Are dentists prescribing too many opioids?

Maybe he had a dental implant placed. She might have had her periodontal surgery. He could have had four impacted wisdom teeth removed. Whatever the dental treatment, you know the patient will likely have pain after the anesthesia wears off. You should write them a prescription for a strong analgesic medication… or should you?

According to the experts we spoke with, the answer is no-at least for the majority of dental patients. For most post-operative pain management best practices, you need not look further than your average medicine cabinet: ibuprofen and acetaminophen, a.k.a, Advil and Tylenol.

Dr. Paul Moore, dentist, pharmacologist and professor at the University of Pittsburgh School of Dental Medicine, believes that nonsteroidal anti-inflammatory drugs (NSAIDs) should be the first-line drugs for the overwhelming majority of acute dental post-operative pain management cases.

“One of the things I have been advocating is combining Advil with acetaminophen, which is Tylenol.¹ You get even more pain relief than with either of those drugs alone. I’ve always suspected that, but it wasn’t until recently that we saw some good studies that were convincing that the combination is something we can use instead of Vicodin. It’s an alternative that doesn’t require using opioids.”

Dr. Kenneth L. Reed, retired periodontist, currently practicing dentist anesthesiologist and Associate Program Director of the Dental Anesthesia Residency, as well as attending for the Advanced Education in General Dentistry and graduate pediatric dental residency programs for NYU Langone Health Center agrees that NSAIDs should be the first-line choice for post-operative analgesics in dentistry. The rare exception would be patients with allergies or other health conditions that prohibit their use.

“NSAIDs should be the first line in every other case, though. Acetaminophen (Tylenol^®) should be the second line. A combination of a NSAID and acetaminophen is far superior to any opioid available, orally, IM or IV,” he explained. “Opioids may be added as a third agent in those very rare cases that do not respond to a combination of a NSAID and acetaminophen. That is the proper use of opioids as post-operative analgesics in dentistry. Opioids are tremendously over-prescribed.”

Dr. Moore believes that a combination of patient expectations and routinely using post-operative pain management strategies that should be reserved for severe/hard to manage cases (around 20 percent in his estimation) contribute to clinicians prescribing opioid medication. He published a commentary Why Do We Prescribe Vicodin? in the July 2016 issue of the Journal for the American Dental Association (JADA).

Dr. Jason Goodchild, a general practice owner in Havertown, Pennsylvania, and Associate Professor and Chair of the Department of Diagnostic Sciences at Creighton University School of Dentistry, also supports the combination of ibuprofen and acetaminophen regimen. The combination has shown better results in the literature than using ibuprofen alone after treatment and addressed the source of the pain, inflammation.

“All the opioids will do is cloud your sense of pain, taking you out of that feeling rather than addressing the actual underlying cause of the pain, which is inflammation. That’s why the idea of anti-inflammatory agents, the nonsteroidal anti-inflammatory agents like ibuprofen, become the best pain medications because they affect the etiology or underlying cause of pain,” Dr. Goodchild explained.

Dr. Mark Donaldson, Director of Clinical Pharmacy Performance Services for Vizient, has spent the last 18 years focusing on dental pharmacology and dental therapeutics. He believes based on evidence from dental literature clinicians have the road map to do the right thing and use the right drug with the right dose for the right patient and the right procedure.

“But because universities, because older prescribers, and ultimately because patients continue to say ‘I like my Percocet. I like my Vicodin,’ dentists prescribe the opioids,” he said. “I just have to remind dentists of the power of the pen. I tell them ‘Look, you cannot be bullied by your peers or patients. If you get to be known as a dental prescriber of opioids, that’s probably a good practice builder, but definitely not the kind of practice you want to build and the kind of patients you want to attract.’”

Dr. Donaldson and Dr. Goodchild lecture and publish together on the subject, proposing an easy-to-remember formula for pain management strategy that avoids narcotics up to 95 percent of the time: 2, 4, 24. 

