Opioids – Information for Dentists

Overview

Prescription opioids continue to contribute to the opioid dependence and overdose epidemic in the United States. In 2019, over 14,000 people died from overdoses involving prescription opioids; this means that over one-quarter of all opioid overdoses involved prescription opioid medications.¹

Recent research shows overdose risk is higher among patients who fill an opioid prescription after a dental procedure, compared to those who don’t. Overdose risk is also higher in family members of those patients, especially their children.²

Additionally, some people develop an opioid use disorder and then seek out drugs with higher potency, such as heroin, so they can experience the euphoria they felt before developing opioid tolerance. In the process, many of those with opioid addiction are accidentally poisoned by heroin or other illegal drugs laced with fentanyl.^3,4

To keep health care professionals up to date on the opioids crisis, the U.S. Department of Health and Human Services and its agencies provide a wide variety of information and resources. Dentists can access information from the National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), the U.S. Food and Drug Administration (FDA), and the Indian Health Service (IHS). See Additional Resources after the Helpful Tips section below for a complete list.

Helpful Tips

• Consider nonsteroidal anti-inflammatory drugs (NSAIDs) as the first-line therapy for acute dental pain management. Studies have found that NSAIDs taken after a dental procedure are at least as effective (or superior) to opioid analgesics for reducing acute dental pain.^5,6
• Consider using multimodal opioid-sparing strategies such as pre-treatment with NSAIDs and long-acting local anesthesia. Several government agencies, professional organizations, and experts point to the need for these approaches.^5,7-9
• If you consider prescribing an opioid for acute pain, follow the CDC guidelines¹⁰:
  • Prescribe the lowest effective dose of immediate-release opioids.
  • Prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids.
• Note that three days or less will often be sufficient, and more than seven days will rarely be needed.
• Be aware that you may be the first to prescribe an opioid to an adolescent if you write a prescription after third molar extraction. Opioids prescribed after wisdom-tooth removal are frequently the first opioid experience for adolescents and young adults.⁵
• It’s important to know research has shown that medical use of prescription opioids is highly correlated with non-medical use of them among high school seniors. Among adolescents who reported both types of use, medical use generally came first.¹¹
• Additional research shows a similar finding in young people ages 13-30 undergoing third molar extraction. A filled perioperative opioid prescription is associated with persistent use of prescription opioids, defined as one or more filled prescriptions from four days to one year after the procedure.¹²
• In view of these risks, consider non-opioid analgesics for this population instead.
• Register with and use your state’s Prescription Drug Monitoring Program (PDMP) to promote the appropriate use of opioids and deter misuse and abuse. When opioid prescribing is indicated, risk of misuse and diversion may be mitigated by consistent PDMP use and patient education.¹³
• Counsel your patients if you prescribe an opioid pain medication¹⁴:
  • Ask about any other medications they’re currently taking, and whether they or any family members have had problems with substance use, such as with alcohol, prescription medications, or illicit drugs.
  • Explain the risks of taking the medication.
  • Describe how to take the medicine, how long to take it, and how to minimize its use by taking over-the-counter pain relievers, and adding opioids only if necessary to manage more severe pain.
  • Explain that alcohol should never be used when taking an opioid medication.
  • Provide guidance on storing medication in a safe place out of sight and out of reach of children, teens, and guests, preferably in a locked cabinet.
• Ask your patients if they use medicines containing buprenorphine that are dissolved in the mouth, including tablets and films dissolved under the tongue or placed against the inside of the cheek. The FDA has recently alerted patients and prescribers about dental issues related to buprenorphine-containing medications used to treat opioid use disorder (OUD) and pain.^15,16 Read important information about dental problems associated with these medications here. Despite the dental risks, buprenorphine is an important treatment option for OUD and pain, and the benefits of these medicines clearly outweigh the risks.

See the Additional Resources section for links to FDA’s Statement and Drug Safety Communication.

