Dental Dilemma: Pain Management vs. the Opioid Epidemic

By Genni Burkhart

On October 26, 2017, the U.S. Department of Health and Human Services declared the opioid epidemic a public health emergency.

While prescription drug monitoring programs (PDMPs) and the National All Schedules Prescription Electronic Reporting Act (NASPER) have contributed to a reduction in opioid prescriptions, as well as a decrease in the number of opioid overdose deaths due to prescription drugs (1), more than four times as many people died from drug overdose than from homicide in the first month of 2021.

Additional data from the National Center for Drug Abuse Statistics includes:

• Drug overdose deaths have increased 30% year-over-year.
• Drug overdoses have taken the lives of nearly one million people since 1999.
• Opioids are a contributing factor in 7 out of every 10 overdose deaths.

Given this, it's easy to see why this crisis is considered one of the most devastating public health catastrophes since the HIV/AIDS epidemic of the 1980s. Nevertheless, opioid analgesics are still among dentists' most commonly prescribed drugs, equaling roughly 7.6% of all opioid prescriptions in 2019, or 10.9 million scripts.

The Dental Dilemma

For dental professionals, balancing effective pain management with mitigating drug abuse in patients has become somewhat of a high-wire act. Yet, prescribers still face a significant dilemma in pain management - the risk of abuse vs. undertreatment.

Research from the National Institutes of Health (NIH) suggests that 75% of opioid abuse is attributed to the introduction of opioids through prescriptions. The same research also concluded that more than half of 14- to 17-year-olds receive opioid prescriptions following wisdom tooth extractions.

Furthermore, dentists were the third-most-frequent prescribers of opioid pain medications (2010 research). Dentists have since fallen to fifth place due to increased awareness and training on opioid abuse. (2)

Pharmacy Times published an article in January of this year highlighting that the average three-day supply of opioids for adults and children remained unchanged following dental procedures. (3)

The article concluded that opioid prescribing for dental procedures was not significantly affected by updated state mandates, such as dentists continuing to supply patients with 3-day supplies of opioids, even when the national allowed limit was reduced to a 7-day supply. Also, nearly 50% of the states analyzed allowed dentists to exceed the prescribing limits based on "professional judgment."

Recognizing the persistence of this issue, the Centers for Disease Control and Prevention (CDC) released revised national guidelines (CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022) in November 2022, while the American Dental Association (ADA) released revised guidelines for treating acute dental pain in children (aged 12 and under) in the September 2023 issue of The Journal of the American Dental Association.

National training and education programs have also helped dental professionals better understand this issue and find effective nonopioid medication alternatives. A training program at Oregon Health & Science University has allowed dental professionals to understand the complexities of this issue better and effectively address it.

The updated guidelines and training have common recommendations, including:

• Help patients understand what pain level to expect before undergoing dental procedures.
• Evidence-based recommendations to determine the most effective way to manage pain in pediatric patients, including dosing that may differ from the packaging on over-the-counter medications.
• The effectiveness of nonopioid anti-inflammatory painkillers and creating a pain management plan the patient can understand and follow.
• Review relevant research, recommended guidelines, and state and federal laws when prescribing opioids.
• Use state-specific Prescription Drug Monitoring Programs.
• Collaborate with the patient's primary care provider or other specialists to coordinate the best possible plan for managing pain.
• Are you subconsciously stereotyping patients when prescribing drugs or pain management practices?

The Painful Truth

Pain is a powerful motivator. Moreover, for dentists, it's one of the main reasons patients come to see you or the primary motivator in keeping them away. Pain is also highly subjective and difficult to measure without interjecting personal perception.

To better understand the effect of opioids on treating pain, let's first distinguish between acute and chronic pain in the oral healthcare setting. The majority of oral pain falls into two categories:

1. The sudden acute category includes toothache, postoperative pain, caries, periodontitis, pulpitis, or trauma.
2. Prolonged chronic oral pain can be caused by neurological issues, temporomandibular joint dysfunction (TMJ), arthritis, or cancer. Effective chronic pain management must first get at the cause, which can be outside the scope of dentistry, including referring the patient to a specialist or consulting with their primary care provider to undergo further testing and treatment.

Concerning acute pain, opioid analgesics such as hydrocodone, oxycodone, and morphine are standard options for treating severe acute pain. While they can reduce pain and offer relief in the short term, they are accompanied by serious risks, including addiction and even death from overdose. Instead, the CDC recommends pain relievers such as ibuprofen, naproxen, acetaminophen, acupuncture, massage, and heat or ice applications.

The ADA suggests selecting pain management strategies corresponding to postprocedural, acute pain. While this chart isn't a "one size fits all," it can guide oral analgesics for varying levels of "anticipated pain."

For specifics on selecting an acute pain management strategy or how the Anticipated Postprocedural Pain Levels According to Dental Intervention are listed, visit the ADA's Oral Analgesics for Acute Dental Pain resource page.

In Conclusion

In 2020, an average of 44 people died daily in the U.S. from prescription opioid abuse.

It's suggested that dental professionals, especially students and those new to the profession, become familiar with the phrase "Lower Doses, Fewer Days" and use nonopioid pain management as a first option.

This can involve critical chairside discussions with patients to better understand their unique situation and pain tolerance, as it's a vital component of the pain management balancing act nearly every dentist faces. 

Fortunately, research is promising concerning opioid alternatives. In place of opioid analgesics, ibuprofen, acetaminophen, and nonprescription naproxen sodium (NapS) are highly effective at relieving post-dental procedure pain. Increased research indicates that nonsteroidal anti-inflammatory drugs (NSAIDs) can mitigate the need for opioids after dental procedures more effectively than opioids.

For more information on DOCS Education training, courses, and continuing education regarding opioid prescriptions and DEA MATE Compliance, visit our course listings here.

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References:

1. Dowell D, Zhang K, Noonan RK, Hockenberry JM. Mandatory provider review and pain clinic laws reduce the amounts of opioids prescribed and overdose death rates. Health Aff (Millwood) 2016;35:1876–1883. doi: 10.1377/hlthaff.2016.0448. [PMC free article] [PubMed] [CrossRef] [Google Scholar
2. IMS Health, National Prescription Audit, United States, 2012.
3. Chua KP, Nguyen TD, Waljee JF, Nalliah RP, Brummett CM. Association Between State Opioid Prescribing Limits and Duration of Opioid Prescriptions From Dentists. JAMA Netw Open. 2023 Jan 3;6(1):e2250409. doi: 10.1001/jamanetworkopen.2022.50409. PMID: 36630136; PMCID: PMC9857382.

Author: With over 13 years as a published journalist, editor, and writer Genni Burkhart's career has spanned politics, healthcare, law, business finance, technology, and news. She resides in Northern Colorado, where she works as the Editor in Chief of the Incisor at DOCS Education.