Addressing the Opioid Crisis

Opioids are a class of drugs that includes legal prescriptions, such as codeine, morphine, oxycodone, hydrocodone, and pharmaceutical fentanyl, as well as illegal drugs such as heroin and illicitly manufactured fentanyl (IMF). Opioids can be classified as natural, semi-synthetic, or synthetic. They reduce pain by binding to opioid receptors throughout the body.^1–3 Prescription opioids are commonly prescribed to manage both chronic and acute pain.⁴ Opioids have often been prescribed by dentists for the management of acute dental pain and can be used to effectively manage pain when prescribed and taken appropriately.^4–7

Opioid misuse has created an epidemic leading to opioid use disorder (OUD), overdose, and death.⁴ Individuals who regularly use illicit opioids often initially misuse prescription opioids.⁸ In the United States from 1999 to 2017, the number of deaths due to opioid overdoses reached almost 400,000, and the total death rate from opioid overdose has grown each year subsequently. In the US from 2016 to 2017, the death rate from synthetic opioids, specifically IMF, increased 45.2%. Conversely, death rates from prescription opioids and heroin have remained high, although relatively stable.⁹ The opioid crisis in the US was officially declared a public health emergency in October 2017 by the US Department of Health and Human Services (HHS).¹⁰

The opioid crisis is a multi-faceted, complex issue that affects individuals, families, and communities. Healthcare providers must be knowledgeable about opioid misuse, OUD, and opioid overdose, including the usage of naloxone, a medication that rapidly reverses an opioid overdose. Dental hygienists need to know how to address this crisis in clinical practice, which may include learning about the national prescription drug monitoring program (PDMP), medicine take-back programs, and a team approach to opioid stewardship. Although dental hygienists are non-prescribing providers, it is vital to actively participate in the mitigation of this multi-dimensional public health issue.

PRESCRIPTION DRUG MONITORING PROGRAM

PDMPs are statewide databases that collect information from pharmacies on dispensed controlled substances and allow registered users, including dentists, to check the prescription history of patients.¹¹ With the intent of improving opioid prescribing practices and identifying patients at risk for opioid misuse, the US Centers for Disease Control and Prevention (CDC) recommends checking the PDMP regularly, at least every 3 months and prior to writing opioid prescriptions.¹² Effective provider use of PDMPs can be valuable in identifying at-risk patient behaviors such as doctor shopping, potential diversion, and the obtainment of multiple opioid prescriptions.^12,13

PDMPs are considered one of the most promising state-level interventions to improve opioid prescribing; however, their success depends on their level of utilization by prescribers.^14,15 Studies show that the use of PDMP by dentists has been low.^5,16 This may be due to lack of exposure to formal addiction training and education, infrequent opioid prescribing, and irregular usage of opioid risk mitigation strategies.¹³ As such, states have implemented a variety of ways to make PDMPs easier to use. Examples include the integration of PDMPs into electronic health record systems, the ability to delegate access to PDMPs, and streamlining the PDMP registration process for eligible providers.¹⁴

Dental hygienists are ideally positioned to serve as PDMP delegates. They treat patients more frequently than other providers and regularly update patient medical histories, including current medication use. As delegates, dental hygienists would be able to review patient information in the PDMP and report it to the prescriber. Few states have recognized and adopted the use of dental hygienists in this manner. As a profession, advocating for participation as PDMP delegates is prudent in the fight against opioid misuse.

NATIONAL PRESCRIPTION DRUG TAKE BACK DAY

Prescription drug misuse, which includes prescription opioids, is among the fastest growing drug problems in the US. In 2016, the Substance Abuse and Mental Health Services Administration reported approximately 11.8 million people ages 12 and older misused opioids.¹⁷ More specifically, 3.6% of adolescents ages 12 to 17 reported misusing opioids in 2016. Most adolescents who abuse prescription drugs obtain them through someone they know, typically without their knowledge.¹⁸

Patients need to be aware of options for discarding unused or unwanted medicines including prescription opioids. The US Food and Drug Administration (FDA) recommends medicine take-back options as the preferred method to safely dispose of most types of unused or expired prescription and over-the-counter medicines. Medicine take-back options include periodic events and permanent collection sites.¹⁹ The National Prescription Drug Take Back Day organized by the US Drug Enforcement Agency (DEA) is a semiannual event held once in October and again in April. At the 17th National Prescription Take Back Day held on April 27, 2019, 937,443 lbs of unused or expired pharmaceuticals were collected.²⁰

Permanent collection sites are another option for consumers to safely and effectively discard medications. Authorized permanent collection sites may be in retail pharmacies, hospital or clinic pharmacies, and law enforcement facilities.²¹ Most of these programs, which are registered with the DEA, use on-site drug disposal boxes or offer a mail-back option.²² When using a drug take-back option, all personal information should be removed from the pill bottle or medicine packaging.¹⁹

In circumstances when a drug take-back option is unavailable, the FDA has outlined alternatives for medicine disposal. Most medicines can be discarded in the trash with proper drug disposal guidelines or by flushing down the toilet, but only after checking the FDA’s list of medicines recommended for disposal by flushing, or “flush list.”²³ Prescription drugs, such as opioids and other controlled substances, are on the flush list. Fentanyl, hydrocodone, morphine, and oxycodone are prescription opioids approved by the FDA for disposal by flushing only when take-back options are not readily available. The FDA recognizes the potential negative effects that flushing may have on the environment. However, the FDA asserts the known risks from accidentally ingesting or misusing these drugs far outweigh the possible environmental concerns.²³

Dental hygienists should educate patients on proper drug disposal and its significance in minimizing risks for opioid misuse and overdose. Promoting events, such as the National Prescription Drug Take Back Day and providing resources such as the DEA website for current listings of collection sites, will encourage patients to take an active role in preventing opioid-related issues.

