Purposeful Prescribing: A Dentist’s Role in the Opioid Epidemic

In our oral surgery student clinic, we have a laminated sheet to reference when writing our two most common post-surgical prescriptions: Norco® (acetaminophen/hydrocodone) and amoxicillin. As a third-year student frazzled and sweaty, with forearms set to ache for days following an exhausting extraction, this sheet is a lifesaver. It provides suggestions for dosage and pills dispensed, and reminds students to include the patient’s address when writing for controlled substances. This sheet is a helpful reference for prescription writing structure, but the nuances of prescribing narcotic medications are far greater than what can be squashed between two layers of lamination plastic.

If you’ve taken a break from the books and tuned into the news over the past few years, you’ve likely seen coverage on the opioid crisis. Opioids include prescription pain medications, heroin, and synthetic opioids, and their misuse killed 42,249 people in 2016.¹ The crisis has had an estimated impact of $78.5 billion and left an unfathomable emotional burden on the millions of family members left in the wake of addiction’s destruction.² Dentists play a role in this crisis by prescribing many of the opioids that lead patients down a path to addiction. As students of dental medicine, we must not only be competent in prescribing medicine, but we must also be aware of the comprehensive impact these medicines can have on society.

Who should I worry about?

All patients are at risk for drug addiction. An extraoral exam can reveal a much different presentation than the cinematic depictions of a unkempt addict with poor dentition, facial scabs, and crazy eyes. An opioid addict can be the thirteen-year-old swimmer on the junior high team, the grandma with a pocketbook full of photos of her garden and grandchildren, or the mom with two little kids in tow. Opioids can affect anyone, of any age, race, education level, or socioeconomic class. The CDC emphasizes that safe opioid prescribing practices are not just indicated for “high risk patients.”³ Each and every patient in our chair is at risk for opioid abuse, and the precautions we take as mindful practitioners can safe their lives.

Where do dentists fit into the opioid epidemic?

Dentists prescribe a notable amount of opioid prescriptions. Studies have estimated that dentists write 12% of all opioid prescriptions, and unused dentally-prescribed opioids cause 1,500 deaths each year.⁴ Two-thirds of dental opioid prescriptions are written for surgical visits, with the other one-third prescribed for non-surgical visits, mostly restorative work.⁵ Dentists were the top prescribers of opioids to 10 to 19 year-olds in 2009, and the most dramatic increase in dental opioid prescriptions was seen in patients 11 to 18 years-old, with prescriptions rising from 99.71 to 165.94 per 1,000 patients over just a five-year period from 2010 to 2015.²

What can I do to help?

The strongest weapon we have against opioid addiction is education. We must educate ourselves and our patients on the proper role of opioids in dentistry. National organizations like the Centers for Disease Control and Prevention (CDC) are valuable sources of evidence-based information. The guidelines written by these organizations can help shape the way we prescribe pain medications. Although most dental pain is acute, the CDC does not have a policy on opioid prescriptions written for acute pain. The American Dental Association (ADA) recommends that dentists follow the CDC for Guideline for Prescribing Opioids for Chronic Pain until the CDC releases a guideline specific for acute pain.⁶ The following are key dental points of the chronic pain guidelines, as summarized by the CDC³:

• Opioids are not first-line or routine therapy for chronic pain
• Discuss benefits and risks and availability of non-opioid therapies with patient
• Start low and go slow
• When opioids are needed for acute pain, prescribe no more than needed; three days or less will often be sufficient
• Do not prescribe extended-release/long-acting opioids for acute pain
• Follow-up and re-evaluate risk of harm; reduce dose or taper and discontinue if needed
• Check PDMP for high dosages and prescriptions from other providers
• Arrange treatment for opioid use disorder if needed

One way to avoid opioid misuse is to consider their alternatives such as non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs are a safe and effective alternative to opioid prescriptions and should be considered first-line pain management for acute dental pain. Studies have shown that 400 mg of ibuprofen plus 1,000 mg of acetaminophen is more effective and has less risk than opioid medications.⁵

