Dentistry is in a unique position among the health care professions to assess and manage the patient with controlled substance risk. The concern over opioid risk is not new, and historically dentists have had to balance the critical need for adequate pain care with the importance of recognizing the consequences of using controlled substances for their patients. Barriers for providing adequate patient assessment and management may be greater in dentistry than other health care fields, although these barriers can be recognized and overcome. Collaboration with cotreating providers will improve patient outcomes and reduce patient risk.
Dentistry is in a unique position among the health care professions to assess and manage the patient with controlled substance risk.
The concern over opioid risk is not new, and historically dentists have had to balance the critical need for adequate pain care with the importance of recognizing the consequences of using controlled substances for their patients.
Barriers for providing adequate patient assessment and management may be greater in dentistry than other health care fields, although these barriers can be recognized and overcome.
Collaboration with cotreating providers will improve patient outcomes and reduce patient risk.
According to the Centers for Disease Control and Prevention, in 2017, 17.4% of the US population received 1 or more opioid prescriptions, with the average patient receiving 3.4 prescriptions. This figure decreased dramatically in 2018. Based on a 2019 IQVIA report, opioid prescribing decreased by 17.1% from 2017 to 2018, with a decrease of 43% since the peak in 2011. Although this decrease is encouraging, considerable work is still left to be done. Given the outcries by patients and the health care professionals who care for them, a better balance should be achieved between the need to provide effective and safe analgesia and the societal obligation to avoid a turn to previous prescribing habits and the consequences of such.
Despite the desire to attribute the prescription opioid crisis to a single cause, there are, in fact, numerous causes of the prescription opioid epidemic. The recent report from the President’s Commission on Combating Drug Addiction and the Opioid Crisis noted that “the root causes of the modern opioid crisis are complex and traceable to at least 30 or more factors.” Fortunately, the prescription opioid crisis has declined, although it has been replaced by a crisis of far more deadly illicit opioids. Controversies regarding opioids in pain management seem to have become more salient in regard to chronic pain rather than acute pain. , Irrespective, extreme caution in opioid prescribing still needs to be exercised, even in the field of dentistry in which acute pain management remains the primary focus.
For acute dental pain, the relative effectiveness of nonsteroidal anti-inflammatory drugs have received insufficient attention, because there was level of comfort with prescribing opioids. Even vulnerable populations such as adolescents have been routinely and repeatedly prescribed opioids for conditions such as migraine headache and other pain-related disorders for which there is little evidence of treatment efficacy, and often contraindication. All of these efforts, at least in part, were thought to contribute to what had been termed a prescription opioid epidemic in the United States. Significant social, economic, individual, and family impacts have been widely reported and discussed, although newer shifts in prescribing practices and other factors are now seen as relieving the problem.
Within the past several years, the opioid prescribing rates for all health care specialists have decreased, particularly in dentistry. In 2017, prescription opioids continued to contribute to the epidemic in the United States, with data from the Centers for Disease Control and Prevention suggesting that they were involved in more than 35% of all opioid overdose deaths. It should be noted that the methods that Centers for Disease Control and Prevention used to determine this number were likely flawed, resulting in an overstatement of the percentage of total opioid deaths accurately attributable to prescription opioid overdoses. Irrespective, improved opioid risk mitigation, including frequent urine drug screening, use of prescription drug monitoring programs (PDMPs), and easier access to naloxone is likely to have had a positive impact on prescription opioid misuse associated morbidity and mortality. Nonetheless, individuals with severe opioid use disorders risk have shifted to street-acquired drugs, owing to the decreased availability of prescription opioids that can be used for abuse in conjunction with the considerably lower relative costs of heroin and illicit fentanyl and its analogues. Some investigators believe that recent deaths can be attributed to polypharmacy, that is, a mix of legal substances, in conjunction with diverted controlled substances and/or illicit substances, rather than solely medications from the prescribing physician or dentist.
Opioids and dentistry
Although general dentistry was somewhat less impacted by the early direct marketing efforts, the right to pain relief efforts did provide tacit permission to ignore opioid prescribing risks. Dentists rarely prescribed long-acting agents, and seldom prescribed short-acting agents for long periods of time. There are examples of high numbers of short-acting opioids after surgical procedures such as third molar extractions. At 1 point, dentistry was second after primary care physicians in prescribing overall quantities of short-acting opioids.
Potentially complicating the problem, some investigators have suggested that there have also been excessive surgical treatments, particularly in young adults, resulting in their needless exposure to opioids. In a retrospective cohort study, Schroeder and colleagues found that a substantial number of adolescents are exposed to opioid prescriptions after third molar extractions. They postulated that opioid-naïve young patients were at a higher risk of opioid use/misuse with this sort of exposure. Historically, these concerns have been more common in other procedure-based health care disciplines, with data demonstrating that 1 in 16 surgical patients becomes a long-term user after being prescribed opioids for a surgical procedure. In an attempt to mitigate this problem, national efforts have been undertaken to decrease the number of controlled substances prescribed to patients upon discharge from the hospital, as postsurgical opioid use has been established as a predictor of increased readmission rates and higher risk of substance abuse.
