Tackling the Opioid Epidemic: What Dentists Can Do
Across the country, accidental deaths from opioids have been skyrocketing. It’s difficult to read a paper or a news website without some sort of mention of the growing crisis. Sadly, Washington isn’t immune from the problem, and although the number of deaths from prescription opioids has dropped from 464 in 2005 to 287 in 2015, that number is misleading because in the same time period, the number of deaths from heroin overdoses has nearly tripled, from 120 in 2005 to 345 in 2015. And while you might not initially see a correlation, the fact is that people are becoming addicted to prescription medications like Oxycodone, OxyContin, and Vicodin, and when they can no longer acquire or afford those, they’re turning to heroin, which is cheaper and easier to get. These drugs have become like a bullet in a gun.
How are people getting the prescription drugs in the first place, how are they becoming addicted, and what role do dentists play in the opioid epidemic? Ricardo Quintero, Diversion Program Manager for the Drug Enforcement Agency (DEA), had this to say, “There are many factors to getting hooked on opioids, but the fact is that people are becoming addicted. Heroin is flooding our streets, and users flow across all socioeconomic backgrounds. There is no divide. People from all walks of life are affected.”
We also spoke with Dr. Stephen H. Anderson, an ER physician in Washington, and Dr. Amy Cook, a WSDA member, to find out what dentists in the state can do to help slow the supply of pills to the street by changing how they prescribe pain medications and educating their patients. ER physicians have been actively fighting the opioid battle since 2008, when they decided to take ownership of the problem and work to reduce the number of pills “diverting” to the street because so many opiate overdoses were landing in their gurneys. Now people like Anderson and Cook are championing the cause, working to educate dental professionals about the dangers of pain medications.
Following the trail
“Way back in the ‘90s,” explains Anderson, “there was a big push to address people’s pain. Doctors and dentists were told that they had a toolbox they could use, and we had tools like Tylenol and ibuprofen in one side, and in the other side of the toolbox we had opiates like OxyContin and oxycodone. We were taught that opiates relieved pain, and we were encouraged to reach for them first.” Around the year 2000, Anderson says, doctors started to see an uptick in overdose deaths attributable to prescription opiates and providers began to realize that they were part of the problem. In 2008, physicians in Washington realized just how catastrophic the issue was when it became the No. 1 cause of accidental deaths in the United States. “Think about that,” Anderson says. “More than car accidents, more than any other cause of accidental death, it was opiate overdose.” An epidemic was emerging.
How did we get here? Anderson says, “We were warned by the Rolling Stones years ago about ‘running to the shelter of your mother’s little helper,’ and Grace Slick sang, ‘One pill makes you larger, and one pill makes you small.’ Part of the problem was that baby boomers bought into the idea that pills made things better, and divesting them of that idea means that patients have to accept that we may not be able to alleviate every ounce of pain. We don’t want to create a new problem while trying to resolve another.” Today boomers are at the center of the bell curve of addiction, the greatest number in terms of population of opioid-addicted people. The quickest rising populations of addicts, however, are at the two ends: older people, who are at a huge risk for becoming addicted, and youth. “The issue is that as pill counts on the street decline, people are turning to heroin because it is far cheaper than pills,” says Anderson, echoing Quintero. “Youth are much more likely to use heroin. When we were younger, my vision of a heroin addict was the cover of Jethro Tull’s Aqualung album, a shabby street urchin who only used pills if he couldn’t score heroin. That’s not the vision of a heroin addict any longer. In 2017, we’re seeing people who had something that caused a small amount of pain, a doctor or dentist who prescribed a 10-day course of opioids, and a patient who is hooked and turns to heroin. It’s housewives, football players, and grandmas, believe it or not. It’s people walking among us. Fifty thousand people died from opioid overdoses last year.”
1 in 5 will become addicted
The problem, according to Anderson, is that 1 in 5 patients who are given a 10-day prescription of opioids will become addicted. Many providers write those longer prescriptions out of convenience, and Anderson says that has to stop. “I think that doctors and dentists are trying to keep patients out of pain. It has been the norm in many areas, like orthopedics and oral surgery,” he says. “I’m not trying to attack anybody, but the idea of 10 days of pills, when the reality is that most people only use three or four, has to change. Most people put them in their medicine cabinet and then their kids or the neighbor’s kids find them, and they end up in circulation. Educating patients to say no to longer prescriptions, and getting doctors and dentists to prescribe less will help.”
