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Blocking the Path to Addiction
Can a Simple Over-the-Counter Solution Help Dentistry Stop the Opioid Abuse Epidemic?
By Lisa Neuman
Ninety-one Americans died today as a result of an opioid overdose.1,2
That’s not a misprint. Today, a mom lost her son. A son lost his dad. A dad lost his friend. A friend lost his sister. A sister lost her coworker. A coworker lost a neighbor. Today, it is not only likely that you know someone who has been lost to an opioid overdose, it is nearly guaranteed.
It is an epidemic with alarming statistics. In 2009, the number of fatal drug overdoses outnumbered the number of fatal motor vehicle accidents in the United States for the first time.3 In 2014, more than 28,000 people died from opioid-related drug overdoses—ranging from legally prescribed painkillers such as Percocet and Vicodin to street-obtained heroin—up from more than 16,000 deaths in 2010.1,3 In 2015, according to data reported in Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health, 12.5 million Americans misused prescription pain relievers, 20 million people had full-blown substance-abuse disorders, and 78 people died every day from an opioid overdose, a rate that was already almost four times what it was in 1999.1
But this rate is still rising according to findings from the Centers for Disease Control and Prevention (CDC), which reported that 91 people died every day from an opioid overdose in 2016—more than 33,000 in total.2 During his term, outgoing US Surgeon General Vivek H. Murthy, MD, MBA, a vice admiral in the US Public Health Service, recognized substance-abuse disorders as “one of the most pressing public health crises of our time.”1
As a result of these increasing mortality rates caused by substance misuse between 1999 and 2014, the CDC has lowered white Americans’ life expectancy by 4 months.1 It found that other population groups were not as adversely affected by opioid mortality mostly because they have more difficulty getting access to prescription painkillers.
In addition to both a shortened life expectancy as well as a significantly diminished quality of life for the abuser, his or her family, and the community at large, the misuse and abuse of illegal drugs and both prescribed and non-prescribed narcotic drugs costs the United States an estimated $200 billion a year in lost productivity, healthcare interventions, and law enforcement efforts;1 the CDC found in a recent study that opioid abuse alone accounts for $78.5 billion of that total, and fatal overdoses of opioid-class drugs cost the economy $21.5 billion in 2013.3 By comparison, the costs in lost productivity and healthcare resources associated with a serious disease such as diabetes are $245 billion each year.1
The Substance Abuse and Mental Health Services Administration of the US Department of Health and Human Services (HHS) estimates that nearly 2 million people are currently abusing or are dependent on prescription painkillers.4 The substance-abuse problem the nation currently faces is not only serious, it is unprecedented.
The Genesis of an Epidemic
How did we get here? How did we get to the point where opioid misuse and abuse has become an epidemic, a public health crisis, one of law enforcement’s biggest challenges, and a monumental drain on the American economy?
“Twenty years ago, there was a great deal of public pressure that reached Congress and medical organizations because millions of people had chronic pain and we [all healthcare providers] were undertreating them,” explains Paul Moore, DMD, MS, PhD, MPH, a dental anesthesiologist and a professor in the Department of Public Health at the University of Pittsburgh School of Dental Medicine. A leading expert on pharmacology, Moore was recently asked to serve on the US Surgeon General’s Expert Panel of Prescription Drug Abuse. “[There was pressure to make] pain the fifth vital sign. So that started an increase in the number of prescriptions for opioids, particularly for chronic pain,” he goes on. “Most of the addiction problems we see are in people who have chronic pain and have access to extended-release, long-acting opioids: fentanyl patches, oxycontin, those kinds of drugs. Because there was an increased supply of those [ER/LA opioids] and the supply significantly increased for 10 to 15 years, we began to see increased abuse of those drugs. As the numbers doubled and then tripled, we began to see increased cases of overdoses in emergency rooms. It’s a problem that we created in an effort to manage people’s chronic pain, which certainly is a noble enterprise in theory, but it didn’t work out so well in practice.”
There is one main difference between the types of pain dentists and medical doctors treat, and that is duration. While medical doctors see millions of people every year in chronic pain from illness or injury—think about cancer or long-term back pain, for example—dentists by and large only see their patients when they are in acute pain, whether it is from an infected root canal, an abscess, a failed restoration, implant surgery, or—the scenario in which the vast majority of opioids are prescribed—third molar extractions.
