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Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic explores how one dental school and one state are framing a response to the opioid epidemic that keeps dental pain mitigation in sight.

Dental pain is real, and most of us were taught that the most effective way to alleviate severe pain was with opioid painkillers. As a result, most dentists prescribe them—with benefits but also unintended consequences for our patients. Today, the majority of young people aged 12–18 who become addicted to painkillers were first prescribed them by a dentist. Given that each year 3.5 million people, most of them young, have their third molars extracted, our role as significant opioid prescribers should come as no surprise. But the bottom line is this: Despite our best intentions, dentists have contributed to what has now become an epidemic, and we need to take an active part in resolving it.
Many of us in academic dentistry are doing just that. ADEA co-hosted a summit on the opioid epidemic with the Substance Abuse and Mental Health Services Administration (SAMHSA) in August. The meeting convened representatives of 17 southern and mid-Atlantic dental schools to learn about the scope of the problem and share strategies that academic dental institutions can use to prevent prescription drug misuse and addiction. These strategies include:

  • Screening patients to identify their risk for substance misuse.
  • Educating faculty and students about pain management, addiction and prescribing practices
  • Consulting prescription monitoring programs (PMPs) to identify patients who may be “doctor shopping.”
  • Developing relationships with addiction treatment providers to facilitate referrals.

Most of the dental schools present at the summit had already taken concrete steps in these directions, and the three Boston-based dental schools—Boston University Henry M. Goldman School of Dental Medicine (GSDM), Harvard School of Dental Medicine (HSDM) and Tufts University School of Dental Medicine (TUSDM)—had gone even further, engaging in a state-sponsored effort to create dental education core competencies for the prevention and management of prescription drug misuse.
(To learn what’s happening in other states, see the 2017 ADEA Summary of State Legislation and Regulations Addressing Prescription Drug and Opioid Abuse on the ADEA Advocacy and Government Relations key state issues webpage.)

Ronald Kulich, Ph.D., of the Craniofacial Pain and Headache Center at TUSDM, co-chaired the competency-creation effort and spoke at the summit. He explained that in 2015, Massachusetts Governor Charlie Baker asked the state’s medical schools to develop a set of core competencies that would address the opioid epidemic. When these were complete, the dean of the Tufts medical school approached the TUSDM dean, Huw Thomas, B.D.S., M.S., Ph.D., and asked him to sign off on their use by dental schools. Huw asked Ron to weigh in.

“Their fit for dentistry was, at best, not perfect,” Ron told me. “Dentists deal with acute pain. We wanted to make sure that pain was in the forefront.”

TUSDM volunteered to form a new working group, which Ron co-chaired with Huw and David Keith, D.M.D., B.D.S., Professor of Oral and Maxillofacial Surgery at HSDM. The Governor’s Dental Education Working Group on Prescription Drug Misuse developed an independent set of dental core competencies, which have now been adopted by the three Massachusetts dental schools and can serve as a guide to dental educators elsewhere in the country.

This policy initiative was one of several in the state, which has been hard-hit by the opioid epidemic. Massachusetts has also established a PMP that collects dispensing information on controlled substances to help prescribers deter drug diversion—the practice of making prescription drugs available to another person for illicit use—and assess whether their patients might be at risk for drug abuse.

I wanted to discuss these activities further with Ron and find out what steps TUSDM is currently taking to prepare graduates to prescribe appropriately. Ron arranged for me to speak with two of his TUSDM colleagues as well: William Jackson, Psy.D., Assistant Professor and Co-Director of the Interprofessional Facial Pain and Headache Rounds, and Ellen Patterson, M.A., M.D., Assistant Professor and Director of Interprofessional Education. Ellen is taking the lead on translating the core competencies into the predoctoral curriculum.

Content related to prescribing and addiction has already been woven into the first and second years:

  • Starting with Introduction to the Dental Patient courses in years 1 and 2, students learn to identify risk factors for addiction and to use screening tools. (Tufts uses the NIDA Quick Screen developed by the National Institute on Drug Abuse. A SAMHSA-developed tool, SBIRT, which covers screening, brief intervention and referral to treatment, is also available and has been integrated in the curriculum at GSDM.)
  • Students and faculty also are invited to take part in weekly Interprofessional Facial Pain and Headache Rounds, during which faculty and regional experts present on pain and addiction. (Other health professionals are welcome to attend. Contact Ron if you’re interested.)
  • Tufts hosts a yearly educational program where students hear from law enforcement about the diversion of prescription drugs for nonprescription uses. Students “rub shoulders” with police and learn that they are “not the bad guys,” Ron says, and the officers in attendance gain a better understanding of the complex decision-making challenges prescribers face.

