On a Friday afternoon, a dentist’s mind raced. Her patient was asking for a fifth refill of Percocet. The dentist was positive that the pain from a third molar extraction had passed and feared the patient had a substance dependence disorder. The patient complained of stabbing shoulder pain in addition to a residual ache in his jaw, and he explained that his usual doctor was on vacation. He couldn’t sleep at night. The pain was terrible. He was desperate. He pleaded in distress for just one more refill. While the dentist knew the “right thing to do”, three powerful factors clouded the dentist’s professional judgment: 1) he was a long-time loyal patient; 2) she believed that the shoulder pain was indeed intense; and 3) the patient was a uniformed police officer well liked in town.
This scenario is fictional, but not farfetched. Any dentist, any day, anywhere can find themselves facing the same dilemma. Pain management, including pain of dental origin, can be a difficult task for any health care provider. The use of opioids to manage pain has increased over time, as have opioid-related morbidity and deaths. Dentists may prescribe opioid medications to their patients, but how does the opioid crisis affect dental practices?
A. The opioid pandemic is everywhere
In a 2018 study, more than 12 percent of Canadians reported having used opioid pain relief medications in the past year, and almost 10 percent had engaged in problematic use that could harm their health.1 Given that opioid addiction primarily affects those in sub-optimal socio-economic conditions,2 with the addition of emotional, financial, and other struggles brought about by the COVID-19 pandemic, these numbers have increased significantly. The Public Health Agency of Canada (PHAC) has published data showing “a substantial increase in opioid-related harms and deaths since the beginning of the COVID-19 outbreak.”3 If your dental practice sees 20 patients a day, there is a strong chance two or more of those patients have engaged in problematic opioid use in the past year. If your office includes ten or more team members, it’s probable that one of them has struggled in the past year or is currently struggling with problematic opioid use.
B. Problematic opioid use impacts oral health
Providing high quality care to all requires awareness of the myriad ways that substance dependence or misuse can manifest. Specifically, the effect of uncontrolled opioid abuse may be evident when performing an oral exam. These effects are often exacerbated by a lack of regular comprehensive dental care, poor oral hygiene and unhealthy dietic habits. Some patients who have suffered with extensive and destructive substance use often exhibit xerostomia, angular cheilitis, candidiasis, gingival laceration, rampant caries, bruxism, periodontitis, multiple missing teeth, oral infections, and a decreased response to local anesthetic and pain medications.4
C. As prescribers, dentists have contributed to the current crisis
The dental profession, together with the broader medical community, has significantly contributed to the opioid health crisis in Canada and will play a role in the future trajectory of the opioid crisis.5 According to Choosing Wisely Canada’s Opioid campaign, it is explained that “for post-operative dental pain, the dose and frequency of a non-opioid (ibuprofen and/or acetaminophen) analgesic should be optimized. If this is not sufficient for managing pain, an opioid may be considered. If an opioid analgesic is appropriate, consider limiting the number of tablets dispensed and discuss the proper use and disposal of opioid drugs.” (https://choosingwiselycanada.org/hospital-dentistry/#1-1).
Dentists are acutely aware of the risks of over-prescribing opioids and in most cases appropriately limit their use.6 As with so many aspects of dentistry, practitioners should maintain familiarity with the latest scientific literature on opioids while taking the time to get to know their patients. Nevertheless, it can be hard to distinguish drug-seeking behaviour from a legitimate need for analgesic medication. Some techniques used by those suffering from a substance dependence disorder include:
- making a specific request for a particular drug
- claiming to require a refill on lost or stolen medication
- claiming to be allergic to all medication other than opioids
- claiming to be an out-of-town patient
- claiming that their regular dentist or physician is unavailable.7
When typical non-opioid analgesics are not managing a patient’s dental pain, a referral to their medical doctor or a specialist may be warranted before resorting to the use of opioid medications. Additionally, it’s not just active users that you need to consider. Some of your patients have recovered from substance dependence. The saying “once an addict, always an addict” can have a negative connotation, but among former users the danger of relapse is real. Before prescribing opioids to someone, realize that doing so has the potential to reignite a crisis in their life. It can be easy to forget in the day to day, but being a dentist carries great responsibility.
D. Addiction affects dental assistants, dental hygienists, admin teammates etc.
While dentists are most likely to confront the issue of opioids in the role of healthcare providers, consider that oral health care professionals “have the same risk of developing substance use disorders … as the general population; 10 to 15 per cent … will have a drug and/or alcohol problem sometime in their lives.”8 If you’ve never experienced the severe addiction of a loved one, you may miss the early warning signs. Experts describe four stages of addiction:
- Regular use
- Substance dependence
- Full blown addiction
During the first three stages, as the drug gradually alters the user’s body chemistry, people can function and appear outwardly normal. Inwardly, however, users may be arriving at a point where accessing a substance becomes as urgent as breathing or eating. Because drug dependence can go undetected for quite some time, we must ensure that we follow best practices related to the storage and management of prescriptions and medications in our dental practice.
- Medications should be stored in a secure locked area of the practice
- The authority to access electronic prescriptions should be limited and password protected
- Electronic prescription templates should default to the lowest medication/dose
- Appropriate audit trails and drug reconciliation logs should be maintained
- Processes must be in place to help prevent and manage any theft of drugs or prescription pads
- Dentists should not prescribe to members of the dental team (or friends and family) unless they are patients of record being treated for a dental concern
E. Dentist, heal thyself
And we cannot forget about ourselves – dentists can often struggle with intense pressure and the temptation to abuse our privilege to prescribe. It could start as spontaneous consumption of leftover medications to help manage pain or stress, but with continued use can affect one’s professional and personal lives. Part of the reason that people don’t reach for help is shame and the stigma associated with opioid dependence. Dentists should practice the same compassion to themselves that they would extend to a patient who is going through a tough period. If you or a loved one struggles with dependence, know you are not alone. Millions of Canadians are waging similar personal battles. “North America is currently in the grips of a crisis of opioid-related overdoses, and stigma is considered a major driver of the harms.”9 In addition to being compassionate with oneself, it’s important to be aware that support is available for dentists and team members. Many have access to extended health care benefits or an employee assistance program through work (personally or through a family member).
- Andrew D Fraser, et al., Prescription Opioid Abuse and its Potential Role in Gross Dental Decay, Curr Drug Saf. 2017;12(1):22-26.
- Andrew Lombardi, et al., The Opioid Crisis and Dentistry: Alternatives for the Management of Acute Post-Operative Dental Pain, Oral Health
- Jamie Falk, Kevin J Friesen, Cody Magnusson, Opioid prescribing by dentists in Manitoba, Canada: A longitudinal analysis, J Am Dent Assoc. 2019 Feb;150(2):122-129.
- S. Steele, Dental Patients, Narcotics Abuse and You, Ontario Dentist, March 2011, Vol 88, No 2, March 2011, 18-21.
- CDA Oasis, What is the impact of opioid-related stigma and the danger of reproducing it?, Feb 21, 2020
About the Authors
Dr. Michelle Budd works with dentalcorp’s Compliance & Risk Management team as a Patient Safety Consultant, helping practices across Canada maintain professional compliance. She graduated from Western University with a Doctor of Dental Surgery degree and earned a Master of Public Health degree.
Julian Perez is Senior Vice-President of Legal and Risk at dentalcorp, responsible for the development and oversight of programs to support practice delivery of optimal patient care. He earned a bachelor’s degree from Yale University and a JD from Columbia University’s School of Law.