Opioid addiction presents an equal-opportunity problem that cuts a swathe through the North American population at all economic levels. Is there anything dentists can do about the national prescription drug epidemic caused by the lure of opiates? Dr. Normand Bach says yes.
This article first appeared in the newsletter, DE's Breakthrough Clinical with Stacey Simmons, DDS. Subscribe here.
Opioid addiction doesn't play favorites
In the latest war-on-drugs front, people from all parts of society are fighting addiction and overdose from prescription painkillers. Residents of Kentucky's poorest Appalachian towns, where the only businesses that thrive are the pharmacies, (1) fit the generally accepted image of those who suffer from opioid addiction. But increasingly, the face of this addiction comes from the ranks of the upper middle class. (2) Opiates offer an equal-opportunity addiction problem that cuts a swathe through the North American population. In 2015, overdose deaths due to prescription pain relievers were distressingly high at 20,101. (3)
What can dentists do about this distressing situation? Plenty.
Fight the source, not the symptom
Measures for battling this nationwide opioid epidemic have focused largely on the pain clinics that have sprung up in weed-like fashion in recent years. Very often these clinics are only very loosely tied to medically approved regimens of pain treatment, and instead feed the growing population of addicts.
While these clinics are definitely a problem, it might help to dig deeper into the addiction problem and focus on where all of those prescriptions are coming from. Dentists prescribe 12% of immediate-release opioids, (4) so they can definitely play a role in helping solve the nation's opioid epidemic. Sometimes it's merely a case of finding out whether a patient is collecting prescriptions from multiple sources for the same ailment or condition. That's where drug monitoring programs come in.
Drug monitoring programs
Some states have Prescription Drug Monitoring Programs (PDMPs), which gives prescribers access to data on the prescription of controlled substances in their state. The program dictates that they must consult the database before issuing prescriptions for substances such as opioid analgesics.
The impact of the number of prescriptions dentists write can be astonishing. A 2015 study showed that a mandatory PDMP caused prescription rates to drastically decrease in volume over a three-month period. (5) The total number of opioid pills prescribed dropped 78%. This seems to suggest that much of the overprescribing of opioids is due to patient abuse of the medical system. But what can dentists do, beyond participating in PDMP systems, to help alleviate the problem?
Here are four ways dentists can help alleviate the national opioid epidemic:
1. Be aware that for teens, opioid abuse can start at the dentist.
Teens who go in for routine dental treatments, such as having wisdom teeth removed, are sometimes given opioid painkillers. According to a report cited in an NBC news segment covering dentists' role in opioid addiction, 61% of teens were given a prescription for opioids after a tooth extraction. (6) The report also quoted a medical expert who said that for about half of patients, over-the-counter painkillers are sufficient.
2. Start screening.
The same NBC report spoke of one girl who told her dentist that she was an addict. He prescribed Fentanyl anyway, and then the patient relapsed. This highlights the importance of screening for drug addiction.
As of November 2015, three out of four dentists screen their patients for illegal drug use, a percentage that could stand to be higher. (7) The study also cited that just over half (54%) of dentists believe that drug screenings should be their responsibility.
3. Practice patient assessment and referral.
One of the rationalizations for screening is that for some people, a visit to the dentist is the only interaction they have with the medical system. Tooth pain and other critical dental issues are hard to ignore, prompting even the uninsured and the cash-poor to make appointments with dentists to fix their teeth. Since doctors are the second-largest group of medical professionals who prescribe opioid pain medication, (8) they're often sought out by patients seeking opioids for recreational use or because they're addicted. As such, this is the only chance these patients may have for a medical professional to intervene and refer them to a substance abuse program.
4. Offer patient education.
Helping patients understand the dangers of opioids is one way to help. Dr. Maxine Feinberg, president of the American Dental Association, said: "As health-care professionals, we’re on the front lines of this issue and see how it causes devastating destruction for every life that it touches. Together, we can harness the collective power of preventative education and intervention to help reverse this epidemic." (9)
Looking to the future
In the future, the dental industry needs more studies in the pipeline. Determining the optimal number of doses actually required to treat dental-related pain would be helpful, as would impact studies such as the PDMP study cited above. Some academics are already looking ahead. Imagining the future, dental schools in the United States are being proactive about fighting opioid abuse.
