Wake Up Call from the Northeastern District Dental Society:

Wake Up Call from the Northeastern District Dental Society:

John D. Wainio*, D.D.S., Adam R. Huneke, D.D.S.**, and Gary J. Hedin, D.D.S.†:

Introduction
First the bad news: Dentistry has a painful drug problem.

Next, the good news: The Northeastern District Dental Society has a “strategic plan” to help relieve the pain in our district and hopefully beyond.

Now, reality: The plan can only work if individual dentists and organized dentistry make a strong, proactive commitment to work toward solving this “painful drug problem”.

Our entire profession is a large stakeholder in a very serious worldwide problem affecting millions of patients. The problem is abuse and misuse of two narcotic medications commonly used for dental pain throughout the world; they are Hydrocodone and Oxycodone. These “controlled substances” are out of control, resulting in serious and painful professional, ethical, and social consequences.

In the big picture, the efforts of individual dentists through to all of organized dentistry, from small local study clubs and component societies to the American Dental Association, working together can make a difference in the worldwide problem of Hydrocodone and Oxycodone abuse. On a personal and local level, which is an essential part of the big picture, every dentist who has the privilege and responsibility of being licensed by the Drug Enforcement Agency to prescribe narcotics can make a significant impact. Dentists can make that impact by learning all they can about Hydrocodone and Oxycodone and giving informed and thoughtful consideration to every narcotic prescription they write. If the result is one less crime committed, one less addiction disabled, or a single drug-related death averted, this may be the most important contribution to the public on behalf of the dental profession that can be made. The question is, are we as individual dental professionals and members of organized dentistry willing to make a personal commitment to understand the phenomenal ramifications and serious responsibility that goes with each dose of these drugs prescribed?

Dentistry’s Prescribing History
Collectively, dentists prescribe large amounts of Hydrocodone and Oxycodone. The ADA News on June 7, 2010 reported more than one billion doses of Hydrocodone and Oxycodone were prescribed by dentists in 2002. This was 12 percent of the total for medicine and dentistry, and did not include narcotics prescribed by urgent care physicians for dental pain. According to a ten-year (1998-2008) study by the Substance Abuse Mental Health Services Administration (SAMHSA), since 2002, drug abuse has increased significantly. Therefore it can be assumed that the number of doses prescribed has also increased well beyond one billion.

Although dentists routinely prescribe two of the most often prescribed and most abused and misused prescription drugs in the world, the direct effect day to day on individual practices is relatively small. Our challenge is to look at the big picture. If we remember that our role as members of the dental profession is to serve the public, and if we make a serious commitment to work at solving this problem, each of us can have a small but significant impact, and we will collectively reap huge rewards for our patients and profession. Lives will be saved, crime and addiction will be lessened, and dentistry will be elevated to a higher status in the eye of the public - a lofty and difficult, but attainable, goal.

Organized Dentistry at Its Best
The Northeastern District Dental Society is seeing the big picture and has developed a strategic plan for dealing with the abuse and misuse of Hydrocodone and Oxycodone in our district. Our commitment came about because of one very active and talented drug seeker in Duluth. He affected the lives of 25 dentists, 20 urgent care physicians, and 15 pharmacists as he successfully “conned” and betrayed their trust. This resulted in several thousand doses of Hydrocodone and Oxycodone wrongfully obtained by him over a two-year period. The effect he had on each individual practice was small but significant. Collectively he affected a portion of four professions in Duluth, and he became well known to dentists, pharmacists, physicians, and law enforcement.

As a result of encounters of this drug seeker with 60 different professionals, the Duluth Dental Forum, a local study club of 35 members, devoted an afternoon of education and discussion featuring interaction with members of law enforcement, dentistry, and pharmacy. Many thoughts and ideas were exchanged, as well as presentation of scientific information on Hydrocodone and Oxycodone. After this “forum”, it was decided that more of our profession needed to be informed and involved. The matter of prescription narcotic abuse was brought to the Northeastern District Dental Society. A task force (ad hoc committee) was formed to study the issue in order to deal proactively with these abuses, and a strategic plan was developed. The reasons for this plan are as follow: Narcotic pain medications commonly prescribed by dentists are being abused by patients, wrongfully obtained, and sold for profit. This is underscored almost daily by media coverage of “pharm parties”, overdose deaths, pharmacy robberies, and a variety of drug seeking activities.

The NEDDS Strategic Plan
The outline of the strategic plan created by the Northeastern District Dental Society is as follows:
1. Identify problem medications
a. Hydrocodone: the most commonly prescribed, wrongfully obtained, illegally sold and abused prescription medication. Other names for Hydrocodone when combined with acetaminophen, aspirin, and ibuprofen include: Lortab, Vicoden, Lorcet, Anexsia, Bancap HC, Ceta Plus, CoBesic, Hycet, Margesic, Maxidone, Norco, Stagesic, Zydone, and Vicoprofen.
b. Oxycodone: sought by abusers for its narcotic effect and high street value. It is not prescribed as often as Hydrocodone by dentists. Other names for Oxycodone when combined with acetaminophen, aspirin, and ibuprofen include: Oxycontin, Percocet, Percodan, Oxydose, Ocyfast, Roxicodone, Intensol, Supendol, Endocet, Oxycocet, Endodan, and Oxydododan.

