Family dentists and oral surgeons are on the front lines of the fight against opioid addiction.
Last October, UnitedHealthcare, the largest health benefits provider in America, began rolling out new policies and programs targeting oral health professionals and their use of opioids for teens and young adults, the populations most susceptible to opiate addiction. In fact, oral health professionals write 12 percent of all opioid prescriptions, including 45 percent of opioid prescriptions for adolescents, according to a UnitedHealthcare pharmacy claims analysis representing more than four million claims.
With more than 5,000 licensed dentists across the state and 292 in Southwest Washington alone, according to the most recent numbers from the Washington State Department of Health, dentists have the ability to make a serious dent in the number of local adolescents with access to opiates.
The UHC approach is comprehensive, and includes policy changes, industry outreach and public service advertising. The policy changes and outreach targets are primarily based on Centers for Disease Control & Prevention (CDC) recommendations and UHC data.
All first-time opioid prescriptions written by dental health professionals for people age 19 and under are now capped at three days and fewer than 50 morphine milligram equivalents per day, as recommended by the CDC.
Such a policy change can affect the flow of business, said Dr. Ronald Hsu, a pediatric dentist with Vancouver-based Storybook Dental, and president of the Clark County Dental Society. If a normal course of opioids is one week, and the first-time prescription is capped at three days, he said that may mean that patient will have to come back for a possible unnecessary refill appointment, shutting someone else out of the appointment time. And in pediatric dentistry, “opioids are prescribed by weight rather than age,” so a 16-year-old, for example, who weighs as much as a large adult, may need more than 50 milligrams per day to control a deep pain.
There is a standard prior authorization process for a policy exception, but it does add one more hoop to jump for dentists.
That said, Hsu agreed that most pain issues in adolescents can be taken care of as well as or even better than opioids with a combination of plain old Tylenol and ibuprofen, which is the standard recommendation from the CDC.
“I rarely prescribe opiates,” said Hsu. “Most pediatric dentists are voluntarily giving up their DEA number, because you can use all these other medications, including antibiotics, and they’re not controlled substances. For surgeons who see these older adolescents and young adults, they are much more impacted by these policies.”
A recent study from Stanford University found that teens and young adults can end up in a battle with opioid addiction following wisdom teeth removal, and more than 70 percent of wisdom teeth extractions for people ages 16 to 22 result in at least one opioid prescription. All UnitedHealthcare dental plan participants with dependents ages 16 to 22 will receive information by mail about the risks associated with opioids, specifically in connection to wisdom teeth extractions. UHC has also teamed with Shatterproof, a nonprofit focused on adolescent opioid addiction, to run TV and radio PSAs making the connection between oral health and potential addiction.
Dental health professionals in the top 10 percent of highest opioid prescribers in UnitedHealthcare’s network last year received information about their status. Following UnitedHealthcare’s outreach, prescribing patterns improved by 17 percent. This year, UHC will reach out to its top 20 percent of opioid prescribers.
If outreach is so successful, some may wonder why policy changes are needed. Isn’t this just another example of insurance companies policing dental health professionals?
“Yes and no,” Hsu said. “Because for adolescents and children, opiates don’t work well when it comes to actual pain control. It solves the brain problem, but when it comes to actual reduction of pain, Tylenol and ibuprofen work better. … And when you do have a big surgery like wisdom teeth extraction, opiates could be of help but you would need more than two to three days worth. In many ways UHC isn’t necessarily overstepping evidence. The insurance industry is putting up guardrails, but if their policy conforms to our guidelines, it should have no effect on what we usually do.”
A multi-faceted solution
The debate over guardrails in the healthcare industry will likely continue, though most seem to agree that a multi-faceted solution is the only sensible one. But in this era of “doc shopping” and stealing prescription codes –which happened once to Hsu – where the buck stops remains a fuzzy question.
“When you codify something, it’s a bit like the gun control debate, the law abiding citizen gets inconvenienced a little bit, and those who go behind the shadows are still going to do what they do,” Hsu said. “One of the questions I always have is: when the pharmacies keep track of all prescriptions and who gets them, instead of putting all the owness on prescriber side, why not put the owness at the point of dispensary? This is just a question I have.”
Dr. Ted Wong, UHC’s Chief Dental Officer, said pharmacies have a critical role, as do healthcare providers, insurance companies and professional associations.
“In tackling the national opioid crisis…we are always looking to work collaboratively. UnitedHealthcare is uniquely positioned to leverage data to make change,” he said. “We don’t do it in a vacuum, we aren’t trying to interfere with the delivery of care. Current recommended practices drive positive change.”
Since the policy-roll out in October of 2018, UHC has seen extraordinary results, making the case that policy change works to enforce evidence-based public health recommendations, and Wong said UHC hasn’t seen “any push-back from providers.”
“(Since the pharmacy policy was enacted in October of 2018), we’ve seen a reduction by 90 percent of prescriptions that exceeded the CDC guidelines,” Wong said. “It wasn’t surprising because there was a hard stop on it. We had the right processes in place.”