O p i o i d P re s c r i b i n g i n D e n t a l

P r a c t i c e : Managing Liability Risks

David A. Keith, BDS, FDSRCS, DMDa,*, Ronald J. Kulich, PhD
b,c,d
,
Alexis A. Vascianniee, Richard S. Harold, DMD, JDf

KEYWORDS
 Safe prescribing  Controlled substances  Pain management  Opioids
 Dental Practice

KEY POINTS
 Dentistry has been on the forefront of acute pain management for more than 200 years,
and continues to have an obligation to focus on “rational prescribing” with their patients.
 The opioid use crisis and concerns over controlled substance risk have changed practice
patterns throughout health care.
 As the role of dentistry has expanded, dentists have an increasing obligation to assess
and mitigate risk for their patients, and regulatory agencies are increasingly mandating
strategies for risk assessment.
 Common violations of legal and regulatory requirements made by practicing dentists are
reviewed, and strategies to maximize safe prescribing practices are outlined.

INTRODUCTION

From a public policy perspective, past dental practice patterns have had an impact
on the opioid epidemic. In one of the earlier conferences on controlled substance
risk within the practice of dentistry, Denisco and colleagues1 concluded that “den-
tists cannot assume that their prescribing of opioids does not affect the opioid abuse
problem in the United States.” The American Dental Association’s (ADA’s) recent
policy on opioid prescribing2 focuses on the important role in dentistry with respect
to minimizing the impact of the opioid crisis. In response to these recommendations,

a
Oral and Maxillofacial Surgery, Massachusetts General Hospital, Harvard School of Dental
Medicine, Fruit Street, Warren 1201, Boston, MA 02114, USA; b Tufts University School of
Dental Medicine, Craniofacial Pain & Headache Center, 1 Kneeland Street, Boston, MA 02111,
USA; c Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General
Hospital, Boston, MA, USA; d Department of Psychiatry, Massachusetts General Hospital, Bos-
ton, MA, USA; e Department of Diagnostic Sciences, Tufts University School of Dental Medicine,
1 Kneeland Street, Boston, MA 02111, USA; f Department of Comprehensive Care, Tufts Uni-
versity School of Dental Medicine, 1 Kneeland Street, Boston, MA 02111, USA
* Corresponding author.
E-mail address: [email protected]

Dent Clin N Am 64 (2020) 597–608

https://doi.org/10.1016/j.cden.2020.03.003 dental.theclinics.com
0011-8532/20/ª 2020 Elsevier Inc. All rights reserved.
598 Keith et al

dentists need to understand the legal, regulatory, and ethical environment surround-
ing dental pain management. As the nature and characteristics of the prescription
opioid crisis have evolved, so do the legal and regulatory parameters. Hence, den-
tists need to keep abreast of advances in pain management practices and policies
and guidelines.

