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To the Editor The important Original Investigation by Schroeder and colleagues1 that was recently published in JAMA Internal Medicine demonstrates the potential dangers of prescribing immediate-release opioids to a vulnerable population of adolescents and young adults. There are a few facts concerning the surgical removal of third molars that we would like to highlight. The authors state that these teeth normally erupt between the ages of 16 to 25 years. However, the teeth being targeted for surgery are usually impacted and only partially erupted or fully embedded in bone below the soft tissue. The trauma associated with their surgical removal consistently produces moderate to severe pain—the reason the US Food and Drug Administration considers it a pivotal acute pain model in analgesic approval.2 We were surprised that only 2.4% of first prescribers were classified as general surgeons or oral and maxillofacial specialists. Oral surgeons, who have 3 or 4 years of postdoctoral hospital-based training, possess doctor of dental medicine or doctor of dental surgery degrees, as do general dentists, so exactly who the first prescribers were was somewhat confusing. Others have reported that 60% of immediate-release opioid prescriptions are written by oral surgeons.3
Because patients are still numb following third molar procedures, the clinician can only estimate what the intensity of the patient’s postoperative pain will be.4 So they often write for the worst-case scenario by prescribing nonsteroidal anti-inflammatory drugs (NSAIDs), but also an average of 20 acetaminophen/hydrocodone tablets.4 We believe only 25% of these patients will require these potentially addicting drugs for a maximum of 3 days.5
Postsurgical dental pain is mainly driven by inflammation with prostaglandins being a key modulator. This explains the remarkable efficacy of NSAIDs when administered at optimal doses in this patient population and justifies the American Dental Association’s recommendation for their use as first-line therapy when managing acute dental pain.6 We have developed flexible analgesic guidelines that recommend around-the-clock dosing of NSAIDs for the first 24 to 48 hours instead of on an as-needed basis.5 The addition of acetaminophen, 500 mg, to an NSAID regimen appears to further limit postoperative pain severity. Immediate-release opioid preparations containing acetaminophen should only be added to the NSAID regimen when other opioid-sparing strategies are ineffective.5
The concerns of outpatient opioid prescribing described in the article by Schroeder and colleagues1 are common in both dentistry and medicine. The authors’ index population had a small but significantly higher incidence of previous nonopioid substance abuse than the control population. Before prescribing opioids, clinicians should rule out any previous substance misuse, assess mental health status, mandatorily employ prescription drug–monitoring programs, and discuss the potential dangers of these drugs with adolescents and their parents.
Corresponding Author: Elliot V. Hersh, DMD, MS, PhD, Department of Oral and Maxillofacial Surgery and Pharmacology, University of Pennsylvania School of Dental Medicine, 240 S 40th St, Philadelphia, PA 19104-6030 (email@example.com).
Published Online: May 20, 2019. doi:10.1001/jamainternmed.2019.0185
Conflict of Interest Disclosures: Dr Hersh reports receiving grants outside of the submitted work from the National Institutes of Health National Institute on Drug Abuse, Altrium Partners, Charleston Laboratories, Pfizer Consumer Healthcare, and Penn Center for Precision Medicine. He has also presented to the University of Pennsylvania and outside entities (eg, study clubs, societies, for continuing education credit) on rational analgesic prescribing and opioid alternatives, prescription opioid abuse, and dentists’ roles. No other disclosures are reported.
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Hersh EV, Saraghi M, Moore PA. Dangers of Opioid Prescribing for Young Adults After Dental Procedures. JAMA Intern Med. Published online May 20, 2019179(7):997–998. doi:10.1001/jamainternmed.2019.0185
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