Expert: William J. Walker, Pharm.D. - 9/21/2004

Question
I am allergic to pain medicines that have morphine/codine in them.(even synthetic).  I can't take lortab, percocet, talacen, ultram, darvocet.  Also, I'm allergic to sulfa drug.  What are some pain medicines that I might be able to handle?  I had oral surgery last week and have been in extreme pain because all I could take was 600mg. ibuprophen every 4 hours and fioricet.

Answer
First of all what is it exactly that you experience with the opiates?    You mention an allergy to opiates across the board.    And an allergy to sulfa.    Sulfa allergies are commonplace and usually these are significant enough to warrant complete avoidance.    Codeine and morphine allergies are also commonly reported but they are much less significant with respect to actual allergic processes.    Meaning that most reported "allergies" to opiates are actually sensitivities or intolerances.    Many patients are quite sensitive to these agents and also to the noted side effects.   Making them poor choices indeed in many cases.    Other patients just don't tolerate them well at all.    In terms of both physiological response and subjective response.    But true allergies are not that common at all.    As in the outcome of frank and severe rash or anaphylaxis.   While itchiness is very common,  as are nausea and vomiting and general dysphoria these are not immune globulin mediated problems.   And while respiratory depression is also common it is a direct pharmacological effect and not an anaphylactoid response.

But all of that aside,   you are certain that these agents are not acceptable for you and that is all that matters.   My inquisitiveness is not to redress your claims but rather to attempt to understand how it is that you react to these agents.

Having said that it is a complicated matter trying to select an appropriate agent for you.    Many of the likely choices remaining are non-steroidal anti-inflammatory agents that are also well known to cause or increase the risk of bleeding.   Not a preferred property after surgery and especially oral surgery where post-operative bleeding is already prevalent.    Ketorolac (Toradol) is one of these agents.   A most effective post-op analgesic but it is very harsh on the stomach lining and it carries a five day maximum treatment limit because of bleeding risk.    While it would be a potent and effective analgesic for you it would probably create more problems in persistent gingival bleeding.    And if 3600 mg of ibuprofen daily has not made any difference at all in your pain then I am skeptical that NSAIDS are functioning well at all for you.   

You have listed almost every possible variety of opiate and associated derivatives as being problematic so that it rules out most of the therapeutic options in that arena.

Diflunisal (Dolobid) is a potent salicylate that might be useful.    Like aspirin it is highly efficacious as an analgesic but it is perhaps more like an NSAID as well.    This is one of the main analgesics utilized by dentists for post-procedural dental pain.    It seems to work well in this situation.    You could try using this at 500 mg every six hours.    It requires a new prescription from your dentist.    It still carries some risk of bleeding but it is considerably less than either ibuprofen or ketorolac.

Minor toothache pain is responsive to topical localized treatment with eugenol (clove oil) as an anesthetic.   It probably represents too little too late in your case however.   But as an augmentation it might help.    

Since most dental pain is the result of direct irritation to nerve endings there is potential for other adjunctive medications to have benefit.   Things like gabapentin or even low dose amitriptyline are excellent in neuropathic pain and they might really help curtail the severe nerve pain here.    The downside is that they have not commonly been used in dentistry and there is little precedent to warrant consideration by most practitioners.   However the literature does reflect that this is being done so there is hope that with some gentle persuasion your dentist would give it a try.

Anesthetics are also potential remedies.   The very principle of local anesthesia during dental procedures is the logical precursor to this concept.   While Novocaine is effective it is not practical in the post-operative setting.   But there are oral pastes that employ the similar lidocaine that could really help.

Finally,   there is the more invasive neural blockade.   The dental pain is easily traced back to specific nerves and pathways lending itself well to nerve block.    It is not simple as it requires skilled administration but there is the benefit of complete relief for a period of time while there is healing and/or further procedures done to eliminate the source of pain entirely.    There is usually no reason for dental pain to persist as a chronic condition.