AME: A Pain Management Puzzle

[00:00:00] Let's be honest, running a dental practice takes grit and determination. Between keeping your schedule on track, supporting your team, and delivering top-notch care, it can feel like there's never enough time in the day. And when things aren't organized, that's when the real stress starts to build. I've talked to so many practice owners who say the same thing. There's got to be a better way to stay organized. And the truth is, there is. They've developed the Color Method, a smart, color-coded system for organizing our instruments and materials. We're talking procedure tubs, trays, burr blocks, and affordable cassettes,

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[00:00:59] where your team can thrive and your patients and your bottom line feel the difference. If you're ready to trade clutter and disorganization for control, visit colormethod.com. Trust me, you'll wonder why you didn't do it sooner. That's colormethod.com. Your path to a more efficient, stress-free practice. Check it out today. Your future self will thank you. This is a production of the Very Dental Podcast Network.

[00:01:28] Alan Mead is a dentist with too much time on his hands and too much recording equipment in his basement. Armed with an obsession to bring entertaining and informative content to the dental world in a way that's never been done before. I give you the Alan Mead Experience.

[00:01:47] Well, hello and welcome to another episode of the Alan Mead Experience. I am your host, Dr. Alan Mead. I'm a dentist, podcaster, and a traveler. Or I'm going to be a traveler because here's the deal. I'm going to Chicago Midwinter this week. As this releases, which will be on the 17th of January, President's Day. Happy President's Day.

[00:02:13] I'll be leaving to go to Chicago Thursday morning, bright and early, probably 3 o'clock in the morning, something like that. I'm driving. I would have gone Wednesday night and slept in a comfortable hotel room and leisurely made my way to breakfast prior to going. No, no, no, no, no, no.

[00:02:28] I'm going to a concert on Wednesday night for my tuba player. Can't miss that. So instead of trying to drive all night, I'm going to get up super early in the morning and I will be at the Chicago Midwinter early on Thursday. I mean, basically when the floor opens up on Thursday. So that's what I'm going to do. Pretty excited about that. I will be there Thursday, Friday and Saturday. I already have a bunch of people I'm podcasting with. However, if you happen to be at the Chicago Midwinter meeting, you should definitely come find me.

[00:02:58] I'm going to be spending a lot of time. I'll either be on the floor or I'll be spending a lot of time in the podcast lounge, which they have built. They had it last year, I think for the first time last year. I have literally signed up for all of the spots that I was allowed to. It's a great place to record podcasts. It's slightly quieter, but you still have like the din of the meeting going on. It's off to the side. If you are looking in the like the main entrance to the exhibit floor on at the Midwinter, it's on the far left side.

[00:03:28] It's like the furthest dregs of any booths over there or even further away than that. But so it's a little off the beaten path there, but it's kind of great because it's not too far from everything, but it's also a little bit away. It's great. I'm very excited about it. I know I've been talking about a lot on the show. Pretty psyched about it. And I would love to record with you if you are at the Chicago Midwinter and want to sit down with me. And you're thinking, well, what would I possibly talk about? Here's the deal.

[00:03:53] Some of the best podcasts that I've ever recorded have had no plan. And we just had a conversation because there's almost always something good to talk about. So if you're feeling like you wouldn't have anything to say, it's a big lie and we can make this work. I'm not kidding. So come by and say hello. I will be there. Or I'll be running around looking at lots of stuff on the floor. There's a ton of stuff that I'm going to be checking out. Shoot, I should probably record an entire Alan Mead experience about all the stuff that I want to see at Chicago.

[00:04:20] Maybe what I'll do is I'll record it maybe in my hotel room after one of the days. I don't know. Maybe Friday night. I got to tell you, my intention is to podcast a lot. And each time I've done this, by the time I'm done when they close the doors on me at five o'clock in the afternoon, I'm whipped. I'm really tired.

[00:04:43] I am going to be going to, I think on Thursday night, a party for its premier Inceptidont invited me. And they are releasing their big new product called Buffer Pro, which I actually talked with them about earlier a couple months ago, which is pretty neat. It's a single-use buffering solution. So you don't, basically you can, I think it fits on the, I have not actually seen it yet. I'll be seeing it on the, on the floor in Chicago.