Substance use disorders
In contrast with other substance use disorders, opioid use disorder has received greater attention over the past several years. Despite this attention, alcohol abuse and other types of substance abuse are more commonly seen in health care settings, including general dental practice. Furthermore, patients with polysubstance use issues are at greater risk. Hence, all types of substance use and abuse deserve close attention by dentists who see these patients in their practice on a daily basis.
The Substance Abuse and Mental Health Services Administration states that “substance use disorders occur when the recurrent use of alcohol and/or drugs causes clinically significant impairment, including health problems, disability, and failure to meet major responsibilities at work, school, or home.” Although more detailed diagnostic criteria are reviewed in later chapters and available elsewhere (eg, the Diagnostic and Statistical Manual of Mental Disorders, 5th editions), the broad-based description from the Substance Abuse and Mental Health Services Administration best fits the appropriate lay definition of substance abuse. Substance use disorders are classified as a brain disease, with a focus on minimizing the common stigma associated with the illness. As with any chronic disease, multiple treatment trials may be necessary, but recovery is often possible with proper treatment, regardless of the severity of the illness.
When any substance use disorder is present, the patient’s status is also often complicated by the coexistence of mental health disorders. Substance use disorder is rarely a stand-alone illness, necessitating a broader scope of patient assessment. In this series, we strongly encourage the dentist to devote attention to the mental health comorbidities often present in patients with high substance use risk. Data from the Substance Abuse and Mental Health Services Administration underscore this overlap ( Fig. 1 ).
Common substance use disorders seen within dental practice include alcohol, nicotine, and more recently cannabis use disorders, and each is associated with an array of dental and medical consequences. Among adults age 18 and older in 2018, 14.4 million adults or 5.8% of the age group suffer from an alcohol use disorder, with fewer than 8% receiving treatment. Alcohol abuse remains the third leading preventable cause of death in the United States, the first being tobacco, the second being poor diet and physical inactivity. Tobacco abuse, a disorder commonly addressed in dentistry, predicts a higher likelihood of opioid misuse in the context of treating chronic pain. Similarly, the mere presence of cannabis in a patient’s urine predicts a higher likelihood of subsequent aberrant urine toxicology screening when chronic opioids are being prescribed. Given the interrelationship of these comorbid risk factors, predicting patient behavior associated with substance abuse is challenging. Nonetheless, cost-effective screening in the dental office can provide the dentist with important information, resulting in improved patient management, and the patient may be offered more efficient referral and access to effective treatment.
Historical antecedents to managing pain and addressing substance use risk
Dentistry now plays an important role in the management of the patient’s overall health, with national organizations such as the American Dental Association and the American Dental Education Association increasingly highlighting the need for responsible assessment of substance use risk and better management of these complex patients. Most important, this effort must be balanced with adequate pain care for the patient. Although some may believe that concern over the balance between substance use risk and effective pain management is new, they have been voiced in dentistry for more than a century.
Since its inception as a health care specialty, dentistry has played a crucial role in acute pain management and analgesia. The first successful public demonstration of ether for surgical purposes was provided by the dentist William Thomas Morton at Massachusetts General Hospital on October 16, 1846. Horace Wells and other dentists also were using similar agents to care for their patients years before. As ether moved from a recreational frolic drug toward common medical use, surgeries dramatically increased in number across the United States and Europe. Concurrent with the famous anesthesia demonstration, opioids were coming into widespread use throughout the nineteenth century to better manage pain for a range of conditions, including acute dental pain. Not unlike today’s controversies, national debates ensued regarding the role of opioids and the prescription of other potentially risky substances by physicians and dentists, and discussions of industry influence and physician bias were as common then as they are today. In 1891, Oliver Wendell Holmes Sr., the famed physician and anatomist from Harvard, was widely quoted in newspapers across the country when he stated “if a ship-load of miscellaneous drugs, with certain very important exceptions, drugs, many of which were then often given needlessly and in excess, as then used could be sunk to the bottom of the sea, it would be all the better for mankind and all the worse for the fishes.” Because of lack of regulations of drugs such as opioids and cocaine, there was widespread opioid prescribing for multiple conditions. To decrease the sudden increase of drug dependence, the Harrison Narcotic Control Act was passed in 1914. Nonetheless, the concerns did not abate.
Historically, the twentieth century witnessed better control of acute pain with a range of effective strategies for analgesia and anesthesia. Effective nonopioid analgesics were introduced, especially agents such as acetaminophen and nonsteroidal anti-inflammatory drugs (see Shehryar Nasir Khawaja and Steven John Scrivani’s article, “ Managing Acute Dental Pain: Principles for Rational Prescribing and Alternatives to Opioid Therapy ,” in this issue).
