What can dentists do to help combat opioid abuse? Two experts offered solutions in this continuing education session at the Yankee Dental Congress on Thursday, Jan. 26.
Massachusetts, the host state of the 2017 Yankee Dental Congress, can be considered one of the many fronts in the war against prescription opioid abuse. David A. Keith (BDS, FDSRCS, DMD) and Monica Bharel (MDP, MPH) provided information to arm dentists in the fight against the opioid crisis in their continuing education session, “The Prescription Opioid Crisis and Dentistry,” at the conference in Boston on Thursday.
The location of the Congress is well-suited for this particular topic. Bharel illustrated that point with statistics. Imagine four jumbo jets full of people ages 44 and under. That’s how many people are dying from opioid overdoses in the state each year, she said. That’s about 5 deaths a day — a 390 percent increase over the last 15 years. What’s worse, she explained, is that 74 percent of the deaths in 2016 involved a presence of fentanyl, a lethal opioid more potent than what is typically prescribed.
Dentists, according to Bharel and Keith, play an important role in reversing this deadly trend.
“I’m not saying dentists are a problem,” Keith said. “But we are a part of the issue, and we need to do something here.”
Keith explained that dentists are the chief opioid prescribers for a particularly vulnerable portion of the population: children and young adults ages 10 to 19. This is troublesome when you consider that 70-80 percent of misused prescription opioids originate from legitimate prescriptions.
Where are these prescriptions coming from in the dental field? Keith said third-molar removal “is a source of quite a large number of opioids in our society.”
He supported that statement with statistics. About 66 million prescriptions for opioids are written after third-molar removal in America. Typically, the number of pills per prescription is about 20, of which, on average, about eight get consumed. That means about 40 percent, or 39 million pills, are not being used, Keith explained, highlighting that unused pills are a source of the problem.
So what can dentists do? Ultimately, Keith and Bharel said, dentists need to identify drug-seeking behavior and be more judicious in prescribing opioids. With regard to the former, Keith said that he has seen chronic oral pain lead to opioid dependence.
“These patients are going to be much more difficult to treat,” Keith said. “They may be more likely to abuse opioids.”
These are patients who present with burning mouth syndrome or who may have experienced nerve damage as the result of a surgical procedure. Keith said that it is critical to consult your state’s prescription drug monitoring program to ensure that the patients aren’t doctor shopping.
“We would be remiss to say that dentists prescribe legitimately, but sometimes are scammed,” he said.
As an example, he presented the case of a 33-year-old health care worker who reported jaw pain who recently moved from a neighboring states. After consulting the prescription drug monitoring system, he discovered that this person had 20 prescriptions in the past 6 months, 16 of which were narcotics. They were issued by 18 prescribers, 15 of which were dentists, and filled at 10 different pharmacies. This patient had a similar profile in a neighboring state, he added.
When treating post-operative pain, Keith steered dentists in the direction of NSAIDs. Though not effective for chronic pain, NSAIDs tend to be a safer option following operations, such as third-molar removal. Dentists can also preemptive doses of NSAIDs, or use more or longer-lasting local anesthesia. He did, however, caution against acetaminophen toxicity, particularly since the drug is present in so many other medications.
He referred dentists to the Published Dental Analgesia Guide, which offers the following guidance:
· Pain Level 0-3 (Mild): Typically associated with single extractions or endodontics; ibuprofen or acetaminophen
· Pain level 4-6 (Moderate): Typically associated with implant surgery or soft tissue impaction; ibuprofen, acetaminophen or sometimes codeine
· Pain Level 7-10 (Severe): Typically associated with boney impaction or complex implant surgery; oxycodone with acetaminophen and NSAIDs.