Role of dentists in reducing prescription drug abuse

Controlled substance abuse has skyrocketed over the last several years in the U.S., which is why hydrocodone combination products such as Vicodin and Norco were reclassified to Schedule II drugs in 2014 (requiring a Schedule II authority to prescribe).

This reclassification stemmed from a U.S. Food and Drug Administration (FDA) concern about “the abuse and misuse of opioid products, which have sadly reached epidemic proportions in certain parts of the United States,” resulting in the recommendation that hydrocodone combination products be placed into a more restrictive classification and schedule. With the reclassification comes more monitoring and control over prescriptions, prescribers and dispensers.

In California, more than 1 billion dosage units of hydrocodone combination products were dispensed in the 2013-14 fiscal year, according to the state’s Controlled Substance Utilization Review and Evaluation System (CURES). What's more, approximately 100 percent of the hydrocodone use worldwide occurs in the U.S., according to Tony J. Park, PharmD, JD, who co-hosted a lecture on the topic at CDA Presents The Art and Science of Dentistry in Anaheim on May 2.

“Government studies have shown that just about every bit of the hydrocodone that is manufactured in the world is consumed in the United States,” Park said at the lecture titled Addressing the Epidemic of Prescription Drug Abuse – A New Paradigm for Interprofessionalism Between Prescribers and Dispensers, which will be held again on Aug. 21, 12-2 p.m., at CDA Presents in San Francisco.

According to Park, who is the general counsel for the California Pharmacists Association, emergency room visits involving nonmedical use of opioid analgesics increased from 144,600 in 2004 to 305,900 in 2008. In addition, treatment admissions for primary abuse of opiates other than heroin increased from 1 percent of all admissions in 1997 to 5 percent in 2007.

The purpose of the lecture, which also was led by Michael Bundy, PharmD, DMD, MD, was to help dentists recognize the magnitude of the problem of controlled substance abuse of drugs initially obtained through legitimate means, and understand the pharmaceutical options for acute pain control in dentistry. The course also helped attendees to distinguish between old and new rules of dispensing controlled substances by pharmacists.

“We want to make sure everyone is aware that there is a problem with narcotic prescription abuse divergence in our country and explain what we as prescribers can do to try to limit that as much as possible,” said Bundy, who is currently employed in the maxillofacial surgery department at Kaiser Permanente in Los Angeles. Before his career in dentistry, Bundy completed pharmacy school, equipping him with a comprehensive knowledge of several of the key components of prescription drug prescribing and dispensing.

Bundy said 12 percent of all of the immediate-release opioid prescription drugs are written by dentists in the U.S., just slightly less than family physicians. Part of Bundy’s presentation was to make sure dentists know what to do to prevent being taken advantage of by drug abusers, yet make sure their patients receive the medications necessary to alleviate discomfort following dental procedures. Bundy offered a few recommendations:

  • Review the patient’s medical history.
  • Know the patient.
  • Set expectations for the patient.
  • Agree to a pre- and post-op patient treatment plan.
  • Understand the importance of adequate local anesthesia.
  • If in doubt, contact the patient’s primary care physician.

“It’s never a bad idea to consult with a patient’s primary care physician, especially when dealing with somebody who has a complicated medical history or a history of drug abuse or dependence, for whatever the reason — it might be for a legitimate medical problem,” Bundy said. “I think that given the fact that many of our patients are healthy, but a fair number are also patients with significant medical problems, it is a good idea to make contact with the primary care physicians to make sure that what we are doing for the patient’s acute pain is not going to negatively effect their overall health.”

Every case and every patient is different, so while Bundy admits there is no standard pathway to take when determining the route to pain relief, he said, “Having a general regimen that works well in your hands is key.” Bundy also advised dentists to maximize the amount of nonopioid medications to the patient’s benefit, noting that studies have shown that much of the time this approach is better than opioid medication.

“The last time I checked, most of the pain that is involved in dentistry involves some degree of inflammation,” Bundy said.

Because most postoperative dental pain has an inflammatory component, NSAID (nonsteroidal anti-inflammatory drugs) such as ibuprofen therapy is essential and often superior to opioids for pain control.

His recommendation is to offer a combination of NSAIDs and acetaminophen, which may prevent the need for opioids altogether. If that does not work, or the pain is severe, then dentists might add a hydrocodone/APAP combination or oxycodone/APAP combination as needed, but “always avoid large quantities,” he said.

Another tip he offers dentists is to not prescribe anything prior to the patient’s procedure.

“You might not see that patient again. They might be going on down the line and doing that to the next dental office,” Bundy said.

Further, if a patient is complaining that they are still experiencing discomfort a week after a dental procedure, rather than simply refilling a prescription, another appointment may be warranted, Bundy said.

