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Opioid use: Reframing how we think about pain management

Imagine it is 2 a.m., and you are cramming for your pharmacology exam. You flip through the hundreds of flashcards you created to memorize the properties of the medications and corresponding treatment protocol. You come across analgesics, specifically opioids, and remember they are used to alleviate pain.

In school, we learn about the properties and proper dosages of the drugs we will one day prescribe, as well as how to address potential concerns of usage with our patients, but in order to enhance our own patient care mentality, we should reframe how we think about pain management overall.

How society views pain

There’s no denying that dentistry and pain are intertwined. Our patients come to us when they want their pain relieved and, on many occasions, still leave with some level of discomfort. In dental school, we learn about A-delta fibers and C-fibers. We learn that pain can be acute or chronic. We learn to ask the following questions: When did the pain begin? How long does it last? Does it feel dull or sharp? Then we use this information to develop differential diagnoses and a proposed treatment. But we tend to forget that pain is a complex phenomenon. It’s evolutionary, and it acts as a sign indicating that something is wrong.

As dentists, our success doesn’t lie in the complete eradication of a patient’s pain but in our ability to listen to their stories so that we can help them manage it safely and effectively. What we may not always remember is that person to whom we’re prescribing the opioid after a standard tooth extraction may be dealing with issues outside of the dental office, such as anxiety, fear or some other form of acute and chronic pain. Knowing this information affects our decision on what medication we prescribe to them. Some decide to try and find their own way outside of prescriptions to deal with their pain. I’ve heard that people have found a use for cannabis and strains similar to gorilla glue when trying to cope and deal with pain but I digress.

Now, opioids effectively relieve short-term pain; however, they are not meant to resolve it long term and shouldn’t always be the first choice for pain management, especially when you consider the potential for addiction and easy accessibility. So how do we determine the best prescribing protocol?

What’s being done?

Dental schools across the country are responding to this. Our education is rooted in evidence-based dentistry, and studies have shown that the combination of ibuprofen and acetaminophen is just as potent as an opioid in the management of post-extraction pain.

In Massachusetts late last year, the Baker-Polito Administration, along with the deans of the state’s three dental schools and the Massachusetts Dental Society, announced dental education core competencies for the prevention and management of prescription drug misuse.

In April 2018, the ADA and ASDA lobbied at congressional appointments for mandatory continuing education, imposing prescribing limits to seven days, supporting monitoring programs and improving the quality of these programs. ASDA’s own B-13 policy urges dental schools to provide resources for dental students to appropriately address opioids with their patients.

What’s left to do?

The resources that we receive as students not only need to include proper prescribing practices but how to discuss the concerns surrounding opioid misuse with our patients. Our acknowledgement that pain can be physical and emotional is the first step in advancing our education. We should also understand how social determinants of health, such as social and physical environment, economic stability, health care and education, impact the opioid epidemic.

The next step is advocating for opportunities to practice discussing these topics prior to entering clinic. This includes learning to recognize signs of potential drug-seekers, resources near our schools for those with misuse disorders and discussing pain management alternatives with patients.

The last is to advocate for education core competencies and continuing education based on the most up-to-date prescribing protocols. Our education — from the classroom to the clinic — should incorporate the idea that pain is a multi-faceted issue and we can no longer think about it in just one way. Doing this will help us reframe what we think about pain management and improve the way we tackle this crisis.

~Roopali Kulkarni, Pennsylvania ’19, ASDA President

Roopali Kulkarni

Roopali Kulkarni, Pennsylvania '19, is the 2018-19 president of ASDA.

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