The Role of Opioids in the Management of Acute and Chronic Pain in Dental Practice 1

GUIDELINES
Approved by Council – November 2015

The Role of Opioids in the Management of

Acute and Chronic Pain in Dental Practice

The Guidelines of the Royal College of CONTENTS

Dental Surgeons of Ontario contain INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

practice parameters and standards

MANAGEMENT OF ACUTE PAIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

which should be considered by all

MANAGEMENT OF CHRONIC PAIN
Ontario dentists in the care of their Chronic Pain Primarily of Oral-Facial Origin . . . . . . . . . . . . . . 6
• Temporomandibular Disorders . . . . . . . . . . . . . . . . . . . . . . . . 6
patients. It is important to note that these • Neuropathic/Neuralgic Pain . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Chronic Pain Not Primarily of Oral-Facial Origin . . . . . . . . . . 8
Guidelines may be used by the College
MANAGEMENT OF RISK FOR OPIOID USE
or other bodies in determining whether
Assessing Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
appropriate standards of practice and Patient Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Detecting Problematic Opioid Use . . . . . . . . . . . . . . . . . . . . . . . . 9
professional responsibilities have been Managing the High-Risk Patient . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Dealing with a Shortage of Interprofessional Support. . . 1 1
maintained.
ADDITIONAL ISSUES
Use of Analgesics for Pediatric Patients . . . . . . . . . . . . . . . . . 1 1
Content of Prescriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2
Clarity of Prescriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2
Securely Issuing Written Prescriptions . . . . . . . . . . . . . . . . . . 13
Safeguarding the Dental Practice . . . . . . . . . . . . . . . . . . . . . . . . 1 3
• Securing and Monitoring In-Office Drugs . . . . . . . . . . . 13
• Staff Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

APPENDICES
S creening Tools: The CAGE-AID Questionnaire and
the Opioid Risk Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
4
Additional Resources and Reference Materials
6 Crescent Road Available on the Internet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Toronto, ON Canada M4W 1T1
T: 416.961.6555 F: 416.961.5814
Toll Free: 800.565.4591 www.rcdso.org
2 Guidelines | November 2015

Introduction particularly when complications begin to exceed

their competence to manage independently.

The management of pain is an important component

The purpose of this document is to guide dentists in
of dental practice. In this context, dentists frequently
the appropriate role of opioids in the management
consider the use of analgesics and other drugs to
of acute and chronic pain in dental practice, and to
manage the patient’s condition, which requires
present “best practices” for their use.
appropriate knowledge, skill and professional
judgment to be effective and maintain safety.

Before prescribing any drug, dentists must have Management of

current knowledge of the patient’s true health status
and clinical condition. This can only be acquired Acute Pain
by obtaining a medical history and conducting an
appropriate clinical examination of the patient in Patients presenting in acute pain deserve effective,
order to make a diagnosis or differential diagnosis, or timely and safe management of their condition.
otherwise establish a clinical indication for the use of This should involve active intervention through
a drug. There must be a logical connection between dental procedures (e.g., caries removal, pulpectomy,
the drug prescribed and the diagnosis or clinical incision-and-drainage, extraction) that are carried
indication. out as soon as possible, whenever possible.

For many dentists and patients, the management For the majority of patients, postoperative pain will
of pain and the use of opioids are often linked. be most significant for approximately two to three
However, in most instances, dental pain is days, after which it is expected to diminish. Thus,
best managed with effective, timely and safe in most situations, analgesics should be prescribed
treatment, and the use of non-opioids, including for the management of postoperative pain for three
acetaminophen and non-steroidal anti-inflammatory days, with declining amounts needed thereafter.
drugs (NSAIDs). In those instances in which the
patient’s pain cannot be managed with non-opioids, Before recommending or prescribing any drug for
dentists must consider whether an alternate postoperative pain, the following principles should
treatment or drug is clinically appropriate. be considered:

Dentists must exercise reasonable professional • Patients deserve effective, timely and safe pain
judgment to determine whether prescribing an management.
opioid is the most appropriate choice for a patient. • The source of the patient’s pain should be
These drugs are highly susceptible to misuse, abuse eliminated directly through dental procedures
and/or diversion, and may result in harm. If there are that are carried out as soon as possible,
no appropriate or reasonably available alternatives, whenever possible.
the benefits of prescribing an opioid must be • The use of any drug involves potential risks.
weighed against its potential risks, especially when • The use of an analgesic should be individualized,
used long-term. based on the patient’s medical history and the level
of anticipated post-operative pain.
In addition, dentists who prescribe an opioid for • A non-opioid (e.g., acetaminophen or an NSAID)
a patient should place reasonable limits on their should be maximized before adding an opioid.
prescriptions and consider opportunities for • A preoperative and/or loading dose of an NSAID
collaborating with other health care professionals, may be beneficial.
 The Role of Opioids in the Management of Acute and Chronic Pain in Dental Practice 3