[00:05:14] I am certain that I will be talking with someone about it in a podcast. In any case, pretty exciting. I'm kind of excited for that. So I will be doing that. I'll be at the Chicago Midwinter. I will be probably eating some kind of Asian fusion food, probably alone. I mean, someone might be able to convince me by the time I get done with podcasting, I'm so tired. I go to bed early. I really do. I am a party pooper. I will, the nightlife will not be lost on me. I'm afraid. Cause I'll be so whipped after all this.

[00:05:43] It's always kind of been like that. The Midwinter takes it out of me. I love it. I'm staying in the same hotel I always stay in. It's, it's like a mid, mid priced kind of plane. It's right in the middle of everything though. I love it. I will probably be filling my, my refrigerator with snackies from Eataly, which I always do. I'll, I'll go and get some fancy sparkling water and meats and cheeses just cause I like to have that stuff. It's pretty great. All that's pretty fun. That's my Chicago routine. In any case, I'm going to be recording a ton of content.

[00:06:13] I can hardly wait. So it's going to be very fun. So, and the good thing is I'm driving. So I have control over my in and out to Chicago, which sound, a lot of people like, I would never want to drive there. Here's the thing, man. I'll be coming in kind of early, real early on Thursday morning. So I'm hoping that the traffic isn't too horrible bad. But on top of that, I'm going to park once and take buses back and forth to McCormick from my hotel. So it's going to be kind of awesome.

[00:06:37] So I was in Cleveland visiting actually Kevin Fryer of all people in outside of Cleveland to see the solar eclipse last April. And in one of the turnpike stops on Ohio, they had those little easy pass transponder things. You could actually buy one right there. And of course, I'm sure it's for the turnpike in Ohio. But these easy pass things kind of work in whatever. Any place that takes a transponder, they essentially work. And so it links to your account.

[00:07:05] So this is the first time I've ever driven to Chicago with a transponder. I am so excited. Like this might be one of the most exciting parts of it. I don't have to stop at the toll gates. I just go right through and they'll just charge my little, ah, I can hardly wait. That's one of the worst parts about driving to Chicago is having to stop and wait in line and all that stuff. And I just get to drive through the gate. I'm so excited. Technology. I just love it. So anyhow, I'll be in Chicago. Looking forward to that. I've literally been, I have not gone anywhere for a really, really long time.

[00:07:35] So just being able to drive to Chicago and go to the midwinter is very exciting. I can't really wait for that. So if you're there, come find me. I would love to see you. So today's episode is going to focus on a post that Dr. Russell Schaefer made. And he made it actually in the very clinical Facebook group. So I'm sort of stealing there. But I mean, honestly, it was a really good post for Al.

[00:08:00] It was a good Al post because it sort of has to do a little bit with addiction and pain management. So I'm just going to read you what Russell wrote right here. And then I'm going to just respond a little bit. So from Dr. Russell Schaefer, our favorite podcaster, denture guru, and, you know, New Orleans resident. So damn interesting. Okay, I'm going to try that again. So damn interesting view that I wasn't sure what to do with. So I wanted your opinion.

[00:08:29] A good way to start a post in the very clinical podcast or in the very clinical Facebook group. I removed a bunch of teeth on a patient taking methadone for narcotic recovery. The patient told me that she didn't want anything that would jeopardize her going back into addiction. So I prescribed Etotolac, which is an anti-inflammatory, as I find it works really well. 500 milligrams every 12 hours. I tell her to mix it with Tylenol, 1,000 milligrams every six hours. Patient calls back asking for something stronger.

[00:08:58] I tell her there isn't anything else, but she can stop the Etotolac and switch to Advil if she wants. She requests benzos, and I refuse. We're all getting frustrated, obviously. I tell her, hey, let me get with your pain management MD and see if there are any other options for you. Thinking maybe they have some other ideas to help this woman because I'm a pushover. The MD asks me if I would normally prescribe narcotics for the procedure that I did, and I tell her yes.

