The opioid epidemic has been fueled by soaring numbers of prescriptions written for pain medication. And often, those prescriptions are written by dentists.
"We're in the pain business," says Paul Moore, a dentist and pharmacologist at University of Pittsburgh School of Dental Medicine. "People come to see us when they're in pain. Or after we've treated them, they leave in pain."
Indeed, 12 percent of prescriptions for immediate-release opioids are written by dentists. In 2012, dentists ranked fourth among medical specialties for their opioid prescribing rates, according to data from QuintilesIMS. It has made dentists targets for people "doctor shopping" in order to get opioids.
"I have dentures," said Shawn Bishop, who is recovering from an opioid addiction at Hope House, a treatment center in Boston. "I had went to get some legitimate work done. And I got some Percocet. I realized that by going to another dentist, I could get some more Percocets."
Bishop, now 59, recounts the times he teamed up with others to play dentists for their opioid pills.
"He would look at our teeth or Mark's teeth in particular," Bishop said. "He would look at his teeth and say, 'Yeah, we need to take this one, this one, and this one.' And Mark will always say, 'Well, I can't do it today. Can we make an appointment for next week?' And then the doctor will say, 'Yeah, I need to write a prescription of Percocets.' He kept bad teeth and toothaches just so he can do that, you know?"
For Bishop and his friends, the enterprise of getting opioid pain pills from dentists grew so routine that, he says, he became a professional at it.
"It was almost like they knew their part to play and we knew ours," he said. "It was like actors in a little sketch there."
Massachusetts has taken the lead in trying to reduce opioid prescription abuse. Last year, Gov. Charlie Baker's office passed a law to prevent drug misuse. Dental schools in the state are also required to teach a set of core competencies that their students are required to meet before graduating. Students will have to demonstrate that they know how to consider nonopioid treatment options.
"At least at the medical school, the dental school, nursing school and pharmacy school level, you don't graduate from those places without having studied this stuff and understanding both the positives and the negatives associated with using it," Baker says. "In addition to that, making sure as a condition of relicensure, you're getting everyone who is writing prescriptions as part of that process."
Now, after decades of criticizing health care providers for undertreating pain and not prescribing enough pain medication, the pendulum is swinging back. Some dentists are getting back up to speed about alternatives to opioids.
"For most dental pains, the nonsteroidal anti-inflammatory drugs (NSAIDS) --that's Advil, Aleve, Naproxen — those agents are every bit as effective as one Vicodin or one Percocet," Moore says. "That's been shown over and over and over again."
This next generation of dentists is not only learning about how to prescribe opioids appropriately, but also about how to think about pain differently. At the Harvard School of Dental Medicine, students are learning how to approach pain a world away from opioids.
"You can approach it from opioid therapy, you can approach it from different neuropathy drugs, you can approach from stretching exercises to meditation," says Kellie Moore, a fourth-year dental student at Harvard. "And just kind of like, exhausting all the options."
Leaning on different methods of pain treatment can yield mixed success, she says: what works with one patient might not work for another.
Dental students are also rethinking what the goal of treating pain is.
"On a scale of 0 to 10, with 10 being the worst, if we can get you to a 4 or 5, could you live with that and still function daily?" says Sam Lee, a fourth-year dental student. "If the answer is yes, then I think it's important to the patient understand that that's what we're going to try to maintain as the new normal for them."
David Keith, an oral surgeon at Massachusetts General Hospital, agrees.
"I think it does us a disservice, making us and the patients assume that they should have a total smiley face and a zero level of pain," he said. "That's not the real world. So we take a tooth out. We do a dental implant. You're going to be sore for a few days, but that doesn't mean you can't go to work."
The changing definition of pain is part of a larger change in the profession of dentistry. And Jeff Shaefer, an orofacial pain specialist who teaches at the Harvard School of Dental Medicine, says the role of the dentist is changing as a direct result of the opioid crisis.
"Dentistry is part of the problem and I think that hurts — that we've been overprescribing medication," he says. "Having a standard regimen to give every patient is not appropriate."
