New Allies in the Fight Against Opioid Addiction
Late on a Friday afternoon, a new patient comes into the dental office with a toothache. She’s in severe pain, she says, and her X-rays reveal a cavity. There isn’t time to start a procedure, so her dentist books an appointment for first thing Monday morning. She asks the dentist to prescribe her something for the pain, just to get her through the weekend.
“What would you do?” Ronald J. Kulich, a professor of diagnostic sciences, asks a roomful of second-year students at the Tufts School of Dental Medicine. “Write her a script for 30 pills? What’s your gut reaction?”
Kulich, a psychologist who specializes in chronic pain, is using this hypothetical case to help his students understand the basics of addiction screening. It’s part of a continuing effort to stem the tsunami of prescription-painkiller addiction that has swamped the United States since the early 2000s. (See also “Tufts Dental School Joins Effort to Curb Opioid Abuse.”)
Every day, 44 Americans die from an overdose of prescription painkillers, which includes opioids, hydrocodone, oxycodone and methadone, as well as benzodiazepines like Valium and Xanax, according to recent data from the Centers for Disease Control and Prevention. The next generation is also at risk. Every 25 minutes a baby is born suffering from opioid withdrawal, according to the National Institute on Drug Abuse. The alarming statistic represents a fivefold increase since 2000. That’s why it’s crucial for dentists to know the signs of and risk factors for addiction before taking out that prescription pad.
Drawing from a mosaic of real-life cases, Kulich offers students more detail about his hypothetical patient. She has a pleasant demeanor, but she’s unemployed and may be so permanently as a result of back surgery. She had a post-surgery prescription for Vicodin, but she says she didn’t refill it. She smokes a little less than a pack of cigarettes a day and takes an anti-anxiety medication to help her sleep. She takes some heavy-duty headache meds, and she has an allergy to the drug suboxone.
At least one student recognizes this last red flag—suboxone is used to treat opioid addiction.
“I encourage you to use the patient’s medicine list as a way to complete your evaluation,” Kulich advises the students. “Sometimes that will tell you more than a patient will. Knowing esoteric medications will give you a nice history.”
Since 2010 dentists and physicians practicing in Massachusetts have been required to check the state’s prescription monitoring program (PMP) database, which is housed on a secure website and keeps track of all prescriptions filled by patients in the last year. The database, which is populated by data from pharmacists and health-care providers, is designed to prevent patients from doctor shopping to obtain multiple painkiller prescriptions from multiple providers.
All 50 states plus the District of Columbia and Guam employ PMP technology. Massachusetts was among the first to mandate its use and to work aggressively toward training physicians and dentists in identifying patients at high risk for substance abuse, says Kulich, who is working with state agencies in Massachusetts to determine how health-care practitioners and law enforcement can work together to address addiction.
The PMP can also help dentists make better clinical decisions, avoid drug interactions and foster better collaboration with their patients’ other health-care providers, he says. “It’s going to give you an opportunity to have a conversation with the patient,” says Kulich, who acknowledges some dentists are reluctant to broach the topic of addiction with their patients. “Assessment doesn’t have to ruin your relationship with the patient, but may improve it and give you a chance to have a frank discussion.”
In Kulich’s hypothetical case, the PMP reveals the patient filled not one, but two prescriptions for opioid painkillers recently, one from a dentist, the other from a physician. Whether she lied about it or forgot, says Kulich, doesn’t really matter. Dentists still need to treat their patients’ pain.
A cautious dentist might opt to prescribe this patient a very small number of pain pills and require her to come back on Monday for follow-up. An over-the-counter analgesic such as acetaminophen or ibuprofen could work, although these drugs also carry risks, such as stomach and cardiovascular side effects. For some patients, prescription opioids remain the safest and most effective strategy for pain control, providing the dentist conducts an adequate assessment of risk, says Kulich.
“It’s not about shifting away from opioids,” he says. “The buzzword is ‘rational prescribing.’”
Jacqueline Mitchell can be reached at firstname.lastname@example.org.
A version of this article first appeared in the Winter 2016 issue of Tufts Dental Medicine magazine.