Post-operative pain management – avoiding opioids?

A DOCS Education Gold member asks:

I went to the level one DOCS course for the second time this summer in Memphis. It was great to see and hear things a second time after I had been doing sedation a while. One of the things I missed the first time was not dispensing narcotics anymore after dental treatment. Since the meeting, I have almost completely quit prescribing narcotics (whereas before the meeting I was prescribing narcotics every time I did any surgery or RCT). With surgeries now, I prescribe amoxicillin 875 (dispense 10, take 1x/day until gone), and decadron 4mg (2 tab 1x/day for 3 days and then 1 tab/day for 2 days). I give them the "Sweet 16" Tylenol/Advil combo the day of treatment and tell them to do that every 8 hours as needed.

I have had a few patients get pretty upset when I won't prescribe them narcotics. These patients probably have a drug problem, but what if they are just truly hurting after dental surgery (extractions, implants)? Should I go back to prescribing narcotics? (I know for the patients not to take narcotics the day they are sedated b/c of the possible risk of oversedation.)

How truly effective are antibiotics, steroids, and the "Sweet 16"?

I don't want my patients to be hurting.

Would love your input on this. Also are there studies out there showing that narcotics are not needed at all after surgery?

The patient in particular I am thinking of I sedated a week ago and placed 4 implants on the lower. The tissue was pretty torn up. He was a nightmare to sedate (6 triazolam and he was still coherent). He is in pain management. I ended up giving him one prescription for narcotics the next day, then a week later, he wanted another and got pretty upset when I wouldn't. How do you control pain in someone who is in pain management?

Dr. Jerome Wellbrock, DOCS Education faculty responds:

In general, we do not recommend narcotics the day of the sedation in order to avoid additional CNS depressants on board along with the previously dosed sedation meds. The day after sedation, if you want to prescribe narcotics then you can use your normal guidelines for pain control.

Patients who are in either pain control management or addiction recovery are a different situation. I would highly recommend a consultation with both the treating physician and the patient before giving any narcotics at all. These patients, because of a history of either pain management or previous addiction, can be difficult to sedate especially with oral sedation.

Antibiotics should be used judiciously and only in cases of bacterial infection or in cases that sincerely warrant prevention of bacterial infection that would either be threatening to the patient or to the success of the dental procedures.

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