Opioids and dentistry
The numbers are staggering. In 2016, for every 100 people in the U.S., health care providers wrote 66.5 opioid prescriptions. Sadly, 8 to 12 percent of those with these drugs in hand develop an opioid use disorder leading to an unintended side effect: addiction. That leaves some reaching for that next pill, even if the initial pain that prompted the prescription has long since subsided. Increasing doses are needed to maintain an often euphoric effect and keep withdrawal at bay. But these larger doses prompt higher risk of sedation, hypoxia and death.
It happens all too often, as an estimated 46 people in the U.S. die each day from overdoses involving prescription opioids.
The response to this epidemic is complex at best. According to the Centers for Disease Control and Prevention, opioid prescriptions peaked in 2012 at more than 255 million — that’s a quarter of a billion scripts. Numbers declined to 214 million opioid prescriptions by 2016, the lowest in more than a decade, but the struggle to curb patient misuse is far from over for health care providers — including faculty and students at Texas A&M College of Dentistry.
Protocol revamped
“When I was a student, everybody got opioids,” recalls Dr. Michael Ellis ’85, ’93, ’97, clinical associate professor in oral and maxillofacial surgery at the College of Dentistry. Now a member of the Texas A&M Health Science Center Opioid Task Force, Ellis remembers a directive from his chief oral surgery resident during his own education that was standard for teaching institutions at the time, but today makes him wince: Do not take out teeth on a Friday and write a prescription for less than 20 hydrocodone. “When I was in practice as a general dentist, the reps would just bring boxes of it,” Ellis adds. “We never thought anything of it other than trying to balance the patient’s level of pain or what the expectation would be for that patient based on what we did to them.”
Flash forward 20 years. Now, opioids are only prescribed as a last resort. And in much smaller quantities.
“Patients are provided very specific directions to take an alternating schedule of ibuprofen and acetaminophen,” says Ellis. It’s a regimen that mirrors American Dental Association standards.
“If we really get into someone doing a significant piece of surgery — cutting bone, cutting a tooth in half — I’ll write them a prescription for six to 10 hydrocodone. We tell them to consider it a rescue medicine.”
Other alternatives such as Exparel, a long-lasting local anesthetic injected immediately after wisdom tooth extraction, for instance, can allow young patients to have a pain-free recovery, no opioids needed. Such therapies come at a cost, though: The shot can run in excess of $200.
A delicate discussion
Attentiveness to the opioid issue isn’t limited to the dental school’s clinics.
Dr. Jayne Reuben, associate professor in biomedical sciences and director of instructional effectiveness, doesn’t waste any time in covering a delicate topic in the pharmacology courses she oversees: diversion.
“I tell students that it may not be the patient who has a problem; it could be the patient’s family member,” says Reuben. “The patient may get the medication they need, but then there’s diversion or misuse because there is an addiction problem. Be attentive to the fact that there may be an issue in the family, but be delicate about asking those kinds of questions.”
An awareness that there may be multiple factors at play can be invaluable, Reuben adds.
“It takes rewiring of the brain for addiction to occur, otherwise everyone who takes opioids would become addicted to them. The roles of genetics, environmental factors, lifestyle and even personality are important. People who engage in high-risk sports appear to be more susceptible to addiction.”
“You don’t want people to hurt, and you don’t want to give them a problem they don’t have. Thirdly, you don’t want to feed a problem they do have. It’s always a balance.”
—Dr. Michael Ellis
An interdisciplinary perspective helps, too, which is why students get firsthand information from pharmacists next door at Baylor University Medical Center as part of their coursework. The pharmacists give the students a crash course in the latest on drug laws, codes, prescription writing and the Texas Prescription Monitoring Program, which collects prescription data on all Schedule II, III, IV and V controlled substances dispensed in the state.
Databases and doctor shopping
While Texas dentists are only required to self-query once per year regarding the controlled substances they have prescribed, they can look up patients at any time to see what that individual has been given — to help offset a trend known as “doctor shopping.”
Eyebrow-raising results taken from a National Dental Practice-Based Research Network survey of more than 700 dentists nationwide and shared during a January 2018 webinar revealed that just more than half of respondents reported actually utilizing their prescription drug monitoring systems, with the majority sharing they turned to the resource when treating patients perceived to be high risk.
Because patients might be hesitant or embarrassed to admit to a history of abuse, such databases provide invaluable information to augment common red flags during otherwise routine appointments, such as patient requests for specific medications, a history of frequent emergency room visits and alleged allergies to opioid alternatives.
While dental students don’t have direct access to the monitoring programs, time spent in the oral surgery clinic with faculty and graduate students helps cue them in about when opioids are and aren’t necessary.
Finding a balance
“Every situation is on a case-by-case basis, and it is important to thoroughly know the patient’s medical history in order to make recommendations that would be best for them,” says D4 Leke Olowokere.
When doing what’s best for the patient involves writing a prescription for opioid painkillers, Ellis strives for balance.
“All teeth aren’t the same, and given patient response with the very same surgery is not the same,” Ellis says. “Some swell more than others; some don’t swell at all. People at different points of life respond differently to pain. How do you discern how much pain medication everybody uses?
“You don’t want people to hurt, and you don’t want to give them a problem they don’t have. Thirdly, you don’t want to feed a problem they do have. It’s always a balance.”