Introduction
Opioid abuse is one of the major burdens of the US healthcare system. Every year, millions of citizens are diagnosed with opioid abuse; the outcomes of it are often fatal. Among other healthcare practitioners, dentists are accountable for prescribing many types of opioid analgesics. Whereas many patients may about their real symptoms to obtain the desired prescription, some physicians do not follow all the necessary precautions to avoid the problem of overprescription. The problem of opioid overuse in the USA has become highly acute, and effective solutions are crucial to mitigate the growing risk. Hence, it is crucial to evaluate the level of prescriptions among dentists and outline the possible ways of reducing them. The present paper argues that dentists need enhanced training on pain management and should implement innovative technologies to manage their patients’ prescriptions to avoid adverse outcomes.
Opioid Prescription in Dentistry
The scope of dentists’ practice involves a variety of skills and operations, including treatment, surgery, and pain relief. The latter is an especially crucial issue since it involves prescribing opioids to patients with the aim of minimizing their pain. Research indicates that many dental specialists fail to adhere to the suggested opioid prescription guidelines (Lutfiyya, Gross, Schvaneveldt, Woo, & Lipsky, 2018). The aspects of dentists’ approaches to the process of narcotic prescription will be discussed in detail below.
In the USA, dentists prescribe analgesic opioids to their patients extensively. As Steinmetz, Zheng, Okunseri, Szabo, and Okunseri (2017) report, the growing number of such prescriptions is becoming a serious public health concern in the country. There are several risks associated with excessive opioid prescriptions in dentistry. First, dental patients tend to have opioid leftovers frequently, which makes them vulnerable to narcotic misuse and overuse (Lutfiyya et al., 2018). Second, there is reported disproportionality in dentists’ prescriptions by age. For instance, more than 30% of all prescriptions are written for adolescents (Lutfiyya et al., 2018). For patients of this age, such practice is particularly dangerous since even one opioid prescription has the potential to raise the “lifetime risk for future opioid abuse” (Lutfiyya et al., 2018, p. 1012).
Reasons for Prescribing Antibiotics
It is vital to note that dentists prescribe opioids for compelling reasons. For example, Baker, Avorn, Levin, and Bateman (2016) report that it is highly common to prescribe opioid analgesics after surgical tooth extraction. This issue can be considered problematic as opioids are not the most effective option for pain reduction. Although there is no sufficient data on nationwide statistics of opioid prescribing upon this procedure, researchers note that there are non-narcotic alternatives that can show similar results in patients, too. For example, Baker et al. (2016) report that the combination of acetaminophen and nonsteroidal medications has the potential to provide effective analgesia for dentists’ post-operative patients. Therefore, although dentists have no legal restrictions to prescribing opioids for patients who have undergone operative treatment, they may use it to their detriment.
Other common reasons to prescribe opioids in dentistry include diagnostic, restorative, preventive, and periodontal procedures, surgical and orthodontic manipulations, root canal treatment, and implant installation (Steinmetz et al., 2017). For example, dentists may prescribe opioids to reduce acute pain and as a follow-up measure after a third moral extraction. It is vital to mention that dentists tend to engage in overprescription due to several reasons, including easy access to opioid substances in rural locations, low cost, and a lack of stigmatization in comparison to illicit drugs (Steinmetz et al., 2017). The outcomes of this challenging issue include chronic pain, opioid abuse, and mental health issues in patients, and will be addressed in the following section of the paper.