2. Develop recommendations on use of narcotic pain medications for dentists.
a. Use caution when prescribing pain medications.
b. Avoid refilling narcotic medications without seeing the patient.
c. Use extra caution with new patients or with patients not seen recently when prescribing.
d. Consider non-steroidal anti-inflammatory drugs.
e. Remember that drug seekers/abusers come in all shapes and sizes; there is no stereotypical seeker.

3. Communicate concerns and recommendations to NEDDS members through:
a. Executive council
b. Member mailings and email.
c. NEDDS meetings; devote a meeting to the topic of drug abuse.

4. Be proactive working with pharmacies, urgent care physicians, and law enforcement.

5. Use MDA and ADA resources.
a. Legal resources, HIPPA, etc.
b.Minnesota Dental Association Environmental and Safety Committee
i.MDA communication systems: Northwest Dentistry, MDA News, and electronic media.
c. American Dental Association
i. Tufts Study
ii. Dentists Wellness Committee

Initiative Forward
To date, our Ad Hoc committee has carried out many of the objectives of our strategic plan with the cooperation of the Northeastern District Dental Society. We are presently working on several initiatives, and are seeing results. We have not solved the problem, but we are already making a difference. These efforts have created an awareness among local dentists, urgent care physicians, pharmacists, and law enforcement professionals. The understanding, awareness, and knowledge shared regarding common problems and frustrations will facilitate a cooperative and collaborative approach to the concerns we share.

In the big picture, the overall effect can not be measured quantitatively. However, one very satisfying outcome of our efforts came with recognition of Duluth’s local “drug seeker” by several dentists, urgent care physicians, and pharmacists, resulting in several confrontations as he continued his drug-seeking activities. Our latest information about him has been encouraging. He is seeking rehabilitation in a drug treatment program, and is under the care of a physician. We wish him good luck on his road to recovery.

More to Come
As we moved forward with our strategic plan in the Northeastern District, we came to understand that the abuse and misuse of narcotic medication for dental pain is not unique to our local area. Some initiatives and mandates were already or are now being put into place and will affect all dentists throughout Minnesota. These include: the Minnesota Board of Pharmacy-sponsored Prescription Monitoring Program (PMP), unalterable prescription forms, and a 2011 mandate requiring dentists to use electronic prescriptions.

Be It Resolved
Each of the above is a reflection of the big picture and underscores the statewide and nationwide seriousness of prescription narcotic abuse. With this in mind, our Ad Hoc Committee recognized the need to get the MDA more involved in “our plan”, because all members in Minnesota are affected and need information that can best be provided by MDA communication systems. To facilitate involvement by the MDA, the NEDDS proposed resolution B8S-1 at the MDA House of Delegates meeting September 23-25. The resolution passed and had unanimous approval of the Board of Trustees. The resolution is as follows:

Whereas: All three levels of organized dentistry, from component to ADA, must proactively work together in solving narcotic drug problems as abuse and misuse is a serious problem affecting every dentist who prescribes these medications.

Resolution: Resolved, that the Minnesota Dental Association Board of Trustees or President assign to the appropriate committee and staff responsibility of informing members of : 1. Awareness of, and resources available in dealing with narcotics abuse. 2. Upcoming changes regarding prescribing of narcotic and other pharmaceutical drugs and to publicize resources presently available and/or developed, including but not limited to the Minnesota Prescription Monitoring Program, E Prescriptions, and unalterable prescriptions. Available resources such as MDA News, Northwest Dentistry, the MDA websites, etc. should be used to provide regular ongoing communications on a timely basis as information continues to evolve.

With this directive to the MDA by the House of Delegates, the MDA is now committed to provide communication resources that will offer invaluable information and support for members as they deal with misuse and abuse of narcotics prescribed for dental pain.

Conclusion
In summary, the only way that narcotics can be made available for misuse and abuse is by our personal prescription. In the big picture, the problem is huge yet very simple. Individually dentists and physicians as a rule are very conscientious in prescribing small amounts of Hydrocodone and Oxycodone for dental pain. Collectively, even in small amounts every dose that goes unused, is abused, or is diverted illegally adds up to a very significant and serious problem. With large quantities of “controlled” medications out of control, serious and thoughtful consideration must be given to every dose prescribed. Hopefully our strategic plan, the MDA resolution, and this article will inspire all of us to work at changing the big picture and relieving the pain of prescription narcotic abuse.
If any member, study club, or component society would like to offer information or discuss prescription drug abuse, please contact members of the Ad Hoc Committee or members of Northeastern District Dental Society.
The NEDDS Ad Hoc Committee on dental use and abuse of prescription pain medication is made up of Drs. Gary Hedin, Adam Huneke, and John Wainio. They may be contacted at:
• Gary Hedin:
Phone: (218) 878-3732
Email: hedingj@gmail.com
• Adam Huneke:
Phone: (218) 728-5095
Email: ahuneke@gmail.com
• John Wainio:
Phone: (218) 722-1846
Email: same as Dr. Huneke


*Drs. Wainio and **Huneke are general dentists in private practice in Grand Rapids, Minnesota. Email is ahuneke@gmail.com.
†Dr. Hedin is a general dentist in private practice in Duluth, Minnesota. Email is hedingj@gmail.com