A new Missouri law limits the dosage and type of opioid pain medications prescribed by the state’s dentists — amid mounting evidence that painkillers after routine dental work are contributing to the national addiction epidemic.
Senate Bill 514, signed by Gov. Mike Parson earlier this month, says that dentists should restrict opioid prescriptions to no more than the equivalent of 10 regular Vicodin pills per day and shouldn’t prescribe long-acting opioids like Oxycontin at all.
Dan Kessler, the president of the Missouri Dental Association, said the trade group worked with lawmakers on the language and supported the bill.
“I think we all are for limitations and not over-prescribing or not even using things like hydrocodone,” Kessler said.
Under the new law, dentists who exceed the dosage limits or prescribe extended-release opioids will have to document why in the patient’s medical record.
If they don’t, it could be grounds for the state’s dental board to investigate them and potentially pull their license, Kessler said.
“I hate to say it’s on the honor system but it kind of is,” Kessler said. “But if you’re a repeat offender and things happen, like people are OD’ing on it, then you’re exposed.”
Dentists were responsible for only 6.4% of all opioid prescriptions in the U.S. as of 2012, but a study published in JAMA Internal Medicine in December showed that they have an outsized role in adolescent and young adult addiction.
The study found that people age 16 to 25 whose first opioids were prescribed by a dentist were more than 10 times more likely than their peers to be diagnosed with opioid abuse within a year of getting that prescription.
Teens and young adults are more susceptible to addiction because their brains are still developing, and dentists are the most frequent opioid prescribers for adolescents because that’s when most people have their wisdom teeth removed.
“This statute will minimize the critical role in the exposure of this group who are vulnerable to misuse,” said John Dane, the dental director for the Missouri Department of Health and Senior Services.
In March, The Star profiled Anna (her last name was withheld to protect her privacy), a 27-year-old Kansas City woman who had gotten hooked on opioids after having her wisdom teeth removed 10 years ago. She initially got about 10 days of pills, then ended up getting another prescription after she went back to the dentist and he found a tooth shard still lodged painfully in her gums.
After that prescription ran out, she got pills from friends and then progressed to injecting heroin. It took substance abuse counseling, a medication called Suboxone and a daily jogging regimen to get her off the drugs .
Randall Williams, the director of the Missouri health department, said that in addition to keeping people with prescriptions from getting addicted, the new limits should help keep pills out of the hands of people who weren’t prescribed them by reducing the overall supply.
Williams said research shows that 80 percent of illicit heroin use stems from people who started with prescription opioids, but half got them from someone else’s prescription — a problem known as drug diversion.
“We believe decreasing the amount of exposure to prescription opioids, whether from a health care provider or a diverted source, is a major step toward preventing addictions that lead to overdose deaths,” Williams said.
Missouri was already one of 15 states that, as of October, restricted all medical professionals to prescribing no more than seven days’ worth of opioids for acute pain in patients who aren’t already on the drugs. But Kessler said these are the state’s first restrictions aimed only at dentists.
A few other states, including Alabama and Arkansas, already had similar regulations aimed at dentists, according to the American Dental Education Association. Some states also require them to take continuing education courses on appropriate use of opioids.
Kansas doesn’t have any dosage limits specifically for dentists and is not among the states that restrict providers’ to seven-day prescriptions.
Some patient advocacy groups have criticized strict opioid limits because they don’t account for patients’ size or other factors that affect their opioid sensitivity. They’ve also said the laws will end up pushing more people to illegal heroin, though those critiques generally apply to patients with chronic pain, not temporary pain caused by a dental procedure.
Missouri’s new daily dosage limit for dentists is 50 morphine milligram equivalents — a ratio that compares morphine to other opioids. That’s about 10 standard-dose tablets of hydrocodone-acetaminophen, a composite pain reliever commonly known by the now-defunct brand name Vicodin.
People on dosages above that level are twice as likely to overdose, according to the Centers for Disease Control.
Kessler said that in his 35 years of experience as a practicing dentist, that dose is usually more than sufficient for even the most painful dental conditions, like an abscessed tooth.
But the documentation exception is there for the patients who need more, like those who have built up a tolerance to opioids.
“They’re going to be more used to having this and it’s not going to work as well for them,” Kessler said. “But just for a regular patient who hasn’t been taking a lot of pain medications, that should be plenty.”