your publisher review in JADA recently about the efficacy of a combination of
ibuprofen and acetaminophen to manage pain what were your conclusions and what
are the clinical significance of that
the use of those two drugs to non opioid drugs ibuprofen which is advil and the
sedum in ofin which is tylenol it's always been suspected that they might
have some additive effects some way that they actually provide greater analgesia
than either one of those drugs alone and it's kind of based on an old
pharmacologic principle that when you combine two drugs that have different
mechanisms that when you put them together you can get added benefits but
the data was never there until about four years ago and we're beginning to
see some clinical trials that really demonstrate that this is pretty
remarkable in terms of how much additional analgesia particularly in our
an inflammatory pain model that you get with that combination and and clinically
what's important it seems to me is we have always been kind of in this
position of either taking tylenol or taking ibuprofen advil or having to take
vicodin or percocet as our analgesic this actually gives you a position where
there's kind of another level another step in our kind of continuum of
analgesics from mild ones to moderate ones now we can throw in this
combination and the findings are that this might be opioid sparing in the
sense that it doesn't require that you use vicodin all of a sudden you have an
alternative to having to go to an opioid wonderful now you mentioned vicodin and
percocet do you think that dentist's are over prescribing when it comes to those type
of opioids. I mean over prescribing is just a loaded term I think we have a
dilemma and it's a dilemma that we see in dentistry we see it in doing
bunionectomy as we see it when we do orthopaedic knee surgery and the problem
is we do surgeries on an outpatient basis
we prescribe a drug when the patient is still numb so we don't haven't have any
idea how much pain they're going to have and what we're prescribing for is how
much pain they may or may not have in three days or two days and the question
then becomes how do we know who needs it and the answer is we don't know for sure
we did a wonderful study where we instead of looking at what was
prescribed we looked at how many of those opioid pain relievers were what's
actually used by our patients and what you see is about 15 percent of the
patients don't want to use a vicodin or percocet they don't fill it and they
don't use it you see a couple patients two or three percent who in fact have
dry sockets and have extreme the pain and they need more than we give them but
in that middle section there on average they use a tablets but we don't know who
needs what and our we're at a loss on how we can make sure they are not having
pain because that really is our first job is to treat our patients but we also
don't want them to leave 20 tablets sitting in a medicine cabinet unsecured
therein otherwise our problem you also use the term opioid sparing so are there
any strategies involved in using opioids sparing when it comes to acute management
of pain that they should be aware of well I think what we're doing now is
both in medicine and in dentistry and in podiatry and all of our surgical fields
is we're trying to think of ways that we can prevent pain and particularly
prevent severe pain and if we can use mechanisms that keep you from having
severe pain then the need to use opioid analgesics is going to decrease and that
it's been shown in a couple models in dentistry I think the first one I recall
was work using marking maybe fifty years ago that if in fact after surgery you
use a long-acting local anesthetic well then the patient is numb for six
ten hours and doesn't need to have a real strong opioid pain reliever
additionally in oral surgery that we are kind of customed to giving steroids
corticosteroids like dexamethasone that prevents swelling and decrease the
discomfort postoperatively and most recently I think we've seen use of
non-steroidal drugs drugs like naproxen drugs like ibuprofen and to offer those
and give those to patients before they leave the office before they're ever in
pain to try to get blood levels established so that you decrease the
need for opioids in the in six eight ten hours after surgery it's a reasonably
good strategy it falls into that multimodal pain management model that we
all talk about these days so you said decreasing the use of
opioids so there's still a place maybe for the use of opioids and would it be
any strategy somehow to teach the dental students and dentists how to use opioids
in case it's needed well I think we're really moving in that direction to a
great extent I mean I think there's new curriculums being developed in terms of
how we teach opioid prescription writing and safe prescription writing for our
students there are a number of things that we talked about one is just the
basis of is this patient is it appropriate to give an opioid to this
patient do they have a history of abuse are they pregnant are they on drugs that
may have caused drug interactions that's kind of the medicine part probably you
know more about that than I do but on the other hand we like to think about
