Cannabis Patient: What Should I Do After Oral Surgery?

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“Dear Mike, I’m about to have all wisdom teeth pulled out and my dentist informed me that it will take 7 days for my mouth to heal enough to use THC again and not risk a dry socket. I don’t want to have my mouth so dry that it causes more problems but also don’t want the harsh dental pain – I’m worried about taking the pain pills even for a few days. I normally smoke, dab, and ingest THC for pain but have used CBD in the past. Is it safe for me to use a few of the Vicodin or Codeine they give? Should I use CBD because I’m at a loss of what to do?”

Shane, a grower, and cannabis patient from Michigan asked this important question 3 weeks ago before surgery – he’s all healed up now and feeling great.

Using THC before Sedation has some added risks, using it after Oral Surgery is asking for problems.

Let’s take Shane’s question and answer it in phases. He first asks if he can use THC after his Oral Surgery. Unfortunately, there are certain drawbacks to smoking weed after you have had your wisdom teeth removed, and even bigger ones when it comes to dabbing which causes excessive coughing and can dislodge the healing socket. Ingesting THC can be even more problematic as it will cause the mouth to lose moisture for extended periods. The dreaded ‘cotton mouth’ can cause a painful Dry Socket to occur. The bottom line is this is a time we must consider other options for acute pain – and we all know that dental pain is intense and disabling.

What's a dry socket and how do I avoid this?

When you have a tooth pulled, it’s extracted from the socket that attaches to the bone. Our mouth will naturally clot the area with blood in order to protect the now empty area that once held both bone and nerve. When the mouth dries out, these healing sockets can displace that clot – especially when we cough. Sometimes in the removal of a tooth, this is a minor issue but when it comes to the dreaded wisdom teeth it’s almost always a situation in which we need time to heal. If the clot comes out of its area it’s considered a dry socket and is extremely painful.

What are Shane's options?

Cannabis edibles that are very low dose could be ingested – this would give a small amount of pain relief without drying out the mouth too much – but it’s a risk that could lead to catastrophe as any type of THC intake is bound to dry out our mouths. For most people it only takes a few days until the pain-killing cannabinoid can be utilized – it’s just riding the storm out until you get there. Most of us know inhaling any smoke or vapor can be catastrophic as well when the sockets are healing. At first, it’s going to be CBD to the rescue for inflammation as much of our pain comes from all of the swellings.

In answering his question of whether or not it’s okay to use pain medication, one must consider history. If he’s never had an addiction or past dependence on pain medication the answer is simple – but if there’s a history of addiction one must consider whether any dose at all would be a trigger and a patient should have assistance in managing the prescription if this route is taken (someone else holds the Rx bottle). It should be a short supply (5-6 tabs) of the actual pro drug Codeine and NOT Hydrocodone. Every dose should be paired with CBD – utilizing the contraindication with Pro Drugs.

Old school codeine is a Pro Drug – a class of pharmaceuticals that must metabolize to its most effective (and addictive) form which is the metabolite many know as a drug itself – morphine. If CBD, dosed at 25mg, is taken with Codeine it will not allow it to metabolize into the substrate morphine. Hydrocodone or Vicodin won’t work this way and is actively addictive from moment one. The basic difference between these two is huge when it comes to dependence, this is why we’ve seen an explosion in overdoses and more with newer drugs over the past 20 years – synthetic opioids. Drugs like morphine and codeine can kill just like the synthetics do but the facts are laid to rest in statistics – Synthetic pain medicine is by far more dangerous and addictive.

CBD to Drug Interactions can be used in very positive ways – but the user must practice caution.

Why would I suggest very short-term use of Codeine?

Let’s face it, THC dries our mouth out so much that after oral surgery we could face issues that necessitate further surgeries. “I’ve had to do gum transplants on cannabis users that refused to quit smoking or using THC during the healing process” explains Southern California dental expert and plastic surgeon Nima Mashkouri, “The cost for gum transplants can run over $10,000.00 conservatively, it makes sense to put down the weed for a while.” Now that’s some input I’d listen to as Mashkouri is considered one of L.A.’s most prominent reconstructive and cosmetic oral surgeons.

