A Prescription for Change

The current opioid crisis did not happen overnight (See The Three Waves of the Opioid Crisis). Between 1999 and 2017, almost 400,000 Americans died from an overdose involving an opioid.⁵ The horrifying escalation in overdose deaths that we are seeing today has its roots in the huge increase in the number of opioids being prescribed in the 1990s. The number of opioids prescribed by US healthcare providers quadrupled between 1999 and 2010, and the number of opioid-involved overdoses currently occurring is 6 times higher than the total in 1999.^2,5 Although the number of opioid prescriptions has decreased since 2012, the amount remains about 3 times as high as the number in 1999, with 17.4% of the US population filling at least one prescription for an opioid in 2017.⁶

Long-term opioid abuse often begins with the use of immediate-release opioids, such as Vicodin^® (ie, hydrocodone/acetaminophen) and OxyContin^® (ie, oxycodone), which are prescribed to treat acute pain.^7,8 Although prescription immediate-release opioids provide effective pain management for moderate to severe pain when prescribed and taken as directed, these drugs have a high potential for misuse and abuse and can lead to addiction and death.

Ironically, it turns out that nonsteroidal anti-inflammatory drugs (NSAIDs) are often as effective and far safer for the treatment of acute dental pain than opioids or opioid-containing medications.⁹ "What we in dentistry, and all of medicine, unintentionally got wrong was the belief that nonopioid pain management was less effective than it really is," agrees Omar Abubaker, DMD, PhD, professor and S. Elmer Bear Chair in the Department of Oral and Maxillofacial Surgery at the Virginia Commonwealth University School of Dentistry. "Ibuprofen and acetaminophen, in high enough therapeutic doses, used individually or in combination, are actually good enough for treating most dental pain," he says. "We never gave nonopioid treatments a chance; we went straight to opioids." In short, US healthcare prescribers of all types have written too many unnecessary opioid prescriptions as well as written opioid prescriptions for too many pills that lasted for too many days.

How and why this happened is important to understand because today's opioid crisis in the United States arose as a result of these prescribing practices. Even as recently as 2016, the proportion of opioid prescriptions written by US dentists following third-molar surgery (ie, 22.3% or 11.4 million prescriptions) was 37 times greater than the proportion written by dentists in England (0.6% or 28,082 prescriptions), which has similar populations and medical and dental training as the United States.¹⁰ "What is so unappreciated is that adolescent British patients who have had third molar extractions do not routinely receive an opioid prescription and do not seem to be suffering more discomfort or pain," explains Paul A. Moore, DMD, MS, PhD, MPH, professor of pharmacology, dental anesthesiology, and dental public health at the University of Pittsburgh School of Dental Medicine.

"We know that the people of the United States represent less than 5% of the world's population, but we consume over 80% of the narcotics," notes Harold Tu, MD, DMD, director of the Division of Oral and Maxillofacial Surgery at the University of Minnesota School of Dentistry. "In the United States, we consume 99% of the hydrocodone," he points out.¹¹ "To provide a contrast in terms of the marketing of opiates, the US market for opiates is an approximately $10 billion market for a population of 325 million. In China, where the population is 1.3 billion, the amount spent on opiates is only $530 million. This is a dramatic difference."¹²

Opioids have existed for thousands of years, starting with naturally occurring opiates such as morphine, which is derived from the opium poppy. More recently, synthetic and semisynthetic opioids such as Vicodin and OxyContin became available. These drugs are structurally similar to natural opiates, but their modified chemical structures make them even more potent and more easily absorbed by the gastrointestinal system than naturally occurring opiates.⁴

In 1970, Congress passed the Controlled Substances Act as part of the "war on drugs," creating the US Drug Enforcement Administration (DEA) to fight drug abuse and illegal distribution. The DEA created five "schedules" for drugs and some chemicals based on their accepted medical use and potential for abuse and addiction. The intention was to achieve a balance that would ensure the availability of opioids for medical and scientific needs while simultaneously preventing, detecting, investigating, and prosecuting diversion and illegal distribution.⁴

However, in the early 1990s, patients with chronic pain and pain specialists began to criticize the government's regulations and pain treatment guidelines for unintentionally creating an epidemic of untreated pain. The American Pain Society and other groups advocated that pain be measured and recognized as the "fifth vital sign" along with blood pressure, heart rate, temperature, and respiration. In response to these concerns, healthcare professionals and medical boards began promoting more proactive use of opioids.⁴ Not surprisingly, opioid prescribing began to escalate as a result.

