Dentistry and Opioids

This letter is in response to the perspective article, “Dentists’ Current and Optimal Opioid Prescribing Practices: A Proactive Review,” published in the September/October 2019 issue of Missouri Medicine.

As a Missouri dentist and the current Missouri Dental Association (MDA) president, I’d like to take the opportunity to inform your readers about what the dental profession, both at the national and state level, is doing to address the opioid epidemic. We’re far from solving the opioid crisis, but dentistry has not idly stood by.

For more than a decade, the American Dental Association (ADA) has advocated to keep opioid pain medications from harming dental patients and their families. Nationwide, dentists have written nearly half a million fewer opioid prescriptions over a five-year period.¹ In 2018, the ADA was the first— and remains the only—national health professional organization to agree to mandated limits on opioid prescriptions.

As a state constituent of the ADA, the MDA fully supports the 2018 ADA policy on opioids,² one of which includes “support for statutory limits on opioid dosage and duration of no more than seven days for the treatment of acute pain, consistent with Centers for Disease Control and Prevention evidence-based guidelines”—limits passed by the 2019 Missouri legislature that the MDA supported.

The ADA has dedicated extensive resources to address the opioid crisis,³ including creating practical guides for safe prescribing, and providing free online CE and other tools and information for managing dental pain—especially for patients at risk for drug overdose and/or addiction.

The ADA and the MDA urge our dentist members to consider non-steroidal anti-inflammatory drugs (NSAIDs) as a first-line therapy for acute pain management. Research⁴ published in the April 2018 Journal of the American Dental Association (JADA) indicates NSAIDs, alone or in combination with acetaminophen, are more effective with fewer side effects than opioids for acute pain management.

As to specific points raised in the Missouri Medicine article, it begins by noting, “when compared to dentists in England, dentists in the United States prescribe vastly more opioids.” While it remains true that U.S. dentists write prescriptions for more opioids than their colleagues in England, dentists are not unique among American providers. Both dentists and physicians in the U.S. write many more opioid prescriptions than their counterparts in England. For example, according to a UN report,⁵ 99.7 percent of the world’s hydrocodone use occurs in the U.S. As a profession, dentistry has been grappling with this issue and making positive recommendations for almost 10 years. Since 2011, many key opioid-related articles in the JADA have asked dentists to consider their roles in the crisis and how to address it head on.⁶ In short: we as a profession and association are focused on the next steps to take to improve the communities we serve.

The article also discusses what our Missouri legislature is doing. As health care providers in this state, dentists and physicians BOTH must shoulder responsibility related to the epidemic, but so too must our lawmakers. Missouri is the only state in the nation without a statewide Prescription Drug Monitoring Program (PDMP). Establishing the PDMP is a critical next step for our state. MDA policy adopted in 2010 states, “the MDA will provide support for development of a PDMP.” Though recent legislative efforts have fallen short, we continue to push for the legislature to act. The perspective article also notes passage of SB 514⁷ which included opioid prescription language. The MDA supported appropriate requirements limiting opioid prescriptions and worked specifically with the Missouri Dental Board on its changes to the Dental Practice Act through rules which promulgated limits on opioid controlled substances for treatment of a patient’s acute pain.

With regard to the article’s reference to toothaches and emergency departments, Missouri has seen a significant drop in the number of dental-related ED visits from 2014–2018, attributed in part to increased funding for Dental Medicaid, which the MDA always supports legislatively. We hope this translates to care being provided in dental offices, thus decreasing hospitals treating only the symptoms with possible, unnecessary opioid prescriptions.

The opioid epidemic is everybody’s business, and there’s certainly more work to do. However, we were heartened to see this perspective article proposes many of the actions already undertaken by the dental profession to address the crisis.