The Role of Dental Hygienists in Combatting the Opioid Epidemic

The opioid crisis has claimed more than 930,000 lives in the United States since 1999. Plus, the COVID-19 pandemic resulted in an increase in the number of opioid overdose deaths.^1–4

The types of drugs involved in opioid deaths are constantly changing; currently, synthetic opioids are of particular concern and overdose deaths are frequently associated with a combination of controlled substances.^1–4

Although their overall rates of opioid prescribing have declined, dentists still prescribe about 6.4% of all opioid medications written in the US and they are the highest prescribers of opioids to the adolescent population, who are particularly at risk for substance misuse and abuse.^5–9

Opioids At a Glance

Opioids are used almost exclusively for pain relief. They are effective for acute pain experienced after trauma or surgery and are also used to reduce chronic pain (eg, cancer, back, neck).

Prescription opioids have a long history of efficacy for their intended use. In dentistry, short-acting opioids—such as oxycodone, hydrocodone, and codeine—are most commonly prescribed for acute post-operative pain.¹⁰

Opioids have several contraindications and side effects, including respiratory depression, which can lead to death.^10,11 Because of their potential misuse, opioids are categorized as Schedule II controlled substances by the Controlled Substances Act and are subject to strict regulation.¹²

Prescribing dentists are required to follow both federal and state regulations addressing the safe and effective use of opioids in dental practice. Professional associations, such as the American Dental Association (ADA); state dental societies; and specialty groups have published position papers, articles, books, and guidelines to assist dentists in reducing opioid addiction.^13–19 The American Dental Hygienists’ Association also collaborates with organizations to identify, promote, and utilize available substance abuse and addiction resources and programs.

Assessment and Management of Patients With High-Risk Substance Use

Dental hygienists play a critical role in assessing and managing patients with complex health needs. However, their role in prescription opioid risk assessment seems to have been underestimated.²⁰ Several studies have examined the barriers faced by dental hygienists in conducting health risk assessments (HRA).

The National Dental Practice-Based Research Network surveyed dentist and dental hygienist members of the South Atlantic region to evaluate their HRA practices (screening, measuring, discussing, and referring patients) for six health conditions (obesity, hypertension, sexual activities, diabetes, alcohol use, and tobacco use).²¹ The study found the most commonly reported barrier to conducting multiple HRAs was too little time. Lack of reimbursement and lack of referral resources were rarely or never noted as barriers. No consensus was reached regarding clinician comfort or perception of patient discomfort as barriers.

Screening for medical and psychiatric conditions in the dental setting can be an effective strategy for early identification of individuals at increased disease risk. Greenberg et al²² surveyed 3,133 dental hygienists and the overwhelming majority felt it was important to perform chairside screening for certain medical conditions.

Given that dental hygienists are involved in preventive and educational activities, screening for substance abuse disorder seems like a natural extension of their responsibilities. Of the dental hygienists surveyed in the Greenberg study, 94% were willing to refer patients for a medical consultation. The barriers identified were lack of dentist/owner support (98%), patient willingness (98%), and time (98%).

The lack of reimbursement for high-risk substance use assessment was addressed at the 2021 meeting of the ADA’s Code Maintenance Committee, and a new code “Counseling for the Control and Prevention of Adverse Oral, Behavioral and Systemic Health Effects Associated with High Risk Substance Use (D1321)” was approved.²³

Expanding Dental Hygiene Accreditation Standards

Standard 2-8d of the Commission on Dental Accreditation (CODA) Standards for Dental Hygiene states: “Science content must include oral health education, preventive counseling, and health promotion.”²⁴ The dental hygienist may be well suited to serve as the lead dental team member in addressing nicotine addiction.²⁵ However, CODA has no specific assessment guidelines regarding other substance abuse disorders in dental hygiene education.

The National Institute on Drug Abuse provides a list of validated screening tools for health professionals.²⁶ For example, by using the “tobacco, alcohol, prescription medication, and other substance use” (TAPS) screening tool, the dental hygienist can capture nicotine, prescription opioid, alcohol, and illicit drug misuse in one quick and easy-to-administer questionnaire.²⁷

The TAPS screening tool is a smartphone app with a four-item questionnaire that asks patients how often they use tobacco, illicit drugs, alcohol, and prescription drugs for nonmedical purposes. The app scores the responses and indicates whether the patient is high, medium, or low risk for substance misuse. The information can be shared with the dentist and other healthcare professionals.²⁷

Dental hygienists should be considered assets in providing safe and nonjudgmental dental environments for patients with potential substance use problems

Opioid Risk Assessment

Dental patients spend a considerable amount of time with their dental hygienist. As such, the dental hygienist is often an excellent source of information on the behaviors of patients with potential substance abuse disorders, and they may be the best positioned to notice unusual or aberrant behaviors that need to be communicated to the dentist. Sharing these insights will help the entire dental team to be sensitive to the complexities of patients in pain and help to identify patients who may be seeking prescription opioid medications for nonmedical use.^28,29

As of August 28, 2021, all 50 states, the District of Columbia, and Guam have mandated prescribing dentists to register with and use their region’s prescription drug monitoring program (PDMP) when prescribing controlled substances. The details of PDMPs vary by state but the basic information obtained can help identify multiple, overlapping prescriptions and potential misuse.