Additional Resources

Below are additional resources about the opioid crisis. (Information for your patients can be found on the NIDCR Opioids & Dental Pain webpage for consumers.)

• Pain Management Best Practices Inter-Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations
  The Pain Management Best Practices Inter-Agency Task Force was convened by the U.S. Department of Health and Human Services in conjunction with the U.S. Department of Defense and the U.S. Department of Veterans Affairs with the Office of National Drug Control Policy to address acute and chronic pain in light of the ongoing opioid crisis.
• HHS.GOV/OPIOIDS
  A website from the U.S. Department of Health and Human Services that provides information about the national opioid crisis as well as help and resources.
• NIH NIDAMED: Clinical Resources
  Resources for health professionals from the NIH National Institute on Drug Abuse on the causes and consequences of drug use and addiction, and advances in pain management.
• NIH NIDAMED Clinical Resources — Screening for Substance Use in the Dental Setting
  Tips on asking about substance use and discussing pain management with your patients.
• NIH Helping to End Addiction Long-term (HEAL) Initiative
  Trans-agency effort to speed scientific solutions to stem the national opioid public health crisis.
• NIH Pain Consortium
  A consortium that enhances pain research and promotes collaboration among researchers across the many NIH Institutes and Centers that have programs addressing pain.
  • The NIH Pain Consortium Centers of Excellence in Pain Education (CoEPEs) focus on the development, evaluation, and distribution of pain management curriculum resources.
• NIH RePORTER
  RePORTER allows users to search a repository of NIH-funded research projects. It includes project summaries, funding institution names, principal investigator names, and many other details about individual research projects.
• CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016
  Although these guidelines focus on opioids and chronic pain, they also briefly address opioids and acute pain; see page 24.
• Recommendations for Management of Acute Dental Pain: A collaboration between the Indian Health Service Division of Oral Health (DOH) & Indian Health Service National Committee on Heroin, Opioid and Pain Efforts (HOPE)
  The purpose of this document is to provide evidence-based guidance on prescribing for acute dental pain. This guidance seeks to reduce unnecessary opioid prescribing and assist dentists in selecting the most appropriate, effective, and safest pain medication based on patients’ individual medical status.
• U.S. Food and Drug Administration (FDA) Statement. FDA warns about risks of dental problems associated with buprenorphine medicines dissolved in the mouth to treat opioid use disorder and pain
  Statement from the FDA describing dental issues associated with the use of buprenorphine-containing medicines used to treat opioid use disorder and pain.
• FDA Drug Safety Communication. FDA warns about dental problems with buprenorphine medicines dissolved in the mouth to treat opioid use disorder and pain
  Questions and answers from the FDA about recent findings related to dental issues associated with the use of buprenorphine-containing medicines used for the treatment of opioid use disorder and pain.
• FDA: Safe Disposal of Medicines
  A webpage with information such as where and how to dispose of unused medicines.

