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Is it Time to Relegate Routine Opioid Prescriptions to the Oral Surgery Archives?

March 18, 2020
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by Samuel Molind, DMD, Diplomat, American Board of Oral & Maxillofacial Surgery

The first introduction to opioids for teenagers and young adults is often in the dentist’s office when they are prescribed pain medications following oral surgery. However, because opioid prescriptions may be associated with subsequent opioid abuse in this patient population, alternative therapies for managing acute dental pain may be warranted.

In the retrospective cohort study, “Association of Opioid Prescriptions from Dental Abuse,” published in JAMA Internal Medicine, researchers analyzed the private insurance claims of 754,002 patients age 16 to 25 years. Of these individuals 29,791 received one or more opioid prescriptions from a dentist. The mean number of pills prescribed for third molar extractions was 20. Among the 14, 888 individuals in the index dental opioid cohort 1,021 (6.9 percent) received another opioid prescription 90 to 365 days later, compared with 30 of 29,776 (0.1 percent) opioid-nonexposed controls. According to the researcher, approximately 6 percent to 7 percent of adolescents and young adults exposed to opioids by dental professionals may develop opioid abuse or addiction.

Oral health professionals are taking their role in the opioid epidemic seriously. The American Dental Association reports that dentists have written nearly half a million fewer opioid prescriptions over a five-year period; however, is that enough?

Hydrocodone-acetaminophen became the gold standard for pain management after oral surgery procedures despite no references in the literature showing opioids were more effective than nonsteroidal anti-inflammatory drugs (NSAIDS), as well as failure of pharmaceutical manufacturers to substantiate marketing claims of the nonaddictive nature of their new opioid formulations. Studies dating back to the 1980s, most using third molars for their pain model, have consistently shown the superiority of NSAIDS over opioids for acute dental pain management.

A growing number of opioid-sparing treatments and prescribing protocols are being described in the current oral-maxillofacial, orthopedic and other surgical literature. The handwriting is on the wall: Opioids prescribed after oral surgery can be curtailed substantially.

Have any of your patients been sparked to addiction by a good-faith prescription from your hand? Because addiction occurs downstream and its occurrence is often not shared because of privacy concerns, how often would you, the prescriber, become aware?

Are the reasons for prescribing opioids to manage postsurgical pain in a patient without contraindications for an NSAID evidence-based or based on habit? Does reluctance to eliminate regular opioid prescriptions come from hoping to avoid inconveniencing patients, practice partners or yourself with after-hours pain calls? Are opioid prescriptions written begrudgingly, fearing the sting of a “one-star rating” on social media from patients aghast you did not provide opioids?

In 2017, of the almost 50,000 U.S. opioid overdose deaths, how many began with an opioid prescription from oral surgery? What is an acceptable percentage of patients developing abuse or addiction problems to justify exposing the young brain to prescription opioids? Is it worth it, particularly in light of the scientific evidence, standards of care and our drug culture?

Sam Molind, DMD

About Sam Molind, DMD

Team Leader, Global Health Outreach Dr. Sam Molind left his Montpelier, Vermont practice in 1998 to begin Global Health Outreach (GHO) and directed it for 12 years. Prior to his work with GHO, Dr. Molind served as Associate Professor of Surgery at the University of Vermont Medical School and had a private oral and maxillofacial surgery practice in Montpelier. Dr. Molind was president of the medical staff at the Central Vermont Medical Center, was a board examiner for the American Board of Oral and Maxillofacial Surgeons for six years and was the president of the Vermont State Dental Society. Dr. Molind and his wife Dorothy began a Crisis Pregnancy Center in Central Vermont where Dorothy served as the Executive Director. Sam and Dorothy have been active in establishing the Good Samaritan Haven, an emergency shelter for the homeless and a health and wellness clinic for the underinsured and uninsured in Central Vermont. Dr. Molind, a lifetime member of CMDA, has participated in numerous short-term healthcare mission trips since 1985. He has been on the CMDA Board of Trustees and served on the Biomedical Ethics Commission. Dr. Molind has led surgical teams into Central Asia for 10 years to help develop a maxillofacial surgical residency program and has helped organize and develop maxillofacial surgical programs in the Middle East and Southeast Asia. In April 2005, Dr. Molind was the first time recipient of the United States Agency for International Development (USAID) Citation from the Bureau of Global Health for outstanding support of their mission by training maxillofacial surgeons, providing medical, surgical and dental care and for his commitment to improve the lives of many thousands of people around the world. Dr. Molind received the American Association of Oral and Maxillofacial Surgeons’ 2006 Presidential Achievement Award. The Presidential Achievement Award recognizes those fellows and members of the AAOMS whose important and long-standing contributions have benefited the specialty of oral and maxillofacial surgery in the areas of clinical, academic, research and public service activities.

1 Comment

  1. Avatar Dr. Richard Troxler DMD on March 18, 2020 at 4:18 pm

    Hey Sam. Good article ! I have gone from writting 18-20 scripts for opioids per year to about 8-10 now per year. Most patients do very well with ibuprofen 600-800mg q8h prn. But there are some patients that need 1-2 days post-op of pain control where ibuprofen/ tylenol just don’t quite do the trick. For those patients I must do a good medical history and if needed I give a script of no more then 5 tablets of a narcotic. I do think that narcotics do have a place in dentistry, but limiting the number of pills, and doing a good medical history are very important.

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