End first exposure: Dentistry's biggest opportunity in the opioid crisis

By Kerry K. Carney, DDS, CDE

Sometimes you read a research article and it hits you between the eyes like a sledgehammer. So it was when I read “Prescription Opioids in Adolescence and Future Opioid Misuse” published in the journal Pediatrics in 2015. It made me really reconsider the impact dentists can have on ameliorating the opioid crisis.

The devastation of prescription opioid misuse and its associated overdose deaths can hardly be overstated. Opioid overdose emergency department visits rose 30 percent in all parts of the U.S. from July 2016 through September 2017, according to an article in the March 2018 CDC monthly report Vitalsigns. “Opioid Overdoses Treated in Emergency Departments: Identify Opportunities for Action” reports that midwestern states were particularly hard hit with a 70 percent increase in opioid overdoses. Opioid overdoses increased for both women (24 percent) and men (30 percent) as well as in all age groups, and people who have had an opioid overdose are more likely to have another overdose. Opioid overdoses in large cities increased by 54 percent in 16 states, according to the report.

When I first wrote about the United States opioid crisis in the November 2015 issue of the CDA Journal, the death rate from prescription opioids was about the same as the number of fatalities that could be expected if two jumbo jets crashed … every month. Now the figures are even worse. It is more like three jumbo jets full of victims every month.

Some regions are more hard-hit than others. The drug overdose death rates in those high-incidence areas are even more harrowing. Whereas the national death rate is just over 19 per 100,000, Pennsylvania has a rate of 37, Ohio and New Hampshire have rates of 39 and West Virginia has a rate of 52. These top four states accounted for more than 10,000 deaths in 2016.

These statistics should spur everyone to try to do something to stem this tide of tragedy.

Legitimate use of prescribed opioids is known to be associated with opioid misuse among adults, according to the aforementioned Pediatrics journal study. The use of prescription opioids to relieve chronic back pain carries such a substantial risk of future opioid misuse that it has been suggested that the risk outweighs the analgesic benefits. Though this risk pattern has been shown in adult populations, the study investigated the size of the risk in an adolescent population.

“An association between legitimate opioid use before high school completion and an increased risk of subsequent misuse after high school could change the risk/benefit considerations for clinicians who treat pediatric patients with painful conditions,” the study’s authors state.

What they found was striking. According to the study:

Legitimate opioid use by 12th grade significantly predicts future opioid misuse after high school. However, this association is concentrated among adolescents who are least expected to misuse opioids: 12th-grade students who have little to no history of drug use and strong disapproval of marijuana use.

In the overall sample, individuals who have an opioid prescription by the 12th grade are, on average, 33 percent more likely to misuse prescription opioids after high school by age 23 than those with no history of an opioid prescription … Specifically, among respondents with low predicted risk for future opioid misuse in 12th grade … an opioid prescription increases risk for opioid misuse after high school threefold.

To reiterate, “among 12th-grade students who have little experience with illegal drug use and strongly disapprove of marijuana use, a legitimate opioid prescription predicts opioid misuse after high school,” the authors state.

The authors also postulate that the “novelty of drug-use effects may help explain why an opioid prescription predicts future opioid misuse most strongly among individuals with little to no experience with use of illegal drugs. For these drug-naïve individuals, an opioid prescription is likely to be their initial experience with an addictive substance. Most likely the initial experience of pain relief is pleasurable, and a safe initial experience with opioids may reduce perceived risk. A pleasurable and safe initial experience with a psychotropic drug is a central factor in theories of who goes on to misuse drugs.”

It is important to emphasize that “results do not support legitimate opioid prescription use, by itself, as a major contributor to chronic opioid misuse, at least not by age 23,” the authors state. But they do emphasize the importance of their findings for clinical practice:

For clinical practice, the results suggest an unrecognized risk of opioid prescribing. This risk should be incorporated into prescribing decisions and patient counseling. Until recently, the short-term use of opioids to treat pain was thought to carry a negligible risk for precipitating future misuse. Our current study and others have associated short-term prescriptions with misuse for some youth. When informed of these risks for children, parents may opt for nonopioid options as the initial treatment of minor painful conditions.

There are many factors that may influence the numbers of people misusing opioids but dentistry has an important role to play. Dentists are responsible for only a small percentage of all opioid prescriptions written in the United States. However, we play a crucial role because dentists are the primary prescribers of opioids for adolescents. The study “Characteristics of opioid prescriptions in 2009,” published by the Journal of the American Medical Association in 2011, states that we write more than 30 percent of the opioid scripts for the population aged 10 to 19. This seems logical because this young population has few needs for postsurgical or chronic pain medication. Traumatic accidents and oral surgery are probably the most common events that require pain management in this age group.

We may be crucial to this young population. When we write a script for a completely appropriate opioid for short-term, postsurgical pain management, we need to realize that we may be responsible for that child’s first exposure to opioids. This young population appears to be more at risk than the adult population for later opioid misuse when their first exposure is for a legitimate need from a trusted oral health care provider.

If we tie these research findings to what is well-proven and well-known about the susceptibility of the developing brain in the adolescent to the introduction of pleasurable experiences and subsequent risk behaviors to reproduce this emotional state, we should be thunderstruck. We should have a heightened concern as individuals and as a profession about our prescribing and dispensing of opioids to this significantly more vulnerable population.

It is fortunate that we have alternatives to help manage dental pain. Recent evidence indicates that 400 mg of ibuprofen in combination with 1,000 mg of acetaminophen has proven to be more effective than opioids in controlling pain and reducing inflammation, according to the study “Benefits and harms associated with analgesic medications used in the management of acute dental pain” published in the Journal of the American Dental Association in April 2018. We may not have to be responsible for a child’s first exposure to opioids if we first try simple, easily accessible, over-the-counter medications.

We need to understand fully our crucial role. We do not have to be the provider of the first opioid exposure to a pediatric population at risk for later opioid misuse. We need to be able to translate the risk/benefit balance of that first opioid exposure during the informed consent discussion with the pediatric patient’s parent or guardian. In the context of the current opioid crisis, our most important contribution to the future health and welfare of our adolescent patients may be the pain management recommendations we make.

A version of this editorial originally appeared in the July 2018 issue of the Journal of the California Dental Association and is reprinted here with permission.

For more articles about CDA and dentistry’s work to reduce opioid misuse and abuse, read the September CDA Update, a special edition of CDA’s monthly magazine dedicated to this issue.

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Opioids in California: What is CDA doing?
By Kerry K. Carney, DDS, CDE
CDA began addressing opioids more than three years ago, but the data and countless personal stories tell us that now is a good time to pull together all our resources and efforts and provide our membership with a 360-degree look at the issue in California and CDA’s leadership on it.

The September 2018 issue of the Update, CDA’s monthly news magazine, focuses entirely on the opioid crisis gripping America and on dentistry’s leadership role in this crisis. Articles include “Rethinking pain management in our dental practices,” by Solomon Poyourow, DDS, MD, MPH, and “End first exposure: Dentistry’s biggest opportunity in the opioid crisis” by Kerry K. Carney, DDS, CDE. Other articles discuss legislative efforts to curb opioid abuse, alternatives to opioids for managing pain and instructions for prescribing controlled substances electronically.