Q&A with Dr. Dale Misiek

As the opioid epidemic continues to impact virtually every community throughout the nation, the government has taken steps at the local, state and national level to combat overprescribing and reduce the number of individuals exposed to opioids. However, it’s no secret that opioids have been considered optimal pain management in the surgical setting for decades and are often still prescribed. A recent JAMA study revealed that more than two-thirds of patients have leftover opioids after surgery¹, resulting in a high number of pills available for possible diversion or misuse.

Dr. Dale Misiek, a board-certified oral and maxillofacial surgeon at the Carolinas Center for Oral and Facial Surgery in Charlotte, North Carolina, recognizes his role in prescribing opioids and has taken action within his practice.

Dr. Misiek now utilizes non-opioid pain management options within his practice to help minimize, and in some cases eliminate, the need for opioids following surgery. He recently spoke with Shatterproof and shared useful information on non-opioid options and tips for how patients, and parents, can navigate a pain management conversation with their surgeon.

1. Wisdom tooth extraction is often the first-time patients are exposed to opioids. What should parents be aware of if they learn their son or daughter needs to have their wisdom teeth removed?

While teens and young adults comprise the majority of patients undergoing wisdom teeth removal, these teeth often do not become symptomatic until later in life requiring removal as an adult. The reason for concern in younger patients is they are the most vulnerable to neurobiological changes in the brain which can lead to addiction. When parents are guiding a son or daughter through the process, I encourage a three-way conversation (parent, patient and doctor) to ensure all parties understand exactly how pain will be managed before, during and after surgery. Patients and caregivers should educate themselves on the non-opioid options that are available. Take advantage of helpful resources like this one.

2. How can patients and caregivers talk with surgeons about opioids and non-opioid options?

As surgeons, it’s our job to educate, answer questions, and put patients at ease. In my experience, patients do better after surgery when they know what to expect before their procedure—that’s why it’s important to ask your doctor about the amount of discomfort that might be associated with your procedure and how to manage it appropriately.

When speaking with your surgeon, useful talking points to keep in mind include a patient’s pain tolerance, personal history of substance use disorder (SUD) or SUD within the family, any particular concerns about pain medications/opioids, options to avoid opioids, concerns about recovery at home, level of caregiver support available during recovery, general thoughts on pain management and pain medications, and what to expect during recovery. Do not hesitate to ask about all pain management options available, including options to avoid opioids. After all, pain is different for everyone, and both patients and parents should feel empowered to have proactive conversations with their physicians.

3. How troublesome do you think the opioid epidemic is for oral and maxillofacial surgeons?

For decades, opioids were widely considered the gold standard to manage pain. While there is still a time and place for opioids to address pain, a multimodal approach including effective non-opioid options – such as acetaminophen, ibuprofen and local anesthetics—can effectively manage pain without the side effects and risks of opioids. Since dental professionals rank fourth among medical specialties for their opioid prescribing rates² , utilizing these non-opioid options truly have been a game-changer for me.

4. Has your use of opioids changed in recent years because of this societal problem? How are you managing pain for your oral surgery patients?

I have become very careful to prescribe opioids only when necessary. Prior to surgery, I make sure to explain to patients and their caregivers that there are non-opioid options that can manage pain for the first few days following surgery; this allows me to reduce, or in some cases, completely eliminate the need to prescribe opioids.

At my practice, we utilize a long-acting numbing medication injected into the mouth at the time of surgery for patients requiring wisdom teeth removal and other oral surgeries. This non-opioid medication lasts for the first few days following surgery, allowing patients to take an NSAID like ibuprofen to manage pain. Using this strategy, I have never seen my patients’ pain more effectively managed in the 36 years I’ve been practicing.

5. Given the heightened awareness of the opioid epidemic in the last year, do you find your patients are more receptive when you present a non-opioid option to them?

Yes, I’ve found that most patients and their parents are happy to hear that non-opioid options are available to manage pain and minimize the need for opioids. The opioid epidemic continues to make headlines in virtually every area of the country, so patients and caregivers are becoming more and more knowledgeable about the risks and dangers of being exposed to these highly addictive medications. In fact, a national survey found more than seven in 10 patients indicated they would opt for a non-opioid medication to treat postsurgical pain from wisdom tooth extraction if given the choice, and approximately 80 percent indicated they would do so even if the medication was associated with additional cost. Given the demand, it’s clear that oral surgeons should be routinely providing their patients with non-opioid options.

6. If my college-aged child does receive opioids after surgery, what precautions can I take to minimize the risk of opioid misuse?

While parents should feel empowered to tell their doctor they don’t want their child to take opioids, they can also request a lower dose and a smaller prescription—for example, a 3-day rather than a 7-10-day supply. If a young adult does receive opioids, it is important to take the proper precautions to ensure they are being used safely and as directed. Have a discussion with the doctor about when and how to taper off the medication as soon as possible. Parents can keep opioid prescriptions locked away and dose the correct amount for the patient as necessary.

Once the pills are no longer needed, unused prescriptions should be dropped off at a local pharmacy or other location that participates in a drug take back program. The DEA also hosts two National Prescription Drug Take Back Days, usually in April and October, each year.

7. What is the biggest misconception patients have when it comes to oral surgery?

One of the biggest misconceptions oral surgery patients have is that effective pain management can only come in the form of an opioid—it is my responsibility to inform my patients that non-opioid options are available. As with any surgery, some level of pain is expected. The long-acting numbing medication that I use provides pain relief for a few days, often when pain is at its peak. Through the use of this method, oral surgery patients find that their pain is effectively managed without the dangerous side effects of being exposed to opioids.

8. Are non-opioid options available for other surgeries beyond wisdom teeth extraction?

Yes, within the oral surgery space non-opioids are available for other procedures including jaw surgery and other procedures that result in muscle and/or soft tissue injury.

Beyond oral surgery, patients can also utilize non-opioids to manage pain following various other procedures including knee replacement, hip replacement, gallbladder removal, C-section, weight loss surgery, among others. That is why it’s so important to proactively discuss effective pain management options with your clinician before undergoing any type of surgery.

Originally published in 2018.