Dentists prescribe approximately 9% of opioid analgesics dispensed by outpatient US retail pharmacies annually and are the highest percentage prescriber group for patients between 10 and 19 years of age.

It is worth noting that dentists have reduced the volume of opioid prescriptions by dentists in the U.S., as reported by Tompach in the Journal of Oral and Maxillofacial Surgery. The percentage of opioid prescriptions decreased from a peak of 15.5% in 1998 to 9% in 2022. However, a concerning trend emerged in the number of opioid prescriptions per 1,000 dental patients, particularly among adolescents aged 11 to 18. Importantly, adolescents receiving prescription drugs are at an elevated risk of future opioid misuse.

 

With all this in mind, does a patient with real pain post-surgery need to “white knuckle” it through the misery? 

Traditionally, opioids have been a common choice for treating various acute and chronic conditions. However, recent research, increased awareness of the potential for chemical dependence, and a large push from the CDC, state boards, and associations have led to changes in prescription recommendations and practices. The use of opioids and their associated risks is particularly crucial in pain management, especially when dealing with patients who have a history of addiction or other chemical dependencies. The field of pain medicine relies on scientific advancements and evidence-based practices to guide practitioners in devising pain management strategies that effectively minimize the risk of addiction or relapse while efficiently addressing pain and disability in patients.

With the right knowledge and tools, a knowledgeable healthcare provider can help stabilize pain safely and responsibly.

This course aims to assist dental professionals in navigating the complexities of pain management for patients with chemical dependence and opioid use disorders. It will cover topics such as identifying risk factors and optimizing the use of effective therapies while mitigating potential risks.

In October 2017, the US Department of Health and Human Services officially declared the opioid crisis a public health emergency in the United States. Since this declaration, extensive research has revealed the profound impact of addiction stemming from overprescribing opioid pain medication. Opioids were first introduced to the US pharmaceutical market in 1999, leading to a fourfold increase in prescriptions through 2010. In 2017, studies demonstrated that over 11.4 million Americans had misused prescription opioids, resulting in a staggering $78.5 billion economic burden and 48 overdose-related deaths daily. Notably, the US consumes 80% of all opioid prescriptions globally despite comprising just 5% of the world’s population, a phenomenon contributing to the first decline in overall life expectancy in US history.

Research has revealed that the dental industry has played a significant role in exacerbating the opioid crisis. Dentists surpass pain medicine physicians (though still less than primary care and internal medicine doctors) in writing opioid prescriptions. Historically, dentists have prescribed opioids in excessive quantities, at higher strengths, and for longer durations than necessary. This has resulted in over 50% of opioids prescribed by dentists following tooth extractions remaining unused, potentially contributing to opioid misuse. While public health measures like state prescription drug monitoring programs (PDMPs) have reduced opioid prescriptions by 27.5% from 2012 to 2017, dental opioid prescriptions have only decreased by 2.2% over the same period.

These developments underscore the pivotal role of dentistry both in contributing to and addressing the opioid crisis. While opioid prescription guidelines and practices continue to evolve, it is undeniable that opioids have been a fundamental component of pain management for the past two decades. Emergency medicine statistics reveal that patients presenting to the emergency room with odontogenic concerns are more than twice as likely to receive an opioid prescription as other patients. In 2012, over 50% of the 2.18 million emergency visits related to nontraumatic dental pain resulted in opioid prescriptions.

As a profession, dentists encounter patients on a daily basis who have received opioid prescriptions and may have been affected by these pain management practices. With 5-17% of the US population grappling with substance abuse disorders, it is imperative for dentists to comprehend how opioid prescriptions can impact pain and patient management and to apply current best practice guidelines for the safe prescription of pain medications for all patient populations, including those with chemical dependence. To do this effectively, one must understand the various dependencies that opioid prescriptions can induce.

 

Terminology

The terms dependence, tolerance, and addiction have often been used interchangeably; this practice is inaccurate and limiting when providing patient care.

Physical or chemical dependence is a predictable and normal response to any opioid prescription, even when used appropriately and as directed by a physician or dentist. It is characterized by the emergence of withdrawal symptoms following a sudden dose reduction. This is a typical physiological response or neuroadaptation to opioid exposure and should be considered when prescribing and managing a patient’s treatment plan.