ALGORITHM FOR MANAGEMENT OF ACUTE PAIN

Mild to moderate pain expected Moderate to severe pain expected

Acetaminophen

Acetaminophen 1000 mg provides NO Contraindication to NSAIDs?

sufficient pain relief (see text)

NO YES

NSAID Add codeine to

acetaminophen
Add codeine to NSAID, OR
acetaminophen or ASA add oxycodone to
If more analgesia
OR acetaminophen
required
add oxycodone to
acetaminophen or ASA

Attribution: Adapted with permission from Haas, D.A. (2002). An Update

on Analgesics for the Management of Acute Postoperative Dental Pain.
Journal of the Canadian Dental Association, 68(8),476-482

• The dose and frequency of an analgesic should be Only in a minority of situations is an opioid
optimized before switching to another analgesic. required.
• Long-term use of any analgesic should be avoided,
whenever possible. The above algorithm suggests the following
• The analgesic dose should be reduced in older approach:
individuals.
• For children, the analgesic dose should be 1. First consider acetaminophen. If professional
calculated on the basis of weight. judgment determines that an adult dose of
1,000 mg q4h (maximum of 4 g per day) is, or
From a risk/benefit standpoint, acetaminophen will be, insufficient, then consider point 2.
should be the first analgesic to consider and is 2. Consider an NSAID. If deemed insufficient,
usually sufficient for mild to moderate pain. Studies then consider point 3.
of acute pain in dentistry demonstrate that an 3. Consider a combination of acetaminophen or an
appropriate dose of an NSAID should manage the NSAID with codeine 15 – 30 mg, q4-6h prn pain.
vast majority of moderate to severe pain experienced If deemed insufficient, then consider point 4.
by dental patients. There is some evidence that suggests 4. Consider a combination of acetaminophen or
alternating acetaminophen with an NSAID may be an NSAID with codeine 30 – 60 mg or oxycodone
beneficial for managing moderate to severe pain. 5 – 10 mg, q4-6h prn pain.
4 Guidelines | November 2015

Before prescribing an analgesic for any patient,

consider the following: Only in a minOrity Of situatiOns is an OpiOid required.

Is pain estimated to be mild-to-moderate?

If yes, then consider: If the use of an opioid is determined to be
• Acetaminophen 500 – 1000 mg q4h (maximum of appropriate, then:
4 g per day) for adults
• Acetaminophen 10 – 15 mg/kg q4h (maximum of • Limit the number of tablets dispensed for any
65 mg/kg per day) for children opioid prescription. For most patients, consider the
following limits:
Is pain estimated to be moderate-to-severe? – for codeine 15 mg combinations (e.g., Tylenol#2®):
If yes, then consider: maximum of 36 tablets
1. Is the patient in good health with no – for codeine 30 mg combinations (e.g., Tylenol#3®):
contraindications to NSAIDs? maximum of 24 tablets
– If yes, recommend or prescribe an NSAID, such – for oxycodone 5 mg combinations (e.g., Percocet®):
as ibuprofen 400 mg q4h prn or an appropriate maximum of 24 tablets
dose of flurbiprofen, diflunisal, naproxen,
ketorolac, ketoprofen, floctafenine or etodolac. I
2. Does the patient have a contraindication to
NSAIDs, such as an allergy, gastric bleeding issues
or severe asthma?
– If yes, recommend or prescribe a combination of
acetaminophen with codeine or oxycodone.

Is pain estimated to be severe?

If yes, then consider:
• A local anesthetic block with bupivacaine
• A higher dose of an NSAID, such as ibuprofen If the patient returns complaining of unmanaged
600 mg (assuming there are no contraindications) pain, and this is confirmed by history and clinical
• Adding codeine 30 – 60 mg to the NSAID or examination, then:
acetaminophen
• Adding oxycodone 5 – 10 mg to the NSAID or • Reassess the accuracy of the diagnosis and/or
acetaminophen (such as Percocet®) source of the patient’s pain.
• Consider non-pharmacologic management of
Before prescribing an opioid for any patient, the patient’s pain, including direct treatment
consider the following: (e.g., pulpectomy, incision-and-drainage,
extraction).
• Is the patient’s pain well-documented? • Consider recommending or prescribing the
• Is the patient currently taking an opioid? maximal dose of the NSAID or acetaminophen
• Does the patient’s medical history suggest signs and discontinuing the opioid.
of substance misuse, abuse and/or diversion (see • Consider prescribing the maximal dose of the
section below on Assessing Risk)? NSAID or acetaminophen and the same dose of
• Given the efficacy of non-opioids, do the benefits of the opioid.
prescribing an opioid outweigh the risks? • Prescribing an increased dose of the opioid should
be considered last.
 The Role of Opioids in the Management of Acute and Chronic Pain in Dental Practice 5

If the patient returns again complaining of

unmanaged pain after a second prescription for an SUMMARy OF APPOINTMENTS
opioid, and this is confirmed by history and clinical (assuming the same diagnosis and/or source
examination, then: of the patient’s pain):

