Opioids – Information for Dentists

Overview

Prescription opioids continue to contribute to the opioid dependence and overdose epidemic in the United States. In 2021, more than 16,000 people died from overdoses involving prescription opioids; this means that nearly 1 in 6 of all opioid overdoses involved prescription opioid medications.¹

The opioid overdose death rate in 2021 was 25 deaths per 100,000 people², more than the death rate due to car accidents, which was approximately 13 deaths per 100,000 people.³

Recent research shows overdose risk is higher among patients who fill an opioid prescription after a dental procedure, compared to those who don’t.⁴ Overdose risk is also higher in family members of those patients, especially their children.⁴

Addiction or overdose is possible for anyone who takes prescription opioids.⁵ Starting in the early 2000s, some of those addicted to prescription opioids began transitioning to heroin because it was cheaper and easier to get.⁶ The shift toward heroin use contributed to the escalation of opioid-associated fatalities, now further exacerbated by adulteration of heroin with fentanyl or fentanyl analogues.⁶

To keep health care professionals up to date on the opioid crisis, the U.S. Department of Health and Human Services and its agencies provide a wide variety of information and resources. Dentists can access additional resources from the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), the U.S. Food and Drug Administration (FDA), the Indian Health Service (IHS), and the Office of the Surgeon General. State licensing boards, departments of health, and professional societies also have resources about opioid prescribing. (See Additional Resources section below.)

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.^7, 8
• Consider using multimodal opioid-sparing strategies such as pretreatment with NSAIDs and long-acting local anesthesia. Several government agencies, professional organizations including the American Dental Association and the American Association of Oral and Maxillofacial Surgeons, and experts point to the advantages for these approaches.^7-14
• Nonopioid therapies are at least as effective as opioids for many common types of acute pain, including dental pain.¹⁵
• If you consider prescribing an opioid for acute pain, follow the 2022 CDC guidelines.¹⁵
  • Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and only consider opioid therapy for acute pain if benefits are anticipated to outweigh risks to the patient. Before prescribing opioid therapy for acute pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy.
  • CDC has also developed the Dental Pain Care webpage, which provides a high-level overview of opioid use for dental pain based on CDC’s 2022 Clinical Practice Guideline for Prescribing Opioids for Pain.
  • Per the Dental Pain Care webpage: When diagnosis and severity of acute pain warrant the use of opioids,
    clinicians should—
    • Prescribe immediate-release opioids (Recommendation 3), at the lowest effective dose (Recommendation 4), and for no longer than the expected duration of pain severe enough to require opioids (Recommendation 6) to minimize unintentional long-term opioid use.
• Avoid prescribing due to pain from underlying disease.
• 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.⁷
  • It’s important to know research has shown that medical use of prescription opioids is highly correlated with nonmedical use of them among high school seniors. Among adolescents who reported both types of use, prescription-opioid use generally came first.¹⁶
  • Additional research shows a similar finding in young people ages 13 to 30 years 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.¹⁷
• In view of these risks, consider non-opioid analgesics for this population instead. Research has found nonsteroidal anti-inflammatory drugs in combination with acetaminophen may be more effective, with fewer side effects, than are many of the available opioid-containing formulations.¹⁸
• 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 reduced by consistent PDMP use and patient education.¹⁹
• Counsel your patients if you prescribe an opioid pain medication.²⁰
  • Ask about any other medications they’re currently taking, and whether they have had problems with substance use, such as with alcohol, prescription medications, or illicit drugs.
  • Ask about any health problems for which they may already be taking opioids.
  • Consult with the prescribing provider about other opioid prescriptions.
  • 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.
  • Keep in mind patients may get acetaminophen from multiple sources, including what you prescribe.
  • 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, teenagers, and guests, preferably in a locked cabinet.
  • If the patient is a minor or lives at home with siblings, counsel their parents about proper drug administration (dosage and timing) and safe storage.
  • Provide information on how to safely dispose of unused medication.
• 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 alerted patients and prescribers about dental issues related to buprenorphine-containing medications used to treat opioid use disorder (OUD) and pain.^{21, 22} 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.)

Government Resources

• 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.
• National Opioids Crisis: Help and Resources
  A page from the U.S. Department of Health and Human Services with prevention, treatment, and recovery information.
• NIH NIDAMED: Clinical Resources
  Resources for health professionals and those in training about screening, addressing, and treating addiction from NIH’s National Institute on Drug Abuse.
• 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
  NIH-wide 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 Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022
  This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016 and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1–3 months), and chronic (duration of >3 months) pain.
• 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 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.
• Facing Addiction in America: The Surgeon General’s Spotlight on Opioids
  The Spotlight on Opioids assembles opioid-related information from the Surgeon General’s Report on Alcohol, Drugs, and Health into one document to better inform the general public, especially family and friends of people with an elevated risk of opioid overdose, opioid misuse, and/or opioid use disorder.

