Training dentists to write prescriptions only after thorough re-evaluation with the patient is a move that many hope will limit unneeded prescriptions from being filled.While America fights a crippling opioid crisis, Alabama is challenged on an unparalleled scale. Ranked No. 1 in the nation in opioid prescriptions per capita with a 269 percent increase in overdose deaths since 2000 in Jefferson County alone, this crisis is plaguing health professionals and patients alike, as many struggle to get the epidemic under control.
At the University of Alabama at Birmingham School of Dentistry, professors are taking the lead in the dental field to combat the growing opioid epidemic in hopes that their measures will be translated into other practices and fields across the state and country.“The public health crisis we are dealing with stems from many roots, ranging from easy access to prescription medication and the quantity in which medication is prescribed, to the inability of physicians to set realistic expectations with patients about pain,” said Nico Geurs, DDS, chair of UAB’s Department of Periodontology. “As dentists, we’re facing a watershed time when patients have a list of requests for pain medications that they think they need and expect to receive, none of which are in line with reality. Pain management with opioids has been normalized in American culture, and it’s rapidly spiraling out of control.”
Michael S. Reddy, DMD, DMSc, left, and Nico Geurs, DDSIn response to the growing emergency, Geurs and Michael S. Reddy, DMD, DMSc, dean of the UAB School of Dentistry, have been selected as representatives on a new opioid council formed by the American Dental Education Association with the goal of implementing transformative measures into dental education curriculums on the student and practitioner levels. From educating faculty about best practices for writing prescriptions, to leading task forces that revise dental school curriculums relating to medication, this council will help lead collaborative task forces that aim to change the trajectory of the opioid epidemic.
As physicians and officials alike are starting to better understand the magnitude of the prescription medication situation in America — a country that makes up 5 percent of the world’s population yet prescribes 80 percent of the world’s prescription painkillers — many believe starting with proper education at the student level, then developing continuing education programs for practicing dentists, will cultivate a new standard of care; when looking at the state of the crisis in the dental field, many professors are looking to dental school education as a linchpin.
To Geurs, education is a critical component, but ultimately the approach is multi-fold. It involves setting expectations with patients about pain management and treating addiction like the disease it is in order to see change. If dentists can better understand the causes of supply and demand, they have the potential to curb the number of prescriptions that are written and can help influence change.
Pain management
In looking at the rise of opioid addiction in dentistry, accurately setting pain realities for patients plays a tremendous role in curbing addiction before it starts. Geurs uses the following example to show how the cycle gets out of control: “A dentist may stress that the procedure ‘won’t be too challenging,’ setting the expectation to the patient that they won’t experience any pain. Post-surgery, the patient naturally experiences moderate pain for a few days, but perceives that pain to be out of this world due to their thought that no pain would occur. The dentist then prescribes pain medication — typically four pills a day for 10 days — whereas traditional NSAIDs like ibuprofen and acetaminophen could easily have done the job. The patient may take three or four pills, leaving them with nearly 35 extras. The next time that patient experiences any discomfort, they have a lot of medication to turn to. They may share a pill with a friend or family member. The cycle of misuse begins.”
| “It’s up to us to acknowledge and prep the patient for the amount of anticipated pain they may experience, but also recognize that pain management is not a one-size-fits-all approach." |
“It’s up to us to acknowledge and prep the patient for the amount of anticipated pain they may experience, but also recognize that pain management is not a one-size-fits-all approach. Even the most seemingly challenging of procedures should warrant only a few days of discomfort, and certainly not an extended amount of pain that calls for a prescription of 40 pills,” Geurs said.
When trying to pinpoint the catalyst for this epidemic, many dentists now realize that pain assessment was seen by many as daunting and timely, and opioid prescription became an accepted solution for all problems regardless of size or scope. As the School of Dentistry works to groom future dentists to treat opioid prescription with select caution, UAB’s dental faculty understand they need to take the curriculum beyond just understanding the pharmacology of drugs, and to understand the roots of pain and key management solutions that will serve in the patient’s best interest.
Geurs says estimating expected pain is challenging; but it is the gatekeeper’s responsibility to make educated decisions about who warrants a true prescription, versus those who can take the NSAIDs method of treatment. There is a distinct difference in discomfort and pain, and ensuring that dentists find that line is critical. Training dentists to write prescriptions only after thorough re-evaluation with the patient is a move that many hope will limit unneeded prescriptions from being filled.
Addiction as a disease
With a widespread epidemic that is rapidly claiming lives, the first step in prevention is teaching the next wave of dentists proper care before they enter practice. With faculty at the forefront of teaching these measures to students, the school recently hosted a presentation and forum regarding the issue with guest speaker A. Omar Abubaker, DMD, Ph.D., Elmer Bear chair and professor at Virginia Commonwealth University’s Department of Oral and Maxillofacial Surgery. Abubaker’s son died of accidental drug overdose, and he has committed himself to teaching other dentists about the depth of the opioid epidemic. He believes that, until gatekeepers of prescriptions diagnose and treat addiction as a disease head on, change cannot happen.
As the next wave of dentists writing prescription pain medication, students at UAB's School of Dentistry are learning best practices for treating pain management and how to serve patients with potential exposure to addiction.In his presentation, Abubaker shared staggering statistics, including that opioid addiction sees 175 related casualties every day; a more dramatic comparison is that it equals a commercial plane crash a day. Addiction affects 40 million Americans, yet Abubaker explains that we tend to turn a blind eye to its horrors. “Until dentists begin taking a proactive stance in recognizing, intervening and referring patients, co-workers and colleagues for appropriate evaluation and treatment, the cycle will continue.”
In looking forward, the School of Dentistry is focused on implementing standards that teach students about the disease of addiction, rather than viewing addiction as a habitual choice. If dentists can recognize and treat signs of addiction from the start, they can avoid feeding into the patient’s disease and have the ability to set the patient on a path to recovery.
“In dentistry, we view the mouth as a mirror to the body,” Geurs said. “We can diagnose signs of cancer and diabetes; but when we recognize addiction, we aren’t filtering those patients in need to appropriate physicians to get them the care they need. This gap has continued to grow drastically in Alabama, and we as dentists have the ability to place a key role in curbing prescription medication from getting into the wrong hands.”
Planning for future curriculum, the School of Dentistry is evaluating screening tools for addiction risk and action steps to be taken when patients are in need. Geurs hopes this development will translate to practicing dentists and provide a strong foundation for continuing education courses that can be accessed across the city and state. Abubaker credits schools for making strides to teach limiting the number of pills that can be prescribed in a dosage, like moving from prescribing 40 pills to prescribing only eight.
As part of Geurs and Reddy’s involvement on the council, collaboration with other dental schools and state agencies will be critical in helping to establish baseline standards on prescription patterns, developing a substance abuse education program and garnering practicing dentists to buy into this new model of care. The School of Dentistry sees this as a unique responsibility to serve as leaders and foster fundamental change in the field.
“Closing the loop isn’t easy, and this is new territory for all of us,” Geurs said. “For the School of Dentistry to be in a position where we can help alter the trajectory of this epidemic is one that we take with great responsibility, and we hope public and clinical education will help protect others moving forward.”