• Reassess the accuracy of the diagnosis and/or First Appointment

source of the patient’s pain. • day of procedure/first appointment
• Consider non-pharmacologic management of the • prescription for an opioid is issued
patient’s pain, if appropriate.
• Consider recommending or prescribing the Second Appointment
maximal dose of the NSAID or acetaminophen • patient returns complaining of unmanaged pain
and discontinuing the opioid. • possible Second prescription for an opioid
• Consider the risk for opioid misuse, abuse and/or
diversion. If this is suspected, consider consulting Third Appointment
with the patient’s physician (or other primary family • patient returns complaining of unmanaged pain
health care provider) and/or pharmacist regarding • possible third prescription for an opioid and patient
drug history and management of risk. advised that no further prescriptions for an opioid
• Consider prescribing the maximal dose of the will be issued without consultation/referral
NSAID or acetaminophen and the same dose of
the opioid. Fourth Appointment
• If a third prescription for an opioid is issued, then • patient returns complaining of unmanaged pain
advise the patient that no further prescriptions for • patient referred for pain management and any
an opioid will be issued without consulting with further prescriptions for an opioid are issued only
the patient’s primary family health care provider in consultation with the patient’s primary family
and/or a dental specialist with expertise in pain health care provider and/or a dental specialist with
management and referring as appropriate. expertise in pain management

If the patient returns again complaining of Dentists who prescribe an opioid for a patient
unmanaged pain after a third prescription for an independently should limit the number of consecutive
opioid, and this is confirmed by history and clinical prescriptions to a maximum of three, using the
examination, then: suggested maximum number of tablets. Further
prescribing should take place only in consultation
• Refer the patient to his/her primary family health with the patient’s primary family health care provider
care provider or a dental specialist with expertise and/or a dental specialist with expertise in pain
in pain management for management of pain and management.
assessment for problematic opioid use.
• Avoid prescribing any further opioids until
consulting with the patient’s primary family health Management of
care provider and/or a dental specialist with
expertise in pain management and referring as
Chronic Pain
appropriate.
The diagnosis of chronic pain refers to pain that is
• Consider recommending or prescribing the
prolonged, generally of three to six months duration,
maximal dose of the NSAID or acetaminophen
and subsumes chronic nociceptive pain, central pain
alone, until an interprofessional consultation
and sympathetically maintained pain. These may
has been conducted.
all cause a “chronic pain syndrome”, often with a
behavioural or psychosocial component.
6 Guidelines | November 2015

CHRONIC PAIN CONDITIONS IN DENTAL PRACTICE

Primarily of Oral-Facial Origin Not Primarily or Solely of Oral-Facial Origin

• Temporomandibular Disorders • Tension-Type Headache (Muscle Contraction

– Muscular/Myofascial Type Headache) with facial pain
– Intra-articular
– Degenerative/Inflammatory • Secondary Trigeminal Neuralgia from Central
Nervous System Lesions
• Neuropathic/Neuralgic Pain
– Trigeminal Neuralgia (Tic Douloureux) • Cervicogenic Headaches with facial pain
– Secondary Trigeminal Neuralgia from
Facial Trauma • Temporal Arteritis
– Postherpetic Neuralgia (Trigeminal)
– SUNCT Syndrome (Shortlasting, Unilateral, • Cluster Headache
Neuralgiform Pain with Conjunctival Injection
and Tearing) • Migraine Headache
– Unclear But Likely Neuropathic Pain
° Glossodynia and Sore Mouth (also known
as Burning Mouth Syndrome)
° Atypical Facial Pain (Atypical Facial
Neuralgia, Migratory Odontalgia, etc)

In dental practice, patients may present with chronic CHRONIC PAIN PRIMARILy OF
pain primarily of oral-facial origin or as part of, or in ORAL-FACIAL ORIGIN
conjunction with, another primary pain diagnosis.
The management of acute pain implies the
If the patient’s pain is primarily of oral-facial origin, elimination of a causative disease or disorder,
the dentist or dental specialist may be the primary whereas the objective with chronic pain is
caregiver. However, if it is not primarily or solely of generally management of the patient’s symptoms
oral-facial origin, the dentist should collaborate with and any related dysfunction. This may involve
or refer to a physician or medical specialist, who may various modalities, including physical treatment,
assume the responsibility of the primary caregiver. pharmacotherapy, cognitive/behavioural methods,
and complimentary or alternative therapy. In rare
Even if the patient’s pain is primarily of oral-facial cases, surgical intervention may be considered as a
origin, the dentist should consider collaborating with last resort.
other health care professionals, particularly when
appropriate pharmacotherapy involves the use of Temporomandibular Disorders
drugs with which the dentist lacks experience or For muscular/myofascial pain, in general, the most
complications begin to exceed his/her competence effective first line of therapies are the physical and
to manage independently. cognitive/behavioural modalities. If parafunctional
habits are contributing to the patient’s symptoms,
 The Role of Opioids in the Management of Acute and Chronic Pain in Dental Practice 7

