LAUSR

The recent commentary on post-surgical dental pain management protocols and the potential for opiate “misuse” (Dionne 2020) notes concerns about opiate dependence and overdose risk. We wonder if quality perioperative analgesia can be provided without opiates for people already using them? People who inject drugs (PWID) regularly consume opioids and are therefore a key risk group for opioid overdose (Colledge et al. 2019). They have worse oral health than the general population (Truong et al. 2015) and have many reasons for not seeking dental care, including poverty, stigma, inadequate analgesia, and potential hyperalgesia (Robinson et al. 2005; Hersh et al. 2020). We assessed oral health related quality of life and dental service utilization in a PWID cohort (Horyniak et al. 2013). Of the 928 individuals interviewed, only 28% had visited the dentist in the previous year, with about 50% of these visits for tooth extraction or pain relief. To address the complexity of managing acute pain in opiate dependent individuals, Australian guidelines utilize a “reverse pain ladder,” which can involve incrementally higher opiate doses, opioid rotation strategies and multimodal analgesia (Huxtable et al. 2011; RACGP 2017). Opioid-containing formulations, primarily codeine with paracetamol, represent the majority of analgesic prescriptions by dentists in Australia (AIHW 2019), but it is not clear how many PWID are given these drugs or whether dentists are equipped to prescribe opioids according to guidelines. Understanding the drivers for PWID avoiding dental treatment is paramount so that they receive comprehensive oral health care. If inadequate analgesia is such a driver, then welldesigned studies to assess innovative pain relief protocols, including therapeutic agents affecting the endogenous opioid system, individualization of analgesic protocols, and adjunct methods, such as cognitive interventions and relaxation techniques are required (Szeverenyi et al. 2018; Colvin et al. 2019).