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After oral surgery, some people experience more pain than others. According to a recent study, this pain has a strong positive correlation with opioid-induced nausea and vomiting. This was found based on a post hoc analysis of clinical trial data that was originally presented at PAINWeek 2016. This relationship was most apparent 10 hours after surgery.


According to co-author Dennis A. Revicki, PhD, senior vice president of outcomes research at Evidera, the data analysis was performed in order to better understand the relationship between pain and nausea in acute pain settings. Data used was from a double-blind, randomized, Phase III study evaluating the safety and efficacy of CL-108 compared with HC/APAP and placebo. CL-108 is a combination of hydrocodone, acetaminophen and rapid-release promethazine. This was tested on patients with moderate to severe pain after having at least two impacted third molars extracted. The data analyzed came from 211 patients receiving CL-10 and 205 patients receiving HC/APAP.  


Dr. Revicki stated that patients who experienced more intense nausea also reported higher severity of pain. Two significant predictors of pain severity were being young and being female. According to Dr. Revicki, few studies in the past have focused on the relationship between pain and nausea in this context. While people hypothesized a strong association, the degree to which nausea affected pain severity was unknown. Dr. Revicki feels that making efforts to reduce the nausea in patients receiving opioids for acute pain may decrease the severity of pain, improve patient satisfaction and facilitate recovery.


Dr. Revicki said that the rates and effects of nausea can be kept to a minimum using pain medications that have fewer associations with nausea. Antiemetics can also be administered to reduce the nausea. If opioid-induced nausea and vomiting is reduced, patients in acute settings may experience improvements in pain relief. This is the first study, to Dr. Revicki’s knowledge, to use linear growth curve modeling analysis to explore the relationship between pain and nausea.


David S. Craig, pharmacist lead of acute pain and supportive care medicine at Moffitt Cancer Center, says that he is “not overwhelmed” by the the study’s findings. The association doesn’t surprise him because according to him, common opioid-related systems such as nausea and vomiting have a negative effect on patients’ reporting of pain intensity. Dr. Craig also states that it is very common for users with acute postoperative pain to experience nausea and vomiting, and that for many nausea is considered a “more bothersome symptom” than acute pain. Because of this, Dr. Craig states that pain management strategies such as acetaminophen and NSAIDS, which reduce the reliance on opioids, are important for these patients. When opioid usage is eliminated, there is not a need to treat opioid-induced nausea or vomiting.


Dr. Craig says that if opioids are necessary, it is important to avoid or reduce the use of other CNS-active drugs such as benzodiazepines, promethazine and diphenhydramine. These are the most common drug combinations found in people who died of a drug overdose. Instead, it’s a good idea to use NSAIDs, acetaminophen or regional and interventional techniques.


While there are varying takes on this study, it is important that we think about the relationship between pain after oral surgery and the nausea that some patients experience. If we can figure out a way to eliminate these symptoms, some of the biggest problems associated with oral surgery could be solved.