10/05/2018

Opioids in California: What is CDA doing?

By Kerry K. Carney, DDS, CDE

I spoke the other day with a colleague who has a personal connection to the tragedy that is the national opioid crisis. Out of this experience, my colleague made a commitment to his bereaved friend: He promised he would do whatever he could to help reduce the number of deaths attributed to prescription opioids. He then asked me, “Where is CDA in this crisis?” I shared with him all of CDA’s activities that I was aware of but it occurred to me that some dentists may not fully understand dentistry’s role and how CDA is answering this tremendous social challenge.

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.

First, what is the problem?

Record numbers of people are using, abusing and dying from opioid medications. According to the Centers for Medicare and Medicaid Services, more than 115 people died every day in 2016 from opioids and 40 percent of those overdose deaths involved a prescription opioid. The Substance Abuse and Mental Health Services Administration estimates that 2.1 million Americans suffer an opioid use disorder.

Federal and state agencies have gone on high alert and significant attention and resources are focused on the problem, but it did not occur overnight and there is every reason to think it will take multiple strategies and changing behaviors in numerous participants to effect needed change.

What are we doing about it in California?

CDA noted the rising problem early on and over the last several years has responded to reverse the trend in this state.

Here is a summary of CDA’s actions:

  • In one dedicated place on CDA’s website, members can easily access updated, comprehensive information on opioids and CURES. On the cda.org homepage, a large “button” on the right directs readers to a webpage with links to resources and news from CDA, the dental board, ADA and others.
  • Since spring 2014, CDA Presents The Art and Science of Dentistry has offered a course on the pharmacologic and regulatory concerns of opioid prescribing. Michael Bundy, MD, DDS, PharmD, and Tony Park, PharmD, JD, discuss pain management options and best practices, red flags for substance use disorders, pharmacists’ and dentists’ responsibilities when prescribing and dispensing controlled substances, and the use of CURES, California’s prescription drug monitoring program. “Clinical and Legal Considerations for Prescribing Controlled Substances” will be presented again at the San Francisco convention on Friday, Sept. 7, at 3:30 p.m.
  • In November 2015, CDA collaborated with the California Pharmacy Association to publish an issue of the Journal of the California Dental Association devoted to the science and practice of pain management in dentistry. That issue captured best practices for managing acute, inflammatory pain, recognizing that opioids are actually not the best or most effective choice in most instances. Highlights of that issue are covered in another section of this special-edition Update.
  • In June 2016, as the deadline for mandatory CURES registration approached, CDA hosted a webinar presented by the Department of Justice to assist members with and answer their questions about the CURES 2.0 registration process.
  • Since 2015, CDA has published many articles with information about CURES registration and dentistry’s role in fighting the opioid epidemic in the Update and member newsletter. Those articles can be accessed on the “CURES and Opioid Pain Management” webpage on cda.org.
  • CDA has worked with the Dental Board of California’s Substance Use Disorder subcommittee to ensure California dentists have the information they need to practice safe and effective pain management for their patients. The board’s website now links to CDA’s opioid resources page.
  • CDA Practice Support publishes a regulatory compliance guide to help members become and remain compliant with all laws and regulations related to the prescribing, dispensing and administering of controlled substances.

We are proud that CDA has been proactively informing dental professionals on this issue since its early recognition and will continue to do so.

Legislation addresses opioid prescribing

The California Legislature has also been busy over this time period, strengthening laws and regulations associated with controlled-substance prescribing. CDA is an important source of education for legislators and legislative staff during this process, as numerous bills from multiple authors seek to address the problem from various angles and have not always recognized how acute pain management, which is the primary concern in dentistry, differs from chronic pain management.

  • Senate Bill 809 (DeSaulnier) in 2014 established a fund to upgrade and maintain California’s prescription drug monitoring program, CURES. All licensees authorized to prescribe, order, administer, furnish or dispense controlled substances now pay an annual fee of $6 to the fund, which is collected in conjunction with licensure renewal fees. SB 809 also required these professionals to register for a newly constructed system, known as CURES 2.0, by Jan. 1, 2016. Assembly Bill 679, supported by CDA, extended the registration deadline to July 1, 2016.
  • SB 482 (Lara), passed in 2016, requires all licensees authorized to prescribe, order, administer, furnish or dispense controlled substances to check CURES under specified circumstances. Acknowledging that CURES 2.0 is a new system, this law included a requirement that implementation begin after certification by the Department of Justice that CURES is fully operational; certification happened April 2, 2018, and implementation occured on Oct. 2, 2018. Prescribers in California are required with some exceptions, to check CURES when writing a prescription for Schedule II-IV medications. One exemption relevant to dental treatment allows prescribing a one-time nonrefillable five-day supply of a controlled substance if prescribed as part of a treatment for a surgical procedure the provider performed — an exemption CDA was instrumental in securing.
  • The legislative session included bills that, once operative in 2019 and beyond, will place informed consent requirements on the prescriber of opioids to minors, change the operation, reporting and data retrieval within CURES and require e-prescribing for all prescribers.

These early actions have had a positive impact; dentists are writing fewer opioid prescriptions and for fewer numbers of pills, as are other health care providers. This is great news, but it is not the end of the story.

Research into the epidemic of addiction is revealing that dentists have a unique position in this crisis. Dentists are frequently the first sources of exposure to an opioid for patients ages 11 to 18. See more on that subject on page 4 of the September Update.

California and CDA are not the only source of information and action in organized dentistry. The American Dental Association provides multiple professional resources, including:

Supporting members in their practices and in service to their patients and the public is what CDA does every day, for every member. In my role on the executive committee, I am pleased to see this up close, to know it and contribute to it. And as you can see, CDA has been busy, working with regulators, legislators and our members to reduce opioid use in California, and you can be sure we will continue that work.



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Rethinking pain management in our dental practices
By Solomon Poyourow DDS, MD, MPH
Dentists do a good job managing acute, short-term pain and dentists are not the primary prescribers of opioid analgesics for adults. However, we perform a lot of dental surgeries that result in a lot of opioid prescriptions, and we prescribe the majority of opioid analgesics for children ages 11 to 18. Let’s take a closer look at acute pain management and why it’s time to change our behavior.

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