PITTSBURGH — If you've ever had a root canal or tooth extraction, you might have been handed a prescription for Vicodin or another opioid painkiller to help you recover after your procedure.
Opioids have routinely been prescribed to adults and children for dental procedures for decades, and dentists are among the top prescribers of the drugs after family physicians, responsible for an estimated 1 in 10 opioids in the United States.
But prescriptions for the powerful narcotics have fallen in recent years, as the opioid crisis has underscored the need to be more judicious when prescribing the drugs. Local dentists are increasingly turning to alternatives to manage pain — and patients don't seem to mind.
"I found through my own experience treating patients at Children's Hospital that we could take a non-opioid approach for pretty significant surgeries and patients have a more than adequate experience," said Dr. Bernard Costello, dean of Pitt's School of Dental Medicine.
The evidence supports that. Studies have shown that non-opioid medications can work as well or even better for managing pain after dental work.
Dr. Costello said he used to prescribe opioids to patients on a "just-in-case" basis so that they'd have them on hand if needed. But now he's shifted to a "break glass" approach, in which he only prescribes them after non-opioid medications don't work.
In 2019, Pitt Dental Medicine adopted opioid-free pain management guidelines for most of the procedures performed in its clinics. The guidelines take into account severity, duration and individual risk considerations when prescribing pain medications for patients. In the first year after implementing the plan, opioid prescriptions fell by 54%, according to Dr. Costello. In the second year, they decreased by another 48%.
In December, the dental school pledged that it would incorporate responsible pain management into student and resident training as part of their curriculum. Dr. Costello said training the next generation of dentists to use fewer opioids is key to preventing misuse of the drugs.
The shift to using fewer opioids is happening across the country. In a study published in the Annals of Internal Medicine in December, researchers found that the amount of opioids prescribed by dentists fell by about 41% from 2008 to 2018. That was similar to the decrease in opioids prescribed by primary care physicians but not as steep as the decline by some other medical specialists, like surgeons, oncologists and emergency physicians.
"I think they really have tried to get away from clinically unnecessary prescribing," said Dr. Bradley Stein, senior physician policy researcher at the RAND Corporation's Pittsburgh office, and an author on the study.
That's good news for worried patients and parents of teenagers, whose first exposure to opioids is often after having wisdom teeth removed. Around 5 million people a year get their wisdom teeth removed, many of them teenagers and young adults. Avoiding prescribing opioids to this group could reduce the risk of abuse, misuse and addiction later on in life.
A 2018 study in the Journal of the American Medical Association found that young people ages 13 to 30 who filled an opioid prescription immediately before or after they had their wisdom teeth out were more than twice as likely to fill two or more prescriptions in the next year compared with peers who got their wisdom teeth out but never filled an opioid prescription.
"There really is a societal benefit of trying to help dentists more thoughtfully prescribe and manage pain because then you're avoiding exposing younger individuals to opioids who may not be exposed otherwise," Dr. Stein said.
MANAGING PAIN WITHOUT OPIOIDS
James Boyle, an oral and maxillofacial surgeon in York, Pa., said there are several ways to manage pain without the use of opioids.
Dentists sometimes recommend that patients take Advil or Motrin before a surgery to start building up the medication in their system so they're not "chasing the pain," said Dr. Boyle, who's also the past president of the Pennsylvania Dental Association. This helps minimize the discomfort before it begins.
After surgery, patients can take over-the-counter drugs in the category known as nonsteroidal anti-inflammatory drugs, or NSAIDs, which include ibuprofen, naproxen and aspirin. These drugs help with pain by reducing inflammation at the site where it's occurring.
Patients can also take acetaminophen safely with an NSAID since they work in different ways. Acetaminophen, or Tylenol, blocks the transmission of pain signals in the central nervous system. Dentists may prescribe acetaminophen or an NSAID at higher doses to patients.
In addition to non-opioid medications, there are other ways to manage pain after a dental procedure. Patients should eat soft foods for the first 24 hours after a dental surgery.
"Get your favorite flavor of ice cream," Dr. Boyle said. Mashed potatoes, scrambled eggs and oatmeal are all good choices. Patients should avoid anything hot, such as soup and coffee. Spicy and chewy foods should also be avoided.
Keeping your head elevated is also important in the first day or so after a dental surgery. Dr. Boyle instructs patients to relax and watch a movie and keep ice on their face as often as possible. His practice provides special Velcro straps to hold an ice pack in place. Ice not only decreases inflammation and swelling but also numbs the pain.
TAKING OPIOIDS RESPONSIBLY
Most opioid prescriptions for dental procedures are intended to provide medication for only a few days, but even when they're prescribed by a doctor, they can lead to addiction, overdose or death. Patients should never take prescription opioids in higher amounts or more often than they're prescribed.
"Narcotics are prescribed with very specific directions," Dr. Boyle said. He said you should talk to your doctor before your procedure about how much and how often to take your medication.
Your pharmacy will also provide an insert with information on how to take your medication and when to call your doctor. When you pick up your prescription, most pharmacists will warn you about medications you shouldn't take with an opioid prescription. For instance, taking sleep aids with opioid painkillers can increase the risk of overdose. You should also not drink alcohol while taking opioids, as mixing the two could cause nausea and vomiting, headaches, fainting or trouble breathing.
When taking an opioid, it's also important to be mindful of certain side effects. Excessive drowsiness, constipation and slow breathing may be signs that your dose is too high.
Because leftover or unused opioids can end up in the wrong hands, you should properly dispose of any pills you don't take. Pennsylvania has a prescription drug take-back program where you can take leftovers to locations like police stations or pharmacies.