a stabilizing-type oral appliance may be helpful. If Unlike acute pain, pharmacologic management of
sleep disordered breathing is suspected, a referral chronic temporomandibular pain implies long-term
for a sleep assessment, followed by appropriate use, which may result in drug tolerance, escalating
management, may be considered. dosage and increased risks of adverse effects. Opioids
are rarely indicated.
In severe cases of muscular/myofascial pain
or if nocturnal parafunction is contributing to For more detailed information about the
the symptomatology, a muscle relaxant may be management of temporomandibular disorders, refer
prescribed, such as cyclobenzaprine, orphenadrine, to the Guidelines on the Diagnosis and Management
tizanidine or methocarabamol. Generally, these of Temporomandibular Disorders & Related
drugs are prescribed for short periods of two to Musculoskeletal Disorders, which is available on the
four weeks, but occasionally a longer course is College’s website at www.rcdso.org.
appropriate with regular monitoring. If additional
pain management is necessary, acetaminophen or Neuropathic/Neuralgic Pain
an NSAID may be recommended. Benzodiazepines For neuropathic/neuralgic pain, whether
are generally not recommended for long-term use (apparently) primarily of oral-facial origin or not,
because of their significant potential for misuse, collaboration with a physician or medical specialist
abuse and/or diversion. is advisable to confirm that it is not part of a more
generalized/systemic pain disorder and rule out a
For intra-articular, degenerative or inflammatory central space occupying lesion. Brain and/or base
disorders, the physical and cognitive/behavioural of skull imaging are recommended. In addition,
modalities may again be considered. Although the if the dentist is not experienced in prescribing
evidence for their use is weak, stabilizing-type oral the appropriate drugs, she/he should transfer the
appliances may be helpful. responsibility of principal prescriber to the patient’s
physician or an appropriate medical or dental
For mild to moderate pain management, specialist, while maintaining a collaborative role in
acetaminophen is the drug of choice. Daily adult the patient’s care. At minimum, the dentist or
dose should be tailored to the minimum necessary dental specialist’s role includes monitoring for a
to manage the pain (maximum of 4 g per day). The local/dental cause or contributing disorder.
risks of hepatotoxicity, nephropathy, anemia and
thrombocytopenia increase with duration of use. Generally, neuropathic/neuralgic pain is
best managed pharmacologically, although
NSAIDs are a useful adjunct, both for their analgesic other adjunctive modalities are often helpful.
effect and, when appropriate, anti-inflammatory Anticonvulsants are usually the drugs of choice
activity. All NSAIDs risk gastrointestinal bleeding for neuropathic/neuralgic pain, including
and cardiovascular thrombotic events, including carbamazepine, gabapentin and pregabalin. Prior
stroke and myocardial infarction. With celecoxib, to prescribing carbamazepine or related agents,
the gastrointestinal risks are lessened, but there liver function tests are mandatory to establish a
is evidence that the cardiovascular risks may be baseline, with follow-up testing periodically. Certain
increased, especially in patients with a history of antidepressants, particularly the tricyclic amines,
myocardial infarction or cerebral vascular accident. are also useful in selected situations. Opioids are
Although adverse effects are not always related rarely indicated, except for the most severe cases,
to dose or duration, long duration in particular unresponsive to the first line of therapy.
increases risk.
8 Guidelines | November 2015

When prescribing anticonvulsants and/or

antidepressants, these drugs should be started at
Management of Risk for
a low dose and then slowly increased until relief is Opioid Use
accomplished, while not exceeding the maximum
dose. Similarly, these drugs must not be discontinued In some instances, the prescription of opioids may
abruptly, but rather patients should be weaned be deemed necessary to manage a patient’s pain.
from them carefully. Again, the dentist should However, opioids are often prescribed in excess of
consider collaborating with the patient’s physician, what is required. Many factors may contribute to the
particularly when appropriate pharmacotherapy over-prescribing of opioids in dentistry, including:
involves the use of drugs with which the dentist • habit or convenience;
may lack experience or when complications • lack of knowledge regarding the efficacy of
begin to exceed his/her competence to manage non-opioid analgesics;
independently. • patient demands and expectations;
• inadequate patient history regarding alcohol and
CHRONIC PAIN NOT PRIMARILy OR SOLELy other substance use;
OF ORAL-FACIAL ORIGIN • desire to avoid conflicts or complications.

For pain that is not primarily or solely of oral-facial

Dentists should not prescribe opioids to manage
origin, in general, the dentist or dental specialist is not
potential postoperative pain without regard to
the primary care provider. Possible exceptions to this
the possibility for problematic opioid use. While
rule include cases involving tension-type headache
dentists typically prescribe a limited quantity of
when a muscular/myofascial temporomandibular
opioids for acute pain (e.g., 24 tablets), excess tablets
disorder is a significant component. In such cases,
may remain after the patient’s condition has been
the College’s Guidelines for the Diagnosis and
successfully managed. These excess tablets may
Management of Temporomandibular Disorders &
then become a source for recreational drug abuse or
Related Musculoskeletal Disorders are applicable.
diversion by the patient, a relative or a friend.

