ADDRESSING THE OPIOID CRISIS - Delta Dental Of Minnesota

ADDRESSING THE OPIOID CRISISMary Johnson, DDSVice President of Dental Services, Delta Dental of MinnesotaEileen Crespo, MDVice President of Medical Services, Delta Dental of MinnesotaDelta Dental of Minnesota

A NOTE FROMTHE AUTHORSDental and medical professionals providedistinct types of health care with patientwell-being as the common goal. Theopioid crisis has caused each one of us toreevaluate our approach to patient painmanagement in significant ways.As health care professionals, we are pleasedto present a co-produced contribution intothe body of research and recommendationssurrounding this crucial effort. It is our beliefthat we are stronger when we work together.We seek to educate and work toward athoughtful reassessment of everyone’s role inproviding evidence-based acute dental painmanagement for patients. A reevaluation inprescribing habits in an effort to reduce opioidmedication is important to both professions.As health care providers, we all can bringsubstantial weight to this fight. We believe it isour responsibility to do so.Signed,Mary Johnson, DDSVice President of Dental Services,Delta Dental of MinnesotaEileen Crespo, MDVice President of Medical Services,Delta Dental of Minnesota2Delta Dental of MinnesotaTable of ContentsSummary. 3Situational Analysis. 4How We Got Here. 5State and National Organizations React. 6Supporting Evidence. 7What We Can Do. 8Conclusion. 10References. 11

ADDRESSING THE OPIOID CRISISSUMMARYEvery day, an estimated 116 Americans dierelated to opioid abuse1. In 2017, the UnitedStates government declared the opioid crisisa public health emergency as the statisticsof abuse, overdose and death increased toalarming rates4.The relationship between prescription opioidsand opioid abuse is well-documented. In fact,the misuse of prescription pain relievers is thesecond-most common form of illegal drugabuse, just behind marijuana8.Opioid addiction can begin with wisdomteeth extractions. Some estimates report thatupwards of 3.5 million teenagers and youngadults are exposed to opioids for the first timewhen they are prescribed opioid medicationsfor home use after third molar extractions15.Dentists are the leading prescribers for opioidmedications for 10- to 19-year-olds16, an age atwhich the developing brain is at an increasedrisk of addiction17.A powerful contributing factor to drug abuseis leftover pain medication. One study foundthat more than one-half of opioid medicationsprescribed after dental surgery were leftunused19, and instead of disposing of theseleftovers, a majority of families kept them “justin case20.” The majority of abused medicationsby teenagers are obtained from a parent’smedicine cabinet21.To meaningfully impact the opioid crisis,dental and medical providers alike can takethe following steps:Aim for pain reduction rather than eliminationProviders should not strive to make the patientpain-free, but educate patients that somediscomfort is typical following dental procedures.Focusing on pain management and improvingpatient education will help decrease the potentialfor opioid addiction.Change our prescribing practicesAs multiple studies14, 30, 34, 36 have shown, careproviders in both medical and dental environmentsshould use a pain management guideline for acutedental pain which prioritizes the use of non-opioidmedications. Use of a prescribing guideline, suchas the University of Minnesota School of Dentistryguideline found on page 9, has shown a reductionof opioid prescriptions while providing appropriatepain control.Educate and encourage safe disposalHealth care providers should educate themselvesabout the options for safe disposal of opioidmedications. Providers should verbally reviewwith the patient the importance of the useof the drug as directed and of the need forimmediate disposal of unused medications.Providing appropriate patient education, includingbrochures or other resources that emphasize thismessage, in addition to offering multiple optionsfor disposal are important. Many communitiesoffer take-back programs, which may includeprescription drop boxes at police stations,city halls or local pharmacies37. Web-basedresources, such as DEA or FDA websites, arealso available37, 38.Find additional resources at:DeltaDentalMN.org/opioids3Delta Dental of Minnesota

ADDRESSING THE OPIOID CRISISSITUATION ANALYSISWe are in the midst of a serious nationalhealth crisis.Every day, an estimated 116 Americans die relatedto opioid abuse¹. According to the 2016 NationalSurvey of Drug Use and Health, 11.8 million peopleaged 12 or older had misused opioids in the prioryear, and the majority of them used prescriptionopioid medications2.In 2016, opioid overdose caused the deaths ofmore than 42,000 Americans– a 28 percentincrease over the previous year3. In the same timeperiod, the number of synthetic opiate overdosedeaths more than doubled (9,580 to 19,413)3.As the statistics of abuse, overdose and deathincreased to alarming rates, in 2017 the UnitedStates government declared the opioid crisis apublic health emergency4.The relationship between prescription opioids andopioid abuse is well-documented. The availabilityof prescription opioids has resulted in significantopioid misuse. There are more prescriptions foropioids, both written and filled, in the U.S. thanany other country5. In 2012, the number of opioidprescriptions in the United States peaked at 255million6. Of those, dentists prescribed 18.5 million7.The misuse of prescription pain relievers is thesecond-most common form of illegal drug abuse,just behind marijuana8. Moreover, misuse ofprescription opioids have been shown to serveas a gateway drug to heroin abuse9.Today, drug overdoses are the No. 1 cause ofdeath among Americans under 50 years of age10.4Delta Dental of MinnesotaOpioid overdose-causeddeaths in America2015-201642,24930,240201528%2016Today, drug overdoses are theNo. 1 cause of death amongAmericans under 50 years of age.