Tolerance is a condition resulting from persistent drug use, characterized by a markedly diminished effect with regular use of the same drug dose or by a need to increase the dose markedly over time to achieve the same desired effect. Any extended use of an opioid painkiller has the potential to lead to some degree of tolerance, a factor that should be taken into account when addressing a patient’s pain management.

Both dependence and tolerance develop gradually over time, typically within several days to two weeks of continuous use. Due to the predictable nature of these biological processes, responsible prescribing and patient management can be employed to prevent or minimize the development of dependence and tolerance.

Substance abuse and addiction are maladaptive behaviors. They are not indicative of on-label and correct use of opioid pain prescriptions.  Either of the following characterizes substance abuse:

• Misuse of prescription drugs, the use of a medication in an unsanctioned or inappropriate manner
  
• Acquisition and consumption of illegal drugs or alcohol

Therefore, instances where a patient exceeds the prescribed frequency utilizes a prescription intended for a friend or family member, or obtains multiple prescriptions from various healthcare providers without disclosure all constitute examples of substance abuse. Not all cases of substance abuse lead to addiction; instead, substance abuse heightens the risk of developing addiction and is considered a high-risk behavior.

Addiction can be further categorized into two distinct classifications: active addiction and recovery. Active addiction is medically characterized by the presence of maladaptive behaviors, which encompass but are not limited to the following: loss of control, compulsive substance use, excessive preoccupation with the drug or substance, and persistent use despite experiencing physical harm. The diagnosis of addiction is established when specific maladaptive and drug-seeking actions are observed. These actions may include behaviors such as hoarding drugs during symptom-free periods, specifically requesting certain drugs by name, engaging in theft or borrowing of medications from others, forging prescriptions, engaging in “doctor shopping” to obtain multiple prescriptions from various providers, unauthorized dose escalation, or other high-risk conduct. It’s essential to recognize that isolated incidents are less indicative of addiction than the persistence of behavioral patterns over time, which, when observed in conjunction, lead to a formal diagnosis. This diagnosis can only be made by appropriately qualified behavioral health practitioners.

Diagnosing addiction can be challenging, mainly because of a phenomenon known as pseudo-addiction. Pseudo-addiction, which differs from active addiction, is most commonly observed in patients who have previously experienced inadequate pain management or have been denied sufficient pain medication by healthcare providers who are cautious about prescribing opioids. Consequently, these patients may exhibit behaviors resembling those of active addiction, such as requesting specific medications by name, seeking medications that may appear inconsistent with their pain levels, or hoarding drugs, but they do not have an active addiction. Therefore, it is crucial to establish open communication with patients and gather comprehensive medical and social histories to understand their motivations and treatment preferences better.

Patients in active recovery may also express concerns and a desire to obtain narcotics, but their reasons differ significantly from those of patients actively struggling with addiction. A common pattern among patients in recovery is the reluctance to discontinue narcotic medication when it is no longer medically necessary for pain control, primarily to avoid experiencing withdrawal symptoms. For patients in recovery, the fear of withdrawal can serve as a powerful motivator, potentially jeopardizing their progress. Instead of seeking opioids for pain relief, patients in recovery may desire them primarily to prevent narcotic withdrawal symptoms, which can also interfere with effective pain management at standard doses.

Achieving adequate pain control for patients in recovery involves dental clinicians collaborating with pain management or addiction medicine specialists. This partnership can combine pain control strategies with methadone maintenance for optimal results. Referring patients to an addiction or pain management specialist can facilitate the acquisition of methadone prescriptions, typically in the range of 15-20 mg per day. Integrating with other pain medications can effectively manage pain while preventing narcotic withdrawal symptoms, ultimately improving the patient’s overall pain management experience.

 

Acute and Chronic Pain

One of the most detrimental mistakes a healthcare provider can make concerning pain medication and patients with a history of dependence is under medication. Often driven by fear or excessive caution, providers may mistakenly assume that a patient with a dependence history should never receive an opioid prescription again, regardless of their current pain or circumstances. The foremost authorities in pain management, particularly for this patient group, are the World Health Organization (which advocates a stepwise approach) and the Joint Commission on Accreditation of Healthcare Organizations (which sets standards for pain management). Both emphasize that the key to successful pain management for individuals in recovery or those with addiction issues is appropriately addressing the specific pain at hand.

