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“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.”23 The specific recommendation for adolescents and young adults is based on emerging evidence that two thirds of all patients receiving opioids for third molar extractions are 14 to 24 years old, there is a three‐fold variation in the amounts prescribed, and substantial proportions are left unused and available for subsequent misuse.4,9 Because the developing brain is at increased risk for addiction, limiting opioid exposure to the shortest duration is very important in this population.24‐26 The ADA recommends reviewing the CDC recommendations for safe opioid prescribing (see Appendix B), and the Bree Collaborative AMDG Opioid Prescribing Guideline Implementation workgroup emphasizes its importance, given the vulnerability of this population.27 Providers should be aware that the Food and Drug Administration approved tramadol and single‐ ingredient codeine only for use in adults. Both opioid containing products are contraindicated in children younger than 12 years due to the risk of serious breathing problems in some children with ultra‐rapid metabolism.28 Providers should also limit use in adolescents between 12 and 18.29 Providers should check the Washington State Prescription Monitoring Program (PMP; also called the Prescription Drug Monitoring Program or PDMP in other states) for every patient before prescribing opioids to be certain there have been no prior or concurrent prescriptions of opioids or sedatives. This is strongly recommended by both the CDC Guideline for Prescribing Opioids for Chronic Pain and by the AMDG Interagency Guideline on Prescribing Opioids for Pain.23,30 Per McCauley et al, “a notable minority of dental patients had incidents of multiple preexisting opioid prescriptions, a factor implicated in patient misuse, abuse, overdose and diversion.”31 Recent data suggests that in New York, which has implemented a mandatory PDMP program, there have been substantial reductions in opioid prescriptions and increases in non‐opioid analgesic therapy among dental prescribers. Among patients receiving pain medications in dental practice, 30.6% received an opioid prior to mandatory PMP implementation, while this number dropped to 14.1% and 9.6% in the two three‐month periods following implementation.25 This recommendation is also consistent with the ADA February 2017 Statement on the Use of Opioids in the Treatment of Dental Pain: “Dentists should register with and utilize the prescription drug monitoring program to promote the appropriate use of controlled substances for legitimate medical purposes, while deterring the misuse, abuse and diversion of these substances.”27 See Appendix B for the full list of ADA recommendations. Dental Guideline on Prescribing Opioids for Acute Pain Management Adopted by the Bree Collaborative, September 27th, 2017 Page 7 of 12 Appendix A: Benzodiazepines, Sedative-hypnotics, and Anxiolytics · Benzodiazepines o Alprazolam o Chlordiazepoxide o Clonazepam o Clorazepate o Diazepam o Estazolam o Flurazepam o Lorazepam o Midazolam o Oxazepam o Quazepam o Temazepam o Triazolam · Barbiturates o Butabarbital o Butalbital o Mephobarbital o Phenobarbital o