NEWS + ISS U E S
Exparel:
A low-dose bupivacaine used for pain management STE PHA NI E JA I PAU L Georgia ’22
EXPAREL, generically known as bupivacaine liposome, is a local anesthetic indicated for minor surgeries to control pain and reduce the need for the prescription of opioids for postoperative pain management. When injected into a surgical site, Exparel numbs the area for up to five days following the procedure, according to the Mayo Clinic. It has been used in over six million cases to date for surgeries involving the colon, kidneys, feet, ankles and hands, as well as for hernia repairs, hysterectomies and Caesarean sections. One of the limitations of Exparel is its cost, which is between $175–325 per dose depending on the size, with a shelf life of 30 days when stored at room temperature. In January 2019, the American Dental Association (ADA) added a CDT code for billing Exparel (D9613). This procedure code is defined as “the infiltration of sustained-release therapeutic drug” and is used in combination with appropriate dental procedure codes. This code allows for the reimbursement of Exparel in oral surgery procedures, where the drug is currently used. As the only non-opioid, single-dose, long-acting local analgesic currently approved for infiltration and field block anesthesia, Exparel eventually could have profound impacts in dentistry beyond oral surgery.
12
Exparel has the potential to decrease the number of opioid prescriptions needed after surgery.
Dr. Jeffrey James, program director for oral and maxillofacial surgery at the Dental College of Georgia, explains that there are risks and benefits associated with the use of Exparel, especially in the context of third molar extractions. The most painful time period after wisdom teeth extractions is three days post-op, when inflammation is highest. A pharmacologic agent that targets this time period post-extraction is a major benefit, for patients and providers. Additionally, Exparel has the potential to decrease the number of opioid prescriptions needed after surgery. Exparel’s long-acting anesthetic properties are useful for pain management; however, the prolonged numbness that patients experience with the drug makes it difficult for dentists to rule out procedural complications such as nerve damage, says Dr. James. During wisdom teeth extractions, there is always a risk of prolonged or permanent numbness to oral structures such as the lower lip. It is possible that Exparel could reach the inferior alveolar nerve, resulting in prolonged lip numbness. It would then be difficult to determine if a patient has nerve damage following the procedure. This effect is not limited to dental extraction procedures but any surgical procedure. However, long-term
VOLUME 4 NUMBER 1
N E WS + ISSUES
follow-up over weeks to months would allow the surgeon to determine if nerve damage occurred. Other downsides to Exparel are the short shelf life and cost, preventing this anesthetic from being purchased in bulk. Dr. James is involved in a study at the Dental College of Georgia that hopes to determine if an Exparel injection following uncomplicated extraction of third molars would decrease postoperative pain levels, reduce the need for opioid pain prescriptions and increase patient satisfaction. In this double-blind study, patients are asked to rate their postoperative pain and to record the number of pain medications taken. Preliminary data reveals that no pain medication is needed postoperatively when Exparel is administered. Although Exparel is the current focus of several ongoing research studies, there is still significant room for exploration into this topic. One future area of study includes evaluating if more widespread
JANUARY 2020
use of Exparel can lead to long-term reduction in prescribed narcotics. For the most part, with modern and preventative dentistry, pain is no longer the main image of the profession. However, pain from dental treatment is sometimes still overrated by patients and overcompensated for by dentists prescribing pain medication. Dentists account for the highest prescribers of opioids to patients aged 10–19, and in a survey published by the Journal of the American Dental Association in 2011, 41% of dentists expected patients to have leftover drugs from their prescriptions and 33% did not ask about drug addiction. It is important for dentists and students to acknowledge dentistry’s role in this epidemic, and one of the ways to help alleviate it is by learning about and implementing new practices, such as the use of non-opioids to manage post-surgical pain. #
13