Effective pain management in dentistry ensures patient comfort and fosters trust between the patient and the dental professional. However, the rise of opioid use disorder (OUD) has added complexity to prescribing practices.
Dental professionals must now navigate the dual responsibilities of alleviating pain and minimizing the risk of opioid misuse.
Related: Pain Management: Evidence-Based Guidance for Prescribing Opioids
Understanding Opioid Use Disorder (OUD)
Opioid Use Disorder is a chronic, relapsing condition characterized by the compulsive use of opioids despite harmful consequences. It often begins with legitimate prescriptions but can escalate due to various factors, including genetics, stress, and environmental influences.
OUD typically manifests in individuals during their late teens or early twenties. Key signs include taking opioids in larger amounts or over a longer period than intended, persistent desire to cut down usage without success, and significant time spent obtaining or recovering from opioid use. Cravings and continued use despite social or interpersonal problems are also common indicators.
Epidemiology and risk factors
From 1999 to 2020, over 564,000 people in the United States died from opioid overdoses. The epidemic has evolved in three waves: an initial surge due to prescription opioids, followed by increases in heroin-related deaths, and more recently, fatalities involving synthetic opioids like fentanyl.
Risk factors for developing OUD are multifaceted:
- Biological factors: Genetic predisposition, gender differences, and existing mental health disorders can increase susceptibility.
- Environmental factors: Unstable home environments, parental substance use, peer pressure, and community attitudes toward drugs play significant roles.
- Developmental factors: Adolescents are particularly vulnerable due to the ongoing maturation of the prefrontal cortex, which affects decision-making and impulse control.
Protective factors, such as strong family support, positive social relationships, and engagement in extracurricular activities, can mitigate these risks.
Root causes of the opioid epidemic
The opioid crisis is the result of a complex interplay of factors, with prescriber practices and pharmaceutical influences being significant contributors.
Prescriber practices
In the mid-1990s, there was a paradigm shift in pain management. Healthcare providers prescribed opioids more liberally to address pain more effectively. This well-intentioned approach lacked adequate attention to the potential for negative consequences, such as dependency and addiction. Between 1999 and 2010, opioid prescribing in the U.S. quadrupled, contributing to increased availability and misuse.
Pharmaceutical influence
Pharmaceutical companies played a pivotal role by aggressively marketing opioids to healthcare providers. Direct-to-physician marketing strategies often downplayed the risks of addiction, leading to increased prescribing rates. Studies have shown a correlation between pharmaceutical marketing of opioids and higher overdose mortality rates.
CDC guidelines for prescribing opioids
In response to the opioid crisis, the Centers for Disease Control and Prevention (CDC) developed guidelines to assist clinicians in prescribing opioids responsibly.
Initiating opioid therapy
- Recommendation 1: For acute pain, nonopioid therapies are preferred. Opioids should only be considered if the benefits outweigh the risks, and patients should be informed about these risks.
- Recommendation 2: For subacute and chronic pain, maximize nonpharmacologic and nonopioid pharmacologic therapies. Opioids should only be initiated if the expected benefits for pain and function outweigh the risks.
Opioid selection and dosage
- Recommendation 3: When opioids are necessary, prescribe immediate-release formulations rather than extended-release versions.
- Recommendation 4: Start with the lowest effective dosage and proceed cautiously if dosage increases are considered.
Duration and follow-up
- Recommendation 6: For acute pain, prescribe the minimum quantity of opioids necessary, often sufficient for three days or less.
- Recommendation 7: Reassess patients within one to four weeks of starting opioid therapy to evaluate benefits and potential harms.
Risk assessment and mitigation
- Recommendation 8: Before and during opioid therapy, evaluate patients for risk factors of opioid-related harms and develop strategies to mitigate these risks.
- Recommendation 9: Utilize state Prescription Drug Monitoring Programs (PDMPs) to review patient histories and detect potential misuse.
- Recommendation 11: Exercise caution when prescribing opioids alongside benzodiazepines or other central nervous system depressants.
Best practices for pain management in dentistry
Conduct thorough evaluations, including medical and dental histories, to understand the patient’s pain and overall health status. Assess risk factors of opioid misuse, such as personal or family history of substance abuse.
Prioritize non-opioid therapies
Consider nonpharmacologic interventions like cold therapy, rest, or physical therapy when appropriate. Nonopioid analgesics, such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), are often effective for dental pain.
Patient education
Engage patients in discussions about their pain management plan. Explain the risks and benefits of opioid therapy, proper medication use, and the importance of adhering to the prescribed regimen. Educate on safe storage and disposal of medications to prevent diversion.
Careful documentation
Maintain detailed records of all prescribing decisions, including the rationale for using opioids, dosages, and patient education provided. Documentation is crucial for legal compliance and continuity of care.
Continuing education and training
Stay current with evolving guidelines and regulations for pain management in dentistry. Participate in continuing education focused on pain management, opioid prescribing, and recognizing signs of substance misuse.
Collaboration with other healthcare providers
Work collaboratively with physicians, pharmacists, and other dental professionals to coordinate care. This is especially important for patients with complex medical histories or those receiving opioids from multiple providers.
Use of prescription drug monitoring programs (PDMP)
PDMPs are state-run electronic databases that track prescriptions of controlled substances. They serve as a tool to prevent opioid misuse by:
- Identifying patients obtaining prescriptions from multiple providers.
- Providing clinicians with a patient’s prescription history to inform prescribing decisions.
- Reducing the incidence of “doctor shopping” and prescription fraud.
Dentists should consult the PDMP before prescribing opioids to ensure safe prescribing practices.
Use of electronic prescribing of controlled substances (EPCS)
EPCS allows for the secure electronic transmission of controlled substance prescriptions. Benefits include:
- Reducing prescription errors and fraud.
- Enhancing the efficiency of the prescribing process.
- Complying with DEA requirements for authentication and security.
Adopting EPCS can help dental practices improve prescribing safety and comply with regulatory standards.
Conclusion
Pain management in dentistry requires a delicate balance between effectively treating pain and minimizing the potential for opioid misuse. By adhering to evidence-based guidelines, utilizing PDMPs, engaging in patient education, and prioritizing nonopioid therapies, dental professionals can provide safe and effective pain management. As frontline healthcare providers, dentists have a critical role in combating the opioid epidemic while ensuring patient comfort and well-being.