To effectively address a patient’s pain, dental clinicians must have a comprehensive understanding of it and know how to provide effective medication. In the realm of medical pain management, pain is typically categorized into three types:

1) acute pain,

2) chronic pain, and

3) end-of-life pain.

Acute pain, by definition, lasts for less than three to six months and often stems directly from a known cause. Once the underlying source of acute pain is resolved, the pain usually diminishes. In the field of dentistry, the majority of encountered pain falls into this category: acute pain.

The goal of acute pain management is consistent across all patients, regardless of their history of chemical dependence: achieving effective pain relief and eliminating pain as a reasonable endpoint or objective. Additionally, diagnosing and identifying the root cause of the pain and addressing it promptly are crucial steps. For all patients, including those with a history of chemical dependence, healthcare providers should aim to manage pain using nonopioid and non-psychotropic alternatives. However, when pain is sufficiently severe and persistent and nonopioid options prove inadequate, the use of opioids is justified, both in the general population and among patients with dependence histories. With proper patient management and follow-up, prescribing narcotics for acute pain in patients with a history of chemical dependence does not necessarily result in relapse.

In contrast, chronic pain management aims to achieve reasonable relief while maximizing the patient’s functional capacity. Chronic pain is relatively uncommon in general dentistry. Given the interplay between addiction and chronic pain, any persistent chronic pain should be referred to a specialist for further assessment and management. Best practices for chronic pain management encompass several key principles: medication being prescribed and managed by a single provider, optimization of patient stability at home and work, including the maintenance of routines, gradual weaning of pain medication to avoid withdrawal symptoms, and the use of minimal dosing and timing with effective follow-up. These best practices apply to all patients, including those with a history of chemical dependence.

End-of-life care typically falls outside the scope of general dentistry and should always be referred to specialists. In pain management for terminal patients, addiction is not a primary concern; the main focus is providing comfort and optimal pain relief. The only consideration is the pain management mechanism, as patients with a history of addiction may require higher doses to control pain.

 

Drug Seeking Behaviors

Patients may engage in drug-seeking behavior with dentists for various reasons, including the following:

• Pain Relief: Dental procedures can be painful, and some patients may exaggerate their pain or request specific medications, such as opioids, to seek more potent pain relief.
  
  
• Prior Addiction or Dependence: Individuals with a history of substance abuse or addiction may seek drugs from dentists to feed their addiction or to prevent withdrawal symptoms.
  
  
• Euphoria: Opioids and certain other medications can induce feelings of euphoria. Some patients may feign pain or dental issues to obtain these drugs for recreational purposes.
  
  
• Secondary Gain: Patients may seek drugs for reasons unrelated to dental pain, such as selling or sharing them with others. This can be motivated by financial gain or social pressure.
  
  
• Inadequate Pain Management: In some cases, patients genuinely experience pain due to inadequate pain management in their dental procedures. They may resort to drug-seeking behavior to address unrelieved pain.
  
  
• Misinformation or Misperception: Patients may have misconceptions about the effectiveness of specific drugs or believe that certain medications are necessary for their condition, even when they are not.
  
  
• Fear or Anxiety: Dental anxiety is common, and some individuals may request sedatives or other medications to alleviate their fears or phobias.
  
  
• Lack of Access to Healthcare: In cases where individuals lack access to healthcare or have limited resources, they may seek drugs from dentists as an alternative to more appropriate medical care.
  
  
• Manipulation: Some patients may employ manipulative tactics, such as making false claims or providing deceptive information, to convince dentists to prescribe medications they desire.
  
  
• Provider Pressure: Patients may encounter unscrupulous healthcare providers who readily prescribe medications without thorough evaluation, leading to a pattern of drug-seeking behavior.

It’s crucial for dentists and healthcare professionals to remain vigilant and discerning when evaluating patients’ requests for medications. They should use their clinical judgment, assess patients’ medical histories, and consider guidelines for responsible prescribing to ensure that pain is adequately managed while minimizing the risk of drug misuse, abuse, and diversion. Education and open communication with patients about pain management options and the potential risks associated with certain medications can also help deter drug-seeking behavior.

