The More Things Change…

Sam Quinones is widely credited for his 2015 book Dreamland as the definitive source for the genesis of the opiate crisis in the United States. His most recent book The Least Of Us details how the opiate crisis has now evolved to the more common abuse of fentanyl and it’s analogues apart from heroin at it’s epicenter.

Here at CE Dojo and in the past as Old Well Consulting, we have painstakingly chronicled the association of opiate abuse and early adolescent exposure to prescription opiates both here on this blog and in our popular webinar Strategies For Acute Pain Management In Dentistry. Unfortunately, Dentistry has been identified in many studies as one of the most frequent prescribers of opiates to this vulnerable age demographic.

Even more unfortunately, I have my own suspicions why Dentistry is being identified. Sam Quinones was recently interviewed by Drug Free NJ about his most recent book but I honestly was startled by a comment he made. When discussing how adolescents and young adults are particularly at risk for opiate addiction the indications for prescription opiate use was raised. Quinones stated at roughly 59 minutes into the webinar…unequivocally that athletic injuries – and wisdom tooth removal (M3) – were the usual culprits.

Did I say “wisdom tooth removal”? I had a hunch…but the 900 lb gorilla in the room just beat his chest.

And you know who this really points to, right? You got it – oral and maxillofacial surgeons (OMS).

I am just the messenger, but I think we (OMS) all need to take very critical stock of what has been stated. M3 removal is part of the core of procedures routinely performed on a daily basis by OMS and it is a strong revenue source for practices all across the country. While there has been much research into evidence based support of elective M3 removal, the question becomes which public health concern (morbidity from delayed M3 removal versus prospective opiate addiction) takes precedence?

I have thought about Mr Quinones statements for over a month now – how can these seemingly competing sets of concerns be best addressed? Here’s what I have concluded:

  • Limiting opiate exposure and use in favor of over-the-counter (OTC) analgesics is obviously key.
  • Using less potent opioids (hydrocodone vs oxycodone) would be supportive.
  • Consider use of liposomal bupivicaine (Exparel) for extended pain control
  • Timing surgery to optimize ease of removal would really seem to be the most important factor to decrease post-operative discomfort and maximize the effectiveness of OTC analgesics.
  • Earlier than ideal surgery to accommodate a referral is frankly unethical and should be discouraged
    • Example – an orthodontist who is uncomfortable with management of serial extractions will need to push removal of M3 necessitating much earlier surgery in addition to lower incisor gingival grafting due to arch expansion.
  • Providing a small quantity of prescription opioid analgesics under direct parental supervision for “rescue” would seem appropriate in some circumstances.

It is up to us (OMS) to be good stewards of responsible opiate prescribing to one of our more common and most vulnerable patient demographics. If we do not take the lead, others will do so for us. Recent events in North Carolina regarding office-based general anesthesia are case-in-point. Continuing “cookie cutter” approaches to patient management should be replaced by individualized care. Referring general practitioners can further help their patients by differentiating and acknowledging preventive versus medically necessary care, and supporting specialty recommendations to defer care to optimize post-operative management in favor of OTC analgesics.

David MH Lambert, DDS

Diplomate, American Board of Oral & Maxillofacial Surgery

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