Tufts also prepares students to routinely use the Massachusetts PMP in their practice. “Dental students are not familiar with the vast array of medications catalogued in the PMP,” Ellen told me, “and the electronic health records used by most dental schools are not typically set up to flag medications that carry risks of addiction.”
Ron agrees that dental records are not well designed for that type of intervention, and they reveal other challenges as well. “We mined about six years of dental records looking at opioid use and other things,” he told me. “Ibuprofen was spelled 12 different ways, and that’s just the ‘tip of the iceberg.’ So we have work do to in terms of how prescription drug monitoring is adopted by the field in general.”

The next step will be to build prescribing education into the clinical portion of the curriculum so students understand that discussing a patient’s risk for addiction is part of their job.

“Risk assessment for substance use is about more than identifying which medications patients have been prescribed,” William told me. “It’s also about assessing behavior. How are patients using those medications? Are they engaged in risky behaviors?”

“This broader risk assessment is not yet standard practice in dentistry,” Ellen added. “To achieve that will require a culture shift.”

The Tufts team is creating video vignettes to help students and faculty become more comfortable with discussing medication use with patients. “These are not difficult or lengthy conversations. They are just awkward conversations,” Ellen said, “but once you’ve done it a few times, it becomes second nature.”

Ellen is a physician and rightly observes that during their training, medical students watch both residents and attending physicians conducting patient assessments over and over again. Dental students rarely get that experience. She hopes the videos will provide a similar type of exposure so that dental students become comfortable with the process.

Ellen plans to eventually train a cadre of standardized patients with whom students can practice these interactions. Simulating patient assessments will help students appreciate the human complexity of treating dental pain in a way that mitigates risk for their patients. As William pointed out, “Pain is not just a physical sensation. There are a lot of psychological aspects to the pain experience.”

Ron and Ellen agreed. “When we’re asked to assess pain,” Ellen observed, “we immediately think about the intensity of the pain on a scale. But really, what we need to be measuring is function. The patient’s ability to function is a much better measure of whether or not their treatment is successful.”

Functional assessment represents a significant departure from the “fifth vital sign” view of pain that was introduced by the American Pain Society in 1996 and disseminated by The Joint Commission, which accredits hospitals. Sadly, as Ron points out, this back and forth in our relationship with pain is nothing new.

“Back in the 1800s, we were going through the same process in terms of concern about opioid use and conflict of interest with physicians who were prescribing various pain treatments. Fears associated with opioids, overprescribing and concerns over non–evidence-based medicine has been happening in cycles for the last 200 years.”

Fortunately, there are also periods of progress, but these require the type of broad-based approach that Massachusetts is championing and that Tufts and some others are putting into practice.

William wants dental schools to understand that revising curricula is not sufficient on its own. Policy work at the state level is vital to solving the problem, and so is institutional assessment. “We need to ask, How are opioids being prescribed, and what type of pain medications are being used within the dental school?”

Tufts is monitoring its own prescribing practices and has found that faculty now write 20 prescriptions per 1,000 visits as compared to 30 prescriptions five or six years ago. Perhaps most notably, the endodontic department, which adopted a policy of prescribing over-the-counter medications first, now has an exceptionally low opioid prescribing rate.

The school has also begun collecting data on use of the state’s PMP through the efforts of a third-year dental student, Jessaca York, and her supervisor, Bhavik Desai, D.M.D., Ph.D. “They found that there were 15,000 visits over three years with almost no documentation of PMP results,” Ron told me. Now that Tufts has this baseline data, Ron and his colleagues will watch to see how things change. They’ll also be assessing their students in about 18 months to see whether they have acquired the desired pain-management and risk-prevention skills.

So, the call to action is clear: We must act on multiple levels to reduce patients’ risk for addiction. We need government policies and resources that support better prescribing, institutional accountability for prescribing practices and curricula that prepare the next generation to take a holistic approach to treating pain.

Tufts may be unique in its three-pronged approach to addressing the opioid crisis, but it is not alone. Harvard’s and Boston University’s dental schools are also trailblazers, and many other ADEA member institutions include individuals who are taking courageous steps to change prescribing practices within their establishments.

Allied dental programs also have a vital role to play in this effort. Ron, Ellen and William pointed out that patients may spend most of their dental visit talking with dental hygienists or other allied personnel.

“Dental hygienists have a very preventive focus,” Ellen said. “We think they’re an underutilized resource in addressing this issue. Even though they don’t typically prescribe opioids, they are very much part of the solution.”