Should Gabapentin Be Used for Dental Pain?

By Pat Anson, PNN Editor

Since it was first approved as an anti-seizure medication in the 1990’s, gabapentin (Neurontin) has become one of the most widely studied and prescribed drugs in world.  Although gabapentin is only approved by the FDA for epilepsy and postherpetic neuralgia (shingles), it is widely prescribed off-label for fibromyalgia, neuropathy and many other types of pain.

Hundreds of clinical trials have been conducted to find new uses for gabapentin -- for everything from asthma and obesity to alcoholism and improving your sex life. Gabapentin has been pitched for so many different conditions that a drug company executive infamously called it “snake oil.”

Now gabapentin is being touted as a “promising alternative” to opioids for dental pain. In a new study at the University of Rochester Medical Center’s Eastman Institute for Oral Health (EIOH), researchers found that gabapentin, when combined with ibuprofen or acetaminophen, was more effective than opioids in relieving pain after tooth extractions.  

“We hypothesized that using a combination of the non-opioid pain medications and adding gabapentin to the mix for pain would be an effective strategy to minimize or eliminate opioids for dental pain,” said Yanfang Ren, DDS, a dentistry professor at EIOH.   

Ren and his colleagues treated over 7,000 patients at an urgent dental care clinic with different combinations of opioids, ibuprofen, acetaminophen and gabapentin after tooth extractions. The “failure rates” of the medications were determined by how often patients returned to the clinic for additional pain relief.

The study findings, published in JAMA Network Open, found that non-opioid medications, including those with gabapentin, had failure rates significantly lower than opioids.      

Dental Pain Failure Rates

• 0.9% Acetaminophen/ibuprofen

• 3.4% Gabapentin/acetaminophen

• 5.3% Gabapentin/ibuprofen

• 9.2% Codeine/acetaminophen

• 19.4% Hydrocodone/acetaminophen

• 31.3% Other opioid combinations

Providers at the dental clinic have already put their findings into practice by sharply reducing the use of opioids. Prior to that, about 1,800 patients at the clinic were treated each year with opioids. Researchers estimate the reduced opioid prescribing may have prevented 105 of those patients from developing a problem with “persistent opioid use.”

“This study represents continued efforts by our team and other dentists to minimize the use of opioids for dental pain,” said Eli Eliav, DMD, the director of EIOH. “Additional studies, preferably randomized controlled clinical trials, are needed to confirm the safety and effectiveness of this approach. It is our duty to continuously seek safe and effective treatment for our patients in pain.”

Gabapentin has issues of its own. Patients prescribed gabapentin often complain of mood swings, depression, dizziness, fatigue and drowsiness, and a 2019 review found little evidence gabapentin should be used off-label to treat pain. There are also many reports that gabapentin is being abused and sold on the streets because it can heighten the effects of other drugs.

100 Million Pain Pills Unused After Dental Surgery

By Pat Anson, Editor

Over half the opioids prescribed to patients following dental surgery go unused, according to a small study by researchers who say the leftover pills could be abused or stolen by friends and family members.

Researchers affiliated with the University of Pennsylvania’s Perelman School of Medicine and School of Dental Medicine followed 79 patients who had their wisdom teeth removed or some other type of surgical tooth extraction. Seventy-two of them were given opioid pain medication after the surgery.

On average, patients received 28 opioid pills and – three weeks later -- had 15 pills (54%) leftover. Only five patients used all of the prescribed pills.

From that small sample, researchers project that as many as 100 million excess pain pills are prescribed annually by dentists.

 “When translated to the broad U.S. population, our findings suggest that more than 100 million opioid pills prescribed to patients following surgical removal of impacted wisdom teeth are not used, leaving the door open for possible abuse or misuse by patients, or their friends or family,” said lead author Brandon Maughan, MD, an emergency physician and health services researcher at The Lewin Group, a health policy consulting firm.

“Given the increasing concern about prescription opioid abuse in the United States, all prescribers – including physicians, oral surgeons and dental clinicians – have a responsibility to limit opioid exposure, to explain the risks of opioid misuse, and educate patients on proper drug disposal.”

Twenty-four hours after surgery, patients in the study reported an average pain score of 5 out of 10 while taking pain medication. By the second day, more than half (51%) reported a low pain score (0-3 out of 10), and by the fifth day, almost 80 percent had a low pain score.

“Results of our study show within five days of surgery, most patients are experiencing relatively little pain, and yet, most still had well over half of their opioid prescription left,” said co-author Elliot Hersh, DMD, a professor in the department of Oral & Maxillofacial Surgery and Pharmacology at Penn Dental Medicine.

“Research shows that prescription-strength NSAIDs, like ibuprofen, combined with acetaminophen, can offer more effective pain relief and fewer adverse effects than opioid-containing medications. While opioids can play a role in acute pain management after surgery, they should only be added in limited quantities for more severe pain.”

The study, published in the journal Drug and Alcohol Dependence, also found that drug disposal kiosks in pharmacies and small financial incentives may encourage patients to properly dispose of their unwanted pain medication.

Patients in the study received a debit card preloaded with $10. If they completed surveys assessing their pain and medication use after surgery, they received an addition $3 credit on the debit card. Patients who completed a follow-up health interview received an additional $10.

Patients were also provided with information about pharmacy based drug disposal programs, which led to a 22% increase in the number of patients who had either disposed or planned to properly dispose of their leftover opioids.

“Expanding the availability of drug disposal mechanisms to community locations that patients regularly visit – such as grocery stores and retail pharmacies – may substantially increase the use of these programs,” Maughan said.

Reducing the excess prescribing of opioids for acute pain is one of the goals of the Centers for Disease Control and Prevention. The CDC's prescribing guidelines state that three days or less supply of opioids “often will be sufficient” for acute pain caused by trauma or surgery, and that 7 days supply “will rarely be needed.”  Those guidelines, however, were developed for primary care physicians, not dentists.