Results of Overprescription
One of the primary reasons why overprescription of opioids has become a concern is that if acute pain is not managed properly, it is likely to develop into persistent or even chronic pain in individuals (Moore, 2009). Dana, Azarpazhooh, Laghapour, Suda, and Okunseri (2018) note that even appropriate use of opioid analgesics can cause severe adverse outcomes, such as loss of consciousness and development of infections. For example, prescribing antibiotics to manage the symptoms of the prophylaxis of dental infections can lead to Clostridium difficile infection (Thornhill et al., 2015). In addition, opioid misuse can lead to severe outcomes in pregnant females. For instance, McCarthy, Leamon, Finnegan, and Fassbender (2017) report that drug misuse is associated with an increased risk for comorbidities and mortality, as well as enhanced risk for neonatal abstinence syndrome and fatal withdrawal. Furthermore, excessive prescriptions also serve as an additional financial burden. According to Katz et al. (2013), the cost of treatment of opioid abuse and overdose exceeds tens of millions of dollars yearly.
Studies suggest that even a single case of opioid misuse can lead to severe outcomes in patients. For instance, McCauley et al. (2016) report that the history of previous opioid prescriptions has the potential to cause opioid misuse and abuse in the future. As a result of continuous overprescription, patients may develop chronic substance use disorders and overdose; accidental deaths are among the adverse results of the issue as well. These facts suggest that the procedure of prescribing opioid drugs to dental patients requires significant attention, caution, and precision even if performed once.
The Problem of Opioid Misuse/Abuse and Overprescription
Statistical Data
There is a growing concern among healthcare specialists and researchers about the level of opioid misuse. As mentioned above, while opioids have a high potential to reduce pain rapidly and effectively, they are also likely to be misused or abused, causing addiction. Scholars note that between 5% and 25% of all prescription opioids are not used to satisfy medical needs (Denisco et al., 2011). Over the past few decades, a growing rate of non-medical use of opioids has contributed to both fatal and nonfatal outcomes. The role of dentists in the process of opioid misuse and abuse is critical since these specialists usually prescribe immediate-release (IR) opioids, especially oxycodone and hydrocodone, frequently (Denisco et al., 2011). Notably, dentists are responsible for prescribing almost 15% of IR opioids (Denisco et al., 2011). The current data reveal that these medical professionals are accountable for the largest percent of opioid prescriptions along with family physicians. Thus, it is possible to conclude that dentists contribute to the excessive use of opioids significantly, as abusers commonly use IR opioids in particular.
Recent research studies report a growing number of individuals suffering from a substance use disorder. As of 2015, around 20.8 million Americans were identified as drug abusers (Nack, Haas, & Portnof, 2017). Among them, 2.0 million Americans had a prescription pain reliever disorder, which demonstrated an increase of almost 1.5% between 2013 and 2015. It is crucial to mention that US citizens constitute the largest opioid consumer group in the world. While Americans comprise less than 5% of the world’s population, they are responsible for using up to 80% of opioids in general and almost 100% of hydrocodone, in particular (Nack et al., 2017). The prescription statistics are alarming, as they grew from around 190% in 1997 to more than 585% in 2005 (Nack et al., 2017). In addition, statistical data prove that opioid overuse can often lead to fatal outcomes. Researchers note that these substances count for more fatal cases than heroin and cocaine. For instance, in 2015, around 65% of deaths associated with drug overdose were opioid-related (Nack et al., 2017). In comparison, within the past several years, more people have died of opioid overuse than of car accidents. These data constitute the need to educate dentists on opioid use disorder.
Causes of Overprescription
Several causes may contribute to the incidence of opioid misuse among the population. For instance, some dentists may lack sufficient knowledge of pain varieties or approaches to pain management, resulting in their inability to deny a prescription. Moreover, unfortunately, dental pain is frequently exploited by narcotic-abusing patients (Hupp, 2013). A person may come to the dentist’s office or emergency room complaining about severe pain and requesting immediate help. Many patients simulating pain with the aim of obtaining a prescription may be insistent and convincing, which can potentially lead to decreased alertness in medical professionals (Hupp, 2013). In such cases, it is crucial to remember that most likely, a person truly experiencing pain will agree to pulpotomy or extraction. Meanwhile, there are individuals who do not exhibit real signs of acute ache but agree to no other treatment than an opioid-involving one (Hupp, 2013). Thus, dentists should pay special attention to these patients since they are most likely to be abusers.