OPIOID OVERDOSE AND NALOXONE

In the US, opioid overdose is a significant public health issue. People dependent on opioids are most likely to experience an overdose. The CDC reported an estimated 78,840 hospitalizations for nonfatal opioid overdoses and an estimated 140,777 emergency department visits for opioid-related poisonings in the US in 2015.²⁴ In 2016, the number of opioid overdose deaths reached an alarming rate, contributing 66.4% or 42,249 drug overdose fatalities.²⁴ In 2018, the US Surgeon General released a public health advisory urging Americans to be knowledgeable about naloxone, an opioid antagonist, while increasing its availability and distribution.²⁵ In response, emergency medical personnel, healthcare professionals, and individuals have received training on how to use naloxone.²⁶

Dental hygienists must regularly update medical histories, social histories, and medications including those the patient may be taking for pain relief. Performing a thorough review of medications is critical in identifying patients who are engaging in some level of opioid use. It is important to ask who prescribed the medication, current dosage, and the duration of the medication usage. It is equally important to discuss any side effects the patient may be experiencing and the efficacy of the medication. Dental hygienists are well-positioned to educate patients about risks of addiction. As such, clinicians should have resources for patients who may have OUD or who disclose a desire to seek help, such as the HHS national help and online locator to find nearby treatment facilities.²⁷

Additionally, dental hygienists need to be able to recognize the signs of an opioid-related overdose and appropriate patient management. Opioids can affect the ability to breathe effectively and in high doses can cause respiratory depression and death. An opioid overdose is known as the “opioid overdose triad” due to three key symptoms: pinpoint pupils, unconsciousness, and respiratory depression.²⁸ Signs of respiratory depression may include slow, shallow breathing and choking or gurgling sounds. Other signs of opioid overdose might include pale, blue or cold skin, and a limp body.²⁹

The dental team must be prepared for a potential opioid overdose in the clinical setting. This requires reviewing existing policies, preparing staff, and updating emergency kits to include naloxone for opioid overdose.³⁰ After patient evaluation and calling 911, naloxone, if available, should be administered to anyone who presents with signs of opioid overdose or suspected overdose. Naloxone is approved by the FDA and can be administered by intranasal spray or by intramuscular, subcutaneous, or intravenous injection.^26,31 Naloxone is a safe antidote for an overdose or suspected overdose and can be used to reverse respiratory complications.²⁹ Multiple doses of naloxone may be necessary in some cases. If there is no reaction within 3 minutes of the first administration, a second naloxone dose should be administered.³¹

PROMOTING OPIOID STEWARDSHIP

A recent study found that dentists are among the highest prescribers of opioids in the US.^32,33 Despite the widely known risks associated with opioid use, some dentists continue to write unnecessary opioid prescriptions. The application of opioid stewardship could be a step in the right direction in addressing this issue.

Opioid stewardship is an emerging concept, similar to antimicrobial stewardship programs, that is designed to promote the safe use and prescription of opioids.³⁴ Dental hygienists are in a prime position to promote opioid stewardship, specifically during patient education. This is an opportunity to raise awareness of the serious health risks and side effects of opioid use while promoting the safe storage and disposal of medications. Dental hygienists can also actively assist patients in making informed decisions about pain management, as well as provide resources or referrals for patients in need.

In an effort to promote opioid stewardship and support patients with pain management, dental hygienists should be aware of the US CDC’s Guideline for Prescribing Opioids for Chronic Pain. These guidelines encourage communication between patients and providers on the appropriate use of opioids to manage pain.³⁵ For acute dental pain, nonsteroidal anti-inflammatory drugs, such as 400 mg of ibuprofen combined with 1,000 mg of acetaminophen, can provide greater pain management than opioid prescriptions while avoiding risks associated with opioid therapy.³⁶ If opioids are the optimal medication to treat pain, prescribing the lowest effective dose for 3 days, but no longer than 7 days, is prudent. In addition, opioids and benzodiazepines should not be prescribed simultaneously because both cause central nervous system and respiratory depression, increasing the risk of overdose.³⁵ At least 33 states have adopted legislation to address limits on opioid prescriptions as of October of 2018.³⁷ As such, dental hygienists should be knowledgeable not only about the CDC recommendations, but also about their states’ legislation on prescribing opioids. Dental hygienists should work together with other members of the healthcare team to ensure the avoidance of such drug combinations and/or interactions.

SUMMARY

Dental hygienists, as nonprescribing healthcare providers, can still play a key role in alleviating the opioid crisis in the US. As part of the dental team, dental hygienists should help raise awareness of the risks and side effects of opioid use while recognizing signs and symptoms of opioid use disorder and opioid overdose. Additionally, dental hygienists can support efforts to address this public health issue by supporting the use of PDMPs, promoting the proper disposal of opioids, and encouraging opioid stewardship. Collectively, with dental providers and other healthcare teams, dental hygienists can take steps to improve opioid practices and usage.

Acknowledgment

The authors would like to thank Julie H. Schiavo, MLIS, AHIP, for her assistance with this manuscript.

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From Dimensions of Dental Hygiene. September 2020;18(8):32-35.