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A message from the ADA president

Preventing opioid abuse from the dental chair

January 22, 2018

ADA President
Joseph P. Crowley


Dear Colleagues:

Shortly after I was installed as ADA president, I read an article about Dr. Omar Abubaker, an oral surgeon in Richmond, Virginia, whose 21-year-old son died suddenly after overdosing on a combination of heroin and benzodiazepine. Even though he was an oral surgeon who routinely prescribed Percocet for post-operative pain, he’d missed all the signs that something was wrong. In fact, the experience made him realize how little he really knew about how drugs alter the brain and the warning signs of drug dependence.

Being a parent myself, Dr. Abubaker’s story hit close to home, so much so that I asked if he’d be willing to share his story and reflect on how it’s changed his practice. You can read his story in this edition’s My View.

In 2016, opioids (including prescription opioids, heroin and fentanyl) killed more than 42,000 people — more than any year on record — and 40 percent of those deaths involved a prescription pain reliever, according to the Centers for Disease Control and Prevention. This doesn't count the 1.8 million Americans (including 152,000 teenagers) who reported abusing or being dependent prescription pain relievers, according to the Substance Abuse and Mental Health Services Administration, and the unknown number whose addiction to heroin and other illicit drugs started with a prescription pain reliever.

Like all surgeons, there are times when our patients will need to manage post-operative pain. It’s inherent to our specialty. And when opioid analgesics are called for, we can do a lot to keep these potentially addictive pain medications from becoming a source of harm. 

Today, I’m asking dentists everywhere to reflect on how we manage dental pain and take several specific steps to help keep opioid pain relievers from harming our patients and their families.

  • First, consider using non-narcotic pain relievers as a first line of treatment. The data on opioids finds they are not as effective as other treatments and are associated with more adverse events. Often, some combination of nonsteroidal anti-inflammatory drugs (such as ibuprofen, naproxen, etc.) and acetaminophen or aspirin can be just as effective.
  • Second, when an opioid pain reliever is indicated, consider prescribing fewer pills in accordance with the latest pain management guidelines and your own state law. If your state allows it, partial filling may be an option. A federal law enacted in 2016 permits dentists to request that their prescriptions be partially filled, subject to state law.  It also allows pharmacies to dispense the remaining portions in increments without further authorization from the prescriber.
  • Third, it goes without saying that we should counsel our patients about the benefits and drawbacks of using opioid analgesics, especially how these drugs can be addictive. We should also instruct them how to safely secure, monitor and dispose of them at home. Most people who abuse prescription opioids get them for free from a friend or relative, and those drugs are often obtained from the home medicine cabinet and sometimes the trash.
  • Fourth, learn to recognize when a patient might have a substance use disorder or be prone to addiction. We should all know how to briefly counsel these patients and refer them for appropriate treatment. It can be an uncomfortable conversation, but it’s one we need to have and know how to have it.

Likewise, learn to recognize when a patient may be seeking an opioid for illicit purposes. Noticing suspicious behavior is one way. Another is to check your state’s prescription drug monitoring database to see if a patient might be “doctor shopping.” Some states even require it.

The ADA is here to help you put these ideas into practice.

  • Take a look at the ADA’s statement on the use of opioids to treat dental pain. The statement covers everything from using non-narcotics as the first-line pain therapy to screening and counseling patients for potential drug problems. It was revised in 2016 specifically because of the opioid crisis facing us today.
  • Watch for the ADA’s next round of free continuing education webinars on safe and effective opioid prescribing. They are free, tailored to pain management in dentistry, and available to members and non-members alike. Plus, the ADA CERP credential provides a sound basis for state regulatory agencies to accept the continuing education credit for licensure.

The ADA produces about four webinars a year covering everything from screening and counseling patients to using prescription drug monitoring programs. To register, visit Success.ADA.org/opioids.

  • Review the “ADA Practical Guide to Substance Use Disorders and Safe Prescribing.” This easy-to-use clinical reference manual includes techniques dentists can use to manage pain for patients who may be at risk for substance dependence. The guide is available at Catalog.ADA.org.
At the national level, the ADA has been pursuing common sense policies to address dentistry’s role in preventing opioid abuse. The ADA successfully lobbied for a 2016 law supporting a number of activities to help prevent opioid misuse and abuse. We are now pressuring Congress to fund those activities. We are also pressuring federal agencies to better tailor their prescriber education and outreach to the medical indication.

Make no mistake: Dentistry has not been idle on this issue. The greatest percentage decrease in opioid prescribing rates between 2007 and 2012 occurred in emergency medicine (-8.9 percent) and dentistry (-5.7 percent), according to an article published in the September 2015 edition of the American Journal of Preventive Medicine.  Those data are over five years old, but they are the best we have and it’s a part of the story that needs to be told.

As a profession, we can do a lot to keep opioid pain relievers from harming our patients and their families. We can be more judicious in our prescribing when less aggressive treatments are indicated. We can also make sure patients leave our offices knowing about their abuse potential and how to safely secure, monitor and discard them at home.

With your help, we can hopefully end this tragic and entirely preventable public health crisis that has been devastating our families and communities. Find out more at ADA.org/opioids.