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back programs, a DEA‐approved take back program, or FDA guideline forsafe disposal of medicine. c. Advise the patient to avoid combining opioids with benzodiazepines, sedative‐hypnotics, anxiolytics, or other central nervous system depressants, including alcohol. These combinations exponentially (not just additively) increase risk for dangerous respiratory depression. Dental Guideline on Prescribing Opioids for Acute Pain Management Adopted by the Bree Collaborative, September 27th, 2017 Page 4 of 12 Intraoperative Period 1. Use pre‐emptive analgesia where indicated. Consider long‐acting local anesthetic injections (bupivacaine + epinephrine 1:200,000) unless contraindicated. Postoperative Period 1. Prescribe non‐opioid analgesics as the FIRST line of pain control for dental procedures. a. Prescribe combinations of non‐steroidal anti‐inflammatory drugs (NSAIDs) and acetaminophen following dental procedures where post‐operative pain is anticipated unless there are contraindications: i. NSAIDs contraindications include, but are not limited to: known hypersensitivity to the drug, history of gastrointestinal bleeding, and aspirin sensitivity asthma. ii. Acetaminophen contraindications include, but are not limited to: severe liver disease, known hypersensitivity to the drug. iii. Adjust dose or duration and monitor for patients with hepatic or renal impairment or drug‐ to‐drug interactions and consumption of more than two to three alcohol‐containing drinks per day. iv. Consider a selective cyclooxygenase‐2 inhibitor (e.g., celecoxib) for patients at risk for bleeding (e.g., on anticoagulation therapy). b. Advise patients not to take multiple acetaminophen‐containing preparations concomitantly. Refer patients to FDA’s Taking Acetaminophen Safely video. 2. If use of an opioid is warranted, follow the CDC guidelines: “Clinicians should prescribe the lowest effective dose of immediate‐release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.” a. Prescribe opioids IN COMBINATION with first‐line therapy. Avoid multiple acetaminophen‐ containing preparations concomitantly. b. For adolescents and young adults through 24 years old who are undergoing minor surgical procedures (e.g., third molar extractions), limit opioid prescriptions to 8 to 12 tablets. c. Codeine and tramadol are contraindicated in children younger than 12 due to variability in metabolism. The use of codeine and tramadol should also be avoided in those aged 12 to 17. See FDA warning here. d. Avoid prescribing opioids in combination with benzodiazepines, sedative‐hypnotics, or anxiolytics. See Appendix A for a list of benzodiazepines, sedative‐hypnotics, and anxiolytics. 3. Dentists should recognize multimodal pain strategies (e.g., ice) for management of acute postoperative pain as a means for sparing the need for opioid analgesics. Dental Guideline on Prescribing Opioids for Acute Pain Management Adopted by the Bree Collaborative, September 27th, 2017 Page 5 of 12 4. Educate the patient and family on appropriate use and duration of opioids in a language and at a level (e.g., 8th grade reading level) that they can understand. a. Review possible adverse effects of opioids, including the sensation of drug craving. Remind them of the dangers of prescription