HISTORY OF OPIOIDS AND PAIN MANAGEMENT

Prescribing patterns for the management of acute pain have changed over the years,
ranging from extreme conservatism following the passage of the Harrison Narcotic Act
in 1914,3 which for the first time in US history made the possession of opioid-
containing medications illegal without a prescription, to the period of liberal opioid pre-
scribing beginning in the 1990s. At that time, pain specialists and advocacy groups
began to complain that government regulations, policies, and pain management
guidelines presented barriers to adequate pain relief. As a result, a dramatic increase
in demand for prescription opioids occurred, and by 2010, opioid prescribing had
increased dramatically with corresponding increases in overdoses and deaths. As a
consequence of the current opioid crisis, government and regulatory agencies are
now paying close attention to prescribing practices, and this increased scrutiny is
affecting the dental profession as well.4
All prescribers have a responsibility to minimize the potential for drug misuse and
diversion while maintaining legitimate access to opioids for patients in need of such
analgesic treatment.,1,5,6 The ADA statement6 on the use of opioids in the treatment
of dental pain recommends that dentists reduce the need for “just-in-case” pre-
scriptions for dental pain. The statement covers the complexities of modern pain
management in dentistry, including the nature of drug addiction, ways to screen
patients for potential substance use disorders, and techniques for motivating at-
risk individuals to seek appropriate treatment. Additional recommendations of the
ADA include following the US Centers for Disease Control and Prevention (CDC)
opioid prescribing guidelines7 for chronic pain when appropriate, using their state’s
Prescription Drug Monitoring Program database, completing continuing education,
and prescribing nonopioids as the first-line therapy for acute dental pain. The ADA
supports statutory limits on opioid dosage and duration of no more than 7 days for
the treatment of acute pain, consistent with CDC evidence-based guidelines. The
Association’s position is that as a profession, dentists can still do more to keep opi-
oids from becoming a potential source of harm. The ADA also promotes interpro-
fessional cooperation by working together with physicians, pharmacists, and
other health care professionals, policy makers, and the public.6 Recent studies
suggest that the specific issues currently facing the dental profession are the
disproportionate number of opioid prescriptions written by dentists for teenagers
and young adults who are at increased risk of developing substance abuse issues.8
Dentists are the leading source of opioid prescribing for adolescents and young
adults because they are most likely to present with third molar issues.9 Often pa-
tients do not consume the entire prescription and a number of pills are left over
and subject to diversion. The adherence with evidence-based guidelines recom-
mending nonsteroidal anti-inflammatory drugs and acetaminophen as first-line
analgesics, which are more effective than opioids, will help minimize diversion
and opioid misuse.10
When required, the prescribing of opioids is appropriate only after risk assessment
and cooperation with other medical disciplines. The basic principles of prescribing for
the management of dental pain are outlined in Box 1.
 Opioid Prescribing in Dental Practice 599

Box 1
Guidelines for prescribing controlled substances for acute dental pain

1. Conduct a medical and dental history to determine current medications, potential drug
interactions and history of substance abuse.
2. Follow and continually review Centers for Disease Control and Prevention and state
licensing board recommendations for safe opioid prescribing.
3. Register with and use prescription drug monitoring programs (PDMPs) to promote the
appropriate use of controlled substances for legitimate medical purposes, while
deterring the misuse, abuse, and diversion of these substances.
4. Have a discussion with the patient about responsibilities for preventing misuse, abuse,
storage, and disposal of prescription opioids.
5. Consider treatment options that use best practices to prevent exacerbation of or relapse of
opioid misuse.
6. Consider nonsteroidal anti-inflammatory analgesics or acetaminophen as the first-line
therapy for acute pain management.
7. Recognize multimodal pain strategies for management for acute postoperative pain as a
means for sparing the need for opioid analgesics.
8. Consider coordination with other treating clinicians, including pain specialists, when
prescribing opioids for the management of chronic orofacial pain.
9. Be aware that practicing in good faith and using professional judgment regarding the
prescribing of opioids for the treatment of pain should not result in discipline for the
willful and deceptive behavior of patients who successfully obtain opioids for nondental
purposes. Good dental treatment records should support your prescribing decisions.
10. Dental students, residents and practicing dentists, and dental hygienists are encouraged to
seek continuing education in addictive disease and pain management as related to opioid
prescribing.

Adapted from American Dental Association. Statement on the use of opioids in the treatment
of dental pain. Available at: https://www.ada.org/en/advocacy/current-policies/substance-use-
disorders. Copyright ª 2005 American Dental Association. All rights reserved. Reprinted with
permission.

Despite adhering to these principles, the dentist may be subjected to manipulation,

deception, or various types of prescription misuse by the patient, which could result in
diversion of opioid pills. These actions come in different forms.

