The opiod epidemic has been a hot topic both in medicine and dentistry.  Although it has cost many individuals their lives, and cost their families and our communities countless amounts, I can only partially applaud this effort.  Dentist should be prescribing opioids in a fashion that uses the lowest possible dose for the lowest possible time period.  Extended release oral opiods have very few places in dentistry, especially for typical surgical procedures such as surgical extractions and implants. Most dental procedures also do not typically require opioid prescriptions for greater than 7 days.  In addition, the consideration of non opiod pain management is considered standard of care in pain mangement.  A multimodal approach has far greater efficacy in the management of both acute and chronic pain.

Where I tend to disagree with the proposal is the practicality of the use of MMEs for most practitioners.  MMEs were designed as a way to transition patients from parenteral to enteral opioids.  Many dentists are not familiar with this concept, and although it has been adopted by the CDC as a determining factor for when patients are at higher risk for overdose, it does little for the average prescribing dentist.

In addition, the widespread use of nalaxone is not a solution to this problem.  The demand for naloxone has caused an astronomical increase in the price of this medication.  Although most commonly describe this medication as a harmless reversal for opioid overdose, it is simply a temporary reversal of respiratory depression.  There is no question that this medication has saved lives, but the blanket use of nalaxone for any patient with "any risk factor of prior overdose, substance abuse, or doses in excess of 120 MME."  There are numerous risk factors for substance abuse, and this regulation will likely result in the unnecessary overuse of naloxone.

Regulation and the policy of stressing the importance of pain scores and patient satisfaction helped create the opioid epidemic.  Addressing the core issue of over prescription and over use of opioids is important and this regulatory action may help the issue, however the use of MMEs and naloxone for "any risk factor of prior overdose, substance abuse ..." is not likely to change the current situation.  In fact, it may lead to excessive waste of resources. Finally, the requirement of CE in controlled substances has long been required in NY, where I had also held a license.  The coursework has been ineffective in the curtailing of the opioid epidemic.

Jonathan L Wong, DMD, DADBA, DNDBA, FADSA

Diplomate, American Dental Board of Anesthesia

Diplomate, National Dental Board of Anesthesia

Fellow, American Dental Society of Anesthesia