In 2008, in the midst of a spike in opioid deaths, ER physicians in Washington developed guidelines for prescribing opiates for chronic pain. They also created the Emergency Department Information Exchange (EDIE), a program operating in six states now, and scheduled to push out nationally. EDIE works like this: When you check into the hospital, your information is sent to the cloud, where it searches to see if you’ve been in the ER more than five times in the last year. That information alone informs the ER physician that you’re at significantly higher risk for a lot of other problems. It also searches to see if there is a case-management plan for things like schizophrenia, diabetes, or any other disease you might have that is managed, not cured. If there’s a case-management plan up there, the information gets downloaded to the ER in the first two minutes that it is registered. So even before ER physicians walk in the room, they have a report saying, “The patient has been to 32 ERs already this year, typically shows up for dental pain trying to get Percocets. Try not to give them to him.” Or it might say he has low back pain or diabetes, and to work on those. By providing a resource showing if a patient has been shopping docs for prescriptions, the program helped reduce the number of opiate prescriptions coming out of the ER department by 24 percent. “When you look at people who are addicted to prescription opioids, and you ask them where they get their opioids, only 3 percent get them from drug dealers,” Anderson says. “Fifty to 60 percent of people get them from a friend or family member who says, ‘Try these, they worked for me.’ The remainder are stolen from someone’s medicine cabinet. We realized that step one had to be decreasing the pill count on the street, and the way to do that is to educate the providers as to why this is important.”
Getting dentists involved
“We’ve done a pretty good job with the medical community, but the dental community is only just now waking up to the issue,” says Anderson, who concedes that dentists comprise a smaller portion of the equation, but they’re important nonetheless. (Family medicine doctors are still the biggest prescriber of opiates.) “We started to engage the dental community about five years ago, and dentists like Dr. Amy Cook took note of what we were saying,” Anderson says. “Dentists are still part of the equation, and we need to engage them as well, encourage them to go back to the toolbox, and reach for alternatives that aren’t opiates. Decreasing pill counts on the street is still the big message that we need to get to dentists.”
Cook agrees, saying, “My husband is a police chief, and as I get to know people in his world of law enforcement, the DEA, detectives, and city mayors, I’ve had people ask me how responsible I think dentists are in terms of contributing to the opioid problem. At first I didn’t understand, and didn’t feel that dentists were responsible for contributing to the problem very much. After I was asked a couple of times, and I became more involved in the issue, I realized that dentists had to get on board.” For her part, Cook is much more circumspect when prescribing opioids, talking with patients beforehand and providing information about over-the-counter alternatives. “As a GP, I don’t need to prescribe opioids very often, but like so many of us, I was taught in dental school that if I do a simple extraction, I should automatically write a prescription for 20 to 30 Vicodin. I don’t do that anymore. It’s just not necessary. I have a conversation with my patients before and after the procedure, and most people know themselves and what they need and will refuse opioids. But a lot of people will say that they have leftover opioids from a previous procedure, which tells me they were overprescribed in the past.”
The danger, of course, is what happens to the remaining pills. Cook’s husband locks all prescription medications in a safe, but she worries that most people don’t. “As a dentist, I never knew we were supposed to do that,” she says, “Or that I should tell my patients to do that. I tell my patients to keep it out of sight, because anyone coming into their house could be looking for it, and if your house is up for sale, know that anyone in your house could access your medicine cabinet and any drugs you keep there. As dentists this is not on our radar. There is this perception out there that only patients who are new to us or are a little rough around the edges will be looking for drugs, but anyone can become addicted easily. Even the clean-cut ‘normal’ patient could be addicted.” And lest you think that people stealing drugs at open houses is an urban myth, Ryan Leaf, football’s once-heralded player, has admitted to visiting open houses pretending to be interested in purchasing, when really he was rifling homes in search of opiates.
Using the prescription monitoring program
One of the tools Anderson says helps is the prescription monitoring program (PMP). The problem with the PMP, he says, is that it is clunky and, from a workflow perspective, it is a nightmare. It’s free, but time is money when you’re in a busy office, and if doctors or dentists have to take five minutes moving through four different screens with passwords, they not likely to want to use it. “Rather,” says Anderson, “I’ll be inclined to say I’ll look if I get a bad feeling about someone. But I’m not going to look everybody up that I want to write a prescription for, and I should.
The problem is, it’s not just the 22-year-old who is shopping for opiates, it’s the 32-year-old housewife with a kid out in the waiting room who you can’t really understand why you’re negotiating over Percocet with.” However, an innovative solution is available. “Through a joint program with Collective Medical Technologies (the company that runs EDIE), the state, and ACEP, we built a program that queries the PMP on every patient who checks into the ED,” Anderson explains. “Based on high-risk patterns we agreed on, if the search triggers an alert, the PMP is sent to us inside the EDIE alert that appears on our ED track boards and in the triage summery.”
