Solving the Opioid Crisis Teach-Out

Romesh Nalliah, DDS, MCHM, is Clinical Associate Professor and Director of Pre-Doctoral Clinical Education at the University of Michigan School of Dentistry. He specializes in Cariology, Restorative Sciences, and Endodontics.

The following interview was conducted with Professor Nalliah via email.

Please introduce yourself, and let us know about the work or research you do here at the University of Michigan.

My name is Romesh P. Nalliah and I practice general dentistry. I am also a Clinical Associate Professor and the Director of Clinical Education in the Dental program at University of Michigan’s School of Dentistry. I am responsible for the pre-doctoral dental clinics and my role involves finding a balance between providing excellent, high quality patient care and helping students learn dental medicine.

My area of interest in research is process evaluation. I have studied surgical processes, hospital processes, educational processes and even the processes surrounding public health issues such as motor vehicle traffic accidents (1) and jaw fractures due to assault (2). With my background in “big data” I have joined Dr. Chad Brummett and the Michigan Opioid Prescribing Engagement Network (Michigan OPEN)(3). Reducing opioid prescribing and customizing pain management for our patients is also aligned with University of Michigan’s Precision Health Initiative (4).

How would you describe the opioid crisis? Why is it significant?

Opioid addiction is a major problem in the United States. In 2013, it was estimated that $78.5 billion was spent on overdose, abuse and dependence on prescriptions opioids(5). Notably, the datasets used in these studies don’t capture post-discharge costs like rehabilitation, or consequential costs like unemployment – clearly, true economic burden may be grossly underestimated. The Center for Behavioral Health Statistics and Quality reported that 2 million people were suffering prescription opioid addiction in the United States in 2014 (6).

Data from the Centers for Disease Control and Prevention demonstrate that there were 12,727 deaths in 2015 due to natural and semi-synthetic opioid overdose in the United States (7). This is about 35 deaths in the United States each day! Additionally, in 2015 there were 12,990 overdose deaths associated with heroin (heroin is a drug processed from morphine) (8).

How can dentists impact the opioid crisis?

Research has shown that surgical dental procedures, root canal treatment, and implant procedures had the highest rates of opioid prescriptions by dentists (9). Troublingly, these procedures also had the highest increase in rates over the study period. Evidence must be expanded regarding effective pain control in dental medicine and this evidence must inform strong prescribing guidelines.

Importantly, dentists are involved in one of the first experiences of healthy young people with opioids – opioid naïve individuals. That is opioid prescription subsequent to the removal of wisdom teeth. Based on evidence there is reason to believe that alternatives to opioids can be equally effective in pain management. Dentists must be very thoughtful when introducing this young cohort to opioids.

Prescribing of opioids for dental procedures? Limit days supply? Use alternative pain medications?

Sixty percent of dentists are in solo-practice (10) and there is limited guidance for clinical decision-making relating to opioids (11). Left to their own decision-making processes there is enormous variability in approaches to pain relief – in one study, the number of tablets prescribed by dentists varied from 10 to 40 (12). This study also demonstrated that 0.52% of dentists did not ever prescribe a narcotic for pain management after removal of an impacted tooth. Notably, research has shown 54% of opioids prescribed by dentists remain unused (13). It is these unused drugs that can get into the hands of an addict or someone experimenting (which can quickly lead to addiction).

Additionally, research has shown that there are effective alternatives to opioids: Investigators concluded that there is “no clinically important differences in pain reduction at 2 hours with ibuprofen and acetaminophen or 3 different opioid and acetaminophen combination analgesics.” (14)

What are other possible pathways to solutions?

In dental medicine there is a need for a multifactorial approach. Firstly, evidence-based guidelines must be developed for prescribing. Secondly, alternative prescribing techniques must be mandated in continuing dental education requirements to maintain licensure in boards of registration in dentistry. Thirdly, the isolation of dentists from the rest of the health system must be overcome through strong communication and electronic health records that communicate (in real time) with their patients’ medical record. When the dentist prescribes an opioid the patients’ primary care physician should be aware of it (in real time) through a shared electronic health record. Finally, there needs to be a national drug database to combat opioid addition.

Footnotes:

1. Allareddy V, Anderson IM, Lee MK, Allareddy V, Rampa S, Nalliah RP. World J Pediatr. 2015. Hospital-based emergency department visits in children with motor vehicle traffic accidents: estimates from the nationwide emergency department sample. Aug;11(3):261-6.
 
2. Nalliah RP, Allareddy V, Kim MK, Venugopalan SR, Gajendrareddy P, Allareddy V. Economics of facial fracture reductions in the United States over 12 months. Dent Traumatol. 2013 Apr;29(2):115-20.
 
3. Michigan Opioid Prescribing Engagement Network website. Accessed 11/28/17 and available at www.michigan-OPEN.org
 
4. University of Michigan website. Accessed 11/28/17 and available at https://precisionhealth.umich.edu/
 
5. Florence CS, Zhou C, Luo F, Xu L. The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013. Med Care. 2016 Oct;54(10):901-6.
 
6. Center for Behavioral Health Statistics and Quality. (2016). Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (HHS Publication No.SMA 16-4984, NSDUH Series H-51). Retrieved from http://www.samhsa.gov/data/.
 
7. Centers for Disease Control and Prevention website. Accessed 11/26/17 and available at https://www.cdc.gov/drugoverdose/data/overdose.html
 
8. Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015. MMWR Morb Mortal Wkly Rep 2016;65:1445–1452.
 
9. Steinmetz CN, Zheng C, Okunseri E, Szabo A, Okunseri C. Opioid Analgesic Prescribing Practices of Dental Professionals in the United States. JDR Clin Trans Res. 2017 Jul;2(3):241-248. doi: 10.1177/2380084417693826. Epub 2017 Feb 9.
 
10. American Dental Association (ADA) survey on employment of dental practice personnel. Published by ADA in 2013. Accessed 10/23/2017 and available at http://www.ada.org/en/science-research/health-policy-institute/data-center/dental-practice
 
11. American Dental Association website. Accessed 11/27/17 and available at http://www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/statement-on-opioids-dental-pain
 
12. Mutlu I, Abubaker AO, Laskin DM. Narcotic prescribing habits and other methods of pain control by oral and maxillofacial surgeons after impacted third molar removal. J Oral Maxillofac Surg. 2013 Sep;71(9):1500-3.
 
13. Maughan BC, Hersh EV, Shofer FS, Wanner KJ, Archer E, Carrasco LR, Rhodes KV. Unused opioid analgesics and drug disposal following outpatient dental surgery: A randomized controlled trial. Drug Alcohol Depend. 2016 Nov 1;168:328-334.
 
14. Chang AK, Bijur PE, Esses D, Barnaby DP, Baer J. Effect of a Single Dose of Oral Opioid and Non-opioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial. JAMA. 2017 Nov 7;318(17):1661-1667.