Stacey Chazin, MPH, CHES

March 28, 2018

Opioid abuse and related deaths have reached epidemic proportions across the country, garnering attention from all levels of government, health care payers, clinicians, and the public. In 2016, 2.1 million people had an opioid use disorder and 116 people died every day from opioid-related overdose. This crisis is not new: between 1999 and 2015, more than 183,000 people in the U.S. died from overdoses related to prescription opioids. While growing attention has helped mobilize resources to fight the epidemic, often lost in the headlines is the considerable extent to which dental disease and the health care system’s response to it are fueling the crisis. The American Dental Association’s (ADA) March 26 announcement of an interim policy on opioid prescribing — one of the first from a major professional health association — may help to change that.

Dentists prescribe 12 percent of immediate-release opioids in the U.S. and are the most frequent prescribers of opioids for individuals ages 10 to 19.

Sounding a clarion for Medicaid and public health leaders, dentists prescribe 12 percent of immediate-release opioids in the U.S. and are the most frequent prescribers of opioids for individuals ages 10 to 19 — often after wisdom teeth extractions. Oral surgeons remove wisdom teeth in three million people annually; the majority are under age 25, and almost all receive an opioid prescription following surgery. Since the brain does not mature until age 25, this age group is particularly susceptible to opioid addiction, even after small doses. Adolescents exposed to opioids have a 33 percent higher risk of abusing prescription painkillers later in life. Further, less than half of opioids prescribed after surgical dental extractions are used by the patient. These opioids are, then, left for potential misuse or diversion to others. 

Medicaid and Public Health Solutions to the Crisis

Addressing oral health-based drivers of opioid abuse calls for solutions that span state Medicaid and public health agencies and health plans, and promote safe prescribing by providers and safe use by patients. For example:

  1. Require use of Prescription Drug Monitoring Programs (PDMPs). While almost all states have PDMPs — electronic databases that track controlled substance prescriptions — only 42 require providers to use them. Where no such mandate exists, only about one-third of eligible prescribers use the system, but not necessarily for every patient, every time. Mandates significantly increase use of PDMPs, with corresponding decreases in commonly misused controlled substances and related morbidity and mortality. Following implementation of New York’s 2013 mandate, the odds of a patient receiving an opioid prescription declined by 58 percent.
  2. Promote or mandate adherence to opioid prescribing guidelines by providers. Examples of guidelines include: not prescribing telephonically; prescribing in small dosages; and screening patients for substance abuse. Some states, including New York, Pennsylvania and Massachusetts, have gone as far as limiting initial opioid prescriptions to seven days. In a collaborative effort through CHCS’ State Oral Health Leadership Institute, made possible by the DentaQuest Foundation, Oregon’s Medicaid agency and health department developed a poster and brochure on safe opioid prescribing practices as part of a broader project to engage oral health care providers in battling the epidemic.

    In Ohio, guidelines for new prescriptions limit opioids to a seven-day supply for acute pain in adults, and a five-day supply for youth.

  3. Align provider payment incentives with safe prescribing. Last year, Ohio’s Medicaid agency began tying provider incentive payments to the quantity of opioids prescribed before and after specific episodes (including tooth extraction) likely to result in an opioid prescription. Guidelines for new prescriptions limit opioids to a seven-day supply for acute pain in adults, and a five-day supply for youth.
  4. Implement emergency department (ED) diversion programs for oral health care. Approximately half of all individuals who visit the ED for a non-traumatic dental condition receive a prescription for an opioid analgesic. Further, most such visits by adult Medicaid beneficiaries may be prevented by more appropriate use of ambulatory or outpatient care. Yet, many ED doctors do not know where to divert or refer patients for initial treatment and follow-up care within the community. Those seen in the ED for a dental condition average nearly two visits, suggesting they are not accessing more appropriate and less expensive care in outpatient settings.

    Without coverage, individuals are less likely to have access to dental care to prevent or treat early disease, leading to advanced disease that may prompt avoidable opioid use.

  5. Educate providers, the public, and dental and medical students about safer and effective alternatives to opioids. Nonsteroidal anti-inflammatory drugs — such as ibuprofen combined with acetaminophen — provide comparable pain relief without risks of opioid misuse and addiction. A public health campaign to raise awareness of these alternatives can reduce both the supply (i.e., number of prescriptions) and demand from patients for riskier opioids.
  6. Expand oral health care coverage in Medicaid. While comprehensive dental services are covered for all children enrolled in Medicaid across the country, only 17 states offer an extensive dental benefit to adult Medicaid beneficiaries. Without coverage, individuals are less likely to have access to care to prevent or treat early disease, leading to painful, advanced dental disease that may prompt avoidable opioid use.

The ADA’s new policy drives home the above recommendations. It calls for: (1) mandatory continuing education on prescribing opioids; (2) prescribing limits on opioid dosage and duration of use; and (3) requiring dentists to use PDMPs. These clear opportunities for oral health care providers and the broader delivery system to improve opioid safety can be advanced by collaboration that leverages Medicaid and public health resources — a cross-sector response to a national health care crisis.

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