Prescription for Trouble

The man on the phone told a compelling story. A former pilot in the Israeli air force, he’d been injured in a plane crash that left him in constant pain. He hoped that the dentist could prescribe just enough painkillers to get him through the weekend.

“What he didn’t remember is that he’d already called me,” says Noshir Mehta, DG73, DI77, professor and chair of general dentistry, who suspected the man—injured in a plane crash or not—was addicted to pain pills and likely seeking prescriptions from multiple sources. “It’s not unusual for us to get calls like this over the weekend,” says Mehta, who is also director of Tufts’ Craniofacial Pain, Headache and Sleep Center.

Prescription painkiller abuse has skyrocketed in recent years. More than 10 million Americans took opioid painkillers such as Percocet and oxycodone for nonmedical reasons in 2002, according to the National Survey on Drug Use and Health. It’s no surprise then that opioid overdose-related visits to the emergency room more than doubled between 2004 and 2008.

One reason for the rise in painkiller abuse has been the huge increase in prescriptions written for legitimate medical reasons. In 2002, health-care providers wrote 29 million oxycodone prescriptions, up 50 percent since 1999. A previous study by Nathaniel Katz, an adjunct assistant professor of anesthesiology at Tufts School of Medicine and director of the Tufts Health Care Institute Program on Opioid Risk Management, found that up to a quarter of those pills—roughly 2,150 doses each day—never get used by the intended recipient, a phenomenon known as drug diversion.

A couple of years ago, Mehta and Katz convened a panel of experts from academia, law enforcement and governmental agencies to explore the role of dentists in preventing opioid abuse and drug diversion. Among the team’s findings was that dentists write about 12 percent of all opioid prescriptions—a number that surprised Mehta and his colleagues.

“Initially, people didn’t think dentists prescribed these opioids, but 12 percent is an extremely high level. It’s becoming more evident that there is abuse potential,” says Mehta.

Checking for Signs

Last year, Mehta, Katz and their colleagues presented their findings in the Journal of the American Dental Association and provided a number of common-sense steps that dentists can take to curb opioid diversion and misuse.

“The first thing a dentist needs to do is understand the patient,” Mehta advises. “Many dentists don’t understand the ramifications, both short- and long-term, of these opioids.”

The consequences are myriad. A patient struggling with addiction to drugs or alcohol could experience a life-threatening drug interaction, while a recovering addict might relapse if prescribed opioids. Nor is the danger limited to the patient in the dental chair.

A spouse or child at home may be wrestling with addiction. That’s why Mehta and his colleagues suggest that questions about substance abuse become a routine part of taking medical histories. “Those questions can be very difficult for the average dentist to ask, but in this day and age, that is part of what we have to deal with,” he says.

But even asking patients these tough questions may not be enough. Mehta and his coauthors encourage specialists to check in with the referring dentist before prescribing heavy-duty drugs. Likewise, general dentists would be well served to confer with their patients’ physicians or even have the physicians write the prescriptions.

“If I am giving out a prescription to a patient, I want to make sure I have spoken to the primary-care physician,” says Mehta, adding that coordinated care between dentists and physicians is good practice—even when the medications in question aren’t addictive—and can prevent accidental drug interactions. “We train our students here to call the doctor, especially when there are multiple medications involved.”

If there’s still doubt, dentists can also use prescription-monitoring programs, electronic databases available in 35 states, to verify patients’ prescription drug history. (You can find information about what’s available online in each state.)

The most obvious way dentists can minimize the risks of potentially addictive painkillers is by writing fewer prescriptions. Dentists in the Tufts clinics rarely prescribe opioids for routine dental procedures. Over-the-counter analgesics such as ibuprofen and acetaminophen work for most people and won’t mask pain from infections or other post-op complications, Mehta notes.

Of course, some patients, including those undergoing painful surgical procedures, will require stronger analgesics. For these patients, Mehta and his research colleagues suggest that simply reducing the number of pills prescribed would keep many doses out of the hands of recreational users.

“Many medications are misused because they hang out in the bathroom cabinet,” says Mehta, who notes that more than 65 percent of teens who have tried prescription painkillers report getting them for free or buying or stealing them from friends or family.

This article first appeared in the Fall 2011 Tufts Dental Medicine magazine.

Jacqueline Mitchell can be reached at jacqueline.mitchell@tufts.edu.