prescribing of nonopioid therapy, if possible, except for palliative and end-of-life care and for cancer pain. Providers were urged, even when deeming the use of opioids appropriate, to prescribe the lowest possible dose, and to closely monitor all patients (CDC, 2016). (See the Resources section of this course for a link to the 2016 CDC recommendations.) Limitations on the dosage of opioids can be controversial, however. A law proposed for the Commonwealth of Massachusetts would have limited first-time opioid prescriptions to a 72-hour supply. Some commentators in the medical community felt that such a strict limit could impose hardship on chronic pain sufferers and interfere with the relationship between provider and patient (Miller, 2015). The law, when passed in 2016, was weaker than first proposed (Miller, 2016), yet still heralded an era of states exercising more oversight of providers’ prescribing practices. Since Massachusetts passed its 2016 law, more than half of U.S. states have put limits on prescribing and dispensing opioids in cases of acute pain (Bulloch et al., 2019). Although examining prescribing practices confirms access to certain medications, it does not necessarily imply that the drugs are being diverted or abused. It is important, however, for practitioners to be apprised of these national trends to help them make sound decisions about their own prescribing practices for their patients. This is especially true for dentists, whose area of focus often requires them to relieve their patients from pain. The next section of this course will offer suggestions to the dental team to best manage and prevent prescription drug abuse in the dental office setting.
more medicine than necessary being prescribed for the amount of pain that might be expected to follow the procedure (Baker et al., 2016). A study published in 2019 found that in 2016 U.S. dentists were issuing 37 times as many prescriptions for opioids as English dentists (Mozes, 2019; Suda et al., 2019). The study also found that, although 22% of U.S. dental prescriptions were for opioids, only 0.6% of English dentists’ prescriptions were for such drugs (Mozes, 2019; Suda et al., 2019). Statistics on prescription drug access show that in 2016, more than a third of people in the United States aged 12 and older who accessed prescription pain relievers for the purposes of nonmedical use during the preceding year obtained these drugs from friends and family for free (Bose et al., 2018). Another 10.6% of the users of nonmedical pain relievers paid their friends and family for the drugs, and 4.0% stole them from the same source. In the years 2012-2013, more than 4 out of 5 of the friends and family whose prescription drugs were accessed by other individuals received their medication from only one doctor (SAMHSA, 2014b). These statistics on prescription drug access through friends and family, in concert with current overprescribing practices, shed light on the prevention tactics that will be needed to address the problem of prescription drug abuse. In 2016, the CDC issued guidelines for prescribing opioids for chronic pain (CDC, 2016). This move came in response to the federal government’s concern over the epidemic, not just of opioid abuse, but of deaths resulting from the misuse and abuse of opioids. Among the CDC’s recommendations were the
MANAGEMENT AND PREVENTION IN THE DENTAL PRACTICE
Identification of prescription drug abusers in the dental practice The rise in prescription drug abuse, particularly abuse of opioid pain relievers, places dental providers in a key position to assist in the identification and prevention of the misuse, abuse, and diversion of these drugs. The ADA encourages dentists to prescribe responsibly; to be aware of the abuse potential with these drugs; to recognize patients who may be seeking drugs for nonmedical purposes; and to educate their patients on the proper storage, use, and disposal of these medications (ADA, n.d.a, n.d.b, 2012, 2019). In addition, a collaborative, interprofessional approach among dental providers and other healthcare providers can assist in efforts to identify and halt this steadily rising public health problem. Team approach
The complex treatment associated with managing patients with chronic pain has provided an expanded opportunity for collaborative practice agreements. Agreements between community pharmacists and pain physicians or primary care physicians are designed to better control and utilize pain medications (Strickland et al., 2007). Some potential roles of the pharmacist in such practices include: ● Counseling patients on the adverse effects of opiates. ● Monitoring OTC drug interactions and monitoring total daily acetaminophen dosage. ● Counseling patients on safe opiate storage and providing lock-boxes. ● Querying all available prescription drug-monitoring databases. ● Providing custom packaging to enable accurate pill counts. ● Providing narcotic antagonists such as intranasal naloxone to high-risk patients to treat opioid overdose. ● Helping lower-income patients obtain drugs at reduced cost. ● Being trained in drug urinalysis results to aid in spotting treatment inconsistencies. Although such extensive agreements be-tween pharmacists and dental providers may appear to be extreme, cooperation between the two professions can be a valuable tool in preventing prescription drug abuse and diversion. The key to the success of such “informal” collaborations is the establishment of rapid and dependable communications between the dental team and local pharmacies. Local pharmacists and dental teams could establish a system to provide rapid responses to queries. Patient safety and vigilance regarding drug abuse can be enhanced if dental practices can rapidly respond to pharmacists’ concerns that may be based on medical or prescription history not available to the dentist. Such queries might involve the following: ● Concerns about prescription or OTC drug interactions, including excessive use of acetaminophen-containing products. ● Pharmacy records that indicate the patient is receiving opioids from multiple sources.
Collaborative practice agreements between pharmacists and physicians is a growing trend. A collaborative practice agreement is a formal partnership between a pharmacist and physician or among a group of pharmacists and physicians to allow the pharmacist(s) to manage a patient’s drug therapy (Academy of Managed Care Pharmacy, 2012; CDC, 2018d). These agreements are entered into on an individual basis and clearly define the roles and responsibilities of both the physicians and pharmacists regarding patient care. Where allowed by law, such agreements can be negotiated between pharmacists and practitioners. As of November of 2016, all but two states allowed pharmacists to enter into collaborative practice agreements (American Pharmacists Association, 2016). Some states allowed such collaborations only in an institutional setting, while the remaining states also allowed them in community settings. Such collaborative practice agreements have historically been used in nondental settings in anticoagulation therapy and for the treatment of medical conditions, including diabetes, hypertension, dyslipidemia, and asthma. Some states allow collaborative practice agreements between pharmacists and physicians only, and exclude other prescribers (American Pharmacists Association, 2015).
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