Do Common Analgesics Beat Opioids for Dental Pain Relief?

The appropriate and safe use of pain medications is of great concern in the United States. More than 115 Americans die every day from an opi-oid overdose.¹ In light of this epidemic, more studies are being conducted to find suitable alternatives to opioids for pain relief.

The fields of dentistry and oral maxillofacial surgery have performed studies showing that the proper use of OTC products can provide greater pain relief with fewer adverse effects (AEs) than opioid medications._^2,3

The most commonly used analgesics for oral pain include acetaminophen, nonsteroidal anti-in-flammatory drugs (NSAIDs), codeine, and oxycodone. Because combinations of medications with differing mechanisms of action can increase pain relief but not the AEs of either medication, dental pain is often treated with combinations of medications.

ACETAMINOPHEN

Acetaminophen increases the body’s pain threshold but does little for inflammation. AEs are rare when acetaminophen is used appropriately. Liver damage may occur if the dose is too high or if it is taken with alcohol.

NSAIDS

NSAIDs act at a cellular level to decrease inflammation, pain, and fever. All NSAIDs come with the risk of gastrointestinal bleeding, ulceration or upset.

OPIOIDS

Opioids, also known as narcotics, modify pain messages in the brain. Common AEs of opioids that tend to diminish over time include dizziness, drowsiness, and respiratory depression. Constipation is a common and persistent AE of opioids; it is wise to recommend a stool softener when dispensing opioids. Other AEs include agitation, dysphoria, euphoria, hallucinations, itching, low blood pressure and/or heart rate, muscle rigidity, nausea, pupil constriction, seizures, sexual dysfunction, urinary retention, and vomiting.

STUDIES

Results from a randomized, double-blind, placebo-controlled study comparing the analgesic efficacy of acetaminophen plus ibuprofen against acetaminophen or ibuprofen alone demonstrate that the combination provides greater analgesic efficacy than either medi- cation alone.⁴

Additionally, a qualitative systematic review of analgesic efficacy for acute postoperative pain was completed, and the findings suggest that a combination of acetaminophen and an NSAID may offer superior analgesia compared with either drug alone.⁵

A randomized placebo-controlled trial comparing the efficacy and tolerability of analgesic combinations found that acetaminophen plus ibuprofen provides statistically significantly more efficacy than acetaminophen plus codeine. Codeine and ibuprofen given together were also significantly superior in pain relief.⁶

A randomized double-blind control trial published in late 2017 concluded that 60-mg codeine added to a regimen of 1000 mg of acetaminophen or 400 mg of ibuprofen did not improve analgesia for acute oral pain.⁷

The Cochrane Collaboration, a globally respected collaboration, has done several reviews on the treatment of acute pain and has found that the number of patients needed to treat to give 1 patient 50% pain relief varies between nonopioid and opioid medications (Table). ^8-10.

APAP indicates acetaminophen; NNT, number needed to treat.

COUNSELING POINTS

Patients benefit from around-the-clock dosing of NSAIDs. Ideally, when pain is anticipated, instruct patients to take these drugs before the analgesic begins to wear off.

If the doses of acetaminophen, NSAIDs, or a combination have reached their ceiling and pain persists, an opioid should be added. Because opioids often come in combination with acetaminophen, it is important to warn patients to track their intake of acetaminophen and not to take more than 4 grams in 24 hours, because of potential hepatic injury.

If a patient is already being treated with opioids for a chronic condition, the pharmacist should reach out to the prescribing physician treating the chronic condition to adjust the dose instead of filling another opioid for acute pain.

CONCLUSION

The studies listed above clearly demonstrate the effectiveness of combining acetaminophen and an NSAID as first-line treatment for oral pain, barring any contraindications. In addition, with the American opioid epidemic, opiates should be reserved for pain not relieved by first-line therapy. This practice will reduce the amounts of opioids required to what would otherwise be given.

References

• Opioid overdose crisis. National Institute on Drug Abuse website. drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis. Updated March 2018. Accessed June 9, 2018.
• Moore PA, Ziegler KM, Lipman RD, Aminoshariae A, Carrasco-Labra A, Mariotti A. Benefits and harms associated with analgesic medications used in the management of acute dental pain: an overview of systematic reviews. J Am Dent Assoc 2018;149(4):256-265.e3. doi: 10.1016/j.adaj.2018.02.012.
• Ibuprofen, acetaminophen more effective than opioids in treating dental pain. ScienceDaily. April 17, 2018. sciencedaily.com/releases/2018/04/180417181101.htm. Accessed July 10, 2018.
• Mehlisch DR, Aspley S, Daniels SE, Brandy DP. Comparison of the analgesic efficacy of concurrent ibuprofen and paracetamol with ibuprofen or paracetamol alone in the management of moderate to severe acute postoperative dental pain in adolescents and adults: a randomized, double-blind, placebo-controlled, parallel-group, single-dose, two-center, modified factorial study. Clin Ther. 2010;32(5):882-895. doi: 10.1016/j.clinthera.2010.04.022.
• Ong CK, Seymour RA, Lirk P, Merry AF. Combining paracetamol (acetaminophen) with nonsteroidal anti-inflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain. Anesth Analg. 2010;110(4):1170-1179. doi: 10.1213/ANE.0b013e3181cf9281.
• Daniels SE, Goulder MA, Aspley S, Reader S. A randomized, five-parallel-group, placebo-controlled trial comparing the efficacy and tolerability of analgesic combinations including a novel single-tablet combination of ibuprofen/paracetamol for postoperative dental pain. Pain. 2011;152(3):632-642. doi: 10.1016/j.pain.2010.12.012.
• Best AD, De Silva RK, Thomson WM, Tong DC, Cameron CM, De Silva HL. Efficacy of codeine when added to paracetamol (acetaminophen) and ibuprofen for relief of postoperative pain after surgical removal of impacted third molars: double-blinded randomized control study. J Oral Maxillofac Surg. 2017;75(10):2063-2069. doi: 10.1016/j.joms.2017.04.045.
• Derry CJ, Derry S, Moore RA. Single dose oral ibuprofen plus paracetamol (acetaminophen) for acute postoperative pain. Cochrane Database Syst Rev. 2013;(6):CD010210. doi: 10.1002/14651858.CD010210.pub2.
• Gaskell H, Derry S, Moore RA, McQuay HJ. Single dose oral oxycodone and oxycodone plus paracetamol (acetaminophen) for acute postoperative pain in adults. Cochrane Database Syst Rev. 2009;(3):CD002763. doi: 10.1002/14651858.CD002763.pub2.
• Derry C, Derry S, Moore RA, McQuay HJ. Single dose oral naproxen and naproxen sodium for acute postoperative pain in adults [published online July 8, 2009]. Cochrane Database Syst Rev. doi: 10.1002/14651858.CD002763.pub2.