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Compendium
April 2019
Volume 40, Issue 4
Peer-Reviewed

Strategies to Scrutinize Opioid Prescribing for Dental Pain Management

David A. Hamlin, DMD, MBA

The use of opioids to treat oral health pain has its roots in opium mixtures used more than 2,000 years ago, homemade concoctions that were not so reliable and had varying potency. The invention of morphine in the early 1800s isolated the active ingredient in opium and was hailed as a wonder drug, offering a safer and more predictable form of pain management. However, during the Civil War many injured soldiers became addicted to this opioid, and it became known as the "soldier's disease."1

Opioids can easily become an addictive substance. As the strength of these medications continued to increase over time, this class of drug became used in an increasing number of health situations for management of pain. One could speculate that, despite the advent of injectable local anesthetics that greatly helped facilitate the performance of dental procedures, without the availability of opioids and other narcotics throughout the centuries individuals may have been lost at epidemic levels to the systemic risks associated with avoiding treatment for severe tooth decay and abscess. Today, unfortunately, individuals are being lost at epidemic levels due to addiction, overdoses, and deaths related to the increased use and potency of opioids. Dental professionals have a front-line opportunity to combat the opioid epidemic and improve the coordination and quality of care for patients who are taking opioids.

A Real Problem

Many alarming statistics paint the picture of the opioid epidemic in the United States and underscore why dental professionals need to take action. Each day about 130 people die from opioid overdoses,2 and opioid overdose deaths in 2016 were five times higher than in 1999.3 The highest numbers of new opioid prescriptions in the dental profession are being written for teenagers whose still-developing brains put them at higher risk for opioid dependence disorders.4 Moreover, for people aged 18 to 25 there is a 6.8% increased chance of opioid dependence disorder within 1 year of having wisdom teeth extracted with an opioid prescription.5 Additionally, one in five individuals with just a 10-day prescription has an increased risk of opioid addiction.6 Finally, while 80% of consumers in a national Cigna survey agree that "anyone could become addicted to opioids, even someone like me," most are unaware or disagree that "opioids are not safe to take for more than 1 week without an increased risk of addiction."7

What Can Be Done?

No one entity can solve this crisis alone. However, there are steps that dental professionals can take, as outlined in the following sections.

Consider Non-opioid Therapies First

As the impact of opioid over-doses and deaths in the US population continues to be felt, it is essential that clinicians find ways to reduce the total number of opioid prescriptions, the strengths of the dosages being supplied, and the quantity. It is important to consider instead the use of proven nonsteroidal anti-inflammatory drug (NSAID) protocols that have been researched. NSAIDs are a non-addictive pain-killing alternative to opioids. In addition, the fact that they treat inflammation is particularly noteworthy, as dental pain is commonly mediated by an inflammatory component.8 Opioids have no anti-inflammatory mechanism of action and, therefore, are only effective for opioid-receptor-blocked pain relief.9

Proceed Cautiously When Prescribing Opioids

Clinicians should start with the lowest therapeutic dose and quantity possible and follow-up with the patient to determine if his or her situation warrants a prescription renewal. A conversation should take place with patients about the risks associated with opioid use. If a patient asks for an opioid and the clinician disagrees, it is important that the clinician remain confident in presenting non-opioid interventions as the best option for effective pain management. Providers also can obtain insights regarding patients' other opioid prescriptions by taking advantage of a state's prescription drug monitoring programs.

Create an Individualized Pain Management Plan

Narcotic pharmacology is a critical part of a dentist's toolkit, but that does not mean it should be used widely. Every patient's pain tolerance level and situation is unique. A pain management regimen for patients should consider all available proven, safe, and effective modalities, with the clinician bearing in mind that while tailoring a plan to the patient is recommended, evidence-based multimodal prescribing regimens have been outlined in the literature and can serve as a starting off point for clinicians.