The analysis of current literature also reveals the evidence that some physicians abuse their professional competency and prescribe opioids in quantities larger than sufficient. For instance, Chen, Humphreys, Shah, and Lembke (2016) have investigated the distribution of opioids by different healthcare specialists. The analysis was focused on drugs containing such substances as oxycodone, hydrocodone, hydromorphone, levorphanol, oxymorphone, fentanyl, methadone, codeine, meperidine, morphine, and opium (Chen et al., 2016). Scholars concluded that the main cause of opioid overprescription was a small number of “prolific prescribers” responsible for about one-third of opioid prescriptions (Chen et al., 2016, p. 259). The findings of this study suggest that it is crucial to perform in-depth investigations on each dentists’ practices and approaches to pain management.
The data presented above shows that oral health practitioners have to be cautious of patients’ likelihood to be opioid abusers. With the increased opportunities of obtaining illicit drugs on the street, the extent of the problem may be considered close to an epidemic (Solomons & Moipolai, 2014). The responsibilities of dentists, therefore, include not only the treatment of toothache and tooth infections but also observation, identification, and recognition of opioid abuse-related oral health complications.
Racial-Ethnic and Gender Disparities in Opioid Prescription
In investigations of opioid use, researchers mention the issue of unequal prescription and distribution of opioids in addition to the problem of overprescription. As Steinmetz et al. (2017) report, the likelihood of receiving opioid prescriptions is higher for certain vulnerable and ethnic minority populations. Specifically, scholars note that people with low income and no or low level of education receive prescriptions more often than individuals having more economic and social advantages. The same disparity can be traced from the perspective of racial differences. Researchers note that there is a higher mortality rate among African Americans than among Caucasians due to a higher number of prescriptions in the former group (Steinmetz et al., 2017). The results of the study by Singhal, Tien, and Hsia (2016) also demonstrate differences in opioid prescription rates based on ethnicity. Scholars emphasize that non-Hispanic white patients are more likely to receive a prescription for abdominal pain and back pain. However, non-Hispanic Blacks receive more prescriptions for a toothache (Singhal et al., 2016).
The findings presented above reveal that, when considering the methods of eliminating the adverse effect of opioid overuse among Americans, it is crucial to consider ethnic disparities among patients, as they often serve as a basis for the disproportionate prescription of opioids. However, this factor is not the only example of differences emerging during the process of prescribing opioids. LeResche (2011) reports that opioid prescriptions tend to differ by patients’ sex; for example, females are more likely to receive a long-term opioid prescription than males. This fact is potentially associated with a higher rate of lifetime use of opioids by women than by men (Serdarevic, Striley, & Cottler, 2017). The problem of gender and ethnic disparities in opioid prescription deserves thorough analysis since it is likely to aggravate the incidence of deaths due to opioid abuse and overdose in certain population groups.
Recommendations for Avoiding Opioid Misuse and Overprescription
Taking into account all of the problems associated with opioid abuse, misuse, and overdose presented in the previous sections of the paper, it is crucial to develop viable solutions for dentists regarding the elimination of the risks leading to adverse outcomes. One of the most effective solutions is the implementation of an electronic health record (EHR) protocol for patients (Wright, Becker, & Schiff, 2016; Zivin et al., 2018). Specifically, Wright et al. (2016) suggest programming EHRs show the number of drugs prescribed to the patient over the past 30 days before the moment of prescribing opioids. Additionally, scholars offer the implementation of the option of the early refill alert. As a result of such an approach, a practitioner will be able to see if the patient has used up the supply of opioids within the period much shorter than prescribed (Wright et al., 2016). Through this implementation, the task of tracking drug prescriptions can be transformed from a time-consuming procedure to a potentially effective element of the prescribing process.