Another way to limit access to opioids is by educating patients on proper prescription disposal. Studies have shown that 54% of opioids prescribed for dental surgery go unused, and leftover pills left in medicine cabinets are the easiest way for drugs to land in the hands of drug-seekers.² For example, a study revealed that non-medical opioid-using high school seniors did not have to look far for a drug supply. Almost 37% used pills from their own prescriptions, and dentists wrote 27% of these misused prescriptions.² Talk to your patients and their parents (if a minor) on disposal of unused pills, and provide information on proper disposal protocol and disposal programs in your area such as local medicine take-back programs and DEA-registered collectors, such as pharmacies or law enforcement agencies.⁷ Due to the high risk of opioid medications, the US Food and Drug Administration recommends immediately flushing these leftover medications if no disposal program is readily available.⁷ The list of medications that should be immediately flushed includes common dental prescriptions such as oxycodone (Oxycontin, Percocet) and hydrocodone (Lortab, Norco, Vicodin) and can be found in full here⁷.

Opioid safety should begin before you ever release prescriptions into your patients’ hands. Be prepared to access prescription drug monitoring programs (PDMPs) when you graduate. PDMPs are valuable statewide databases where practitioners can tap into real-time information on a patients’ drug history. The medications listed in the database generally include opioids and benzodiazepines, which are involved in 71% and 31% of prescription drug overdoses, respectively.⁸ PDMPs also include a history of the patient’s quantity and length of prescription so practitioners can calculate if patients are requesting inappropriate prescriptions.⁸ Red flags can include multiple prescribers, multiple pharmacies and self-pay patients attempting to avoid insurance restrictions.⁸ As of January 2018, 39 states require that healthcare professionals check their state’s PDMP prior to prescribing addictive drugs.⁹ Even if your state does not require PDMP usage, it is important to habitually check the database before writing a first-time prescription for a patient. As stated before, all patients are at risk of opioid abuse, and consulting the database can help uncover drug seekers within your practice.

Why should I care and when should I start?

As future doctors, we are responsible for being prudent prescribers, and that responsibility begins now. The habits we develop as students translate directly into the way we treat as practicing dentists. We should educate ourselves on the risks of and alternatives to opioids and understand how to practice safe and effective pain management. Rarely does dentistry involve life and death, but by actively fighting against our role in drug addiction, we absolutely have the power to save lives.

References

1. What is the U.S. Opioid Epidemic? HHS.GOV/OPIOIDS: U.S. Department of Health and Human Services 2018. “https://www.hhs.gov/opioids/about-the-epidemic/index.html”.

2. Gupta N, Vujicic M, Blatz A. Opioid prescribing practices from 2010 through 2015 among dentists in the United States. The Journal of the American Dental Association 2018;149(4):237-45.e6.

3. . CDC Guideline for Prescribing Opioids for Chronic Pain. In: Prevention CfDCa, editor; 2017.

4. Janakiram C, Chalmers NI, Fontelo P, et al. Sex and race or ethnicity disparities in opioid prescriptions for dental diagnoses among patients receiving Medicaid. The Journal of the American Dental Association 2018;149(4):246-55.

5. Moore PA, Ziegler KM, Lipman RD, et al. Benefits and harms associated with analgesic medications used in the management of acute dental pain. The Journal of the American Dental Association 2018;149(4):256-65.e3.

6. Educate Patients about Addictive Qualities of Painkillers. ADA Center for Professional Sucess. “Educate Patients about Addictive Qualities of Painkillers | American Dental Association | Center for Professional Success”.

7. Disposal of Unused Medicines: What You Should Know. U.S. Food and Drug Administration 2018. “https://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/ensuringsafeuseofmedicine/safedisposalofmedicines/ucm186187.htm – Medicines_recommended”.

8. Keith DA, Shannon TA, Kulich R. The prescription monitoring program data: What it can tell you. J Am Dent Assoc 2018;149(4):266-72.

9. Vestal C States require doctors to use prescription drug monitoring systems for patients. The Washington Post 2018. “States require doctors to use prescription drug monitoring systems for patients