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hydrocodoneor oxycodone incombinationwith
acetaminophen).
4
Themost commonprocedure that
resulted inaprescription for ananalgesicwas tooth
extraction, but only1%of prescriptions for tooth
extraction-relatedpainwere forNSAIDs,whileover
90%of thesepatients receivedaprescription for an
opioidanalgesic.
4
Of concern, this studyalsonoted that patientsover
theageof 45weremore likely to receiveanopioid
analgesicprescription thanyounger patients, and
about 25%of patients attending theclinicwerenot
prescribedanyanalgesicafter an invasiveprocedure
thatwouldbeexpected tocausepain.
4
Moreover,
thehigher prescribing rateof opioidanalgesics
for dental pain in theUS isnot confined todental
healthproviders. A studyof prescribingof opioid
analgesicsbyphysicians inaUShospital emergency
department for painful dental conditions found that
roughly60%of patientsweredischargedwitha
prescription for anopioidanalgesic.
5
Most dentistsdonot screenpatients for past history
of abuseormisuseprior toprescribinganopioid
analgesic. Surveysof dentists andmaxillofacial
surgeons indicate that anaverageof 20dosesof
anopioidanalgesic (commonlyhydrocodoneor
oxycodone) areprescribedpost-procedureand
most dentists expect patients tohave leftover
analgesics.
4,6
Particularlyconcerningwas the
expectationbydentists thatmanypatientsgiven
prescriptions for opioidanalgesicswouldnot require
all of thedosesdispensed.
4, 6
It is thought that unused
opioidanalgesics area significant sourceofmisused
drugs.
3
The riskofmisuseof leftover opioidanalgesics
byyounger individuals isof particular concern.
3
Greater collaborationbetweenCanadiandentists
andpharmacists isneeded toaddress thisproblem.
Onepotential solution toprevent inadvertent
overprescribingof opioidanalgesics is tohave
dentistswriteprescriptions for fewer initial doses.
Instead, dentists couldarrange for additional doses as
needed, tobefilledat thediscretionof apharmacist.
Dentists shouldavoidprescribingopioidanalgesics
if patients arealreadyonabenzodiazepineor havea
knownhistoryofmisuseof thesedrugs and should
beavailable to returnpharmacist’s calls rapidly if a
problemoccurs at renewal time.
7
Table1:
Opioidprescription for chronic,
non-malignant orofacial pain*
Proper Patient Selection
Consider opioidprescription for patientswithneuropathic
pain, temporomandibular disorders,** atypical facial pain,**
rheumatoidarthritis, neckpain, headache.**
Consider a trialwhenpain ismoderate to severe (>4/10),
has anadverseeffect on functionor qualityof life, and
whenpatientshavenot responded tonon-opioidanalgesic
therapies or toopioidanalgesic therapywith codeineor
tramadol.
Consider patient’smedical history, includinggeneralmedical
history, currentmedications (prescriptionandover-the-
counter drugs), recreational druguse (alcohol, cannabis, etc.),
psychosocial history (information related toemployment and
support network, including friends and family), dental exam
(includingappropriatediagnostic tests andassessment of
type(s) of pain), riskassessment (historyof abuse,misuseor
addictionandoccurrenceof other conditions suchas sleep
apnea), andbenefit-to-harmanalysis.
Consent andManagement of Therapy
Obtainverbal orwritten informed consent frompatient.
Discuss anddocument initial andongoingmonitoringof
goals, expectations, risk-benefit (including sideeffects) and
alternatives.
Initiatea short-term therapeutic trial, reassessneed
periodically.
Individualize treatment “start low, go slow” (immediate
releaseopioidanalgesicpreferred for titration, low initial
dosingand titration, regular dosingwithallowanceof as
neededdoses for breakthrough) basedonhealth, previous
exposure toopioidanalgesics, attainment of goals, and
incidenceof adverseeffects.
Avoid concomitant benzodiazepines, if currentlyusing,
decreasedose slowly topermit discontinuation.
Monitor efficacy regularly toensureoptimumpain
management (available tools include theMcGill Pain
Questionnaire
13
, Brief Pain Inventory)
Consider periodicurinedrug screens inpatients at risk for
misuseor aberrant behavior.
Manageadverseeffects as required (e.g., constipation is
common, decreased libido/sexual dysfunction (less common),
sleepapnea (less common), hyperalgesia is rare.
Caution that cognitive impairmentmayaffect drivingand
work safety.
Maintaindetailed records (include reasons for continueduse).
*Basedon criteria frompreviouslypublishedguidelines.
10-12
**Indicates a lack of publishedevidence for opioid agonist efficacy.