Resources from:

The American Dental Association, a national organization of 159,000+ member dentists.

• Educational Materials
• Guidelines
• Policy regarding opioid use, misuse, and diversion

The American Dental Education Association, the national organization representing academic dentistry.

• Summary of State Legislation and Regulations Addressing Prescription Drugs and Opioids

References

1. National Institute on Drug Abuse. Drug overdose death rates. Published June 30, 2023.
2. KFF. State Health Facts. Opioid Overdose Death Rates and All Drug Overdose Death Rates per 100,000 Population (Age-Adjusted). Data Source: Centers for Disease Control and Prevention (CDC), National Center for Health Statistics. Multiple Cause of Death 1999-2021 on CDC WONDER Online Database. Compiled from data accessed on April 19, 2022.
3. Insurance Institute for Highway Safety (IIHS). Fatality Facts 2021. State by state. Published May 2023.
4. 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 Aug;61(2):165-173. doi: 10.1016/j.amepre.2021.02.008.
5. Centers for Disease Control and Prevention. Prescription opioids. Published August 29, 2017.
6. Volkow ND, Jones EB, Einstein EB, Wargo EM. Prevention and treatment of opioid misuse and addiction: a review. JAMA Psychiatry. 2019 Feb 1;76(2):208-216. doi: 10.1001/jamapsychiatry.2018.3126.
7. Indian Health Service, Division of Oral Health; Indian Health Service, National Committee on Heroin, Opioid and Pain Efforts. IHS Introduces recommendations for management of acute dental pain. Published May 29, 2019.
8. Watson H, Hildebolt C, Rowland K. Pain relief with combination acetaminophen/codeine or ibuprofen following third-molar extraction: a systematic review and meta-analysis. Pain Med. 2022 May 30;23(6):1176-1185. doi: 10.1093/pm/pnab334.
9. 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. Report Date May 9, 2019.
10. 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 Nov 29;6:2065. doi: 10.12688/f1000research.12286.1.
11. Hersh EV, Moore PA, Grosser T, Polomano RC, Farrar JT, Saraghi M, et al. Nonsteroidal anti-inflammatory drugs and opioids in postsurgical dental pain. J Dent Res. 2020 Jul;99(7):777-786. doi: 10.1177/0022034520914254.
12. American Dental Association. Oral analgesics for acute dental pain. Updated February 2, 2024.
13. American Dental Association, ADANews. New ADA guideline recommends acetaminophen, NSAIDs to manage pain in pediatric patients. Published August 25, 2023.
14. American Association of Oral and Maxillofacial Surgeons. Opioid prescribing: acute and postoperative pain management. [White Paper]. Revised January 2023.
15. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC clinical practice guideline for prescribing opioids for pain - United States, 2022. MMWR Recomm Rep. 2022 Nov 4;71(3):1-95. doi: 10.15585/mmwr.rr7103a1.
16. 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 Apr;139(4):e20162387. doi: 10.1542/peds.2016-2387.
17. Harbaugh CM, Nalliah RP, Hu HM, Englesbe MJ, Waljee JF, Brummett CM. Persistent opioid use after wisdom tooth extraction. JAMA. 2018 Aug;320(5):504-506. doi: 10.1001/jama.2018.9023.
18. Moore PA, Hersh EV. Combining ibuprofen and acetaminophen for acute pain management after third-molar extractions: translating clinical research to dental practice. J Am Dent Assoc. 2013 Aug;144(8):898-908. doi: 10.14219/jada.archive.2013.0207.
19. McCauley JL, Leite RS, Gordan VV, Fillingim RB, Gilbert GH, Meyerowitz C, 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 May;149(5):353-362. doi: 10.1016/j.adaj.2017.11.031.
20. National Institute on Drug Abuse, NIDAMED. Screening for substance use in the dental setting. Published May 3, 2021.
21. 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. Published January 12, 2022.
22. 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. Published January 21, 2022.

Opioids & Dental Pain Research from the NIDCR

• Inflammation May Curb, Not Cause, Chronic Pain
• How Sound Reduces Pain in Mice
• Facial Pain Comes to Light
• Scientists Find New Pain-Suppression Center in the Brain
• A New View of Nerve Pain
• National Dental PBRN Enters Next Phase
• Dentists Play Vital Role in Addressing Opioid Crisis

Opioids & Dental Pain for Health Care Providers

• Screening for Substance Use in the Dental Setting (from NIDAMED)