Every day, 90 people die in the United States from an overdose that involves an opioid. At least 2 million people suffer from opioid use disorder (OUD). The National Institute on Drug Abuse reports that nearly half of the young people who now inject heroin used prescription opioids first. 1 As the opioid epidemic worsens, it’s vital that our profession takes a close, hard look at our role in addressing and preventing opioid abuse.
In 2012, healthcare providers in the United States wrote 259 million opioid prescriptions. Dentistry’s contribution to this enormous number is significant, as 12% of all immediate-release opioids such as oxycodone and hydrocodone are prescribed by dentists, with some reduction in recent years.2, 3 Third molar extractions, the most common surgical procedure, often are followed by an opioid prescription to control the postoperative pain.
It is important to note that dentists prescribe opioids for these extractions and other procedures for a relatively short period of time. But in the case of third molars, that equals 3.5 million young people with an average age of 20 years who are exposed to opioids each year.2 The question is if these prescriptions can and should be avoided.
Studying the Issue
I had the privilege of recently serving alongside many experts on a committee of the National Academies of Sciences, Engineering and Medicine that was charged with studying pain management and opioid misuse. As the only dentist on the committee, I was able to share with the other healthcare professionals how opioids are used in dentistry, and I was enlightened about their use in other healthcare disciplines as well.
For a year, we studied the complicated issue and produced a report with key findings and recommendations to better address this major public health problem. Generally, trends indicate that premature deaths associated with the use of opioids are likely to climb and that opioid overdose and other opioid-related harms will dramatically reduce quality of life for many people for years to come.
Drug overdose, driven primarily by opioids, is now the leading cause of unintentional injury deaths in the United States. Little is known about why individuals who use prescribed opioids to alleviate pain develop OUD, yet this outcome has become a driving force in the opioid epidemic.
This epidemic has taken nearly 2 decades to develop, and realistically, it will take many years of sustained and coordinated efforts to control, contain, and reverse it devastating effects.
As dentists, when should—and shouldn’t—we prescribe opioids?
- After third molar extractions and other invasive dental procedures, treatment with non-opioid analgesic agents such as nonsteroidal anti-inflammatory drugs (ibuprofen and naproxen) has been shown to provide pain relief that can be as effective as opioids. This approach should be considered as the first line of therapy for patients who do not have contraindications to their use.
- In cases where therapy with opioids is considered, it is recommended that opioids are prescribed only for several days following the dental procedure. Continuing pain beyond that may be related to infection or other complications, and an examination by a dentist should be performed prior to prolonged treatment with opioids.
- Emergency room visits for non-traumatic dental pain often result in opioid prescriptions for dental pain, because most emergency departments are not staffed or designed to provide dental treatment.
- Prescription drug monitoring programs (PDMPs) have proven to be very effective in the dental community. At the Eastman Institute for Oral Health, we studied their effectiveness in our urgent dental care clinic. The number of opioid prescriptions decreased by 78%, while the number of recommended non-opioid analgesics, such as ibuprofen, increased.4
- General dentists often have long-term relationships with their patients and are well positioned to perform risk-factor screenings, including prior or existing drug abuse, chronic pain including arthritis, fibromyalgia, musculoskeletal disorders, back pain, and neuropathic pain.
- We must work together to change the culture of prescribing, which can be accomplished partially through enhancing education for dentists, physicians, and the general public.
I commend the US Food & Drug Administration and the Centers for Disease Control and Prevention for the many steps they’re taking and the programs they’re implementing to address this epidemic. But despite these programs and excellent results, the problem is progressing.
We must continue to make changes in our own practices, continue to stay on top of the issue, and advocate for good research, particularly in better understanding the nature of pain and developing non-addictive alternatives to opioids for pain management.
- Muhuri, P., J. Gfroerer, and M.C. Davies. 2013. Associations of nonmedical pain reliever use and initiation of heroin use in the United States. CBHSQ Data Review 2013 (August). https://www.samhsa.gov/data/sites/default/files/DR006/DR006/nonmedical-pain-reliever-use- 2013.htm
- 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):800-10.
- Levy B, Paulozzi L, Mack KA, Jones CM. Trends in Opioid Analgesic-Prescribing Rates by Specialty, U.S., 2007-2012. Am J Prev Med 2015;49(3):409-13.
- Rasubala L, Pernapati L, Velasquez X, Burk J, Ren YF. Impact of a Mandatory Prescription Drug Monitoring Program on Prescription of Opioid Analgesics by Dentists. PLoS One 2015;10(8):e0135957.
Dr. Eliav has been the director of the Eastman Institute for Oral Health and vice dean for oral health at the University of Rochester School of Medicine and Dentistry since 2013. A native of Israel, where he earned his dental degree, master’s, PhD, and Oral Medicine Specialty from the Hebrew University and Hadassah in Jerusalem, he trained in clinical and basic science research at the National Institutes of Health. An expert in chronic pain, Dr. Eliav is widely published and speaks internationally about orofacial pain, quantitative sensory testing, neuropathic pain, pain modulation, transition from acute to chronic pain, and the role of inflammation in neuropathic pain. He has also served as editor-in-chief of Quintessence International since 2008. He can be reached at Karen_Black@urmc.rochester.edu.