"There was great concern about the inadequate treatment of pain," says Raymond Dionne, DDS, PhD, who is a visiting professor in the Department of Cell Biol-ogy at the University of Connecticut School of Medicine. "But once that mantra became accepted, less scrupulous people began to realize that there was money to be made in this area. For example, Purdue Pharma, the maker of OxyContin, pushed physicians to ‘aim for making ev-eryone pain free,'" Dionne explains. "Then, regulatory groups got involved, and every time patients were in a doctor's office, they were asked to rate their pain on a scale of 0 to 10. If they reported anything above a 2 or 3, an action had to be taken to alleviate that pain; otherwise, doctors risked getting bad scores from insurance carriers."

Unfortunately, concerns regarding the undertreatment of pain opened the door for an aggressive marketing campaign by opioid makers. Possibly the most well-known of these is Purdue Pharma, which effectively convinced prescribers to give patients opioids by overstating the benefits of opioids and understating the associated risks of addiction. In addition, the US Food and Drug Administration approved the long-term use of opioids-an approval that many experts contend was made without sufficient evidence of the safety of long-term use.⁴ "OxyContin was marketed as safe, effective, and less addictive for long-term use," Dionne notes. "At one point, Purdue had thousands of salespeople going around the country to doctors' offices, pushing the myth that opioids were not addictive and that to be a good doctor, you had to treat people to the hilt."

In addition, health insurance companies increased the quantity of opioids that were covered per office visit in order to reduce the need for costly follow-up visits, Dionne says. Therefore, it should not be surprising that a dramatic increase in the demand for prescription opioids occurred, and by 2010, opioid prescribing in the United States had increased by a shocking 400%.²

In March 2019, Purdue Pharma and the family that controls the company agreed to pay $270 million to the state of Oklahoma to settle allegations that it helped set off the nation's opioid crisis with its aggressive marketing of OxyContin. It is the first settlement to arise from a wave of lawsuits against Purdue and other opioid manufacturers, including Endo International, Johnson & Johnson, and Teva Pharmaceutical Industries. There are 45 states suing Purdue for its alleged misconduct in the marketing and sales of OxyContin.^13,14

Although physicians are the primary source of opioid prescriptions in the United States, dentists have also played a role in the crisis, and they will continue to play an important role in turning the situation around. In 1998, dentists were the top specialty prescribers of opioid pain relievers, accounting for 15.5% of all opioid prescriptions in the United States.¹⁵ That percentage fell to 6.4% by 2012 (ie, 18.5 million prescriptions),¹⁵ but a 2018 analysis of claims data for privately insured US dental patients concluded that the opioid prescription rate per 1,000 dental patients had slightly increased from 130.58 in 2010 to 147.44 in 2015.¹⁶ The same study found that about 68% of all opioids prescribed by dentists were prescribed during surgical visits and that approximately 31% were associated with nonsurgical dental visits, most of which were for restorative procedures.¹⁶

Many people are surprised to learn that oral surgeons write the majority of opioid prescriptions for US children and adolescents aged 10 to 19 years old-a statistic that is driven by wisdom tooth extractions.^7,16,17 Dentists account for over 30% of opioid prescriptions written for young people, and this group is particularly vulnerable to opioid dependency and overdose (See Why Are Young People More Vulnerable to Opioid Addiction?). "This means that approximately 3.5 million Americans who are around 20 years of age are likely to be exposed to opioids through dentistry," notes Alan Schroeder, MD, a clinical professor of pediatrics at the Stanford University School of Medicine. He is the lead author of a 2019 study that found a nearly 7% increase in the absolute risk of persistent opioid use and a 5.4% increase in the subsequent diagnosis of opioid abuse among opioid-naïve 16- to 25-year-old patients who filled an opioid prescription from a dental provider.¹⁷ Schroeder suspects that the vast majority of these prescriptions follow wisdom tooth extractions, and a similar study demonstrated that patients who fill an opioid prescription after wisdom tooth removal are nearly 3 times as likely to continue using opioids as those who do not fill the prescription.¹⁹