Otherwise, the dentist’s or dental specialist’s role

It should be emphasized that a dentist has no
is complementary to the physician or medical
obligation to prescribe any drug, including opioids,
specialist, principally in monitoring and/or
if he or she does not believe it is clinically appropriate,
controlling the oral-facial and/or dental component
even if the patient has been prescribed them in
of the patient’s complaint.
the past and despite any demands or expectations.
In appropriate instances, a dentist must have the
It should be recognized that chronic pain may be
clarity of purpose and conviction to refuse a patient’s
a function of psychosocial and/or physical factors,
request for opioids when it appears to be unjustified
and that a history of trauma (either psychological or
or suspect, in order to protect him or her from
physical) may precipitate and/or perpetuate pain in
unnecessary medication and abuse potential, and
general. In addition, it should be acknowledged that
to limit the diversion of these drugs to the streets.
addiction to any substance, including opioids, may
be precipitated by the experience of pain.
The dentist should strive for adequate pain
management, while simultaneously assuming the
responsibility of limiting the potential for drug
misuse, abuse and/or diversion.
 The Role of Opioids in the Management of Acute and Chronic Pain in Dental Practice 9

ASSESSING RISK In addition, dentists should advise patients about

what to do if they miss a dose, and remind them that
When prescribing opioids, a dentist must have crushing or cutting open a time-release pill destroys
current knowledge and ensure comprehensive the slow release of the drug and may lead to an
documentation of the patient’s pain condition and overdose with serious health effects.
general medical status. This should include a review
of the patient’s alcohol and other substance use and Patient information pamphlets and other
screening for sleep apnea. educational materials regarding opioid use are
available on the internet, including:
If additional assessment is desirable regarding
a patient’s risk for opioid misuse, abuse and/or • Are you thinking about taking opioids
diversion, various screening tools may help with this (painkillers) for your pain?
determination. Examples include the CAGE-AID http://nationalpaincentre.mcmaster.ca/
Questionnaire adapted to include drugs and the documents/AreYouThinkingAboutTaking
Opioid Risk Tool (refer to Appendix 1). OpioidsEnglishJan2014.pdf

A discussion about potential benefits, adverse • Unintended Consequences: Sometimes

effects, complications and risks assists the dentist medications end up in unusual places... Like Trail
and patient in making a joint decision on whether Mix Parties
to proceed with opioid therapy. http://nationalpaincentre.mcmaster.ca/
documents/UnintendedConsequencesAug2012.pdf
Before prescribing opioids, the dentist should ensure
the patient’s expectations are realistic. The goal of • Youth and prescription painkillers: What parents
analgesic therapy is rarely the elimination of pain, need to know
but rather the reduction of pain intensity. http://knowledgex.camh.net/amhspecialists/
resources_families/Documents/Youthand
PATIENT EDUCATION Misuse%20E.pdf

It is recommended that dentists advise patients

DETECTING PRObLEMATIC OPIOID USE
on the safe use and storage of opioids by
communicating the following: When prescribing opioids, dentists must be alert for
• Read the label and take the drug exactly as directed. behaviour that suggests patients are experiencing
Take the right dose at the right time. problems with the appropriate use of opioids
• Follow the other directions that may come with the or have an opioid use disorder (as described in
drug, such as not driving, and avoiding the use of the Diagnostic and Statistical Manual of Mental
alcohol. Disorders [DSM-5] of the American Psychiatric
• Store opioids in a safe place out of the reach of Association.) Such a disorder may include seeking
children and teenagers, and keep track of the opioids for non-medicinal use or diversion purposes.
amount of drugs.
• Never share prescription drugs with anyone else, It may be difficult to determine whether a patient is
as this is illegal and may cause serious harm to the experiencing problems with opioid use. Indicators of
other person. an opioid use disorder include:
• Return any unused drugs to the pharmacy for safe • escalating the dose (e.g., requesting higher doses,
disposal, in order to prevent diversion for illegal use running out early);
and to protect the environment. Drugs must not • altering the route of delivery (e.g., biting, crushing
be disposed of in the home (e.g., in the sink, toilet controlled-release tablets, snorting or injecting
or trash). oral tablets);
10 Guidelines | November 2015