Prescription Tampering
The use of written prescriptions represents a liability for the prescriber, as the script
can be altered or forged. A survey from West Virginia documented the various ways
that opioids can be illegally obtained in the dental practice11 (see Box 2).
Electronic prescribing, allowing prescribers to electronically write prescriptions for
controlled substances and permitting pharmacies to receive, dispense, and archive
these e-prescriptions will help to curb these abuses. Electronic prescribing for
controlled substances (EPCS) will also provide more robust audit trails and “identity
proofing” responsibilities for prescribers and vendors. E-prescribing is legalized in
all states and the District of Columbia with 82% of retail pharmacies fully enabled to
accept these electronic prescriptions. E-prescribing is not mandated by the federal
government; however, states are empowered to regulate prescribing. For example,
in New York State, EPCS is required for both legal and controlled substances;
600 Keith et al

Box 2
Strategies for illegally obtaining controlled substances

 Fake pain symptoms: 43%

 Patient claims lost/stolen prescription: 28%
 Forged written prescription: 14%
 Altered pill number: 14%
 Fake prescription call-ins: 9%
 Stolen prescription pads: 9%
 Altered numbers on prescriptions: 9%

Data from Tufts Health Care Institute. Executive Summary: the role of dentists in preventing
opioid abuse—Tufts Health Care Institute Program on Opioid Risk Management 12th Summit
Meeting, March 11–12, 2010.

however, adoption has been slow because of implementation complexities. In Massa-

chusetts, mandatory electronic prescribing has been delayed until January 1,
2021.11–13
The ADA has stated that dentists who are practicing in good faith and who use pro-
fessional judgment in prescribing opioids for the treatment of dental pain should not be
held responsible for the willful and deceptive behavior of patients. Dentists still need to
be aware of these deceptive practices and make every effort to avoid the 2 most com-
mon deceptions: diversion and doctor shopping. Good treatment records document-
ing findings, diagnoses, and treatment plans will help support the dentist’s decision to
prescribe opioids when appropriate.

Drug Diversion
Drug diversion is defined as the intentional transfer of a substance outside the guide-
lines set forth by the Food and Drug Administration (FDA), Drug Enforcement Admin-
istration (DEA), state licensing boards, and prescribing health care professionals.14
Drug diversion is typically motivated by money or a substance use disorder.
Controlled substances can be diverted at several steps along the course from
manufacturer to patients and beyond.15 (p2) Excessive prescribing contributes to
drug diversion, as unused medications increase available inventory subject to poten-
tial abuse. Dentists are obligated to prescribe in a responsible manner, guarding
against diversion while ensuring that patients have an adequate supply of analgesics
for control of dental pain. Dental practices are targets for patients with substance use
disorders who attempt to inappropriately obtain controlled substances for nondental
purposes, creating a challenge to determine which patients are presenting for legiti-
mate dental purposes and which are presenting with the conscious goal of feigning
discomfort to obtain controlled substances.

Doctor Shopping
Doctor shopping is a common technique used by patients whereby they frequent mul-
tiple providers complaining of the same problems to obtain multiple controlled sub-
stance prescriptions either for themselves or others. Although it is not possible for
the dental practitioner to screen out all drug seekers, a thorough clinical examination,
review of states’ prescription drug monitoring programs (PDMPs) and documentation
will help protect and support the dentist should scrutiny by the DEA, licensing
 Opioid Prescribing in Dental Practice 601

authorities, or law enforcement occur. Strategies to mitigate risk should include doc-
umenting clinical and radiographic findings, asking patients for photo identification,
and formulating a diagnosis and treatment plan, even if the treatment plan is as simple
as referring to a specialist. Dental hygienists and other staff members are often an
excellent source of information on patient drug-seeking behavior. An observant front
desk receptionist may be in the best position to notice unusual or aberrant behavior
and can pass this information along to the dentist.15 (p145 146)

