The diversion of opioid medications used for non-medical purposes is a currently a major public health problem. For example, since 2002, the prevalence of high school seniors in the United States using opioids for non-medical purposes has been 10 percent for hydrocodone and five percent for oxycodone.1 Such abuse can potentially lead to addiction and even death from overdose. In fact, opioid overdose is now the second most common cause of unintentional death in the United States.2
There are many ways in which legitimately prescribed opioids can be diverted for non-medical use. These include theft, sale and improper disposal of unused, properly prescribed drugs. Moreover, studies have shown that among persons 12 years or older, who used opioids non-medically in the past year, 54 percent obtained them from a friend or relative.3 It has been suggested that one potential source of such drugs is the pain medications prescribed by dentists after the removal of impacted third molars that were not used by the patient.4,5
To determine whether such patients are prescribed more tablets of a narcotic than would reasonably be needed for postoperative pain control, a 2013 survey was sent to 600 randomly selected oral and maxillofacial surgeons in the United States, asking them whether they routinely prescribed a narcotic for patients after impacted third molar removal, the most common drug used, and the dosage and number of tablets prescribed4 (Fig. 1). They were also asked if they pretreated patients with a non-steroidal anti-inflammatory drug (NSAID) or prescribed one along with the narcotic, injected a steroid, or used a long-lasting local anesthetic post-operatively. There was a 64 percent response rate (384/600).
Only two of the 384 responding oral and maxillofacial surgeons stated that they did not prescribe a narcotic post-operatively for patients who had impacted teeth removed. The most frequently prescribed drugs were hydrocodone (n=233), oxycodone (n=55) and codeine (n=5). The most frequent dose of hydrocodone was 5mg, but some respondents prescribed 7.5 mg and even 10mg tablets.
Three hundred and twenty-eight respondents reported the exact number of tablets they always prescribed. This varied from 10 to 40 tablets (Table 1). Although the most common amount was 20 tablets, 80 respondents prescribed more than 20, with 40 of them prescribing 30 tablets. Only 34 percent pre-treated their patients with an NSAID, although 60 percent did recommend such use post-operatively. Eighty percent of the respondents injected their patients with steroids and 62 percent used a long-lasting local anesthetic.
The findings from this study raise the question of whether the possible diversion of narcotics prescribed for patients having impacted teeth removed is strictly an American problem, or if it also might occur in other countries. Because Canada has the second highest consumption of prescribed oral opioid narcotics in the world6, it was considered of interest to determine if oral and maxillofacial surgeons had similar analgesic prescribing habits as those in the US. Therefore, in 2014, a survey similar to the one used in the American study was sent to 336 active members of the Canadian Society of Oral and Maxillofacial Surgeons.7 One hundred and fifty-eight surveys were returned for a 47 percent response rate.
Only 11 of the 158 respondents indicated that they did not prescribe a narcotic for patients after the removal of impacted third molars. The most frequently prescribed narcotic was codeine (108), followed by oxycodone (31). The most commonly prescribed dose of codeine was 30 mg. Fifty-six of the respondents who used codeine prescribed 30 tablets, 17 prescribed 20, 16 prescribed 25 and four prescribed 40. For those who used oxycodone, the number of tablets ranged from nine to 40, with nine prescribing 20, three prescribing 25, five prescribing 30 and two prescribing 40. Eighty-six percent injected a steroid, 32 percent pretreated their patients with an NSAID, 56 percent injected a long-lasting local anesthetic and 80 percent who prescribed a narcotic also had their patients use an NSAID post-operatively.
What are the lessons that one can learn from these two studies? Clearly, it is important that clinicians use proper discretion in deciding the number of tablets of a narcotic to prescribe for post-operative pain control. The pain following the removal of impacted third molars usually reaches a maximum on the first post-operative day and lasts for three to four days, gradually decreasing in intensity. Thus, assuming that a patient uses six tablets of an appropriate analgesic on the first day, four each on the next two days, and even a few on the fourth day, 15 to 20 tablets should be more than sufficient. Prescribing more on the chance that the pain lasts longer than four days is not advisable because such continued pain may be due to an infection or an alveolar osteitis, and the patient should be seen by the doctor. Moreover, it is such prescribing habits that can lead to potential drug excess and diversion.
One of the most interesting findings from comparing these two studies is the difference in the narcotic that is most frequently prescribed in the two countries. Whereas, American oral and maxillofacial surgeons preferred to use hydrocodone, codeine was preferred in Canada. However, the Canadian oral and maxillofacial surgeons generally either also prescribed an NSAID, or suggested patients use it in an over-the counter form along with the codeine. By using this combination, they avoided patients taking more potent, more addictive, opioids.
Mutlu et al. have described the five most important steps that will result in effective post-operative pain contro.l4 First, the clinician should select a drug with sufficient potency to control the amount of expected pain. This will be different in patients having a simple tooth extraction, who may only require an NSAID, and those having impacted third molars removed, who may require an opioid. The second step is to have the patient start the drug before the onset of the pain. Third, the analgesic should be taken on a regularly scheduled basis, so that the pain threshold is maintained at a high level, rather than fluctuating between high and low levels. Forth, they recommend using small doses of the drug at frequent intervals, rather than large doses at long intervals. This also avoids unfavorable fluctuations in the pain threshold.
Finally, because an analgesic drug alone may not be sufficient to manage all post-operative pain, it is essential in cases where severe pain is expected to include the pre-emptive use of an NSAID, the use of a steroid, and injection of a long-lasting local anesthetic. By following these guidelines, and avoiding prescribing excessive amounts of opioid analgesics, clinicians hopefully can reduce the potential diversion of such drugs by dental patients.OH
Daniel M. Laskin, DDS, MS, is a Professor and Chairman Emeritus, Department of Oral and Maxillofacial Surgery Virginia Commonwealth University School of Dentistry, Richmond, Virginia. He can be reached at dmlaskin
Bruce R. Pynn, DDS, FRCD(C), is Associate Professor, Northern Ontario School of Medicine, Thunder Bay Campus, and Thunder Bay Regional Health Science Centre, Private practice Thunder Bay, ON.
Oral Health welcomes this original article.
1. Johnson LD, O’Malley PM, Bachman JG, et al. Monitoring the Future National Survey Results on Drug Use. 1975-2009: volume 1: secondary school students (NIH publication No. 10-7584) http://monitoring thefuture.org/pubs/monographs/vol 1_2009.pdf. Accessed September 29, 2014.
2. Unintentional drug poisoning in the United States (July 2010). National Center for Injury Prevention and Control. Centers for Diseaase Control and Prevention. http://www.cdc.gov/HomeandRecreational Safety/pdf/poison-issue-brief.pdf. Accessed September 29, 2014.
3. Substance Abuse and Mental Health Services Administration. Results of the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publications No. (SMA) 13-4795, Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013, pp29-30.
4. Mutlu I, Abubaker AO, Laskin DM. Narcotic prescribing habits and other methods of pain control by oral and maxillofacial surgeons after impacted third molar removal. J Oral Maxillofac Surg 71:1500, 2013.
5. Denisco RC, Kenna GA, O’Neil MG, et al. Prevention of prescription opioid abuse: The role of the dentist. JADA 142:800, 2011.
6. Fischer B, Argento E: Prescription opioid related issues, harms, diversion and interventions in Canada: A review. Pain Physician 15:ES191, 2012.
7. Pynn RP, Laskin DM. Comparison of narcotic prescribing habits and other methods of pain control by oral and maxillofacial surgeons in the United States and Canada. J Oral Maxillofac Surg 72:1, 2014.