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PA I N M A N AG E M E N T

Pain Management
Protocols and Proper
Opioid Prescription
Adam Burr, DDS
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Pain Management
Pain Management Protocols
and Proper Opioid Prescription
Adam Burr, DDS
ABSTRACT
In response to the opioid crisis facing America,
this article is designed to help dental practitioners
discover tools and resources available to promote
alternative pain management techniques and
develop a simple protocol to maximize safety when
prescribing opioids. The discussion will also cover
real-world solutions for promoting responsible pain
management with patients.
LEARNING OBJECTIVES
• Discuss the current opioid epidemic and how
the dentist plays a role.
• Analyze alternative pain management
techniques and the steps to creating a
prescription protocol that maximizes safety.
• Describe tactical real-world solutions for
promoting responsible pain management
techniques.
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D
ental practitioners must be informed on the
dangers of prescribing opioids. Resources
are available on alternative pain management
techniques. A simple protocol can be developed to
maximize safety when prescribing opioids, and real-
world solutions can be implemented with patients to
promote responsible pain management.
OPIOID USE AND ABUSE IN THE UNITED STATES
Throughout the last decade, the magnitude of damage
in the United States caused by opioid use and abuse
has become all too apparent. Despite many available
resources and efforts made on both national and state
levels through programs, advocacy groups, and train-
ing of healthcare professionals, the devastation from
opioid addiction remains prevalent. An estimated 1.7
million Americans currently suffer from opioid use
disorder and addiction.1
There is a divide between the number of opioid-
related deaths and other causes of death and how
the nation has responded to the opioid crisis in the
past. The number of fatalities due to firearms, car
accidents, and alcohol are reported as much lower
each year in comparison with opioid overdose, yet
those other issues have long captured media attention
that fuels ideas, debates, proposals, and solutions.2
The rate of death caused by opioid overdose is
not only higher than those other causes of death,
it is also increasing (Figure 1).3 Undeterred by an
increase in awareness campaigns, accessibility of
prescription drug monitoring programs (PDMPs),
and stringent Drug Enforcement Administration
prescription guidelines, deaths from opioid abuse
continue to rise each year. Furthermore, there has
been a dramatic rise in deaths caused by synthetic
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1
Fig 1. Overdose death rates involving opioids, by type, United States, 2000-2017.
opioids, yet a lesser increase in fatalities due to
using illicit street drugs such as heroin. On a
positive note, deaths from commonly prescribed
opioids have stabilized.
How is it that deaths from prescribed opioids
are now stable but deaths from overdoses overall
continue to increase? In a typical situation, a
patient with a legitimate condition may be pre-
scribed an opioid. There is a high likelihood that
it will be misused, so a use disorder or addiction
may occur. Due to increased awareness and strict
prescription guidelines and regulations, the pa-
tient will have a difficult time purchasing illegal
opioids because they have become much more
expensive. At the same time, accessing black
market heroin and synthetics can be achieved
less expensively because they are not passed
through a legitimate supply chain.4 The illegal
supply of heroin and synthetic opioids is not
regulated, and much of the illicit supply in the
United States contains dangerous impurities.5
For example, in the latest emerging trend, opi-
oid abusers are switching to fentanyl. Originally
designed as a pharmaceutical drug, it is now being
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manufactured illegally. In pure form, fentanyl is
50 to 100 times more potent than heroin.6 Due
to these factors, an accidental overdose is more
likely to occur than with more controlled opioids.
