Do dentists prescribe narcotics excessively?

Dealing with pain is an inevitable sequela to dental treatment. Although several drug regimens primarily involving narcotics have been used in the past, availability of nonsteroidal anti-inflammatory drugs (NSAIDs) has increased recently. A study was conducted to analyze dental prescribing patterns for analgesics. Data analysis of a survey of 130 dentists revealed that respondents still rely on narcotic analgesics for pain relief and generally exceed needed potency and quantities in their prescribing habits. Dentists are treating rather than preventing pain, and NSAIDs are underused.

Abstract De.llingwith pain ts an inevitable sequela to dental trealmcht. Al­though several drug reg imen~ pri­marily invnlvins narcotics havp been used in the past~ availability of nonsteroidal anti-inflamm.:ttory drugs (NSAIOs) has incre-ased re~ cent Iv. A study was conducted to analyze dental prt..-'Suibing patterns for analgesics. Data analys.is of a survey of 130 dentists revealed that respondents still rely on nar­cotiC analgesics for pain rel ief and generally exceed needed potenC)' and quantities in their prescribing habits. Dentists are treating father thom preventing pain, and NSAIDs .1re underused. Do dentists prescribe narcotics excessively? P roviding good d ental care Cll ­tails p revent ing and allevl<lting disease and pain \Vhen some den ­tal services are rendered, immedi­ate or posttreatment discomfort is inevitable. To aUdY pain , an"s­thelics are used during treatment, and <lnesthelics and analgesics are used after treatment. Many phar­macological choices are available for mitigating pain. In 1987 ac­etaminophen (I'ylenol) with co­deine was the sixth most frequent­ly prescribed new and refilled pre· scription medicatlOll L By 1993, because of increased popularity of other analgesics, Tylenol with codeine had fallen to 32nd place." During this time, nonste roidal anti -inflammatory drugs (NSAJDs) increased in popularity. Thought­ful decisions conccrning pain management are In the best inter­est of patients and practitioners and can be made without compro­mising patients' comfort. Excessive use of I1drcotic anal­gesics is a problem. Abuse of hero­in (introduced in the United States as a nonaddictive analgesic in 1898) was pa rt ly responsible for the first Food and Drug Act of 1906. Legisla tive attempts at drug control have been numerous, in­cluding: The Harrison Narcotic Act of 1916: Food, Drug, and Cos­metics Act of J 938: Durham­Humphrey Law of 1952, Kefau­ver- Harris Bill of 1962; and Drug Control Amendments of 1965. The Controlled Substance Act of 1970 provided statutory control of narcotics and other addictive agents. Under this law, only prac­titioners who Me registered with the Drug Enforcemen t Agency may order controlled substances. Yet, up to IS percent of the med­ications from controlled subs\iJnce prescnptions arc sold on the street, one third of all drugs sold illegally are prescription drugs. The reason for the great demand for prescript ion drugs is product quality. Because prescription drugs are concentrated and pure, they are preferred to i!legally manufactmed or processed drugs. For example, a tablet of hydro­morphone IDilaudidl. which costs about $1 in a pharmacy, may be sold for more than $75 on the street 1 The availability of prescription medications on the street is attrib­uted partly to prescribing prac­tices of some dentists. The ques­tion "Am [contributing 10 the local drug market?" must be considered whenever a controlled-substance prescription is wrillen. Prcscrip· lion-drug traffickers can be decep­tive, manipula tive, or abusive, and use a number of ruses. " Pain management is a topic of perenn ial interest to dentis ts. They prescribe analgesics most frequcntly among medications. '. Pain was relieved 100 years ago with various forms of ethanol and opIUm Around 1900, the first nonnarcotic analgesics Inota bly acetylsalicylic acid [a spirin)) be­came available. Since then, other compounds with great ra nge in analgesic potency have been de­veloped. The advent of NSAlDs opened another area of pain con­trol The era when dentists rou­tinely prescribed a dozen Empirin No.3 , Tylenol No.3, or Percocet tablets is concluding. The scope of traditional analgesic therapy dur­lllg that era was treating symp­toms. NO'IN, when properly ad­ministered before and after treat· ment, NSAIDs can provide com­plete relief by interrupting pain generation Dionne described an approach to analgesic therapy in - 312 GENFRAI nFNTI"TRY/IIIIY_AIII,t I<:;T lW)(, I volving the advantages of NSAIDs and narcotics. 