“In dentistry we don’t normally treat chronic pain,” Moore says. “Or, the chronic pain we do treat we don’t manage with opioids. We’re not routinely using the long-acting agents—Oxycontin or methadone—that are causing so much concern. Nevertheless, we do write prescriptions for opioids [for acute pain], and in the last 4 or 5 years we’re beginning to address the necessity for that. If we’re not entirely the problem, we at least have the capability to be part of the solution.”
Dentistry’s Responsibility as Prescribers
In July 2016, Carol Gomez Summerhays, DDS, immediate past president of the American Dental Association (ADA), wrote to the membership in an issue of ADA News that with a 6% decrease in opioid prescribing rates between 2007 and 2012, dentists have dropped from being the second to the fifth most-frequent prescribers of opioid-based pain medications (behind family practitioners, internists, general practitioners, and surgeons on the medical side of healthcare), but, “…The bad news is that research on dental prescribing practices is still scant, leaving lawmakers to make far-reaching policy decisions based on anecdotal evidence and haphazard assumptions.”5 In September 2016, President Summerhays and ADA Executive Director Kathleen T. O’Loughlin answered a request for information from HHS asking how federal opioid prescriber educational programs could be improved, writing that, “Our main concern is that the Department’s programs and activities have not sufficiently distinguished pain management in dentistry from pain management in medicine.”6 They pointed out that the current strategy developed by the US Food and Drug Administration addresses extended-release and long-acting opioids, which are rarely used in dentistry to manage acute dental pain on a short-term basis, if they are used at all.6
Even without clear guidance in the form of federal policy, dentistry has made some strides in lessening its own role in the opioid crisis. Most states have a prescription monitoring program (PMP) to help physicians, nurse practitioners, dentists, and other healthcare providers who are licensed to prescribe access information about the dispensation of federally controlled substances, including prescription drugs with abuse potential. In some states, dentists and physicians are mandated to check the PMP prior to prescribing opioids; Massachusetts is one state with such a mandate. Morton Rosenberg, a professor in oral and maxillofacial surgery and the head of the Division of Anesthesia and Pain Control at Tufts University School of Dental Medicine, explains that Massachusetts is also the first state to stipulate that prescribers cannot write for more than a 7-day supply of Schedule II or Schedule III drugs—which include the opioids—for new adult patients, and they also cannot write for more than a 7-day supply of these drugs for any minor patient at all. “These measures are in place to prevent the phenomenon known as ‘doctor shopping,’ where patients go from provider to provider hoping to obtain a prescription for these addictive narcotics,” Rosenberg says. “We’re the first state to mandate these measures.”
The Commonwealth has built in required courses in pain management for both medical and dental students, which Rosenberg says is also a first of its kind. “The three dental schools in Massachusetts—Boston University, Harvard University, and Tufts University—have put together a dental core competency for the current intervention and management of prescription drugs,” he says. “We are the first state to mandate these three measures together to prevent opioid abuse. It is key to be very careful to make sure that our patients are not in pain, but these drugs need to be prescribed intelligently, judiciously, and effectively.”
Changing the Prescribing Paradigm
For dentistry, there are options for pain management that are far safer, and far more efficacious, than the potentially more dangerous class of opioid drugs. Some clinicians, and certainly most patients, might be surprised to know that these better options are available in the neighborhood drug store right where one would look for a bottle of Excedrin (aspirin), Aleve (naproxen sodium), or Advil (ibuprofen) for a headache or a sprained ankle—in the nonsteroidal anti-inflammatory drug (NSAID) aisle.
“The first-line drugs should be NSAIDs,” says Elliot Hersh, DMD, MS, PhD, a professor in the Department of Oral & Maxillofacial Surgery/Pharmacology at Penn Dental Medicine of the University of Pennsylvania. “What clinicians need to know, whether they be general dentists or oral and maxillofacial surgeons, is that generally NSAIDs supplied at optimal doses—for ibuprofen that would be 400 to 600 mg and for naproxen sodium it would be 440 to 550 mg—will outperform typical doses of opioid-combination drugs. What I mean by outperform is that in randomized, double-blind, controlled clinical trials, the NSAIDs have been shown to have greater efficacy and fewer side effects. They tend to be better tolerated. The opioids should only be used as add-on drugs when NSAIDs alone can’t manage all of a patient’s pain. In the model we studied, that’s about 20% to 25% of patients who have had their impacted third molars removed.”
