The misuse of and addiction to opioids including prescription pain relievers, heroin, and synthetic opioids such as fentanyl is a serious national crisis that affects public health as well as social and economic welfare. Dentists were the top prescribers of opioids to 10 to 19 year-olds in 2009. Alternatively, non-steroidal anti-inflammatory drugs should be prescribed. There are many efforts happening to improve opioid prescriptions and we, as a dentist can be of great asset in dealing with this crisis and preventing it further.

The Impact
According to 2018 data, more than 128 people in the United States die every day due to opioids overdose. The misuse of and addiction to opioids including prescription pain relievers, heroin, and synthetic opioids such as fentanyl is a serious national crisis that affects public health as well as social and economic welfare. The total economic burden in the United States is $78.5 billion a year including the costs of healthcare, lost productivity, addiction treatment, and criminal justice involvement. More devastating is unfathomable emotional burden on the millions of family members left in the wake of addiction. [1,2]

From 1999 to 2017, more than 700,000 people have died from a drug overdose out of which 400,000 were due to opioids including prescription and illicit opioids 2 which is higher than deaths from H.I.V, car crashes or gun violence at their peaks. 

How are dentists contributing?
More than 191 million opioid prescriptions were dispensed to American patients in 2017—with wide variation across states. [2] Dentists prescribe a notable amount of opioid prescriptions. Studies have estimated that dentists write 12% of all opioid prescriptions, and unused dentally-prescribed opioids cause 1,500 deaths each year. [3] Two-thirds of dental opioid prescriptions are written for surgical visits, with the other one-third prescribed for non-surgical visits, mostly restorative work. [4,5]

Dentists were the top prescribers of opioids to 10 to 19 year-olds in 2009, and the most dramatic increase in dental opioid prescriptions was seen in patients 11 to 18 years-old, with prescriptions rising from 99.71 to 165.94 per 1,000 patients over just a five-year period from 2010 to 2015. [5]

Who should I worry about?
Opioids can affect anyone, of any age, race, education level, or socioeconomic class and might be completely unnoticed on external examination. The CDC emphasizes that safe opioid prescribing practices are not just indicated for “high-risk patients.” Each patient in our chair is at risk for opioid abuse, and the precautions we take as alert practitioners can save their lives. [6]

What can I do to prevent it?

• We must educate ourselves and our patients on the proper role of opioids in dentistry. National organizations like the Centers for Disease Control and Prevention (CDC) and ADA (American Dental Association) are valuable sources of evidence-based information. [7,8]
• Alternatives such as non-steroidal anti-inflammatory drugs (NSAIDs). Studies have shown that 400 mg of ibuprofen plus 1,000 mg of acetaminophen is more effective and has less risk than opioid medications. [4]
• Educating patients on proper prescription disposal. Studies have shown that 54% of opioids prescribed for dental surgery go unused, and leftover pills left in medicine cabinets are the easiest way for drugs to land in the hands of drug-seekers. [6] The list of medications that should be immediately flushed includes common dental prescriptions such as oxycodone (Oxycontin, Percocet) and hydrocodone (Lortab, Norco, Vicodin)
• Before you dispense the prescription be prepared to access prescription drug monitoring programs (PDMPs). PDMPs are valuable statewide databases where practitioners can tap into real-time information on a patients’ drug history. The medications listed in the database generally include opioids and benzodiazepines, which are involved in 71% and 31% of prescription drug overdoses, respectively. [8] 
• PDMPs also includes a history of the patient’s quantity and length of prescription so practitioners can calculate if patients are requesting inappropriate prescriptions. [8] Red flags can include multiple prescribers, multiple pharmacies, and self-pay patients attempting to avoid insurance restrictions. [8] As of January 2018, 39 states require that healthcare professionals check their state’s PDMP prior to prescribing addictive drugs. [9]

What contributions can I make to address the crisis?
The ADA encourages dentists to seek continuing education in Screening, Brief Intervention, and Referral to Treatment (SBIRT) for patients who may be at risk for substance abuse and/or be prone to addiction.

SBIRT is an evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs. It is comprises of three basic components. [11]

• Screening: Specialized techniques for identifying risky substance use behaviors.
• Brief Intervention: Specialized techniques for motivating at-risk individuals to change their behavior.
• Referral to Treatment: Specialized techniques for referring these patients for appropriate diagnosis and treatment (e.g., support line, addiction counselor, treatment facility, etc.).

SBIRT is based on an Institute of Medicine recommendation, which called for community-based screening for health risk behaviors. [10]

How to identify drug abusers?
Longo et al [11] described the following characteristics in patients with drug use disorders:

• It is important to identify the under prescribed patients due to Physician’s or patient’s fear of addiction who seek more dosage and patients who overuse the drug. When prescribing the drug, the prescriber should always co-relate the patient’s claim and examination findings.
• Drug-Seeking behavior should be identified by accessing the patient’s manipulative or demanding behavior to get the prescription.
• “Doctor Shopping”- A term defined as patients visiting multiple practitioners to receive multiple prescriptions. Doctors and pharmacists should closely monitor this type of activity.
• Scamming: Manipulating providers to change their decision to prescribe the medication which they declined before. This characteristic is pathognomonic of an abuser.

Many studies have demonstrated that opioid analgesics do not provide greater pain control than non-opioid analgesics for acute or chronic pain. Also, opioid-containing analgesics have a high risk of adverse effects than their non-opioid counterparts. There are many efforts happening to improve opioid prescriptions and we, as a dentist can be of great asset in dealing with this crisis and preventing it further.