Prescription Drug Monitoring Programs

PDMPs provide one of the most important vehicles for risk mitigation, and details of
these programs are discussed in “Special Screening Resources: Strategies to
Identify Substance Use Disorders, Including Opioid Misuse and Abuse” by Keith
and Hernández-Nuño de la Rosa in this issue. The issue of liability for using or not us-
ing the PDMP databases has not been clearly defined in all jurisdictions and depends
on the current laws of each state. Nonetheless, the prescribing dentist does have a
duty to warn the patient about the adverse effects of the medications prescribed,
and practice with reasonable care and in good faith when prescribing medications
for pain control.15,16
PDMP databases can ensure safe and effective pain management for their patients.
They also provide an excellent opportunity to discuss these risks with the patient. The
dentist should check with their state dental societies and licensing boards for up-to-
date information on applicable state regulations. Although prescribers are not required
to obtain the patient’s permission to access the PDMP in most states, it is recommen-
ded that the prescriber initiate a conversation with the patient, as well as cotreating,
and the patient’s other health care providers. If significant misuse or abuse is sus-
pected about the PDMP search, dentists also are within their rights to contact the
DEA or the local police department. As with all communications, patient care is
maximized, and the dentist’s risk is reduced when any of these actions are fully
documented.

DOCUMENTATION

Proper documentation is the professional and legal responsibility of all dental practi-
tioners. Not only do dental records provide for continuity of care when treatment is
transferred from one provider to another, but they provide a legal record to document
that care has been provided according to professional standards. It is important to
remember that judges, juries, dental board members, and lawyers maintain that “if it
wasn’t documented, it wasn’t done.” This policy applies to all visits, telephone conver-
sations with patients and other care givers, prescriptions, and other clinically related
issues. Accurate dental records are essential not only when documenting treatment
but also when prescribing medications.15 (p171) Typically, it is beneficial to record exact
quotes from the patient, conversations with treating providers, and contacts with law
enforcement.
Specific documentation for a controlled substance treatment plan also is essential.
Some states require a written informed consent before prescribing opioids even for
short-term treatment of acute dental pain. States are legislating the prescribing of
opioids more frequently and more aggressively with limitations on the amount of medi-
cation that can be prescribed, and the steps prescribers need to take to avoid diver-
sion. For example, Massachusetts requires that the PDMP be queried every time a
Schedule II or III medication is prescribed and limits the quantity of an initial opioid pre-
scriptions to a 7-day supply.17 In addition, Massachusetts requires that dentists
602 Keith et al

discuss substance abuse risks, disposal of unused medication, and the option to have
prescriptions filled for fewer quantities when prescribing Schedule II medications. It is
important to document in the patient treatment record that this discussion has taken
place.
Treatment agreements addressing the clinician and patient rules for prescribing, us-
ing, and refilling controlled substances are common when opioids are written on a
chronic basis. Although less common in dentistry, patients taking opioids under su-
pervision of their primary care physician, pain specialist, or addiction specialist will
have a controlled substance agreement in place. The general terms include provisions
that the patient agrees to get prescriptions from only 1 prescriber; use 1 pharmacy; not
use alcohol, other opioids, or illicit drugs or substances; submit to pill counts and
random urine tests; and agree to participate in other treatments as indicated. If a pa-
tient has an agreement of this sort and requires dental surgery for which an opioid may
be necessary, it is incumbent on the dentist to check with the primary prescriber to
discuss a time-limited and dose-limited increase in opioids for the postoperative
period.18
Dentists always practice “universal precautions” with respect to infection control. It
is now strongly recommended that they adopt similar practice precautions when
considering prescribing an opioid pain medication for a patient. The use of the Risk
Assessment Checklist, as outlined in ”Dentistry’s Role in Assessing and Managing
Controlled Substance Risk: Historical Overview, Current Barriers, and Working
Toward Best Practices by Dhadwal and colleagues in this issue, ensures that all as-
pects of the decision-making process from initial examination and assessment to
writing the prescription and subsequent follow-up are conducted in a safe, efficient,
and responsible manner.