GROWING PAINS
Young adults aged 18 to 25 years have a higher
risk of misusing a legitimate opioid prescription.7
Any opioid provided to an adolescent for any
reason will increase their chance of abuse in
the future, regardless of whether they have ever
used illegal drugs previously. In fact, individuals
given a legitimate opioid prescription by 12th
grade are 33% more likely to misuse opioids
after graduation.8 Essentially, these are “normal”
adolescents who, up until this time, probably
have just said no to drugs as they have been
taught. They then have wisdom teeth extractions
and are sedated with some combination of an
opiate. Soon the pain sets in, so they begin to
take the prescription opioid that was provided by
their dentist or their oral surgeon. It relieves the
pain and makes them feel good. However, these
prescriptions are incredibly potent for a young
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Dentists can confidently attest to the effectiveness
of comparable options that have been proven
to be as effective, if not more effective than
opioid treatments.
person who is not used to such powerful medica-
tions. Misuse can easily turn into abuse, and this
abuse can quickly escalate into addiction. Many
times, they will progress to something stronger,
cheaper, and easier to acquire. Although this
story is nonspecific, it happens too often, based
on the statistics.
THE PAIN-FREE MYTH
At some point in time, opioids became the
gold standard for pain relief. In the 1980s
and 1990s a trend emerged where society
felt the right to feel no pain at all. Opioids
were extremely effective, but the research at
that time stated that they were nonaddictive.
An unprecedented pharmaceutical marketing
campaign ensued, and the rest is history—the
crisis was created. The goal to be 100% pain
free still exists today; many patients may ex-
pect to feel no pain at all. From the moment a
patient presents with severe pain, healthcare
professionals may be expected to eliminate
it because of the many powerful prescription
medication options available.9
THE ROLE DENTISTS PLAY:
LEARN, COMMIT, HEAL
Almost one-fourth of a patient’s somatosensory
and motor neurons are in the lips, face, mouth,
teeth, and gums, and each day, dentists routinely
perform microsurgery just millimeters away
from these extremely sensitive nerves. Patients
expect practitioners not only to fix oral dis-
ease but to minimize any resulting discomfort.
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However, practitioners should consider that
prescribing for pain relief beyond what may be
needed to reasonably resolve it may contribute
to the opioid crisis.10
Because the majority of the dentist’s time
is spent fixing a problem caused in the teeth,
management of resulting symptoms is usually an
afterthought and rarely covered in educational
courses, even though dentists rank No. 3 over-
all of healthcare professionals for prescribing
opioids.11 Although the dental profession is not
entirely responsible for the opioid crisis, it has
played a role. Therefore, it is now arguably the
responsibility of the profession to commit to be-
ing part of the solution. When healthcare profes-
sionals are equipped with information regarding
how to manage patient pain, they must do so
responsibly. Acquiring this knowledge requires
extra time and effort, often without compen-
sation. Yet few things are more rewarding for
healthcare providers than treating and healing a
patient—without causing additional issues such
as addiction.
OPIOID ALTERNATIVES
Despite many effective alternatives, far too often
opioids remain the top choice to manage dental
pain. When recommending an opioid alterna-
tive to patients, dentists can confidently attest
to the effectiveness of comparable options that
have been proven to be as effective, if not more
effective than opioid treatments.
The metric used to measure the efficacy of
pain relief is called the number needed to treat
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2
Fig 2. Efficacy in treating postoperative pain (APAP = acetaminophen).
(NNT) (Figure 2). If a medication has an NNT of
1 (best), it is 100% effective at reducing pain by
50% in every patient, which is considered clini-
cally acceptable when determining analgesic
efficacy.12 However, because both dentists and
patients may expect 100% pain reduction, there
can be a perception problem.
Studies show that naproxen is just as effective
at relieving pain as two Percocet® (oxycodone
and acetaminophen) tablets, with a combination
of ibuprofen and acetaminophen being the most
effective.12 Another study regarding wisdom
teeth extractions and postoperative pain revealed
that 325 mg of acetaminophen in combination
with 200 mg of ibuprofen provided better pain
relief than oral opioids.13
Aspirin
Statistics show that 600 mg of aspirin has an
NNT of 4.4, which is just as effective as 15 mg
of oxycodone at eliminating 50% of pain.14,15
Aspirin has the following attributes: it is an
analgesic that reduces pain, an antipyretic that
reduces fever, an anticoagulant that blocks
blood clotting, and an anti-inflammatory that
reduces the body’s natural inflammatory re-
sponse to tissue damage and pain. Aspirin is
contraindicated for patients with an allergy to
it and other nonsteroidal anti-inflammatory
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drugs (NSAIDs); patients with asthma, chronic
gastritis, or gout; patients receiving anticoagu-
lants; and patients who are pregnant.16
Acetaminophen
Acetaminophen is also an analgesic and anti-
pyretic. A 1,000-mg dose has an NNT of 4.6
and is as effective as oxycodone in eliminating
pain.15,17 However, there is a perception among
some patients that acetaminophen is not a po-
tent analgesic. This is simply not true based on
research, so practitioners should not automati-
cally dismiss acetaminophen as a viable option.