Hersh advises that if an NSAID doesn’t provide sufficient pain relief on its own, the next step would be to combine it with 500 mg of acetaminophen, which is the equivalent of one Extra Strength Tylenol. “That combination appears to have a profound opioid-sparing effect,” he says.
As potent inhibitors of prostaglandin synthesis via a blockade of the cyclooxygenase (COX) enzyme system at the site of the surgical trauma or injury, NSAIDs reduce inflammation and edema, and, therefore, pain.7 While patients with a true NSAID allergy, have NSAID-sensitive asthma, extremely poor renal function, are pregnant or breastfeeding, or have other medical contraindications may need to avoid these medications, they are generally safe as long as they are taken as instructed.7 Opioids, on the other hand, have no ability to reduce inflammation or the sensitization of free nerve endings at the surgical site, which are the primary causes of dental pain. “If you look at the studies using pure opioids in postsurgical dental pain, they perform—at best—modestly well. In fact, it’s been shown that 400 mg of ibuprofen, which is equivalent to two Advil, actually had greater analgesic effects than 60 mg of immediate-release morphine,” Hersh explains. “That’s twice the morphine dose typically used in breakthrough cancer pain, and we know that cancer pain is not the same as postsurgical dental pain. When you’re talking about postsurgical dental pain you’re talking about a prostaglandin component. NSAIDs work by blocking the synthesis of prostaglandin, so they’re actually hitting the target of the pain the patient is feeling. They’re not working by changing a patient’s perception of pain, where they may still feel pain but they don’t care anymore [because of the euphoria caused by the drug]. That’s what the opioids do.”
Convincing Patients—and Clinicians—To Go OTC
Regardless of the drugs’ actual mechanisms, there has long been a cultural expectation that postoperative dental pain will be severe enough to require opioid analgesics to manage. This expectation is especially high after third-molar extractions, where the patient is typically younger than 21 years of age and in a population segment that is particularly susceptible to opioid addiction. But even with all the data available showing that opioid analgesics are in many cases far less effective than a simple cocktail of acetaminophen and a NSAID in managing dental pain, why are dentists still one of the top five prescribers of these powerful agents when safer solutions exist? How does the profession go about changing the patient perception that Advil or Aleve is going to do better than Vicodin or Percocet? “There’s the problem,” Hersh acknowledges. “Of course, because the opioids are tightly regulated and DEA scheduled, there’s both a patient perception and sometimes a clinician perception that these are strong pain relievers and, therefore, they must work better than drugs that at lower doses are available over-the-counter. One of the problems we have as dentists is that we write the scripts for these drugs while the patients are still numb, so we don’t have conclusive evidence on how they are going to feel once the numbness wears off. They just got their impacted third molars removed but typically they’re not in pain yet. So we write the script and kind of base what we write on how long the surgery was and how much bone was removed, but that doesn’t always necessarily predict who’s going to have the most pain,” he says.
In a “Viewpoint” column in the October 2016 issue of Inside Dentistry on the topic, Louis F. Rose, DDS, MD, clinical professor of periodontics at the University of Pennsylvania and New York University and professor of medicine and surgery at Drexel University, College of Medicine, wrote that, “We are all aware that dental pain can be harsh and debilitating. We are naturally inclined to give our patients something to make them feel better, and the request for a potent painkiller is often driven by patient demand and their belief that the stronger a pill, the better it will work. They anticipate suffering after an extraction or other dental surgery and to mollify their anxiety, we acquiesce to their requests for potent pain medication to the point that giving opioids has become common practice.”
“On average, dental pain prescriptions are for 20 tablets of Vicodin, maybe a little less for Percocet,” Moore elaborates. “Our data shows that 15% of patients don’t use that prescription at all after third molar extractions. Another 15% of patients do experience dry sockets or other complications, and so they may need some extra help to stay on top of that pain and will use a full prescription of 20 tablets. For the remaining 70% of patients, they may only use about seven or eight pills, on average.”
Raymond Dionne, DDS, MS, PhD, a research professor at East Carolina University School of Dental Medicine and frequent co-author with Moore and Hersh, agrees as well. “Even using the highest level of pain, like we do when we conduct studies in the oral [dental impaction] surgery model, nearly every head-to-head study shows that a good NSAID given prior to or immediately after the surgery is going to induce analgesia that is greater than or comparable to what you would get with an opiate but with far less side effects,” he says. “When you think about the idea of having the greatest efficacy, preventing pain, and minimizing side effects, the opiates seem to be coming in second place anyway. Then you add in the potential for opiate abuse or misuse, and there is limited rationale for why you would want to use an opioid drug.”
