Recommendation on Opioid Prescribing

Proper management of pain is a high priority in the United States.  In the last several years, health-policymakers, health professionals, regulators, and the public have become increasingly interested in the provision of better pain therapy and in the reduction of drug diversion and addiction.

Due to concerns about drug misuse, diversion and addiction, and regulatory scrutiny, physicians may want guidance as to what principles should generally be followed when prescribing opioids for chronic or recurrent pain states. Regulators have also expressed a need for guidelines to help them to distinguish legitimate medical practice from questionable practice and to allow them to appropriately concentrate investigative, educational, and disciplinary efforts, while not interfering with legitimate medical care.

Pain should be diagnosed and treated in a comprehensive, systematic, collaborative, patient-centered fashion.

Oral and maxillofacial surgeons must demonstrate safe and competent opioid prescribing for acute and postoperative pain in their patients. Responsible prescribing of opioids must be a priority, including accessing the state’s prescription-drug monitoring program as well as educating the patient and family about potential risks – and the safe use, storage, and disposal – of opioid analgesics. Because prescribing protocols evolve over time, practitioners also should stay informed of the latest public health trends, including possible alternatives to opioid pain treatment. In following with the American Association of Oral and Maxillofacial Surgeons (AAOMS), the Colorado Society of Oral and Maxillofacial Surgeons (CSOMS) believe that the practitioner-patient relationship must be upheld, allowing for practitioner judgment in the management of a patient’s pain – including drug types, dosages, and treatment durations. Pain management decisions should be individualized and only determined after a careful assessment of the level of risk to – and condition of – the patient. While oral and maxillofacial surgeons should ultimately make all final prescribing decisions, CSOMS encourages our members to be aware of and utilize the recommendations set forth in the AAOMS White Paper “Opioid Prescribing: Acute and Postoperative Pain Management” as a supportive resource. Considerations and recommendations for the management of acute and postoperative pain as outlined in the AAOMS White Paper include the following:

• A nonsteroidal anti-inflammatory drug administered pre-emptively may decrease the severity of postoperative pain. 

• A perioperative corticosteroid (dexamethasone) may limit swelling and decrease postoperative discomfort after third-molar extractions.

• A long-acting local anesthetic (e.g., bupivacaine, etidocaine, liposomal bupivacaine) may delay onset and severity of postoperative pain.

• The oral and maxillofacial surgeon should avoid starting treatment with long-acting or extended-release opioid analgesics.

• Providers should prescribe non-steroidal anti-inflammatory drugs (NSAIDs) as first-line analgesic therapy, unless contraindicated. If NSAIDs are contraindicated, providers should prescribe acetaminophen (N-acetyl-p-aminophenol [APAP]) as first-line analgesic therapy.

• NSAIDs and APAP, taken simultaneously, work synergistically to rival opioids in their analgesic effect, but dosage levels and times of administration should be carefully documented to prevent over dosage.

• When indicated for acute breakthrough pain, consider short-acting opioid analgesics. If opioid analgesics are considered, start with the lowest possible effective dose and the shortest duration possible.

• When prescribing opioids, state law may require prescribers to access the state prescription drug monitoring program (PDMP). If there is any suspicion of patient drug misuse, abuse and/or addiction, the OMS should access the PDMP. To assess for opioid misuse or addiction, use targeted history or validated screening tools.

• All instructions for patient analgesia and analgesic prescriptions should be carefully documented.

• When deviating from these prescribing recommendations – or those required by state laws or institutions – the oral and maxillofacial surgeon should document the justification for doing so. Oral and maxillofacial surgeons also should:

• Address exacerbations of chronic or recurrent pain conditions with non-opioid analgesics, non-pharmacological therapies and/or referral to specialists for follow-up, as clinically appropriate.

• Limit the prescriptions of opioid analgesics to patients currently taking benzodiazepines and/or other opioids because of the risk factors for respiratory depression.

• Inform patients that the recommended maximum daily dose of acetaminophen should not exceed 3,000 mg. To avoid potential APAP toxicity, an oral and maxillofacial surgeon choosing to prescribe an opioid should consider one that is ibuprofen-based.

• Counsel patients that the recommended maximum daily dose of ibuprofen is 3,200 mg. Note: Higher maximal daily doses have been reported for osteoarthritis while under the direction of a physician.

• Educate patients on the expectations of postoperative pain management and the anticipated levels of relief.

• Not prescribe acetaminophen with codeine to treat pain in children younger than 12. For more information, visit the FDA Drug Safety site.