Opioid prescribing in dentistry

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Hi, I'm Jo Cheah and this is the Australian Prescriber Podcast. Joining me today is Dr Leanne Teoh. Leanne is both a dentist and a pharmacist in Melbourne and also lectures in dental therapeutics at the University of Melbourne. Leanne is the author of an editorial in the October edition of the Australian Prescriber titled Opioid Prescribing and Dentistry: Is There a Problem? Welcome Leanne. Thanks for taking the time to chat with us today.

Thanks so much for having me, Jo.

So, you've stated in the first sentence of your article, that Australia is in an opioid crisis right now. So, just for a bit of background, are you able to go through some basic statistics of the opioid health crisis in Australia?

Absolutely. Opioid-related harm is a major public health issue in Australia at the moment. The statistics are such that on average, every day, three people die and there are 150 hospitalisations due to pharmaceutical opioid misuse. In fact, the most common reason for people to enter Australian drug and alcohol treatment programs is due to prescription opioid or benzodiazepine use.

What stirred your interest in opioid stewardship?

Being a pharmacist, appropriate prescribing in dentistry has always just been a personal interest of mine. And in particular, antibiotic and opioid stewardship.

Just because we're talking about dental treatments and dental pain in your article, what are the recommended treatments or the recommended management of dental pain?

So, as a dentist, key management of patients with pain centres around diagnosis and then dental treatment. Dental treatment is actually the most effective and quickest way of getting people out of pain, as a dentist is able to address the cause, whether that be by doing a filling or cleaning the teeth or extracting the tooth. Once dental treatment is done, there's often a significantly reduced need for any analgesia. But of course, there will be procedures such as an extraction, for example, where analgesia will be needed, or if the patient cannot get to the dentist for whatever reason.

And so, from a medications perspective, first line for dental pain is ibuprofen and paracetamol. That's in Therapeutic Guidelines Oral and Dental Version 3. And countless studies have shown that anti-inflammatories are far superior to opioids in reducing dental pain. As we know, anti-inflammatories inhibit the production of the prostaglandins that mediate inflammation and attenuate the acute inflammatory process, whereas opioids only reduce pain perception. However, studies have shown that the combination of ibuprofen with paracetamol taken at the same time produces more pain relief than either alone, which is why that combination is recommended as first line in the therapeutic guidelines.

Excellent. So, you're in a unique situation as both a dentist who prescribes and a pharmacist who dispenses. So, what are your personal experiences with prescribing and dispensing opioids?

As a pharmacist, in my personal experience, I do actually see opioids sometimes being prescribed as first line for dental pain. And in particular, the combination of paracetamol and codeine. That's just in my personal experience, after you dispense the prescription, go and chat to the patient and provide counselling. As I alluded to before, research now shows that opioids are not that effective and codeine in particular, actually, is really not effective for dental pain. A good example is a study by Adrian Best and colleagues published in 2017. It was a randomised, double-blind and controlled trial. They had two groups of patients undergoing surgical wisdom tooth extractions. One group was given ibuprofen, paracetamol and codeine. The codeine dose was 60 mg, four times a day. And the other group was given ibuprofen and paracetamol only. They tracked their pain scores for 48 hours afterwards and found that the additional codeine made absolutely no difference. The pain scores in the two groups were the same. So, this is one of several studies that highlights how ineffective codeine is for dental pain, but in general opioids don't confer that much extra analgesic benefit, which is why they are second-line agents.

So, do you have any general advice for pharmacists who may come across inappropriate opioid prescriptions? As you say, we often find out why someone's been prescribed a medication once we hand it out and counsel them. So, yeah. What sort of advice do you have for pharmacists in that situation?

Dental pain in the pharmacy is often a fairly common presentation, I suppose. I think pharmacists are perfectly placed to, of course, assess a drug history and recommend, over-the-counter, ibuprofen and paracetamol if appropriate. And I do think that the counselling that pharmacists are so good at doing is very important here. So, what I mean by that is that ensuring that the ibuprofen or paracetamol have been recommended at appropriate doses. So, from the Therapeutic Guidelines, that's 400 mg of ibuprofen and 1 g of paracetamol taken at the same time. We know that when they're taken at the same time, they produce a synergistic analgesic effect, prolonged pain relief, and also a faster time to perceptible pain relief. And that's really important in acute pain situations.

Also, to ensure that they have been administered appropriately. So, what I mean is that they are not being taken with food. We know that the absorption of NSAIDs and paracetamol is delayed and reduced with food. We want those high, early plasma concentrations because not only does it produce a faster time to perceptible pain relief, but also lower rates of remedication. So, taking these analgesics with food makes them less effective.

Those are really great counselling points. So, how significant do you think the contribution of dental scripts is to opioid misuse in Australia?

We don't know. To my knowledge, there isn't any linked data between dental opioid prescriptions and opioid misuse. So, we don't actually know the contribution or if there is any at all. However, there are some studies from the US which looked at the exposure of adolescents to opioids by dentists. So, one study by Schroeder and colleagues in 2019, looked at health insurance data and found that almost 6% of adolescents who were exposed to opioids through their dentist went on to misuse opioids or had an opioid abuse-related diagnosis compared to 0.4% of a similar group that were not exposed to opioids through their dentist. And the authors concluded that these dental prescriptions may be associated with an increased risk of subsequent persistent opioid use. So, while this is not Australian data, I think it's really important to bear in mind when considering what to prescribe for dental pain, given this potential risk of harm, but also that opioids shouldn't be used routinely anyway. As I mentioned before, they're not that effective and there's far superior alternatives.

So, why do you think some dentists... So, in your article, you've quoted, "16 to 27% of dentists prefer to prescribe opioids over other measures."

