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0 Comments Sep 1, 2017 | News Europe

The prescription opioid abuse epidemic and dentistry’s part in this dilemma

Post a comment by Prof. Elliot V. Hersh, USA

An article related to the prescription opioid abuse epidemic in the United States appears in the Philadelphia Inquirer on an almost weekly basis. Unfortunately, we as dentists contribute to this problem. It has been reported that dentists (including dental specialists) prescribe 12 percent of immediate-release (IR) opioids that also contain acetaminophen (Vicodin, Percocet, Tylenol#3), behind only family physicians, who prescribe 15 percent of IR opioids.[1] Two specific areas of concern are prescribing these drugs when they are not indicated, and when indicated prescribing too many opioid-containing pills.

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Dr Elliot V. Hersh Dr Elliot V. Hersh

The analgesic efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) in postoperative dental pain has been firmly established for many years.[2] NSAIDs like ibuprofen (Advil, Motrin IB), naproxen sodium (Aleve, Anaprox) and etodolac (Lodine) work remarkably well, even after the surgical extraction of impacted third molar teeth.[3,4] In fact, meta-analysis data reveals that even an over-the-counter dose of 400 mg of ibuprofen exceeds the analgesic efficacy of a single Percocet (acetaminophen 325 mg/oxycodone 5 mg) or two Tylenol #3s (600 mg acetaminophen/60 mg codeine).[3,5] Unless NSAIDs are contraindicated (such as a history GI ulcers, anticoagulant therapy, NSAID-induce asthma or allergy or lithium intake) they should be the first line drugs prescribed for post-surgical dental pain. Opioid combination drugs with acetaminophen should only be added to the NSAID regimen when the anticipated post-procedural pain will be severe or when NSAID therapy alone is resulting in break-through pain.[3] One treatment strategy to avoid the use of opioids altogether in moderately severe to severe pain is to combine an optimal dose of an NSAID (ibuprofen 400 – 600 mg or naproxen sodium 440 - 550 mg) with acetaminophen 500 mg.[6]

It appears that when opioid-containing analgesics are indicated, some clinicians continue to prescribe an excessive amount of them. A recent joint collaborative study between emergency room physicians at Presbyterian Hospital and PDM faculty from the Department of Oral Surgery/Pharmacology revealed that when Oral and Maxillofacial Surgeons were allowed to follow their typical prescribing habits to treat anticipatory pain in 67 dental impaction cases, the average number of opioid-containing pills prescribed was 28. However, the mean number of opioid -containing pills actually used by the patients was 13, translating to a total of 1010 unused pills.[7] Many of these patients had also been prescribed an NSAID (etodolac or ibuprofen), so optimal multi-modal analgesic therapy was being employed. These unused opioids heighten the risk of misuse and diversion.

The price of a Vicodin on the streets is about US$5 (€4.30) while that of a Percocet is US$10 (€8.50). Percocet costs twice as much because oxycodone possesses double the potency (twice the strength) of hydrocodone. Unfortunately, a bag of heroin on the streets can be purchased for as little as US$10 and cost becomes a major reason why some patients that initially get hooked on prescription opioids transition to heroin.

There is certainly a genetic component predisposing an individual for the illicit use of opioids. These are probably some of same people who are at high risk for becoming addicted to gambling, video games, food and other behaviours which can also have negative impacts on one’s life. Most people (85% -90%) do not like the acute effects that opioids cause. The drowsiness, nausea, vomiting, and constipation associated with these drugs becomes a major turn-off to most people. But there are some who like the euphoric feeling of these drugs. With continued use of these drugs, people become tolerant to many of the unpleasant side effects (except constipation) of these drugs.

In Pennsylvania, it is not the law that practitioners employ the online Pennsylvania Drug Monitoring Program (PDMP) on all patients to which an opioid-containing drug (or any drug with potential abuse potential, i.e. benzodiazepines) is going to be prescribed. This programme tracks the patient prescription records across state boundaries for potential drugs of abuse. It is then really up to the clinician to make a determination if the patient displays a pattern of prescription drug misuse. There are upgrades to this programme for a cost which will calculate a value between 0 – 10, with a value of 6 or greater being a “red flag” for a “doctor shopper”.

Editorial note: Dr Elliot V. Hersh is professor at the University of Pennsylvania’s School of Dentistry in Philadelphia in the US. On Friday morning, he will present a paper with the title “Evidence-based analgesic therapy” as part of this year’s FDI World Dental Congress programme in room Miro. A full list of references is available from the publisher.

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