Opioid abuse continues to dominate the national conversation. In 2015, 12.5 million people misused prescription opioids, with 15,281 deaths, according to the Department of Health and Human Services. The medical establishment is now investigating how to manage these often needed prescriptions without exposing patients to risks. Dentistry is no exception, though many questions remain.
“We don’t yet have guidelines relating to best practices when it comes to the number of pills, the dose of the medication, or the strength of the medication,” said Mark Bicket, MD, an assistant professor of anesthesiology and critical care at the Johns Hopkins University School of Medicine. “In general, the principle of using the lowest dose appropriate for the patient applies, and that extends into deciding if opioids are appropriate for treating pain or not.”
For example, opioids often are prescribed after third molar extractions. Yet a 2016 study found that only 46% of these pills actually were taken properly, resulting in more than 100 million pills left over and available for misuse and abuse by these patients and others. This dangerous surplus is the result of the challenges in predicting how much pain patients will feel and how much medication they will need to mitigate it.
“Dentists, like most caring people, don’t want patients to have significant pain that they could help control. It’s also difficult for us right now to determine how much pain someone will have after a procedure,” Bicket said. “Pain is a pretty personal experience, or I guess I should say it is a unique experience, that depends on some personal characteristics as well as what type of procedure that you had done.”
Earlier this year, the ADA released an official statement on the use of opioids in treating dental pain. According to the ADA, dentists should consider nonsteroidal anti-inflammatory analgesics as the first line of therapy for acute pain management, along with multimodal pain strategies. When opioids are necessary for chronic orofacial pain, the ADA advises, dentists should coordinate with other treating doctors including pain specialists.
“Many people’s pain after dental procedures can be effectively controlled by Tylenol or acetaminophen, as well as nonsteroidal anti-inflammatory drugs like ibuprofen, or Aleve, that you can get commonly over the counter,” Bicket said. “You can write prescriptions for stronger doses of these drugs as well.”
When dentists do need to prescribe opioids, Bicket said, they should remember that patients who are prescribed longer courses of treatment have a greater risk of developing an addiction than those prescribed shorter courses. Dentists also need to talk about these risks with their patients, he added, including any previous use of opioids.
“I think one of the important things to recommend is that prescribers check with patients about their risk for opioids misuse, if they have a history themselves or a family history of drug misuse,” Bicket said. “Also, dentists should look at their patients’ past prescriptions for opioid medications through a prescription monitoring program.”
When opioids are prescribed, patients need to store them securely so others in the household don’t use them either intentionally or unintentionally, Bicket said, noting that dentists should ask their patients if they have lockable cabinets or drawers or other options at home for such storage. Also, dentists should reach out to their patients during the course of the prescription to see how it is going, for the patient’s benefit as well as their own.
“For dental prescribers, it is helpful to understand how much pain their patients will anticipate and actually experience after surgery, and follow-up phone calls are a great way of getting that feedback from the patient to understand if their opioid prescriptions are being used and, if so, how much of them patients are actually using,” Bicket said. “Follow-up phone calls by their staff members would certainly be one way to accomplish that.”
If there are leftover pills once treatment is complete, patients should be advised to return them to the pharmacy. Some police departments collect extra pills as well. Also, many municipalities participate in the annual National Prescription Drug Take Back Day, set for October 28 this year. And if these options are unavailable, Bicket advises flushing leftovers down the toilet, as the public health concerns of unused opioids are greater than any potential environmental risks.
“People are often surprised to learn that 90% of opioids that are misused come from family, friends, or legitimate prescriptions,” said Bicket. “They’re not typically attained from drug dealers. They’re usually opioids that are in people’s possession that they have that are left over or opioids that are prescribed for a medical reason that then get diverted into nonmedical use.
These misused opioids have a significant impact on individuals and on society alike. Each day, according to the Centers for Disease Control and Prevention, more than 1,000 people are treated in emergency departments for misusing prescription opioids. Also, as many as one in 4 people who receive prescription opioids long-term for non-cancer pain in primary care settings struggle with addiction. Now, dentistry, industry, and the government are responding.
For example, the American Association of Oral and Maxillofacial Surgeons has teamed up with Pacira Pharmaceuticals and Aetna to reduce the number of opioids prescribed to patients following third molar extractions by at least 50% nationwide through the use of Exparel, a non-opioid bupivacaine liposome injectable suspension.
CVS Caremark will limit certain acute opioid prescriptions for patients who are new to therapy to 7-day supplies. The pharmacy chain also will limit the daily dosage of opioids based on the strength of the drug and require the use of immediate-release formulations before extended-release opioids are dispensed. Plus, CVS announced plans to improve education and counseling about abuse for patients while ramping up the number of disposal kiosks it offers.
Also, the Food and Drug Administration (FDA) has notified 74 manufacturers of immediate-release opioids that their drugs will be subject to a more stringent set of requirements under a Risk Evaluation and Mitigation Strategy that will include training for providers who provide these drugs. The FDA also will issue a guidance document for applicants seeking approval of generic abuse-deterrent formulations of opioid drugs.
“I think the conversation up to now has really acknowledged the public health crisis that we’re seeing in terms of the number of individuals who have been impacted,” said Bicket. “The public is starting to appreciate that opioid misuse and diversion are long-term issues that we face. The treatment for opioid use disorder is not an order of days or weeks. It’s a complicated medical problem that’s a chronic illness that people have.
Dentists who want to learn more about how they can help stem the tide of opioid diversion and misuse can find resources online, such as the CDC’s Guideline for Prescribing Opioids for Chronic Pain; the ADA’s presentation on Opioid Prescribing in Dental Medicine and other webinars; and tools for identifying abuse from the Partnership for Drug-Free Kids.