Frequently Asked Questions for Opioid Prescribing

Addiction to heroin, synthetic fentanyl, and other illicit drugs can easily start with first-time exposure to an opioid that is legally prescribed to treat a painful condition. And some clinical specialties—such as pain medicine, physical medicine/rehabilitation, emergency medicine, surgery and dentistry—will always see a higher proportion of these patients than others. It is inherent to the type of medicine they practice.

The ADA has identified several articles that bring dentistry’s role in the opioid crisis into focus.

• Prevention of prescription opioid abuse: The role of the dentist (JADA July 2011)
• The role of the oral health community in addressing the opioid overdose epidemic (JADA August 2018)

The ADA does not have specific guidelines for prescribing opioids in the dental practice for acute pain. However, the Association has identified several models that are specific to dental settings.

• Center for Opioid Research and Education (CORE) at Johns Hopkins University (2018)
• New Jersey Dental Association Guidelines on Prescribing Opioids in the Dental Practice for Acute Pain (2017) (PDF)
• Washington State Dental Guideline on Prescribing Opioids for Acute Pain Management (2017) (PDF)
• Pennsylvania Guidelines on the Use of Opioids in Dental Practices (2015) (PDF)
• Prescribing Recommendations for the Treatment of Acute Pain in Dentistry (Compendium of Continuing Education in Dentistry) (2011)

The ADA also notes that an overview of systematic reviews published in the April 2018 edition of the Journal of the American Dental Association (JADA) found that combinations of ibuprofen and acetaminophen were more effective at relieving acute dental pain with fewer acute adverse events.^* The authors concluded that the use of non-steroidal medications (NSAIDs), with or without acetaminophen, offered the most favorable balance between benefits and harms, optimizing efficacy while minimizing acute adverse events.

The ADA recommends that dentists consider non-steroidal anti-inflammatory analgesics as the first-line therapy for acute pain management.

These guidelines should not be construed as a standard of care and are not intended to replace state laws and/or the independent judgment of the dental practitioner. The field of pain management is ever evolving and dentists are encouraged to stay abreast of the latest developments in the field.

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* Moore PA, Ziegler KM, Lipman RD, et al., Benefits and harms associated with analgesic medications used in the management of acute dental pain: an overview of systematic reviews. J Am Dent Assoc. 2018;149(4): 256-265.

Yes. Among other things, the ADA encourages dentists to:

• Consider nonsteroidal anti-inflammatory analgesics as the first-line therapy for acute pain management.*
• Follow and continually review state licensing board recommendations and Centers for Disease Control and Prevention (CDC) guidelines for safe opioid prescribing.
• Be aware of each patient's substance use history and to take this into consideration when planning treatment and prescribing medication.
• Counsel patients about the benefits and drawbacks of using opioid analgesics, including their inherent abuse potential, and provide instruction on how to safely secure, monitor, and dispose of their unused medication at home.
• Screen patients for risky substance use behaviors and, when indicated, be able to refer them for appropriate treatment (e.g., support line, addiction counselor, treatment facility, etc.).
• Register with and use the state prescription drug monitoring program to promote the appropriate use of controlled substances for legitimate medical purposes, while deterring the misuse, abuse and diversion of these substances.
• Seek continuing education in addictive disease and pain management as related to opioid prescribing, which could include understanding the biological triggers for addiction, specialized techniques for identifying risky behaviors, motivating at-risk individuals to change their behavior, and counseling patients how to safely store, monitor, and dispose of their unused medications.

Click here to view the ADA's official policies, positions, and statements on drug addiction and other substance use disorders.

These recommendations should not be construed as a standard of care and are not intended to replace the independent judgment of the dental practitioner. The field of pain management is ever evolving and dentists are encouraged to stay abreast of the latest developments in the field.

These and other topics are explored in depth in the ADA Practical Guide to Substance Use Disorders and Safe Prescribing.

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* Moore PA, Ziegler KM, Lipman RD, et al., Benefits and harms associated with analgesic medications used in the management of acute dental pain: an overview of systematic reviews. J Am Dent Assoc. 2018;149(4): 256-265.

The Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain (2015) contains only a cursory mention about the particulars of managing acute pain. In fact, the document expressly states:

"Some of the recommendations might be relevant for acute care settings or other specialists, such as emergency physicians or dentists, but use in these settings or by other specialists is not the focus of this guideline."

Until the CDC publishes a guideline for prescribing opioids for acute pain, the ADA recommends that dentists review and follow the relevant portions of the CDC chronic pain guideline, subject to state law.

"Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed."

The CDC guideline should not be construed as a standard of care and is not intended to replace state laws and/or the independent judgment of the dental practitioner. The field of pain management is ever evolving and dentists are encouraged to stay abreast of the latest developments in the field.

Additional information is available at CDC.gov.

An overview of systematic reviews published in the April 2018 edition of the Journal of the American Dental Association (JADA) found that combinations of ibuprofen and acetaminophen were more effective at relieving acute dental pain with fewer acute adverse events.^* The authors concluded that the use of non-steroidal medications (NSAIDs), with or without acetaminophen, offered the most favorable balance between benefits and harms, optimizing efficacy while minimizing acute adverse events.

The ADA recommends that dentists consider non-steroidal anti-inflammatory analgesics as the first-line therapy for acute pain management.

The full article is available at jada.ada.org.

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* Moore PA, Ziegler KM, Lipman RD, et al., Benefits and harms associated with analgesic medications used in the management of acute dental pain: an overview of systematic reviews. J Am Dent Assoc. 2018;149(4): 256-265.

Yes. Since 2012, the ADA has offered free continuing education webinars covering various aspects of addiction, pain management, and safe and effective opioid prescribing in dentistry. The webinars are free, convenient to access, and tailored to pain management in dentistry.

Live webinar participants can receive one CDE credit per broadcast.

The ADA produces four webinars a year thanks, in part, to a grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) and the American Academy of Addiction Psychiatry (AAAP).

Find out more at ADA.org/opioids.

No. The Drug Enforcement Administration does not currently require advanced training in pain management, prescribing controlled substances, and/or chemical dependency as a condition of obtaining or renewing a DEA registration to prescribe controlled substances. However, many states require dentists to complete such training as a condition of licensure renewal.

The ADA encourages dentists to seek continuing education in addiction and pain management as related to opioid prescribing, which could include understanding the biological triggers for addiction, specialized techniques for identifying risky behaviors, motivating at-risk individuals to change their behavior, and counseling patients how to safely store, monitor, and dispose of their unused medications.

Check with your state dental board or controlled substance authority to determine whether your state requires such training and, if so, what the requirements are.

Check with your state dental board or controlled substance authority to determine whether your state allows electronic prescribing of Schedule II controlled substances.

In 2010, the Drug Enforcement Administration amended its regulations to provide practitioners with the option of issuing electronic prescriptions for controlled substances in lieu of paper prescriptions (see 75 FR 16235, March 31, 2010), subject to state law.

Again, check with your state dental board or controlled substance authority to determine whether your state allows electronic prescribing of Schedule II controlled substances.

Information is also available at DEA.gov.

Check with your state dental board or controlled substance authority to determine whether your state allows partial filling of Schedule II controlled substances.

Sec. 702 of the Comprehensive Addiction and Recovery Act of 2016 (21 U.S.C. 829(f)) permits dentists to request that their prescriptions for Schedule II controlled substances be only partially filled, subject to state law. It also allows pharmacies dispense the remaining portions in increments without further authorization from the prescriber.

This partial fill authority only applies where it is not otherwise prohibited by state law.

Again, check with your state dental board or controlled substance authority to determine whether your state allows partial filling of Schedule II controlled substances.

Information is also available at DEA.gov.

The ADA encourages dentists to seek continuing education in Screening, Brief Intervention, and Referral to Treatment (SBIRT) for patients who may be at risk for substance abuse and/or or be prone to addiction.

SBIRT is an evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs. It is comprised of three basic components.

• Screening — Specialized techniques for identifying risky substance use behaviors.
• Brief Intervention — Specialized techniques for motivating at-risk individuals to change their behavior.
• Referral to Treatment — Specialized techniques for referring these patients for appropriate diagnosis and treatment (e.g., support line, addiction counselor, treatment facility, etc.).

SBIRT is based on an Institute of Medicine recommendation* that called for community-based screening for health risk behaviors.

These and other topics are explored in depth in the ADA Practical Guide to Substance Use Disorders and Safe Prescribing.

Information is also available at SAMHSA.gov/sbirt.

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* Institute of Medicine, Committee on Quality of Health Care in America (IOM). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC, 2001.

If you or someone you love is struggling with addiction, call the Substance Abuse and Mental Health Services Administration hotline at 1-800-662-HELP (4357). It's confidential, free, and available 24 hours a day, 365 days a year.

ADA members may also take advantage of the ADA Dentist Health and Wellness Program by calling 1-800-621-8099. All inquiries are confidential.

You can also find a treatment center near you.

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