The prescription drug crisis has affected all sectors of the population, and so it is inevitable that dentists will increasingly see at-risk patients or those with substance use disorders in the course of their professional activities. Recognizing these patients and the special needs that they may have is now part of the standard of care for the profession. Screening for substance misuse involves a thorough history and review of the patient’s medical record and, as appropriate, reviewing prior records and use of available screening tools.
Key points
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Dentists should use screening tools (eg, Opioid Risk Tool and NIDA Quick Screen) and other techniques to identify patients at risk for developing SUD and be able to intervene upon suspicion or identification of an SUD.
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Dentists should identify the rationale for and benefits of active communication and collaboration with other treating clinicians (interprofessional collaboration) and know when to consult with a Pain specialist.
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Dentists should recognize the importance of periodic reassessment, follow-up, and documentation with ongoing and long-term management of pain and opioid analgesics.
Introduction
The prescription drug crisis has affected all sectors of the population, and so it is inevitable that dentists will increasingly see at-risk patients or those with substance use disorders (SUD) in the course of their professional activities. Recognizing these patients and the special needs that they may have is now part of the standard of care for the profession. Screening for substance misuse involves a thorough history and review of the patient’s medical record and, as appropriate, reviewing prior records. Several risk assessment tools are available that can help identify relevant risk factors and quantify the level of substance misuse risk. Accessing the patients’ prescription drug monitoring program (PDMP) data will identify the recent history of controlled substance prescriptions and provide information on potential misuse activities. None of these tools are definitive but can help to provide information to the dentist in order to identify and discuss risk factors with the patient.
Prescription drug monitoring programs
PDMPs are state-run programs that collect and distribute data about the prescription of controlled substances. These programs are administered by a variety of state agencies, including Boards of Pharmacy, Departments of Health, Professional Licensing Boards, and Law Enforcement Agencies. The intent of PDMPs is to help prevent substance misuse by providing historic data on patient’s-controlled substance prescriptions. All states, other than Missouri, currently have a PDMP in effect, and many state programs are interoperable with those in other states ( Fig. 1 ). The goal is to have all state-based PDMPs interoperable, so prescribers can check their patients’-controlled substance history across the country.
As an example, the Massachusetts PDMP, administered by the Department of Public Health and now called Massachusetts Prescription Awareness Tool (MassPAT), is a computer-based system that collects controlled substance prescription data submitted by pharmacies in the state and those who deliver controlled substances medications to the state on all controlled substances, within 1 business day. In Massachusetts, this includes all opioids, benzodiazepines, gabapentin, and tramadol. The data provide registered users, including dentists with the appropriate licenses, with information about the controlled substance prescription data for their patients.
Each state has its own specific regulations, and in Massachusetts, use of the database has been mandated since October 2016. The law instructs prescribers to check this database each time when prescribing controlled substances. PDMP data can indicate forged and altered prescriptions, doctor shopping, prescription rings, unlawful dispensing, as well as prescription, distribution, and health care fraud. Data show that there is a greater impact on clinician adherence with this mandate in place.
Prescription monitoring program data
The MassPAT database consists of the patient’s name, date of birth, sex, address, name of the drugs prescribed, strength, quantity, number of days, prescriber name, prescription number, pharmacy where filled, number of refills, morphine equivalency per day (morphine milligram equivalents [MME]), payment type, and state where prescription was filled. It also lists the prescribers’ names, addresses, and telephone numbers, as well as the pharmacies’ name, address, and telephone number. A summary provides the total number of controlled prescriptions, number of prescribers, pharmacies used, private pay numbers, and active daily MME in the last year. Each of these pieces of data can be useful and is subject to interpretation.
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Name. Patients may be known by nicknames or abbreviated names but are listed in the database under their legal names, sometimes with a middle initial (eg, Jackie Smith vs Jacqueline Smith vs Jacqueline M. Smith). Misspellings are also possible.
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Date of birth is a mandatory field and will differentiate between people with the same name but different birth dates.
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Address. Addresses can be entered with varying information (ie, apartment numbers, street names, and local community names vs municipality [Charlestown vs Boston, MA]). Two addresses may indicate that the person has moved but can also show that the person is registered at 2 or more separate locations, sometimes with the intent to escape detection. This is less likely now with increased interoperability.
