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Body + BrainBody & Brain

When Addiction Starts at the Dentist

ByTeresa CarrNOVA NextNOVA Next

Photo credit: Public Domain

Like many teens and young adults, my son had his wisdom teeth taken out while he was on summer break from school. The oral surgeon instructed him on the over-the-counter medications he could take to relieve pain—then, as an afterthought, handed him a prescription for a week’s worth of opioids, “just in case.”

We didn’t fill that prescription, but most people do. Eighty percent of people aged 13 to 30 who had their wisdom teeth removed filled an opioid prescription according to an analysis of nearly 80,000 patients published in the Journal of the American Medical Association last August.

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That decision to stop by the pharmacy can have lasting consequences. In the JAMA study, people who filled their opioid prescription were nearly three times as likely as those who didn’t to continue to use opioids in the year following their procedure. Other research has found that teens who take a prescribed opioid in high school are more likely to use these drugs later on.

Here’s the twist: My son likely got better relief from safer, over-the-counter drugs.

There’s a myth that opioids are more effective than OTC pain relievers, says David Preble, D.D.S., J.D., senior vice president of the American Dental Association (ADA) Practice Institute, which develops policy to help guide dentists. “Back when I was in dental school, we were actually taught that,” he says. “But evidence has brought to light the mechanisms of these drugs, the efficacy of them. We now know that, for most short-term pain, non-opioid alternatives are as good as an opioid and, in some combinations, may actually be better.”

My son likely got better relief from safer, over-the-counter drugs.

The realization that the risks of opioids outweigh the benefits for most patients, combined with alarm over the ongoing opioid epidemic, led the ADA to adopt a comprehensive opioid policy in 2016. Among other things, the guidelines call for dentists to prescribe the drugs only as a last resort if other approaches provide insufficient pain relief.

As a profession, dentistry is a relatively minor contributor to the problem of opioid overprescribing in the U.S., says Preble. But dentists play a larger role when it comes to prescribing opioids to teens and young adults because surgery to remove wisdom teeth is common at that age. “We’re a small part of the pie, but we take responsibility for our part and we want to change,” he says.

How an OTC combo can beat a narcotic for pain relief

Until recently, evidence to challenge the myth that opioids always offer superior pain relief was lacking. Clinical trials that examine how well pain relievers work compare the drugs to a placebo, or sugar pill—not to each other. “It honestly took a long time to develop the statistics that would allow us to compare results from trials of different medications,” says Paul Moore, M.D., professor in the department of dental anesthesiology and dental public health at the University of Pittsburgh School of Dental Medicine.

Moore is lead author of a “mega-review” of that statistical evidence, gleaned from five other large systematic reviews of studies comparing how well different drugs alleviate dental pain. The analysis, published in the August issue of the Journal of the American Dental Association, included data from 450 studies involving a total of more than 58,000 people aged 15 and older who’d had dental surgery—in most cases, to remove their wisdom teeth.

Results showed that taking both over-the-counter ibuprofen (Advil) and acetaminophen (Tylenol) together edged out a prescription opioid (a combination of acetaminophen and the opioid oxycodone) when it came to pain relief. The most effective doses were 400 mg of ibuprofen and 1,000 mg of acetaminophen, but even at half that strength, the combo worked marginally better than an opioid.

Researchers defined “effective” as reducing someone’s maximum pain level for 4 to 6 hours. So on a scale of 1 to 10, if your pain level is an 8, an effective medication should reduce your pain level to a 4 or lower. By that standard, about 7 out of 10 people taking the combination of OTC drugs experienced effective relief.

“The secret is in using two drugs that each work by a different mechanism,” says Moore. “When you combine them, you get a synergistic effect.”

Ibuprofen and a similar OTC drug naproxen (Aleve) belong to a category of medications known as non-steroidal anti-inflammatory drugs (NSAIDs). “That type of drug is effective because it focuses on where the pain comes from,” he says. When you are injured, or an oral surgeon operates to remove a tooth, your body responds by releasing hormone-like substances called prostaglandins that cause inflammation and amplify pain signals from the nerves. NSAIDs block the enzymes that make prostaglandins, so you have less swelling and pain.

As for acetaminophen, “it’s not clear exactly how it works,” says Moore. One theory is that the drug also stops the production of prostaglandins, but only in the central nervous system and not in the body’s tissues. So, it helps turn down pain signals in your brain, but won’t reduce swelling in your sprained ankle or inflamed gum.

Opioids such as OxyContin, Vicodin, and Percocet work by yet a different mechanism. They bind to receptors on the nerve signals in the spinal cord and brain that transmit pain signals to keep the messages from getting through. At higher doses, opioids work well to alleviate severe pain from major surgery or serious injury. But the drugs have to be used cautiously in those settings, says Moore, because they also interfere with pathways in the brain that govern respiration. At high doses or when combined with alcohol or another sedating medication such as a tranquilizer or sleep drug, opioids can cause breathing to cease altogether. “When an overdose occurs, it’s because someone just stops breathing,” says Moore.

The lower, short-term doses of opioids typically prescribed by dentists are safer than long-term or high doses more commonly prescribed by other doctors. Still, even at low doses, opioids can cause side effects such as nausea, vomiting, constipation, and leave you feeling groggy and fuzzy-headed. In Moore’s analysis, “patients reported side effects far more frequently with opioids than with the other medications.”

Both NSAIDs and acetaminophen are typically quite safe when used in low-to-moderate doses for short periods of time. But NSAIDs should be avoided by anyone with congestive heart failure, a history of ulcers or a bleeding disorder, poorly-controlled high blood pressure, or kidney disease. With acetaminophen, you need to be careful not to take more than the maximum daily dose of 4,000 mg as that can cause severe—and in some cases fatal—liver damage. It’s safer to stay closer to a maximum of 3,000 mg daily (six Extra Strength Tylenol).

