When it comes to prescription-drug misuse, you don’t usually think of dentists as the source. No one talks about “dentist shopping” or “dental pill mills.” But a new study shows that in fact dentists prescribe 12% of all immediate-release opioids; they’re second only to general practitioners as the biggest prescribers.
More than two-thirds of people who misuse painkillers get them from the medicine cabinets of family and friends, so reducing the overall amount of “leftover” opioids, whether they were prescribed by dentists or doctors, could help cut nonmedical use.
The question is how to do so without leaving people suffering in pain — dental pain being one of the worst that can be experienced. I asked my own dentist, Dr. Dennis Bohlin, the educational coordinator for the New York State Dental Association’s committee on chemical dependency: “It’s an extraordinarily complex problem and there’s not much impetus for dentists to do anything about it,” he says.
Bohlin explains that dentists typically prescribe 20 pills after painful procedures, even if patients don’t need that many painkillers. Not only is 20 the number dentists were taught in dental school, but it’s also enough to reduce the likelihood that they’ll be called the middle of the night for extra medication. “There are not a lot of financial or other incentives for changing, other than altruism,” Bohlin says.
George Kenna, professor of psychiatry at Brown University, is an author of the new study. He and his colleagues want dentists to be more aware of their prescribing practices and to try not to prescribe more than needed. Kenna suggests prescribing in smaller quantities, for instance, with refills. “I’ve had nine root canals and gum grafts. I know what pain is and I know when I need Vicodin,” Kenna says. “The idea is not to restrict legitimate access.”
If patients know they have refills, they may be less likely to hoard drugs, a habit that contributes to many cases of misuse. “Patients are loathe to get rid of opioids. If there’s an emergency, they want to have a powerful analgesic in the house,” says Bohlin. “That’s probably not inappropriate if you are responsible and can safeguard it.”
Kenna recommends that all families who choose to keep these medications on hand store them in a well-hidden or locked box to prevent teenagers and children from misusing them. “If you’re not going to throw them away, fine,” he says. “Everyone can understand that you don’t want to wake up at 1 a.m. and no pharmacy [is open]. You can secure these medications. That would go long way toward stopping adolescents from initiating use of these medications. And then if they are missing, you know there’s a problem.”
In addition, taking advantage of drug “take back” days sponsored by the Drug Enforcement Administration and by some pharmacies can help patients get rid of excess drugs safely. Flushing them down the toilet is not recommended because they can end up in the water supply.
The researchers also advise dentists to take a medical history of patients, including substance use problems, and to coordinate better with oral surgeons so that patients who are referred for further treatment don’t wind up with extra prescriptions.
No system is perfect, however. Bohlin, himself a long-term recovering addict and an expert on addiction in dentists, recently got fooled by a patient requesting an opioid prescription. “I called the pharmacy and they said, ‘We won’t fill that,’” because apparently she was known to them as an active addict, he says.
“We have to respect people’s pain,” says Bohlin, who will treat recovering addicts with opioids if necessary, but will often have a significant other or recovery sponsor take charge of the drugs. “That’s why this is such a complex problem.”