DISPOSAL OF CONTROLLED SUBSTANCES

When prescribing controlled substances, many states now require practitioners to

advise patients how to store and dispose of unused medications in a safe fashion.
Most police stations and many pharmacies have disposal bins in their lobbies where
the public may dispose of unused medication with no questions asked. The FDA has
specific recommendations regarding the disposing of controlled substances.19 The
prescription bottle label should be removed or scratched out with a marker to cover
up any identifying information.15 (p153)

COMMON REGULATORY VIOLATIONS BY DENTAL PRACTITIONERS

Abuse, misuse, and diversion sometimes occur when dentists prescribe controlled
substances for themselves, staff, family, or friends who are outside the scope of
dentistry. Dental boards are known to discipline dentists for prescribing outside
the scope of their practice even for antibiotics and cough and cold medication. Exces-
sive prescribing of controlled substances even for patients of record, if not substanti-
ated in patients’ records, could result in serious consequences, including referral
to the DEA.15 (p170) For those dentists personally suffering from a substance use dis-
order, the temptation to abuse one’s prescribing privileges can have disastrous
consequences.20
The DEA’s mission is to enforce the controlled substances laws and regulations.
The agency can initiate a practice inspection if a violation of these laws is suspected.
Furthermore, a review of the dental practice’s opioid prescribing history can become a
part of a dental licensing board’s inspection initiated as a result of other dental prac-
tice license violations (eg, infection control). Many states also require the dentist to
 Opioid Prescribing in Dental Practice 603

complete biennial training on safe and effective opioid prescribing/pain management.

Even if a dentist does not write prescriptions, Massachusetts requires that the dentist
maintain a valid controlled substance state registration for the sole purpose of
ordering/replenishing the emergency drug kit required for each dental office. It is
each dentist’s responsibility to know what is expected to comply with state and fed-
eral regulations.19
The best way to prepare for DEA or state licensing board inspections is to main-
tain accurate and comprehensive practice and dental treatment records that
demonstrate that one has prescribed within the accepted standard of care. Should
a dentist keep controlled substances in his or her office, regulatory agencies will
want to be convinced that this is being done in a safe and secure manner. The
DEA has a standing policy not to interfere with the doctor-patient relationship
and dictate how providers prescribe. On the other hand, should a dentist be an
outlier, that is, prescribing many more opioids than similar providers, or prescribing
or giving refills without an examination, he or she will receive heightened scrutiny by
the DEA. Dentists’ treatment records should support their clinical decisions to pre-
scribe. Care should be taken to document the findings, diagnosis, and treatment
plans, and to assess pain levels and obtain informed consent when prescribing opi-
oids. Although use and documentation of PDMP results is required in most states,
the issue of liability for using or not using the PDMP databases has not been clearly
defined in all jurisdictions. A brief review of the DEA Web site of cases that this
agency brought against prescribers during 2004 to 2019 identifies a series of cases
involving dentists. Box 3 lists common issues reported in legal cases before the
DEA. Details involving each individual case may vary. Some allegations involve
illegal distribution and trafficking of controlled substances, record-keeping viola-
tions. money laundering, prescribing opioids for sex, and involvement in a “pill
mill.”21 Box 4 lists specific details for several complex cases that involved
controlled substances and the practice of dentistry.

Box 3
Common issues reported in legal cases

 Prescribing dosages and amounts of controlled substances that were not justified based on
the diagnoses and conditions documented.
 The dental records reflect deficiencies including lack of consistent intake history, few
documented tests, lack of basis for diagnosis or rationale of treatment provided, lack of
care coordination with primary care physicians and other specialists, lack of interval records
documenting clinical progress, lack of documentation of discussion, or use of alternative
therapies and regular comprehensive examinations, and lack of exit strategies from
treatment with controlled substances.
 The dentist failed to take appropriate action when the patient breached his or
her opioid contracts and ignored signs of addiction to controlled substances, billing
insurance companies for complicated follow-up visits without justification in the
clinical record.
 Treating patients and prescribing medications for conditions that were outside the scope of
practice of dentistry.
 The dentist prescribed medications for herself/himself that were outside the practice of
dentistry.
 Signing prescription blanks in advance of prescribing controlled substances.
604 Keith et al