"All people are vulnerable to addiction, but young people at the age when wisdom tooth extractions are often performed-around the time they are about to go off to college-are particularly vulnerable," Schroeder notes. "They get a bottle full of pills after the procedure, but experts say you either need none or very few, so there are a lot of leftover pills." More than half of the opioids prescribed after wisdom tooth extraction go unused and end up being diverted and misused, often by a friend or family member.^22,23 Studies suggest that more than a third of the opioids abused by high school seniors come from their own leftover or unused prescriptions or those of other teens.²⁴ Teenagers and young adults often consider prescription opioids safer than "street drugs" and share them with friends and family.⁴

According to the US Centers for Disease Control and Prevention (CDC), the likelihood of chronic opioid use increases with each additional day of medication supplied from the 3rd day forward. The sharpest increases in chronic use have been observed after the 5th and 31st days of therapy, a second prescription or refill, a cumulative dose of 700 morphine milligram equivalents, and an initial 10- or 30-day supply.⁷

"Like many healthcare professionals educated in the 1980s and 1990s, I was taught to consider pain the fifth vital sign, and I felt an ethical obligation to generously address patients' pain," Abubaker explains. "Around 99% of the time, anyone who had his or her wisdom teeth removed received an opioid prescription. However, opioid prescriptions can lead people, especially vulnerable younger people, to become long-term users of opioids."

Abubaker speaks from more than just a professional point of view; he speaks from the perspective of great personal tragedy and heartbreak. In 2014, his youngest son, Adam, died after overdosing from a mixture of heroin and benzodiazepines at the age of 21. Adam's substance abuse began with a prescription for Vicodin that he received after shoulder surgery for an injury that he sustained when he was 17. That prescription for 90 pills was Adam's first exposure to narcotics. "It is difficult to comprehend that a high school football injury and the medical advice to take one or two Vicodin tablets every 4 to 6 hours as needed for pain led Adam to addiction and death," laments Abubaker. And yet, that is exactly what happened. Adam became addicted to prescription narcotics, which eventually progressed to addiction to heroin. He entered treatment and was in recovery for almost a year before relapsing and dying of an overdose.

Grief drove Abubaker to learn more about what had happened to Adam, and he enrolled in a postgraduate program in addiction studies. The more he learned, the more he became alarmed about dentistry's role, as well as his own role, in the opioid epidemic and the degree of naïveté he had possessed regarding prescribing opioids to his patients. "Once I found out that what I was doing was not right, I had to change what I was doing," Abubaker says. "Likewise, when we, as a profession, acknowledge that parents are losing their sons and daughters to opioid addiction every day, we have to correct what we are doing." Abubaker teaches 3rd-year dental students about the physiology of pain and the recent history of addiction in the United States, trying to instruct the next generation of dentists so that they won't make the same mistakes that his generation did. At conferences and professional association meetings, he emphasizes the importance of the new opioid prescribing guidelines and research on acute pain management. "My goal is to ensure that each practitioner who leaves my class will be less inclined to prescribe an excessive amount of opioids, perhaps protecting one more son or daughter against the harm of narcotics."

In March of 2018, the American Dental Association (ADA) updated its policy on the use of opioids to treat dental pain, officially supporting measures that include the following¹⁵:

• Provision of mandatory continuing education courses in prescribing opioids and other controlled substances. These courses should place an emphasis on preventing drug overdoses, chemical dependency, and diversion.

• Institution of statutory limits on opioid dosages and duration of treatment. If the use of opioids is warranted, clinicians should follow CDC guidelines and prescribe a quantity no greater than what is needed for the expected duration of pain that is severe enough to require opioids. This is often 3 days or less, unless the circumstances clearly warrant additional opioid therapy, but no more than 7 days for the treatment of acute pain, which is consistent with CDC's prescribing guidelines.²⁵

• Registration with and use of state prescription drug monitoring programs (PDMPs). This practice helps to promote the appropriate use of opioids and to deter misuse and abuse.

