The Minnesota Dental Association’s Environment and Safety Committee offers the following article in its continuing focus on keeping dentists aware and informed about drug-seeking activities among the patient population. For background on this initiative, readers may see the article “Wake Up Call from the Northeastern District Dental Society: Initiative Concerning Drug-Seeking Activity” by John D. Wainio, D.D.S., Adam R. Huneke, D.D.S., and Gary J. Hedin, D.D.S. in the November-December 2010 issue of Northwest Dentistry, pages 20-31.
As health care providers, appropriate pain management is our professional, ethical, legal, and moral responsibility. This includes the use of controlled substances, which are often necessary tools routinely used for pain management. Unfortunately, today’s reality is that we must be acutely aware of the fact that the number of people abusing prescription medications has more than doubled over the past decade.3 As providers, it is not uncommon to wonder if an individual patient’s pain “real”, or is this person an addict?
In the United States, the illicit use, abuse, and diversion (channeling of pharmaceuticals for non-medical, illegal purposes or abuse) of prescription medications has become a serious public health and social problem. The challenge for health care providers is to balance the needs of their patients’ pain management with appropriate prescribing and use of pain relieving medications. To aid in addressing this challenge, the Minnesota Board of Pharmacy has established the Minnesota Prescription Monitoring Program.
Opioid analgesics are widely accepted for the treatment of severe acute pain and chronic pain related to active cancer or at end of life. To contrast this, the use of chronic opioid therapy to treat non-cancerous chronic pain remains highly controversial.1 According to the Office of National Drug Control Policy, prescription drugs account for the second most commonly abused category of drugs, behind marijuana and ahead of cocaine, heroin, and methamphetamines. To underscore the impact on the health care system, in 2007, hospitals in the United States recorded more than 116 million emergency department visits with an estimated 0.8 million of those visits associated with misuse or abuse of pain relievers, which were most commonly narcotic pain relievers (e.g., oxycodone and hydrocodone products). Another one third of these emergency department visits were for misuse or abuse of pharmaceuticals to treat insomnia and anxiety, primarily benzodiazepines (e.g., alprazolam, clonazepam, and diazepam).4
Opioids and the Human Body
Why is it that opioids are so commonly misused and abused?
Opioids act on multiple systems. To inhibit pain, opioids act as agonists on opioid receptors, where they form a direct inhibitory effect on pain transmission at the level of the spinal cord and further reduce pain through activation of a descending pain-modulatory pathway. Additionally, opioids activate the mesolimbic dopamine system, which has been associated with both natural and drug rewards. Emerging evidence from the pain and reward literature suggests similarities in the anatomical (brain) substrates of painful and pleasant sensations.2
Recognizing that opioids affect the reward centers of the brain in the same way that we may derive pleasure from eating or sexual stimulation helps us understand why there is such a strong reward effect with opioids, and therefore why they are such a powerful motivator of behavior. In certain biologically susceptible people, the use of opioids interferes with the individual’s ability to think clearly, exercise good judgment, control behavior, and feel normal without continued use of the drug. It is this influence on the reward centers of the brain that makes opioids produce an intensely rewarding effect, and often an escape from daily reality, that can lead to abuse. This poses a unique challenge because of the need to balance prevention, education, and enforcement with the need for legitimate access to controlled substance prescription drugs.5
Legitimate Access: When to Prescribe Controlled Substances
When prescribing controlled substances, it is important to identify the characteristics of drug-seeking behaviors and signs suggestive of prescription medication abuse. Individuals who use narcotics to the extent that they interfere with the person’s ability to do routine activities or fulfill regular responsibilities at home, school, or at work would be considered to be abusing opioids. Other signs that individuals are abusing opioids include maladaptive behaviors that impact adversely on relationships or frequent involvement with legal problems related to opioid use. While not an exhaustive list, some of the common behaviors that might indicate that a patient is seeking drugs for the purpose of diversion or abuse include:
• demanding to be seen immediately or stating that he or she is visiting the area and is in need of a prescription “to tide me over” until returning to a local physician;
• appearing to feign symptoms such as tooth, face, or head pain in an effort to obtain narcotics;
• indicating that non-narcotic analgesics do not work;
• requesting a particular narcotic drug;
• complaining that a prescription has been lost or stolen;
• requesting more refills than originally prescribed;
• using pressure tactics or threatening behavior to obtain a prescription; or
• showing visible signs of drug abuse.
