Having oral surgery? Ask your surgeon about what kind of pain medicine you will get.
Typically, dentists prescribe narcotics such as Percocet (oxycodone), Vicodin (hydrocodone) and codeine. But breakthroughs in non-opioid medications are giving dentists and patients better and more effective ways to treat post-surgical pain.
Dr. Mark Fletcher, of Avon Oral, Facial and Dental Implant Surgery in Avon, acknowledges that “there’s always going to be some pain associated with surgery,” and “a lot of people come in expecting the worst.” Some people are pleasantly surprised when they don’t feel anything after wisdom teeth extractions, but most people need something to alleviate the pain. For the past four years, Fletcher and his colleagues, Drs. Stuart Lieblich and Daniel Gill, have used Exparel (bupivacaine liposome injectable suspension) as a non-opioid local analgesia for patients in office-based dental implant reconstruction cases and in wisdom tooth as well as complex tooth extractions.
Unlike opioids, which work by attaching themselves to naturally occurring opioid receptors in the brain and releasing endorphins that generate a feeling comparable to a runner’s high, Exparel is an extended-release local anesthetic that blocks nerve impulses at the incision site. It is an enhanced form of the commonly used bupivacaine, but contained in liposome granules, providing sustained release at the site of the injection. Fletcher likens the granules to soap bubbles, which “are injected into the tissues. The body will break down those granules, releasing the local anesthetic effect directly at the site of the pain.” Administration of Exparel requires training, and Fletcher and his colleagues instruct other dentists on its use. It is a viscous solution that must be injected in small amounts over a larger area, not a thin liquid that spreads easily from the injection site. Exparel is administered at the end of the surgery so that it will last for three, sometimes four days, when pain is at its peak. After that, if a patient is still hurting, ibuprofen or other over-the-counter pain relievers can manage pain.
Fletcher notes that prior to the use of Exparel in his practice, he would prescribe 15 to 20 pills of extra-strength Vicodin. “A lot of patients would use the entire prescription,” he says. “Some would use half of them. The expectation by the patients was that they were going to get narcotics. The other expectation was that if the doctor gave it to you, you had to take it.” That’s not always necessary, he says. People have different tolerances for pain and should take painkillers carefully and as prescribed by the doctor. He also observes that the media coverage of the nation’s opioid addiction is getting patients to question doctors about alternative pain medicines. “Now people are more reluctant to take Percocet or Vicodin,” he says, and they ask for something else to relieve pain.
More young people are at risk of opioid addiction, and initial exposure to an opioid following even routine surgery can start the cascade in a susceptible individual, Fletcher says. Numerous studies have tried to determine a person’s risk for addiction. There are “some genetic mutations that affect the brain that will predispose one person to addiction over another,” Fletcher says. People having wisdom tooth extractions are often “opioid naïve… . This younger, potentially more vulnerable population is at risk of developing an addiction even after one prescription following surgery. Add to that some young adults who have a potential to engage in risky behaviors such as taking an opioid and driving or consuming them with other agents, such as alcohol, which further diminishes their judgment,” he says.
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The National Institute on Drug Abuse reports that Connecticut is among the top 10 states with the highest rates of deaths from opioid-related overdoses. Women are 40 percent more likely than men to become continuing users of opioids after surgery. Some researchers believe that this may be because of biological tendencies. Elderly patients are often more vulnerable to the effects of pain medicine. Pharmaceutical companies are working on abuse-deterrent opioids, but most of those medications have not yet received approval by the Food and Drug Administration. Exparel, which was approved by the FDA in 2011 for use in specific oral surgeries, has also been approved for use in other surgeries and procedures.
Both Mary Casey and her son, Casey Weingart, then an 18-year-old high school senior, were adamant about not taking prescribed opioids following the extraction of his four wisdom teeth. As the owner of Casey Bail Bonds, she often deals with people whose addiction to opioids began with prescribed painkillers. “I am more cognizant as a parent as to what could happen with these medications, which is why I did not want to give my son any of the prescription pain pills,” she says. “I just did not want to go down that road unless it was absolutely necessary.” Weingart adds that he knows a few people who are dependent on drugs. “I’m not friends with them, but I know the outreach of the opioid epidemic,” he says. “I didn’t want to get involved in something so strong. I didn’t want to leave anything to chance.”
Fletcher educated them on Exparel. “There was no question in my mind that it was the better route and safer route to go.” Mary Casey says, “Because of the way it is administered in the office and the patient isn’t even aware of the effects it is having on them, it is safer, in my opinion.” Her concern was that a pill taken periodically during the days following the surgery would give her son that pleasant experience that narcotics bring and would make him want more of it. “That, to me, is the most important component of that particular drug.” She would recommend a non-opioid to other parents without hesitation.
Weingart recalls that he “didn’t feel a thing” when the Exparel was injected. He just knew that it was a new medication. “It was incredible,” he recalls. He ended up taking “a couple of ibuprofens” for the pain after the Exparel wore off.
“Our numbers have fallen off a cliff in terms of our opioid prescriptions,” Fletcher says. We are down to giving “five to six pills of Vicodin now [and] in some cases zero. The goal is to become an opioid-free practice.”