Madeline Pucciarello, MPH

December 5, 2018

With the United States in the grip of an opioid epidemic, public health care leaders are seeking innovative solutions to address the crisis. Educating dental providers is one way that states can help reduce unnecessary opioid prescribing. At the Oregon Health Authority, Statewide Dental Director Bruce Austin, DMD and Dental Program Manager Kellie Skenandore have been working to educate dental providers on Oregon’s prescribing guidelines and increase the use of the Prescription Drug Monitoring Program (PDMP) by dentists in their state.

CHCS recently spoke with Dr. Austin and Ms. Skenandore to discuss the state’s strategy to prevent opioid addiction. Both Dr. Austin and Ms. Skenandore are recent fellows of CHCS’ State Oral Health Leadership Institute, made possible through support from the DentaQuest Foundation.

Q: Your work in Oregon focuses on decreasing addiction rates by targeting dental providers. What role do dentists play in opioid prescribing?

Acute prescribing, even in small amounts for a short term, can cause some patients to experience future trouble.

A: B. Austin: I’ve been a prescriber for over 30 years and knew of the opioid issue in the medical field. I was naïve in my thinking that dentists didn’t play a role because we only prescribed a few prescriptions. Looking further, I realized that dentists do play a role, and a pretty big role, in the overall chronic opioid use, misuse, and abuse cycle. Statistics show that dentists are the leading prescribers of opioids to people ages 10-19. That corresponds with wisdom tooth age, so for many patients, wisdom tooth removal is their first exposure to narcotics. Acute prescribing, even in small amounts for a short term, can cause some patients to experience future trouble.

Once Kellie and I realized this, we got that message out to any group we spoke with. One of our presentation slides simply states: “Dentists do play a role in the opioid issue.” That tends to get dental groups paying attention like it did for me when we started with this work.

Q: Your work targets opioid prescribing to address acute dental episodes. What actions have you taken to decrease dental opioid prescriptions?  How does the PDMP work?

A: K. Skenandore: We developed educational materials with the assistance of funding from the public health department. We created a set of dental prescribing guidelines as well as a brochure that provides information on the role of dentists in the opioid prescribing environment.

We also included information on the PDMP in our provider presentations. Providers can see if the patient has had access to opioids and if she or he has a spike in frequency of prescribing. It has a broad utility, but we’ve had a lot of trouble in getting health care providers of all types, including dentists, to register for the PDMP. Bruce and I wanted to address this by increasing awareness, so we went out and started telling them about the PDMP.

About a year into our project, the legislature approved House Bill 4143 requiring all providers prescribing controlled substances to register for the PDMP. However, the legislation didn’t require prescribers to use it. Sixty-seven percent of dental providers in the state are currently registered; the numbers have come up some, but they have a way to go.

Q: State strategies for addressing the opioid epidemic often involve stakeholders, including sister agencies. How did you engage stakeholders to help build momentum around your work?

We pushed our way into the party in a few cases and became a part of the Oregon Opioid Task Force and other work.

A: B. Austin: The way that Oregon Health Authority is set up allows for a lot of integration. My position reaches across all divisions where oral health has any of kind of a role. We were already somewhat integrated systematically, but this work really let us actively involve many of those divisions, including Medicaid, health policy analytics, and public health. It was a great opportunity for us to further that integration more than just on paper.

That being said, we had to assertively insert ourselves into groups that wouldn’t have necessarily invited us otherwise. We pushed our way into the party in a few cases and became a part of the Oregon Opioid Task Force and other work.

A: K. Skenandore: We need to be aware of possible insertion points and be very straightforward and open with people about what we’re trying to achieve. Being open and forthcoming has proved to be fruitful.

We also insisted that the dental prescribing guidelines not just be rolled up into the acute prescribing guidelines. Dental easily gets lost in the shuffle — so we wanted to single it out and keep it on a level playing field with all the other entities.

Q: How are your efforts beginning to make a difference?

A: B. Austin: We’ve seen dental-related visits to emergency departments (EDs) decrease drastically in the last year or two.  I think the reduction in dental emergency department visits is partly related to the new philosophy of fewer opioids prescribed and more use of the PDMP to identify spikes in opioid prescribing. In a recent presentation I gave, an ED doctor noted that he thinks the reduction is due to the message that dental patients aren’t going to continue to get opioids in the ED due to a problematic tooth. That was good to hear from him.

Q: What are you currently working on?

A: K. Skenandore: We have been working with the Oregon Health & Science University’s School of Dentistry to implement a learning module on dental prescribing through a grant we received. The module not only addresses undergraduate students but graduate students and those in continuing education programs as well.

A: B. Austin: The point is to get the message out to all dental school faculty. Everyone needs to be on the same page. We wanted to reach not only students, but dentists and dental hygiene graduates, and those in pharmacy, nursing, and global medicine. There has been a lot of excitement from all parties involved.

Q: What advice do you have for states looking to address the opioid epidemic through oral health levers?

We have to find those linkages and commonalities. That’s the best way to approach this type of work, because people then see that it’s relevant to them as well.

A: K. Skenandore: We’ve learned that we won’t achieve anything unless we ask questions and be assertive. This was something we gained through our leadership training. If we don’t ask questions, no one makes the linkage to oral health because they were thinking within their own silo. It’s really difficult to integrate oral health with primary care. You need to look for those bridges where the two disciplines can meet. I think oral health has a role to play in diabetes care, maternal health, etc. The same applies to the opioid scenario. We have to find those linkages and commonalities. That’s the best way to approach this type of work, because people then see that it’s relevant to them as well.

A: B. Austin: It also goes back to our “aha!” moment, that dentists do really play a role in the opioid issue. We can’t continue to think like I did initially — that we’re not part of the overall issue. Repeating that message is important.


Case Studies: Improving Oral Health through Cross-Agency Partnerships in Missouri and Rhode Island

The State Oral Health Leadership Institute, led by CHCS, brings together Medicaid dental program directors and state oral health program directors to advance shared goals for Medicaid and public health programs. These new case studies highlighting success stories in Missouri and Rhode Island illustrate how inter-agency and cross-sector partnerships can be used to increase oral health care utilization among low-income populations. Learn more »

 

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