Another major recommendation to avoid overprescription refers to educational and training endeavors. The Centers for Disease Control (CDC) issued the CDC Guidelines for Prescription Opioids for Chronic Pain in 2016, which is used as a guiding document for many state boards (McEwen & Prakken, 2018). The recommendations features in these guidelines explain when to initiate opioids, how to select the right dose, and when to continue or discontinue opioid use. Additionally, the CDC insists on healthcare practitioners’ regular training and education on pain management (Olsen, 2016). Finally, as mentioned above, each medical professional, including dentists, can take some measures to avoid opioid misuse and overprescription by carefully analyzing each particular patient’s case. It may be crucial for healthcare professionals to offer an alternative treatment or refuse to prescribe opioids significantly reduces the risk of overdose.
Alterations in Dental Treatment if a Patient is on Opioids
Some patients may require changes in dental treatment if they are opioid-dependent and cannot be treated with the help of opioid analgesics. When a person attending a dentist has acute pain, it may be challenging for the specialist to distinguish between real pain and addiction (Nack et al., 2017). Therefore, dental specialists have to create a referral base including pain management professionals, psychiatrists, and addiction specialists. Several reasons for referring a patient to an addiction specialist have been identified. They include positive opioid screens or opioid abuse, excessive alcohol consumption, mental symptoms, concurrent prescription for sedatives and opioids, refusal to try other pain-relieving options, and an opioid use disorder with continuous impairing pain (Becker, Merlin, Manhapra, & Edens, 2016). Addiction specialists can test patients for opioid abuse and share the results with dentists upon request. The most reliable way to assess along-term abuse is using hair samples, while recent use can be detected by a urine test (Nack et al., 2017).
Upon confirming the abusive status of a patient, a dentist should decide on an alternative treatment method. Most frequently, opioid antagonists (naltrexone) or long-lasting opioids (methadone or buprenorphine) are utilized to treat opioid-dependent patients (Nack et al., 2017). The use of long-lasting opioids allows mitigating withdrawal symptoms, and then, the dentist can progressively reduce the dose until the patient stops withdrawing in its absence. Out of the two suggested long-lasting opioids, buprenorphine is more commonly used by US dentists (Nack et al., 2017). Buprenorphine is an “opioid partial agonist” with a “high affinity for the opioid receptor” (Nack et al., 2017, p. 183). The most typical form of buprenorphine prescribed for opioid-dependent patients is Suboxone, a 4:1 combination of buprenorphine and naxolone. Because long-term users can experience withdrawal symptoms upon stopping buprenorphine, it is crucial to consult with the addiction professional before prescribing any painkillers for such patients (Nack et al., 2017).
For most dental and oral surgical operations, specialists recommend nonsteroidal anti-inflammatory drugs (NSAIDs) “with or without concomitant acetaminophen” instead of opioid-based drugs while continuing buprenorphine (Nack et al., 2017, p. 183). For postoperative patients, Suboxone has proved successful as an opioid replacement. For anesthesiology purposes in dentistry, intubated inhalation anesthesia is recommended (Nack et al., 2017). Therefore, there are some effective ways of replacing opioids in the dental treatment of opioid-abusing patients. The dentist’s role in such a case is to identify an abuser timely and address the addiction specialist to create the most suitable treatment plan.
Conclusion
The analysis of the problem of opioid overuse and overprescription in dentistry allows for concluding that it is an acute issue in the US healthcare system. Many patients addressing dentists or emergency care units with toothache pretend that they are in pain to obtain an opioid prescription that will be later used for non-medical purposes. At the same time, many practitioners lack knowledge or attention to such instances, which results in an excessively high rate of opioid use, misuse, abuse, and overuse among US citizens. The problem is aggravated by the fact that doctors tend to prescribe opioids differently to various ethnic groups and genders. The most viable solution in the present situation is to improve the electronic health record system so that it would contain information on opioid prescriptions and would have an option of the early refill alert. Only by combining the efforts of dentists, addiction professionals, and psychiatrists will it become possible to eliminate the epidemic of opioid abuse in the USA.
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