• engaging in illegal activities (e.g., double-doctoring,

INDICATOR ExAMPLES
prescription fraud, buying, selling and stealing drugs).
Altering – Injecting, biting or crushing oral
The following chart lists indicators of problematic the route of formulations
opioid use or an opioid use disorder. delivery – Biting, chewing, swallowing or
injecting topical preparations
Dentists may take practical steps to help prevent (e.g., sustained-release analgesic
patches)
problematic opioid use:
• If the patient is not well known to you, ensure her Accessing – Taking the drug from friends
or his identity has been verified; for example, by opioids from or relatives
requesting two or three pieces of identification other sources – Purchasing the drug from the
(e.g., health card, driver’s licence, birth certificate). “street”
• Verify the presenting complaint and observe for – Double-doctoring
indicators of problematic opioid use. Unsanctioned – Multiple unauthorized dose
• Screen for current and past alcohol and drug use escalations
(prescription, non-prescription, illicit) use. – Binge rather than scheduled use
Consider using screening tools (refer to Appendix 1).
Drug seeking – Recurrent prescription losses
• Consider whether the patient may be experiencing
– Aggressive complaining about
problems with opioid use or have an opioid use
the need for higher doses
disorder if she/he:
– Harassing staff for faxed scripts
– requests a specific drug by name and/or states
or fit-in appointments
that alternatives are either not effective or s/he is – Nothing else “works”
“allergic” to them;
– refuses appropriate confirmatory tests (e.g., x-rays, Repeated – Marked dysphoria, myalgias,
etc.); withdrawal GI symptoms, craving
symptoms
– indicates losing previous filled prescriptions or
spillage of drugs. Accompanying – Currently addicted to alcohol,
• Ask to speak with the patient’s primary family conditions cocaine, cannabis or other drugs
health care provider and/or pharmacist. – Underlying mood or anxiety
• Ask the patient if she/he has received any opioids in disorders not responsive to
the last 30 days from another practitioner and look treatment
for any signs of evasiveness. Social features – Deteriorating or poor social
function
Under the Controlled Drugs and Substances Act, – Concern expressed by family
1996, and its regulations, a person who has received members
a prescription for a narcotic, such as an opioid, shall
Views on – Sometimes acknowledges being
not seek or receive another prescription or narcotic
the opioid addicted
from a different prescriber without telling that
medication – Strong resistance to tapering or
prescriber about every prescription or narcotic that
switching opioids
he or she has obtained within the previous 30 days. – May admit to mood-leveling
effect
MANAGING THE HIGH-RISK PATIENT – May acknowledge distressing
withdrawal symptoms
Dentists who are considering prescribing opioids or
other drugs with abuse potential for patients with a Attribution: Prescribing Drugs (Policy Statement # 8 – 12),
history of problematic opioid use or an opioid use 2012, College of Physicians and Surgeons of Ontario
 The Role of Opioids in the Management of Acute and Chronic Pain in Dental Practice 11

disorder should clarify the conditions under which minimize harm for the welfare of patients. In some
they will prescribe, including consultation with the situations, determining what may be beneficial
patient’s physician. The physician may consider, in versus harmful is difficult. Nevertheless, dentists
appropriate circumstances, monitoring for indicators must attempt to provide care in a way that upholds
of problematic opioid use (e.g., urine drug screening) these principles as best as possible.
and the utility of a treatment agreement.
Traditional interprofessional support may not always
A treatment agreement may be an effective tool, be available. Even in such situations, the principles
especially for a patient who is not well known to the of patient management described in this document
dentist or at higher risk for problematic opioid use. still apply.

A treatment agreement is a formal and explicit When dealing with a shortage of interprofessional
written agreement between a practitioner and a support, dentists should make reasonable attempts
patient that sets out terms regarding adherence to to leverage whatever resources are at hand. For
the therapy. An agreement may state that: example, a dentist may consider:
• the patient agrees that only one practitioner will • referring the patient to Health Care Connect,
prescribe opioids; which helps Ontarians who are without a family
• the patient will use the drug only as directed; health care provider to find one. People without a
• the patient acknowledges that all risks of taking the family health care provider are referred to a family
drug have been fully explained; doctor or a nurse practitioner who is accepting new
• the patient will use a single pharmacy of his or her patients in their community (http://www.health.
choice to obtain the drug. gov.on.ca/en/ms/healthcareconnect/public/);
• consulting with an experienced colleague regarding
A treatment agreement helps to establish the patient management;
dentist’s expectations of a patient before prescribing • consulting with the patient’s pharmacist to verify
begins and the circumstances in which it may stop. the patient’s history of prescription drugs and
The consequence for not meeting the terms of the discuss options/alternatives;
agreement should also be clear: the dentist may • consulting with the local public health unit
decide not to continue prescribing opioids. regarding available resources in the community;
• consulting with the College.
DEALING wITH A SHORTAGE OF
INTERPROFESSIONAL SUPPORT
Additional Issues
The College recognizes that at times, dentists may be
faced with the prolonged management of a patient’s pain USE OF ANALGESICS FOR PEDIATRIC
in undesirable circumstances, especially when there is a PATIENTS
shortage of interprofessional support; for example, the
Acetaminophen is usually considered the drug of
patient does not have a physician (or other primary
choice for pediatric patients. It should be administered
family health care provider) or the referral to another
in a dose of 10-15 mg/kg q4-6h, up to a maximum
practitioner with expertise in pain management is not
of 65 mg/kg per day. Ibuprofen can also be used in a
possible for an extended period of time.
dose of 10 mg/kg, q6-8h.

