Michelle Budd, D.D.S, Patient Safety Consultant, dentalcorp; Julian Perez, J.D., SVP, Risk Management & Compliance, dentalcorp
In a small town in a small province, a dentist’s mind raced. Her patient sat in front of her asking for a fifth refill of Percocet. The dentist was positive that the pain from a 3rd molar extraction had passed, and she feared the patient had a substance dependence disorder. The patient complained of stabbing shoulder pain in addition to a residual ache in her jaw, and she explained that her usual doctor was on a three-week vacation. She couldn’t sleep at night—the pain was terrible—the patient was desperate. She pleaded in distress for just one more refill. While the dentist knew the ‘right thing to do', her thoughts scattered. There was serious dissonance. In addition, three powerful factors clouded the dentist’s professional judgment: (1) she viewed this long-time loyal patient as a friend and wanted to please her; (2) she believed that the shoulder pain was indeed intense; and (3) the patient was a uniformed police officer well known and liked in her town. “What do I do?” the dentist anxiously wondered.
This scenario is fictional, but not farfetched. Any dentist, any day, anywhere in Canada 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? Let me count the ways.
A. The opioid pandemic is everywhere, it can affect you, your patients, and your team
In a 2018 study, more than 12% of Canadians reported having used opioid pain relief medications in the past year, and almost 10% had engaged in problematic use that could harm their health. Given that opioid addiction primarily affects those in sub-optimal socio-economic conditions, 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.” 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 narcotic use.
B. Problematic narcotic 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 on a person with a significant history of drug use. 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, a high percentage of missing teeth, oral infections, and a decreased response to local anesthetic and pain medications.
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. 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. As with so many aspects of dentistry, practitioners should maintain familiarity with the latest scientific literature on the risks and benefits of opioids while taking the time to get to know each of 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.
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 stronger (and stronger) opioid medications. Given the increase in opioid-related deaths in across Canada, dentists may even consider Naloxone as an appropriate addition to the emergency kit. This is certainly the recommendation of harm reduction experts and advocates. Some experts argue that dentists should not be required to carry naloxone because evidence of the drug’s life-saving capabilities in dental offices was “considerably more difficult to find than … expected”; however, they don’t cite any risk of carrying naloxone.
One last thing about prescribing narcotics: it’s not just active users that you need to consider. Some of your patients have recovered from substance dependence, gotten rid of their demons, and carried on to lead successful lives. 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 and, yes, dentists too.
While my dental colleagues are most likely to confront the issue of opioids in our role as healthcare providers, dental team members also struggle with addiction issues. Indeed, 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.” If you’ve never lived through or experienced the severe addiction of a loved one, you may miss the early warning signs. Experts describe four stages of addiction:
(2) regular use
(3) substance dependence
(4) 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 treating for a dental concern
- the use of opioids on such patients should be as uncommon as it would be in the general patient base
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 is real. It could start as spontaneous consumption of a few leftover medications here or there 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 whose 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.” In addition to being compassionate with oneself, it’s important to be aware that support is available for dentists and team members. Speaking with your physician is a good start and 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.
 Overdose Response with Naloxone, Ontario Harm Reduction Network, https://ohrn.org/naloxone/.
 CDA Oasis, What is the impact of opioid-related stigma and the danger of reproducing it?, Feb 21, 2020