his wisdom teeth taken out this drug has
some very dangerous potentials in terms of misuse and abuse and you need to be
very careful about all doing that and I think that that’s a one of those
teaching moments that I think we all ought to think about when we prescribe
particularly to an adolescent or a young adult
great thank you very much thank you for coming I enjoyed it all right we’ll do
it again sometime you

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