Park acknowledged that dentists play a relatively small part in the amount of controlled substances that are prescribed, but noted they are “still an integral part of the health care system where there are enough bad actors that unfortunately target dentists to collect and aggregate small amounts of controlled substances to create this concern.”

Dentists also contribute to the quantity of unused opioid pills abused by family members or sold to others. A dentist may prescribe Vicodin for post-operative pain and the patient may not take any, instead storing them in the medicine cabinet for a “rainy day.”

This, combined with an attitude switch over the last two decades within the health care industry when it comes to pain management, has contributed to the problem.

“A long time ago, the attitude within the health care industry toward pain management was that we were stingy. What I mean by that is for a patient who presented with reported pain, the health care prescriber would usually give just the bare minimum to deal with that pain. But the pendulum has swung completely the other way over the past 10 to 20 years, where now attitudes toward pain management are more aggressive. Health care providers prescribe controlled substances and opioids much more frequently to control pain,” Park said. “Unfortunately, because of the pendulum swinging so far the other way, we have the opioid drug abuse that we have today. Health care professionals are now having to adjust based on efforts to move the pendulum back to the middle, hopefully to a moderate position where we’re not quite as stingy as we were in days past, but where we’re not as loose with prescribing as we have been recently.”

Park said pharmacists are not immune to the changing environment either, as the Board of Pharmacy is cracking down on pharmacists more now, too.

“Pharmacists are no longer allowed to look at themselves as just the keepers of the drugs,” Park said. “Pharmacists must do something else. There is a responsibility on the part of the pharmacist to perform due diligence when it comes to dispensing. The pharmacist may need to access CURES to ascertain the patient’s prior history, or evaluate the distance between the patient’s home residence and the prescriber, or home and the dispensing pharmacy as a way to uncover drug-seeking behavior.”

Red flags pharmacists look for include: nervous patient demeanor, the age of the patient, multiple patients at the same address, cash payments, early refill requests, prescriptions for unusually high quantities and prescriptions for duplicative drugs.

Park also reminded dentists in attendance of the lecture that they must register to be able to access the CURES system by Jan. 1, 2016 (go to pmp.doj.ca.gov and register as a “Practitioner”).  All dispensed controlled substance prescriptions are recorded in CURES, which allows prescribers to look up a patient’s controlled substance current usage and past history.

“If you have their entire, comprehensive substance control profile available to you on your computer screen, then that may affect your prescribing practice,” Park said. “If you see this patient went to dentist A, dentist B, dentist C, dentist D over the past couple of weeks, that’s probably a high indication that that patient is not going to the dentist for a legitimate pain issue or dental needs, but perhaps they are scamming dentists for controlled substances.”

CDA reminds dentists to visit the Drug Enforcement Administration’s website to ensure their Schedule II registration is up-to-date. Pharmacists are now checking the website for proper authority before filling Schedule II prescriptions. Dentists whose registration status is not updated should anticipate receiving phone calls from the pharmacist prior to filling prescriptions for Vicodin, Norco or similar products.

CDA also reminds dentists who write controlled substance prescriptions that they must ensure their tamper-resistant forms are up-to-date (the forms must have the prescriber’s address preprinted on them). Dentists can purchase tamper-resistant prescription forms only from state-approved printers. A list of approved printers is on the Department of Justice’s website.

CDA also has a “Controlled Substances Prescribing and Dispensing” resource available on cda.org.

For more information on how to attend this lecture at CDA Presents in San Francisco, visit cdapresents.com.

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Following the October 2014 reclassification under federal law of hydrocodone combination products (HCPs) such as Vicodin and Norco from federal Schedule III to federal Schedule II, some dentists report pharmacies refusing to fill emergency prescriptions telephoned in for HCPs, under circumstances in which they may traditionally have been accepted. This article is intended to clarify the state of the law with regard to such HCPs and help dentists understand the requirements and limitations on oral prescriptions for a Schedule II drug.

Now that hydrocodone combination products, such as Vicodin and Norco, have been reclassified as Schedule II drugs, CDA Practice Support has been receiving inquiries about how to prescribe these drugs electronically. Dentists can no longer call or fax prescriptions for these drugs to pharmacies because Schedule II drugs have more restrictions.

Despite concerns expressed by the ADA and other stakeholders, the Drug Enforcement Agency (DEA) has finalized a rule to classify hydrocodone combination products such as Vicodin and Norco as Schedule II drugs instead of Schedule III. The reclassification, effective Oct. 6, will impact dentists with a Schedule III DEA registration because they will have to reregister with the DEA for Schedule II authority to continue prescribing/refilling certain pain-relieving medications for their patients.