ADDRESSING THE OPIOID CRISISHOW WE GOT HEREThe complexities surrounding the developmentof the opioid crisis cannot be overstated, andseveral driving forces behind its advancementhave been identified. Pharmaceutical companies,government regulatory agencies, and healthcare providers are among the groups thatplayed a role.Stock photo posed by model.In 2010, Hydrocodone/Acetaminophen (Vicodin, Norco)was the most prescribed drug in theUnited States.Pharmaceutical manufacturers introducedextended-release opioid medications in the 1990s.These newer opioids were marketed not just foradvanced cancer and surgical procedures, butfor chronic pain from other causes. Providerswere reassured by the same manufacturers thatthe drugs were not addictive11. Following theseassurances, prescribing rates rose so quickly thatin 2010, Hydrocodone/Acetaminophen (Vicodin,Norco) was the most prescribed drug in theUnited States12.At the same time, health care regulatory agenciesendorsed pain as the fifth vital sign13.5Delta Dental of MinnesotaThe endorsement of the fifth vital sign by theJoint Commission on Accredited HealthcareOrganizations in 2001 and the Center for Medicareand Medicaid Services required providers toassess patients’ pain level14. This became a metricand quality measure tied to reimbursement.Opioid addiction can begin with wisdom teethextractions. Some estimates report that upwardsof 3.5 million teenagers and young adults areexposed to opioids for the first time when theyare prescribed opioid medications for homeuse after third molar extractions15. Predictably,dentists are the leading prescribers of opioidmedications for 10- to 19-year-olds16, an age atwhich the developing brain is at an increased riskof addiction17.Exposure to opioids in this age group has beenassociated with higher risk for future misuse ofthe drug. According to a 2016 report, legitimateopioid use before high school graduation isindependently associated with a 33 percentincrease in the risk of future opioid misuse18.A powerful contributing factor to drug abuseis leftover pain medication. One study foundthat more than one-half of opioid medicationsprescribed after dental surgery were leftunused19, and instead of disposing of theseleftovers, a majority of families kept them“just in case20.” If medications are not secured,a teenager can obtain medications from aparent’s medicine cabinet. In fact, two-thirdsof teens who report abuse of prescription painrelievers obtained them from friends, family oran acquaintance21.This “just-in-case” attitude highlights not onlya general lack of awareness to these risk factors,but emphasizes the lack of information aboutnecessary and appropriate disposal of opioidmedications.

ADDRESSING THE OPIOID CRISISSTATE AND NATIONALORGANIZATIONS REACTMultiple organizations have recognized the need forintervention to address opioid addiction and abuse.The following organizations have developed policiesand education to address the problem:The American Dental Association (ADA)updated its opioid statement in 2016 to includerecommendations for dentists to consider nonsteroidal anti-inflammatory analgesics as thefirst-line therapy for acute pain management22,and in 2018 released a new opioid policy whichsupported: prescription limits and mandatorycontinuing education for dentists; a statutoryopioid dosage duration limit of seven days; anddentists registering with and using PrescriptionDrug Monitoring Programs (PDMP)23.The American Association of Oral andMaxillofacial Surgeons (AAOMS) publisheda white paper on opioid prescribing and painmanagement24.The Minnesota Board of Dentistry issued astatement on safe prescribing and use of opioidsin dental settings25.The University of Minnesota Department ofOral and Maxillofacial Surgery implementeda mandatory opioid protocol, developed topromote safe opioid prescribing for acutepostoperative pain, which closely resembled theADA and AAOMS recommendations.6Delta Dental of MinnesotaThe Nebraska Board of Medicine has offeredguidance that prescribing must include a doctorpatient relationship and should be based on amedical diagnosis and the documentation ofunrelieved pain26.Several medical organizations, including theCDC, have issued prescribing guidelines 27, 28.In addition, more than 130 Congressional opioidbills have been introduced since the 115thCongress began in January 201729.