Is it Time to Relegate Routine Opioid Prescriptions to the Oral Surgery Archives?
March 18, 2020
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?