I, when a prectising Dentist and after retiring from active practice of dentistry, was prescribed and I used prednisone for several years in an attempt to obtain relief from physical pain. this pain was a result of some injuries which were received in my earlier life. This was very helpful, physically, and I am certain that my knowledge of the possible harmful effects of continuing to use this over a long period of time avoided an addiction problem.

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

My suggestion is that the Board of Dentistry regulation mirror exactly the board of medicine related to requirements for treatment of acute pain.  It appears there are differences between the required co-prescribing of naloxone.  I also support the mandated check of the PMP for all opioid prescriptions written, not just for second prescription. 

Under 18VAC60-21-102 B. "conduct an assessment of the patient's history and risk of substance abuse" is stated.  That is a nebulous statement.  I'd appreciate more guidance.

Under 18VAC60-21-106 I am against the addition of 2 hours CE for pain management every 2 years.  There are dentists who don't prescribe.  There are those of us who've had a very long history of very few prescriptions filled per month, etc.  Making us take 2 hours every 2 years is only good for PR and will not cause us to write fewer prescriptions.  Remember, it was the DEA that reclassified most Class III to Class II and as a result, a patient who leaves my office after surgery now must get a prescription for a narcotic (if I feel OTC's, etc. will not be sufficient), as they will have to come back to the office to get one and many live an hour away and it's likely to be after hours.  I can no longer call or fax one to their pharmacy.  When I asked at a study club how many dentists were writing more scripts than before the DEA action, all hands of those who prescribed went up.  However, we've done an excellent job in educating our patients and few of the prescriptions are actually filled. 

I personally don't like or tolerate the narcotics and have tried to keep patients away from them.  Don't add 2 hours of CE for every 2 years.  There must be a threshold for it.  Also, unless there is new information or proof that there is a problem with dentists prescribing narcotics, the board of dentistry should not require this additional CE.  They have the ability to revisit this issue if a problem is identified and then they could enact emergency regulations to address the specific problem.