The Role of Dentists in Preventing Opioid Abuse Understand the scope of the problem Understand dentists role in addressing the problem Recommendations for prescribing Strategies to reduce opioid abuse Gary W. Allen, DMD,MS Vice President of Dental Services Advantage Dental garya@advantagedental.com

Opioid Prescriptions by Age and Physician Specialty JAMA 2011, Characteristics of Opioid Prescriptions in 2009

Dentist Opioid Prescribing Practices 85% oral surgeons almost always prescribe opioid analgesics Average Rx = 20 tabs prn pain (range 10 – 40) 24% prescribe more than would generally be necessary Journal of Oral and Maxillofacial Surgery, September 2013 2010 Survey West Virginia dentists: 36% expect their patients to have leftover drugs JADA 2011, Prevention of prescription opioid abuse: The role of the dentist

Unused opioid analgesics and drug disposal following outpatient dental surgery: A randomized controlled trial 79 patients had wisdom teeth removed 94% received opioid prescription Average prescription = 28 opioid pills After 24 hrs pain scale = 5 After 2 days pain scale = 3 After 3 weeks, average pills remaining = 15 Extrapolate to U.S. population: 100 million unused opioid pills University of Pennsylvania Perelman School of Medicine Drug and Alcohol Dependence, Sep 16, 2016 Providing information about drug disposal programs led to 22 percent increase in number of patients who disposed of unused medication

Established prescribing behaviors Prescribing for the most severe outcome Patient expectations and demands Unaware or disregard of the evidence for NSAID/APAP in combination JADA 147(7) July 2016

Recommended Opioid Prescribing Guidelines for Dentists Ask about other medications & use the PDMP Consult with PCP/BH provider for patients with history of substance abuse Do not offer refills Prescribing over the phone is discouraged Use combination opioids when Rx is necessary Oregon Opioid Prescribing Guidelines Task Force Dental Subgroup Oct 12, 2016 http://public.health.oregon.gov/PreventionWellness/SubstanceUse/Opioids/ Documents/oregon-recommended-opioid-guidelines-dentists.pdf

Recommended Opioid Prescribing Guidelines for Dentists (cont.) Prescribe in small doses (should not exceed 10 tablets) Follow stepwise guidelines for acute pain management Mild to moderate: ibuprofen Moderate to severe: ibuprofen + APAP Severe: ibuprofen + hydrocodone/APAP Inform patients how to secure medication and dispose of leftover medication Should not prescribe more than 7 days from last appointment – assess in clinic Oregon Opioid Prescribing Guidelines Task Force Dental Subgroup Oct 12, 2016 http://public.health.oregon.gov/PreventionWellness/SubstanceUse/Opioids/ Documents/oregon-recommended-opioid-guidelines-dentists.pdf

Strategies to Reduce Opioid Abuse OHA: Communicate guidelines; engage dental professional organizations & Board of Dentistry CCO Measures CCO opioid prescribing reports & monitoring Quantity limits Oregon legislature: HB 2114 Limits to 7 day supply For <18 yrs: discuss with parent/guardian If >7 days, document diagnosis, why opioid necessary & why non-opioid alternative is not appropriate

Advantage Dental Measures to Reduce Opioid Abuse Educate & reinforce with providers Monitor provider prescribing patterns Required PDMP enrollment for OHP provider credentialing Incentive metrics

Best Drugs for Dental Pain Forget about Vicodin, Percocet, and other potentially dangerous, addictive opioids. Over-the-counter painkillers may work better. By Teresa Carr January 24, 2017 To find an authorized medication take-back program near you, go to DisposeMyMeds.org or DEAdiversion.usdoj.gov and search for "drug disposal.” Or call the DEA’s Registration Call Center at 800-882-9539. Health Care Countless Opioid Pills Unused by Dental-Surgery Patients Sept. 27, 2016