Providing adequate pain management and concurrent assessment of risk
Safe and effective pain management is critical in dentistry, particularly in acute pain management. Echoing guidance from all professional organizations, the Dental Education Core Competencies for the Prevention and Management of Prescription Drug Misuse note that “dentists deal predominantly with acute pain, using standard evaluations and evidence-based treatment protocols that are highly effective for acute pain.” This is now commonly termed “rational prescribing.” Rational prescribing does not mean “not prescribing.” In addition to selecting safer and more effective nonopioid agents when appropriate, interventional and nonpharmacologic strategies also can play a role. Assessing risk, knowing the patient, and setting realistic patient expectation can also help to guide decision making.
Although other articles in this special issue provide more detailed guidance with specific detailed case vignettes, the case of a 19-year-old woman illustrates a common scenario of low to moderate controlled substance risk. She presented for an urgent dental visit and was a longstanding patient in the practice with the patient and her family being well-known to the dentist and staff. Her previous office visit had been approximately 1 year prior, with irregular follow-up, partially owing to a recent job loss and insurance change. The assistant fit her in for an evaluation of her new complaint of dental pain before the weekend. An initial thorough examination and assessment revealed a diagnosis of irreversible pulpitis, with a treatment recommendation for a pulpectomy on #21. Because she had not been seen for more than a year, diligent reassessment by the dental hygienist revealed that the patient was taking hydrocodone and diazepam prescribed by her primary care physician, with the dosing being unclear. The patient stated that “my medications are mostly the same, except for some changes in my headache and neck pain medications. I had been using a little bit of Vicodin for my neck, but it hasn’t helped with this new dental problem. I use a little bit of diazepam as it gets me through the night.” She further revealed that she occasionally used “a few Fioricet, a couple per month for my migraines. I’m not on any other medications.” In the conversation with the dentist, her social history revealed that she had a strong social support system, a stable relationship, and planned marriage soon.
As with most patients, this dentist had a good rapport with the patient who was well-known to the practice. A narrow approach could have been pursued, finalizing plans for the dental procedure, and the patient could have been discharged with the standard follow-up. Strong analgesics would unlikely have been needed, and the patient’s care could have been managed with a short-term nonsteroidal anti-inflammatory drug. Despite this common care scenario, the case presented the dentist with an opportunity to more thoroughly address opioid risk. As discussed in greater detail in articles elsewhere in this issue, this patient presented with a number of substance use risk factors that required further assessment. Although her opioids were apparently low dose, she admitted to using an opioid left over from another prescription for a dental problem, a condition for which the medication was not prescribed. Additionally, she was concurrently using 3 controlled substances (an opioid, a benzodiazepine, and a barbiturate), a factor that can increase risk. Although the dentist may not have been mandated to check the PDMP because a prescription for opioids was not as yet planned, it was a reasonable option to consider a PDMP check before initiating the dental procedure. In this case, the check revealed that she had had 1 prescription from her primary care physician filled 11 months prior for hydrocodone/acetaminophen 325/5 mg, #10 with no refills, with no other opioids listed. She was prescribed and filled diazepam 2 mg #45/mo on an ongoing basis from primary care, and her most recent Fioricet prescription for 30 tablets had been refilled 6 months prior. These PDMP results were consistent with her self-report. As part of the reassessment, the hygienist also administered a brief self-report substance use screener, on which the patient denied abuse of other substances other than for smoking less than 1 pack of cigarettes per day. This young woman’s case is relatively common to most dental practices. Further discussion revealed risk factors that often go unnoticed. She had polypharmacy issues and was using opioids for a problem for which they were not prescribed, that is, her recent dental pain. Her risks were further heightened in that she may have been experiencing stressors associated with a recent job loss. Even at low dosages, she remained on a medication regimen that posed additional risks for women of childbearing age, should she have become pregnant. It also was noted that she was smoking, representing a risk factor that is predictive of other substance use disorders, including an opioid use disorder. The patient’s positive relationship with the dentist provided a unique opportunity for further assessment and management. Even if the dentist merely made note of these risk factors and supportively addressed these concerns, there is an opportunity to exert a substantive impact on the patient’s overall health care and well-being. This discussion typically builds on the positive relationship between the patient and clinician. Despite their sensitivity, such personal discussions also predict better general adherence with other dental treatment recommendations, and thus overall treatment outcomes may be improved. This factor is discussed in an article in this issue on the importance of actual discussion as opposed to mere questioning in communicating with patients.
Throughout this issue, we discuss assessment protocols that can guide the dentist in evaluating patients who may have a low to a high risk of substance misuse. Although an increasing number of standardized risk screeners are available for physicians, we have elected to focus on practical strategies that are more likely to fit general dental practice ( Fig. 2 ). It is not expected that the dentist would cover every risk factor for all patients. The very complex, high-risk patient may be well-served with the most thorough assessment, that is, covering all of the assessment components addressed in Fig. 2 . Consultation and referral with an addiction medicine specialist should be considered an option in cases in which substantial risk is present. Finally, the role of the dental hygienist cannot be discounted. Indeed, it is not uncommon for the hygienist to have the closest relationship with the patient, and they can effectively use the brief risk screeners outlined in additional articles in this issue.