[00:09:22] She says, well, you can prescribe the patient narcotics if the level of pain requires narcotics, regardless of her recovery status. So this blew my mind a bit, and I told her that I just didn't feel comfortable giving a patient who told me that they're addicted to narcotics. Narcotics. I talked to some other physicians, and this is what they – I talked to some other physicians, and this is what they view as the standard of care. I mean, get it if someone – I mean, I get it. I mean, I get it if someone is going through cancer.

[00:09:52] But on the other hand, this is a much more minor procedure. Thoughts? So the facts are this. A patient in – I'm going to say this in quotes – recovery, using methadone for recovery, tells our friend Russell that they do not want any narcotic pain medications for this. Then, after the surgery, decides I need some pain medication. I need something stronger than what he's given.

[00:10:19] And honestly, what he gave is quite – I think quite reasonable depending on how brutal the surgery was. Now, I got a couple opinions here. First off, I prescribe narcotics for surgery, sometimes endo, like with moderate to severe pain potential. I prescribe that. But I just renewed my DEA license, and it was like a million dollars, and you had to take eight credit hours of CE for it. It's – having a DEA number is becoming like – it's a lot. There's a lot to it now.

[00:10:49] But I did it because the few times that I prescribe it, I'm glad that I have it. I think patients are too. So that's one thing. Now, and of course, I have to tell you – most people who listen to the podcast know this. I'm a recovering person, and I actually – the stuff I got in trouble with was opiates, narcotics. And so, like on some level, I have a lot of thoughts about this.

[00:11:11] But I will tell you, even as someone who has concerns and wouldn't use narcotics myself, I do think that they are useful for pain management. I don't think that they're not a useful drug just because they have potential for problems. But I also know that I'm not the guy who writes a lot of these scripts. I write a few of these scripts. So that's just where I'm coming from. But I will tell you that I think that there are times that they're useful. So the second thing to talk about is the fact that this woman – okay.

[00:11:41] I would have a different take on this depending on where the patient was coming from. So I have been in recovery for 23 years. I went into treatment 23 years ago, and I have not used narcotics since then. And I have had anesthesia once for surgery. And actually, I asked the anesthesiologist what they would be using.

[00:12:07] Just – I wasn't going to try and tell them what to do because I don't know what to do. But – and I also – since it had been 20-some years since I'd had any kind of opiates, I wasn't sure how I was going to react. I think it's kind of funny because people who used to use a lot of opiates but have been long-term clean are like, I don't know how this is going to affect me. Is my tolerance still there? Is it going to be hard for them to take me into it? Well, first off, they told me they're not using any opiates to take me down. I think they used the gas. I inhaled some isoflurane maybe.

[00:12:36] I can't remember. And then they used propofol also to get me under. And so they didn't use fentanyl, which is interesting because I always thought fentanyl was one of the things they did. But in any case, it was – I was under the care of an anesthesiologist. I told them about my recovering status. They were unimpressed. They did not seem to care one bit, which is fine. I can live with that. It's cool. I don't want to tell them their job. And I had the easiest surgery and post-surgical recovery. It was a piece of cake. It was like nothing. It was great. It was great.

[00:13:06] So I experienced that. So if I've had any opiates, I actually don't even know because they told me that I wasn't going to. And then some of you may remember back in 2020, I got hit by a pickup truck while I was riding my bike on the road, just down the road from my house actually. And I was crossing a highway. The guy was turning left. He didn't see me. He wasn't going highway speed. So it's one of those things where it sounds much more dramatic than it was. But I'm not going to lie to you.

[00:13:34] When you get hit by a truck, it's a pretty dramatic thing. So – and I got to the ER. My wife picked me up. You can imagine my phone screen broke. Can you imagine such a thing? My bike was all bent up. I dragged my bike off the road. And an ambulance came. And my wife ended up taking me to the ER. I didn't want the gazillion-dollar ambulance ride. And so they took scans.

[00:13:59] Actually, they put me on IV Toradol, which frankly I feel like if I could choose, I would just have an IV Toradol in my arm at all times because that was none of the pains in my body. I felt no pain. But it was not narcotic at all. It was not a buzz or anything like that. I was just like, wow, my body doesn't hurt. Of course, when you have a broken back, your body hurts a little bit.

