The Costello Guidelines for Prescribing Pain Medications™

Statement of Purpose 

The rampant abuse of opioid medications has necessitated a dramatic change in the way healthcare providers consider managing pain after a procedure, or as part of ongoing treatment. Prescription pain medications containing opioids are a part of a variety of pain management strategies. While much has been done to decrease the patterns of over-prescribing pain medications, these recommendations are provided to help clinicians’ decision making, specifically regarding the use of narcotic-based pain medications. It is very clear that several non-addictive alternative analgesics are as effective as opioid pain medications in many situations and are almost always preferred for patients undergoing outpatient procedures. These alternatives, such as NSAIDS and acetaminophen may avoid the risk of addiction, or the side effects associated with opioids. While it is recognized that narcotics can and should be avoided in most outpatient scenarios, clinical judgment should always be applied when making decisions and individual care should be based on many factors. Exceptions are inevitable but should be rare. 

The Costello Guidelines for Prescribing Pain Medications (The Guidelines) established conservative protocols for prescribing pain medication following performed procedures at The University of Pittsburgh School of Dental Medicine and our affiliates. However, we invite all conscientious healthcare providers to adopt The Costello Pledge and The Guidelines. 

Guidelines for Responsible Pain Management 

In the process of delivering care and assessing post-operative pain, the prescriber should try to estimate the severity, duration, and patient’s individual risk when prescribing pain medications. For example, the simpler the procedure (e.g., routine versus surgical extractions), the less likely the patient will suffer severe post-operative pain. In addition, individual patient characteristics may alter patient thresholds for pain or increase sensitivity to opioids (e.g., advanced age, history of substance abuse, obstructive sleep apnea, concomitant use of benzodiazepines, or other drugs that may cause respiratory depression or mental status changes). Pain is multifactorial and it is up to the healthcare provider to make informed and consultative decisions with their patient regarding what medications are indicated and appropriate in each clinical scenario. 

  1. Providers should prescribe pain medication other than opioids as first-line analgesic therapy, unless contraindicated. 
  1. The Patient’s Prescription Drug Monitoring Program (PDMP) database should be reviewed as per Commonwealth regulations if considering an opioid prescription. 
  1. When opioids must be utilized as a primary or rescue medication, the lowest potency opioid should be chosen to help relieve the patient’s pain. Therapy duration should be estimated based upon the severity of the procedural insult and the nature of the procedure. 
  1. Opioids should not be prescribed to a patient who is already prescribed opioid medications by another provider for chronic pain or substance abuse disorder (related or unrelated to the current problem) without consultation with the pain management physician and a plan that is documented in the electronic medical record. 
  1. When opioid prescriptions are provided, they should be limited to a three-day supply unless otherwise indicated for unusual circumstances. 

See The Costello Guidelines for Prescribing Pain Medications™ 

Strategies for Anticipating the Level of Post-Procedure Pain in Outpatients 

While pain tolerance is variable in individuals, most procedures can be classified with potential pain levels as mild, moderate, or high when the surgical disruption is typical for the procedure performed. Individual variations may necessitate modifying the guidelines. 

Mild

Simple extractions, anterior teeth, periodontal-diseased teeth, asymptomatic teeth requiring an extraction (i.e., extractions for orthodontic purposes with no periapical pathology), elective root canal therapy, simple periodontal procedures. 

Moderate

Surgical extractions, difficult posterior teeth, mild to moderately symptomatic teeth (i.e., periapical pathology), apicoectomies, periodontal surgery in several areas, most autogenous bone grafting procedures. 

High

Very difficult surgical extractions, some completely impacted teeth, some severely symptomatic teeth (i.e., significant periapical pathology), some urgent or emergent root canal therapies where extensive inflammation is not relieved. 

 

See The Costello Guidelines for Prescribing Pain Medications™ 

 

References and Additional Resources   >>