Potential drug-seeking behaviors include the following:

• Patients who ask for extraction of a restorable tooth
  
  
• Patients who ask for a specific opioid medication by name
  
  
• Patients who ask for a full prescription (e.g., 30 tablets) when the prescription is written for six or eight tablets
  
  
• Post-operatively, after an extraction, patients who repeatedly contact the dentist for more pain medication may be drug-seeking, although dentists should never dismiss patients who are reporting pain.
  
  
• Patients who wish to have “drug-only” treatment either refuse or are not interested in non-drug treatment.

 

Pain Management Strategies For Those With A History Of Addiction

The primary and foremost principle in pain management for patients with a history of chemical dependence is ensuring effective pain relief. This holds paramount importance because inadequate pain relief is a significant factor contributing to relapse in individuals in recovery. Patients with a history of dependence may resort to self-medication, using other substances, or altering prescription instructions when their pain is not adequately addressed. To prevent under-medication of pain in this patient population, it is essential to follow key best practices:

 

• Select Medications Based on Pain Adequacy: Choose medications based on their capacity to manage the patient’s pain effectively. Studies have revealed that primary care physicians and other healthcare practitioners tend to underestimate their patients’ pain levels. This discrepancy can lead to insufficient pain management. Acute pain should be treated as a medical priority because failing to address it adequately can result in escalating and challenging-to-control pain.
  
• Implement Around-the-Clock Dosing: Employ around-the-clock dosing to proactively manage pain and prevent patients from falling behind in pain control. Medication schedules should be structured with fixed intervals and overseen by someone other than the patient to minimize the risk of misuse.
  
  
• Utilize Long-Acting Opioids with Short-Acting Options: Opt for long-acting opioids as the primary choice for pain control, supplemented by short-acting opioids as needed for breakthrough pain. Long-acting opioids help optimize pain control while minimizing alterations in mental state.
  
  
• Establish Screening Schedules: Create screening schedules before initiating any pain medication regimen for recovering addicts. A pretreatment agreement can outline one-, three-, and six-month drug screenings after discontinuing pain medication to promote accountability. Failure to complete a drug screening would be considered a positive result, triggering proactive monitoring for relapse and offering medical intervention when necessary. Collaboration with the patient’s primary care physician is advisable, and in some cases, integrating the pain control regimen with participation in a recovery support program can be beneficial.
  
  
• Thoroughly Document Medication Regimens: Document all medication regimens comprehensively, including the need for narcotic analgesics, medication dosage, dosing intervals, quantity dispensed, and mutually agreed-upon refill intervals. Document all follow-up interactions with the patient during the medication regimen and after discontinuation.
  
  
• Gradual Medication Tapering: When discontinuing medication, ensure that all regimens are slowly tapered over several days under close medical supervision to prevent withdrawal symptoms. Some patients may require admission to a short-term detoxification program to safely discontinue medication without risking relapse.

 

Inflammation

Pain management in general dentistry can be broadly categorized into two primary areas:

1. Relief from Odontogenic Pain: This type of pain, stemming from conditions like pulpitis, pericoronitis, or other dental pathologies, is typically associated with inflammation. Microbial pathogens can trigger an inflammatory response in various host tissues, making pain medications with anti-inflammatory properties particularly effective in alleviating odontogenic pain. According to a 2018 data review prompted by the American Dental Association, researchers concluded that nonsteroidal anti-inflammatory drugs (NSAIDs), either alone or combined with acetaminophen, were as effective as, or superior to, other options for managing pain after invasive dental procedures. Their recommendation emphasized that “NSAIDs should be considered the drugs of choice for alleviating or minimizing pain of endodontic origin.” This preference was reinforced because opioids had a higher incidence of acute adverse reactions than NSAIDs and acetaminophen.
2. Pain Control After Invasive Procedures: Following procedures such as tooth extractions or root canals, effective pain management is crucial. The choice of medication depends on the severity of the pain. The World Health Organization’s stepladder approach outlines prescription guidelines based on pain intensity:

• • Step 1 (Mild Pain): Treatment should begin with acetaminophen, NSAIDs, and COX-2 (cyclooxygenase-2) inhibitors.
  • Step 2 (Moderate Pain): If pain persists after Step 1, the protocol advances to Step 2, which recommends the aforementioned medications plus a weak opioid like codeine or hydrocodone.
  • Step 3 (Severe Pain): For severe pain, Step 3 suggests adding a potent opioid such as morphine, oxycodone, hydromorphone, or methadone to the treatment regimen.

