Let’s not complicate opioids in dentistry
It's no secret that the opioid epidemic is wreaking havoc on the US. Dentists should take proper precautions so as not to contribute to the problem.
This article originally appeared in the Principles of Practice Management e-newsletter. Subscribe to this informative twice monthly practice management ENL here.
NEARLY EVERYONE IS AWARE OF THE CRISIS OUR NATION IS FACING regarding the overprescribing of narcotic pain medications. The devastation to our families, friends, and communities are well reported and documented. Historically, dentists may have played a part in the problem, not from malice, but from lack of knowledge and/or time constraints.
Several months ago, I took my daughter to MoPOP, the Seattle museum “dedicated to contemporary pop culture.” She was particularly interested in a visiting exhibit with several Rube Goldberg machines. Essentially, these machines solve simple tasks with an intentionally overcomplicated device. For most of us, whether in dentistry or life, we’re constantly searching for the exact opposite—a simple, easy, efficient, and inexpensive way to complete our tasks. Implementing a prescription protocol to maximize safety and prescribe opioids for pain management doesn’t have to be complicated.
Here is a simple step-by-step protocol that will help dentists efficiently prescribe opioid medications easily and at no cost.
Step 1: Consider non-narcotics first
A clinician should not routinely prescribe opioid medications for acute dental pain.(1)The combination of ibuprofen and acetaminophen is more effective and has fewer side effects than opioids.(2) To streamline this, have a pre-inked stamp created for these prescriptions. Here is an example:
600 mg Ibuprofen Disp: 20 tabs
500 mg Acetaminophen Disp: 40 tabs
Sig: Take 1 tab Ibuprofen + 2 tabs
Acetaminophen q 6 – 8 hrs prn pain
If a patient has a medical condition that precludes taking ibuprofen or acetaminophen, ketorolac tromethamine is a good alternative.
Step 2: Check the state’s prescription monitoring program (PMP)
When choosing to prescribe opioids, always check the state’s PMP program prior to writing the prescription. This will help ensure that dentists are not providing narcotic medications to any patients who are abusing them or obtaining them for illegal distribution.
Forty-nine states have PMPs (Missouri is the exception). To save time, sign up with the state’s program and bookmark a link to the login page of the website. Make it simple and easy to access on the computer that’s used most often in the practice. Keep the password handy so that valuable time isn’t spent searching for or resetting the password.
Step 3: Limit opioid prescriptions to a two- to three-day supply
Opioid prescriptions for acute pain should be no more than 20 low-dose, short-acting opioids, or three days of medication, whichever is less.(1) Examples of these kinds of medications are hydrocodone (Norco, Vicodin, Xodol) and oxycodone (Percocet, Percodan, Roxicet, Tylox). Limiting the number of pills prescribed will reduce the surplus of opioids available to patients and the community, thereby diminishing the harm these substances can cause.
Step 4: Discuss with patients the risks and potential consequences of taking opioids
Patients who are prescribed opioid medications should be advised not to operate heavy machinery, drive a car, or participate in other work or home activities that might be affected by the sedating effect of opioids.(1) It should also be understood by these patients that opioid medications are highly addictive; one can become physically dependent in as few as five days.(3)
Step 5: Review the safe storage and disposal of opioids
Proper storage and disposal can reduce the opioids involved in illegal distribution and overdose. Considering the great harm of excess opioids to the community, every opioid prescription should be accompanied with storage and disposal information.(1) Unfortunately, disposal information is complicated and always changing. Remind patients to read the information provided with their prescription when they pick it up from the pharmacist.
As health-care professionals, we must commit to the safe and proper prescription of opioid medications. By following the simple protocols described here, we can easily create a free and efficient system in our practice to ensure that the drugs we prescribe do not pose any harm to our patients and communities.
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(This article sponsored by Pacific Dental Services)
William McGlashan, DDS,has been practicing dentistry since 1985 and is a graduate of University of Southern California Herman Ostrow School of Dentistry. He is currently an owner dentist supported by Pacific Dental Services in Renton, Washington.
1. Dowell D, Haegerich TM, Chou R. Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep. 2016;65(No. RR-1):1–49.
2. 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;144(8):898-908.
3. Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use — United States, 2006–2015. MMWR Morb Mortal Wkly Rep. 2017;66:265–269.