At Harvard School of Dental Medicine (HSDM), for example, new core competencies instituted just last year show one way to take action. New dentists graduating from HSDM will now be trained in primary, secondary, and tertiary prevention techniques. (10) Harvard is not the only school to take such a proactive approach. In fact, three dental schools in Massachusetts alone have adopted strategies to train new dentists to combat opioid abuse by teaching skills in pain management, prescribing painkillers, and detecting improper use of opioids. (11) If these schools are any indication of the direction dentists will be taking, we can hope for improvement in the days and years that lie ahead.
This article first appeared in the newsletter, DE's Breakthrough Clinical with Stacey Simmons, DDS. Subscribe here.
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References
1. Galewitz P. The pharmacies thriving in Kentucky's opioid-stricken towns. The Atlantic website. https://www.theatlantic.com/health/archive/2017/02/kentucky-opioids/515775/. Published February 7, 2017. Accessed February 15, 2017.
2. Freyer FJ. Heroin use spikes among women, higher-income groups. The Boston Globe website. https://www.bostonglobe.com/metro/2015/07/07/heroin-use-rise-among-women-and-middle-income-people/1bj3fmcvs7aIHWueylFCmN/story.html. Published July 8, 2015. Accessed February 15, /2017.
3. Opioid addiction 2016 facts & figures. American Society of Addiction Medicine. http://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf. Accessed February 15, 2017.
4. Denisco RC, Kenna GA, O'Neil MG, et al. Prevention of prescription opioid abuse: the role of the dentist. J Am Dent Assoc. 2011;142(7):800-810.
5. Rasubala L, Pernapati L, Velasquez X, Burk J, Ren Y-F. Impact of a mandatory prescription drug monitoring program on prescription of opioid analgesics by dentists. PLoS One. 2015;10(8):e0135957.
6. Hooked: How opioid abuse starts at the dentist for many Americans. NBC News website. http://www.nbcnews.com/nightly-news/video/hooked-how-opioid-abuse-starts-at-the-dentist-for-many-americans-710032451882. Published June 21, 2017. Accessed February 15, 2017.
7. Dentists tapped for new role: Drug screenings. Columbia University's Mailman School of Public Health. ScienceDaily website. Published August 13, 2015. Accessed February 15, 2017.
8. Golubic S, Moore PA, Katz N, Kenna GA, Hersh EV. Opioid prescribing in dentistry. Inside Dentistry website. https://id.cdeworld.com/courses/5061-Opioid_Prescribing_in_Dentistry. Published March 2, 2017. Accessed March 29, 2017.
9. ADA joins task force to investigate opioid crisis. DentistryIQ website. http://www.dentistryiq.com/articles/2015/08/ada-joins-task-force-to-investigate-opioid-crisis.html. Published August 14, 2015. Accessed February 15, 2017.
10. New core competencies in dental education will combat opioid misuse. Harvard School of Dental Medicine. http://hsdm.harvard.edu/news/new-core-competencies-dental-education-will-combat-opioid-misuse. Published February 12, 2016. Accessed February 15, 2017.
11. Freyer FJ. Dental schools adopt strategy to combat opioid abuse. The Boston Globe website. http://www.bostonglobe.com/metro/2016/02/11/hoping-combat-opioid-crisis-dental-schools-adopt-pain-management-strategy/AdbYECzgmn5npPfTzeQFzO/story.html Published February 11, 2016. Accessed February 15, 2017.
Normand Bach, DMD, MSc, FRCD(C), received his dental degree from the University of Montreal in 2002, and completed a certificate of multidisciplinary residency at Notre-Dame Hospital in 2003. In 2008, Dr. Bach completed a master’s degree of science and a certificate in orthodontics at the University of Montreal. He is currently an associate professor at the University of Montreal and is responsible for the undergraduate orthodontic clinic, in addition to maintaining a private practice limited to orthodontics in Montreal. Contact him through his website.