The paramount responsibility of dentists is to

ASA is contraindicated for pediatric patients, because
the health and well-being of patients, which is an
it can potentially induce Reye’s syndrome.
expression of the core ethical value of beneficence.
This requires dentists to maximize benefits and
12 Guidelines | November 2015

Health Canada has recommended that codeine Written prescriptions must be legible. It is
only be used in patients aged 12 and over. This is recommended that dentists use the generic name
due to the potential of the rare complication of of the drug to ensure prescriptions are clear and
ultra-rapid metabolism of codeine leading to consider including more information, when
morphine overdose. appropriate (e.g., include both brand name and
generic name, and the reason for prescribing the
CONTENT OF PRESCRIPTIONS drug). When writing prescriptions, dentists must
pay particular attention to the use of abbreviations,
Dentists must provide the following information symbols and dose designations, and should avoid
with a prescription: using abbreviations, symbols, and dose designations
• name of the patient; that have been associated with serious, even fatal,
• full date (day, month and year); medication errors.
• name of the drug, drug strength and quantity or
duration of therapy; According to medication safety literature, the use of
• full instructions for use of the drug; verbal prescriptions (spoken aloud in person or by
• refill instructions, if any; telephone) introduces a number of variables that can
• printed name of prescriber; increase the risk of error. These variables include:
• address and telephone number of dental office • potential for misinterpretation of orders because
where the patient’s records are kept; of accent or pronunciation;
• signature of prescriber or, in the case of • sound-alike drug names;
electronically produced prescriptions, a clear and • background noise;
unique identifier, which signifies to the dispenser • unfamiliar terminology;
that the prescriber has authorized the individual • patients having the same or similar names;
prescription. • potential for errors in drug dosages
(e.g., sound-alike numbers);
For prescriptions that vary from common practice, • misinterpretation of abbreviations.
dentists should consider providing additional
information for the pharmacist. In addition, the use of intermediaries (e.g., office
staff) has been identified as a prominent source of
If the prescription is for a monitored drug, as defined medication error.
in the Narcotics Safety and Awareness Act, 2010,
dentists must also provide their registration number, Dentists must have protocols in place to ensure
as well as an identifying number for the patient that verbal prescriptions are communicated in a
(e.g., health card number) and the type of identifying clear manner. The more direct the communication
number it is (e.g., health card). between a prescriber and dispenser, the lower
the risk of error. Accordingly, if dentists use
Dentists should be aware that pharmacists are verbal prescriptions, it is recommended that they
responsible for confirming the authenticity of each communicate the verbal prescription themselves.
prescription, which may require direct confirmation If this is not possible, it is recommended that
with the prescriber before the prescription is filled. dentists consider asking a staff person who has
an understanding of the drug and indication to
CLARITy OF PRESCRIPTIONS communicate the prescription information, unless
the prescription is a refill.
Dentists must ensure that all written and verbal
prescriptions are clearly understandable.
When verbal prescriptions are used, it is recommended
that the accuracy of the prescription be confirmed
 The Role of Opioids in the Management of Acute and Chronic Pain in Dental Practice 13

using strategies such as a ‘read back’ of the also be kept in a secure area in the office, preferably
prescription and/or a review of the indication for the with the drugs, and reconciled on a regular basis.
drug. It is recommended that the read back include:
• spelling of the drug name; Whenever drugs in the above-mentioned classes are
• spelling of the patient’s name; used or dispensed, a record containing the name of
• dose confirmation expressed as a single digit the patient, the quantity used or dispensed, and the
(e.g., “one-six” rather than “sixteen”). date should be entered in the register for each drug.
Each entry should be initialled or attributable to the
In addition, to reduce the risk of error due to patients person who made the entry. In addition, this same
having the same (or similar) names, it is advisable to information should be recorded in the patient record,
communicate at least one additional unique patient along with any instructions for use.
identifier to the dispenser.
When dispensing monitored drugs for home use
SECURELy ISSUING wRITTEN by patients, dentists are also required to record an
PRESCRIPTIONS identifying number for the patient and the type of
identifying number it is in the drug register, as well as
In issuing prescriptions for opioids, dentists should in the patient record.
consider taking the following precautions:
• If using a paper prescription pad: Dentists are required to report within 10 days
– write the prescription in words and numbers; of discovery the loss or theft from their office of
– draw lines through unused portions of the controlled substances, including opioids and other
prescription; narcotics to the Office of Controlled Substances,
– keep blank prescription pads secure. Federal Minister of Health.
• If using desk-top prescription printing:
– use security features, such as watermarks; Staff Education
– write a clear and unique signature. Dentists should use staff training sessions and
• If faxing a prescription: meetings to discuss the dangers of drug and
– confirm destination and fax directly to the substance abuse, to remind staff of the safeguards
pharmacy, ensuring confidentiality; and protocols in the office to prevent misuse of
– destroy paper copy or clearly mark it as a copy. supplies, and to provide information about resources
that are available to dental professionals to assist
SAFEGUARDING THE DENTAL PRACTICE with wellness issues.