Box 4
Cases involving controlled substance in dentistry
Source: David A. Keith email, January 29, 2020.
I. Drug Enforcement Administration (DEA) action, documentation, prescribing for relative,
lack of required training. Specifically, Illinois Department of Financial and Professional Regu-
lation alleged that Respondent prescribed Vicodin and Tramadol, on a monthly basis be-
tween 1996 and 2018, to treat a patient with temporomandibular joint dysfunction
("TMJ") syndrome, and failed to obtain ongoing diagnostic and/or radiological studies to
verify and confirm the extent of that patient’s continued TMJ symptoms, as well as autho-
rizing numerous prescriptions for controlled substances without properly evaluating and
monitoring the patient for signs and symptoms of drug addiction or abuse.
The stipulations in the Consent Order also included allegations that DEA Diversion Investi-
gators (DIs) conducted an inspection of Respondent’s dental practice and discovered that he
prescribed Ambien and Codeine to his wife without documenting the prescriptions or
dental examination necessary for those prescriptions in her chart. Id. at 2. He also stipulated
that the DIs conducted a count of controlled substances and found a substantial amount
of substances unaccounted for, including a shortage of 1034 Hydrocodone 5/500-mg tab-
lets, a shortage of 500 tablets Hydrocodone 5/325 tablets, and a shortage of 1960 tablets
Diazepam 5 mg. Id. In addition, according to the Consent Order, Respondent was unable
to produce a biennial inventory, he failed to adequately maintain dispensing records for
controlled substances, and he failed to maintain inventory records of controlled substances
for 2 years. Id. The DIs also determined that (1) everyone in Respondent’s dental office
had access to the controlled substances cabinet; (b) Respondent kept a 500-count bottle
of Vicodin, a 100-count bottle of Halcion, and a 500-count bottle of Valium in his home,
a nonregistered address; and (c) Respondent kept a 100-count bottle of Vicodin in his
desk drawer.
Respondent also failed to complete the required 9 hours of continuing education in sedation
techniques for the 2009 to 2012 renewal cycle and failed to ensure that his staff had completed
the requisite training to assist him in dental sedation procedures (https://www.deadiversion.
usdoj.gov/fed_regs/actions/2019/fr0920_3.htm).
II. Out-of-state case, practicing outside of the scope of practice. A dentist prescribed
Hydrocodone for his fiancée’s father who had back pain. When this did not work, he
prescribed Fentanyl patch 75 mg. The patient died within 24 hours of using the patch of
a Fentanyl overdose because the patient was opiate naı̈ve. Violations: treating a
condition outside of scope of dental practice, treating an individual who was not a
patient of record. Not understanding the potential risks of prescribing a strong opioid in
an opiate-naı̈ve individual. Hydrocodone has a 2.4 times higher mean morphine equiva-
lency than Fentanyl patch (https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_
dose-a.pdf).
Courtesy Karen Ryle MS RPh Associate Chief Pharmacist, Massachusetts General Hospital,
Boston, MA- Email communication)
III. Regulatory actions, multiple prescribing violations (www.caewatch.org/board/dent/
shankland/complaint.shtml). The dentist was charged with, among other complaints, pre-
scribing excessive amounts of narcotic and sedative drugs. Specifically prescribing excessive
amounts of opioids, prescribing meperidine chronically (“which is unequivocally contraindi-
cated for chronic pain management”), prescribing 2 to 3 times the maximum daily dose of
APAP (Acetaminophen) without any “periodic liver function tests to ensure that they are
not experiencing hepatotoxicity,” failing to “measure pain intensity and/or document
your findings in order to assess benefits from opioids therapy,” prescribing excessive
amounts of carisoprodol and Ambien, prescribing opioids “chronically, without evidence
of efforts to wean the patients’ dosages or attempt alternative management of their con-
dition.” The dentist entered into a Consent Agreement with the State Board of Registration
in Dentistry under which his dental license was suspended for 6 months, he agreed to com-
plete 300 hours of continuing dental education with specific criteria, during 1 calendar year
he was barred from prescribing any opioid narcotics or central nervous system–acting med-
ications, and his records would be available for review and monitoring.
 Opioid Prescribing in Dental Practice 605

