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Opioid Alternatives

Aetna’s comprehensive strategy to combat the opioid epidemic

Aetna’s comprehensive strategy to combat the opioid epidemic consists of a three-pronged approach:

Prevent misuse and abuse
Intervene when we identify at-risk patients and behavior
Support patients with access to evidence-based treatments

In the Spring 2018 issue of the Dialog, we shared US opioid-prescribing statistics.  We know that dentists prescribe 12% of all immediate-release opioids in the United States, behind only family physicians, who prescribe 15%.   For patients aged 10 to 19 years, dentists were the main prescribers.1

In 2017, Aetna sent letters to dentists and oral surgeons who were identified by claims data to have prescribed a greater than seven-day supply of an opioid at least five times in the last two years for routine dental procedures. 
Continuing our efforts in the “Prevent abuse” category, Aetna is piloting coverage of liposomal bupivacaine, a non-opioid alternative that oral surgeons can use in conjunction with extractions of impacted third molars.  https://news.aetna.com/2017/11/alternative-opioids-for-wisdom-tooth-extractions/  We hope that this will reduce or potentially avoid opioid exposure in post surgical settings for the 10-19 age group.

Regardless of the dental procedure, the analgesic efficacy of nonopioid analgesics such as acetaminophen (APAP) and the nonsteroidal anti-inflammatory drugs such as ibuprofen (NSAIDs) is typically underestimated. For decades, studies have repeatedly found that NSAIDs are superior to opioids at conventional dosages.2 They also produce a lower incidence of side effects than opioids, including the potential for abuse.  We encourage dentists to consider the following takeaways regarding non-opioid alternatives in managing their patients’ pain before prescribing an opioid4:

  • Although patients may assume they will receive an opioid pain medication following dental surgery, a simple conversation may lead to a mutual decision to try a nonopioid pain management regimen first.
  • Traditionally, oral health professionals have been taught that nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen should be used for mild-to-moderate pain, and opioids prescribed for severe pain. In fact, the evidence indicates that NSAIDs are more effective than opioids for severe pain.5
  • An even better option may be the combination of acetaminophen and NSAIDs because the site of action of acetaminophen differs from that of NSAIDs.
  • The American Dental Association suggests that clinicians assess a patient’s possible history of substance abuse as part of the medical/dental history, and consider “multimodal strategies for managing acute postoperative pain as a means for sparing the need for opioid analgesics.”6

To assist you in having effective counseling conversations with your patients regarding choosing and using OTCs for pain management, resources are available at https://www.getreliefresponsiblyprofessional.com/patient-education.  Various patient counseling resources are available for download through GET RELIEF RESPONSIBLY®, and include:

  •        Pain reliever comparison chart
  •        Checklists for health considerations when choosing the appropriate OTC analgesic
  •        Adult and Children’s OTC Pain Reliever Dosing charts
  •        Materials to help your patients understand the OTC medicine label

1 Volkow ND, McLellan TA, Cotto JH, Karithanom M, Weiss SRB. Characteristics of Opioid Prescriptions in 2009. JAMA : the journal of the American Medical Association. 2011;305(13):1299-1301. doi:10.1001/jama.2011.401.

2Becker DE. Pain Management: Part 1: Managing Acute and Postoperative Dental Pain. Anesthesia Progress. 2010;57(2):67-79. doi:10.2344/0003-3006-57.2.67.

3Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. MMWR Recomm Rep 2016;65:1–49.

4Fonner A, Reed K STRATEGIES FOR MANAGING ACUTE DENTAL PAIN
Decisions in Dentistry. March 2017;3(3):29–30,32–33.

5Moore PA, Hersh EV. Combining ibuprofen and acetaminophen for acute postoperative pain management: translating clinical research to dental practice. J Am Dent Assoc. 2013;144:898–908.

6American Dental Association. Statement on the Use of Opioids in the Treatment of Dental Pain. Available at: ada.org/en/about-the-ada/ada-positions-policies-and-statements/statement-on-opioids-dental-pain. Accessed February 3, 2017.

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