Acetaminophen is contraindicated for patients
with an allergy to NSAIDs; patients with liver
disease, asthma, chronic gastritis, or gout; pa-
tients receiving anticoagulants; patients receiv-
ing warfarin; and patients who are pregnant.
The maximum daily dose of acetaminophen is
3,000 mg.
Naproxen
A 500-mg dose of naproxen sodium has an
NNT of 2.7. Studies show that naproxen alone
is more effective in relieving pain than oxyco-
done.12 Naproxen is an analgesic, an antipyretic,
and an anti-inflammatory. Its contraindica-
tions are similar to those of aspirin, including
patients with an allergy to NSAIDs; patients
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with asthma, chronic gastritis, or gout; patients
receiving anticoagulants; and patients who are
pregnant. The maximum dose of naproxen is
1,000 mg.18
Ibuprofen
Ibuprofen is an analgesic, an antipyretic, and an
anti-inflammatory. The NNT of ibuprofen varies
based on the dose. Although generally effective
in moderate doses, the effect is even greater in
higher doses. A 400-mg dose of ibuprofen has
an NNT of 2.5, whereas 800 mg holds an NNT
of 1.7.15 The contraindications for ibuprofen are
similar to those of other NSAIDs, and the maxi-
mum daily dose of ibuprofen is 3,200 mg.19
Winning Combinations
As stated earlier, the combination of ibuprofen
and acetaminophen has been repeatedly proven
to have the best pain reduction result. It is im-
portant to reemphasize that research supports
options such as these that are safer and just as
effective, or even better than opioids for reduc-
ing dental pain. It is the dentist’s professional
responsibility to change patient expectations by
educating them about the many equal alterna-
tives for pain management.
ADDITIONAL SUGGESTIONS FOR
MANAGING PAIN
Take Deliberate Care When Prescribing to
Adolescents
When prescribing medication for pain manage-
ment to adolescents, the dentist must consider that
they are at a particularly high risk for developing
misuse habits if given an opioid for any reason.7,8
Long-Acting Anesthetics
After a procedure that is certain to lead to post-
operative pain or discomfort, the dentist can
consider giving patients a long-lasting anesthetic
such as procaine.20 Patients should be informed
that the purpose is to allow enough time to fill
any prescriptions needed before the anesthetic
starts to wear off.
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Steroidal Anti-Inflammatories
There are common treatments such as fillings
and crowns where pain is a result of inflamma-
tion within the nerve in and around the teeth
and can become symptomatic afterward. This
is especially true for patients who have severe
bruxism or attrition. Prescribing a potent steroid
such as dexamethasone or a methylprednisolone
dose pack for inflammation after treatment is
another way to effectively reduce pain. Before
steroids are prescribed, the contraindications and
drug interactions should be checked. Steroids
should not be prescribed for a long duration,
but prescribing them for a few days can greatly
reduce postprocedure pain.21-25
BEHAVIORAL MANAGEMENT
Setting Patient Expectations
Dentists should have an honest conversation with
patients regarding what to expect after any dental
procedure. The idea that any postoperative expe-
rience will be pain free should not be conveyed,
because patients with realistic expectations are
less likely to be concerned if the situation gets
worse. To mitigate pain, non-opioid options
should be offered first. If prescribing an opioid
is considered, an informed consent discussion
should take place beforehand to review any es-
tablished opioid prescription policy.
