Taking a look at the role the dental industry plays in the opioid overdose crisis and what dentists can do about it.
Almost every day it seems there’s a headline on America’s opioid overdose crisis. And for good reason: More than 115 people in the United States die every day after overdosing on opioids, according to the National Institute on Drug Abuse. And in October 2017, President Donald Trump declared the opioid epidemic a national public health emergency.
The start of the opioid crisis can be traced back to the late 1990s when healthcare providers began to prescribe opioid pain relievers at greater rates, after being reassured that patients wouldn’t develop addictions. This in turn led to widespread misuse of those medications. According to the NIH, roughly 21 to 29 percent of patients prescribed opioids for chronic pain misuse them.
Opioids include a range of drugs, from licit prescription pain relievers like oxycodone, codeine and fentanyl to the illicit drug heroin. In addition to causing an increased overdose death rate, opioid addiction contributes to the spread of infectious diseases as well as the rising incidence of neonatal abstinence syndrome.
The dental industry plays a small yet significant role when it comes to the opioid epidemic. In 1998, dentists were the top specialty prescribers of opioid pain relivers, accounting for 15.5 percent of all opioid prescriptions in the nation, according to the American Dental Association. Fortunately, by 2012, this number had fallen to 6.4 percent. Nevertheless, dentists are typically one of the first medical professionals to prescribe opioids to teens and young adults for the treatment of acute pain, such as prescribing Vicodin or Percocet after wisdom teeth removal.
“When we think about what the dentist’s role is, in my mind, we may not be prescribing that much, but we are likely to be somebody who is prescribing to a person who has never had an opioid before,” says Paul A. Moore, BS, DMD, MS, Ph.D., MPH, a professor at the University of Pittsburgh School of Dental Medicine and a spokesperson for the ADA. “If you’re the first prescriber, you need to stop and do some counseling, do some history taking to see if they’re at risk. And when you prescribe to an adolescent, you just have to stop and think that in adolescents, their central nervous system isn’t fully developed, and as a function of that they’re frequently risk takers.”
In light of the growing opioid overdose crisis, the ADA this March announced a new policy to combat the opioid epidemic. The policy supports mandatory continuing education in prescribing opioids and other controlled substances; statutory limits on opioid dosage and duration of no more than seven days for the treatment of acute pain; and dentists registering with and utilizing Prescription Drug Monitoring Programs (PDMPs) to promote the appropriate use of opioids.
“As president of the ADA, I call upon dentists everywhere to double down on their efforts to prevent opioids from harming our patients and their families,” says ADA President Joseph P. Crowley, DDS, in a statement. “This new policy demonstrates ADA’s firm commitment to help fight the country’s opioid epidemic while continuing to help patients manage dental pain.”
Dr. Moore says PDMPs have been particularly effective, especially in states that make their use mandatory.
“Starting about four years ago, states began to set up systems whereby if you have a patient come into your office who is in acute pain or is possibly in acute pain and you want to write a prescription for Vicodin, you can call a telephone number and that number has a database that can tell you whether that patient has received a Vicodin or a narcotic in the last two weeks or the last month,” Dr. Moore explains. “So, now you have some knowledge of whether this patient is doctor shopping or not.
“About a year ago, every state has a PDMP that’s linked into pharmacies,” he adds. “The pharmacies, when they dispense an opioid, they report that they’ve just dispensed 30 tabs of Vicodin to Mr. Jones. And so now I know, when that patient comes into my office, whether this is a legitimate prescription or whether this is someone who is misusing opioids.”
Dr. Moore says that all dentists may not be thrilled with the ADA’s new policy, but that it’s necessary given the current state of the opioid epidemic in the country.
“None of us want a legislator making a decision on how I’m going to treat a patient or how I’m going to write a prescription, but this addiction is pretty traumatic. It’s terrible what’s going on,” he says.
Up next: A shift in education...
A shift in education
Education and hands-on experience are critical for dental students to understand the intricacies of dentistry. Ongoing education of appropriate prescribing habits is also key. Unfortunately, pain management is a topic that has often been juggled around in dental schools.
“The teaching of pharmacology and specifically orofacial pain management has been very variable over time and across the country,” says David Alexander Keith, DMD, BDS, a professor of oral and maxillofacial surgery at the Harvard School of Dental Medicine. “As CODA requirements for accreditation for dental schools have not been specific or detailed, dental schools have been left to their own devices. Pain management has rarely been taught by a specific department and has been delegated to oral and maxillofacial surgery, or other departments alone or in combination.
“This has led to a variety of sometimes opposing approaches and conflicting attitudes,” he continues. “The specific issue of opioid prescribing has suffered the same fate until recently. The result has been that many dentists now in practice are ill prepared to deal with the prescription opioid crisis as they lack the training and knowledge base.”
Fortunately, dental schools across the country, in collaboration with the American Dental Education Association, are now addressing this issue and assessing their curricula to better prepare graduating dentists. For instance, in Massachusetts in 2016, a collaboration among the three dental schools in the state, the Massachusetts Dental Society, the state’s Department of Public Health and a student group established enhanced training for dental students in strategies to prevent prescription drug misuse. These statewide “core competencies” were said to be the first of their kind in the nation.