• Use of nonnarcotic pain relievers for first-line treatment. The ADA urges dentists to use nonnarcotic pain relievers as a first-line treatment for acute dental pain.²⁶

For adults, a combination of 400 mg of ibuprofen and 1,000 mg of acetaminophen has been found to be superior to any opioid-containing medications that have been studied.⁹ A meta-analysis in the Journal of the American Dental Association confirmed that, for the treatment of acute dental pain, the use of opioids is no more effective than the use of 400 mg of ibuprofen and 1,000 mg of acetaminophen in combination or 400 mg of ibuprofen alone and that the use of ibuprofen and acetaminophen in combination offers the most favorable balance between benefits and harms.⁹ Moore, who was the lead author of the meta-analysis, explains that although the analgesic efficacy of nonprescription NSAIDs has been known since the 1980s, only during the last 10 years have there been studies in the European and US literature that show how effective ibuprofen is in combination with acetaminophen and that this combination does not possess the side effects and addictive potential associated with opioids.

1. Prescriber Behavior Must Continue to Change
Moore points out that one of the challenges that the den-tal profession faces in its efforts to reduce opioid prescribing is changing entrenched prescribing behaviors.²⁷ "A lot of older practitioners were taught to prescribe opioid and acetaminophen combination medications," he says, "because that's all that existed before ibuprofen became available. It is hard to change what you feel is known and trusted, and dentists were taught that opioids were the most effective oral analgesic for postoperative pain. I graduated from dental school in 1973, and I taught what I was taught."

When ibuprofen came along, it was initially indicated for dysmenorrhea and then later for acute pain. "At the time, it was thought that ibuprofen was a mild analgesic and that Vicodin was a strong analgesic," Moore explains. "But, when we looked at the data, what we found was quite surprising. Ibuprofen is actually a very effective drug for acute inflammatory pain, and although we spent many years thinking that Vicodin worked better than ibuprofen, there are no studies demonstrating that Vicodin is more effective than ibuprofen in combination with acetaminophen, and it certainly has more side effects."

2. Opioids Do Not Address the Causes of Pain
An important difference between opioids and NSAIDs is that NSAIDs are potent inhibitors of prostaglandin synthesis and target the inflammatory pain encountered with acute infection, tissue injury, and surgical trauma. Opioids are devoid of anti-inflammatory activity. "Most acute dental pain is inflammatory in origin, and NSAIDs are extremely effective in inhibiting inflammatory pathways," notes Dionne. "Opioids bind to receptors on the nerve pathways in the spinal cord and brain that transmit pain signals, preventing the messages from getting through, but they do not address inflammation," he emphasizes. "When you have tissue injury, know that the etiology is inflammation, and have a handle on what some of the important mediators are, it makes more sense to go after that etiology at the start rather than trying to fix it later on," he adds. "A milligram of prevention is better than a pound of rehabilitation."

Tu agrees, saying, "In our specialty, opioids are certainly appropriate to use for major facial trauma, certain types of major reconstructive procedures, and cancer surgery, but for routine pain associated with dental alveolar procedures, the first analgesic regimen of choice should be NSAIDs and acetaminophen."

3. A Multimodal Pain Management Strategy Optimizes Analgesia
A multimodal pain management strategy uses a combination of different classes of analgesics to provide superior pain relief and minimize the use of opioids and their adverse effects. Before oral surgery, the patient is given an NSAID (eg, naproxen, ketorolac) to cut down on prostaglandin production and prevent inflammation. In addition, an anti-inflammatory steroid (eg, dexamethasone) can be given intravenously during surgery to suppress swelling. Bupivacaine, a long-acting local anesthetic, is used to numb the mouth for 6 to 8 hours so that there is a period of time after the procedure when the patient is still numb and does not have severe pain. Ibuprofen, with or without acetaminophen, is given after surgery.²⁸

4. Individualized Treatment With Reevaluation Limits Overprescribing
"It is nearly futile to attempt to predict how much pain an individual patient will experience following a procedure that produces tissue injury," Dionne notes. There is sub-stantial variability in how individual patients experience pain and analgesia, and the perception of pain is also affected by individual differences and expectations based on experiences and sociocultural influences.^27,28 However, dentists frequently prescribe postsurgical opioids while the patient is still numb and feeling OK, so they must make their best clinical judgment of the patient's needs based on the length of the procedure and the degree of surgical trauma. Because they cannot know the actual degree of pain that an individual patient will experience, dentists often practice "just in case" prescribing.