As a prescriber of controlled substances, the dentist must also be aware of the signs of narcotic abuse. This may include feelings of analgesia (feeling no pain), sedation, euphoria, respiratory depression (shallow breathing), small pupils, bloodshot eyes, nausea, vomiting, itching or flushed skin, constipation, slurred speech, confusion, or poor judgment.
The Evolution of Prescription Drug Monitoring Programs
Prescription drug diversion may involve activities such as “doctor shopping” by individuals who visit numerous health care providers to obtain prescription medications or prescription forgery. A 2006 study evaluating the effectiveness of Prescription Drug Monitoring Programs (PDMP) suggests these programs reduce the per capita supply of prescription pain relievers and stimulants, which in turn reduces the probability of abuse for such drugs.3 Currently, individual states are beginning to see the potential benefit of a PDMP, and are using these programs as a means to control the illegal diversion of prescription controlled substances. With the intent to help prescribers and pharmacists identify patients who may be engaging in prescription medication abuse, fraud, or diversion, Minnesota implemented its own Prescription Monitoring Program.
Although somewhat controversial, in 2007, and subsequently revised in 2009, the Minnesota legislature passed into law the requirement for the Minnesota Board of Pharmacy to establish a controlled substance prescription electronic reporting system for all Schedule II, III, and IV controlled substances. Minnesota is the thirty-fourth state to implement a Prescription Drug Monitoring Program. This program offers a searchable database for both prescribers and pharmacies to check whether patients are getting too many prescriptions of controlled substances from different providers — i.e., “doctor shopping”.
Minnesota law requires all dispensers (i.e., pharmacies) to report certain information concerning both the prescription and dispensing of Scheduled drugs. Prescribers can register for and access the Minnesota Prescription Drug Monitoring Programs’ database at the Minnesota Board of Pharmacy website (http://pmp.pharmacy.state.mn.us/). From there it is a matter of entering the patient’s full name and birth date for the database to run a query. The dentist will be supplied with a printout list which includes the date the prescription was filled, drug name, dose, quantity, prescriber name or identification number, and pharmacy. Although dispensers must file reports for the database, doctors and pharmacists are not required to consult the database to see if their patient is a potential drug abuser, and no one is routinely reviewing reports to find abusers. Furthermore, health care providers and pharmacists who do consult the database are not required to report patients they suspect of abuse or to withhold prescriptions from those patients.
We must keep in mind that health care professionals practice in an environment of legal and regulatory influences, where some patients with pain also have an addictive disease. As dentists routinely manage acute oral and dental pain by pharmacological means, people who abuse prescription medications see dentists as easy targets to “score” prescription opioids and controlled substances. This potential for deception must be balanced with our professional responsibility to prescribe and dispense controlled substances appropriately, guarding against abuse while ensuring that patients have medication available when appropriate and necessary. However, dentists also have a personal responsibility to protect themselves and their practices from becoming easy targets for drug abuse and diversion. Becoming aware of the potential signs and symptoms of drug seeking behavior and recognizing the signs of controlled substance misuse will safeguard patients, practices, and practitioners. Utilizing the services of the Minnesota Prescription Monitoring Program may help to not only improve patient care, but to facilitate appropriate pain management and help identify patients having drug seeking behaviors.
1. Chou R, Fanciullo GJ, Fine, PG et al. Opioid treatment guidelines: Clinical guidelines to the use of chronic opioid therapy in chronic non-cancer pain. J Pain 2009;10,2(February):113-130.
2. Leknes S, Tracey I. Science and society: A common neurobiology for pain and pleasure. Nature Reviews Neuroscience 2008;9(April):314-320.
3. Manchikanti L. Prescription drug abuse: What is being done to address the new drug epidemic? Testimony before the subcommittee on criminal justice, drug policy and human resources. Pain Physician 2006;9(4):287-321.
4. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. The DAWN Report: Highlights of the 2009 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. Rockville, MD, December 28, 2010.
5. Substance Abuse and Mental Health Services Administration. Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings (Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA 10-4856Findings). Rockville, MD, 2010.
To register for and access the database that provides prescribing information and history on controlled substances, dentists may go to:
The Minnesota Prescription Drug Monitoring Programs’ Database at the Minnesota Board of Pharmacy website at http;//pmp.pharmacy.state.mn.us/
*Dr. Herman is a diplomate of the American Board of Orofacial Pain and a fellow of the American Academy of Orofacial Pain. He is co-owner at the Minnesota Head & Neck Clinic and an adjunct assistant professor at the University of Minnesota TMD, Orofacial Pain, Oral Medicine and Dental Sleep Clinic, Minneapolis, Minnesota. Email is Herm0024@umn.edu.