The role of opioid alternatives in oral surgery

Postsurgical pain is one of many common fears patients have before undergoing a surgical procedure. Historically, opioids have been the primary prescribed pain medication after surgery and dental extractions. Today, despite other options for pain control, there are still too many opioids being prescribed, according to a 2016 poll from the National Safety Council. There are several other modalities that should be used to prevent and treat postoperative pain and discomfort.

A 2016 research letter published in the Journal of the American Medical Association suggests that opioids are commonly prescribed following surgical tooth extractions and that patients between the ages of 14 and 24 are most likely to have the prescription filled.

Timothy Gocke, DDS, from Virginia Oral, Facial & Implant Surgery.

What can start out as well-intended pain relief can end in patients experiencing unwanted and potentially debilitating side effects. In the worst cases, it can lead to opioid misuse, abuse, or addiction.

Managing pain

Managing pain is a top concern for oral surgeons, but, increasingly, managing opioid exposure is also of critical importance. As clinicians, we have to balance the need to provide adequate pain relief with the risks and side effects of the medications we prescribe. Until recently, our options were limited when over-the-counter products did not provide sufficient relief. Fortunately, there have been recent advances in the availability of effective opioid alternatives.

Attention is turning to the use of nonopioid options across surgical procedures, especially in oral surgery where patients and their caregivers -- often parents of those undergoing wisdom tooth removal -- are anxious about postsurgical pain and what can be done to ensure recovery is as comfortable as possible. Many times in my own practice, parents will voice concern over their child being prescribed opioids after surgery. No parent wants to see his or her child in pain; however, opioid addiction has become a hot-button issue in many communities across the country.

Some opioid alternatives for oral surgery include nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, cyclooxygenase-2 inhibitors, and acetaminophen. These NSAIDs have been effective for managing postoperative inflammation and pain in both dentistry and medicine. Evidence, such as a February 2008 study in the Federation of American Societies for Experimental Biology Journal (Vol. 22:2, pp. 383-390), suggests that simple analgesics should form the basis of any pain management strategy.

Every patient is different

First, of course, before prescribing any patient medication, I perform a medical history and physical. Every patient is different, and you must use your clinical knowledge and skills to tailor the pain management plan. Based on the person's medical history, I may prescribe ibuprofen before the surgery to decrease postoperative pain.

I talk to my patients and their caregivers about one approach I have implemented that helps manage postsurgical pain while minimizing or, in some cases, completely eliminating the need for opioids after surgery. This approach includes a long-acting, nonopioid pain reliever called Exparel (bupivacaine liposome injectable suspension, Pacira Pharmaceuticals) that is injected into and around the surgical site during a patient's operation.

Exparel is formulated to slowly release bupivacaine over time. It is injected just like local anesthesia, but it must be injected 20 minutes after injection of any other local anesthesia (i.e., lidocaine or septocaine) except bupivacaine. It can be used for any surgical procedure where a soft tissue flap is elevated and is not indicated for nerve blocks, only for infiltration.

I first began using this nonopioid pain reliever eight months ago after learning about it from my colleagues at Inova Fairfax Hospital in Falls Church, VA. Other surgical specialists were using it successfully to allow their patients to avoid narcotics in postsurgical pain management.

Anecdotally, my patients report taking fewer, if any, opioid pills after a procedure since I began using Exparel. This is my experience and shouldn't substitute for your own research and clinical experience. I can report that many people I see in my practice are happy to hear that opioids may not be necessary.

Other opioid alternatives that I have used in my own practice include IV ketorolac (NSAID), IV acetaminophen, and a prescription of 600 mg or 800 mg ibuprofen taken by mouth every six hours. I have also instructed patients to take over-the-counter Tylenol every six hours by mouth.

Starts in the doctor's office

The fight against prescription drug abuse must be waged on many fronts, but for many patients, it starts in their doctor's office.

It is imperative that healthcare professionals actively educate patients about the pain management options available to them, including alternatives to opioids. By doing so, we empower them to have control over their own pain management plan, while potentially mitigating the societal burden of opioid use.

Times are changing, and the era in which opioids represent the keystone of pain management is over. Nonopioid strategies are reducing opioid exposure and, therefore, having a positive impact on the overall society epidemic.

Timothy Gocke, DDS, is a board-certified oral and maxillofacial surgeon at Virginia Oral, Facial & Implant Surgery in McLean, VA. Learn more at www.virginiaoralimplantsurgery.com. Dr. Gocke is also chairman of oral and maxillofacial surgery at Inova Fairfax Hospital in Falls Church, VA.

Dr. Gocke is not a paid consultant for Pacira Pharmaceuticals; however, he does use Exparel in his practice.

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