[00:14:21] Now, as I've said many times on this podcast, the neurosurgeon came in and looked at the imaging and said, look, you broke your back in the low rent district is what he said. Basically, it was a minor fracture. Surgery would not make any difference whatsoever. He put me in like a brace for 12 weeks, which was a pain to practice dentistry. But I missed like a day and a half of work from the thing. And I was on ibuprofen. Like I didn't.

[00:14:45] But when I was in the hospital overnight before the neurosurgeon looked at me, they were worried that I might have to have surgery. So they kept me in the bed. And they offered me narcotics. And I have to tell you, after coming off the Toradol, they did not continue the Toradol. That was a bummer. As soon as they took me up after they realized that I'd broken my back, there was no more Toradol. I don't know exactly why that was the case. They took me up to a room and I was to not get off the bed.

[00:15:13] And I had the option for narcotics. And I'm like, you know, this sucks. It hurts, but it doesn't hurt that bad. So like in my mind, I'm like, okay, I've got an option for narcotics if this gets so bad that I'm having it. But it never really did. Like I was on a bed, so I wasn't moving around very much. And the reality is when, you know, the imaging, it was a fracture, but it wasn't like I was all messed up. It wasn't like I was paralyzed or anything like that. It was not that big of a deal.

[00:15:42] So I just took anti-inflammatories. I can't remember. Probably it was it. I don't think they want to be done in Advil. But I took I know I took some Tylenol and some but I just basically I just hurt. And but it wasn't the worst thing. I mean, it was like a like a six or a seven. And I wasn't I wasn't willing to say, okay, let's have some narcotics. If it had been worse, I'm sure that I would have. I'm not trying to I'm not trying to like have the moral high ground here. But I just the story is I didn't really want to go there. I didn't want to I didn't want to risk it.

[00:16:11] But now, on the other hand, had I needed that, I would have had a conversation with my wife and my family and my sponsor. And I would make sure that the people in the hospital knew exactly where I was coming from. Because to be honest, I'm not convinced the people at the hospital really know or understand much about about recovering people and the medication. I think I think they are there to get the job done. And if you say you don't want narcotics, they're fine. No narcotics. But if you told them I'm a recovering person, but I want all the narcotics you have in the place, I think they would give it to you, too.

[00:16:41] I think I think they don't take responsibility for that. And actually, on a podcast I was on a month or so ago with the folks from the Productive Dentist Academy, they thought that there was a lot of liability that the hospital was taking on, you know, offering me narcotics after I had told them that I'm in recovery. I don't know if that's the case, honestly, because here's the thing. If you're in recovery, if you're actually in recovery, whether or not you take narcotics is your responsibility.

[00:17:10] If you're unconscious and someone is doing surgery on you, okay, then it's not your responsibility. The reality is if you are offered it and you take it, that's on you. If it's something that you know is a dangerous thing for you that you shouldn't probably do, that's on you. So that sounds a little harsh, maybe, but actually, as a recovering person, it's not. It's my responsibility to take care of myself. I can't make the world take care of my addiction and take care of my recovery concerns.

[00:17:39] So it is all my choice. But the reality is I don't know legally how that would work. Like if I had taken narcotics while I was in the hospital and gone on a huge relapse bender, would I be able to sue them for having given me narcotics? I don't know. I don't know. Maybe. I don't know. Not something that I really was particularly concerned about. But as a prescriber, it's a whole other thing. So you understand my recovery is my responsibility, and I take that pretty seriously.

[00:18:08] And so I chose not to when I was in a situation where I may have used narcotics in a situation. If I hadn't been in recovery, I probably would have just said, yeah, give me something for pain. But I really didn't want to pour gas on that fire. So I still have not experienced that. And I haven't experienced taking narcotics in recovery, which is kind of cool. It's kind of great that I haven't had to sweat that, which is funny because I remember when I first got clean,

[00:18:38] all of us that were opiate people in treatment were just trying desperately to find, to think of situations where we'd be able to take narcotics, like surgeries and injuries and all this, which is so funny. Because at the time, it's really hard to look down the barrel of never taking these drugs again after it's all I'd been doing for the last four years. And that was my coping mechanism. That was how I was making things work.

