Learn more about the Canadian Dental Care Plan
Opioids and Pain Management

The management of risk for opioid use

Originally published in the August/September 2016 issue of Dispatch

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

In some instances, the prescription of opioids may be deemed necessary to manage a patient’s pain. However, opioids are often prescribed in excess of what is required. Many factors may contribute to the over-prescribing of opioids in dentistry, including:

  • habit or convenience;
  • lack of knowledge regarding the efficacy of non-opioid analgesics;
  • patient demands and expectations;
  • inadequate patient history regarding alcohol and other substance use;
  • desire to avoid conflicts or complications.

A dentist should not prescribe opioids to manage potential postoperative pain without regard to the possibility for problematic opioid use. While opioids are typically prescribed in limited quantities for acute pain, e.g., 24 tablets, excess tablets may remain after the patient’s condition has been successfully managed. These excess tablets may then become a source for recreational drug abuse or diversion by the patient, a relative or a friend.

It should be emphasized that a dentist has no obligation to prescribe any drug, including opioids, if they do not believe it is clinically appropriate, even if the patient has been prescribed them in the past and despite any demands or expectations of the patient.

In appropriate instances, a dentist must have the clarity of purpose and conviction to refuse a patient’s request for opioids when it appears to be unjustified or suspect, in order to protect the patient from unnecessary medication and abuse potential, and to limit the diversion of these drugs to the streets.

A dentist should strive for adequate pain management, while simultaneously assuming the responsibility of limiting the potential for drug misuse, abuse and/or diversion.

The management of risk for opioid use requires appropriate consideration of several issues.

Assessing risk

A dentist must have current knowledge and ensure comprehensive documentation of the patient’s pain condition and general medical status. This should include a review of the patient’s alcohol and other substance use and screening for sleep apnea. A discussion about potential benefits, adverse effects, complications and risks assists the dentist and patient in making a joint decision on whether to proceed with opioid therapy. In addition, the dentist should ensure the patient’s expectations are realistic. The goal of analgesic therapy is rarely the elimination of pain, but rather the reduction of pain intensity.

Patient education

A dentist should advise the patient on the safe use and storage of opioids. The patient should also be instructed to return any unused drugs to the pharmacy for safe disposal, in order to prevent diversion for illegal use and to protect the environment.

Detecting problematic opioid use

A dentist must be alert for behaviour that suggests the patient is experiencing problems with the appropriate use of opioids or has an opioid use disorder. Such a disorder may include seeking opioids for non-medicinal use or diversion purposes. The dentist should be familiar with indicators of problematic opioid use and take practical steps to help prevent their occurrence.

Managing the high-risk patient

A dentist who is considering prescribing an opioid or other drug with abuse potential for a patient with a history of problematic opioid use or an opioid use disorder should clarify the conditions under which they will prescribe, including consultation with the patient’s physician. In appropriate circumstances, this may involve monitoring by the physician for indicators of problematic opioid use (e.g., urine drug screening) and requiring the patient to comply with a formal and explicit written treatment agreement.

Dealing with a shortage of inter-professional support

A dentist may be faced with the prolonged management of a patient’s pain in undesirable circumstances, especially when there is a shortage of inter-professional support. For example, the patient does not have a physician or other primary family health care provider, or the referral to another practitioner with expertise in pain management is not possible for an extended period of time. The paramount responsibility of a dentist is to the health and well-being of patients. This requires the dentist to maximize benefits and minimize harm for the welfare of patients. In some situations, determining what may be beneficial versus harmful is difficult. Nevertheless, a dentist must attempt to provide care in a way that upholds these principles as best as possible by leveraging whatever resources are at hand.

SERIES OF ARTICLES ON THE 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 the Dental Practice, the first dental guidelines of their kind in Canada.

RCDSO VIDEO ON GUIDELINES

The Role of Opioids in the Management of Acute and Chronic Pain Guidelines