In some states, the prescribing dentist can delegate the responsibility for accessing the patient’s PDMP data to a staff member, including dental hygienists. The dentist is liable for any breaches of patient confidentiality with these data.^30–32

Importance of Adapting Motivational Interviewing

Motivational interviewing (MI) is an evidence-based, structured interviewing technique that has been used in dentistry for many years, predominantly to promote the self-management of oral health. MI does not require special training in mental health assessment and can be effectively used by dental hygienists.

The goal of MI is to provide dental team members with the professional communication and listening skills to achieve trusting relationships with their patients. These techniques will also allow dental professionals to enhance history taking, thus promoting appropriate oral health interventions. The use of MI in alcohol, to­bac­co, illicit drug, and opioid use has been discussed in relation to dentistry.^33–35

Eliminating the Stigma of Substance Abuse

Substance abuse is defined as a disease in which a person takes alcohol or drugs repeatedly despite negative consequences. It is not a moral failing or lifestyle choice. Individuals with this diagnosis need to be treated in the same way that patients with diabetes, asthma, or any other medical condition are treated.³⁶ This requires dental professionals to provide a safe, secure, comfortable, nonjudgmental, and confidential environment for patients at risk or with substance use disorders to receive dental care.

Dental hygienists know their patients well and patients have trust and confidence in their dental hygienist. With this type of bond, it is easier for dental hygienists to broach sensitive topics, such as smoking cessation, human immunodeficiency virus, and substance misuse. Patients are usually willing to listen to their dental hygienist’s suggestions and make lifestyle changes. Speaking to patients about high-risk substance use, including opioids, provides an opportunity to educate, counsel, and refer patients to an appropriate provider for follow-up care. This type of education and counseling is within the dental hygienist’s scope of practice.³⁷

Expanding Continuing Education Requirements

The ADA has encouraged oral health professionals to pursue continuing education (CE) in addictive disease and pain management as related to opioid prescribing.^37,38 Twenty-four states require dentists to take continuing education on pain management/opioids and six states mandate the same for dental hygienists.³⁹

A CE requirement would ensure that dental hygienists receive basic education in these areas at least once per licensing cycle and advances the notion within dentistry that dental hygienists play an important role in substance use screening and mitigation.

Christen and Christen⁴⁰ have reviewed educational goals for the dental team with emphasis on the knowledge and competencies of dental personnel necessary for dealing with substance use disorder and for collaborating with other health professionals.

Creating a New Plan to Address the Opioid Crisis

With the need to further mitigate the opioid crisis ever-present, dental hygienists should be considered assets in providing safe and nonjudgmental dental environments for patients with potential substance use problems. Following are recommendations to facilitate the use of dental hygienists in the effort to combat the opioid crisis:

1. State dental boards should require CE in pain management, opioid use and misuse, MI, and risk assessment as part of the licensing requirements for dental hygienists and should stipulate content for these courses.
2. Dental hygiene schools should expand their curricula to include the topics of opioid misuse and abuse, MI, substance misuse risk assessment, in addition to providing training on the use of brief, validated screening questionnaires.
3. Dental and dental hygiene professional associations should work together with primary care providers and medical specialists to promote interprofessional collaboration around substance use and misuse to explore the most time-efficient and cost-effective means of using the skills of the dental hygienist in risk assessment and mitigation.
4. Dental and dental hygiene professional associations should work with medical and dental insurance companies to explore reimbursement strategies for substance use risk assessment and mitigation to promote beneficial health outcomes and encourage substance use screening.
5. Dental hygiene and dental schools should collaborate on research to validate training methods and outcomes to promote sustainable educational programs in substance use assessment and mitigation for dental hygienists.

Conclusion

As dental hygienists often develop trusted and long-lasting relationships with patients, they are well suited to assess for substance abuse problems and appropriately advise patients on how to seek help. Staying abreast of oral health complications related to opioid or other substance misuse is also key to supporting the best possible oral health outcomes in patients.

References

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From Dimensions of Dental Hygiene. January 2023; 21(1)38-41.