Isn’t that insane?

One of my very good friends is a medical examiner for a large county in Metro Atlanta.  Recently, I asked her why drug dealers would mix fentanyl in their products since it kills so many people, and I would think that would be bad for business, and she explained that fentanyl is a great high if it doesn’t kill you.  The problem is that when the fentanyl is added to a batch of drugs, there’s apparently not a lot of quality control when you’re making it in your garage.  As a result, you may have a lot of fentanyl in one dose, and very little in another, so one person could be fine, and the other person could turn up dead.

In the past several years, this problem because even more common after the 2016 opioid guidelines came out.  At that time, the CDC recommended that doctors should avoid daily opioid doses that exceeded daily 90 morphine milligram equivalents (MME), which was intended to help reduce overdoses.  Many states interpreted these limits as absolute and passed laws that limited the length of time opioids could be taken, set strict limits on daily MME, and even required doctors to aggressively reduce existing prescriptions for chronic pain patients.  These cuts were required even for those chronic pain patients, including cancer patients,  who exhibited no signs of addiction, were functional, and their pain was controlled. 

This created a terrible problem for these people, many of whom had taken more than 90MME per day for years in order for them to function. Unfortunately, that resulted in many chronic pain patients’ doses being drastically cut, and their pain was being dramatically untreated.  With doctors afraid to prescribe sufficient medications, many of those people turned to illegal opioids so that they could function.  And many ended up dead.

Because of the damage that was caused to so many patients, the new 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain completely avoids strict dosage limits and limits on the length of treatment. (Although they still recommend less than 90 MME/day for most patients to help prevent overdose.) Instead, the guideline is designed to help providers decide whether to use opioids for pain control, how to select the correct opioid and dosage, how long to prescribe and how to followup, and how to assess the risk/harm of opioid use.  Basically, we need to make sure that patients’ pain is controlled, but we need to make sure we aren’t causing more problems by using opioid treatment.

I’ll admit, when I first heard that dentists were apparently a huge part of the opioid epidemic, I was very skeptical.  We don’t prescribe long-term opioids, and as a rule, most of our prescriptions are short and used only after surgery or endodontic treatment.  How could we be the problem?

It turns out, I was wrong.  Dentists are a huge part of the problem.

The Surgeon General’s 2011 report “Epidemic: Responding to America’s Prescription Drug Abuse Crisis” acknowledged that 70% of all first-time opioid users obtained their drugs from their friends and family.  Dentists prescribe more than 30% of all opioid prescriptions, most of them after third molar extractions; this is often the first exposure that children have to opioids. Studies have shown that high school age teens who receive an opioid prescription are 33% more likely to misuse opioids than those who’ve never taken them. Most concerning is the fact that much of the misuse and abuse happens among children that are considered to be at low risk for addiction issues.  A study in 2015 found that when young people had third molars extracted, the average amount of pills that were prescribed to control  post-operative pain was 20 pills, and on average, twelve (60%) of those pills were not used. These leftover pills were then used in 36.9% of all nonmedical uses of opioids by those same kids, which has resulted in opioids being abused by young people more than any drug except marijuana.  A study done in heroin users in 2008 found that 89% had started their drug use by using leftover opioids they obtained from family, friends, and/or leftover personal prescriptions, and most had started misuse in their early teens. Most of them also had progressed from taking the pills, to crushing and snorting the pills, and finally started injecting the pills. From there, many addicts switched to heroin because it was cheaper and easier to get than prescription opioids. 

Please note:  These new guidelines apply to acute (less than 1 month duration), subacute (duration 1-3 months), and chronic pain (more than 3 months) treatment.  Most of us deal only with acute, post-procedural pain, so that’s what we’ll be discussing today. However, if you have a dental patient who is also a chronic pain patient, do a medical consult before performing treatment to determine the best way to control post-procedural pain without increasing the risk of overdose.

So what do these new guidelines mean to us? Basically, we need to make sure that we prescribe opioids only when needed, and prescribe the lowest effective dosage for as short a period of time as possible.  (If higher doses or extended release opioids are prescribed, discuss the risk of overdose with the patient and consider prescribing naloxone to counteract an overdose. Some states require coprescribing naloxone with any opioid.) 

Most throbbing type pain caused by an inflammatory response, such as that caused by extractions, can usually be treated most successfully by a combination of NSAIDs and acetaminophen.  If the patient cannot take these drugs, or you feel that the pain cannot be adequately controlled by these drugs, then opioids may be necessary.  You may want to combine the opioids with NSAIDs and acetaminophen (while making sure not to prescribe too much acetaminophen) in order to reduce the amounts of opioids.  Also, make sure you prescribe immediate-release opioids, not extended-release or long-acting opioids for acute pain, if possible.

Use other methods to reduce postprocedural pain and reduce the need for analgesics, especially after surgery and extractions.  Use long-acting anesthetics, such as bupivacaine (Marcaine) to help reduce and control pain after a procedure. Corticosteroids, such as dexamethasone and methylprednisolone (Medrol dose packs), may be used after third molar extractions to reduce swelling and pain.  Old-fashioned ice packs can help reduce swelling and pain after extractions. Premedicating with NSAIDs before the procedure can help reduce postoperative inflammation and pain. 

Determine whether the benefits of opioid therapy outweigh the potential harm and discuss risks, benefits, and alternatives of opioid therapy with patients.    Make sure they do not combine opioids with benzodiazepines or any other contraindicated prescription drugs, alcohol,  other over-the-counter medications, including benadryl and/or any over the counter sleep medications.  Anything that causes sleepyness or relaxation can depress respiration, and when you mix these drugs with opioids, people have died because they stop breathing.  Here is an article that lists some drugs that can cause problems when taken with opioids. 

Before prescribing opioids, use the PDMP, as required by your state, to ensure that the patient isn’t receiving multiple opioid prescriptions.  Ask the patient about any history with controlled substances and any substance abuse disorders.  If they have a history of substance abuse, are under treatment for substance use, and/or are taking drugs like methadone, naltrexone, and buprenorphine, talk to their doctor about handling pain management issues before any treatment is performed.  Remember also that long-term substance abuse can cause long-term damage to the liver and other organs, so you may need to be careful with anesthetics, you may have some bleeding issues, and you may need to be careful with dosages.