Opioid Prescription Policy
It is strongly recommended that dentists imple-
ment an opioid prescription policy into their
practice (Figure 3). A solid, patient-geared
document is useful in preconditioning pain
management expectations, specifically toward
opioids. A policy is not a legal document, nor is it
designed to fulfill obligations for informed con-
sent, but it is helpful when setting expectations
and managing pain, specifically with prescribing
opioids. It can be presented directly in the front
office, examination rooms, or operatories where
patients can clearly access and review it.
When prescribing an opioid, the healthcare
professional should be sure that the patient has
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3
Fig 3. Sample opioid prescription policy.

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read the opioid prescription policy to clearly
understand what to expect afterward if a refill
is needed. Preconditioning patients’ expectations
to individual practice standards for prescribing
opioids for pain management will greatly reduce
unreasonable expectations—and because the
conversation has already taken place about what
to expect postoperatively, patients will more
readily accept that they may be in discomfort
while their body heals after treatment.
When Opioids Are Considered
Sometimes an opioid is the right answer for post-
operative pain. When prescribing an opioid is
considered, the healthcare professional should
pay close attention to the patient’s medical his-
tory, review any personal or family history of
misuse, abuse, or addiction, and comply with
individual state regulations and requirements
for informed consent.
Interactions With Other Medications/
Mental Disorders
Patients with other comorbidities, such as depres-
sion, anxiety, and posttraumatic stress disorder,
are more likely to abuse opioids if provided a
prescription. In addition, prescribing an opioid
concurrently with other medications, such as
benzodiazepines, will increase the central ner-
vous system (CNS)-depressing actions of those
medications and can lead to overdose.26,27 Dentists
should also discuss alcohol consumption with
the patient (also a CNS depressant), as well as
whether naloxone should be provided. Naloxone
is an opioid receptor antagonist that reverses the
binding of the opioid to its receptors, reversing
the symptoms of overdose. Dentists who consider
prescribing an opioid should be very familiar
with what naloxone is and how to prescribe it;
they should also discuss with the patient, family
members, or loved ones when it should be used.28
Legal Considerations
Practitioners who choose to create an opioid policy
should always verify state laws to ensure compliance.
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PDMP requirements should be checked for informed
consent, limitations on duration for each prescrip-
tion, and any continuing education requirements.
After checking the state’s PDMP, the practitioner
can decide which type of opioid(s) to prescribe based
on the level of expected pain, individual health, and
other medications. Dentists should prescribe for the
shortest amount of time possible and be familiar
with any individual state prohibitions in regard to
duration; many states prohibit prescriptions lasting
longer than 7 days. Extended or long-acting formula-
tions should be avoided. Research has shown that
patients who take long-acting or extended-release
versions of opioids are more likely to overdose.29
Because there is risk of losing a prescription pad or
having it stolen, practitioners may also be required
to switch to an electronic prescription pad when
prescribing opioids.
Morphine Milligram Equivalent Dose
Generally, opioids have some comparison or ratio
of potency to morphine, so many states require
practitioners to calculate the morphine milligram
equivalent dose (MME) of each prescription be-
forehand. According to the Centers for Disease
Control and Prevention, the MME should be less
than 50 to reduce the risk of abuse.29
Calculating the MME
To calculate the MME of a prescription, the highest
dose possible should be assumed. For example, if
a patient is prescribed one or two Vicodin® (325/5
acetaminophen and hydrocodone) pills every 6 to
8 hours for pain, the most that patient could take
is two Vicodin pills every 6 hours, for a total of
eight pills per day: Multiply eight by 5 for a total
of 40 mg of hydrocodone in 1 day. Then multiply
that total amount by the MME conversion factor
(1 for hydrocodone), which would equal 40 MME
for 1 day.29
REAL-WORLD SOLUTIONS
Case 1
A 25-year-old male patient presented to the
author’s practice with severe pain through the
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submandibular region extending into the tem-
poromandibular region due to multiple decayed
teeth and apical lesions. His medical history was
negative—he had no known allergies and was
not receiving any medications at the time. He had
been scheduled back for treatment but was in such
severe pain that he could not sleep or function.