Scientifically speaking, Codeine is indeed a prodrug with 10-15% of its dose being converted to the active morphine metabolite. CBD interacts with all Pro Drugs – causing them to not metabolize into their active ingredients. Codeine itself is thought to have very little analgesic activity before that metabolism occurs by utilizing the CYP450 family of enzymes (specifically CYP2D6). Then that morphine morphs once again due to digestive enzymes into both active and inactive metabolites that are eliminated by the kidneys. CBD, which is very well known to be an enzyme hog in its metabolism process literally tells pro drugs “No, you can’t go down your metabolite lane – I’m taking over the wheel to this car and kicking you out.”

For this reason, a person that only uses Codeine for a few days after oral surgery coupled with CBD has very little, if any, risk of physical dependency. The only looming question is the history of the patient. If they’ve got a history of addiction then this is a questionable route for pain relief as it could be a trigger – many addicts will ask this same question nervously before oral surgeries and the advice is always the same. As long as the recovering addict is mindful that they’re utilizing the medicine for acute pain, they’re countering it with CBD, they’ve forewarned the dentist of their addiction, they get a maximum of 5-6 tabs to use sparingly for a few days with CBD on every dose. Nobody should be shamed out of using medicine in replacement of cannabinoids when we know that the cannabinoid can cause a problem – that’s nonsensical.

So what did Shane do?

We put together a protocol that started 3 days before his oral surgery. It included 50 mg. of CBD used 3x a day leading up to the procedure to help metabolize the copious amounts of THC oils, edibles, dabs, and other THC products he uses daily. This is to make sedation a little easier and safer as well as to prepare the gums for the trauma to come. When someone is having oral surgery there’s already a problem that’s causing inflammation so we attacked that right away. We had him make some 10-milligram gummy edibles so they’d be low dose and easy to swallow – with instructions not to use them until 72 hours after the procedure. The first 3 days, even with a history of addiction to Oxycontin years in his past, Shane used Codeine and CBD.

On Day 3 after the procedure, he messaged me on social media to tell me he’d only used one pill that day and was flushing the one he had left. “It worked, I didn’t get wasted from those things, they helped me. Can I use the gummy now or will I lose my sockets” he typed to me with excitement? There’s no way to guarantee that the patient won’t eat too many gummy’s and cause the mouth to dry out but we’re now 3 days into healing and already exiting the fearful drugs that were not meant for long-term use anyway. “By using CBD with the doses I never felt like I even took a pill, I’m not sure if it was psychological or not but CBD worked better than it ever has before,” he told me.

“It didn’t feel the same at all, I didn’t high off those pills. The pain wasn’t as bad as I thought and the time went by fast because I slept a lot. Using CBD with the codeine made me nervous, I kinda freaked out because it’s a pain pill you know and I went through such a harsh withdrawal in 2016 from Oxy and other drugs.” Shane went on to tell me more of his experience based on patient-to-patient advice, “It made me nervous when you told me it was okay to use pills for a couple of days, I sorta thought you lost your mind Mike because you hate pills I thought. But this makes sense and it worked, now that it’s over it’s hard because I’m about to hit my 4-year clean date. My girlfriend helped me through this and she thinks I’m still 4 years clean, I didn’t stick a needle in my arm and I didn’t abuse anything. The CBD worked and I’m healed.”

There are so many questions that come across my desk every day – and some like this one can be quite difficult to respond to. For me just looking into how Shane should handle his situation made my skin crawl – I must admit that as I just hit one-year opioid-free. With the world on fire talking it up about CBD, Expos, and symposiums held every day, and social media networks ablaze with people typing away advising each other, and sharing information we’re watching people become free. Free from the control of a medical complex that simply hasn’t had our best interests in mind. As cannabis and hemp, industries gain momentum, patient and industry education ramps up. As we push and push for natural medicine, it’s important we keep in mind that sometimes pharmaceuticals can be not only useful but necessary.