Dentistry’s Role in the Opioid Crisis
James B. Bramson, DDS
The opioid crisis has been described as the worst epidemic of addiction in the history of the United States. Drug overdoses kill nearly 64,000 people every year. That's more than the total number of lives lost during the wars in Vietnam, Iraq, and Afghanistan combined.1 To illustrate the issue of overprescribing, in a little more than a decade, two pharmacies in Williamson, West Virginia, dispensed 20.8 million prescription painkillers to a town of just 3,191 residents.2 Seems incredible, doesn't it?
In the past several years, almost every state has enacted legislation or regulations to curb the delivery of opioids. Generally, these are prescribing rules regarding the size and duration of an opioid prescription, professional guidelines, reporting requirements, and database registries.3
Make no mistake, this is a very big business. In 2016, the US market was over $10 billion.4 Obviously, the years of aggressive sales and marketing tactics, free coupons, and incentives to healthcare professionals succeeded in increasing prescription rates. However, the maker of OxyContin® recently said it would stop promoting opioids to doctors-a move that comes fully 22 years after the painkillers were initially linked to the widespread addiction in the United States.5 It's a nice gesture, but certainly long overdue and more than a little disingenuous.
Based on the statistics, our actions hardly seem enough. Stern public service announcements, clever billboards, drug registries, and more police carrying naloxone are all thoughtful measures, but they won't solve the problem alone. I believe that we need a comprehensive, federal intervention strategy that combines funding for mental health, community outreach, controls on drug dispensing, and a host of other activities. A 2017 report from the President's Commission on Combatting Drug Addiction and the Opioid Crisis presents more than 56 recommendations.6 Actions to initiate many of these should be taken.
General dentists and oral surgeons are not insignificant prescribers of opioids. In 2009, for patients aged 10 to 19 years, dentists were the nation's largest prescribers (30.8%, 0.7 million), followed by primary care physicians (13.1%, 0.3 million) and emergency medicine physicians (12.3%, 0.3 million).7
It's time for dentists to take our respective professional role in curbing this addiction. Rightfully, the ADA is stepping up its awareness and education efforts related to opioid addiction and has made several recommendations.8 There are a number of activities that dentistry can champion, including the following:
Providing patient education. Dentists should forthrightly discuss the need for and type of pain medications with patients, addressing the seriousness and possibility of opioid addiction. Does the patient really need an opioid? Studies have shown that ibuprofen with acetaminophen provides equal or better pain control in most patients following dental surgery or tooth removal.9,10
Reducing prescription size. If an opioid is needed, limit the number of tablets to prevent abuse, especially for younger patients. Some states limit the size of an opioid prescription to a 3-, 5-, or 7-day supply. In other instances, medical insurance carriers are limiting reimbursement on prescription size.
Supporting drug monitoring programs. It is vitally important that drug prescribing information is collected in accessible databases. Some insurance carriers, more so on the medical side, are reaching out to health professionals about their personal opioid prescribing patterns when they deviate greatly from the norm.
Mandating professional education. The provision of formal, mandated continuing education on a regular basis regarding opioids, addictions, and prescribing practices and protocols should become a part of a dentist's licensure process within the state or within the process of obtaining a DEA license.
Opioid addiction has become a national tragedy. Hundreds of lives are lost daily to this problem. Dentists who prescribe opioids must take greater caution when prescribing these painkillers, and the profession must address its part in improving education, awareness, counseling, and abuse prevention efforts.
About the Author
James B. Bramson, DDS, has been a private practitioner, a Hillenbrand fellow, and a former executive director of the ADA. He recently retired as the chief dental officer at United Concordia Companies, Inc.
References
1. Name X. The full title of the article. Time. 2018;191(9) 2018:X-X.
2. NBC News. Welcome to Williamson, W.Va., where there are 6,500 opiod pills per person. NBC News Website. https://www.nbcnews.com/news/us-news/welcome-williamson-w-va-where-there-are-6-500-opioid-n843821. Published February 1, 2018. Accessed July 16, 2018.
3. American Dental Education Association. Summary of State Legislation and Regulation Addressing Prescription Drug and Opioid Abuse. ADEA Website. www.adea.org/WorkArea/DownloadAsset.aspx?id=37730. Published October 6, 2017. Accessed July 16, 2018.
4. Eunjung Cha, A. The drug industry’s answer to opiod addiction: More pills. The Washington Post. https://www.washingtonpost.com/national/the-drug-industrys-answer-to-opioid-addiction-more-pills/2016/10/15/181a529c-8ae4-11e6-bff0-d53f592f176e_story.html?utm_term=.bda0a545ead9. Published October 16, 2016. Accessed July 16, 2018.
5. Whalen, J. Purdue Pharma to Stop Promoting OxyContin to U.S. Doctors. The Wall Street Journal. https://www.wsj.com/articles/purdue-pharma-to-stop-promoting-oxycontin-to-u-s-doctors-1518307565. Published February 10, 2018. Accessed July 13, 2018.
6. The President’s Commission on Combating Drug Addiction and the Opiod Crisis. The White House Website. https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Final_Report_Draft_11-1-2017.pdf. Published November 1, 2017. Accessed July 13, 2017.
7. Volkow ND, McLellan TA, Cotto JH, et al. Characteristics of opioid prescriptions in 2009. JAMA. 2011;305(13):1299-1301.
8. Crowley JP. A message from the ADA President. American Dental Association. https://www.ada.org/en/publications/ada-news/2018-archive/january/a-message-from-the-ada-president. Published January 22, 2018. Accessed July 16, 2018.
9. Teater D. Evidence for the efficacy of pain medications. National Safety Council. https://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf. Accessed July 16, 2018.
10. Moore P, Hersch E. Combining ibuprofen and acetaminophen for acute pain management after third-molar extractions: translating clinical research to dental practice. J Am Dent Assoc. 2013;144(8):898-908.