It is essential to exercise caution when prescribing pain medication, particularly in patients with a history of chemical dependence. Medications to avoid in such cases include:

• Meperidine: This medication has a short duration of effectiveness and a strong potential to induce euphoria, making it risky for patients in recovery who may seek a more intense high.
• Propoxyphene: Propoxyphene and combination medications contain minimal pain relief but have a high potential for abuse.
• Agonist-Antagonist Category Drugs: Drugs like pentazocine, nalbuphine, and butorphanol can precipitate opioid withdrawal syndrome, making them unsuitable for individuals with a history of addiction.

Careful consideration of pain medication choices, tailored to the patient’s specific needs and history, is essential for effective pain management in dentistry.

 

Referrals To Drug and Psychological Treatment

Dentists can play a crucial role in recognizing signs of substance abuse or addiction in their patients and facilitating referrals to drug and psychological treatment when needed.

Dentists can have a list of local referral agencies, with contact information, on paper and listed on their websites to give to patients. They may also wish to have public statements in their offices and on their websites that they support efforts to curb problems with addictions in our society and want to address patients’ problems with pain fully but also not put them at risk for addiction.

 

Screening and Assessment:

Implement routine screening tools to assess patients for substance abuse or addiction risk during dental visits. Tools like the NIDA Quick Screen or the CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) questionnaire can be helpful.

Pay attention to behavioral cues and physical signs, such as unexplained dental issues, frequent requests for pain medications, or changes in behavior, that may indicate substance abuse problems.

 

Communication and Building Trust:

Create a supportive and nonjudgmental environment where patients feel comfortable discussing their concerns or issues related to substance use.

Build trust with patients; they are more likely to open up about their struggles if they believe their dentist genuinely cares about their well-being.

 

Referral Resources:

Establish a network of local drug and psychological treatment resources, including addiction specialists, counselors, and rehabilitation centers, to whom you can refer patients.

Be aware of community resources, such as Narcotics Anonymous (NA) or Alcoholics Anonymous (AA) meetings, that can be valuable for patients in recovery.

 

Consultation with Specialists:

Consult with addiction medicine specialists or pain management experts when managing patients with complex substance abuse issues.

Seek guidance from mental health professionals or counselors when addressing psychological or co-occurring disorders.

 

Patient Education:

Educate patients about the potential risks of substance abuse, especially related to prescription medications, and inform them about the importance of responsible medication use.

Share information about available treatment options and the benefits of seeking help.

 

Document and Maintain Confidentiality:

Maintain confidential patient records documenting any substance abuse concerns, discussions, or referrals.

Comply with legal and ethical obligations regarding patient confidentiality while ensuring that necessary information is shared with treatment providers when required.

 

Offer Support and Encouragement:

Express concern for the patient’s health and well-being and provide encouragement for seeking treatment.

Offer ongoing support throughout recovery, such as follow-up appointments and check-ins.

 

Collaboration with Other Healthcare Providers:

Collaborate with primary care physicians, addiction specialists, and mental health professionals to ensure comprehensive care for patients with substance abuse issues.

 

Training and Continuing Education:

Stay updated on the latest developments in addiction medicine, pain management, and mental health through training and continuing education courses.

 

Legal and Ethical Considerations:

Be aware of and adhere to legal and ethical guidelines regarding patient consent and referrals for treatment.

By taking these steps, dentists can contribute to their patients’ early detection and intervention of substance abuse issues and help them access the necessary drug and psychological treatment for their recovery and well-being.

 

Comprehensive treatment for patients with a history of chemical dependence and a well-defined long-term plan and strategic follow-up steps are essential for responsible and effective care. Despite the complexity introduced by a history of narcotic abuse, successful pain management remains achievable with the right approach. By identifying the signs and symptoms of addiction, dependence, and withdrawal, practitioners can equip themselves to deliver the highest standard of care.

