17 Implications of Dentistry in the Opioid Epidemic

The History of the Opioid Epidemic

Beginning in the 1990s, health advocates began to push for better pain management options for patients, seeking to treat pain as the fifth vital sign (Scher et al., 2018). Shortly after, pharmaceutical companies began marketing new opioids, with the claim that they had a low risk for abuse. The combination of these factors increased the number of opioids prescribed considerably, beginning with chronic pain management, then spilling over to acute pain management. By the end of the decade, overdose deaths from prescription opioids began to increase rapidly, eventually causing a public health crisis now known as the opioid epidemic. Opioid prescription rates continued to rise in the 2010s (Kenan et al., 2012).

Surprisingly, physicians, including surgeons and emergency room doctors, were not solely responsible for these increases in overprescription. Although dentists were not the leading prescribers of opioids, there was a significant increase in opioid prescriptions by dentists in the early 2010s (Larache et al., 2020). Dentists were also the highest prescribers of opioids to adolescents and young adults due to the number of third molar extractions, or wisdom tooth removals, in this age group (Chua et al., 2021). This is concerning, considering that adolescents are at an increased risk of developing addictions in general due to a propensity for risk-taking behavior and poor impulse control (Levy et al., 2019). As opioid-related deaths continued to rise through the 2000s and 2010s, regulatory measures were implemented to monitor and control opioid prescribing (Bedene et al., 2022). A major turning point in the fight against the opioid crisis occurred when the Centers for Disease Control and Prevention (CDC) released new opioid prescribing guidelines in 2016. However, similar measures aimed at the dental community were not finalized until 2018 (Yan et al., 2022). Considering the fact that wisdom tooth surgery is often an adolescent’s first exposure to opioids and that the majority of adolescents undergo this surgery, it is important for both dentists and patients to be aware of strategies to decrease the risk of opioid addiction in teens and young adults. Implementing these strategies could eventually limit the impact of the opioid epidemic on younger generations.

How Dental Prescribing Practices Contributed to the Crisis

Due to the increase in opioid prescriptions for acute pain that occurred in the 1990s, the use of opioids in dental practices rose similarly to medical counterparts until the mid-2010s. Although prescriptions increased among surgeons and dentists, those among surgeons increased by only 18%, whereas those among dentists increased by 67.8% during the same timeframe (Larache et al., 2020). In a study analyzing dental opioid prescriptions in half a million dental visits, almost one-third exceeded recommended dosages. Over half of these prescriptions exceeded the recommended 24-hour supply (Suda et al., 2020). In another study, researchers found that one in four patients took opioid painkillers for up to ten days following a wisdom tooth removal (Denisco et al., 2011). There is an association with long-term opioid use in patients consuming as few as three days worth of an initial opioid prescription, with risks increasing for each additional day of use (Shah et al., 2017). In a past survey of general dentists who performed wisdom tooth extractions, 41% estimated that patients would have leftover opioids after their procedure (Denisco et al., 2011). Having leftover medication has been associated with the misuse of prescription opioids (Denisco et al., 2011). Prior to the 2016 CDC guidelines, dentists were overprescribing opioids in terms of both dosage and duration while simultaneously increasing the number of prescriptions written, unknowingly contributing to the opioid epidemic.

Opioid Policy and Guideline Reforms

As the opioid epidemic intensified throughout the 2000s, state officials began recognizing the importance of implementing strategies to reduce opioid misuse and diversion. One of the earliest methods was the establishment of prescription drug monitoring programs (PDMPs). Despite the prior existence of a few PDMPs, one as early as the 1930s, the number of states with PDMPs significantly increased during the 2000s and into the 2010s (Holmgren et al., 2020). These were intended to enable physician tracking of opioid prescription use by individual patients in order to prevent “doctor shopping.” The efficacy of these programs improved after changes were made to make information accessible to providers in real-time, a technology first implemented in Oklahoma in 2012 (SAMHSA, 2017).

The 2016 CDC guidelines on opioid prescribing practices largely addressed the appropriate use of opioids for chronic pain management, limiting applicability to the dental community. However, one of the twelve recommendations did address the use of opioids for acute pain. It suggested that opioid use be limited to the prescription of immediate-release drugs only and at the lowest effective dosage to manage pain. It also advised providers to limit the duration of therapy to three days and in rare cases, a maximum of a week (Dowell et al., 2016). In an initial statement by the American Dental Association (ADA) in late 2016, they endorsed these CDC guidelines. Additionally, they recommended that dentists screen patients for substance use disorders, use PDMPs before prescribing opioids, and receive continuing education on pain management and drug addiction (ADA, 2016). The CDC guidelines and ADA statement prompted reductions in opioid prescribing by dentists. Further reductions ensued following an updated 2018 ADA policy (Yan et al., 2022).

Turning the Tides

Following the release of guidelines by the CDC and the ADA statement and policy, dental providers began to realize the dangers of previous prescribing patterns. Eventually, dentists began to prescribe opioids more conservatively, dramatically decreasing the number of dental opioid prescriptions in the United States (Yan et al., 2022). Although these trends were promising, some dentists still overprescribed opioids even in 2019, with a small group of providers accounting for almost half of all high-risk opioid prescriptions (Chua et al., 2022). Additionally, research indicated that there were safer and more effective alternatives to opioid therapy for dental pain, like non-steroidal anti-inflammatory drugs (NSAIDs) (Moore et al., 2015). This indicates that opioids should likely no longer be prescribed for first-line therapy for most dental procedures, including wisdom tooth extractions.

Conclusion

Historically, dentists prescribed opioid painkillers to help manage post-operative pain for wisdom tooth extractions. Teens who undergo wisdom tooth extraction and receive an opioid prescription are more likely than controls to develop an opioid abuse disorder (Schroeder et al., 2019). In order to curb the opioid epidemic and prevent adolescent opioid addictions, dental providers and patients should consider safer alternatives. These may include non-opioid pain medications as first-line therapy, limiting the number of opioid pills supplied, educating patients on the dangers of opioid usage and abuse, discussing appropriate opioid disposal methods, and provider education on appropriate opioid prescribing practices (Keith et al., 2020). By implementing these key prevention strategies and sharing responsibility between dentists, parents, and patients, the impacts of the opioid epidemic in high-risk adolescent populations can be greatly reduced.

To learn more about the opioid epidemic and its effects on other medical specialties, read this chapter.

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