Opioids for acute pain relief: Managing dental patient expectations

This article originally appeared in the Principles of Practice Management e-newsletter. Subscribe to this informative twice monthly practice management ENL here.

In today’s society, many people believe that pain should be controllable. As dentists, how many times have we heard patients say, “I took the pills, but I’m still in pain. How can this be?”

We might think that a patient has a low pain tolerance or is an addict, or we might even think that we didn’t give someone something strong enough.

Where did the myth that pain medications should relieve all pain come from? As oral health-care providers, it’s important to understand patients’ perceptions regarding the efficacy of pain medications, and properly set their expectations before prescribing opioids for acute pain.

Understanding patient perceptions

There have been quite a few studies published in medical journals exploring patients’ expectations of prescribed medications. Factors influencing expectations include their personal experiences with medications, recommendations from family and friends, and the level of trust in their doctor.(1) These factors combined with someone’s understanding or perception of the risks and benefits of the medication will determine whether or not a patient decides to follow the doctor’s recommendations.

In the United States, an additional factor that plays a role in influencing patients’ expectations of the efficacy of their medications is direct-to-consumer marketing. The advertising industry claims that prescription drug advertisements give people more autonomy when they make decisions about their health care. This might be true for patients suffering from rare conditions, allowing them to talk with their doctors regarding the course of their treatments. However, in most cases, this type of advertising promotes false hope that these medications will cure people of their ailments.

Direct-to-consumer marketing harkens back to patent medicines of the 18th and 19th centuries. These were remedies that claimed to cure nearly any malady. They were sold directly to the public with few or no regulations. Wild claims were made by the purveyors of these concoctions, such as they cure or prevent a broad list of conditions, including colic in infants, cancer, venereal disease, tuberculosis, and dyspepsia.² Pain relief was central to the success of these “medicines.” Most were high in alcohol content and fortified with morphine, opium, and cocaine, so for many people they were quite therapeutic.

Fortunately, with heavy support from President Theodore Roosevelt, the Pure Food and Drug Act was passed in 1906 to guard the public against unsafe or unlabeled ingredients and misleading or false advertising.² Unfortunately, 100 years later, our patients still cling to the hope that taking a pill will solve all their problems.

Setting expectations

When it comes to pain relief, the pervasive belief is that an opioid will alleviate all pain. Studies have shown that opioids indeed “show statistically significant and clinically meaningful pain relief (30% decrease)” with what the researchers describe as “modest doses” (<101 mg per day morphine equivalent).”³ When most dentists prescribe an opioid for pain, the doses are limited to far below what was considered modest in these clinical trials. Additionally, “no study has shown clinically significant (≥50% pain reduction) and sustained pain relief with opioids over several months and years.” With a decrease of pain of only 30%, it is clear that opioids will not eliminate pain postoperatively. They will only make the pain more tolerable.

Even our best pain medications, including opioids, can provide only a small percentage of pain reduction. We must be honest with our patients and let them know that after surgery or complex dental treatment they can expect some post-operative discomfort. By setting expectations and providing patients with knowledge concerning the limitations of pain medications, we can avoid misunderstandings that may lead to late-night emergency calls or unneeded emergency visits. It is simply unrealistic to expect that there will be no pain from any given procedure, or that pain medications will make any and all pain go away. Because of this reality, we must master setting expectations with patients while making sure we do no harm and do our absolute best to minimize the pain associated with these procedures.

ALSO BY DR. WILLIAM McGLASHAN
What every dentist needs to know about prescribing opioids
Let’s not complicate opioids in dentistry
2 simple steps to help dentists reduce leftover opioids

William McGlashan, DDS, has been practicing dentistry since 1985 and is a graduate of University of Southern California Herman Ostrow School of Dentistry. He is currently an owner dentist supported by Pacific Dental Services, and serves as a faculty member of the PDS University—Institute of Dentistry.

For the most current practice management headlines, click here.

For the most current dental headlines, click here.

References
1. Dohnhammar U, Reeve J, Walley T. Patients' Expectations of Medicines – A Review and Qualitative Synthesis. Health Expect. 2016 Apr; 19(2): 179–193.
2. History of Patent Medicines. Hagley Museum website. https://www.hagley.org/research/digital-exhibits/history-patent-medicine. Accessed on April 27, 2018.
3. Sehgal N, Colson J, Smith HS. Chronic Pain Treatment with Opioid Analgesics: Benefits versus Harms of Long-term Therapy. Expert Rev Neurother. 2013 Nov;13(11):1201-20.