If opioid drugs have so little efficacy in treating dental pain, and the data show that so many pills go unused—which in itself can invite the potential for abuse if those pills then ultimately fall into the wrong hands—why are they prescribed at all? Why not just recommend an OTC acetaminophen/NSAID cocktail to resolve the pain-causing inflammation, or only prescribe one when a patient has clearly demonstrated a need for stronger pain management postsurgery? In many cases, it may be simply due to habit.8 “It’s strictly due to the continuation of well-established clinical practices,” Dionne says. “Our students [at ECU] performed an inquiry using data collected on 30,000 anonymous patients who had had extractions, and about 70% of the time an opioid analgesic combination had been given. When I questioned the students about this, they all said that although they’d been studying pharmacology, they had prescribed the way they did under the guidance of faculty members who had graduated 20 or 30 years ago, had been in clinical practice and now were teaching, but were still using the same medications they had learned to use way back when opiate combinations perhaps made more sense. So we seem to be kind of frozen in time and we’re having some trouble getting the ship of therapeutics turned around in a new direction.”
Remember the Hippocratic Oath in the Dental Context
By simply discharging patients with clear instructions for taking an OTC acetaminophen/NSAID combination for pain management—and, of course, keeping medical contraindications and drug interactions in mind—the dental profession absolutely has the ability to disrupt to opioid addiction pathway. Dentists have already dropped from second to fifth place as the most-frequent prescribers of opioids. With increased awareness and informed patients, this is one list where it’s a good thing to come in last place.
“As dentists, regardless of whether we’re generalists or specialists, and whether we’re endodontists or oral and maxillofacial surgeons, we all have a moral responsibility to not overprescribe these drugs,” Hersh says. “We also have a responsibility to inform that adolescent, that teenager, that 18- or 19-year-old, that these drugs are powerful agents, they’re mind-altering agents, and that if you’re going to play around with these narcotics, you could severely hurt yourself. People overdose on opioids. People die from overdosing on them. If you get arrested for using or distributing these drugs for purposes not related to your medical or dental care, in most states that’s a felony. You can go to jail, be expelled from school or fired from your job, and just totally wreck your life.”
“Four out of five people who abuse heroin started by taking pills—Percocet, Vicodin,” Moore adds. “That’s a remarkable statement, but yet it should be pretty obvious: You won’t find anybody who just woke up one day and decided to stick a needle in his arm. ‘Oh hey, I think I’ll give that a try today.’ No. They started someplace else and they ended up finding heroin because it’s cheaper and they get high faster when they stick the needle in their arm. It’s dancing with the devil. It’s a very scary thing, and I personally know somebody this has happened to. We all know somebody this has happened to.”
1. US Department of Health and Human Services. Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: 2016.
2. Centers for Disease Control and Prevention. Injury Prevention & Control: Opioid Overdose. https://www.cdc.gov/drugoverdose/index.html. Accessed December 20, 2016.
3. US Department of Health and Human Services. Behavioral Health Coordinating Committee. Prescription Drug Abuse Subcommittee. Addressing Prescription Drug Abuse in the United States: Current Activities and Future Opportunities. Washington, DC: 2013.
4. US Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. Washington, DC: 2015.
5. Summerhays C. ADA News. Dentistry’s role in preventing prescription opioid abuse. July 5, 2016. http://www.ada.org/en/publications/ada-news/2016-archive/july/a-message-from-the-ada-president. Accessed December 20, 2016.
6. Garvin J. ADA urges HHS to elevate dental pain management in opioid training activities. ADA News. September 7, 2016. http://www.ada.org/en/publications/ada-news/2016-archive/september/ada-urges-hhs-to-elevate. Accessed December 20, 2016.
7. MacGill M. NSAIDs: How Do These Painkillers Work and What Can They Treat? Medical News Today. 18 May 2016. http://www.medicalnewstoday.com/articles/179211.php. Accessed December 21, 2016.
8. Moore PA, Dionne RA, Cooper SA, Hersh EV. Why do we prescribe Vicodin? J Am Dent Assoc. 2016;147(7):530-533.