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ADA, NIH look for ways to collaborate on dentistry's role in preventing opioid misuse

April 02, 2018

By Jennifer Garvin

Group photo of ADA leaders and Drs. Somerman and Volkow
Collaboration: The ADA, National Institute on Drug Abuse and National Institute of Dental and Craniofacial Research discuss the oral health profession's response to the opioid crisis. Clockwise from top left are Dr. Lawrence Tabak, principal deputy director, NIH; Dr. Joseph P. Crowley, ADA President; Dr. Kathleen T. O'Loughlin, ADA Executive Director; Nora Volkow, M.D., director, NIDA; and Dr. Martha Somerman, director, NIDCR. Photos courtesy of the National Institute on Drug Abuse
Rockville, Md. — When the ADA announced new policy on opioids in March, other organizations took notice.

One of those was the National Institute on Drug Abuse.

Its director, Nora Volkow, M.D., called the policy, which supports prescription limits and mandatory continuing education for dentists, "impressive" during a March 28 meeting with the ADA.

In addition to calling for prescription limits and mandatory CE, the new policy supports statutory limits on opioid dosage and duration of no more than seven days for the treatment of acute pain and asks dentists to register with and utilize prescription drug monitoring programs.

NIDA and the National Institute of Dental and Craniofacial Research are federal scientific research institutes under the National Institutes of Health. The two organizations met with ADA President Joseph P. Crowley and ADA staff to discuss ways the oral health community is currently addressing the current opioid crisis and opportunities to collaborate in the future.

"It's not exciting that we have to be talking about such a pervasive problem, but it is exciting that as dentists we can be part of the solution," Dr. Crowley said.

"This is one of [the NIH's] highest priorities and that's why I'm here," said Dr. Lawrence Tabak, principal deputy director, NIH, who also attended the meeting.

The ADA first adopted policy on opioids and treating dental pain in 2005. The policy was updated in 2016 and includes recommendations for dentists to consider nonsteroidal anti-inflammatory analgesics as the first-line therapy for acute pain management.

That policy is supported in the April Journal of the American Dental Association article, "Benefits and Harms Associated with Analgesic Medications Used in the Management of Acute Dental Pain." In that article, authors from the University of Pittsburgh School of Dental Medicine, the ADA, Case School of Dental Medicine and The Ohio State University examined five systematic reviews that explored the effectiveness and/or adverse events associated with the use of oral medications for acute pain relief. They found, that for adults, a combination of 400 milligrams of ibuprofen plus 1,000 mg of acetaminophen was found to be superior to any opioid-containing medications studied.

Photo of Drs. Somerman and Volkow
Opportunities: Dr. Martha Somerman, director, National Institute of Dental and Craniofacial Research, left, and Nora Volkow, M.D., director, National Institute on Drug Abuse, talk about ways dentists can help prevent opioid misuse.
In 2008, members of the ADA Health and Wellness Committee, which serves dentists who are themselves in recovery, noticed an increase in patients with substance use disorders, including opioids, noted Alison Bramhall, who manages the committee. This led the committee to develop online CE on the topic, and in 2012 the committee began hosting quarterly webinars on safe opioid prescribing. They started out small but now the webinars regularly draw 2,000-3,000 dentists. The next webinar will be held April 25.

The ADA Board of Trustees adopted 2018's interim policy on opioids after it was drafted and submitted by the ADA Council on Government Affairs during its March meeting. The council also received guidance on crafting the interim policy from the ADA councils on Scientific Affairs, Dental Education and Licensure, and Dental Practice.

NIDA began looking at dentistry's role in opioids misuse in 2004, when Dr. Volkow approached Dr. Tabak — who was then director of NIDCR — and told him after looking at the prescription records, she was worried dentists were the main prescribers of opioids for children and adolescents.

The ADA met with NIDA and NIDCR around that same time and after that, Dr. Volkow said she noticed a dramatic decrease in the number of opioids prescribed by dentists.

In a 2012 article in the Journal of Preventive Medicine, researchers noted that in 1998 dentists were the top specialty prescribers of opioid pain relievers, accounting for 15.5 percent of all opioid prescriptions in the U.S. However, by 2012 this number had fallen to 6.4 percent.

"I'm anxious to see the data from 2016. I think it's going to drop even more. I think it's going to take a cliff dive," Dr. Crowley said.

Now that the new opioids policy is in place, the next step is to give dentists tools to refer patients in need of care without going beyond their scope of practice.

"That is a very important aspect in terms of integrating the care," Dr. Volkow said.

"It's complicated," Dr. Crowley said, "because when patients go to the dentist they don't expect a lecture on whether they're abusing illicit substances."

Dr. Martha Somerman, NIDCR director, agreed. "It's the culture," she said. "We need to go back to the dental schools and change the culture there."

At this point, the conversation turned to dental schools, which are currently addressing the role they can play in the prevention of opioid prescription drug misuse.

Dr. Tabak wanted to know, "What can the ADA do to get this on dental board exams? Because if it's on the boards, everyone will teach to it."

The American Dental Education Association is also addressing the opioid epidemic by convening a summit, hosting webinars and disseminating information about dental schools' developing prescriber training along with other resources and programs. The subject is also the focus of a new policy brief entitled, "The Role of Dental Education in the Prevention of Opioid Prescription Drug Misuse."

"Efforts to minimize and control prescription drug misuse are critically important to dental educators, who play a pivotal role in changing dentistry's approach to pain management," said Dr. Richard W. Valachovic, president and chief executive officer, American Dental Education Association.

In 2016 the ADA Council on Dental Practice wrote a letter to the Joint Commission on National Dental Examinations requesting the commission add national board exam questions on acute pain management and screening for substance use disorders. The JCNDE agreed the questions would be appropriate for the exam and are currently writing the exam questions with the help of subject matter experts from the ADA Dental Health and Wellness Advisory Committee.

The ADA is also developing CE for practicing dentists.

For the last two years, Dr. Paul Moore, a member of the ADA Council on Scientific Affairs and director of the Oral Health Science Institute and chair of the Department of Dental Anesthesiology for the University of Pittsburgh School of Dental Medicine, has taught "Safe and Responsible Prescribing of Opioid Analgesics" at the ADA annual meeting. The course (No. 5800) will be offered again at ADA 2018 in Hawaii.  

In addition to the article on the benefits and harms associated with analgesic medications used to manage dental pain, the April JADA contains three additional cover articles on opioid prescriptions from the dental perspective that examine opioid prescribing patterns, disparities in opioid prescriptions for dental patients receiving Medicaid, and prescription monitoring programs and their role in assisting prescribers.

The gathered organizations also discussed opportunities to address opioid misuse in rural populations and access to care issues related to the crisis.

To see all of the ADA's efforts to prevent opioid prescription drug misuse, visit ADA.org/opioids.