Securing and Monitoring In-Office Drugs

It should be emphasized that there is no provision
Opioids require increased storage security than other
for dentists or their staff to access in-office supplies
drugs. It is recommended that drugs stored in a
of opioids or other drugs that normally require a
dentist’s office be kept in a locked cabinet and out of
prescription for their own use or by their family
sight. Dentists are advised to avoid storing drugs in
members.
any other location, including their homes, and never
leave drug bottles unattended or in plain view.
Dentists should take reasonable precautions to
prevent the unauthorized use of in-office supplies of
A drug register must be maintained that records and
opioids or other drugs by staff and other individuals
accounts for all opioids, as well as other narcotics,
with access to the office.
controlled drugs, benzodiazepines and targeted
substances, that are kept on-site. The register should
14 Guidelines | November 2015

Appendix 1
SCREENING TOOLS: THE CAGE-AID QUESTIONNAIRE AND THE OPIOID RISK TOOL

THE CAGE QUESTIONNAIRE ADAPTED TO INCLUDE DRUGS (CAGE-AID)

1. Have you felt you ought to cut down on your drinking or drug use?

2. Have people annoyed you by criticizing your drinking or drug use?

3. Have you felt bad or guilty about your drinking or drug use?

4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a
hangover (eye-opener)?

Score: /4
2/4 or greater = positive CAGE, further evaluation is indicated

Attribution: Wisconsin Medical Journal. Brown, R.L. & Rounds, L.A. (1995). Conjoint screening questionnaires for alcohol
and drug abuse. Wisconsin Medical Journal, 94,135–140.

OPIOID RISK TOOL

Female Male

Family history of substance abuse

– Alcohol 1 3

– Illegal drugs 2 3

– Prescription drugs 4 4

Personal history of substance abuse

– Alcohol 3 3

– Illegal drugs 4 4

– Prescription drugs 5 5

Age (mark box if between 16 and 45) 1 1

History of preadolescent sexual abuse 3 0

Psychological disease

– Attention deficit disorder, obsessive-compulsive disorder, bipolar, schizophrenia 2 2

– Depression 1 1

Scoring: Low risk: 0–3 points Moderate: 4–7 points High: 8+ points

Attribution: Lynn R. Webster, MD; Medical Director of Lifetree Medical, Inc., Salt Lake City, UT 84106
 The Role of Opioids in the Management of Acute and Chronic Pain in Dental Practice 15

Appendix 2
ADDITIONAL RESOURCES AND REFERENCE MATERIALS AvAILAbLE ON THE INTERNET

Are you thinking about taking opioids (painkillers) for your pain?, 2014
National Pain Centre, McMaster University
http://nationalpaincentre.mcmaster.ca/documents/AreYouThinkingAboutTakingOpioidsEnglishJan2014.pdf

Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain, 2010
National Pain Centre, McMaster University
http://nationalpaincentre.mcmaster.ca/opioid/

Controlled Drugs and Substances Act, 1996

Government of Canada
http://laws-lois.justice.gc.ca/eng/acts/c-38.8/

Diagnosis & Management of Temporomandibular Disorders & Related Musculoskeletal Disorders

(Guidelines), 2009
Royal College of Dental Surgeons of Ontario
http://www.rcdso.org/save.aspx?id=67cf07e5-ee36-4f7d-a45f-57ce198ba0d5

Health Care Connect

Government of Ontario, Ministry of Health and Long-Term Care
http://www.health.gov.on.ca/en/ms/healthcareconnect/public/

Narcotics Safety and Awareness Act, 2010

Government of Ontario
https://www.e-laws.gov.on.ca/html/source/statutes/english/2010/elaws_src_s10022_e.htm

Ontario’s Narcotic Strategy

Government of Ontario, Ministry of Health and Long-Term Care
http://www.health.gov.on.ca/en/pro/programs/drugs/ons/

Prescribing Drugs (Policy Statement # 8 – 12), 2012

College of Physicians and Surgeons of Ontario
http://www.cpso.on.ca/CPSO/media/uploadedfiles/policies/policies/policyitems/prescribing_drugs.pdf?ext=.pdf

Unintended Consequences: Sometimes medications end up in unusual places... Like Trail Mix Parties, 2014
National Pain Centre, McMaster University
http://nationalpaincentre.mcmaster.ca/documents/UnintendedConsequencesJan2014.pdf
http://nationalpaincentre.mcmaster.ca/documents/UnintendedConsequencesAug2012.pdf

Youth and prescription painkillers: What parents need to know, 2013

Centre for Addiction and Mental Health
http://knowledgex.camh.net/amhspecialists/resources_families/Documents/YouthandMisuse%20E.pdf
6 Crescent Road
Toronto, ON Canada M4W 1T1
3654_07/14

T: 416.961.6555 F: 416.961.5814
Toll Free: 800.565.4591 www.rcdso.org