This course was published in the January 2023 issue and expires January 2026. The authors have no commercial conflicts of interest to disclose. This 2 credit hour self-study activity is electronically mediated.
AGD Subject Code: 130
After reading this course, the participant should be able to:
- Describe the status of the opioid crisis.
- Identify the role dental hygienists may play in helping to curb the prescription opioid crisis.
- Discuss the components of effective risk assessment for substance abuse disorder.
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:
- 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.
- 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.
- 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.
- 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.
- 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.
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.
- United States Centers for Disease Control and Prevention. Understanding the Opioid Overdose Epidemic. Available at: cdc.gov/opioids/basics/epidemic.html. Accessed December 2, 2022.
- National Center for Drug Abuse Statistics. Opioid Epidemic: Addiction Statistics. Available at: drugabusestatistics.org/opioid-epidemic. Accessed December 2, 2022.
- American Medical Association. Issue brief: Nation’s drug-related overdose and death epidemic continues to worsen. Available at: ama-assn.org/system/files/issue-brief-increases-in-opioid-related-overdose.pdf?_hsenc=p2ANqtz-9QgQTwsln7vBb2W62 pjWwRAb1Yp-QCkejxgR _NdOZu3BOUzH4YOTjIYcmvba GP8gdhxxt7PcB_If4O-VjaufpYqNRc8i3cIWM_ g6NiiNZeeOEfrg&_ hsmi=89175342. Accessed December 2, 2022.
- Alter A, Yeager C, The consequences of COVID-19 on the overdose epidemic: overdoses are increasing. Available at: odmap.org/Content/docs/news/떔/ODMAP-Report-May-2020.pdf. Accessed December 2, 2022.
- American Dental Association Health Policy Institute. Opioid Prescribing by Dentists. Available at: Available at: ada.org/~/media/ADA/Advocacy/Files/Opioids 2018_ADA HPI_. Accessed December 2, 2022.
- Suda K, Zhou J, Rowan et al. Overprescribing of Opioids to Adults by Dentists in the US, 2011–2015. Am J Prev Med. 2020;58:473–486.
- Miller C, Ke C, Witty J, Nagarajan R. Prescribing patterns of opioid analgesics in a dental setting: 2013–2018. Oral Surg Oral Med Oral Pathol Oral Radiol. 2020;130:402–410.
- Heron M, Nwokorie N, O’Connor B, et al. Survey of opioid prescribing among dentists indicates need for more effective education regarding pain management. J Am Dent Assoc. 2022;153:110–119.
- United States Centers for Disease Control and Prevention. Understanding Drug Overdoses and Deaths. Available at: cdc.gov/drugoverdose/epidemic/index.html. Accessed December 2, 2022.
- Khawaja SN, Scrivani SJ. Managing acute dental pain: principles for rational prescribing and alternatives to opioid therapy. Dent Clin North Am. 2020;64:525–534.
- United States Centers for Disease Control and Prevention. CDC’s Clinical Practice Guideline for Prescribing Opioids for Pain. Available at: cdc.gov/acute-pain/index.html. Accessed December 2, 2022.
- Drug Enforcement Administration. Controlled Substance Schedules. Available at: deadiversion.usdoj.gov/schedules. Accessed December 2, 2022.
- American Dental Association. Current Policies. Available at: ada.org/en/about-the-ada/ada-positions-policies-and-statements/statement-on-opioids-dental-pain. Accessed December 2, 2022.
- Pennsylvania Dental Association. PDA Key Player Working with State and Other Stakeholders in Combating Opioid Abuse Crisis. Available at: padental.org/Online/Resources Programs/Opioids/Opioid_Home.aspx?hkey=a94cf191-39cf-449c-8c6d-8fea11aacf4b. Accessed December, 2022.
- New Hampshire Dental Society. Opioids in the Dental Practice Guidelines for New Hampshire Dentists. Available at: nhds.org/docs/librariesprovider34/private-library-new-hampshire/board-of-trustees/jan-14-2016/opioids-in-the-dental-practice.pdf. Accessed December 2, 2022.
- Washington State Dental Association. Dental Guideline on Prescribing Opioids for Acute Pain Management. Available at: wsda.org/news/blog/떑/著/葪/dental-guideline-on-prescribing-opioids-for-acute-pain-management. Accessed December 2, 2022.
- American Association of Oral and Maxillofacial Surgeons. Opioid Prescribing: Acute and Postoperative Pain Management. Available at: aaoms.org/docs/govt_affairs/advocacy_white_papers/opioid_prescribing.pdf. Accessed December 2, 2022.