The author had to determine what to safely pre-
scribe for pain until the patient was able to begin
treatment. The author looked him up on the state’s
PDMP to enable a more educated decision on how
to prescribe for this patient. It was discovered that
he had not had any prescriptions recently filled,
had not been to any other pharmacies, and had not
had any other prescribers in the previous 6 months.
The author wrote a prescription for him that day
for tramadol and acetaminophen (Ultracet ® ), one
of the author’s defaults for moderate to severe pain
in combination with ibuprofen.
Ultimately, the author prescribed 500 mg of
amoxicillin for his infection, Ultracet for the pain,
and ketorolac to be used in combination with the
Ultracet. Ketorolac is a potent NSAID that can be
used to help reduce moderate to severe pain.30,31
When prescribing ketorolac, the author generally
prescribes 10 mg and has the patient take two pills
immediately and then one pill every 12 hours
thereafter as needed for pain. This was an effec-
tive alternative to prescribing an opioid and simply
hoping the patient would return for treatment.
Case 2
A 39-year-old female patient presented with stage
III, grade C periodontal disease and recurrent de-
cay around all dental restorations. In addition to
having bipolar disorder and depression, she had a
strong history of substance abuse and addiction.
She had been working with an American Society of
Addiction Medicine (ASAM)-certified physician
regarding her addiction. After a lengthy discussion
with her and her loved ones, the author’s practice
determined that there was no way to effectively
restore her teeth given her history, so full-mouth
extractions and fixed implants were discussed.
The patient was receiving Suboxone® prescribed
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by her treating physician, but she also sought other
opioids in between her Suboxone dosages. Suboxone
is a combination of buprenorphine and naloxone.
Buprenorphine is a partial antagonist and agonist
for opioid receptors, meaning that it binds to recep-
tors and introduces actions that the patient may feel
with opioids, but it does not provide the same high
and craving issues after use. Used in conjunction
with naloxone, it will reduce any overdose effects
caused by the introduction of an opioid.32
Patients receiving Suboxone should not be pre-
scribed another opioid under any circumstance
without first clearing it with their physician and
then having the patient go through a detoxifica-
tion period to taper off the Suboxone. There was
a legitimate reason to consider an opioid for this
patient, but that was not a decision that the dentist
should make alone. Ultimately, there must be a
discussion with the physician.
If the dentist is performing extractions and
placing implants in this type of case, a consulta-
tion should take place between the dentist and the
physician. If an oral surgeon is involved, then the
dentist, oral surgeon, and physician should discuss
how to handle postoperative pain. The challenge
is that if patients receiving Suboxone are given
opioids, they will likely misuse that opioid because
of a history of misuse and addiction. They will have
severe withdrawal symptoms, leading to a negative
patient outcome.
Ultimately, the physician informed the patient
as to how long she was going to be off Suboxone
before surgery. An opioid was then prescribed by
the oral surgeon, and the patient was then sched-
uled to see her physician 1 week postoperatively,
which was imperative to assess the opioid use and
reestablish her use of Suboxone.
Case 3
A 37-year-old female patient presented with a non-
restorable tooth No. 30. The crown failed and had
been separated from the root canal-treated tooth.
There was a chronic apical lesion in the area, as well
as gross decay. The patient had a positive history
for substance abuse and a history of Crohn’s and
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liver disease. Her husband was deployed with the
military overseas, and her life was generally highly
stressful. Due to her history of substance abuse, she
was working with an ASAM-certified physician.
The patient was being prescribed Suboxone and
clonazepam. Receiving a benzodiazepine (clonaz-
epam) is a contraindication to receiving an opioid
because they are both CNS depressants. However,
she needed treatment on tooth No. 30, and there
would be moderate pain after removing the chronic
apical lesion. Because of her medical condition, she
was unable to take NSAIDs or acetaminophen;
that restriction is what had originally caused her
opioid use.