[00:19:07] To think that I'd never had it again, it was scary. Scary to think of basically the one coping mechanism that you think is doing you well was not doing you so well. So there you have it. I will say that it was scary. But 23 years later, I'm glad it worked out the way that it did. So that's my take from the point of a patient. Okay, I've experienced this and haven't had to. So there's a couple different things in Russell's situation.

[00:19:36] First off, his patient is in recovery taking methadone. So that's – this patient is doing what they call harm reduction. This is not a patient that is completely abstinent from opiate medications because methadone is an opiate medication. I have mixed feelings about harm reduction. I do understand on some level that harm reduction may have some useful uses, if you will, for some people.

[00:20:05] I'm glad that when I was going in to work on myself for my drug problem, I'm glad that it wasn't an option for me. Because, of course, I think everyone would do that. Taking no drugs, going through withdrawal and, like, going through treatment, that sucks. No one would really want to do that if they had a chance to just say, what if you took a medication that would make it so you don't go through withdrawal and then you can just live your life? Sounds great.

[00:20:30] I'm glad for me that it wasn't an option because I don't know that that's any kind of life for me. And that's a pretty opinionated recovering person saying that. I find it frustrating that for some people, they think this is the best that this person is going to be able to do harm reduction. Maybe it's true. I don't know. I haven't experienced that. I think abstinence-based recovery is better.

[00:20:59] In fact, I know that it is better, but that's not my situation, so I don't want to pass too much judgment. So this patient is taking methadone on a regular basis so that they don't go through withdrawal. The patient tells you that they don't want narcotics because they don't want to jeopardize this recovery. And then they call and say they want narcotics because the pain is so bad. Well, shoot. That puts the prescriber in a weird spot because one minute they said they don't want it, the next minute they said they do.

[00:21:29] Now, as I said before, my recovery is my responsibility. I do think Russell calling the pain management doctor was a really smart move. I think that was a very smart move because first off, you're bringing someone else in who knows something about the situation and who understands, you know, the spot that you're in. So all of a sudden, if you're concerned about, you know, whose responsibility it is,

[00:21:58] that you've got more than one person looking at the problem who understands where you're coming from. So I feel like Russell, having said, told this patient, well, yeah, I would prescribe narcotics in this situation. It was pretty serious surgery. And understand, dentists don't prescribe narcotics the same way that like an orthopedic surgeon does. They give away like candy. We give like 10. You know, it's like, it's just, we just, I know that there's lots of news stories saying,

[00:22:24] oh, my son was first experienced opiates in their dental office because they had their wisdom. And he thought, well, that maybe, maybe, but the reality is we're not, you know, we're not prescribing bottles full of this stuff. I just don't believe that for a second. From my experience, it's just not been the way. And now, literally since I've been in, we've got all these, these PMP programs where you have to check the patient's background and all that stuff. And it's like, it's really, they really don't want us to prescribe this stuff. And I do think that they, it has a place.

[00:22:53] I don't prescribe very often. I probably have prescribed. I don't know that I prescribed in 2025 yet, to be honest. I'm not sure. So it's not very often for me. But if you do a lot of surgery, it's probably more often. Russell said that he would, in this situation, anyone else, he would prescribe. The MD said, well, then you can prescribe for this person. So all of a sudden, Russell's liability is significantly less now at this point. The patient told him that she wanted something stronger. Russell talked to the pain management doctor and the pain management doctor said it was okay.

[00:23:22] As long as that's written down somewhere, if you're concerned for this patient and the patient is really telling you they're dying, I would write the script for it and I wouldn't feel bad about it at all. However, I would have a very blunt, very blunt discussion with this patient. Now understand, this patient, if they're on methadone or if they've been through a treatment program like mine and are in recovery, they are used to blunt conversations about drugs. I promise you that.

[00:23:48] They will – you saying how uncomfortable you are to prescribe them because she literally asked you not to and now she is asking you to do it, I would tell her how uncomfortable you are about this and that she has agency here but you have big concerns about this. So if we're doing this, we're going to do this in a very specific way. The specific way that I would do is I'd do like four of them at a time and if she needs more, I'm going to look. I'm going to have her come in and look at it and she's going to get four more at a time.

