Sunday, February 01, 2015

Don't forget to floss . . . and take your drugs

An MD friend is a substance abuse counselor here in Massachusetts.  She reported to me that a substantial percentage of her clients have been able to maintain their addiction through supplies of opiates prescribed by dentists. In all the recent talk about excessive use of opiates, I had never heard about this source.

So I wondered if there has been any study of this by the profession or coverage of this issue by the media.  After a search, I found this 2010 report from the Tufts Health Care Institute Program on Opioid Risk Management.  Excerpts:

The top specialty prescribing IR [immediate release] opioids in the United States is family practice (approximately 15% of prescriptions written), but this is closely followed by dentistry and internal medicine (both approximately 12% of prescriptions). It is estimated that more than 12 billion dosage units of opioids are dispensed annually in the United States. If dentists write 12% of prescriptions, they prescribe an estimated 1 to 1.5 billion doses of IR opioid products annually. As the epidemic of abuse largely involves IR opioid products, it seems that dentists may be writing opioid prescriptions that are being ingested in the context of nonmedical use or abuse.

When asked about doses of IR opioids that dentists suspect patients have left after a third molar extraction, 36% of dentists expect patients to have leftover drugs, which could be a major source for abuse. Other common procedures showed a similar pattern of doses given, days of therapy, and suspected doses left over.

The survey also examined dentists’ experiences with drug diversion and substance abuse—36% did not ask new patients if they had a history of substance abuse. Other key findings were that 76% of dentists estimated that 1% to 20% of their patient population were substance abusers.

58% believed they were the victims of prescription fraud or theft; the most common methods were fake pain symptoms (43%), patient claims their prescription was stolen (28%), forged written prescriptions (14%), and altered pill quantity (14%). 

Well, these findings were certainly consistent with my friend's report, and the report of the Tufts conference had some thoughtful recommendations.  So was there any follow-up?

An article appeared in the Journal of the American Dental Association with this conclusion:

Dentists can play a role in minimizing opioid abuse through patient education, careful patient assessment and referral for substance abuse treatment when indicated, and using tools such as prescription monitoring programs. 

Dentists cannot assume that their prescribing of opioids does not affect the opioid abuse problem in the United States. The authors suggest that dentists, along with other prescribers, take steps to identify problems and minimize prescription opioid abuse through greater prescriber and patient education; use of peer-reviewed recommendations for analgesia; and, when indicated, the tailoring of the appropriate and legitimate prescribing of opioids to adequately treat pain. The authors encourage dentists to incorporate practical safeguards when prescribing opioids, consistently educate patients about how to secure unused opioids properly, screen patients for substance use disorders and develop a referral network for the treatment of substance use disorders.

I checked the ADA site to see what guidance the industry association might offer to help dentists carry out these general recommendations. There is a page from 2005 entitled "Statement on the Use of Opioids in the Treatment of Dental Pain."  Among other things, it says:

Dentists who prescribe opioids for treatment of dental pain are encouraged to be mindful of and have respect for their inherent abuse potential.

Dentists are encouraged to recognize their responsibility for ensuring that prescription pain medications are available to the patients who need them, for preventing these drugs from becoming a source of harm or abuse and for understanding the special issues in pain management for patients already opiate dependent.

The most recent article I have found is this interview from Medscape:

I think that dentists in practice as well as those still in undergraduate dental schools and certainly those in specialty programs need more information and educational efforts on treating patients in both active disease (addiction) as well as in the various forms of recovery. 

I may be understating what's available and happening out there, but none of this gives me much confidence. My substance abuse counselor friend says that dentists remain a major source of these drugs and are therefore supporting addiction.  Who will step in and make real changes? When will the media investigate and report on this issue?


Ray Collins said...

Back in the early seventies I had a cyst alongside a wisdom tooth removed along with the tooth. The dental surgeon gave me demerol IV. That one-time experience has always helped me appreciate why so many medical personnel became addicted to it.

I haven't had any painful dental procedures since the rampant opioid abuse headlines, so I don't know what my dentists are currently prescribing. Before that time they would give me a week's worth of tramadol IR. (Can't recall the dose.) If I had filled them all, I would have a lot of tramadol unused. Instead I filled the first one long years ago, took one when I got home, didn't need it, and never filled any of the others I received after later procedures.

Any anecdotes about more recent ways of doing things?

Marilyn said...

This is interesting and deserves more exploration. I am sure there are some disreputable dentists out there just as there are a few physicians who supply excessive and unnecessary opiate prescriptions to drug-seeking addicts. And, addicts know who they are and where to find them. And so, increasingly, does the Board of Registration in Medicine, due to reporting mechanisms.

However, there is not much pain worse than dental pain and I've had 3 kids via natural childbirth. If you've ever had an abscess or wisdom teeth extraction, you know what I'm talking about. My experience and that of my kids is that the dentist typically prescribes a very limited supply of percocet (ie about 5 tabs)before moving you along to ibuprofen and you are happy to have it, if you can tolerate the side-effects.

To not treat pain and relieve suffering, when you can, would leave dentists and physicians open to accusations of malpractice. They certainly need to be aware of the pitfalls but they are in a very difficult position.

Nathaniel Katz said...

As the Director of the Tufts Program on Opioid Risk Management I thank Dr. Levy for bringing this important issue, and our work on the topic, to his readers' attention. For interested readers, all the presentations from our meeting on the role of dentists in prescription opioid abuse can be found at This meeting led to an unusual degree of collaborative output from the meeting participants, which included a small cadre of dentists particularly interested in this issue. Several notable publications have emerged, including a summary of the dentist's role in the prescription opioid abuse problem (Denisco R et al, JADA, 2011), updated guidelines on the treatment of acute pain in dentistry, emphasizing the efficacy of non-opioid treatments (Hersh E, Compend Contin Educ Dent, 2011), and various popular pieces on the topic. Has this successful meeting and related output produced changes in dental prescribing practices? This remains an open question. In the 15 years since the prescription opioid abuse epidemic began, change has been sluggish despite the efforts of many committed individuals in government, academia, and hospital systems - a problem that goes far beyond the dental community. With over 15,000 deaths per year in the US from prescription opioid overdoses alone, our collective inability to effectively address this crisis remains a source of frustration to myself and many others. I appreciate Dr. Levy's bringing further attention to it. Nathaniel Katz, MD, MS

Paul Levy said...

Thanks so much for the expanded update!

Paul Levy said...


Of course, appropriate doses are, well, appropriate. The issue I raise is that lots of this stuff finds it way into the wrong hands. Dr. Katz is kind to bring us up to date, but as he and my MD colleague colleague noted, there's still a problem.