Nationally, the profession of dentistry is starting to change as well. This summer, the Commission on Dental Accreditation, which sets accreditation standards for all dental schools, ordered all graduates to be competent in accessing for substance use disorder.
But currently practicing dentists may not be so eager for a change to their profession. Keith, who regularly gives lectures to dentists in the state, has heard their complaints.
"There is a reluctance to add that, as there is reluctance to check blood pressure or check a list of medication their patients are on because it adds time to the day," he said.
ROBERT SIEGEL, HOST:
On the front lines of the opioid crisis, it's a familiar story - the addict whose first exposure to opioids was a legitimate prescription usually from an M.D. but sometimes from a dentist. In 2012, the last year for which we have data, dentists rank number five among primary care providers for opioid prescriptions. In this part of the program - opioids, dentists and pain.
PAUL MOORE: Were in the pain business. People come to see us when they're in pain. Or after we've treated them, they leave in pain.
SIEGEL: Paul Moore teaches at the University of Pittsburgh School of Dental Medicine. He's an advocate for non-opioid pain treatments for dental pain like Advil, Aleve and naproxen.
MOORE: Those agents are every bit as effective as one Vicodin or one Percocet, and that's been shown over and over and over again.
SIEGEL: But Moore recalls making that point to an oral surgeon from Billings, Mont. And he says the oral surgeon reminded him of the business imperatives of dentistry in a small, competitive market. Here's what Moore says the oral surgeon told him.
MOORE: There are three oral surgeons. And if my referral base found out I didn't prescribe Vicodin, it would be implied that I don't care about their pain after I take out their wisdom teeth, and I'd lose all my business.
SIEGEL: Those are prescriptions for legitimate patients. I went to Massachusetts, which has taken the lead in trying to reduce opioid prescription abuse. A 2016 law controls how health providers can prescribe opioids.
FRED NEWTON: We have 95 residential beds - long-term treatment.
SIEGEL: Fred Newton runs Hope House, a Boston addiction treatment center.
NEWTON: Yeah, we have a lot of turnover. As they will tell you, the call of the streets is very strong to them.
SIEGEL: One of the residents is 59-year-old Shawn Bishop. He's been in and out of rehab for a dozen years, and he recalled for me how he learned to play dentists for pills.
SHAWN BISHOP: I have dentures. And I did it accidentally. Actually I went to have some legitimate work done, and I got some Percocets. And I realized that by going to the - another dentist, I could get some more Percocets.
SIEGEL: Addicts frequently forego dental care, so their teeth are often painful. Shawn Bishop recalls a friend and fellow addict named Mark and how they would go to a dentist together.
BISHOP: He would look at our teeth or Mark's teeth in particular - he had bad teeth. He would look at his teeth and say, yeah, we need to take this one, this one and this one. And Mark - oh, well - we'd say, well, I can't do it today; can we make an appointment for next week? And the doctor would say yeah, and he'd write him a prescription of Percocets. And he kept bad teeth and kept tooth aches just so he could do that, you know?
SIEGEL: In Massachusetts, doctors and dentists are now limited to a seven-day supply for the first opioid prescription. They also have to consult the multistate database of prescriptions known as the PMP, the Prescription Monitoring Program, to see if the patient is on any other opioid medication. These new rules are part of a law that was a special cause for Massachusetts Governor Charlie Baker. And he says there are also rules that mandate teaching about treating pain.
CHARLIE BAKER: At least at the medical school level and the dental school and nursing school of pharmacy school level. You don't graduate from those places without having studied this stuff and understanding both the positives and negatives associated with using it - in addition to that, making sure that as a condition of re-licensure, you're getting everybody who's writing prescriptions as part of that process.
SIEGEL: Baker was persuaded to address this issue after campaigning and hearing the stories people told of an overdose or at least an addiction in the family, an addiction that often started with a prescription.
BAKER: Twenty, 30, 40 pills, 50, 60 pills, which are the kinds of numbers I was hearing about when I was out and about as a candidate from a lot of these moms and dads. You know, we created a whole community here of people who literally had their body chemistry altered by the amount of this pain medication they were taking.
