Featured Articles: Pain Management/Opioids

Opioid Crisis: Preaching to the Choir in Oregon

Tuesday, December 12, 2017   (0 Comments)
Share |

Lynn Gerlach, Tamarack Communication

- an interview with Len Barozzini, DDS, Multnomah County -

 

President Trump declared the opioid epidemic a national emergency and then revised that statement to a “public health emergency.” In this, the second in our series on how Region X is responding to this emergency, we interview a dental director who would probably agree that a public health emergency was exactly what he walked into not so very long ago. His story is unlike many, though, in that he quickly discovered he was preaching to the choir.

 

Let’s say you’re an experienced (but not “old”) dentist with 17 years of nonprofit dentistry under your belt, and you come up from Los Angeles to Portland, Oregon, to become the new Dental Director for Multnomah County. What do you expect to find?

 

What Len Barozzini, DDS, found when he stepped into his new role in January 2014 were six dental clinics, all part of the FQHC, suffering from opioid over-prescribing and addiction far beyond what he had expected for a city the size of Portland. Thirty dentists and 20 hygienists were seeing about 300 patients each day. The dentists were on target to write 2700+ opioid (narcotics) prescriptions in 2014.

 

Knowing he had to make a change, Len turned to his cadre of dedicated public health dentists and made a wonderful discovery: They were all onboard, ready to understand the opioid problem and help reduce the impact of dental prescribing on the addiction potential of routinely prescribed pain medications

 

Len did not have a fight on his hands. It was simply a matter of gathering and presenting the evidence to empathetic dentists who were committed to reducing short-term pain for their dental patients and open to any new knowledge that might benefit the community. Len found that reports generated for understanding by the general public – TV news reports, articles in respected newspapers, the story told for a general audience, often with a human-interest component – were far more effective in communicating the problem than dry, scientific studies. His dentists were ready to try non-addictive alternatives, such as Motrin and Tylenol, to relieve pain.

 

“I just didn’t realize how pervasive the problem was,” Len said. “I love Portland, and I was immediately impressed with the public health department dentists. It wasn’t a matter of convincing anyone of the need to change, but simply constructing the protocols and working together to implement them.”

 

In January 2016, Len issued his protocol for Prescribing Scheduled Medications in the Dental Program with three main components: better education for both dentist and patient; increased documentation when prescribing opioids; and required enrollment in Oregon’s Prescription Drug Monitoring Program (PDMP). His document acknowledged the need for “respectful care and appropriate management of dental pain,” but pointed out the dangers inherent in prescribing any scheduled medications – and he openly discouraged them.

 

Len brought in Rachel Solataroff, MD, a respected addiction specialist (and now CEO) at Portland’s Central City Concern, to meet with the dentistry staff. And he imposed strict ceilings on the dosages, strength in milligrams, and number of refills allowed. He mandated that all scheduled medications prescribed would be entered into the Electronic Dental Record as a separate clinical note prior to prescribing. This separate note includes questions to help the prescriber assess a patient’s addiction potential. His protocol set clear standards for prescribing Tylenol #3, Norco, Oxycodone, Tramadol, Lorazepam and Diazepam. And he forbade any refills to be included in an initial prescription. He also required a review of the PDMP for patients “exhibiting suspicious behaviors.”

 

Len further mandated that patients be assessed in the clinic before any scheduled medications are prescribed, and that lost or stolen prescriptions and medications not be replaced.  He reviews the use of the new protocol regularly and has made his providers a simple “cheat sheet,” including a reminder of the four critical questions to ask before prescribing an opioid.

 

He has drafted a letter to patients and requires that it be handed to and discussed with each patient who will be prescribed an opioid. The letter includes a number to call if they or anyone they know is struggling with addiction.

 

That was January 2016. Multnomah County Health Department dentists are now much more likely to prescribe ibuprofen (Motrin) or acetaminophen (Tylenol), since those medications are shown to be more effective than opioids at reducing patients’ acute pain. The results cannot be denied:

·         2014 – 2,727 Class II prescriptions written

·         2015 – 2,179 Class II prescriptions written

·         2016 -  1,473 Class II prescriptions written

 

A 46% reduction in opioid prescribing over two years, including a 33% drop in the first year of implementation, is definitely something to cheer about. But Len cautions that doctors and dentists still face considerable obstacles in the fight to reduce opioid over-prescribing and addiction. “Patients have to be educated about the addictive nature of opioids taken even over a very short period of time,” he explained. “And their expectations for getting the opioids they think they need are unfortunately bolstered by pervasive pharmaceutical advertising and a long-time preference of insurance companies to pay for the less expensive drug.”

 

Many opioids are less expensive than NSAIDS. This makes it difficult as well to get buy-in from insurance companies to pay for non-narcotic medicines.

 

Len makes it clear that it was not only the dentists, but the entire dental team (about 150 people) that made the difference in the substantial decrease in opioids prescribed at Multnomah County Dental.  The dental team is all on the same page, and all now emphasize the dangers of opioids.

 

 

NWRPCA welcomes and regularly publishes white papers and articles submitted by members, partners and associates with subject matter expertise. The appearance of any guest publication in our Health Center News database represents the views of the author and does not constitute endorsement by NWRPCA of the stated opinions or perspectives, nor does it suggest endorsement of the contributor's products or services.

 

 


Membership Software Powered by YourMembership  ::  Legal