A Toothy Problem

Kids Are Getting Needlessly Exposed to Opioids From Routine Wisdom Tooth Removal

Luckily, there’s a non-opioid substitute that might help. But will dentists adopt it?


Here's something about wisdom teeth removal and other routine dental procedures parents might not have worried about before: potential opioids entering their child's system.

“Dentists and oral surgeons are the number one prescribers of opioids for adolescents, the age group 10-19—teenagers really,” psychiatrist Andrew Kolodny, co-director of opioid policy research at Brandeis University’s Heller School for Social Policy and Management and executive director of Physicians for Responsible Opioid Prescribing, told The Daily Beast. “There are studies that show that children who are exposed to opioids ... prescribed after their wisdom teeth come out are much more likely to use opioids non-medically—basically recreationally, to abuse them later in life,” Kolodny said.

That worry isn't idle panic. A 2015 University of Michigan survey showed young people exposed to opioids by the end of high school had an overall 33 percent increased risk of opioid misuse between the ages 19-25. “Good kids”—those teens categorized as at low risk of future drug abuse—were at 300 percent greater risk. These are kids who actually reported disapproval of regular marijuana use, according to the National Institute on Drug Abuse

“Strikingly, the risk was found to be most concentrated among teens who would be expected to be at low risk of drug misuse: those with no illicit drug experience and those who reported that they disapproved of regular marijuana use. Among those with low predicted risk of future opioid use in twelfth grade, having an opioid prescription increased their risk of post-high-school opioid misuse three-fold,” according to the National Institute on Drug Abuse website.

The brain is not fully developed until age 25, Kolodny said. But before that, young people are at an elevated risk from opioid exposure for three reasons.

For starters, a young person is going to get more of a dopamine (pleasure or reward neurotransmitter) “kick” than an adult would from the same amount of opioids because of lower baseline dopamine levels in the developing brain. There’s also the fact that the brain is fully developed, so it doesn’t assess risk very well, accounting for the tendency of younger people to take more risks, including risky drug behavior.

But what might really affect a person’s risk of getting addicted to opioids is brain plasticity. MRI scans show structural studies changes from as little as 30 days of daily opioid use, with no evidence of reversal after six months. Sure, these studies are on adults, but it’s believed that the developing brain is even more plastic and therefore more at risk of structural changes which may be permanent.

Despite being legally prescribed, opioids are no joke, especially when given to kids. Derived directly from opium, their effects are basically the same as that of heroin. Kolodny even went so far as to call them “heroin pills.”

So what’s a concerned parent to do?

First of all, parents and others should realize that when it comes to pain management and opioids, health care providers are often shockingly clueless.

“Although in general I would tell parents that they should trust their doctors and dentists, in the case of opioids, this is a situation where they can’t necessarily trust their doctors and dentists,” Kolodny said. “Doctors and dentists have been underestimating how addictive and dangerous these drugs are, and we’ve been overestimating how helpful they are, and that has a lot to do with the influence for 15 years of a brilliant marketing campaign.”

Pedro Franco is clinical adjunct assistant professor of oral and maxillofacial surgery faculty at Texas A & M College of Dentistry in Dallas and the immediate past president of the American Academy of Oral and Maxillofacial Surgeons.

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Franco’s oral surgery practice, like that of a slowly-increasing number of other oral surgeons, such as Victor Raposo and Curt Hayes of Colorado, is opioid-free.

These three oral surgeons, in fact, provide Exparel, a relatively expensive long-acting anesthetic painstakingly and precisely injected into the surgical site for proper effect, to their patients. Exparel became available in September 2016, in a smaller and more affordable 133 mg dose appropriate for oral surgery needs. It was approved in 2012 for general surgical use.

He argued that oral surgeons are, in fact, leading the charge on alternatives to pain management.

Franco, who grew up in Columbia, South America, is no stranger to drug problems.

Between 5 and 7 percent of patients will have an issue when exposed to dental opioids, but Exparel doesn't show similar side effects. To Hayes, Exparel is a much better substitute than the dental opioids that are commonly used.

“I don’t want to be the one to send them into a relapse,” Hayes said, explaining why he has, at times, personally covered the costs for those who can’t afford the extra expense, which at his office averages about an additional $250 dollars for wisdom teeth removal.

By numbing the surgical site for two to three days, Exparel is intended to reduce the amount of additional pain medication that’s needed. Post-operation, these dentists rely on a clinically-studied rotation of ibuprofen and acetaminophen (Advil and Tylenol). They all say that the regimen has worked extremely well, and all agree that, despite what some research might indicate, that the NSAID regimen alone is not enough for all patients.

Opioids, in these offices, are an absolute last resort. But there’s good news on the payment front for those with Aetna dental insurance, which since October is the first and only insurer covering the cost of Exparel. This reimbursement is part of a recently-announced research partnership between three players—Aetna, Exparel manufacturer Pacira Pharmaceuticals, and the American Academy of Oral and Maxillofacial Surgeons—to study the effectiveness of Exparel in reducing the amount of opioids prescribed post-surgically.

Exparel is not without controversy, however, with some research questioning its advantages and whether it’s worth the extra cost.

Franco, in turn, questioned the accuracy of such studies. He said that administration of Exparel in multiple injections around the surgical site is “very technical,” and he wondered whether researchers were forming the necessary “pockets” from which the medication would slowly release.

Some practices, including those of these three dentists, are also avoiding the use of opioids such as fentanyl during the procedure itself.

Whether there’s a risk involved in the use of opioids when a patient is unconscious is not entirely clear, Kolodny said, but less is always better than more.

“We really should be avoiding to opioids when possible,” he said.