Preemptive analgesia These medications can also be given preoperatively to mitigate postoperative pain and postoperative pain medication requirements ( preemptive analgesia ; Fletcher & Spera, 2012). This strategy could also include a glucocorticoid such as dexamethasone 4 to 8 mg orally 30 minutes prior to the procedure (Lunn et al., 2013; Chen, Chen, Hu, Feng, & Song, 2017). This would further be an ideal role for a COX-2 selective NSAID such as celecoxib, as it will preemptively ameliorate the inflammatory response without causing increased bleeding or delayed wound healing compared to the traditional non- Opioid-based analgesics Since opioid-based analgesics are not anti-inflammatory agents, medications such as morphine, hydromorphone, oxycodone, and others are not considered the drugs of choice in treating the three major categories of nociceptive orofacial pain (Moore, Dionne, Cooper, & Hersh, 2016; Hersch et al., 2020). These medications should be reserved for the small percentage
selective NSAIDs (Boonriong, Tangtrakulwanich, Glabglay, & Nimmaanrat, 2010; Derry & Moore, 2013; Xu, Zhang, Luo, Zhou, & Zhang, 2017). In this case, 400 mg administered orally 30 minutes prior to the procedure would maximize this medication’s effectiveness. For those patients currently on an anticoagulant such as warfarin, dabigatran, rivaroxaban, apixaban, betrixaban, or edoxaban, a COX-2 inhibitor such as celecoxib could further replace the postoperative ibuprofen prescription above as 200 mg given every 12 hours for the initial 24-hour post-operative period. of dental patients with severe, uncontrolled orofacial and postoperative pain, and even then, they are best prescribed as combination products that contain acetaminophen or an NSAID in addition to the narcotic moiety (i.e., Vicodin®, Percocet®, Vicoprofen®, and others; Table 2).
Table 2: Combination Products that Contain Acetaminophen or an NSAID in Addition to an Opioid*
Hydrocodone + Acetaminophen
Hydrocodone + Ibuprofen
Oxycodone + Acetaminophen
Codeine + Acetaminophen
Generic Name
Brand name(s) and available strengths (mg)
Many generics and Tylenol #2 - 15/300 Tylenol #3 - 30/300 Tylenol #4 - 60/300
Many generics and brands such as Lorcet, Lortab, Margesic, Maxidone, Norco, Stagesic, Vicodin, Xodol, & Zydone 5/300, 5/325, 7.5/300 7.5/325, 10/300, 10/325
Many generics and brands such as Ibudone, Reprexain and Vicoprofen 5/200, 7.5/200, 10/200
Many generics and brands such as Endocet, Magnacet, Percocet, Primlev, Roxicet and Tylox 2.5/325, 5/325, 7.5/325, 10/325
Controlled substance schedule
III
II
II
II
Usual adult dosages
15-60 mg q4h of codeine, but be sure not to exceed the maximum recommended daily dose of acetaminophen from all sources.
5-10 mg q4-6h of hydrocodone, but be sure not to exceed the maximum recommended daily dose of acetaminophen from all sources. There are many different elixirs available with differing strengths: 2.5/167, 10/325, 10/300, and 7.5/500, all per 5 mL.
5-10 mg q4-6h of hydrocodone, but be sure not to exceed the maximum recommended daily dose of ibuprofen from all sources. There are many different elixirs available with differing strengths: 7.5/325 and 10/300 all per 15 mL.
5-15 mg q4h of Oxycodone, but be sure not to exceed the maximum recommended daily dose of acetaminophen from all sources. Oxycodone elixir with acetaminophen is no longer available in the U.S.
Notes
Tylenol with Codeine elixir contains 120/12 per 5 mL.
* While there are combination products that include aspirin and an opioid such as codeine (Empirin) or oxycodone (Endodan, Oxycodan, and Percodan), combination products with acetaminophen are preferred due to their comparable efficacy yet superior side-effect profile (less postoperative bleeding and lower ulcerogenic risk). Note . Adapted from “Pain Management: Part 1: Managing Acute and Postoperative Dental Pain,” by D. E. Becker, 2010, Anesthesia Progress, 57(2), 67-78; “Introduction to Antinociceptive Drugs,” by H. Kim and R. Dionne, 2010, in J. A. Yagiela, F. J. Dowd, B. Johnson, A. Marriotti, and E. Neidle (Eds.), Pharmacology and Therapeutics for Dentistry (6th ed.; pp. 299-306), St. Louis, MO: Mosby; and “Treatment Guidelines From The Medical Letter: Opioids for Pain,” 2018, The Medical Letter, 60(1544), 57-64.
Opioid-based analgesics used for orofacial pain share the common mechanism of agonist activity, principally at the µ-opioid receptor, enhancing the effect of the endogenous pain- relieving chemicals dynorphin, enkephalin, and β -endorphin. These opioid-based analgesics have short half- lives and require repeat dosing (e.g., every 4 hours in the case of morphine); controlled-release formulations typically allow for twice-daily dosing with improved compliance and baseline pain relief for chronic pain (Table 3). Unlike NSAIDs, opioid-based analgesics do not have an analgesic ceiling, and increased pain relief can usually be achieved by increased doses. However, side effects are also dose-dependent and can limit the maximum tolerated dose (Donaldson & Goodchild, 2018a). Their high abuse potential means that all opioid-based analgesics are controlled
substances with increased surveillance by regulatory agencies (e.g., FDA, DEA). A good example of this increased scrutiny occurred with hydrocodone-combination analgesics which accounted for 97,183 abuse-related emergency department visits in 2011 - a 96% increase since 2004 (Center for Behavioral Health Statistics and Quality Substance Abuse and Mental Health Services Administration, 2013). As drug overdose deaths tripled from 1999 to 2014, with 61% of those deaths involving an opioid, the US Drug Enforcement Agency (DEA) responded to the crisis by upregulating hydrocodone-combination from Schedule III to Schedule II of the Controlled Substances Act (effective October 6, 2014) (U.S. Department of Justice Drug Enforcement Administration, 2014). The US DEA defines Schedule II drugs/
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