# Perioperative Pain Management and the Opioid Crisis

## Introduction

Effective perioperative pain management is a fundamental responsibility of the OMFS surgeon. The ongoing opioid crisis has compelled a paradigm shift toward multimodal analgesia that minimizes opioid use while maintaining adequate pain control. OMFS surgeons are among the top prescribers of opioids in dentistry, making responsible prescribing practices critically important.

## The Opioid Crisis: Context for OMFS

Over 100,000 opioid-related overdose deaths occur annually in the United States. Dental prescriptions account for approximately 12% of all opioid prescriptions in the country. Third molar extractions are frequently the first opioid exposure for adolescents and young adults. Studies show that 5 to 8% of opioid-naive patients prescribed opioids after dental procedures continue use beyond 90 days. State prescription drug monitoring programs (PDMPs) are now mandatory in most jurisdictions.

## Pain Physiology Relevant to OMFS

Nociceptive pain results from tissue injury activating peripheral nociceptors and is the predominant type in surgical procedures. Inflammatory pain is mediated by prostaglandins, bradykinin, and cytokines at the surgical site. Neuropathic pain arises from nerve injury or dysfunction and may follow inferior alveolar nerve damage. Peripheral sensitization and central sensitization amplify pain perception postoperatively. Preemptive analgesia, which involves administering analgesics before the surgical stimulus, reduces central sensitization and improves postoperative pain control.

## Multimodal Analgesia

### Principles

Multimodal analgesia combines agents with different mechanisms of action to achieve synergistic analgesia, reduces reliance on any single drug class (particularly opioids), and targets multiple points in the pain pathway at the peripheral, spinal, and supraspinal levels.

### Non-Opioid Analgesics

| Agent | Dose | Mechanism | Key Advantages | Limitations |
|-------|------|-----------|----------------|-------------|
| Ibuprofen | 400-600 mg q6h PO | COX-1/2 inhibition | First-line for dental pain; superior to opioid monotherapy | GI effects; platelet inhibition; renal risk |
| Acetaminophen | 650-1000 mg q6h PO | Central COX inhibition; serotonergic | Complementary to NSAIDs; no platelet effect | Hepatotoxicity at >3-4 g/day |
| Ibuprofen + Acetaminophen | 400 mg + 1000 mg q6h | Dual mechanism | Superior to opioid-containing regimens for dentoalveolar pain | Combined limitations of both agents |
| Ketorolac | 15-30 mg IV/IM | Potent COX inhibition | Strongest parenteral NSAID; immediate postop use | Limited to 5 days; GI/renal/bleeding risk |
| Celecoxib | 200-400 mg PO | COX-2 selective | Reduced GI and platelet effects; useful preemptively | Cardiovascular risk with prolonged use |
| Dexamethasone | 4-8 mg IV/PO | Anti-inflammatory | Reduces edema and pain; antiemetic effect | Hyperglycemia; not an analgesic per se |

Ibuprofen (400-600 mg every 6 hours) is the first-line NSAID for dental pain and is superior to opioid monotherapy for most OMFS procedures. Acetaminophen (650-1000 mg every 6 hours) has a complementary mechanism with a hepatic dose ceiling of 3 to 4 g per day. The ibuprofen-acetaminophen combination has evidence demonstrating superiority over opioid-containing regimens for dentoalveolar pain. Ketorolac (15-30 mg IV/IM) is a potent NSAID for immediate postoperative use, limited to 5 days. Celecoxib (200-400 mg) is a COX-2 selective agent with reduced GI and platelet effects that is useful preemptively. Dexamethasone (4-8 mg IV/PO) reduces inflammation, edema, and pain while also providing an antiemetic effect.

### Local and Regional Anesthesia

Long-acting local anesthetics such as bupivacaine 0.5% with epinephrine provide 6 to 8 hours of analgesia. Liposomal bupivacaine (Exparel) offers extended release up to 72 hours and is FDA-approved for nerve blocks. Regional nerve blocks including inferior alveolar, infraorbital, supraorbital, and maxillary (V2) blocks provide targeted analgesia. Local anesthesia is the most effective component of multimodal pain management.

![Diagram illustrating the multimodal analgesia approach targeting different points in the pain pathway](images/multimodal-analgesia-pathway.jpg)

## Opioid Prescribing Guidelines

### When Opioids Are Indicated

Opioids are indicated for moderate to severe pain uncontrolled by maximum non-opioid therapy, typically after major surgical procedures such as orthognathic surgery, fracture repair, and ablative surgery. Short-course prescriptions of 3 to 5 days maximum are appropriate for most OMFS procedures. The lowest effective dose should be used, and only immediate-release formulations should be prescribed.