- DeMoss M, Nguyen CA, Wood RC, Tysinger JW, Smiley LA. Dental hygienists’ role in the opioid synddemic: Assessing attitudes, perceptions, and practices. Euro Dental. March 19-20, 2020.
- American Dental Association. The Dental Hygienist’s Role in Supporting Patients with Substance Use Disorder (Webinar). Available at: ada.org/resources/practice/health-and-wellness/the-dental-hygienists-role-in-supporting-patients-with-substance-use-disorder-webinar. Accessed December 2, 2022.
- Viswanath A, Barreveld AM, Fortino M. Assessment and management of the high-risk dental patient with active substance use disorder. Dent Clin North Am. 2020;64:547–558.
- Staras SAS, Guo Y, Gordan VV, et al. Dental practitioners’ use of health risk assessments for a variety of health conditions: results from the South Atlantic region of The National Dental Practice-Based Research Network. J Am Dent Assoc. 2021;152:36–45.
- Greenberg BL, Kantor ML, Bednarsh H. American dental hygienists’ attitudes towards chairside medical screening in a dental setting. Int J Dent Hyg. 2017;15:e61–e68.
- American Dental Association. CDT 2022: Current Dental Terminology. Chicago: American Dental Association; 2021.
- Commission on Dental Accreditation. Accreditation Standards for Dental Hygiene Education Programs. Available at: coda.ada.org/standards. Accessed December 2, 2022.
- Gordon J, Severson H. Tobacco cessation through dental office settings. J Dent Educ. 2001;65:354–363.
- National Institute on Drug Abuse. Screening Tools and Prevention. Available at nida.nih.gov/nidamed-medical-health-professionals/screening-tools-prevention. Accessed December 2, 2022.
- McNeely J, Wu LT, Subramaniam G, et al. Performance of the tobacco, alcohol, prescription medication, and other substance use (taps) tool for substance use screening in primary care patients. Ann Intern Med. 2016;165:690–699.
- Valachovic RW. Introduction In: Schatman ME, Kulich RJ. eds. Controlled Substance Risk Mitigation in the Dental Setting. Philadelphia: Elsevier; 2020;64:3.
- Keith DA, Hernández-Nuño de la Rosa MF. Special screening resources: strategies to identify substance use disorders, including opioid misuse and abuse. Dent Clin North Am. 2020:64:513–524.
- D’Souza RS, Lang M, Eldrige JS. Prescription Drug Monitoring Program. Stat Pearls. Available at: ncbi.nlm.nih.gov/books/NBK532299. Accessed December 2, 2022.
- Federation of State Medical Boards. Prescription Drug Monitoring Programs. Available at: fsmb.org/siteassets/advocacy/key-issues/prescription-drug-monitoring-programs-by-state.pdf. Accessed December 2, 2022.
- Keith DA, Shannon TA, Kulich R. The prescription monitoring program data: what it can tell you. J Am Dent Assoc. 2018;149:266–272.
- Schatman ME, Patterson E, Shapiro H. Patient interviewing strategies to recognize substance use, misuse, and abuse in the dental setting. Dent Clin North Am. 2020;64:503–512.
- Schatman ME, Shapiro H, Hernández-Nuño de la Rosa MF, Huot V. Brief motivational interventions: strategies for successful management of complex, nonadherent dental patients. Dent Clin North Am. 2020 Jul;64:559–569.
- Bray KK, Bennett K, Catley D. Fidelity of motivational interviewing training for dental hygiene students. J Dent Educ. 2021:85:287–292.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Arlington, Virginia: American Psychiatric Association; 2013.
- American Dental Association. Current Policies. Available at: ada.org/en/advocacy/current-policies#substanceusedisorders. Accessed December 2, 2022.
- Kulich R. Integrating controlled substance risk assessment and management into dental practice webinar. Available at: ada.org/resources/practice/health-and-wellness/integrating-controlled-substance-risk-assessment-and-management-into-dental-practice-webinar#.Y3432dyP0Qc.link. Accessed December 2, 2022.
- Wiener RC, Waters C, Bhandari R, et al. United States re-licensure opioid/pain management continuing education requirements in dentistry, dental hygiene, and medicine. J Dent Educ. 2019;83:1166–1173.
- Christen AG, Christen JA. Dental education in the prevention and treatment of substance use disorder. Subs Abus. 2022;23(S1):185–206.
From Dimensions of Dental Hygiene. January 2023; 21(1)38-41.