"The dentist tells the patient, ‘You probably are not going to need it, but just in case, here is a prescription,'" Moore explains. "Although you are writing a prescription that may benefit the 20% of patients who will experience severe discomfort, you may also be writing a prescription that will unnecessarily provide the other 80% with an opioid prescription that they do not need." Dentists should not prescribe additional opioids to patients "just in case" their pain continues for longer or is more severe than expected, Dionne notes. In those situations, the patient should be reevaluated. Any continuing request for opioids should be met with concern and necessitate an exam to confirm the nature of the problem as well as rule out possible complications, such as infection, which are not appropriately treated with an opioid.

5. Patient Education Can Help Manage Expectations  Regarding Pain
Dental practitioners can feel obligated to prescribe opioids because patients expect to receive them after oral surgery. Patients may become dissatisfied and believe that their dentists are uncaring if they prescribe nonopioid analgesics after surgical procedures, and practitioners may be concerned about receiving poor ratings from these patients on social media sites. When it comes to pain management and the use of opioids, addressing patient expectations can be a major challenge. If you do not prescribe opiates, some patients may believe that you are not appropriately addressing their pain, Tu notes. Dentists need to do a better job of educating patients about their expectations regarding pain, he says, as well as the potential for abuse and addiction that is associated with opioids.

"Throughout my career, my approach has really been to talk to my patients about how they are managing their pain in terms of functionality," Tu says. "Instead of saying, ‘On a scale of 1 to 10, your pain is going to be an 8, and then, it will go down to a 4,'" Tu uses functionality to assess patients' responses to postprocedural pain management. "I also do not use the lexicon of ‘pain,'" Tu says. Instead, he discusses discomfort and functionality because he believes it reduces anxiety. Following routine procedures, he tells patients, "Your discomfort should be at its worst for the first 2 days, but after that, you should really be able to go back to your daily routine, including school or work." Many of us have difficulty appreciating numerical gauges of pain because we all perceive pain differently, he says.

Most importantly, Tu lets his patients know that he is accessible. "I tell all of my patients that if their discomfort becomes more severe than what we discussed, I want them to give me a call or come back in so we can evaluate what is going on." Patients are appreciative and are very respectful of a doctor's time; abuse of a doctor's time is uncommon, he says. "I do want patients to get in touch with me if they are anxious about experiencing anything that they are not expecting," Tu notes. "That is an integral responsibility of being a doctor."

"Why do US dentists feel that they have to eliminate all pain?" Moore asks. "It is partly a cultural phenomenon-we just want to make the world perfect. However, there needs to be some expectation of pain. We cannot eliminate all pain." Practitioners should counsel their patients that the goal is for them to be as comfortable as possible, but they should be aware that some discomfort is normal and may still occur. "Explain to a kid that when he or she has third molar surgery, it will hurt a little bit," he says. "Having a little pain is a good thing; it reminds you not to stick a toothbrush back there."

Overall, dentists are making changes in the way that they prescribe medications for acute pain, which is evidenced by the reduced levels of opioid prescribing that have been realized since the highs that were reached in 2009 and 2010. Dentists have written nearly half a million fewer opioid prescriptions during a recent 5-year period, from 18.5 million in 2012 to 18.1 million in 2017.²⁶ However, much more work needs to be done to fully address the problem (See Real-World Evidence That Opioid-Sparing Regimens Work).

"There is no question that there has been a positive change in opioid prescriber behavior at my institution," says Tu. "Although changes to and implementation of opioid prescribing guidelines are more direct in an institutional setting, there has been a progressive ripple effect on community practitioners," he says. "I am pleased to say that during the last 2 years, we have seen positive changes in opioid prescribing practices in the community. As dentists, we bear a responsibility in the opioid epidemic; more importantly, however, we have an obligation to be a part of the solution. I am seeing recognition and a change in prescriber behavior with respect to opioids that I think is becoming more and more readily acceptable." There is a growing awareness among both prescribers and patients regarding the dangers of misuse, abuse, and addiction inherent in the use of opioids for pain management (See Recommendations and Precautions for Prescribing Opioids).