Leverage Data From Multiple Sources

Integrated healthcare data from sources such as multi-benefit insurers can offer insights for flagging potential opioid misuse and outlier prescribing patterns. Claims data across pharmacy, medical, and dental benefits can be analyzed to detect opioid use patterns that may suggest possible misuse by individuals, prompting outreach to their healthcare providers. In addition, doctors can be notified when their opioid prescribing patterns are not consistent with the Centers for Disease Control and Prevention's guidelines. More awareness within the prescribing community of their own actions compared to their peers could help bring about change.

Collaborate With Other Stakeholders

The digitalization of data also makes it easier to determine the cumulative effect of multiple opioid prescriptions for one patient. For example, Cigna, a health service company and pharmacy benefit manager, has implemented a personalized dose calculation-morphine milligram equivalents (MME)-program to monitor and manage usage for customers taking high levels of an opioid with the goal of reducing the potential risk of an overdose. Customers and their providers are notified if the total daily dose of opioids across prescriptions is high. (MME is a standard measurement unit used to evaluate the type and strength of the opioid being prescribed.) The average daily MME is a more important factor than the volume of prescriptions. For example, a daily dose equaling or exceeding 90 MME per day increases the risk of an overdose 10 times more than a daily dose of 20 MME per day or less.10

Conclusion

While the dental community cannot stop the use of opioids altogether, with ongoing research, new information on NSAID alternatives, and the continuing development of non-addictive hybrid opioids,11 the need for certain types of opioids will lessen. Given what is now known about the risks of opioid misuse and dependency, these drugs should not be the first medication that dentists consider prescribing to patients after delivering dental services known to result in a pain response. Of course, an educated patient is also essential in fighting the opioid epidemic.

For thousands of years, the medical and dental profession has learned about the benefits and side effects of opioids. Today's dental providers need to be part of the solution to this crisis and help save lives by championing appropriate use of opioids when treating their patients.

About the Author

David A. Hamlin, DMD, MBA
Cigna Dental Director for the Eastern Region of the United States; previously in private practice and clinical research

References

1. Sabatowski R, Schäfer D, Kasper SM, et al. Pain treatment: a historical overview. Curr Pharm Des. 2004;10(7):701-716.

2. Opioid overdose: understanding the epidemic. Centers for Disease Control and Prevention website. December 19, 2018. https://www.cdc.gov/drugoverdose/epidemic/index.html. Accessed March 6, 2019.

3. US Dept of Health and Human Services, Office of the Surgeon General. Facing Addiction in America: the Surgeon General's Spotlight on Opioids. Washington, DC: HHS; September 2018.

4. Gupta N, Vujicic M, Blatz A. Opioid prescribing practices from 2010 through 2015 among dentists in the United States: What do claims data tell us? J Am Dent Assoc. 2018;149(4):237-245.

5. Schroeder AR, Dehghan M, Newman TB, et al. Association of opioid prescriptions from dental clinicians for US adolescents and young adults with subsequent opioid use and abuse. JAMA Intern Med. 2019;
179(2):145-152.

6. Shah A, Hayes CJ, Martin BC. Characteristics of initial prescription episodes and likelihood of long-term opioid use - United States, 2006-2015. MMWR Morb Mortal Wkly Rep. 2017;66(10):265-269.

7. Omnibus Survey, Cigna, 11/3/17-11/6/17.

8. Becker DE. Pain management: Part 1: managing acute and postoperative dental pain. Anesth Prog. 2010;57(2):67-78.

9. Al-Hasani R, Bruchas MR. Molecular mechanisms of opioid receptor-dependent signaling and behavior. Anesthesiology. 2011;115(6):
1363-1381.

10. Opioid Prescribing. Centers for Disease Control and Prevention. CDC Vital Signs. July 2017. https://www.cdc.gov/vitalsigns/pdf/2017-07-vitalsigns.pdf. Accessed March 6, 2019.

11. Ding H, Czoty P, Kiguchi N, et al. A novel orvinol analog, BU08028, as a safe opioid analgesic without abuse liability in primates. Proc Natl Acad Sci U S A. 2016;113(37):E5511-E5518.

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