how we could instruct patients counsel patients on how to go about using this
prescription we're offering that instruction for me and what I teach is
mrs. Jones this is prescription for an opioid you may not have to fill this at
all I'm giving it to you so that you have it on hand in case you do need it
but 60% of my patients going to ever require an opioid to
manage the pain the pain is never that severe so that kind of counseling on
what to expect postoperatively becomes an important part of what we do and then
and then we get there instructions that we're now talking about don't share this
drug with anybody make sure you keep it secured lock and keys so that nobody else
is using that drug and make sure you dispose of it properly after 7-10 days
after you no longer need it so opioid drug abuse still exists obviously so is
there a place for dentists and even ADA in the health of combating this type of
drug abuse that exists in this country and elsewhere well I think we're all
really alert to the kind of increased use of opioids misuse of opioids
overdose deaths in the United States have dramatically increased and I think
all of us physicians dentists patients law enforcement regulatories
even the President of the United States at this point are all interested in how
they can jointly collaborate and cooperate to try to decrease this misuse
of opioids in honesty in the last couple years is really an indication that
prescribing has decreased that the problem is not so much prescription
drugs as it has been but now it's moving in to illicit drugs such as heroin and
fentanyl and the overdose deaths are being reported for that that kind of use
rather than misuse of a prescription drug in the July issue of Jada you
and your co-authors have written a commentary about the vicodin verses and
the inflammatory drugs do you want to make any comments on that for the
audience well I mean we've been arguing for a long time about the fact that in
inflammatory pain in post-operative dental pain the nonsteroidals invariably
are more effective than the opioids particularly the way we
prescribed opioids one tablet four to six hour kind of prescribing of vicodin
the nonsteroidals really work better and particularly the combination of a
non-steroidal with acetaminophen it's just shows extreme efficacy
compared to vicodin but there's a lot of reasons why we prescribed vicodin
sometimes it's just the patient's demand it of us that's probably not a good
reason to to write a prescription for an opioid but we recognize pain management
is the holy grail of good care of compassionate care what a patient knows
is whether they hurt or not at the end of the day and so we're pretty sensitive
to making sure that we do everything we can for our individual patient to make
sure they're not in pain the problem is what happens if this is the patient who
doesn't need more than one tab or two tab or three tab then you get this
unused part that you really need to instruct your patients that you need to
secure it and dispose of it properly but there are contraindications for
nonsteroidals ibuprofen as wellness acetaminophen and
so and so forth where maybe opioids may be the alternative a choice I would
never suggest that we don't need to have opioids as part of our armamentarium our
management tools most of the side effects and contraindications for
nonsteroidals are long-term use not short-term use and so to a great extent
well most of our patients are going to do well on a on a non-steroidal but I
think there are times when the pain is really severe when you're talking about
a dry socket when you're talking about a very acute odontogenic infection the
nonsteroidals may not be able to cover that and that
you may need to go to an opioid pain reliever it had a reasonably good dose
to be able to manage that pain with an oral analgesic
you would add anything there is one thing that makes us unique and I think
you really need to stop and think about the fact that most of our prescribing
not most but a great deal of our prescribing has to do with taking out
wisdom teeth well now we're talking about young adults we're talking about
adolescence and if you look think about your own experience in your own kids the
first time they ever saw a vicodin was probably after they had their wisdom
teeth taken out think about that it only occurred to me four or five months ago
this is really why we are sometimes in the cross hairs with the media because
not that we prescribe a lot we in fact don't prescribe a great number of a
great amount of these agents but we're the first and you know if somebody is
going to get in trouble with alcohol or tobacco or anything it's that first
experience that can really be problem and I i lecture very heavily that we
have a special opportunity and responsibility but particularly an
opportunity to stop and say to this eighteen year old who's just had his
wisdom teeth taken out this drug has some very dangerous potentials in terms
of misuse and abuse and you need to be very careful about all doing that and I
think that that's a one of those teaching moments that I think we all
ought to think about when we prescribe particularly to an adolescent or a young
adult great thank you very much thank you for
coming I enjoyed it all right we'll do it again sometime
you