Abubaker is also encouraged by how the dental and medical students, as well as the dentists and physicians, he teaches diligently listen to and seek guidance from his experiences. "The numbers are definitively changing for the better, and the culture among dental students is changing as well," he says. "The profession has been infused with young dentists and residents who are being taught differently, and continuing education is working." The change is slower among older dentists, but over time, everyone will evolve because of legislation, he says, which includes new prescribing guidelines in Virginia as well as in most other states.³² "The situation is improving, but it is not time to celebrate yet," Abubaker cautions. "Deaths from overdoses of fentanyl are up, and as a country, we still have so much to do and so far to go."

"I think the situation is changing. We are certainly decreasing the number of opioid prescriptions being written, and I believe that we are much more aware about the dangers of prescribing opioids to teenagers," Moore notes. "I think that the end of this crisis, or the ultimate solution, is going to come from the community as adults and parents begin to refuse opioid prescriptions for themselves and their children."

 "The only foolproof way to avoid potential harm from an intervention is to avoid that intervention in the first place," Schroeder states. "If we are operating under the premise that there will always be some kids who will need opioids for pain when their wisdom teeth are extracted, and we are unable to move away from that, then let's also make sure that all of the wisdom tooth extractions that we perform are necessary. I think we have to ask ourselves why we are doing so many wisdom tooth extractions. There is not enough of a focus on that. We perform them more often in the United States than in most other developed countries, and there is insufficient evidence to support why we perform them as frequently as we do."

Finally, consider your patient's visit as a point of intervention for prescription opioid misuse and diversion. For a sizable number of Ameri-cans, a visit to a dentist represents their sole interaction with the healthcare system.³⁰ Dentists often develop long-term relationships with patients; therefore, they are in a unique position to screen for substance abuse and help patients access available resources if needed. Office personnel are also a good resource for people with substance use disorders because patients often express their concerns to staff members more readily than to dentists. Having an empathetic, nonjudgmental dental team is key to identifying substance use problems.

Abubaker embraces this role. "If you speak to patients and families with compassion, tell them that you are worried about them, and show them that you are not being judgmental, you encourage them to talk," he notes. "Breaking addiction is not something that people can usually do on their own. We should not view people who cannot do it themselves as weak. Would you ask patients to cure their diabetes on their own?"

A dentist's education should address all forms of addiction, Abubaker says, not just to opioids and heroin but also to alcohol and cigarettes. "For a while, dentists talked to patients about tobacco cessation, but then, unfortunately, many became too procedure-oriented," he says. "We left these issues to physicians, which I believe created an artificial separation between oral health and overall health. What good is a great smile if you are dying of alcohol abuse or lung cancer?" Abubaker teaches his students that if patients' histories show that they smoke a pack a day-even if they came in for a filling-the dentist should talk with them about it. "Take an active role, for example, in referring them to smoking cessation programs that you can recommend without doing any finger wagging or anything like that," he says. "Tell them, ‘We care more about you than just treating your tooth that needs filling.'"

The ADA offers free webinars tailored to pain management in dentistry that are available to all dentists regardless of whether or not they are ADA members: https://www.ada.org/en/advocacy/advocacy-issues/opioid-crisis/webinars

The ADA provides patient materials on analgesia: https://www.mouthhealthy.org/en/az-topics/o/opioids?utm_medium=VanityUrl

The ADA offers a collection of statements on substance use disorders: https://www.ada.org/en/advocacy/current-policies/substance-use-disorders

The CDC provides a fact sheet that summarizes important information on opioids: https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-a.pdf

More than 2 years ago, the University of Minnesota Dental School became one of the first US dental schools to mandate changes in how opioids were prescribed with the aim of producing a significant decrease in both the number of opioid prescriptions and the number of pills per prescription. "We took a different approach that was somewhat unique to both dentistry and dental schools in that we established a mandated protocol of using nonopioid medications as the first analgesic of choice," Tu explains. "At our dental school, the first analgesic of choice that is recommended and required for a prescriber-both dental students and faculty alike-is an NSAID or an NSAID in combination with acetaminophen. If you decide to prescribe a narcotic or opioid, you are asked to give the rationale for choosing that treatment." Because the dental school mandated the protocol, there has been a drastic decrease (ie, more than 70%) in the use of narcotics as analgesics. "We used to prescribe about 1,100 opioid prescriptions per quarter-a little over 4,000 a year. Now, we are down to about 160 to 170 prescriptions per quarter, which is a significant reduction," Tu notes. Just as importantly, the school has not seen a significant increase in the number of pain management failures, complaints, or requests for additional pain medications.²⁹

