Best Practices for Opioid Prescribing

While best practices state that the use of opioids as first-line agents for acute pain is not preferable,³ dentists continue to prescribe considerable amounts of opioids, with dentists who saw patients for single visits and/or patients seeking emergent care being more likely to prescribe opioids than other practitioners.¹⁰ While after state regulations and ADA recommendations for dentists to use the PDMP has resulted in an increase in PDMP utilization by dentists, dentists continue report a lower than optimal rate of accessing the prescription drug monitoring program (PDMP),^9,10,81 despite being available in all states.^82,83 While 49 states require prescriber registration with PDMP, the requirements for use vary state-by-state.^82,83 Interestingly, mandatory use of the PDMP system for controlled substance prescriptions is associated with a 78% decrease in opioid prescription rates and an increase in the use of non-opioid analgesics.⁸⁴ Currently 49 states, the District of Columbia, and one U.S. territory (Guam) have operational PDMP systems (Missouri is the state which does not have a currently operational PDMP).⁸⁵ A variety of drug schedules are collected in each state’s PDMP and most states allow practitioners and pharmacists to obtain PDMP records for patients under their care.⁸⁶ The status of your state’s PDMP and access information specific to your area can be found at the PDMP TTAC website.

While federal law does not limit the quantity or duration of opioid prescriptions, the Controlled Substances Act (CSA) does identify the following as indicators of a valid rationale for prescribing a controlled substance:

• A legitimate medical purpose exists for the use of the controlled substance.

• The prescription is issued in the usual course of professional practice.

• The prescriber takes reasonable measures to prevent abuse and diversion as part of daily routine practice.^87,88

Healthcare providers may also be held accountable by noncriminal sanctions. A review of medical malpractice claims from 2005-2008 indicated that the following forms of inappropriate medication management by physicians were more common:

• Inadequate communication with other prescribing physicians to coordinate the care plan.

• Failure to recognize signs of medication misuse and/or prescribing controlled substances inappropriately to individuals with known pre-existing substance abuse disorders.

• Prescribing inappropriately high doses of opioids.

• Inappropriate sexual relations with patients.⁸⁹

In addition, there is the possibility of criminal liability. 2015 Dr. Hsiu-Ying “Lisa” Tseng became the first doctor convicted of murder for overprescribing opioid analgesics and the US Drug Enforcement Agency took action related to prescribing patterns against 479 doctors in 2016, up from 88 in 2011.^90,91 While these high-profile cases may make national news, Dr. Andrew Kolodny, executive director of Physician for Responsible Opioid Prescribing has stated, “The well-meaning doctors and dentists are the bigger part of our problem. They are inadvertently getting patients addicted and they are also stocking homes with highly addictive drugs.”⁹⁰ It is imperative for dentists to demonstrate sound, ethical clinical judgement and provide adequate procedural and structural safeguards to mitigate risk to patients and liability for prescribers.