SIEGEL: Reducing the size and number of these prescriptions could mean using less dangerous, non-addictive painkillers. But it could also mean talking with patients differently about pain. For decades, health care providers, having been criticized for under-treating pain, prescribed more and more opioids. Well, now the pendulum is swinging back. David Keith, an oral surgeon at Massachusetts General Hospital, says the aim of being pain-free sounds great, but...
DAVID KEITH: I think it does us a disservice, making us and the patients assume that they should have a total smiley face and a zero level of pain. That's not the real world. And so we take a tooth out. We do a dental implant. You're going to be sore for a couple of days, but that doesn't mean you can't go to work.
SIEGEL: Dr. Keith told me that he heard some resistance from dentists to writing smaller prescriptions. What argument does he hear in favor of describing 20 pills instead of five, six or seven after an extraction?
KEITH: Because I've always done it that way (laughter) - is the usual answer. And I think you've hit on the problem here or at least one of the problems.
SIEGEL: And one of the solutions being tried is to teach new dentists to do it differently.
JEFF SHAEFER: So this is the teaching practice. So this is where we have actually post-graduates. We have programs in all the different dental specialties.
SIEGEL: Jeff Shaefer teaches pain management at Harvard School of Dental Medicine. He took part in writing the core competencies in prescription drug misuse that Massachusetts dental students now have to demonstrate. They have to learn how to screen for substance abuse and how to refer a patient for treatment.
SAM LEE: I'm going to put your temporary crown back on, and then we'll check the occlusion, make sure everything is OK when you bite down.
SIEGEL: That's fourth-year dental student Sam Lee at the teaching practice at Harvard Dental School. Lee was one of a group of fourth-year students I sat down with.
KELLIE MOORE: Kellie Moore - nice to meet you.
SIEGEL: Kellie Moore...
DAISY JI: Daisy Ji - how are you?
SIEGEL: Daisy, nice to meet you.
JON SHAPIRO: Jon Shapiro.
LEE: Samuel Lee - nice to meet you - good.
SIEGEL: Lee and his fellow dental students like Daisy Ji have to be taught about prescribing opioids and assessing patients for substance use disorder.
JI: This is something that our predecessors really haven't had to deal with until recently. And I think dentists are, for example, one of the highest prescribers of opioids. So I think we're all having a shift in terms of perspective of how to treat pain away from opioids.
SIEGEL: I asked the dental students what they've learned about pain. Kellie Moore works at a community health center.
MOORE: You can approach it from opioid therapy. You can approach it from different neuropathy drugs. You can approach it from stretching exercises to meditation to stress for - and just kind of, like, exhausting all of the options with the patient and exploring what works for a patient and what doesn't.
SIEGEL: Sam Lee says it's important to lower expectations of a perfectly pain-free outcome.
LEE: On a scale of zero to 10 with 10 being the worst, if we can get you to maybe a four or a five, could you live with that and still function daily? And if the answer is yes, then I think it's important to have that patient understand that that's what we're going to try and maintain as the new normal for them.
SIEGEL: And Jon Shapiro comes away with the wisdom that pain is relative.
SHAPIRO: This morning, I just came from scaling a root planing. I was digging into this guy's gums and just cleaning everything out - and blood everywhere, didn't flinch. He didn't even need anesthesia. But then I've had other patients where you can just touch their tooth, and they'll jump. They'll scream. They'll just say it hurts. And so pain is relative, but it's also really difficult to quantify.
SIEGEL: And that's a dilemma dentists face. We experience pain in very individual ways. The prescription we get for pain shouldn't just be so big that it covers all possibilities. Again, professor Jeff Shaefer of Harvard Dental School...
SHAEFER: Dentistry is part of the problem, and I think that hurts - that we've been overprescribing medications. And you know, having a standard regimen to give every patient is not appropriate.
SIEGEL: He offered this measure of the urgency of teaching addiction issues to all dental students in the nation. Typically, Shaefer told me, a new standard may be phased in over time. This summer, the Commission on Dental Accreditation said, start doing it right away.
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