Virginia Commonwealth University's Department of Oral and Maxillofacial Surgery also changed its prescribing guidelines. "I used to give a prescription for Vicodin to all patients who were getting their wisdom teeth removed," Abubaker says. Now, all patients get prescriptions for ibuprofen plus acetaminophen. For some cases, Abubaker will give patients a prescription for 4 to 5 tablets of Vicodin and tell them to shred the prescription if they do not need it on the first day. "Only 5% of my patients go on to fill their opioid prescriptions, which I believe serves as proof that we have been overtreating pain," he says. The new opioid-sparing regimen has resulted in a big change. "For the first 6 months of 2018, we observed a 70% decline in the average number of tablets per prescription when compared with the average 4 years ago. In 2013, the department wrote prescriptions for an average of 26 tablets, mostly for Vicodin. In 2018, it is down to an average of 8 tablets. We also achieved a decrease of more than 60% in the number of patients who received opioids after oral surgical procedures. In 2013, 57% got an opioid prescription and in 2018, only 21% did-that's a reduction from 1 in 2 to 1 in 5," Abubaker says.

The first wave began with increased prescribing of opioids in the 1990s. Then, from the late 1990s to 2009, there was an increase in overdose deaths involving prescription opioids (eg, natural opiates, semi-synthetic opioids, methadone).

The second wave began in 2010 when overdose deaths were driven by heroin. Because prescription opioids became too expensive or too difficult to obtain, people with substance use issues turned to cheaper, easier-to-get heroin. Approximately 80% of heroin users started out using prescription opioids.

The third wave began in 2013 with significant increases in overdose deaths involving synthetic opioids. According to the latest available figures from 2016, fentanyl is the opioid most commonly involved in overdoses, the percentage of fentanyl-related overdoses rose 113% each year from 2013 to 2016, and fentanyl was involved in nearly 45% of the overdoses in 2017 alone.

Opioids target the part of the brain that is associated with reward and reinforcement. Opioid receptor activation increases the levels of dopamine in the brain. Opioids and dopamine work together to generate the "high" and encourage drug-seeking behavior by inhibiting control or aversion while increasing reward. When this process is compounded by the fact that the prefrontal cortex-the part of the brain responsible for planning, decision-making, and self-control-does not fully develop until the mid-20s, the risk of opioid addiction becomes higher in young people. Risk factors for opioid addiction among young people include the following:

•Being prescribed opioids before high school graduation is independently associated with a 33% increase in the risk of future opioid misuse after high school.²¹

•For some teenagers with little or no experience using illegal drugs, getting a prescription opioid is likely to be their first experience with an addictive substance. If that experience is safe, pleasurable, and seemingly endorsed by a medical expert, it may reduce their perceived risk of using opioids later in life.²¹

•A study found that patients who filled their prescriptions for opioids after wisdom tooth extraction were nearly 3 times as likely to continue to use opioids in the year following the procedure when compared with those who did not fill their prescriptions.¹⁹

1. When considering prescribing opioids, dentists should conduct a complete medical and dental history, including a review of current medications, to determine the potential for drug interactions and uncover any history of substance abuse.

2. To support your prescribing decisions, maintain good records that document your findings, diagnoses, and treatment plans.³⁰ If opioids are to be prescribed, discuss with patients how to safely secure, monitor, and discard unused pills to prevent their diversion.

3.  Register with and use your state's PDMP to promote the appropriate use of opioids and deter misuse and abuse. PDMPs allow dentists to review a patient's history of controlled substance prescriptions and determine whether they are receiving opioid dosages or dangerous combinations that put them at a higher risk for overdose. Mandatory use of a PDMP was shown to be associated with a 78% decrease in the quantity of opioids prescribed and an increase in the use of nonopioid analgesics.³¹

4. Partial filling of Schedule II controlled substances may be an option in your state. Check with your state dental board (https://dentalboards.org/state-boards/) or the National Association of State Controlled Substances Authorities (https://www.nascsa.org/stateprofiles.htm).