Yes. It's an interesting question. Our survey simply showed that, yes, approximately one in five dentists prefer to reach for a paracetamol or an opioid as first line for dental pain after extractions. We don't know the insight into the why, unfortunately, only that this is their preference.

Good point. So, in what situation would opioid prescribing be appropriate in dentistry?

Yes. I can appreciate that. Unfortunately, not everyone can tolerate a traditional non-selective anti-inflammatory or COX-2 inhibitor, whether that be because of drug interactions or comorbidities or other medical conditions. And these people cannot get to the dentist in a timely manner. And they're in a lot of pain such that paracetamol alone isn't enough. I guess that's when paracetamol, in addition with an opioid, may be needed. The other time, I think is when people have tried an NSAID and paracetamol, and they're taking it correctly, appropriate dose and timing, etc. And they are unable to get to the dentist in a timely manner and are still in pain. And that's when an opioid can be prescribed in addition, but really only as second line.

Mm-hmm (affirmative). And you made some good points in your article as well that if opioids were prescribed, dentists can prescribe smaller quantities than the PBS maximum allowed quantity. So, yeah, did you have any other comments on sort of appropriate prescribing in that sort of scenario?

Yes. I mean, we know that the most common source of opioids or misuse are leftover tablets from legitimate prescriptions sourced through social networks. And we know that people are often, in general, prescribed more opioid tablets than what they need. And these unused tablets are sitting in someone's kitchen cupboard and can be used for other pain conditions where opioids are not recommended as first line or possibly given to a family member or friend who's in pain. So, it exposes people to opioids unnecessarily. So, I do think it's important for all prescribers to prescribe only the quantity that they actually think is necessary or what they think the patients actually need.

Yep. Great point. And yeah, just a reminder that if people did have leftover tablets at home that they weren't using to return them to your community pharmacy for disposal.

Yes, definitely.

Yep. So what counselling should dentists offer patients when providing them with an opioid prescription?

So, I think there are a couple of things. Firstly is to manage patient's expectations of pain. It can be very helpful, I think, to give people realistic expectations of pain management from the very start. We know that pain experience is subjective and it's modulated by anxiety, past pain experience. And in general, there can be a lot of anxiety for some people associated with visiting the dentist and dental procedures. So, I think in an effort to help relieve people's anxiety and fear, I think there can be a tendency to refer to these medicines as strong drugs or painkillers, which gives patients the impression that they will reduce pain to zero or nothing, which of course is unrealistic and not true. Very few analgesics will actually reduce pain to nothing. And when people still have some pain, they can think something is wrong or that their medications are not working. And that's when they'll return asking for more pain relief or want the dose to be increased. So, explain to patients that these medicines will reduce or manage their pain is better, I think.

And of course, secondly, all prescribers of opioids should explain to patients about what the medicine is and why they're being prescribed it, how to take it, but also to explain the potential risks of dependence and the importance of seeking dental treatment so they won't have to keep taking medication.

So, you did talk about codeine a little bit earlier. So in Australia we have recently rescheduled codeine from a pharmacist-only medicine or Schedule 3 to prescription-only medicine or Schedule 4. So, how has that rescheduling of codeine effected the prescribing or sales of other opioids?

So, we did do a study published earlier on this year actually. We compared dental opioid prescriptions a year after the up-schedule compared to the previous year. And we found that there was a mean increase in the combination product, paracetamol 500 mg and codeine 30 mg, by 21%. And there was a mean increase in the use of oxycodone by 24%. So, I think there's a couple of things to bear in mind when interpreting that data. Firstly, the data from that study is not linked data. So, it simply tells us that there's a pattern over that time, but it doesn't tell us the ‘why’ or anything about the appropriateness of the prescriptions. And also, that data is now around 20 months old and a lot has happened in this space during that time. There's been a lot of targeted education about opioid prescribing in the dental industry and certainly recent trends of dental opioid prescribing may be different.

What are some signs for a dentist to look out for in a patient who may be doctor shopping and with the intention to misuse a prescribed medication?

There are documentations and literature about some characteristics of people seeking drugs for nonmedical use such as complaining about the need for a specific drug, or asking for a very particular drug by name, and claiming multiple allergies to alternative medicines. Personally, I know of dental colleagues who have received letters from the Department of Human Services, informing them that they prescribed an opioid to a patient who was possibly seeking drugs for nonmedical use, as these patients were dispensed several high-risk drugs from multiple prescribers in the proceeding few months. No doubt, my colleagues did establish a true therapeutic need. But I think this highlights the need for dentists to have access to prescription monitoring programs such as SafeScript. It will allow dentists to make better informed prescribing decisions. It will simply provide them with more information.

Very interesting. So, SafeScript, which is a real-time prescription monitoring program, which you mentioned in the article, is only currently available to pharmacists, doctors and nurses. So, has there been any progress to allow dentists to have access? And is there a rough timeframe for this to occur?

Not that I know of at this stage.

So, where can dentists learn more about appropriate opioid prescribing? And are there any courses or resources that you can recommend?

The Australian Dental Association has recently provided a lot of information about the appropriate use of opioids in dentistry, in the form of webinars and news bulletin articles. And the NPS, of course, also has a lot of information for all prescribers as well as the public and provides great resources on opioid stewardship.

Yep. And you did refer to the Therapeutic Guidelines as well, which is a great reference for prescribers and pharmacists.

Absolutely.

Thank you so much, Leanne. That's all the time we have for today's episode.

Thank you so much, Jo.

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The views of the hosts and their guests on the podcast are their own and may not represent Australian Prescriber or NPS MedicineWise. I'm Jo Cheah. Thanks again for listening to the Australian Prescriber Podcast.