Dentists reassess their role amid growing opioid crisis


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Dentistry at a crossroads

Dentists, oral surgeons and endodontists have long occupied a rather overlooked position when it comes to addressing pain. While general practitioners and primary care doctors have taken the spotlight, especially in the last year, dentists are also frequent prescribers of immediate- release opioids like Vicodin and Percocet.

In some ways, who can blame them? They see patients experiencing some of the worst of it, from terrible tooth infections to the cruel phenomenon that is a dry socket (this is the condition when a nerve becomes exposed after a tooth extraction). They also provide post-operative pain management for procedures like the one Hatzell underwent.

But as the nation struggles with a major drug epidemic, one that has been linked to some 165,000 prescription drug overdose deaths in the last 15 years, and one that has in part been fueled by the misuse of prescription painkillers, dentistry is at a crossroads.

When prescriptions go unused, they may be diverted for non medical use. One report estimated that a fifth of opioid prescriptions are subject to medical misuse.

It all means that many in the field are now reassessing their role in ways they might not be used to. That has meant new approaches and an even more elemental realization about how to best treat the pain that’s rooted in the mouth.

Challenges in changing practices

One challenge, though, is countering long-held perceptions.

“The opioids have a lot of hype,” said Dr. Elliot Hersh, a professor of pharmacology and oral surgery at the University of Pennsylvania School of Dental Medicine and a research collaborator with Dr. Moore.

Hersh is a leading researcher on post operative dental pain (some drug manufacturers have funded his research), and he says anti-inflammatory drugs like Ibuprofen just don’t have as much hype.

“Why? Because they’re available over the counter,” he said. “And what a lot of the lay public believe is if they’re available over the counter, they’re weak and they don’t work.”

It’s also taking a while, he says, to cut through the noise of widely marketed over-promises to the public and to doctors that opioids were the ideal option, that they weren’t as potentially addictive as we now know they are. He takes a self-described hardline approach in the classroom with future dentists, even bringing in a retired narcotics officer to be a regular presenter in his class.

“I’ve been teaching my students that you have to be really, really careful with these drugs,” he said. “That if you write too many of these drugs, for either good or bad intentions, either the state dental board and, or the DEA [Drug Enforcement Agency] is going to come down on you.”

Still, none of this is an exact science. Every patient’s response to pain is unique.

Hersh has found around one in five patients still need a combination of both anti-inflammatory medication and narcotics to control it.

And here’s the problem.

“The patients are still numb when we prescribe, so we don’t know who that 20 percent is going to be that also requires an opioid added on,” said Hersh.

A doctor may have a sense of what’s to come, depending on what happened during the surgery,
but why some patients feel more pain than others is still a mystery. It all means that dentists may end up writing a prescription for at least some opioids to be on the safe side. If a patient has breakthrough pain in the middle of the night, a dentist can’t just call in a prescription because of the drug’s classification.

Even though about three quarters of some 560 clinicians surveyed by the American Dental Association a few years ago preferred ibuprofen in treating post operative pain for wisdom teeth extractions, even more – some 85 percent – reported that they still prescribed an opioid. The average was 20 tablets of a hydrocodone acetaminophen combination, to be taken “as needed.”

Still, it’s a tricky scenario, as the issue then becomes “they use one or two [pain pills] and there’s eight left over,” said Hersh.


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