Opioid Safety in Dentistry
Hi, my name is Dr. Steve Yun, MD. I am a board-certified dental anesthesiologist in southern California.
Last month I had the opportunity to tour Paisley Park, the former home and estate of Prince outside Minneapolis. It was an amazing experience, but also a somber reminder of how we lost a musical genius to the opioid epidemic. We have all read the statistics and headlines about the opioid crisis, but what should be our response as a dental community? First, we should maintain our perspective. I believe that dentists and oral surgeons are NOT to blame for the opioid crisis. Only a very small percentage of opioids are prescribed by the dental profession, and it is unreasonable and unrealistic to expect to solve the crisis by focusing on doctors' prescription pads. Drug abuse is a complex problem, and we need to place more resources on the true root causes such as mental illness, poverty, and physical/emotional abuse. Nevertheless, we should do our part to not exacerbate the current situation and by implementing small changes, we can make a significant impact. In my own practice, I rarely use long-acting opioids in dental sedation cases, esp. for pediatric patients. In my hospital practice, we are also turning away from opioids by using alternative medications (such as ketamine, esmolol, intravenous Tylenol, etc) and regional nerve blocks. (Just recently, I did an interscalene nerve block for complex rotator cuff surgery. The patient was pain-free for over 25 hours after surgery without the use of opioids!). As dental professionals, here are some measures we can all take: 1. Re-educate our patients and manage their expectations about pain. "Discomfort" after dental procedures is to be expected, and can be managed very effectively with NSAIDs and Tylenol. 2. Reduce the number of opioids we do prescribe. In the past, we often prescribed 20-30 pain pills with multiple refills. Current guidelines call for just 8-12 pain pills with no refills for acute pain. Reducing the number of pain pills in circulation reduces that likelihood that they will "saved for a rainy day" and be misused in the future. 3. Educate patients about the proper storage and disposal of opioids. (WalMart, for example, offers a free opioid disposal system.) 4. Explore other medications, such as intravenous acetaminophen, intravenous ibuprofen, and Exparel (liposomal bupivicaine). 5. Exercise extreme caution in patients who have a history of opioid abuse/dependence, sleep apnea, and are taking other sedatives (benzodiazepines). 5. Utilize resources such as your state's Prescription Drug Monitoring Program to monitor all your patients' controlled substance use. In California, all dentists and physicians should be enrolled in the CURES program (Controlled Substance Utilization Review & Evaluation System). It is very tempting and easy to blame dentists and physicians for the current opioid crisis. But in reality, only a very small percentage of our patients (probably well less than 1% according to a 2018 study in Reason magazine) will actually demonstrate signs of "opioid misuse." Nevertheless, even one case of opioid misuse/abuse is one too many, and so we can and we must be part of the solution. I will be speaking on Opioid Safety at the upcoming Dental Safety Conference sponsored by the Organization for Safety, Asepsis and Prevention (OSAP) in Dallas on June 2. I am looking forward to speaking and learning from others about their efforts to help reduce the impact of the opioid crisis.