INTRODUCTION
In the last 10 years, substance use disorders (SUDs) and opioid misuse have caused an overabundance of major societal problems in the United States. According to the National Institute on Drug Abuse, while “most people take prescription medications responsibly, an estimated 52 million people have used prescription drugs for nonmedical reasons at least once in their lifetimes.”1 According to the Center for Disease Control, prescription drug misuse has increased by 250% over 20 years, and drug overdose death statistics quadrupled since 1999, with a 5% increase between 2018 and 2019.2
The National Survey on Drug Use and Health estimates that while about 12.4 million Americans used prescription pain relievers for nonmedical purposes in 2009, 16.7 million people older than 12 abused prescription pain-relieving drugs in 2012.3 Among people aged 12 or older in 2020, 3.3% (or 9.3 million people) misused prescription pain relievers, and 1.7% (or 4.8 million people) misused prescription benzodiazepines. In contrast to prescription drugs, 2020 data indicates that 21.4% of people aged 12 or older (or 59.3 million people) used illicit drugs in the past year alone.2
As dental professionals, we have broad professional responsibilities that are not simply restricted to legal obligations. Our professional duties include ethical obligations arising from our commitments to patients, to society, and to our professional ideals. This article will focus on dental providers’ professional responsibilities concerning substance use and addiction among dental patients. This article does not intend to focus on the legal responsibilities of dentists but rather view our ethical responsibilities as healthcare providers. While such responsibilities may vary from one geographic location to another, our commonly shared moral values and ethical responsibilities remain the same.
DENTISTRY, PAIN RELIEF, AND THE OPIOID CRISIS
Traditionally, dentistry has played a leading role in developing methods for controlling acute pain and analgesia. The first successful use of ether was by the dentist William Thomas Morton at Massachusetts General Hospital in 1846, leading to a considerable increase in the prevalence of dental surgery. Opioids were widely used to manage postsurgical and acute dental pain in a completely unregulated environment, contributing to the country’s first opioid crisis and the passage of the Harrison Narcotics Act of 1914. During the 1990s, dentists were not as likely as medical doctors to be directly targeted by pharmaceutical marketing companies because dentists rarely prescribe painkillers for chronic, long-term conditions. The data showed that in the early days of the crisis, 1 in 16 postsurgical patients became addicted to opioids prescribed after surgery.
THE ADA’S FIRST STATEMENT ON THE CRISIS
In 2005, in response to the worsening state of the opioid crisis in the United States, the ADA released its first specific guidance on the issue of roles and professional responsibilities of dental professionals in the opioid crisis.4
The “Statement on Provision of Dental Treatment for Patients with Substance Use Disorders” urged dentists to adopt clinical practices to better standards, specifically to obtain substance use history from patients; become knowledgeable about substance abuse disorders; utilize their professional judgment in this area; and become familiar with community substance abuse resources and other voluntary, proactive measures.5 While this first step led to a substantial reduction in prescribing opioids, unfortunately, it did not have much impact on efforts to screen patients and assist them in getting treatment for their addiction.
Since then, additional statements and directives have provided more detailed requirements, including mandating protocols and training for dentists to combat the opioid addiction crisis. The goal of this effort was not simply to reduce the number of opioids prescribed by dentists but to require and empower them to become proactive in screening patients for SUDs and helping them get the treatment they need.
THE ADA’S 2016 GUIDANCE ON OPIOIDS
The 2016 statement went beyond simply encouraging dentists to manage the opioid crisis at the level of individual dental practices.6 The statement mandated actions such as obtaining a medical history that includes current medications and a history of substance abuse, staying up to date with CDC recommendations for safely prescribing opioids, and utilizing prescription drug monitoring programs (PDMPs) under the auspices of the National Association of State Controlled Substances Authorities. Dentists were required to discuss the misuse, abuse, storage, and disposal of opioids with their patients and consider recommending nonsteroidal anti-inflammatory analgesics as the first-line therapy for pain management rather than opioids.5 When treating chronic dental pain, the statement suggests that dentists should consider referrals to pain management specialists. The statement also contained some legal guidance to reinforce how proper screening techniques can protect dentists from liability associated with prescribing opioids. It suggests that dentists should not be liable for prescribing opioids to patients with SUDs if they’ve made “good faith efforts” to recognize substance abusers who “willfully” hid their conditions.
THE ADA’S 2018 POLICY ON OPIOID PRESCRIBING
The ADA’s 2018 Policy statement implemented mandatory “continuing education” for dentists on prescribing opioids, emphasizing preventing overdoses, dependency, and diversion.7 It also supported limiting prescriptions for opioids to 7 days for acute pain and improving the quality, integrity, and interoperability of state PDMPs. This policy kickstarted more proactive and effective measures by dentists to combat opioid addiction in their patients.
