By Erin McHenry
For years, family gatherings had become contentious for Harold Tu, D.M.D., M.D., director of the Division of Oral and Maxillofacial Surgery at the University of Minnesota School of Dentistry. Somehow, conversations always drifted to opioids. Tu, a longtime prescriber of opioids, would argue with his son-in-law about the safety and effectiveness of these pain medications. His son-in-law, Andrew Kolodny, M.D., a renowned addiction specialist, had a different perspective.
Kolodny saw the aftermath. He was familiar with the wreckage left behind by addiction, and how often it started with a legitimate prescription.
They’d disagree for a while, until one of the relatives would pipe in to cut it out – Dinner is ready!
Eventually, Tu agreed to join Kolodny at Fed Up!, a national rally demanding action around opioid addiction. He saw and heard stories from families ravaged by prescription drug abuse. He started to reflect on his own prescribing behavior. It opened the floodgates.
“I had an epiphany,” he said. “Dentists play a significant role in the opioid epidemic. And I came to recognize my own role and responsibility in affecting change.”
Particularly for young people, he said. One study found that adolescents exposed to opioids have a 33 percent higher risk of abusing prescription painkillers later in life, even if they have a legitimate prescription. Dentists in particular have an increased responsibility to curb this pipeline of addictive drugs because they prescribe more opioids to teens than any other healthcare provider.
Tu’s evolved perspective is now shaping how the School of Dentistry teaches its students to care for patients. Last fall, Tu established a non-opioid mandated approach to manage acute dental pain for the School of Dentistry’s Division of Oral and Maxillofacial Surgery.
“Dentists need to be part of the solution in decreasing the number of opioid prescriptions and the number of pills prescribed,” he said.
The new protocol requires using non-steroidal, anti-inflammatories (NSAIDs) as the first-line analgesic, such as an acetaminophen-ibuprofen combination, which have been shown to provide equal pain relief without the associated misuse, abuse, diversion and addiction problems.
“Peer reviewed studies in [scientific] literature fully support that non-steroidal medications are equally effective as opioids in managing acute dental pain,” Tu said.
It’s impossible to be completely rid of opioids – some patients may not be able to use NSAIDs for other medical reasons. In those circumstances, there are guidelines for prescribing opioids with the final judgment call reserved for the provider.
Since the protocol was implemented in October 2016, the School of Dentistry has seen a significant drop in the number of opioid prescriptions and the number of pills per prescription. This downward trend has continued.
Meanwhile, UMN dentists have not seen a significant increase in the number of patient requests for additional pain medication, which suggests the new approach manages pain effectively.
“I think everyone is aware of the devastating impact addiction has on society,” Tu said. “This should force us to rethink our use of opioids as the primary treatment for acute pain. We can make a difference in the opioid epidemic, and we are making a difference right here in Minnesota.”
Pain. Pill. Problem.
It’s estimated more than 2 million Americans abuse prescription drugs.
From 2001 to 2011, the number of people seeking treatment for prescription painkillers increased five times.
“Deaths from opioid overdoses are at a level right now reaching proportions as high as the HIV epidemic did in the 80s,” said Richard Nadeau, D.D.S., M.P.H., clinical specialist at the School of Dentistry.
The latest numbers from the NIH show 1 in 8 high schoolers report using prescription opioid painkillers recreationally. The majority of these kids get their pills from friends and family, which is hardly surprising considering a 2016 study found nearly 100 million prescribed painkillers go unused after wisdom tooth extractions.
That’s more than half of the opioids prescribed for the procedure.
“As providers, we need to get the numbers of pills going out the door way down,” Nadeau said. “We don’t need to prescribe so many.”
Since 1999, sales of opioids have nearly quadrupled. Just a few years back, there were as many opioid prescriptions as citizens in the U.S.
Many people don’t know how to dispose of them, either, Nadeau says. Vicodin, codeine and other addictive drugs sit unused in medicine cabinets across the country waiting to be taken.
This glut of prescription pain pills is fueling accidental addiction among well-intended patients who grow to depend on them after a legitimate prescription. That’s because opioids target a specific part of the brain dealing with reward and reinforcement behaviors. These drugs create a feedback mechanism and in time, the body develops a tolerance, requiring a higher dose to find pain relief. Foregoing opioids altogether brings on symptoms of withdrawal, like severe fatigue, vomiting, anxiety and muscle pain. It can steer even the most careful users towards physical dependence.
