Dental professionals possess many resources
for spotting or limiting addiction to opioids
By Carly Scala, RDH
For decades, television has automatically plastered us with news updates about the latest drug bust. We still routinely view scandals and yet another mugshot. As television, social media, and the ability to have nearly anything and everything at our fingertips progresses, we also gain the ability to share helpful information about the current version of this disturbance across America—substance abuse.
I grew up in rural West Virginia. If you haven’t heard of our drug-umentaries, you should check them out. They are eye-opening. During my teenage and young adult years, substance abuse was on the rise in my area too. When I was in public school, it would be no big deal to see my peers drinking as barely teenagers (at high school football games, no less) or trying each other’s pills. At the time, it was called “partying.” My grown self would now like to correct my former self. What I was witnessing was “substance abuse,” and it was just the beginning of a very long and difficult journey in my community. Flash forward 10 years, in my home state of West Virginia, there is a hospital where one of every five babies spends its first days in agony. These helpless children were exposed to opioids or other drugs in the womb.
Trust for America (healthyamericans.org) released a report in 2013 of information gathered from 1999 to 2010 about all 50 states and statistics related to prescription drug abuse. Topping the list was wild and wonderful West Virginia, with 28.9 deaths by overdose per 100,000. From the low 4.1 to 100,000 ratio found in 1999, this new statistic shows a 605% increase between those 11 years. In addition to this, North Dakota ranked lowest at 3.4 per 100,000 in 2010.
Since these studies have been done, however, I think it is safe to say that we are seeing substance abuse of all kinds on the rise. Last year, we lost at least 64,000 Americans to overdoses. Many times, people don’t always see prescription drugs having a possibility to be abused since the prescription comes from a doctor. How could something a doctor has recommended for you be a possibly dangerous or addictive substance? According to the National Institute on Drug Abuse, over 2.1 million Americans are suffering from substance abuse—specifically with opioid medications. Opioid overdose deaths have quadrupled since 1999 and now account for the majority of drug overdoses.
But, what does this have to do with me? I’m in dentistry. In dentistry, we add fuel to the fire by prescribing opioids for instant dental pain management. Many times, substance abuse begins with just that.
Fight starts at your office
You and your lead doctor in your practice have the ability to do your part on making prescription drugs less available to patients. Many doctors are challenging the use of any opioids altogether, and some are prescribing just enough to subside pain while the tooth in question is treated. By being more cautious with limiting prescriptions, this lessens the likelihood of pill seekers clogging up your schedule. In addition to that, there will be less pills to abuse or sell.
The most important discussion related to substance abuse is that it is not racist, sexist, ageist, or classist. When opioids are legally prescribed, they remain easily accessible. This type of substance abuse can latch on to anyone, ranging from your elderly grandmother to your teenage cousin. You can be prescribed and still be addicted, and I’m sure someone immediately popped into your head reading that.
This is why it is important to be able to identify signs of opioid abuse in your clinical operatory, as well as your everyday life. You may be more connected to it than you could possibly imagine.
Substance abuse with opioids, as well as many other drugs, can have mental and physical symptoms. Many users can experience anxiety, irritability, and decreased motivation. On the other hand, they can also present with euphoria and increased self-esteem. Physically, your users will be more alert, have increased sensitivity, increased agitation and energy, decreased appetite, increased sexual arousal, and more difficulty sleeping.
Someone we know
You may have had someone in mind during the entire duration of reading this article about addiction. Everyone is likely connected to an addict in some way: perhaps a neighbor they never really got to know, or possibly someone they love dearly.
For me, it’s personal. I was in a relationship that turned sour once, twice, and three times over the course of three years. It started with him going into medicine cabinets and stealing mom’s pills. This person wouldn’t hide alcohol abuse at all, nor would he hide the prescribed benzodiazepines he was snorting. I finally hit the trail when opioids were introduced to him. Oxycodone would hit him hard and strong, making him nearly comatose. When he would withdraw, he shrugged off the tweaks and seizures. Since those three years ago, I know he began using heroin.
He has been to treatment to get clean multiple times, and they have all failed. He was once a charismatic, very intelligent valedictorian. He has lost that part of his life, including himself, and it all began with opioid abuse before we even knew it was happening. Although it has been a painful transition watching a man I loved turn to substance abuse to cope with life, I do hope his next stint in rehab brings him success and clarity. I wish him well.
My state that raised and loved me has become ravaged with drugs. People I love have become people I don’t know. Plenty of times an addiction has happened so quickly that by the time someone notices, it’s too late. Fortunately, we have the capability to recognize some of these symptoms as they are morphing a loved one or patient.
In the dental chair, some signs you want to look out for are an increased heart rate and increased blood pressure, which goes along with the anxiety and irritability previously mentioned. You will likely notice pupillary changes, depending on the type of substance they are abusing. With opioid abuse, you will see pinpoint pupils. These patients will likely have moderate to severe xerostomia (a side effect for all opioids) followed by generalized decay occurring from the xerostomia.