When a prescription leads to abuse

Of course, one of the main concerns about prescribing opioids to teens and young adults is that the drugs can be addictive.

People get hooked on these drugs because, in addition to interrupting pain circuits in the brain, opioids also block nerve cells in the midbrain that help regulate mood. That allows the neurotransmitter dopamine to flood the brain’s reward pathways, temporarily causing feelings of pleasure and euphoria and damping sensations of fear or stress. Over time, the brain tries to adapt by shutting down the overloaded reward circuits and turning up the danger-sensing circuitry. People start to feel joyless, anxious, and depressed and need the drug just to function. Cravings set in and the person’s life may revolve around finding the next dose.

Young people are at an increased risk for addiction because the part of the brain that releases dopamine, which reinforces the sensation of new, pleasurable experiences, is working on overdrive through the teen years. Meanwhile, the prefrontal cortex—the part of the brain responsible for planning, decision-making, and self-control—doesn’t fully develop until people reach their mid-to-late 20s.

Recent research based on surveys of teens suggests that taking an opioid during those vulnerable years, even if it’s a prescribed drug for pain, increases the risk of later drug use and addiction.

The Monitoring the Future study surveyed a nationally representative sample of teens from 400 public and private schools about their use of illicit and prescription drugs, alcohol, and tobacco as well as their attitudes about substance use. Michigan researchers used data from the surveys to examine trends in both medical and recreational use of opioids in high school seniors from 1976 to 2015. They found that most teens who misused opioids to relax or get high first took the drugs as prescribed by their doctor for pain. The findings were published in the journal Pediatrics in 2017.

Surprisingly, teens at the highest risk are those you might least expect—12th grade students with no history of drug use and who strongly disapprove of using marijuana. A 2015 analysis of the same survey found that teens in that group who took opioids prescribed by their doctor were three times more likely than those who hadn’t to misuse the drugs in the next five years.

Most teens who misused opioids to relax or get high first took the drugs as prescribed by their doctor for pain.

It appears that, for some teens, taking a prescribed opioid primes their brain for misuse in the future. For teens with “little or no experience with the use of illegal drugs, an opioid prescription is likely to be their initial experience with an addictive substance,” says Richard Miech, Ph.D., a professor at the University of Michigan and principal investigator for the Monitoring the Future study. “If that experience is pleasurable and safe, it may reduce their perceived risk of using opioids later on.”

Curbing misuse through responsible prescribing

Dentists prescribe far fewer opioids than they did two decades ago. In 1998, dentists wrote 15.5% of all prescriptions for short-acting opioids such as Vicodin and Percocet; by 2012, that number had dropped to 6.4%.

Still, because many teens and young adults undergo a painful dental procedure such as getting their wisdom teeth removed, dentists wind up being a significant source of opioids for that age group. Marko Vujicic, Ph.D., chief economist and vice president of the ADA Health Policy Institute, says his research has found that about one out of four young people who’ve taken a prescribed opioid got it from their dentist.

Unfortunately, prescribing for that age group appears to be on the rise, according to a recent study of prescribing trends published in the Journal of the American Dental Association. The analysis of data from the insurance claims of more than five million patients found that dentists’ opioid prescribing for young people increased significantly between 2010 and 2015. For example, in 2015, dentists wrote 166 opioid prescriptions for every 1,000 patients age 11 to 18, compared to only about 100 per 1,000 in 2010. Overall, dentists also prescribed higher doses of opioids to teens and young adults than to other age groups.

“We don’t really know” what’s driving those trends says Vujicic, who was a co-author of the study. For young people, the study shows that “the vast majority of prescribing is for surgical visits—something like a wisdom tooth extraction,” he says.

“The thing is, there are proven alternatives,” says the ADA’s David Preble. “Right now, we are trying to get that education out there because we believe that we can change prescribing behavior.”

That education needs to extend to the public as well, says Preble. He points out that as a society, we’ve come to expect a “euphoric absence of pain” that is neither realistic nor safe. Instead, he says, that patients should expect a “very tolerable level of post-op pain” that recedes over a few days. In fact, some tenderness after surgery is useful—it’s a reminder not to chomp down on a hard pretzel and otherwise be careful with the injured area as it heals.

On the rare occasion that OTC pain relievers don’t work well enough, a dentist can prescribe a low dose of an opioid. “By taking the opioid in conjunction with other pain relievers, you can keep the dose extremely low and still have the same efficacy,” says Preble. Even then, most people would only need to take opioids for two or three days, he says.

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As for my son, he had his wisdom teeth out on a Thursday, spent a long weekend watching Netflix and eating soft food, and was off medication and back in school on Monday. We tore up the unused opioid prescription and tossed it into the recycle bin.

“Patients should not eagerly accept opioid pain medication, but rather question whether there is a safer alternative,” Preble says. “And if their dentist does the right thing and tells them how they can manage their post-operative pain with non-opioid medications, don’t think she doesn’t care about you. She cares more about you.”

From 2009 to 2016, opioid overdose deaths doubled in New York State. However, a few areas have a begun to see a decrease in fatalities, including the city of Buffalo and surrounding Erie County. Pinpointing an exact reason for the decline is difficult, but experts in Erie County suspect that a joint effort between law enforcement, public health officials, emergency departments, and peer counselors has something to do with it.

Meet the people combating the crisis. Launch our interactive story, and don't miss NOVA's "Addiction," airing tonight, October 17, at 9/8c on PBS.

Funding for this article is provided by the Conrad N. Hilton Foundation.

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