Acute Postoperative Pain Opioid Prescribing Guidelines

Policy Owner: Associate Dean for Patient Care & Clinic Services

PURPOSE

To establish guidelines for safe postoperative acute pain opioid prescribing. These guidelines are intended to supplement and not replace the individual prescriber’s clinical judgment.

GUIDELINES

1. Unless contraindicated, all patients undergoing dentoalveolar surgery with and/ or N20 should be administered Ibuprofen 400 milligrams (mg) preoperatively.
2. Providers should prescribe non-steroidal anti-inflammatory drugs (NSAIDs) as first-line analgesic therapy, unless contraindicated. If NSAIDs are contraindicated, providers should prescribe Acetaminophen (APAP) as first-line analgesic therapy.
3. Before prescribing postoperative opioids, the Prescription Drug Monitoring Program (PDMP) database will be reviewed for each patient receiving an opioid prescription.
4. When postoperative opioids are indicated, the provider should choose the lowest potency opioid necessary to relieve the patient’s pain. The dose and duration of therapy should be for a short period of time, and for conditions that typically are expected to be associated with more severe pain. Do not prescribe doses or amounts that are in excess to the expected opioid requirements.
5. Opioids may not be prescribed to a patient who is already prescribed opioid medications by another provider. Patients prescribed opioids by another provider may only be prescribed opioids by a School of Dentistry provider after direct communication with the original prescribing provider, and it is agreed that the School of Dentistry will be the only prescriber of opioids. If it is reported that a patient has more than one prescriber of opioid medications, all School of Dentistry opioid prescriptions will cease.
6. Deviation from the prescribing guidelines should be documented and include a detailed explanation as to why the deviation was necessary.

If NSAIDS can be tolerated:

If NSAIDS are contraindicated:

ADDITIONAL CONSIDERATIONS

• Patients should be warned to avoid acetaminophen, or N-acetyl-p-aminophenol (APAP), in other medications. Maximum daily dose of APAP is 3,000 mg per day. To avoid potential APAP toxicity, a dentist should consider prescribing an opioid rescue medication containing ibuprofen.
• Maximum dose of ibuprofen is 2,400 mg per day. Higher maximal daily doses have been reported for osteoarthritis when under the direction of a physician.
• A decrease in postoperative pain severity has been demonstrated when a nonsteroidal anti-inflammatory drug is administered pre-emptively.
• Long acting local anesthetics can delay onset and severity of postoperative pain.
• A perioperative corticosteroid (dexamethasone) may limit swelling and decrease postoperative discomfort after third-molar extractions.
• Acetaminophen with codeine should NOT be the first drug of choice in children less than <12.
• Acetaminophen in children <12: 10mg/kg/dose, q4-6 hr. maximum 90 mg/Kg/ 24 hours.
• Ibuprofen in children <12: 4-10mg/kg/dose q4-6 hours, maximum 40mg/Kg/24 hours.

RELATED INFORMATION

Denisco, Richard C. et al.(2011). Prevention of prescription opioid abuse. The Journal of American Dental Association, 142(7), 800- 810.

Minnesota Dental Association. (2015). MDA Protocol for Assessment and Treatment of Oral/Facial Pain.

Thorson, D. et al. (2014). Acute pain assessment and opioid prescribing protocol. Institute for Clinical Systems Improvement. 

Massachusetts General Hospital. Opioid Prescription Strategy. 

HISTORY

• Approving Body:
• Date Approved:
• Date Amended:

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