As many come to find, drugs are prevalent all over the country—some states more than others. Although patients who just take opioids in normal doses as prescribed may have some of the side effects I listed, it is important to ask questions to gauge how the medication is affecting them. Perhaps they just started taking it and are seeing less than favorable side effects. You can help them compose a list that they can discuss with their regular physician at their next appointment.
Important questions to make sure you are including on your health history form include “drug addiction,” “alcoholism,” and “substance abuse.” If they list medications, inquire about them. If they don’t list medications, ask them to verify again. If they do check those boxes on their health history, reach out to them. There are many things that an addict can benefit from in dentistry, such as fluoride trays to put prescription strength gel in, or accurate information regarding alcohol-containing mouth rinses. Open your minds and hearts into helping those you may not quite fully understand.
Keeping track of abuse
It’s even easier now to see if a patient with suspected substance abuse has been making rounds to local doctors. The Diversion Control Division of the Drug Enforcement Agency and the US Department of Justice has created support with prescription drug monitoring programs (PDMPs). These programs help prescribing individuals become aware with the information about medications that the patient is taking, because sometimes they forget to write them all down. This also helps protect the dentist to not write another opioid prescription for someone when the patient just saw “Dr. Bob” two days ago and was prescribed 30 opioids.
At this time, only 37 out of 50 states have PDMPs: Alabama, Arizona, California, Colorado, Connecticut, Florida, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Minnesota, Mississippi, Nevada, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, West Virginia, and Wyoming. Eleven more states have gone forward with legislation to get PDMPs up-and-running. You can find your state’s website for its PDMP through National Association of State Controlled Substances Authorities (nascsa.org).
A statement issued by the American Dental Association in October 2016 describes how opioids in the dental pain treatment should be handled. Included in this statement are the importance of a thorough medical and dental history, drug contraindications, history of substance abuse, and utilization of PDMPs.
It is recommended that dentists have these difficult conversations with patients about misuse and abuse of opioids. Dentists should also be considering all treatment options to get the patient out of pain so relapse does not occur. NSAIDs should be considered first-line therapy for acute pain management, and recognize multimodal pain strategies. Dentists should be coordinating with specialists and other doctors on how to best prescribe on a larger scale. Lastly, dentists (and dental hygienists) are encouraged to seek continuing education in addictive disease and pain management related to opioid prescribing. We should all be working together.
The Centers for Disease Control and Prevention has launched a prescription awareness campaign to put faces on the danger of opioid abuse. CVS Caremark announced last month that it will limit certain first-time opioid prescriptions to seven-day supplies. The FDA is requiring that manufacturing drug companies of prescription opioids to provide more training to prescribers to prevent abuse and addiction.
The US Postal Service and the Department of Homeland Security are strengthening the inspection of packages coming into our country that could contain even synthentic opioids such as fentanyl. The US government now commits to distributing nearly $1 billion in grants for addiction prevention treatment, and over $50 million to support law enforcement programs that assist those facing prison and facing addiction.
The challenge to dentistry
I challenge the field of dentistry (including myself). What used to be an easy fix for us has now become a playing piece in the game of addiction. We need to work together to find solutions that help people, rather than mask their symptoms.
While this may not be as serious of an issue to some, it is the beginning of an epidemic. I have heard countless stories on how prescribed opioids were the gateway to other drugs, such as heroin. Ten years ago, my classmates were getting prescribed two weeks’ worth of opioids for standard third molar extractions. We were sixteen years old. Can I link the heroin overdoses of these former classmates to what could have been their first opioid encounter? That we may never know.
If we can change something on our end to make these pills less accessible, we should. Let’s treat the pain versus treating the symptoms. Dental pain management with opioids continued to be common practice because of patient expectation and the lack of alternative treatment. Let’s educate our patients with the ever-growing list of diagnostic tools we have at our disposal so they can grasp what treatment is needed for their pain and why.
We have many continuing education courses available to inform us, and it is up to us as professionals to follow up with new information regarding the best available treatment for patients. This does not include the overprescribing of opioids.
I challenge all hygienists to have those tough discussions with patients who are willing to checkmark a box to tell you they are drug addicts. Take an extra look at patients’ eyes during head and neck exam. Run your patients through your state’s PDMP as an extra precaution. Write thorough notes in charts that describe changes that you see in patients.
Promote change in our profession by creating better technology to find alternative ways to treat dental pain. Use differential diagnoses, and refer to specialists. We have a great opportunity to help our loved ones in our community overcome the battle of addiction and opioid substance abuse. All it takes is for each one of us to rise up in agreement and say, “Enough is enough.”
Carly Scala, RDH, is a dental educator and sales representative who specializes in dental hygiene clinical supplies and CE courses. In addition, Carly practices clinically in Parkersburg, W.V. and works as an editor/writer in hygiene publications remotely. Carly has been an ADHA member since graduating in 2014 and spends her free time dreaming of teeth and playing with her two chubby pugs. She can be contacted at [email protected].