Angie Rake, D.D.S., an adjunct professor in the School of Dentistry, understands that firsthand. The UMN alumna’s brother became physically dependent on opioids.
“I remember very vividly, him calling me while in my residency training program,” Rake said.
He had been diagnosed with testicular cancer at 26, and was prescribed Percocet after surgery. He asked Rake if the pills were safe.
“Back in the 90s, we were told opioids are non-addictive, and I told him to take them,” she said. “Unfortunately, he never recovered from his addiction despite multiple interventions and treatments.”
Today, he lives on the streets in Seattle, hopelessly addicted to heroin.
Rake calls it terminal addiction and it changed the way she treats her patients.
She wasn’t able to spare her brother, but she can protect others. Rake has teamed up with Tu to raise awareness about this issue among other dentists.
“My plea as a prescribing surgeon, but also as a sister, a daughter, a wife and a fellow human being: educate ourselves and our patients about opioids and really weigh the benefits and the risks. That naturally leads to the change in prescribing patterns,” Rake said. “If I can just prevent one person from heading down the path of addiction, it’s worth it.”
Cultivating Change in Minnesota
By implementing new prescribing protocols at the School of Dentistry, the University of Minnesota has a unique opportunity to make a difference across the state.
“More than 70 percent of Minnesota dentists are trained at the U, so we can really change the culture in our state,” says Todd Thierer, D.D.S., M.P.H., associate clinical professor at the School of Dentistry. Thierer oversees the University of Minnesota Dental Clinics.
“We are affecting the way our students will practice when they leave,” Thierer said. “If we set up a culture here where opioids are generally not given, that’s what they’re going to take with them into the community.”
The new prescribing protocols are already affecting communities outside the University. Rake has implemented the protocol into her own private practices in Eagan, Lakeville, Shakopee and Owatonna.
“I have drastically cut down on the amount of opioid pain medications I prescribe,” Rake said.
She crunched the numbers, and her clinics have reduced opioid prescriptions 46 percent since 2015. She’s seen an increase in referrals, too. With every patient, she sits down and talks through the risks associated with opioids. She has them sign a consent form detailing those dangers.
“It’s our role to educate patients,” Rake said. “Parents have been very, very appreciative of me taking the time to discuss this. And young patients, too.”
Rake, Tu and Nadeau have spoken extensively on opioid addiction to community dentists through continuing education courses. Earlier this year, they held a conference dedicated to opioid addiction in dentistry. Many dentists didn’t realize how grave the epidemic has become. But their feedback showed an openness to change.
One woman Nadeau spoke to at the conference plans to schedule follow-up conversations with patients to gauge how well they managed their pain, with or without opioids. These patient satisfaction surveys would allow dentists to fine-tune how many pills are really needed. It also creates an opportunity to intervene before a problem starts.
The goal is making dentists a front line for early detection and early intervention. It’s part of three-pronged impact: reducing exposure to opioids, limiting the opioid supply and helping those already struggling with addiction.
“Dentists can be on the forefront of changing prescribing behavior.”
“Dentists can be on the forefront of changing prescribing behavior,” Tu said. “I think what we’re doing at the University of Minnesota clearly demonstrates there’s foundation to that approach.”
Next, Tu and Thierer are in the process of implementing the policy throughout the entire School of Dentistry. They hope it serves as a model to other health care entities.
“People talk about reducing opioids, but we’re actually doing it and implementing it,” Thierer said. “We have an opportunity to do something here to significantly improve lives.”
Of course, with change often comes pushback. In both the medical and dental community, changing prescriber behavior is challenging and often times met with skepticism. Recently, Tu and Rake spoke to a local dental study group about the opioid crisis and their recommended approach to acute pain management. Most were skeptical and remained unconvinced about the need for change.
But as they filtered out of the restaurant, the waiter approached Tu and Rake. He had overheard some of the conversation and thanked them for what they’re doing. The waiter said he was applying to the University of Minnesota to become a nurse practitioner, and this type of innovative, patient-focused approach was the learning environment he wanted for his education.
“That alone to me was well worth it,” Tu said. “If we can make a change in our students, in young people, we’re headed towards a better future.”