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Opioids and Pain Management

The management of acute pain

Originally published in the February/March 2016 issue of Dispatch

This is part one of four in a series of articles that aim to raise member awareness and knowledge of the College’s new guidelines on The Role of Opioids in the Management of Acute and Chronic Pain.

The management of pain is an important component of dental practice. Patients presenting in acute pain deserve effective, timely and safe management of their condition. This should involve active intervention through dental procedures, e.g., caries removal, pulpectomy, incision-and-drainage, extraction, that are carried out as soon as possible, whenever possible.

For the majority of patients, postoperative pain will be most significant for approximately two to three days, after which it is expected to diminish. Thus, in most situations, analgesics should be prescribed for the management of postoperative pain for three days, with declining amounts needed thereafter.

Before recommending or prescribing any drug for postoperative pain, the following principles should be considered:

  • Patients deserve effective, timely and safe pain management.
  • The source of the patient’s pain should be eliminated directly through dental procedures that are carried out as soon as possible, whenever possible.
  • The use of any drug involves potential risks.
  • The use of an analgesic should be individualized, based on the patient’s medical history and the level of anticipated post-operative pain.
  • A non-opioid, i.e., acetaminophen or an NSAID, should be maximized before adding an opioid.
  • A preoperative and/or loading dose of an NSAID may be beneficial.
  • The dose and frequency of an analgesic should be optimized before switching to another analgesic.
  • Long-term use of any analgesic should be avoided, whenever possible.
  • The analgesic dose should be reduced in older individuals.
  • For children, the analgesic dose should be calculated on the basis of weight.

From a risk/benefit standpoint, acetaminophen should be the first analgesic to consider and is usually sufficient for mild to moderate pain. Studies of acute pain in dentistry demonstrate that an appropriate dose of an NSAID should manage the vast majority of moderate to severe pain experienced by dental patients. There is some evidence that suggests alternating acetaminophen with an NSAID may be beneficial for managing moderate to severe pain. Only in a minority of situations is an opioid required.

ALGORITHM FOR MANAGEMENT OF ACUTE PAIN

Attribution: Adapted with permission from Haas, D.A. (2002). An Update on Analgesics for the Management of Acute Postoperative Dental Pain. Journal of the Canadian Dental Association, 68(8),476-482

Before prescribing an opioid for any patient, consider the following:

  • Is the patient’s pain well-documented?
  • Is the patient currently taking an opioid?
  • Does the patient’s medical history suggest signs of substance misuse, abuse and/or diversion?
  • Given the efficacy of non-opioids, do the benefits of prescribing an opioid outweigh the risks?

If the use of an opioid is determined to be appropriate, then limit the number of tablets dispensed for any opioid prescription. For most patients, consider the following limits:

  • for codeine 15 mg combinations, e.g., Tylenol#2®: maximum of 36 tablets
  • for codeine 30 mg combinations, e.g., Tylenol#3®: maximum of 24 tablets
  • for oxycodone 5 mg combinations, e.g., Percocet®: maximum of 24 tablets


In some situations, practitioners may consider exceeding the suggested maximum number of tablets for a single opioid prescription. Practitioners are expected to exercise reasonable professional judgment in determining when this is justified, which should be documented. Such situations, however, should be deemed the exception, and not common practice.

Dentists who prescribe an opioid for a patient independently should limit the number of consecutive prescriptions to a maximum of three, using the suggested maximum number of tablets. Further prescribing should take place only in consultation with the patient’s primary family health care provider and/or a dental specialist with expertise in pain management.

ARTICLES ON THE NEW GUIDELINES

These other articles explain more about the College’s Guidelines on The Role of Opioids in the Management of Acute and Chronic Pain in Dental Practice, the first dental guidelines of their kind in Canada.

Part Two: The management of chronic pain

Part Three: The management of risk for opioid use

Part Four: Additional issues related to the management of pain