Cannabidiol: The quest for a new non-opioid analgesic

Iveta Ramonaite, Dental Tribune International

Tue. 5 December 2023

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NEWARK, N.J., US: Acute and postoperative dental pain are inevitable, and pain management strategies often include the use of opioids; however, many studies have questioned the opioid prescription practices of dental professionals, reporting that the drug is often prescribed too heavily. Among the candidates for a non-opioid analgesic alternative is cannabidiol (CBD), whose use is currently being explored in dentistry, and a recent study has found that the substance shows great promise for pain reduction and could help combat the opioid epidemic in healthcare.

“As a clinician, I treat patients with toothache daily, and my primary concern is treating their pain effectively. I have often felt that my hands were tied when my patients couldn’t take the commonly prescribed pain medications such as Advil and Tylenol, which are known to be highly effective against dental pain. Opioid combinations are next in line, but we know very well about the detrimental side effects of opioids, including misuse potential and addiction,” lead author Dr Vanessa Chrepa, an associate professor and director of clinical and translational research in the Department of Endodontics at Rutgers School of Dental Medicine in Newark, told Dental Tribune International (DTI).

Lead researcher Dr Vanessa Chrepa. (Image: Vanessa Chrepa)

CBD is a primary cannabinoid derived from the cannabis plant. Dental research suggests that the substance has anti-inflammatory, analgesic, antimicrobial, biological and osteoinductive properties. A study reported by DTI has also demonstrated that CBD-infused mouthwash fights plaque as effectively as chlorhexidine, showcasing its untapped potential in dentistry.

“CBD is an exciting drug with many potential applications, including pain management, anxiety, epilepsy and post-traumatic stress disorder,” Dr Chrepa explained. She also said that more than 100 clinical trials are currently testing CBD for various pain conditions.

In the study she led, Dr Chrepa and her colleagues examined the use of two distinct doses of EPIDIOLEX, a pure CBD oral solution regulated by the US Food and Drug Administration, for managing emergency dental pain. The researchers found that a single dose of EPIDIOLEX, either 10 mg/kg or 20 mg/kg, achieved a maximum of 73% median reduction in initial pain during a 3-hour observation period. Additionally, they reported that 85% of participants in the CBD groups reported at least a 50% reduction in initial pain, which translated to a number needed to treat comparable to that of ibuprofen and that of a opioid and acetaminophen combination for acute dental pain. “This means that CBD was equally efficacious as the commonly prescribed dental pain analgesics. It performed beyond our expectations,” Dr Chrepa commented on the findings.

“I have often felt that my hands were tied when my patients couldn’t take the commonly prescribed pain medications.”—Dr Vanessa Chrepa, Rutgers School of Dental Medicine

Although the use of CBD was found to produce some side effects in patients, including sedation, minor abdominal pain and diarrhoea, the researchers assured that they were not surprised by them given that they are common side effects reported on the EPIDIOLEX label and could be effectively treated with an anti-diarrhetic medication.

The study is of great significance to dental professionals and could mean that patients who cannot take non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen owing to medical reasons can now have the option to take CBD. “This is tremendous for us dentists, as it adds another analgesic drug to our armamentarium,” Dr Chrepa stated.

Tackling the opioid crisis with CBD

Besides the potential for pain management, the study carries wider implications for healthcare and could help to replace semi-synthetic and synthetic opioids, such as hydrocodone and oxycodone, which are often prescribed after a dental procedure to address moderate to severe pain.

Despite its legal and social acceptance in some countries, the applications of cannabis in dentistry have been little studied. (Image: Nelson Antoine/Shutterstock)

“When reading the statistics, I was surprised to find out that dentists were sixth out of the ten highest opioid prescribers in medicine, contributing 6.5% of the total opioid prescriptions,” Dr Chrepa noted. She also said that dental patients have a 30% chance of receiving an opioid prescription after a standard dental procedure owing to a lack of effective non-opioid analgesic alternatives.

“CBD is critical here, as it has been shown to be a very effective analgesic for dental pain and does not have psychoactive or addictive properties,” she concluded.

DTI has previously spoken with a dental expert about how dental professionals could help avert antibiotic resistance through antibiotic stewardship. In that interview, Dr Smitha Sukumar, a senior lecturer in tooth conservation at the Sydney Dental School in the Faculty of Medicine and Health at the University of Sydney in Australia, noted that dental professionals have certain responsibilities as prescribing clinicians. “Antibiotics are not a quick fix to tide the patient over,” she told DTI.

Additionally, just recently, the American Dental Association published a new guideline in which it recommended using paracetamol and NSAIDs over tramadol and codeine for first-line treatment in children under 12. The guideline is a crucial step in supporting appropriate and effective treatment of paediatric acute dental pain and will help prevent inappropriate opioid prescriptions among paediatric patients.

The study, titled “Cannabidiol as an alternative analgesic for acute dental pain”, was published online on 1 November 2023 in the Journal of Dental Research, ahead of inclusion in an issue.