### Responsible Prescribing Practices

The PDMP must be checked before every opioid prescription, which is a legal requirement in most states. Risks of opioid use, storage, and disposal should be discussed with every patient. Quantity-limited prescriptions of 12 to 20 tablets are appropriate for most dentoalveolar procedures. Opioids should be avoided for simple extractions, implant placement, or minor soft tissue procedures. Patients at risk for opioid use disorder should be identified, including those with a history of substance use, psychiatric comorbidities, or concurrent benzodiazepine use.

### Commonly Used Opioids in OMFS

| Opioid | Typical Dose | Relative Potency | Key Considerations |
|--------|-------------|-------------------|-------------------|
| Hydrocodone/APAP | 5 mg q4-6h PRN | 1x (reference) | Most commonly prescribed in OMFS; combination product |
| Oxycodone | 5-10 mg q4-6h PRN | 1.5x | Higher potency; reserved for moderate-severe pain after major procedures |
| Tramadol | 50-100 mg q6h PRN | 0.1x | Lower abuse potential; dual mechanism (mu-agonist + SNRI); seizure and serotonin syndrome risk |
| Codeine | 30-60 mg q4-6h PRN | 0.15x | Prodrug requiring CYP2D6; contraindicated <12 years; variable efficacy from genetic polymorphisms |

Hydrocodone/acetaminophen is the most commonly prescribed, at 5 mg every 4 to 6 hours as needed. Oxycodone has higher potency and is reserved for moderate to severe pain after major procedures. Tramadol has lower abuse potential with a dual mechanism (mu-agonist and SNRI) but carries risk of seizures and serotonin syndrome. Codeine is a prodrug requiring CYP2D6 metabolism, is contraindicated in children under 12 and post-tonsillectomy, and has variable efficacy due to genetic polymorphisms.

## Special Populations

Pediatric patients should receive ibuprofen and acetaminophen as first-line agents, with codeine avoided and weight-based dosing used. Patients with substance use disorder require coordination with addiction medicine, consideration of non-opioid protocols, and avoidance of triggers for relapse. Elderly patients have increased sensitivity to opioids and NSAIDs, requiring dose adjustment and renal function monitoring. Patients on medication-assisted treatment (buprenorphine, methadone) should not have their MAT discontinued perioperatively, and the prescribing provider should be consulted.

![Infographic showing evidence-based opioid prescribing guidelines for common OMFS procedures](images/opioid-prescribing-guidelines.jpg)

## Non-Pharmacologic Adjuncts

Cryotherapy with ice application for 20 minutes on and 20 minutes off reduces edema and pain. Patient education that sets realistic pain expectations reduces analgesic consumption. Cognitive-behavioral strategies including relaxation techniques and guided imagery may be beneficial. Acupuncture and TENS have limited evidence but may benefit select patients.

## Regulatory and Ethical Considerations

Federal and state regulations increasingly limit opioid prescribing duration and quantity. Electronic prescribing of controlled substances (EPCS) is mandatory in many states. OMFS surgeons have an ethical obligation to balance pain relief with harm reduction. Pain assessment, treatment plan, and opioid risk assessment should be documented in the medical record.

![Chart comparing analgesic efficacy of common regimens for third molar extraction pain](images/analgesic-efficacy-comparison.jpg)

## Clinical Pearls

The combination of ibuprofen 400 mg and acetaminophen 1000 mg is superior to most opioid-containing regimens for dentoalveolar pain. Preemptive administration of analgesics before incision significantly improves postoperative pain control. The PDMP should always be checked before prescribing opioids to protect both the patient and the provider. Long-acting local anesthetic blocks are the single most effective intervention for immediate postoperative pain. Third molar extraction prescriptions should rarely exceed 12 to 20 opioid tablets.

## References

1. Moore PA, Hersh EV. "Combining Ibuprofen and Acetaminophen for Acute Pain Management After Third-Molar Extractions." *Journal of the American Dental Association*. 2013;144(8):898-908.
2. Nalliah RP, Yee T, Freer E. "Opioid Prescribing Patterns of Oral and Maxillofacial Surgeons." *Journal of Oral and Maxillofacial Surgery*. 2020;78(9):1510-1518.
3. American Dental Association. *Policy on Opioid Prescribing*. Updated 2023.
4. Hersh EV, et al. "Perioperative Pain Management in Oral and Maxillofacial Surgery." *Oral and Maxillofacial Surgery Clinics of North America*. 2022;34(2):221-234.