Article
Increased risk of analgesic overdose during the COVID-19 pandemic
Studies have previously reported accidental analgesia overdoses in patients attempting to self-manage their dental pain because of difficulty in accessing emergency dental services.1,2 The UK and many other countries have paused routine care and re-structured public health services to provide emergency dental care only during the COVID-19 pandemic. This reduced availability of dental services, in addition to self-isolation recommendations, are likely to result in patients self-managing symptoms of dental pain with over-the-counter analgesics, such as acetaminophen (paracetamol) and non-steroidal anti-inflammatory drugs (NSAIDs) and they are therefore at greater risk of analgesia overdose.3,4
It is important that patients in pain receive urgent care advice and intervention, as appropriate. For example, patients experiencing symptomatic pulpitis require extirpation of the pulp or extraction of the tooth, but it may be appropriate to manage any delay, for a short period during the pandemic, with analgesics and ask for guidance should symptoms worsen.
When analgesics are recommended, dentists should enquire about any current analgesic use as part of their medical history check, to avoid potential drug overdoses. This should also include an enquiry into other medicinal or ‘home remedy’ products patients may be taking which could also contain analgesics. Paracetamol is the most common drug responsible for overdoses, causing hepatotoxicity and affecting 90,000 patients each year in the UK.5 For healthy adults (aged 18 and over), the maximum dose of paracetamol is 4 g in 24 hours and for children this varies, depending on age.6
NICE guidelines state that, in an acute overdose, ‘patients who have ingested 75 mg/kg or more of paracetamol in less than 1 hour should be referred to hospital’. Treatment with Acetylcysteine has been shown to decrease morbidity and mortality.7
For a staggered overdose (exceeding the recommended limits beyond an hour), the risk of toxicity is rare for doses between 75–150 mg/kg.8,9 Nonetheless, patients should be medically assessed if there are concerns of overdose. Toxicity is unlikely to occur if <75 mg/kg of paracetamol has been ingested within 24 hours,8 however, caution needs to be exercised for patients with co-morbidities such as hepatic impairment. Overdoses can be asymptomatic, but nausea, vomiting and abdominal pain can manifest as early symptoms.8
Guidance specific for this pandemic is available to dentists to aid prescribing and providing analgesic advice for their patients.10,11