DECREASE IN Opioid PRESCRIBING SENDS PROBLEM UNDERGROUND
According to the CDC, opioid prescriptions decreased by 43% from 2011 through 2018 and continue to fall yearly.8 Limits on prescribing and prescription database usage have combined to reduce the incidence of SUDs induced or worsened by medical professionals. That said, a whopping 35% of opioid overdose deaths are still caused by misuse of drugs prescribed by doctors and dentists. In addition, medical professionals prescribing opioids is just one factor in the skyrocketing incidence of opioid usage, which is why the ADA encourages dentists to go beyond restraint in prescribing opioids to employing affirmative measures to combat the problem. According to the President’s Commission on Combating Drug Addiction and the Opioid Crisis, the root causes of the problem are complex and traceable to at least 30 different factors.9 One of the factors is the high number of underinsured or uninsured people in the United States who rely on pain relief for chronic conditions when they cannot afford medical treatment. This population has combined the small amounts of painkillers they can obtain from physicians with black-market opioids such as heroin and illicit fentanyl to reduce chronic pain. That’s why dentists must be extremely careful not to contribute to this problem by unnecessarily prescribing even small amounts of opioids to people with substance abuse issues or addiction.
DENTISTS AND THE OPIOID CRISIS
The data from many sources shows that the nonmedical use of prescription medications is prevalent. Combating this phenomenon will require continuous effort from physicians, dentists, and other prescribers; pharmaceutical researchers; and government nonprofit organizations.
While some dentists write prescriptions for opioids at an alarming rate, an overwhelming majority of dental providers exercise diligence and caution while using opioids and benzodiazepines in the course of dental treatment. Our profession has made great progress in the prevention of chemical dependency and abuse among dental patients and will continue to do so in the future.
REFERENCES
1. U.S. Department of Health and Human Services: Substance Abuse and Mental Health Services Administration. Key Substance Use and Mental Health Indicators in the United States: Results from the 2020 National Survey on Drug Use and Health. 2021. PEP21-07-01-003.
2. National Institute on Drug Abuse. Misuse of prescription drugs research report: Overview. 2020. Accessed November 1, 2022. https://nida.nih.gov/publications/research-reports/misuse-prescription-drugs/overview
3. Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings. 2011. SMA-11-4658.
4. American Dental Association. Statement on provision of dental treatment for patients with substance use disorders. 2022. Accessed November 28, 2022. https://www.ada.org/about/governance/current-policies#substanceusedisorders
5. National Association of State Controlled Substances Authorities. Prescription monitoring. Accessed October 25, 2022. https://www.nascsa.org/prescription-monitoring
6. American Dental Association. Oral analgesics for acute dental pain. Accessed November 2, 2022. https://www.ada.org/resources/ada-library/oral-health-topics/oral-analgesics-for-acute-dental-pain
7. American Dental Association. American Dental Association announces new policy to combat opioid epidemic. 2018. Accessed November 4, 2022. https://www.ada.org/en/about/press-releases/2018-archives/american-
dental-association-announces-new-policy-to-combat-opioid-epidemic
8. Center for Disease Control and Prevention. U.S. Dispensing Rate Map. 2022. Accessed October 30, 2022. https://www.cdc.gov/
drugoverdose/rxrate-maps/index.html.
9. National Archives. President’s Commission on Combating Drug Addiction and the Opioid Crisis. 2017. Accessed November 16, 2022 https://trumpwhitehouse.archives.gov/sites/whitehouse.gov/files/images/Final_Report_Draft_11-15-2017.pdf
ABOUT THE AUTHORS
Dr. Ruvins earned his DDS degree from New York University. He holds master’s degrees in oral implantology, health care administration, finance, and addiction counseling. Dr. Ruvins co-founded Genesis Behavioral Health Group and the Lighthouse Recovery. He is a colorado certified addiction counselor practicing in Denver. He can be reached via email at eruvins@yahoo.com.
Ms. Brydon earned her master’s degree in social work from Denver University. She is a licensed clinical social worker and a licensed master addiction counselor in the State of Colorado. She is the founder of Road to Me Recovery center and co-founder of Genesis Behavioral Health and clinical director of the Lighthouse Recovery. She can be reached via email at katieb@rd2me.org.
Disclosure: The authors report no disclosures.
FEATURED IMAGE CREDIT: Fizkes/Shutterstock.com.
