Drug monitoring programs help patients and dentists

Every day, dentists are called upon to relieve patients' pain. Sometimes that requires not only dental treatment, but also pharmaceutical assistance to manage pain while the patient heals. Opioid medications have been increasingly relied upon for pain relief, not only by dentists, but across the spectrum of health care delivery. In 2013, more than 137 million prescriptions of hydrocodone were dispensed in the U.S. Unfortunately, these drugs are also the most addictive and potentially deadly of prescription drugs. In the midst of intensified focus on opioid analgesics and rising abuse rates, public health agencies and government regulators are responding, and thoughtful, evidence-based prescribing is a necessity.

With such an important and prominent issue, The Dentists Insurance Company (TDIC) offers advice to dentists to protect both their patients and themselves from potential untoward consequences associated with pain management prescribing practices.

Risk management analysts suggest that when prescribing opioid analgesics, dentists prescribe only the required number of tablets and consider requests for refills cause for re-evaluating the patient's condition. Dental pain is most often acute pain associated with inflammation and in most instances should not require multiple prescription refills to manage. Analysts also note that prescription problems arise from inattention to the number of tablets and frequency of prescriptions provided, unfamiliarity with the drug or drug interactions, and failing to maintain a current health history and record of the patient's current medications.

Further, analysts say common sense, prudence and accurate records are the most important things to keep in mind concerning prescriptions. Knowledge of the drugs prescribed and potential interactions or contraindications is essential, and the use of systems that demonstrate responsible prescription practices and contribute to full documentation are recommended.

The U.S. Drug Enforcement Administration estimates that 7 million Americans abuse prescription medications, including opioid medications prompting the recent reclassification of hydrocodone products, such as Vicodin and Norco, from Schedule III to Schedule II drugs.

Also developed as a tool to reverse this trend are state-run Prescription Drug Monitoring Programs (PDMPs). PDMPs have the capacity to collect and distribute controlled substance prescription information to authorized users. Prescribers and pharmacists can access a patient's controlled substance prescription history prior to writing or dispensing a drug. This information can help prescribers and pharmacists identify patients exhibiting drug-seeking behaviors, as well as high-risk patients who could benefit from early intervention.

Analysts recognize the benefit of PDMPs for checking the patient's Schedule II history and say dentists have multiple responsibilities when prescribing medication. Checking patients' Schedule II history provides additional information for decisions about abuse potential and whether to write a prescription for an opioid medication. From a liability standpoint, a dentist's risk increases if a patient has a history of drug abuse and the dentist cannot prove diligence in checking the patient's history.

While PDMPs vary from state to state, 49 states have operational programs. The PDMP Center for Excellence reports 22 states, including Arizona, Minnesota, Nevada and North Dakota, have laws mandating that prescribers, and in some cases dispensers, use the PDMP in certain circumstances. Alaska, Hawaii, Illinois, New Jersey and Pennsylvania do not have mandatory enrollment, but do have PDMP databases. 

In California, beginning July 1, 2016, all dentists who are authorized to prescribe, order, administer or dispense controlled substances are required to register for California's PDMP, known as the Controlled Substance Utilization Review and Evaluation System (CURES), which is administered by the state Department of Justice.

Analysts say systems such as CURES provide thorough documentation for dentists, and they can simply print the page with the patient's history and add it to the dental record. The following information is reported to CURES for each prescription dispensed:

  • Patient's name, address, telephone number (if available), gender and date of birth.
  • Prescriber's category of licensure, license number, National Provider Identifier (NPI) number and federal controlled substance registration number.
  • National Drug Code (NDC) number of the controlled substance dispensed.
  • Quantity of the controlled substance dispensed.
  • ICD-9 (diagnosis) or ICD-10 code, if available.
  • Number of refills ordered.
  • Whether controlled substance was dispensed as a refill of a prescription or as a first-time request.
  • Date of origin of the prescription.
  • Date dispensing of the prescription is written.

In states where PDMP use is not mandated, TDIC advises dentists to document, at minimum, the following prescription information in the patient's chart:

  • Name and address of the patient.      
  • Date of transaction.   
  • Name, strength, quantity and nature of the controlled substances involved.
  • Pathology and purpose for which the prescription is written.

Because PDMPs vary from state to state, guidelines for dispensing opioids exist in some states while other states are still developing guidelines. For instance, the Dental Board of California is currently working on guidelines to be released next year, while Pennsylvania guidelines on the use of opioids in dental practice were released in June.

The Pennsylvania guidelines state: "Opioid analgesics may be necessary for the relief of pain, but improper use of opioids poses a threat to the individual and to society. Providers have a responsibility to diagnose and treat pain using sound clinical judgment, and such treatment may include the prescribing of opioids. Providers also have a responsibility to minimize the potential for serious adverse effects, including the abuse and diversion of opioids." The Pennsylvania guidelines are available at www.padental.org.

The following resources provide more information:

For more information, contact TDIC's Risk Management Advice Line at 800.733.0634.

Related Items

The CURES enrollment deadline for providers has officially been pushed back from Jan. 1 to July 1 of 2016. The change comes after the governor signed AB 679 (Allen). The bill was amended late in the legislative session due to concern that the most recent Controlled Substance Utilization Review and Evaluation System (CURES) update has fallen behind schedule. The CURES 2.0 was planned to be in use by July 1 of this year, yet the system is still not fully operational. The delay will give the Department of Justice (DOJ) time to finalize CURES 2.0 and for providers to enroll.