“The group gathered data on what was already being done in the schools and proposed a model to address the issue in three domains,” Dr. Keith explains. “The primary preventive domain involves preventing prescription drug misuse by screening, evaluation and prevention (evaluating orofacial pain, risk assessment, use of pharmaceutical and non-pharmaceutical treatments as well as developing appropriate communication skills). Secondary prevention domain involves treating patients at risk for substance use disorders and engaging patients in safe, informed and patient-centered treatment planning. Tertiary prevention domain involves managing substance use disorders, eliminating stigma, and advancing interprofessional and interdisciplinary collaborative efforts.
“The first two domains are most amenable to implementation in an undergraduate dental curriculum,” he adds. “Most of these improvements are already in place in the three Boston dental schools, and graduating classes are familiar with safe and effective pain management in the dental practice setting.”
Arming graduating dentists with knowledge of pharmacology and pain management is essential and will allow them to provide appropriate treatment for patients who are in pain as well as those who are at risk of substance misuse.
“Along with our medical colleagues, we need to take responsibility for prescribing medications that are effective, safe and appropriate to the patient’s needs,” Dr. Keith says. “This requires a knowledge of pain assessment and management and of the risks, benefits and alternatives of a variety of analgesics, including opioids and other non-pharmacologic strategies. … In time, these strategies can help improve dental pain management and reduce the number of opioid pills that are left over and that may be diverted for non-medical use.”
Up next: Changing prescribing habits...
Changing prescribing habits
While dentists are used to prescribing immediate-release opioids for the treatment of acute dental pain, new research suggests that opioids aren’t actually the most effective option. According to a study published in the April 2018 issue of the Journal of the American Dental Association, ibuprofen and other nonsteroidal anti-inflammatory drugs (NSAIDs) alone or in combination with acetaminophen are better at easing acute dental pain than opioids.
“That article quantitatively reviews about 460 clinical trials that have involved almost 60,000 patients,” says Dr. Moore, who was the first author of the study. “The results of that say that the nonsteroidals work every bit as well as Percosets. And it also says that these narcotics are more likely to cause side effects like nausea and vomiting. I think probably the most interesting or exciting thing for me is that one realizes the most effective analgesic when you take out wisdom teeth is two Advil and one extra-strength Tylenol.”
Anita Aminoshariae, DDS, MS, director of predoctoral endodontics and an associate professor in the department of endodontics at the Case Western Reserve University School of Dental Medicine and one of the study’s authors, says the new research will allow dentists to provide their patients with the best care.
“We were interested in summarizing the data available in the medical literature comparing efficacy of medications used for relief of acute pain as well as the harms associated with the various medications,” Dr. Aminoshariae says. “We thought it was important that dentists have accurate and current information for use in clinical decision making.
“We are confident that dentists can use the data summarized in our paper to continue providing quality care to patients,” she continues. “We hope the information will better enable them to talk with patients and explain about the benefits and harms associated with the various topics.”
Although NSAIDs can be a substitute for opioids, Dr. Aminoshariae mentions an article published in JADA in 2016 that showed some patients may not be able to take them, such as those with kidney disease, prior myocardial infarction, NSAID-exacerbated respiratory disease or who are on antithrombotic therapy.
“NSAIDs should be the drug of choice for pain,” she says. “However, if that is not adequate, then a combination of NSAIDs with acetaminophen would be appropriate. If this combination is still not adequate, then prescribing opioids would be the next step. It is important to start with NSAIDs because these drugs are anti-inflammatory. That means they would result in a reduction in swelling, which would decrease pain. Opioids do not have this efficacy.”
Determining the appropriate drugs to prescribe can be a quandary for many dentists, Dr. Moore says.
“Through three or four studies, the average number of Vicodin prescribed to a patient in acute pain coming out of a dental office or surgery is 20 tablets,” he says. “What we found is, when you prescribe it, the patient isn’t in pain. They just had their wisdom teeth taken out, for example. The dentist does 10 of these procedures a day. Three of my patients may need this Percocet, but the other seven probably don’t need it, and nonsteroidals will work terrifically. But you don’t know which three patients are going to need it, so you have to prescribe it to everyone, and there lies the hook. Because what happens to the ones you prescribe for who don’t use them at all?
“When you prescribe them, 20 percent of people don’t fill them or don’t use them,” he continues. “On average, they use about seven to eight pills; less than 50 percent of what you prescribe is used on average. A couple of patients will use up the whole pill box, or sometimes they’ll need a refill because they have a dry socket or something like that. But you don’t know that when the patient is walking out of the office. So, you’re kind of in a Catch-22 here.”
Using long-acting local anesthetics can also help with patients’ pain levels.
“After you do surgery using a regular local anesthetic, we reach in and we infiltrate around the wound with a long-acting local anesthetic,” Dr. Moore says. “That keeps you numb for six to eight hours. We give you a nonsteroidal before you leave the office, pre-emptively. We use corticosteroids to decrease the swelling and discomfort. There are a lot of strategies that are ‘opioid-sparing.’ It might not mean that you never need the opioid, but maybe 50 percent of the people who would normally don’t need it if you use opioid-sparing strategies.”
Altering prescribing habits and pursuing continuing education courses on pain management will be crucial as the dental industry continues to battle the national opioid epidemic. Perhaps just as important are dentists’ relationships with their patients and their involvement at the community level.
“Our role really is prevention,” Dr. Moore says. “Let’s see if we can keep you from taking this. After all, we don’t use Vicodin in Great Britain or Japan or China. Ninety percent of these immediate-acting drugs like Vicodin and Percocet are used in North America. I think our role should be not only our patients but just kind of at a community level explaining that you probably don’t need to be using these drugs. I don’t think we’ll solve the opioid problem until the community says this is not acceptable.”