The State Board of Registration in Dentistry suspended the dentist’s license to practice
dentistry for 2 years. The specific issues were prescribing dosages and amounts of controlled
substances that were not justified based on the diagnoses and conditions documented. The
records reflected deficiencies, including lack of consistent intake history, few documented
tests, lack of basis for diagnosis or rationale of treatment provided, lack of care coordina-
tion with primary care physicians and other specialists, lack of interval records documenting
clinical progress, lack of documentation of discussion or use of alternative therapies and
regular comprehensive examinations, and lack of exit strategies from treatment with
controlled substances. The dentist failed to take appropriate action when the patients
breached their opioid contracts and ignored signs of addiction to controlled substances,
billed insurance companies for complicated follow-up visits without justification in the clin-
ical record, and treated patients and prescribed medications for conditions that were
outside the scope of practice of dentistry. He prescribed medications for himself that
were outside the practice of dentistry. He signed prescription blanks in advance of prescrib-
ing controlled substances.
A brief review of the DEA Web site of cases that this agency brought against prescribers
during 2004 to 2019 identifies approximately 20 involving dentists of a total of
approximately about 600 registrant actions. The specific issues involved illegal distribution
and trafficking of controlled substances, record-keeping violations. money laundering,
prescribing opioids for sex, and involvement in a “pill mill.” REF https://www.
deadiversion,usdoj.gov>crim_admin_actions Accessed 1/6/2020.
IV. Doctor shopping. A 33-year-old female medical researcher complained of “jaw pain” and
went to a local dentist. She had recently moved from a neighboring state and had no prior
dental records or information available. Her previous medical history was noncontributory,
and her dental examination revealed no pathology and mildly tender masseter muscles bilat-
erally. Home care measures and nonsteroidal inflammatory drugs as needed were recommen-
ded. The patient insisted that this would not control her pain and that she required Vicodin
(hydrocodone), which had relieved her pain in the past. The dentist declined to prescribe an
opioid as she felt that the patient’s symptoms were out of proportion to her examination
and that her symptoms could be adequately controlled by other means. She recommended
referral to a specialist. A review of the patient’s prescription drug monitory program (PDMP)
revealed that in the past 6 months she had had 20 prescriptions: 16 for opioids and 2 for ben-
zodiazepines. These had been issued by 18 prescribers, 15 of whom were identified as dentists
practicing within a large metropolitan area within a few miles of each other. She had used 10
pharmacies. Her PDMP from the state in which she previously resided showed a similar pattern.
This is an example of a knowledgeable individual who understood how dental practices work,
recognizing that dentists, even within the same area were not likely to communicate on a reg-
ular basis. She was able to readily manipulate dentists to provide her with opioid prescriptions
with little risk of discovery.

ETHICAL OBLIGATIONS

The role of dentistry is expanding, and more attention is being paid to medical and
psychiatric comorbidities that are commonly present among dental patients. The
ADA and state dental societies have drawn attention to the importance of assessing
substance use risk. Dental school curricula and state regulations are now requiring
training in this area.22 It is hoped that with this training we will see improved strategies
for assessing the at-risk patient within general dental practice. Other articles in this
issue review the background and importance of incorporating these approaches.
Box 5 includes the initial 2005 ADA Statement on Provision of Dental Treatment for
Patients with Substance Use Disorders.
Vearrier discusses the ethical obligations of dentists when prescribing opioid med-
ications in light of the ADA Principles of Ethics and Code of Professional Conduct.23,24
Practitioners should be aware that some states have incorporated the ADA Principles
606 Keith et al