“The 2 stands for two drugs, which would be ibuprofen and acetaminophen. The 4 stands for four doses, so those two drugs are given four times a day. And the 24, of course, stands for 24 hours,” Dr. Donaldson explained.

However, Dr. Goodchild admits that convincing patients that these two drugs are sufficient is an uphill battle.

“Patients think these are two over-the-counter medicines, so how can they be any better than something you prescribe?  Percocet and Vicodin are drugs that are in our lexicon, so they just roll off the tongue. People think, ‘If I’m getting my wisdom teeth out, I should just get Percocet.’ But that’s not the right way to go,” Dr. Goodchild said.

Dr. Reed agrees that the patient perception is one of many factors that plays into the use of prescription opioids to treat post-operative pain.

“When patients go to a doctor, physician or dentist, they expect a prescription for something even if a prescription isn’t necessary. And when patients get a prescription for a pain medicine, they expect an opioid,” Dr. Reed said.

Dr. Goodchild agrees that patients have high expectations for their pain management needs. Dentists, that want to provide the best possible patient experience, want to meet their expectations, to change the perception that going to the dentist is painful.

“We have a less tolerant public, which means patients won’t stand for the idea of not being adequately taken care of. Or at least, that’s the perception.,” Dr. Goodchild explained. “So if they anticipate pain, they expect the dental provider to plan for that and to determine some regimen or come up with some recipe that will make sure that they don’t have pain.

Dr. Reed, who is also the president of the American Dental Society of Anesthesiology (ADSA), cited a statistic that the U.S. consumes over 99 percent of the global use of hydrocodone used in Vicodin^®, Lortab^®, Norco^®.² He explained that the expectation of these drugs is part of the culture, a culture not seen in other countries. “Doctors (physicians and dentists) want to make patients happy, so they prescribe what patients expect: an opioid,” he said.

Are dentists the problem here?

Dr. Moore has studied analgesics for years. He is an advocate with his students and in the industry for less opioid use and more NSAIDs for pain management. He has been on the Surgeon General’s Task Force on Opioid Abuse, the ADA’s Task Force, the American Medical Association’s Working Group and the University of Pittsburgh’s Working Group.

He knows that dentists often take the blame for over-prescribing opioids. But he doesn’t agree. As the only dentist in these situations, he introduces himself like this:

“Hello. My name is Dr. Moore. I’ve been studying analgesics for 25 years. I’m a dentist. I’m a pharmacologist. My job on this committee is to try to keep people from throwing the dentist under the bus all the time.”

Dr. Moore recognizes that the perception could be that it’s always the dentists that do all the over-prescribing. However, he doesn’t’ think it’s a problem to the extent that dentists take the blame for it.

“We’re getting better at it. Things are improving in our profession,” he said.

The numbers support Dr. Moore’s assessment. Because dentists address short-term pain for the most part, most don’t write long-term prescriptions. Most clinicians only prescribe between 12 and 24 tablets.

Considering the small amounts prescribed here, the impact of dental prescriptions on the overall opioid consumption might seem relatively insignificant. Furthermore, dentists are prescribing less than in recent years. According to a message on the ADA website from Dr. Carol Gomez, ADA President, dentists decreased their opioid prescribing rates by 5.7 percent between 2007 and 2012.³ Other prescribers, such as emergency treatment prescribers, have decreased their rates as well.

Despite these efforts by the prescribing community, the problem with opioid addiction in the U.S. is significant and has seen a rapid increase since 1999. It has resulted in thousands of overdose deaths. According to the CDC, drug overdose is the leading cause of accidental deaths in 2014, with 47,055 lethal drug overdoses that year. Of those, nearly 19,000 (18, 893) were related to prescription pain relievers.⁴

Prescription opioids are ubiquitous as well. In 2012, 259 million prescriptions were written for opioids. Experts at the CDC estimate that this figure would allow for every adult to have a bottle of pills.⁵ Since few people throw out unused medication, that means many of these pills are still in medicine cabinets. 