References

1. National Institute on Drug Abuse. Overdose death rates. National Institute on Drug Abuse. https://www.drugabuse.gov/drug-topics/trends-statistics/overdose-death-rates. Published January 29, 2021. Accessed October 15, 2021.
2. Chua KP, Kenney BC, Waljee JF, Brummett CM, Nalliah RP. Dental opioid prescriptions and overdose risk in patients and their families. Am J Prev Med. 2021;61(2):165-173. https://doi.org/10.1016/j.amepre.2021.02.008.
3. Volkow ND, Jones EB, Einstein EB, Wargo EM. Prevention and treatment of opioid misuse and addiction: A review. JAMA Psychiatry. 2019;76(2):208-216. https://doi.org/10.1001/jamapsychiatry.2018.3126.
4. Volkow N. Addressing America’s fentanyl crisis. Nora’s Blog. https://www.drugabuse.gov/about-nida/noras-blog/2017/04/addressing-americas-fentanyl-crisis. Published April 6, 2017. Accessed April 2, 2021.
5. Indian Health Service, Division of Oral Health; Indian Health Service, National Committee on Heroin, Opioid and Pain Efforts. Recommendations for management of acute dental pain. Indian Health Service. https://www.ihs.gov/newsroom/ihs-blog/may2019/ihs-introduces-recommendations-for-management-of-acute-dental-pain/. Updated November 2020. Accessed February 10, 2021.
6. Dionne RA, Gordon SM, Moore PA. Prescribing opioid analgesics for acute dental pain: Time to change clinical practices in response to evidence and misperceptions. Compend Contin Educ Dent. 2016;37(6):372-378.
7. U.S. Department of Health and Human Services, Pain Management Best Practices Inter-Agency Task Force. Pain Management Best Practices Inter-Agency Task Force Report: Updates, gaps, inconsistencies, and recommendations: Final report. U.S. Department of Health and Human Services. https://www.hhs.gov/opioids/prevention/pain-management-options/index.html. Updated May 9, 2019. Accessed February 10, 2021.
8. Wardhan R, Chelly J. Recent advances in acute pain management: understanding the mechanisms of acute pain, the prescription of opioids, and the role of multimodal pain therapy. F1000Res. 2017;6:2065. https://doi.org/10.12688/f1000research.12286.1. Accessed February 10, 2021.
9. Hersh EV, Moore PA, Grosser T, et al. Nonsteroidal anti-inflammatory drugs and opioids in postsurgical dental pain. J Dent Res. 2020;99(7):777-786. https://doi.org/10.1177/0022034520914254. Published April 14, 2020. Accessed February 10, 2021.
10. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain — United States, 2016. MMWR Recomm Rep. 2016;65(1):1-49. http://dx.doi.org/10.15585/mmwr.rr6501e1. Published March 15, 2016. Updated March 18, 2016. Accessed February 10, 2021.
11. McCabe SE, West BT, Veliz P, McCabe VV, Stoddard SA, Boyd CJ. Trends in medical and nonmedical use of prescription opioids among US adolescents: 1976–2015. Pediatrics. 2017;139(4):e20162387. https://doi.org/10.1542/peds.2016-2387. Accessed February 10, 2021.
12. Harbaugh CM, Nalliah RP, Hu HM, Englesbe MJ, Waljee JF, Brummett CM. Persistent opioid use after wisdom tooth extraction. JAMA. 2018;320(5):504-506. https://doi.org/10.1001/jama.2018.9023. Published August 7, 2018. Accessed February 10, 2021.
13. McCauley JL, Leite RS, Gordan VV, et al. Opioid prescribing and risk mitigation implementation in the management of acute pain: Results from The National Dental Practice-Based Research Network. J Am Dent Assoc. 2018;149(5):353-362. https://doi.org/10.1016/j.adaj.2017.11.031. Published March 14, 2018. Accessed February 10, 2021.
14. National Institute on Drug Abuse, NIDAMED. Screening for substance use in the dental setting. National Institute on Drug Abuse. https://www.drugabuse.gov/nidamed-medical-health-professionals/science-to-medicine/screening-substance-use/in-dental-setting. Published November 21, 2018. Accessed February 10, 2021.
15. U.S. Food and Drug Administration, Center for Drug Evaluation and Research. FDA warns about risks of dental problems associated with buprenorphine medicines dissolved in the mouth to treat opioid use disorder and pain. U.S. Food and Drug Administration. January 12, 2022. Accessed March 7, 2022. https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-risks-dental-problems-associated-buprenorphine-medicines-dissolved-mouth-treat
16. U.S. Food and Drug Administration, Center for Drug Evaluation and Research. FDA warns about dental problems with buprenorphine medicines dissolved in the mouth to treat opioid use disorder and pain: Benefits for use outweigh these risks and oral care can help. U.S. Food and Drug Administration. January 12, 2022. Updated January 21, 2022. Accessed March 7, 2022. https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-dental-problems-buprenorphine-medicines-dissolved-mouth-treat-opioid-use-disorder