Drug shopping patients and how to protect yourself

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drug shopping patients
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Is the ADA’s backing enough to help calls for a real-time monitoring system to protect dentists against drug shopping patients become a reality? Tracey Porter reports

A lack of a national real-time prescription monitoring system means Australian dentists may be inadvertently contributing to the misuse of pharmaceutical opioids through inappropriate prescribing.

While the use of opioids in dentistry is on the wane as a result of therapeutic guidelines recommending an alternative range of medication, opioids still play an important part in acute dental pain relief through their inclusion in drugs such as codeine, oxycodone and tramadol.

However, opioid misuse and abuse are well-established public health issues in Australia with pharmaceutical opioid poisoning now surpassing that of heroin use.

To help stem the incidence of opioid misuse, a series of reforms were introduced in 2018, the likes of which included the introduction of smaller pack sizes and making codeine prescription-only. But a recent study on trends in dental prescribing showed that dental opioid prescriptions remain a popular choice by some dentists in relieving acute dental pain.

Its prevalence

Data on the number of dental prescriptions dispensed for all medications listed on the PBS Dental Schedule, from January 2019 to June 2020 shows opioid analgesics were the second most commonly prescribed drug class, representing approximately 21 per cent of total PBS dental prescriptions dispensed over 2020. 

The ‘Trends in Dental Medication Prescribing in Australia during the COVID-19 Pandemic’ report found the most commonly prescribed opioid painkillers were codeine with paracetamol, representing 95 per cent of total opioid analgesic prescriptions. This was followed by oxycodone (four per cent) and tramadol (one per cent). 

The data shows that while total prescriptions of opioid painkillers dropped by around 3100 in April 2020, compared with April 2019, there was an increase in every month of 2020—except April—compared to equivalent months in 2019 for prescriptions of oxycodone.

If a dentist suspects a patient is seeking opioids for non-medical use, they would be able to avoid prescribing opioids and focus on providing active dental treatment and, where appropriate, recommend NSAIDs and paracetamol.

Dr Leanne Teoh, dentist & pharmacist

While noting this reflected changes to the national therapeutic guidelines which recommended oxycodone as the preferred opioid analgesic for severe acute dental pain, the report’s authors noted that codeine with paracetamol is still being prescribed at a rate 30 times higher than oxycodone.  “The increase in opioid use in the post-lockdown period is also concerning given that opioid dependence and addiction represent a major public health issue. In this context, dentists may be inadvertently contributing to the misuse of pharmaceutical opioids through inappropriate prescribing,” the report states.

The Australian Dental Association (ADA), however, has sought to downplay the findings. ADA spokesperson and oral health specialist Dr Sue-Ching Yeoh says that due to the timing of the study, prescribing trends and choices may have been influenced by the “unusual circumstances” of the COVID-19 pandemic lockdown where they may have been used an as alternative to routine operative treatment.

“The data reported in this study is also not linked data, so there is no information provided about the clinical scenario, patient details or appropriateness of the prescriptions,” she says.

Dr Yeoh says she not aware of any exact figures published in relation to proportionate opioid prescribing by dentists to other prescribers, but given that it is not the recommended first choice of pain medication, suspects it would be “relatively low”. 

The root of the problem

The role oral health specialists may play in the crisis was first brought to light by Victorian dentist and pharmacist Dr Leanne Teoh who, in 2018, was part of a team studying the prescribing practices of general dentists in Australia for antibiotics, analgesics and anxiolytics. The group’s findings showed that despite the fact, 16–27 per cent of dentists surveyed preferred prescribing an opioid or paracetamol over a non-steroidal anti-inflammatory drug (NSAID) as first choice for dental pain.

Concerned that dentists may be being used as targets of ‘doctor shopping’, in which drug-dependent people seek drugs for misuse from multiple prescribers, Dr Teoh has since called for dentists to be included in real-time prescription monitoring programs currently accessed by pharmacists, doctors and nurses.

In October she published a follow-up piece titled ‘Opioid prescribing in dentistry – is there a problem?’ in which she flagged data showing a 21 per cent increase in dental prescriptions of codeine 30 mg (with paracetamol 500 mg) and a 24 per cent increase of oxycodone one year after the reforms in comparison to the previous year.

Dentists take their responsibility as prescribers very seriously and must assess the needs of the individual patient before prescribing any therapeutic agents. The responsibility includes the need to consider the risks and benefits overall to the patient from the medication being considered.

Dr Sue-Ching Yeoh, Australian Dental Association

Dr Teoh says the early identification of people at higher risk of developing drug dependence would assist prescribers in clinical practice. 

“That way, if a dentist suspects a patient is seeking opioids for non-medical use, they would be able to avoid prescribing opioids and focus on providing active dental treatment and, where appropriate, recommend NSAIDs and paracetamol.”

And on this at least, the ADA agrees.

In showing its support for a national real-time monitoring system which can be accessed by dental prescribers, the ADA has amended its policy statement on prescribing and dispensing medications in dentistry to state that dentists should have full access to any real-time prescription monitoring system.

While each state and territory is responsible for the management of drugs and poisons legislations in their jurisdiction, there is currently no harmonisation of the legislation. 

Dr Yeoh says if given the go-ahead there would be very few requirements needed to get dentists up to speed with such a system except for “some level of education” to ensure that dentists are aware of how it works and to understand their new responsibilities.

“Dentists take their responsibility as prescribers very seriously and must assess the needs of the individual patient before prescribing any therapeutic agents. The responsibility includes the need to consider the risks and benefits overall to the patient from the medication being considered.”  

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