'o In other reports, the efficacy of NSAIDs or their su· periority over narcotics in alleviat­ing pain is substantiated."'" Some patients are prepared psychologically to accept only nar­cotic analgesics. Dentists are re­sponsible for informing them about the advantages of alterna­tive therapies- which do not pro­duce the pharmacologic side ef­fects of narcotic analgesics (use of which can cause respiratory de ­pression, sedat ion, nausea, psy­chological changes, and depend­ence). Operating motor vehicles and machinery should be avoided when narcotic analgesics are used, but not when NSA IDs aTe used_ Few reports have been pub­lished about the prescribing habits of dentists. Such informa­tion should be obtainable by sur­vey or personal communication, and the authors were interested in determining whether traditional narcotic analgesics are preferred over NSAIDs as a means of con­trolling posttreatment pain. Methods At a state dental convention, a survey was conducted to analyze denta l prescribing patterns for analgesics_ Questions were based on routine dental procedures per­formed by general dentists. Den­tists were asked to read each ques­tion and respond appropriately by writing prescriptions that they would write most commonly in three situations-involving severe, moderate, and mild pain. By analysis, analgesics were grouped into NSAIDs (includ ing aspirin) , acetaminophen, and na rcotics (in­cluding combinations with as­pirin, acetaminophen, or other drugs such as sedatives). Results Survey results are presented in the Figure. average narcotic prescription was for 13 doses The highest number of doses was 24, and the lowest was 6 ,Jlf. Write an analgesic prescription for a patient receiving root canal therapy who has pain and swelling in tooth No.5 but no con­tributi ng medical history_ Would you also prescribe an anti­biotic! N := 130 95"/0 wrote prescriptions % of prescriptions 5% did not perform this procedure 29 5 65 NSAID Nothing Narcotic The average narcotic prescription was for 13 doses The highest number of doses was 24, and the lowest was 8 Antibiotics were prescribed in 83% of cases Fig_ Results of a survey to analyze the dental prescribing patterns for analgesics. Discussion Respondents rely most on narcot­ic analgesics for pain relief. The most commonly prescribed nar­cotic was a brand of hydrocodone and acetaminop hen, perhaps due to hydrocodone's potency (Sched ­ule III , telephone-order prescrib· ing) and good marketing. Hy­drocodone's black-market popu-larity and value should make den­tists more cautious in prescribing this product. To prevent com­plaints from patients, respondents wrote prescriptions that exceeded the needed potency and quanti ­ties, e.g. , 24 oxycodone-aceta­minophen doses after a simple tooth extraction. Classifying pain and prescribing for need rather than (OrH.:t.:IIH:ncc may curb sub stant.:t.' abu,!,c. In a random exami nation of prescriptions written by dent ists ior :-'ll!uicuid patients, a Drug L'tili7atil)n Review Board lOUR) founu thaI 53 percent of prescription." wntten by dentLsts weft: for narcotics, and that nar· cotic presc riptiom ore repea ted for the same c lients ~everal times. In the DUR study, pre script ions excet.:dt.:d the potency needed for mosl denl<ll proct.:­dures. Prescribing patterns for narcot ­ic use und quantities differ for the three theoretical cases. In the ma­jority of cases, pain medicutions nl!ed not be prescribed for more Ihan 48 h ours, Some proc ti tion­as use strong analgesics rather than customize the dosage [i.e. prepare patients proph}'lacticCl ll yl. Even with dentists' highest lIt1er' cst III providing adequate pain control reports about pain control and information from pharmaceu­tical manufacturers indicate that dentists are not improving nor up­dating pain con trol techniques. The origin and perception of pain involve Cl complex mecha­nism that is complicated ftlrther by psychological components. Most d ental pain is mild to mod­erate and is controlled adequately by NSA1Ds, wbich ,He believed to act peripherally. Thus, NSAID thera py is an alternative to nar­co ti cs. Dentists with improved techn ical approaches and ski ll can reduce trauma. The}' can prevent pain by admin istering NSAIDs, which are highly effective when used to their