 

References

1. Thornhill MH, Suda KJ, Durkin MJ, Lockhart PB. Is it time US dentistry ended its opioid dependence? J Am Dent Assoc. 2019;150(10):883-889. doi:10.1016/j. adaj.2019.07.003
2. Centers for Disease Control and Prevention, National

Center for Health Statistics. Prescription Opioid Analgesic Use Among Adults: United States, 19992012. Accessed November 16, 2019. https://www.cdc.

gov/nchs/products/databriefs/db189.htm

3. Centers for Disease Control and Prevention.

Prescription Opioid Data. NCHS Data Brief 189. Accessed November 26, 2019. https://www.cdc.gov/ drugoverdose/data/prescribing.html

4. Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and opioid-involved overdose deaths—United

States, 2013–2017. MMWR Morbidity and Mortality Weekly Report. 2018;67(5152). doi:10.15585/mmwr. mm675152e1

5. Dassieu L, Kaboré J-L, Choinière M, Roy É. Chronic pain experience and management among people who use illicit drugs: A qualitative study in Montreal (QC). Can J Pain. September 2019. doi:10.1080/24740

527.2019.1591811

6. Volkow ND. Characteristics of opioid prescriptions in 2009. J Am Med Assoc. 2011;305(13):1299. doi:10.1001/jama.2011.401
7. Maughan BC, Hersh EV, Shofer FS, et al. Unused opioid analgesics and drug disposal following outpatient dental surgery: A randomized controlled trial. Drug and Alcohol Dependence. 2016;168:328-334. doi:10.1016/j.

drugalcdep.2016.08.016

8. Okunseri C, Dionne RA, Gordon SM, Okunseri E, Szabo A. Prescription of opioid analgesics for nontraumatic dental conditions in emergency departments. Drug Alcohol Depend. 2015;156:261-266. doi:10.1016/j. drugalcdep.2015.09.023
9. Prater CD, Zylstra RG, Miller KE. Successful pain management for the recovering addicted patient. Prim

Care Companion J Clin Psychiatry. 2002;04(04):125-

131. doi:10.4088/pcc.v04n0402
132. Sees KL, Clark H. Opioid use in the treatment of chronic pain: Assessment of addiction. J

Pain Symptom Manage. 1993;8(5):257-264. doi:10.1016/0885-3924(93)90154-n

11. Savage S. Principles of pain treatment in the addicted patient. In: Graham AW, Schultz TK, eds.

Principles of Addiction Medicine. 2nd ed. Chevy Chase MD: American Society of Addiction Medicine; 1998:919-946.

12. Acute Pain vs. Chronic Pain. Cleveland Clinic. Accessed December 7, 2019. https://my.clevelandclinic.org/ health/articles/12051-acute-vs-chronic-pain
13. Mäntyselkä P, Kumpusalo E, Ahonen R, Takala J. Patients’ versus general practitioners’ assessments of pain intensity in primary care patients with non-cancer pain. Br J Gen Pract. 2001;51(473):995-997.
14. Passik SD, Portenoy RK, Ricketts PL. Substance abuse issues in cancer patients. Part 1: Prevalence and diagnosis. Oncology (Williston Park). 1998;12(4):517–524.
15. Dunbar SA, Katz NP. Chronic opioid therapy for nonmalignant pain in patients with a history of substance abuse: Report of 20 cases. J Pain Symptom Manage. 1996;11(3):163-171. doi: https://doi. org/10.1016/0885-3924(95)00165-4
16. Cheatle M, Comer D, Wunsch M, Skoufalos A, Reddy Y. Treating pain in addicted patients: Recommendations from an expert panel. Popul Health Manag. 2014;17(2):79-86. doi:10.1089/pop.2013.0041
17. Moore PA, Hersh EV. Combining ibuprofen and acetaminophen for acute pain management after third-molar extractions. J Am Dent Assoc. 2013; 144(8):898-908.
18. Moore PA, Ziegler KM, Lipman RD, et al. Benefits and harms associated with analgesic medications used in the management of acute dental pain. J Am Dent Assoc. 2018;149(4):256-265.e3.
19. World Health Organization. Cancer Pain Relief. 2nd ed. Geneva, Switzerland: World Health Organization. 1996.