Opioids? Who Needs Them? by Tom Viola, R.Ph., C.C.P. Pain is often described as a sensation by which you are made aware of actual or potential physical injury to your tissues. Pain is rapid, reflexive, reliable and subconscious. You don’t have to think to have pain, and, once you have it, you know it. Pain is also described as a protective response, one of many employed by the body. Protective responses are psychological and involve an emotional reaction They are strongly associated with behavior and are governed by memory. Thus, pain has both a physical component and a psychological component which contribute to its complexity and explains why it is so difficult to treat. To successfully treat pain, we must contend with both its physical and psychological effects. This is certainly true of dental pain. While dental pain may be described as acute, inflammatory pain of relatively short duration, patients who have suffered through long bouts of unresolved severe dental pain exhibit a strong emotional response to any such pain, which may magnify its intensity and duration. Non-opioid analgesics have been proven to be effective in the treatment of dental pain. They include the nonsteroidal anti-inflammatory drugs (NSAIDs, such as Advil and Aleve), as well as acetaminophen (Tylenol). However, many patients believe that since these agents are available without a prescription, unlike opioid analgesics, they do nothing to blunt the emotional response to pain, and that they must be inferior in their ability to relieve dental pain, especially when compared to opioid analgesics (such as Vicodin and Percocet). Nevertheless, many studies have concluded that the opposite is true. At regular doses, non-opioid analgesics are as effective as opioid analgesics in relieving dental pain, without the potential for producing serious adverse reactions (such as respiratory depression) as well as dependence and addiction. NSAIDs are similar to aspirin in that they inhibit the formation of substances called prostaglandins. Some prostaglandins produce pain, fever and inflammation. By blocking the formation of these substances, NSAIDs produce their antipyretic (fever-reducing), analgesic (pain relieving) and anti-inflammatory effects. Ibuprofen is very effective in treating dental pain at doses of up to 600mg. This is because almost all cases of moderate to severe dental pain involve some degree of acute inflammation. However, NSAIDs may cause serious adverse effects, especially at high doses. NSAIDs may inhibit the formation of other prostaglandins which produce the gastrointestinal mucous lining, regulation of clotting, dilation of the bronchioles in the lungs and maintenance of adequate blood flow to the kidneys. Thus, by blocking formation of these substances, NSAIDs may also cause additional effects, such as gastrointestinal upset, bleeding, difficulty breathing and even kidney damage, especially with long-term use. Acetaminophen also produces antipyretic (fever-reducing) and analgesic (pain-relieving) activity, equivalent to that of aspirin, but weak anti-inflammatory effects. However, acetaminophen is very effective in treating dental pain at doses up to 1000mg. While it is thought that acetaminophen, like aspirin and the NSAIDs, inhibits prostaglandins, its exact mechanism of action is not fully understood. Acetaminophen has long been considered the “safe” analgesic, since it produces few side effects at usual adult doses. But, acetaminophen may cause serious liver damage, especially when taken at high doses. Since both NSAIDs and acetaminophen are effective on their own in treating dental pain, and, since both may produce either beneficial and adverse effects based on the dose, it would seem that the use of these drugs together, in combination, would be advantageous. The synergy of using both would allow for greater beneficial effects to be achieved while using lower doses of each, thus minimizing adverse effects. There is yet no analgesic product available in the U.S that combines ibuprofen with acetaminophen in one tablet. Yet, many studies have concluded that comparable doses of ibuprofen or acetaminophen were significantly more effective in the treatment of moderate to severe dental pain when used together than when used alone. Indeed, many dental offices prescribe these drugs in combination for the effective management of dental pain. So, where does that leave opioid analgesics? It is clear that dentistry can be the avant-garde, the first profession to treat moderate to severe post-procedure pain without opioid analgesics. Their potential for producing tolerance, leading to ever-increasing doses, and serious adverse effects, makes opioid analgesics undesirable in the treatment of short-term acute inflammatory pain like dental pain. Their abuse potential has led to a nationwide epidemic of abuse and, unfortunately, their diversion as a street drug. One promising development for dentistry has been the institution of state prescription drug monitoring programs to track the prescribing and utilization of these drugs. These programs have all but eliminated the practice of “shopping” for opioid analgesics by visiting multiple prescribers under false pretenses and they have certainly made life easier for the dental office staff. Does your state offer a prescription drug monitoring program? Consult the following list to find out more. http://www.pdmpassist.org/content/state-pdmp-websites With over 30 years’ experience as a pharmacist, dental educator and author, Tom Viola, R.Ph., C.C.P. has earned his reputation as the go-to specialist for delivering quality dental continuing education content through his informative, funny and engaging presentations. Tom’s programs provide an overview of the most prevalent oral and systemic diseases and the most frequently prescribed drugs used in their treatment, along with specific focus on dental considerations and strategies for implementing effective care plans.
|