Long Term Opioid Use and Dental Local Anesthesia

Norco opioid pain medication used by dentists

Norco – a common opioid pain medication

As a busy private practice dental office, we are constantly doing dentistry, which involves injections of local anesthesia. Like all dentists, we occasionally encounter a patient and/or tooth that is difficult to get numb. Along this theme, an increasingly common phenomenon we are observing involves difficulty in getting patients numb who are long time users of opioids (often called narcotics).

A common situation is a patient with chronic pain who has been taking an opioid type painkiller long term (such as Percocet, Oxycodone, Oxycontin, etc.). A dental procedure that requires effective local anesthesia is attempted on that patient. During the procedure, it is learned rather quickly that the patient is having difficulty either getting completely numb and/or staying numb. Why is that?

Opioids, Narcotics, Pain Pills, Etc.

The term opioid is derived from the word opium, which is a component of the opium poppy. The raw opium can be processed to produce morphine or heroin – both of which are powerful pain relievers. The term opioid simply means a medication that acts on the opioid receptor.

Opium poppy, the basis for narcotics

The opium poppy – the flower from which morphine and heroin are derived. Image courtesy wikipedia.

Millions of Americans take opioids for both acute and/or chronic pain. For those individuals who take them long term for chronic pain, a tolerance will develop, requiring larger doses. Large doses of opioids taken over time can lead to many long term effects. Many of those effects – constipation, dry mouth, etc. – are well documented. What is not well documented nor well researched is how long term use of these painkillers impacts the effectiveness of local anesthesia.

Long Term Opioid Use and Dental Local Anesthesia

Unfortunately, there is very little “official” information available for practicing dentists and dental students on which to rely. The most widely read and cited textbook on local anesthesia for dentists – A Handbook of Local Anesthesia – by Dr. Stanley Malamed – makes no mention of this phenomenon.

Lidocaine is less effective in opioid users.

Multiple studies have shown lidocaine is less effective in opioid users.

However, a survey of recent research has shown multiple articles which directly and/or indirectly give support to this phenomenon:

  • In this article, opium abusers were compared to non-abusers in their response to lidocaine (lidocaine has replaced novocaine as the local anesthetic of choice in dentistry). The abusers were found to require a longer amount of time for the lidocaine to work. And in addition, a greater amount of lidocaine was required.
  • In this study involving rats, the administration of morphine (an opioid) resulted in a decrease in the potency of lidocaine.
  • In another study involving opium vs. non opium users, chronic users experienced a shorter duration of local anesthesia than non users.

In fact, there is a specific term for a related phenomenon, which is Opioid Induced Hyperalgesia. Basically, those individuals who are chronic users can become MORE sensitive to painful stimuli.

However, despite all of these studies, there remains to be seen a widely accepted theory for a mechanism behind the local anesthesia resistance seen in these individuals.

What This Means for Dental Patients

Unfortunately, because this phenomenon is somewhat new and not well documented, not all dentists are aware of these issues. Some tips:

  • Make sure your dentist is aware of your history. This includes patient with a past history of abuse who are on maintenance doses of naloxone or methadone.
  • Don’t be afraid to say “I’m not numb” or “I can feel this.”
  • If you are still uncomfortable, consider switching offices.

As a modern dental office, we’ve had success treating patients on chronic opioids with either buffered local anesthesia and/or IV sedation. So there are solutions out there – you just have to go out and find them.

Hydrocodone Reclassified as Schedule II

Hydrocodone and acetominophen tylenol combination prescribed at the dentist

Hydrocodone and Acetaminophen (brand name Vicodin).

On October 6th, hydrocodone containing medications will be re-classified as a Schedule II controlled substance. Hydrocodone is a high potency prescription level painkiller included in the combinations known as Vicodin and Lortab. Hydrocodone is considered a narcotic and is classified as an opioid type medication. In addition to relieving pain, hydrocodone can cause drowsiness and has the potential for addiction.

Many physicians and dentists, including our Orange, CT dental office, prescribe hydrocodone-containing products to treat pain. As a result, this change affects all dentists and many patients.

Why the Change?

In the past several years, a new epidemic of prescription drug abuse has emerged, with opioid pain killers being the most frequently abused drug. In fact, on average, narcotic painkillers cause or contribute to approximately 16,000 deaths per year in the U.S.

Map of Connecticut Prescription Drug Deaths

Prescription drug deaths in Connecticut. Fortunately there have been no deaths in Orange. Image courtesy the Connecticut Mirror.

In Connecticut, including the greater New Haven area, there has been an average of 272 drug overdoses per year, with many of them from painkillers such as Vicodin. Although there have been no deaths in Orange, our office has seen our fair share of patients who have had abuse problems with these types of medications.

In order to combat this epidemic, the DEA is now making it more difficult to obtain hydrocodone containing prescriptions. Some of the changes are listed below.

How it Affects Dental Offices

All dental offices that prescribe these types of medications are affected. In our office, where we do a significant amount of oral surgery such as tooth extractions, we will be adhering to the new requirements. These include:

  • We can no longer call in prescriptions.
  • In general, we can no longer give prescriptions with refills.

While this may pose a slight inconvenience to our patients, we hope everyone understands that this is not being done to annoy them but to reduce drug abuse in Connecticut and beyond.

Mouths of Prescription Drug Abusers

We all know how devastating prescription drug abuse can be on individuals. The abuse can lead to disastrous effects on the oral health. Below is a photo of a patient who had abused these medications for years:

Photograph of rotting teeth from abuse of percocet and vicodin

Teeth with untreatable decay due to abuse of Vicodin and Percocet. The only solution is a denture. Photo Dr. Nicholas Calcaterra.

We realize that the above photo is graphic and may be disgusting to people. However, it should hit home the point that prescription drug abuse is a serious problem.

By adhering to these new regulations, we hope to be part of the solution to our nation’s prescription drug abuse problem.