[00:24:14] I would be very limited because she told you that she doesn't want you to do this and now she's saying that she does. There were some other really good suggestions in the comments, in the Facebook post. For instance, someone said inject dexamethasone or injectable steroids in the surgical site. That's actually a really great point. Unfortunately, it's probably best done when the patient is still numb. You can do it right at the site.

[00:24:43] Probably a little harder to do once the patient's in pain. Although I would also, like a Medrol dose pack, I would give oral dexamethasone in a second for this kind of thing. And that a lot of times is enough to push people through if they're concerned about narcotics. I think his point about Advil and you can take Advil more often than you can the Ototalac or whatever. I have had that Ototalac as a patient a long time ago for my foot. I sprained my ankle. I didn't find it particularly helpful.

[00:25:13] I think Advil is probably just as good or better. But if he's had good experience with it, that's good. It is nice to be able to give them a different medication to have them try it. Some patients can – I mean, as everyone knows, patients have a very different pain tolerance, like a really different pain tolerance. There are some people that just don't feel much and some people that feel everything. And that's real. And I can't necessarily say people with addiction problems have lower pain tolerance. They might.

[00:25:41] I don't know, but I'm not sure that that's the case. Some people don't need anesthetic for stuff that other people need to be loaded up for. People are different. So all of this comes back to the fact that I have a concern with a recovering person asking for medication after they told you that they don't want it. So that's where we're having a very blunt conversation. Maybe even have the patient sign something or whatever.

[00:26:07] But the reality is that's – I mean, if you can give them something that helps with the pain, then I think you should do it. But I think there needs to be a discussion and a pretty serious blunt talk about it. So if it were a person who is in 12-step recovery of some sort, I would say, hey, let's bring your sponsor into this. Let's bring your family into this. Like maybe if you had someone that can help administer it that you trust, well, that's a whole other story.

[00:26:34] All of a sudden, you're putting on a bunch of guardrails that would be very helpful in this situation. I guess as a recovering person, I just know my addict mind likes to do some stuff, likes to make some stuff up. I would love to be able to take dope and have it be someone else's problem. That would be awesome if I could do that. There's – not now and not me, but I could understand someone who's in that spot could think that. I don't know that that's what's going on with this woman. That's not fair for me to say that.

[00:26:59] But I just know that in a lot of cases, people in active addiction will manipulate situations like this all the time. That's – I mean, if you've ever dealt with a drug seeker, that's exactly what's going on. So understand that you might not be dealing with someone who's shooting straight with you all the time. And yes, there's some liability on your part. But like I said, Russ talking to the physician that's also treating this woman and the physician being on board, if you got that in writing, I say do it. I say you're fine.

[00:27:29] Weird situation. I'm glad Russ brought it to the group because I think it's something we all need to think about. I think it's – this is a situation that almost anyone could get into, honestly. It was just – it's just interesting. It was an interesting conversation. I'm glad he brought it up. That's what Facebook groups are for. Social media is mostly self-administered poison for me, but something useful like this is pretty great. So I appreciate Russell bringing that up. And so that's that. I would love it if you want to talk about this more. This was actually in the Very Clinical Facebook group. So you can join that group or you can join the Very Dental Facebook group.

[00:27:59] You're going to give one of five passwords. Lipscomb, McQuethy, Hornbrook, Timmerman, and Papa Randy. Any of those five will get you in. I'm pretty serious about making people give me the password to get in. I'll just say that. I've turned some people away or I've told them you got to go listen to the podcast so you can get the password. Good conversations there. This is a smaller group. It is not nearly the shit show that the Dental Hacks Nation ever was. It was fun, but it was kind of crazy.

[00:28:26] This is not – this is a pretty calm Facebook group and we have good conversations there too. So if you're in Chicago, come find me. I'd love to podcast with you. And soon enough, you will be hearing lots of great content that I got from Chicago. Looking forward to that. And with that, I appreciate you listening to the show. Recommend it to a friend. Recommend the Very Dental Podcast Network to someone that you don't think listens to it. I really – that's the only way we get to spread this thing because I think we've reached peak podcast.

[00:28:52] It's not – I will not have my face on any billboards in Chicago asking people to listen. So I need you to tell your friends to listen to this. I really appreciate it. Thanks a ton for listening and we will catch you next episode.