history prior to treating dental pain. For example, patients who report a history of bleeding disorders or a condition that requires anticoagulation medications should not be treated with NSAIDs due to the risk of gastrointestinal bleeding as well as some bleeding effect from their antiplatelet activity (Becker, 2010; FDA, 2015). These patients are ideal, however, for considering acetaminophen as a potential pain reliever. Acetaminophen is not without its own risks, however, particularly in certain populations. Because hepatotoxicity is the most adverse side effect of acetaminophen, patients with liver disease or those already taking medications with hepatotoxic potential, for example, would need to avoid or receive a decreased dosage of this medication. Because the NSAIDs and APAP have different sites of action, studies have shown that a synergistic effect can be obtained when both medications are given together (Mehlisch et al., 2010; Merry et al., 2010; Moore & Hersh, 2013). In a 2010 randomized controlled trial, Mehlisch and colleagues compared a single-tablet combination of ibuprofen and acetaminophen to either drug alone for relieving pain in dental patients undergoing third molar extractions (Mehlisch et al., 2010). Results of the study support previous studies and suggest that this combination of analgesics is more effective than either drug administered alone in relieving moderate to severe levels of dental pain following dental surgery (Mehlisch et al., 2010). A Japanese team of dentists found that acetaminophen combined with an intravenous NSAID was as effective at relieving postsurgical pain as the NSAID combined with fentanyl, and that the recovery time of patients treated with this Dental management considerations Aside from prescribing alternatives to opioid analgesics, the dental team must consider additional sources of management to address and prevent prescription drug abuse. These sources include educating both the patient and dental team regarding the issues surrounding prescription drug abuse and ensuring that the proper resources are available to each group. Patient education Patients need to be informed about the perils of prescription drug abuse. They need to safeguard themselves against accidental behavior patterns that may lead to abuse. This requires that patients be honest with their physicians and other healthcare providers about the medications they are taking and that they be careful to take all medications as directed. Most importantly, because patients provide friends and family with the greatest access to drugs for intentional abuse, patients must be knowledgeable about safe practices for storing their medications. Because the medicine cabinet is the customary location for storage, other alternatives must be explored. Using the tagline educate before you medicate , the National Council on Patient Information and Education (NCPIE) advises patients to safeguard all medications in a locked area or drawer. They also suggest taking an inventory of all medications every 6 months, or at least every year (NCPIE, 2008). They also guide patients to properly dispose of all unused or expired medications. To avoid future diversion, they emphasize procedures such as taking these medications out of their original containers and mixing them with unpalatable substances such as coffee grounds or kitty litter and then placing them in a nondescript container such as a sealable bag or empty can. They further remind patients that flushing medications down the sink or toilet is an acceptable manner of disposal if the accompanying patient information or the label indicates that it is appropriate to do so. They also propose that local drug “take-back” programs can serve as excellent alternatives to safely dispose of unwanted medications (NCPIE, 2008). The U.S. Food and Drug Administration advises patients to scratch all personal information off pill bottles and packaging before disposing of them (FDA, 2019a).
regimen was shorter. They concluded that acetaminophen was a good choice when opioids were contraindicated (Yoshida et al., 2018). The effectiveness of the NSAID/APAP combination therapy can be further enhanced with patient education to take the medication “around the clock” at regular intervals to avoid the onset of pain. However, patients should be cautioned not to exceed the recommended safe daily dose of acetaminophen, in particular, due to its hepatotoxicity potential. If breakthrough pain should occur, an opioid alone can be added, or an opioid/ acetaminophen combination can be given. When opioids are indicated, safe prescribing practices include limiting the quantity to that needed for a few days, and again, cautioning the patient to discontinue the use of any other acetaminophen regimen to avoid liver damage (Becker, 2010; Denisco et al., 2011; NIH, 2018b). If pain persists longer than a few days, the patient should return to the office to be reevaluated. Additional strategies In addition to the previously discussed analgesics, nonopioid pain management in the dental office can include administering long-acting local anesthetics before dismissing the patient, to delay the onset of pain (Denisco et al., 2011; State of Washington, 2017). As previously mentioned, oral analgesics such as the NSAID/APAP combinations should then begin immediately, before the local anesthetic effects wane. For patients undergoing dental surgical procedures, prophylactic perioperative administration of an NSAID can also help to mitigate the inflammation related to postoperative dental pain (Denisco et al., 2011). Patient resources Patients who are addicted to prescription medications should seek professional assistance as soon as possible. The SAMHSA- sponsored Behavioral Health Treatment Services Locator is dedicated to helping patients find proper treatment centers in their area (SAMHSA, n.d.a). Patients can access assistance by calling the listed treatment referral helpline or by clicking on the substance abuse treatment services locator link. On this site, patients can access a database of more than 11,000 drug abuse/addiction treatment centers to find the center by name or by location. Also of interest may be the Frequently Asked Questions (FAQs) section that answers questions related to insurance coverage for treatment, specific drug addiction care strategies, or advice concerning finding treatment for a person who is addicted to alcohol as well as prescription pain medication (SAMHSA, n.d.a). (See the Resources section.) Dental team education The dental team must remain well educated on the issues that affect the dental and overall health of their patients (ADA, 2012), including prescription drug abuse. In fact, awareness of this national epidemic has led several states to mandate continuing education requirements specific to this topic. The ADA and several other healthcare organizations have united to train practitioners in the safe and effective use of opioid medications. The Providers’ Clinical Support System (PCSS) training network provides no-cost training to help healthcare professionals effectively treat chronic pain with opioids and to safely address opioid dependence. The user can easily access peer support groups, webinars, and training modules from a consortium of stakeholders, including the American Academy of Addiction Psychiatry (AAAP), the AMA, the American Osteopathic Academy of Addiction Medicine (AOAAM), the American Psychiatric Association (APA), the American Society for Pain Management Nursing (ASPMN), and the International Nurses Society on Addictions (IntNSA; PCSS, n.d.).
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