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Volume 2 Issue 2
S
upporting
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ractice
hydrocodone or oxycodone in combination with
acetaminophen).
4
The most common procedure that
resulted in a prescription for an analgesic was tooth
extraction, but only 1% of prescriptions for tooth
extraction-related pain were for NSAIDs, while over
90% of these patients received a prescription for an
opioid analgesic.
4
Of concern, this study also noted that patients over
the age of 45 were more likely to receive an opioid
analgesic prescription than younger patients, and
about 25% of patients attending the clinic were not
prescribed any analgesic after an invasive procedure
that would be expected to cause pain.
4
Moreover,
the higher prescribing rate of opioid analgesics
for dental pain in the US is not confined to dental
health providers. A study of prescribing of opioid
analgesics by physicians in a US hospital emergency
department for painful dental conditions found that
roughly 60% of patients were discharged with a
prescription for an opioid analgesic.
5
Most dentists do not screen patients for past history
of abuse or misuse prior to prescribing an opioid
analgesic. Surveys of dentists and maxillofacial
surgeons indicate that an average of 20 doses of
an opioid analgesic (commonly hydrocodone or
oxycodone) are prescribed post-procedure and
most dentists expect patients to have leftover
analgesics.
4,6
Particularly concerning was the
expectation by dentists that many patients given
prescriptions for opioid analgesics would not require
all of the doses dispensed.
4, 6
It is thought that unused
opioid analgesics are a significant source of misused
drugs.
3
The risk of misuse of leftover opioid analgesics
by younger individuals is of particular concern.
3
Greater collaboration between Canadian dentists
and pharmacists is needed to address this problem.
One potential solution to prevent inadvertent
overprescribing of opioid analgesics is to have
dentists write prescriptions for fewer initial doses.
Instead, dentists could arrange for additional doses as
needed, to be filled at the discretion of a pharmacist.
Dentists should avoid prescribing opioid analgesics
if patients are already on a benzodiazepine or have a
known history of misuse of these drugs and should
be available to return pharmacist’s calls rapidly if a
problem occurs at renewal time.
7
Table 1:
Opioid prescription for chronic,
non-malignant orofacial pain*
Proper Patient Selection
Consider opioid prescription for patients with neuropathic
pain, temporomandibular disorders,** atypical facial pain,**
rheumatoid arthritis, neck pain, headache.**
Consider a trial when pain is moderate to severe (>4/10),
has an adverse effect on function or quality of life, and
when patients have not responded to non-opioid analgesic
therapies or to opioid analgesic therapy with codeine or
tramadol.
Consider patient’s medical history, including general medical
history, current medications (prescription and over-the-
counter drugs), recreational drug use (alcohol, cannabis, etc.),
psychosocial history (information related to employment and
support network, including friends and family), dental exam
(including appropriate diagnostic tests and assessment of
type(s) of pain), risk assessment (history of abuse, misuse or
addiction and occurrence of other conditions such as sleep
apnea), and benefit-to-harm analysis.
Consent and Management of Therapy
Obtain verbal or written informed consent from patient.
Discuss and document initial and ongoing monitoring of
goals, expectations, risk-benefit (including side effects) and
alternatives.
Initiate a short-term therapeutic trial, reassess need
periodically.
Individualize treatment “start low, go slow” (immediate
release opioid analgesic preferred for titration, low initial
dosing and titration, regular dosing with allowance of as
needed doses for breakthrough) based on health, previous
exposure to opioid analgesics, attainment of goals, and
incidence of adverse effects.
Avoid concomitant benzodiazepines, if currently using,
decrease dose slowly to permit discontinuation.
Monitor efficacy regularly to ensure optimum pain
management (available tools include the McGill Pain
Questionnaire
13
, Brief Pain Inventory)
Consider periodic urine drug screens in patients at risk for
misuse or aberrant behavior.
Manage adverse effects as required (e.g., constipation is
common, decreased libido/sexual dysfunction (less common),
sleep apnea (less common), hyperalgesia is rare.
Caution that cognitive impairment may affect driving and
work safety.
Maintain detailed records (include reasons for continued use).
*Based on criteria from previously published guidelines.
10-12
**Indicates a lack of published evidence for opioid agonist efficacy.