The patient was forthcoming about her sub-
stance use disorder. She was very concerned about
the postoperative pain from the scheduled tooth
extraction because she did not want to take any
additional medications. A conference call was
scheduled between the author, the surgeon, and the
treating physician to discuss all the relevant factors.
Ultimately, the physician tapered her off Suboxone,
and the oral surgeon prescribed Percocet.
The patient then misused the prescription and
2 days later requested a second prescription. The
surgeon consulted with the physician and agreed
to write the second prescription.
In the end, the patient did reinitiate her Suboxone
treatment. Although her old habits resurfaced by
using the Percocet prescription beyond what she
was supposed to use, misuse does not necessar-
ily equal abuse or addiction. It simply means that
she used the prescription outside of the prescribed
doses. Fortunately, she did not fall back into addic-
tion and is doing well.
SAFEGUARDING PATIENTS
AND THE DENTAL PRACTICE
Patients and families of patients who suffer from
the use and abuse of opioids know that opioids
continue to create pain for society as a whole.
Healthcare providers can put safeguards in place
for patients. The goal is to understand alternatives
to opioids and present realistic expectations to
patients about how to manage their pain to reduce
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the risk of becoming a statistic.
It is hoped that some of these solutions will better
safeguard the dental practice as well. It is impera-
tive for dentists to lower patient expectations for
100% pain-free treatments. In addition, implement-
ing an opioid policy will facilitate conversation
about whether opioids are the right option.
Finally, it is important to remember that dentists
should be sure their prescribing aligns with indi-
vidual state regulatory demands to minimize any
uninformed prescribing practices in the office. This
is especially important if independent contractors,
such as oral surgeons, are working in the practice
and treating patients of record.
CONCLUSION
In conclusion, almost everything healthcare
providers do to heal patients has the potential to
cause pain. Unfortunately, dentists cannot control
individual physiology that communicates pain, but
they can help by learning how to safely manage it.
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MARCH 2020
CDE Quiz
2 CDE Credits
TO TAKE THE QUIZ, VISIT
CDEWORLD.COM/EBOOKS/CE/160

Pain Management
Pain Management Protocols and
Proper Opioid Prescription
Adam Burr, DDS

1. An estimated how many Americans currently suffer 6. If a medication has an NNT of 1, it is 100% effective at
from opioid use disorder and addiction? reducing pain by how much in every patient?
A. 840,000 B. 1.7 million A. 10% B. 50%
C. 12 million D. 21 million C. 75% D. 95%

2. Much of the illicit supply of black-market heroin and 7. Aspirin has which of the following attributes?
synthetics in the United States: A. an antipyretic that reduces fever
A. is obtained from Canada. B. an anticoagulant that blocks blood clotting
B. is dissolved in alcohol for transport. C. an anti-inflammatory that reduces the body’s natural
C. contains dangerous impurities. inflammatory response to tissue damage and pain
D. looks like powdered sugar. D. all of the above

3. Individuals given a legitimate opioid prescription by 8. A 1,000-mg dose of acetaminophen has which NNT?
12th grade are how much more likely to misuse A. 1
opioids after graduation? B. 2
A. 10% B. 33% C. 4.6
C. 57% D. 75% D. 27

4. Research in the 1980s and 1990s stated that 9. Naproxen is an:

opioids were: A. analgesic.
A. of low efficacy but high efficiency. B. antipyretic.
B. of high efficacy but low efficiency. C. anti-inflammatory
C. of low efficacy and low efficiency. D. all of the above
D. nonaddictive.
10. According to the Centers for Disease Control and
5. Almost how much of a patient’s somatosensory and Prevention, the MME (morphine milligram equivalent
motor neurons are in the lips, face, mouth, teeth, and dose) should be less than how much to reduce the
gums? risk of abuse?
A. one-tenth A. 1
B. one-fourth B. 2
C. one-half C. 10
D. three-quarters D. 50

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