best advantage.' .. A therapeutic NSAID plasma level before onset of pain grea tly in­creases effectiveness. Maintain­ing th is level. rather than adminis­tering analgesic when pain recurs, offers the most effective pain con­trol The a ction of the NSAID p re­vents formation of prostaglandi ns involved in pain gene ration and transmission. Long·ac ting local anest h etics that supplement initial local anesthesia may elim inate or diminish the need for analgesics following treatment. r.,.'los\ 511,1' dents in a remed ial pharmacology course for denti~ts who have abusL'd their narcotic prescribin~ pri\'ilege. and lost their stale con­trolled- substance license, kept pa­tients pain-free with NSAID..-, tlur· ing the period in which narcotics could not be prescribed. The number of NSAIOs from se\"t~ral chemical classes offer choices in potency, time of onset, duration of action, and cost Prescribed intelli­ge ntly, NSAIDs keep patien ts pain·free with minimal side e f· fects, a nd withmll sedation, respi· ratory depression, or dependency. Conclusions Narcotic analges ics are the most common pain medications pre­sc ribed. Some responden ts pre­scribed up to 2.t doses of strong narcotics following simple tooth extraction, which could be execs· sive. Dentists are treating rather than preventing pain NSAIDs are underused In prevention and treatment of pain to eliminate the objectional side effects o f nar­cotics. We do not suggest that nar­cotic analgesics ne\'er be used, but point out that adequate analgesia for mild to moderate pain can be achieved with nonnarcot ic agents. Careful presc ribing prevents ex­cessive use, abuse, a nd illega l di­ve rsion of narcotics. Dr. Aldous is an a~soci.!Il' professor, De­partment oi Surgery, University of Ul,lh School of Medicine, Salt Lake Cily, and director, General Practice Residen(.\' and Advanced EduC.11ion in General Dcntistr\', Univer~itr of UI.lh. Dr. Engar i~ Auornev-in-Fact ,(hlef Executive Ofii­cer), Prolt'S,ion.11 Insurance Exchange. Salt Lake (ilv, and .1 cliniC.ll IIlSlructor. Department of Palhologv, Un!\erSllv of Utah School 01 M.edicine, in conlunc­tion \\ith Ihe uni~ers.1\'~ General Pr,lC­tiel' ResidenC\ and Adv,Inccd Educ,ltlOIl In General Dcntistr") progr,lOls. Address (orre~ponden(e to: Dr Richard C. Eng.H, 445 E.1S1 4500 South, 'Jo. 130, Salt J.lke Cil~, UT 84107- 1101. References I. Hdrtzema AC PhMma(~Ullc,, 1 ~ervice~ ch,l rthook, (helW,l. ,\l!( hig,lI1: Lewi, I'ublish('r~, Inc .. I ,)lJO:) 1 2 Top 1(10 mC"tJ,c,ltlwh ,\111 Drug­g'~ 1 I'J'1420'J28·2" I C;ol\lmall H. How to lh\\Mt a drug ~l'l'k(·r [nwrg\ led I 'J'JI ,2 S4~­' d 4 \'1((' ~(I\J,ld, Pcr~orl.ll COmmlJlll' (,11ioll. '>alt (,lke Cih Police Dep.Ht· IIwnl. luh ! \lq4 ~ Shllo,1h L Le(' \\B. Hinklev LH '>C'Il·mflicll'd or.)1 in)url to sccurl;' nM­cotlC drll)\" IAOA I ,)H4, 1 08:<J77-q7~. (I (oltonl..' IA. K.lrfr,ml' AH. '\1(-'(1- I( .1110n atld he.)lth hi~lorit:'s: .1 surl(-'v of 4.3111 dl'nl,ll paliel1ts.IAI1A 1 'J 79;'Jil: ""11·:-1H. 7 Mi ll er (), ""pl,111 AL, COllont' )A Oocuml'l1tmg mt'dicatioll U\t:' in <!duh dellt.}1 p.lti('nt\ J <J/-I'-I 'J'JI. ),\0 .. \ 19')2;111:41·48. /-I. ""(""lon L Oral ph.Hman'Ulicab ,lIIr1 .ulult dl'nl.ll p.ltif'l1t' JAOA 1 'J'J4; t21)4'>·6:-" 'J. ~uthk.HI'ka .. JS, Oru~ pre-;cnp­lion pr,1CtIH'~ 01 ho'pital (lp"ti<;I,. Spl"{' ('.Ire- Ocnt!~1 1')(jl:ll:20'i -208. I n. Dionne RA. '-ell approadle~ 10 prCIl;'ntlng and treJlm); po,loperatile IMIll. J'\OA JCJln;lliT'-J,4 II (noper SA. File studie~ on ibuprotl'n (or [lOst~urgical OCilla I p.lin. I\m I /I.·led JlJ84;i7::-0_:--" 12. Sunshine A. Marrero I, Olson N, M(Cormick N, ldsk.l EM. Comp,1rative 'Iud), ni lIurhiprofell. zomepirM sodi­um .. Kct.lminopht'n plu<, codc ine, and dcet.;m inoplwtl for the re lief of posisur­gila i dent,ll p,1in, Am I Med 198(,; 801IA):SO-S2. 13. Cooper SA, MMdlro~si.1n G. Comp.lrison of i1urbiprofen Jnd aspirin in tl1(' r('lief 01 post,urgical p,lin using tht> dent"I [lJin model. Am J ,\o-led I ()1:I6:I'IO(JA!:~6-40. 14. Dionne RA ~uppression oi den­I, ll pain by the prooperJti\(" administra­tion of tlurhlproien. Am J r\\ed 1986; HO:(IA141-4'J. 15. Drug UtiliZJtion Rt'lielV Board otlhe Divi~ion oi Heilhh. Stolte of Utah, PPhon,ll COfTImuniGlImll. Salt Lake Cltr, December 10,1992. 16. Bradlev B. Pain control ior den­tal procedures in patients \\ilh hemo­phil i'l Presented at the Conierence for Oental Cue of the Hemophilia Patient; '\Jol'emher f)-7, 198(,; Ann Arhor, ,\llciligan,