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Medications listed. Each US state defines which medications are listed, and these lists are updated from time to time (eg, Massachusetts added gabapentin [Neurontin] to its list of reported medications in August 2017). Generally, opioids and benzodiazepines are listed. A combination of opioids with benzodiazepines is a sign of concern because 71% of prescription drug overdoses involve opioids and 31% involve benzodiazepines.
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Quantity and days prescribed allow a calculation of number of doses per day. This helps with identification of overlapping prescriptions or early refills. Medications prescribed within a formal methadone maintenance program are not listed in MassPAT; other states also have some limitations on the drugs that are listed.
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Prescribers. Multiple prescribers for the same or similar medications could indicate “doctor shopping,” which is one of the primary ways that people obtain prescription drugs for nonmedical use. However, considering the organization of the health care system, numerous prescribers may not represent a problem because several individuals listed at the same address may represent physicians and nurse practitioners working in the same facility all with access to the same medical record.
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Pharmacies. The number of different pharmacies a patient uses may be a cause of concern. Patients may legitimately use pharmacies close to home or to work for convenience or several pharmacies within the same chain.
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A combination of multiple prescribers and multiple pharmacies. Multiple prescribers and multiple pharmacies combined can indicate misuse potential. There is no universal definition, but 5 prescribers in any 1 year and 4 pharmacies in any 90-day period is used by MassPAT to indicate a level of concern and to generate reports for prescribers to alert them to potential issues.
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Mean morphine equivalency. Opinions vary as to the definition of “high dosing.” The Centers for Disease Control and Prevention suggest that there is a need to address risk at more than MME of 50 mgm/d and encourages clinicians to avoid risk at greater than MME of 90 mgm/d Dunn and colleagues have stated that more than an MME of 100 mgm/d resulted in an 8.8-fold increase in overdose risk. Most dental surgery patients requiring opioids will have an MME of 50 mgm/d or less.
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Payment type. The cost of controlled substances for legitimate purposes is usually covered under medical insurance, with copayments or limitations of quantity, and time between refills mandated by the state or insurance carrier. Self-pay may suggest that the patient is avoiding these restrictions.
The Massachusetts Department of Public Health added the Visano Opioid Stewardship Platform to the MassPAT system on December 9, 2019. This system offers a representation of the data in an interactive form, allowing prescribers and pharmacists to more quickly and easily understand the data and help improve clinical decision making and patient safety. It also provides tools and resources for patients. The system supplements the data found in the MassPAT database: in addition, patient demographics and risk indicators are displayed, and prescribing history is shown in graphic form in addition to a list of local SUD treatment resources. The summary and prescription data are the same as the original MassPAT data. Risk indicators, chosen by MassPAT, include “More than 5 providers in any year (365 Days), More than 4 pharmacies in any 90-day period and more than 40 MME/day and more than 100 MME total.”
Types of misuse
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Doctor shopping. It implies that the patient is going from 1 physician’s or dentist’s office to another and obtaining multiple prescriptions for opioids or other controlled substances for the same symptom. Individual states’ PDMPs classify such cases as “activities of concern” because more detail is often needed before assuming illegal behavior. This behavior is typically characterized by the patient having multiple pill bottles labeled for the same opioid medication, prescribed by multiple practitioners, and frequently filled at multiple pharmacies to avoid detection. The typical scenario is for the patient to present with factitious symptoms, and once an opioid prescription has been obtained, move on to the next location. Dentists are particularly at risk because they predominantly practice alone or in small groups and do not have ready access to patients’ medical records or to colleagues practicing nearby. This scam can also be perpetrated on several members of a group practice especially if they have more than 1 office location and do not have a robust and timely way to communicate repeat appointments, multiple medications, and outside-of-business-hours’ refill requests. This type of activity has been difficult to detect without the real-time data provided by the PDMP. This behavior was documented in a 2017 National Public Radio segment in which 2 prior opioid abusers in a recovery program described how they maintained broken teeth in their mouths to get dentists to prescribe opioids. According to Massachusetts law, patients have the responsibility of informing their providers if they are being treated by another provider and receiving prescriptions for the same ailment. Providers can also refuse to write a prescription if they feel the patient is not being truthful. Doctor shopping and other drug-seeking behaviors point to the benefit of health care professionals’ using tools to help assess opioid addiction risk.
