Opioid Analgesics, Benzodiazepines, and Other Controlled Substances

Opioid drugs (e.g., morphine) and opioid combinations (e.g., acetaminophen with codeine or hydrocodone) were the analgesics of choice for the management of both acute and chronic pain in dentistry until the first decade of the twenty-first century. Recently, however, widespread opioid prescribing and the current opioid epidemic have significantly increased governmental scrutiny of healthcare providers who prescribe controlled substances, and it appears that reductions in legitimate opioid prescribing are linked to increases in heroin and illicit fentanyl use (Dart et al., N Engl J Med 372(3):241–248, 2015). The rationale for using opioids for dental pain was not entirely evidence-based and included the perception that “controlled substances” should be more efficacious than nonaddictive agents (Moore et al., J Am Dent Assoc 147(7):530–533, 2016). However, concerns over increasing abuse and diversion of opioids, as well as increasingly strong scientific evidence for superior pain relief provided by non-steroidal anti-inflammatory drugs (NSAIDs), have combined to fundamentally change the contemporary approach to the management of acute dental pain (Moore et al., Cochrane Lib 9:CD008659, 2015). Benzodiazepines and certain neuromuscular relaxants (e.g., carisoprodol) are also controlled substances with increasing significance as drugs of diversion and abuse. This chapter focuses upon controlled substances used as analgesics, sedatives, and muscle relaxants.