The system’s triggers don’t pick up things such as a single prescription for Tylenol 3, but will red flag more than three prescriptions in a year, or a long-acting opiate, or an opiate with benzodiazepine. Most importantly, the information is pushed to Anderson automatically, as opposed to him having to check for it. The legislature is talking about mandating that providers have to check the PMP, which has worked in some states to decrease overdoses and opiate prescribing, but it doesn’t get a warm reception from providers, who say it obstructs their workflow. With the new system, there is no workflow obstruction because providers get an alert as soon as they start to write a prescription.
Anderson’s hope is that dentists and the WSDA will push for a similar system to be made available in dental practices, but realizes they face obstacles ER physicians don’t have. “What would be best is… an automatic loop that pushed the PMP to you,” he says. “There are HIPAA concerns, which we’re exempted from in emergency medicine. While we’re trying to decide if patients have a medical emergency, we’re allowed to collect data from any source that we can find. HIPAA was written that way specifically to make our job a little easier. Think beyond borders, obstructions, and hurdles, and start thinking about what we could design to put in offices and oral surgery suites to alert people up front about at-risk patients and encourage them to look at the PMP before prescribing.” Anderson even advocates for allowing other staff in the practice to pull up information for the dentist, regardless of HIPAA concerns. He says, “Engaging the PMP and using it is, I believe, critical. If you can build something like the EDIE that pushes the information to you about every person who is at risk, that’s the gold standard that everyone should aspire to and advocate for. Asking the PMP to allow an office manager to pull up the information would work, too. It was originally written to comply with HIPAA, because regulators worried that someone sitting at their home computer would access information about people. I hate to be Machiavellian about this, but if that happens once or twice a year, that’s a shame, but this problem is too big, and we need to do something about it.”
Education and training
Cook uses the PMP, but notes that most dentists don’t even know it exists, and concedes that registration can be a hassle. The DEA’s Quintero encourages providers to sign up for the PMP so that they and law enforcement can partner in the fight against illicit opioid use. “If a dentist checks the PMP, and there is a person presenting in the practice who is a possible doctor shopper, dentists can call the authorities,” he says. Quintero is quick to add he’s not trying to tell providers what to prescribe, “Our role here is to make sure that anyone who has a DEA registration is aware of the opioid problem in America, and promote conversations between them and their patients,” he says. “We do ask them to make an evaluation of what they have. Whether that means choosing another option other than opioids, or writing a prescription for a smaller supply. Between that and education, we can limit what makes it into the street.” Education is at the heart of what the DEA endorses, and representatives regularly speak at opioid summits put on by hospitals and to groups. “We talk to the community about ways to prevent diversion, and we provide education and training, not only within the pharmaceutical community, but also with practitioners like dentists,” Quintero says. “We talk about the opioid problem out in the streets, and what our individual roles are in addressing the issue. We need to get our communities back from the opioid problem, in part by siphoning off the supply of opiates to the community through education. We need education to be successful, working with practitioners, law enforcement, pharmacists, teachers, and others to get the information out to as many people as possible. Even regular citizens can benefit from education about opioids, especially since so much of the diversion happens at home with kids and neighbors taking leftover opiates from medicine cabinets.”
Leftover medications – what’s the best course of action?
For years, patients have wondered what to do with leftover pain pills. Even providers weren’t sure. Cook says, “In the process of talking with law enforcement representatives, I became aware that there are drop-offs for opiates. I started calling around and learned that the Auburn Police Department has a 24-hour drop-off for pills. There are pharmacies that will take drugs, but they’re not consistent, and some will only accept certain drugs, so you have to call ahead. I spoke to Bartell Drugs, for instance, which was listed online as a drop-off. But when I called, they explained that they discontinued the service because so many people dropped off drugs that the program and responsibility became too cumbersome. Check in your area to see who accepts them.” Anderson, concurred, saying, “For years, the only people who would take back opiates were the sheriff’s department or the DEA. A couple of years ago, they changed the law, allowing hospitals and pharmacies to take back drugs. When they changed the law, two interesting things happened. First of all, nobody did it. Everyone worried that there would be liability. The pharmacy director at my hospital once told me, “It’s easier for me to get rid of nuclear waste than a dozen Percocets.” Anderson explains that hospitals have been slow to get onboard because of the requisite paper trail, but he hopes someone will take the initiative and compile a list of pharmacies with take-back programs. Until then, he said, “If your pharmacy doesn’t have a program, consider changing who you do business with.”
We hope you’ll take this information and use it to guide you in the future. Educate patients about the dangers of opiates, consider non-opiate options, or write smaller prescriptions with the understanding that you can always write a refill, if needed.
Visit the Prescription Monitoring Program page here.
If you would like to arrange for an opiate summit in your area, please email Ricardo Quintero, Diversion Program Manager at the DEA, at email@example.com.