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Hoarding. In anticipation of increased pain related to upcoming surgery, patients can mislead their providers about the number of opioid pills they are taking with the result that they hoard medications for an anticipated increased need or “for a rainy day.” Such behavior also heightens the risk of death by suicide or unintended overdose.
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Diversion. It occurs when legally produced controlled pharmaceuticals are illegally obtained for nonmedical use. Examples include physicians, dentists, or pharmacists selling prescriptions or drugs to nonpatients, employee theft, doctor shopping, robberies, and prescription forgeries. Cases of veterinary opioid pain medications being diverted to the human population have been reported.
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Overlapping prescriptions. This is a form of misuse that can occur in different ways. The patient can request early refills from the primary provider or go to another provider for a duplicate prescription. The frequent excuses are vacation requests, increased use due to special circumstances (for example, stressful unforeseen circumstances, trauma, weather changes), and so forth. Patients can also acquire prescriptions for overlapping medical or surgical conditions; for example, a dental extraction while receiving treatment for an orthopedic injury.
Utilization of PDMP data is just 1 way that clinicians can assess the risk for patients who may experience substance misuse. Risk assessment tools, such as the National Institute on Drug Abuse quick screen and Opioid Risk Tool, together with a careful history, accurate diagnosis, and pain management plan are essential elements for ensuring that patients have their pain controlled in an appropriate and safe manner.
The impact of PDMPs as an opioid risk management tool is mixed. The data can help avoid “doctor shopping” and drug interactions. It is also helpful in communication between prescribers and interactions with patients. Concern has been expressed that the data can have a “chilling effect” on prescribing habits and lead to undertreatment of pain and the cause of patients turning to illicit drugs. Rasubala and colleagues found that the impact of mandatory PDMPs significantly reduced the number of opioid prescriptions and number of pills prescribed by dentists.
In Massachusetts, over the period CY2015 to CY2018, controlled substance prescriptions decreased for “all prescribers” and for “all dentists” and continued to decrease after the MassPAT program went live on August 22, 2016. Searches by dentists increased dramatically in the quarter before implementation until October 15, 2016 when all prescribers were required to check the database before prescribing opioids; thereafter, the number of searches remained constant. During this timeframe, prescription counts dropped 47% (60% nationally); solid quantity dropped 55%, and total MME/day dropped 58%. Days’ supply per patient was reduced by 16%, and 20% of prescribers did not renew their prescribing licenses. Dentists also prescribed alternative medications for pain control nationally, 34%, and in Massachusetts, 39%.
The Massachusetts Department of Public Health has recently launched The Massachusetts Substance Use Helpline, a free tool for finding substance use treatment and recovery services. It also provides overdose education, including naloxone distribution sites. In addition, a mobile application is now available to help health care providers apply the recommendations of the Centers for Disease Control and Prevention’s Guideline for Prescribing Opioids for Chronic Pain into the clinical setting. This application includes a Total Daily Opioid Dose (MME) Calculator to identify more quickly patients at risk of overdose as well as access to prescribing guidance and information on motivational interviewing to improve the decision-making process and the communication skills, respectively. All these resources are helpful for the dentist, who may not be part of a broader health care team.
Opioid risk assessment
In a recent study, 58% of Massachusetts dentists thought assessment of substance use was within their scope of practice, with 95% registering with MassPAT. However, the compliance rate was only 20% compared with physicians at 60%. Nationally, 50% of dentists stated that they assessed PDMPs, and in Massachusetts, the number was 38% (5% consistently). Ten percent of Massachusetts dentists used forms or questionnaires to assess opioid risk, and 76% “asked patients directly.” The ability to assess risk was related to levels of training.
Screening tools
Massachusetts law requires that prescribers assess risk before prescribing opioids, and several instruments are available. The National Institute on Drug Abuse (NIDA) Quick Screen ( Figs. 2 and 3 ) asks “how often you have used alcohol, tobacco products, prescription drugs for non-medical purposes and illegal drugs in the past year.” This app can be used on a smart phone and administered in a few minutes; the risk score is calculated and displayed once the information has been entered. The Opioid Risk Tool ( Figs. 4 and 5 ) asks the same questions with the addition of asking about a history of sexual abuse in preteenage years for women, a factor that is highly associated with opioid abuse in later life. Each positive response is scored, and low risk is graded at lower than 3, medium risk 4 to 7, and high risk 8 or above.
