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Dentists seek to curb abuse when helping patients manage pain

Dentists seek to curb abuse when helping patients manage pain
Dr. Kane

Boston—Dentists face a challenge in helping their patients manage pain.

They want to assist and be able to safely prescribe medication that will lessen the pain of a tooth extraction or a root canal. But dentists also want the opioids in the pill bottle to be used for the right purpose and do not want to contribute to the country's opioid abuse problem.

This conflict was at the heart of the Tufts Health Care Institute's Program on Opioid Risk Management, a two-day conference held in March.

In the forefront of the attendees' minds was a statistic that said in 2002, dentists prescribed about 12 percent of the opioids in the United States, amounting to about 1 billion doses, said  Nathaniel Katz, M.D., director of Tufts' Opioid Risk Management program and one of the co-chairs of the meeting. Overall in 2002-03, 190 million opioid prescriptions were dispensed containing 9.4 billion doses, according to a presentation Dr. Katz gave at the conference. His facts come from data presented at a Food and Drug Administration Advisory Committee meeting drawn from IMS Health, a company that supplies the pharmaceutical industry with sales information.

ADA/PDR Guide to Dental Therapeutics offers recommendations on prescribing opioids

By Kelly Soderlund

How many pain pills and the frequency in which they're taken is a subject of discussion among dentists, and medications containing opioids receive special consideration because they are commonly abused.

Older dentists remember what their dental school professors taught them, which may be different than what's being taught to dental students today. Over the years, the types of medications change and the potential for abuse can be different among the various products on the market.

It's hard to come up with a guideline, because the type and quantity of opioids prescribed for pain will likely be different depending on the procedure performed, said Dr. Hal Crossley, professor emeritus at the University of Maryland dental school, who also works with the federal Drug Enforcement Agency on opioid management issues and is a national lecturer on dentistry and drug-related issues.

Dr. Crossley recommends an opioid prescription contain no more than 15 tablets. There is no standard of teaching in dental schools for how much pain medication to prescribe and for how long, said Dr. Crossley.

The lack of standard is twofold. How dental students are taught to prescribe opioids depends on the instructor and their clinical background, and it’s also determined by the type of procedure as well as the trauma associated with the surgery.

According to policy adopted by the 2005 ADA House of Delegates, "dentists who prescribe opioids for treatment of dental pain are also encouraged to periodically review their compliance with the DEA recommendations and regulations." The policy also states dentists should recognize their responsibility to prevent drugs from becoming a source of harm or abuse and understand the special issues in pain management for patients already opiate dependent.

If it's suspected a patient will have pain 24-48 hours after a dental or surgical procedure, ADA/PDR Guide to Dental Therapeuticsthe ADA/PDR Guide to Dental Therapeutics recommends dentists prescribe an opioid or NSAID analgesic on a regular schedule for at least 24-36 hours rather than on an as-needed basis. The total number of pills or capsules prescribed depends on the recommended administration schedule for the specific medication.

The fifth edition of the Guide to Dental Therapeutics was developed by the ADA in partnership with PDR and edited by Dr. Sebastian Ciancio in collaboration with 27 leading experts in the fields of pharmacology and therapeutics. This well-recognized drug reference guide for dentists, it includes information about drugs used in dentistry; drug interactions and contraindications; oral manifestations of systemic medications; and ADA accepted nonprescription medications.

The book (P064) is $59.95 for members and $89.95 for nonmembers. Order by June 30 and save 10 percent with offer code 10416. All ADA Catalog products are available online at www.adacatalog.org or by calling 1-800-947-4746.

Of concern is that there really are no formal guidelines for dentists on how to prescribe opioids safely and effectively, Dr. Katz said. There's also minimal literature in the dental community to describe opioid abuse or how patients are using the opioids they’re prescribed, Dr. Katz said. Those at the conference used anecdotal examples to drive the point home and help each other understand the risk of prescribing narcotics like hydrocodone (Vicodin) or Oxycodone (Percocet).

For 18-20-year-olds who have their wisdom teeth removed, it's their first experience with anesthesia and pain medicine, said Dr. William Kane, member of the ADA's Dentist Well-Being Advisory Committee and chairman of the Missouri Dental Association's well-being committee. They take a couple days worth of pills to get through the postoperative pain but what happens to the unused pills in the prescription, he wondered.

Do they take the drug later to get high and go to a party? Do they give it to a sibling? Does it sit in their parents' medicine cabinet for them to use later?

It was a revelation to the dentists in attendance because since dental school, they'd always been taught a typical pain pill prescription should have anywhere from 12-30 pills, said Dr. Kane, who also practices in Dexter, Mo.

"That's just something that was really eye-opening to me; this may be how some kids get their first foray into misuse of a prescription drug," Dr. Kane said. "We probably need to be more vigilant in terms of the number of pills we prescribe."

There's also the reality of people pretending to have a toothache and calling dentists to get them to prescribe narcotic painkillers on the phone, Dr. Kane said.

Dr. Paul Moore, chair of the dental anesthesiology department at the University of Pittsburgh, presented data collected from a survey of prescribing habits by U.S. oral surgeons, which indicated that 3.5 million young adults have third molar surgery each year. Vicodin and Percocet were far and away the most frequently prescribed postoperative analgesic. The median number of opioid tablets prescribed following third molar extractions was reported to be 20 tablets.

Elliot Hersh, Ph.D., professor of pharmacology at the University of Pennsylvania, also presented clinical research, including data indicating that many of the NSAID analgesics, such as ibuprofen and naproxen, have pain-killing properties that are as good or better than the opioid formulations for treating postextraction pain, with fewer side effects.

The Tufts group, which included dental school faculty, drug company representatives, law enforcement, members of the Massachusetts Drug Enforcement Agency, and people from the National Institute of Drug Abuse and the American Academy of Oral Facial Pain, came up with a list of goals.

The first goal was to develop a description of the prescription opioid abuse in the United States that would be both understandable and relevant to the community and submit it for publication in the dental literature, Dr. Katz said. The group also wants to write guidelines for how opioids are to be used in dental practice, focusing on acute dental pain; work on guidelines for long-term opioid therapy; develop a research agenda to fill in the gaps so research funding agencies can have input; and finalize the analysis of data collected through a survey of dental practitioners in West Virginia who were asked about opioid prescribing practices, he said.

There's also a position paper being writ

Dr. Mehta

Dr. Mehta

ten saying dentists can consider substituting a nonsteroidal, anti-inflammatory medication for an opioid and achieve the same effect, said Dr. Noshir Mehta, co-chair of the meeting, associate dean of international dentistry and director of the Craniofacial Pain Center at Tufts. Dr. Kane said he was encouraged by the number of pharmaceutical company professionals who were present and the interest they took in the presentations.

"I definitely think the drug companies want to be proactive because they were very well represented there and the people there were taking a lot of notes," said Dr. Kane.

The ADA's Dentist Well-Being Advisory Committee believes that educating members is the beginning step in solving this growing problem, said Dr. Lee Gardner, committee chair. Conference leaders were encouraged that the event met this goal.

The data was very good at showing that the majority of dentists are doing the right thing, Dr. Mehta said. They're concerned about their patients, and they're concerned about managing their patient's pain with the minimum amount of opioid necessary.

To learn more about the conference, visit www.thci.org/opioid.