Pharmacy Technician, Lexi Butler fills a prescription order

Pharmacy technician Lexi Butler fills a prescription order Feb. 18 at Kilgore's Pharmacy. In the midst of the opioid crisis, many dentists have been changing their prescription patterns. As a result, the pharmacy has been filling abuse-deterring alternative prescriptions such as Xtampza, said Beth MacLellan, pharmacist and store owner. 

You had your wisdom teeth out, and your dentist gave you a prescription for 16 or 20 Vicodin. You only use three or four.

"Nobody ever told you what to do with the leftovers and you put it in the medicine cabinet thinking ‘I might need that one of these days,’" said John Dane, Missouri's state dental director.

That's potentially a problem.

"That's where a lot of (people) are first getting their opioids to misuse," Dane said. 

In 2018, Missouri had 1,132 opioid overdose deaths, according to the Missouri Department of Health and Senior Services. That's up from 951 deaths in 2017 and 908 in 2016.

"Missouri’s data tells a troubling story," the site reads. 

Boone County recorded 19 opiate-related deaths in 2019, according to the Medical Examiner's office for Boone and Callaway Counties, surpassing other drug and alcohol-related deaths for the year.

To determine if a death is "overdose suspected," Dr. Carl Stacy, medical examiner for Boone and Callaway Counties, said investigators and law enforcement talk to friends of the person who died. What's left behind often tells part of the story. "(Investigators) find paraphernalia, they find empty pill bottles around," Stacy said. 

Last July, Gov. Mike Parson signed SB 514, part of which regulated opioid prescriptions written by dentists, and while Missouri remains the only state without a statewide prescription drug monitoring program, many counties — including Boone — participate in the St. Louis County Prescription Drug Monitoring Program. According to the program's site, 75 jurisdictions — covering 85% of the state's population — participate in the program. 

That's a good thing, said Bill Morrissey, a pharmacist at Kilgore's Medical Pharmacy in Columbia. 

Before the program and the database it now provides, as a pharmacist filling a prescription for a new customer, "you didn't really have a lot to go on," Morrissey said. 

"I think doctors, dentists and prescribers in general are much more cautious and aware than they were even five years ago," he said. 

In light of the number of opioid-related deaths statewide and elsewhere, the American Dental Association, Missouri Dental Association, Centers for Disease Control and Prevention and other organizations have released information to help patients and prescribers make safer decisions about opioids.

In a 2018 statement, then-president of the American Dental Association Joseph P. Crowley urged dentists "to reflect on how we manage dental pain and take several specific steps to help keep opioid pain relievers from harming our patients and their families."

Among them were:

  • Suggesting the use of non-narcotic pain relievers rather than opioids.
  • Prescribing opioids in smaller amounts.
  • Providing counsel and information to the patient.
  • Recognizing when a patient could struggle with a substance use disorder or addiction.

The American Dental Association also provides information about the opioid crisis for patients and dentists, including a link to the organization's Center for Professional Success, where dentists can access free continuing education online.

"It's made us as practitioners more aware of the issue," said Dr. Grant Ressel, a dentist in Columbia who's been practicing for nearly four years. He said opioid prescribing in his office has decreased over the years by a couple days' worth of doses.

But Ressel said opioids are invaluable for dealing with extreme pain.

"Tooth pain can be some of the worst pain you ever feel in your life," he said, adding that he's had patients cite tooth pain as worse than previous pain from kidney stones or even giving birth.

There's a greater emphasis on the opioid issue now than when Ressel was in dental school, he said. Following guidelines like those released by the CDC and taking responsibility for prescribing practices can help dentists do a better job of keeping patients on opioids for a shorter time, when possible.

Heavy dose of education

That's what makes continuous education on the topic so critical.

Dane said that with the recent publicity of the opioid crisis "all providers, not just dentists, have been bombarded with information" from health organizations.

He said that for the last three years, "almost every meeting that the Missouri Dental Association had had something about the opioid crisis and proper prescribing patterns."

"The chronic prescribers have gotten the message and they're changing the prescription practices there," Dane said, referring to providers who regularly prescribe above the average.

According to a January news release from the Missouri Department of Social Services, data from MO HealthNet claims shows a 30% drop in dispensed opioid morphine milligram equivalents for 2019, down 65% since 2012.  The morphine milligram equivalent is a numerical comparison that standardizes opioid potencies into their equivalent morphine amount.

This data only represents HealthNet participants, but the release notes that the decrease includes opioids prescribed for dental procedures as well as long-term chronic cases.

Dane said he also put together data from MO HealthNet and found that in 2019, dentists prescribed on average 2.89 days' worth of opioids, down from the 2016 average of 3.53. He said 2.89 is a good average, but that depending on the procedure, the number could be even lower, since most dental pain peaks at 24 hours and has mostly subsided after 48 hours.

The idea is that prescribing a smaller quantity of opioids — for example, two days' worth of opioids rather than three — will hopefully result in a patient ending up with less extra medication that could potentially be misused.

If you do have leftover pills and want to make sure they don't fall into the wrong hands, the Food and Drug Administration recommends either a local drug takeback program or throwing away the pills. According to the FDA website, before throwing away extra pills, one should "mix them with something undesirable, such as used coffee grounds, dirt, or cat litter" and carefully seal the bag or container before discarding it.

Hy-Vee now has drug takeback receptacles where customers can drop off unused medication. The receptacles are at all Hy-Vee locations.

Morrissey said that if you have a prescription, you are accountable and must take responsibility for the drugs.

"This is a problem for our society as a whole," he said. "It has to be society as a whole that tries to make an effort to fix that."

Besides, there are other ways to manage pain, including over-the-counter pain medications and physical therapy.

“Things are a little better, but we’re not there,” Dane cautioned. “People are still dying from opioid overdoses.”

  • Public health and safety reporter, spring 2020. Studying news reporting. Reach me at cgiffin@mail.missouri.edu, or in the newsroom at 882-5700.

  • I'm the public safety and health editor at the Missourian and a professor in the School of Journalism. I'm experienced in directing investigative projects. Call me at (573) 882-1792 with story tips, ideas or complaints.

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