Did You Just Prescribe A Teenager’s Death?

We can help stop opioid addiction. 

In my years of practice and teaching residents at one of the busiest residency programs in the country, 20 or more doctors that I worked with have dealt with opioid addictions. Of these doctors, ten have had license suspensions or revocations, and two served time in prison. The most unfortunate is that two have succumbed to lethal overdoses.

In my opinion, it is very important to remember that except for career choice, there really isn’t any difference between our patients and ourselves.

We need to be cognizant of the difficulties that our colleagues are facing and probably show a little bit of kindness as well.

Why does this hit home?

After dental school, I did a GPR. From the very first day, I saw ER patients crying with dental pain, but I couldn’t find a reason. We had a small clinic just off the ER, and we would bring the patients there to take x-rays and do complete exams, but we couldn’t find a reason for their pain.

At the same time, we had ER doctors telling us that we couldn’t let them stay there in pain and had to do something for them. They would give us guidance on what to prescribe, which, of course, was Tylenol #3 or Vicodin or something similar.

After my GPR, I started my oral surgery residency, and a similar thing was happening. We were treating 60 to 70 people for emergency extractions every single morning, and the patients were unhappy. They were in pain, and I wasn’t quite sure what to do after removing the offending tooth.

I call it the idiot, idiot, idiot approach.

As the most junior inexperienced guy there, I would ask the idiot above me what to do. He guided me towards what to prescribe, which he learned from the idiot above him.

There was no science or research behind it. It was simply just doing what has always been done.

My early experience in private practice was similar. The first indication that maybe something wasn’t right happened after many years of practice. I remember the patient well. It was someone who I had seen for multiple procedures from early teenage years into early adulthood (the first one being an expose and bond at about 12 years old).

Over the next few years, there was another expose and bond, the wisdom teeth and then there was something else which I no longer remember. What I do remember is after about 10 years after seeing her for the first time, I started seeing local newspaper articles about her arrests for different things that always included possession charges.

How can we help stop opioid addiction?

At some point, I had the realization that I was probably the guy who wrote her first prescription for a strong pain medication with that very first expose and bond many years earlier.

I think the event that really cemented it home was a couple years after that, approximately 2015. I saw a patient for a third or fourth postop over about two weeks for a very simple procedure. They complained of increasing pain, yet the surgical site looked like it was healing very well and there was no evidence of any issues. The next morning one of my team members came into work and was setting up for the day. “Funny story about that last patient from yesterday. I went to Walgreen’s on my way home, pulled into the parking lot, and she was handing over a bag from the pharmacy to somebody who was handing her cash.”

I realized that the postop pain was probably not true. It was probably a way to get a prescription for the “resale market.”

I made the decision that I was going to alter my practice and avoid prescribing opioids. I started out with what I called the “two Advil and rub some dirt in it method.” After reading some research reports showing that NSAIDS are better than opioids for dental pain, I was advising people to take two over-the-counter ibuprofen every six hours. Fail. No, BIG FAIL.

It wasn’t adequate. I needed to do something else in order to manage the inflammation, so they didn’t have pain in the first place. I spent a lot of time developing my technique in order to really determine what was going on to help my patients have a comfortable experience. We know that dental pain is somatic pain and involves inflammation of the tooth, the bone and the surrounding soft tissues.

Very good research definitively shows that NSAIDs are superior to opioids for managing this type of pain. It has also been shown that NSAIDs will actually have their pain relief effect potentiated by acetaminophen.

When we look at the characteristics of NSAIDs, specifically ibuprofen, we see that the maximum pain relief turns out to be only 400 mg. The maximum anti-inflammatory dose is 600 mg, and 800 mg will not give a better effect. The ideal dosing interval turns out to be six hours. If doses are taken more than six hours apart, the blood level will drop too low to have an adequate effect so the ideal dosage for ibuprofen 600 mg every six hours.

We also want them taking over-the-counter acetaminophen at the same time as they are taking the ibuprofen. It is very commonly taught to take ibuprofen and acetaminophen at different times, every three hours so you’re not waiting too long in between doses.

This turns out to be the best strategy when you’re dealing with a fever, but when we’re dealing with pain we want the potentiation, we want them to take the medications at the same time.

Looking at a package of OTC acetaminophen, it will tell you that you don’t want to take more than six in the 24-hour period which turns out to be 3000 mg. However, that is not accurate. The real maximum dose per day is 4000 mg. The dosing regimen that that I am using is 600 mg of ibuprofen and two OTC acetaminophen every six hours around the clock for four days and then every six hours as needed after that.

I have also changed my sedation technique. Instead of fentanyl, I use altered dosages of other medications in order to achieve the same results without exposing my patients to the opioid. Then, there is some preop stuff that we start before the procedure. Tissue conditioning to get the gingiva as healthy as possible, followed by continued tissue conditioning and rinsing for seven days postop.

I’ve incorporated long-acting, slow release, local in order to reduce the sensation in the area slightly in order to reduce the patient’s discomfort. The results? It is very uncommon for my patients to require anything additional. We find that most are back to their normal routine within a couple of days. And I find that my patient’s parents are very pleased with not having their children exposed to anything that’s potentially addictive.

It’s Time To Do Our Part to Stop the Opioid Crisis and Opioid Addiction.

To remove the use of opioids, I’ve changed my practice and developed a new technique. But will everything that I’ve done and continue to do, change the world? And the answer is absolutely NOT. How about you as another dental provider who can also play a part in changing how you are practicing. Can you change the world? And the simple answer is absolutely, NOT. The million-dollar question is can WE change the world?

If a large number of providers change their status quo and put an effort into preventing that first prescription for an opioid in opioid-naïve teenagers around the country, will that make a change? And the answer is ABSOLUTELY. I invite you to please join my mission. Look at how you practice and what you’re doing for your patients. Always do your best to prescribe what is needed and best for them, not necessarily what has always been done.

To learn more about how you can help stop opioid addiction, contact us here.

This article originally appeared in “Dentistry Today.” 11/7/2023.