Box 5
Statement on provision of dental treatment for patients with substance use disorders

1. Dentists are urged to be aware of each patient’s substance use history, and to take this into
consideration when planning treatment and prescribing medications.
2. Dentists are encouraged to be knowledgeable about substance use disorders, both active
and in remission, to safely prescribe controlled substances and other medications to
patients with these disorders.
3. Dentists should draw on their professional judgment in advising patients who are heavy
drinkers to cut back, or the users of illegal drugs to stop.
4. Dentists may want to be familiar with their community’s treatment resources for patients
with substance use disorders and be able to make referrals when indicated.
5. Dentists are encouraged to seek consultation with the patient’s physician, when the patient
has a history of alcoholism or other substance use disorder.
6. Dentists are urged to be current in their knowledge of pharmacology, including content
related to drugs of abuse; recognition of contraindications to the delivery of
epinephrine-containing local anesthetics; safe prescribing practices for patients with
substance use disorders, both active and in remission; and management of patient
emergencies that may result from unforeseen drug interactions.
7. Dentists are obliged to protect patient confidentiality of substance abuse treatment
information, in accordance with applicable state and federal law.

Adapted from American Dental Association. Statement on the use of opioids in the treatment
of dental pain. Available at: https://www.ada.org/en/advocacy/current-policies/substance-use-
disorders. Copyright ª 2005 American Dental Association. All rights reserved. Reprinted with
permission.

of Ethics and Code of Professional Conduct into their regulations. Dentists have an
obligation to keep up to date on advances in pain management so that they “do no
harm” (Principle of Nonmaleficence). Dentists may be asked by patients to prescribe
a controlled substance that is not indicated. Bearing in mind the Principle of Patient
Autonomy (self-governance), the dentist has no obligation to comply with treatment
requests that are not clinically indicated. Consistent with the interactive model based
on communication, cooperation, and shared decision making, the dentist should
inform the patient of the proposed treatment and any reasonable alternatives. Exces-
sive or inappropriate requests by patients for opioids and other controlled substances
may lead the dentist to suspect opioid misuse or abuse. Dentists have a duty to pre-
scribe appropriately, protect the patient from harm, and refer the patient to a specialist
if “doctor shopping” or diversion is suspected.24

SUMMARY

Dentistry should be proud of its long history of providing responsible pain relief, as well
as becoming more cautious in prescribing opioid medications when other safer phar-
macologic options exist. Our fundamental training directs us to first eliminate the
source of dental pain and prescribe analgesics only as adjunctive relief. Long before
the recent opioid prescribing laws were enacted in various states, dentists have his-
torically and appropriately been prescribing limited 2-day to 3-day supplies of opioids
for acute severe postoperative dental pain (less than one-half the quantities now
allowed by law in some states). It appears the United States is making progress in
combating prescription opioid abuse,17 but should efforts to limit diversion, abuse,
and addiction fall short, prescribers may lose their abilities to prescribe some of these
 Opioid Prescribing in Dental Practice 607

medications, thus limiting their options in providing effective pain management.13 For
a prescription to be valid, whether for controlled or noncontrolled medication, it must
be written for a legitimate dental purpose and for a patient of record. Through self-
regulation, the dental profession must continue to establish pain management guide-
lines based on scientific evidence and clinical experience to avoid further regulatory
action restricting our prescribing privileges, which remain one of our most powerful
therapeutic tools.

FUNDING

Portions of this work were supported by the Educational and Research Foundation,
Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Bos-
ton, Massachusettsg. Partial support was received for the preparation of this article
through a grant from “The Coverys Community Healthcare Foundation”.

DISCLOSURE

The authors have nothing to disclose.

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