Another alarming statistic is that four out of five new heroin users first misused prescription painkillers.⁶ As the increase in heroin users climbs, so do the heroin overdose deaths. The most rapid increases in heroin overdose fatalities occurred between 2010 and 2013, with an increase of 37 percent per year.

“The National Institute of Drug Abuse claims, and it’s quite true, the first time people experience recreational prescription drugs, they get them from a medicine cabinet,” said Dr. Moore. He and his colleagues emphasize to their students that when they prescribe opioid medication, doctors should counsel patients on the need to dispose of unused medication and to keep it away from those that shouldn’t have it. And when the patient is a minor, to instruct the parents on these same concepts.

However, substance abuse isn’t the only problem here. Pain management is also a serious health problem in the U.S. The American Academy of Pain Medicine reported the annual cost to the U.S. healthcare system for pain management and the U.S. economy through lost productivity is between $560 and $635 billion, or around $2000 for every person living in the U.S.⁷

Dr. Donaldson believes that reform in pain management for dental practice is not only useful for effective pain management but also makes fiscal sense.

“That’s a huge price tag. This is not all about money, but it starts to frame our discussion as far as what is the global impact? Are there good evidence-based guidelines out there for us to be able to manage pain more appropriately and, in doing so, perhaps do it not just more efficiently, but also more economically?” Donaldson said.

Dr. Moore said that dentists don’t prescribe that much of the overall opioid prescriptions at a national level (only around 6 percent).  However, many of the patients might have their first experience with pain medication with the removal of their third molars (wisdom tooth extraction), which is a major responsibility for dentists.

“Dentists don’t prescribe large quantities of opioids, but we often prescribe to young adults and adolescents, so we need to be very responsible about how we prescribe and make sure we counsel patients how to use them, whether they need to take the pills, how to keep these medications secure, and how to safely dispose of them,” he said.

“That’s one of the things I do teach – the power of the pen,” said Dr. Donaldson.  “It’s like the Spiderman principle: ‘With great power, there must be great responsibility.’ That’s what all of our prescribers need to think about, the power they wield with the pen when they write that prescription.”  

References 

1.  Moore PA and Hersh EV. Combining Ibuprofen and Acetaminophen for Acute Postoperative Pain Management: Translating Clinical Research to Dental Practice.  J Am Dent Assoc 2013;144(8):898-908.

2. Wolfe S. Hydrocodone: Testimony for the Health Research Group of Public Citizen before the U.S. Food and Drug Administration Drug Safety and Risk Management Advisory Committee, January 25, 2013

3. Summerhays, D.D.S, Carol Gomez. “A message from the ADA president.” www.ada.org. 5 July 2016. Web. 1 August 2016. < http://www.ada.org/en/publications/ada-news/2016-archive/july/a-message-from-the-ada-president>.

4.  Center for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, Mortality File. (2015). Number and Age-Adjusted Rates of Drug-poisoning Deaths Involving Opioid Analgesics and Heroin: United States, 2000–2014. Atlanta, GA: Center for Disease Control and Prevention. Available at http://www.cdc.gov/nchs/data/health_policy/AADR_drug_poisoning_involving_OA_Heroin_US_2000- 2014.pdf.

5. Centers for Disease Control and Prevention. (2014). Opioid Painkiller Prescribing, Where You Live Makes a Difference. Atlanta, GA: Centers for Disease Control and Prevention. Available at http://www.cdc.gov/vitalsigns/opioid-prescribing/.

6. Hedegaard MD MSPH, Chen MS PhD, Warner PhD. Drug-Poisoning Deaths Involving Heroin: United States, 2000-2013. National Center for Health Statistics Data Brief. 2015:190:1-8.

7. “AAPM Facts and Figures on Pain.” www.painmed.org. Web. 1 August 2016. < http://www.painmed.org/patientcenter/facts_on_pain.aspx>.