Opioid addiction

and dentistry:
An overview

*CDC (https://www.cdc.gov/drugoverdose/data/prescribing.html)
Dr. Sonia Regina Bordin-Aykroyd DDS MSc
admin@aaofh.org
 Term used to
Opiates designate drugs
& derived from opium
“Opiates” and their chemically
Opioids related derivatives,
such as the semi-
synthetic alkaloids.

Dr. Sonia Regina Bordin-Aykroyd DDS MSc

 Term used for both
natural and synthetic
drugs with morphine-
like properties.
Opiates
& Group of chemically
“Opioids” similar drugs that
Opioids include heroin and
prescription pain
relievers such as:
Hydrocodone,
oxycodone, and
morphine28
Dr. Sonia Regina Bordin-Aykroyd DDS MSc
 Opioids

•Natural opioids: Pain medications, like

morphine and codeine

•Semi-synthetic opioids: Also for pain

medications, like oxycodone, hydrocodone,
hydromorphone, and oxymorphone

•Synthetic opioid, like Methadone: used to

treat pain, but it can also be provided through
opioid treatment programs to treat opioid use
disorders
https://www.cdc.gov/drugoverdose/deaths/prescription/maps.html
Dr. Sonia Regina Bordin-Aykroyd DDS MSc
 Used mostly for their
Opioids analgesic properties for:

& severe pain:

Pain fentanyl, hydromorphone,
methadone, morphine, pethidine
Clinical
applications
➢ substances that moderate to severe pain:
work in the nervous buprenorphine, oxycodone
system of the body
or in specific
receptors in the mild to moderate pain:
brain to reduce the codeine, dihydrocodeine,
intensity of pain. dextropropoxyphene28.

Dr. Sonia Regina Bordin-Aykroyd DDS MSc

 Used mostly for their
analgesic properties:

To induce or supplement
anaesthesia:
fentanyl and fentanyl
analogues such as alfentanil
Opioids and remifentanil

& Other clinical

applications
As cough suppressants:
codeine, dihydrocodeine,
Pain pholcodine and ethylmorphine

To treat gastrointestinal
disorders (diarrhoea):
codeine and diphenoxylate

Treatment of opioid dependence:

buprenorphine and methadone28.
Dr. Sonia Regina Bordin-Aykroyd DDS MSc
 Prescription
pain
relievers

Dr. Sonia Regina Bordin-Aykroyd DDS MSc https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm#illicit4

Prescription
pain
relievers

Dr. Sonia Regina Bordin-Aykroyd DDS MSc https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm#illicit4

 Opioid deaths and Prescriptions
2019

2018 USA - *49,860

Opioid-related
deaths.
2017 USA - 46,802
28% - prescription
Opioid-related
deaths (>firearms). related,
2016 WHO -115,000
2 out 3 of drug- 38 deaths/day or
Opioid-related more than 14,000
deaths (World) - related deaths
1999-2015 > 11.5 million (47,600 in the involved opioids. deaths in the
year2.
Americans, > 12 USA). UK - 2,670 opioid-
y.o. misused related deaths
> 750,000 Opioid prescription pain 58 opioid
prescriptions per (highest ever
overdose deaths reliever opioids 100 Americans. reported)
USA = (4x higher
than Europe15) 17% of Americans
had at least one
opioid prescription
Sources:
filled.
* CDC WONDER).Jan 29, 2021 Average 18 days
https://www.cdc.gov/drugoverdose/deaths/prescription/practices.html per prescription.
**Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC,
National Center for Health Statistics; 2020. Available at http://wonder.cdc.gov. Average dose
***Mattson CL, Tanz LJ, Quinn K, Kariisa M, Patel P, Davis NL. Trends and Geographic more than 45.3
Patterns in Drug and Synthetic Opioid Overdose Deaths — United States, 2013–2019.
MMWR Morb Mortal Wkly Rep 2021;70:202–207. MME.
DOI: http://dx.doi.org/10.15585/mmwr.mm7006a4 Dr. Sonia Regina Bordin-Aykroyd DDS MSc
 Opioid deaths and Prescriptions
1990 - 2020
(USA):
2018 - 2019
841,000 people died from drug overdose.**
(USA):
Overdose deaths involving opioids, have
Synthetic opioid-involved death increased 6 X since 1999.**
rate increased 15.2%.

7% decrease in opioid prescription-

related deaths.

Sources:
* CDC WONDER).Jan 29, 2021
https://www.cdc.gov/drugoverdose/deaths/prescription/practices.html
**Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC,
National Center for Health Statistics; 2020. Available at http://wonder.cdc.gov.
***Mattson CL, Tanz LJ, Quinn K, Kariisa M, Patel P, Davis NL. Trends and Geographic
Patterns in Drug and Synthetic Opioid Overdose Deaths — United States, 2013–2019.
MMWR Morb Mortal Wkly Rep 2021;70:202–207.
DOI: http://dx.doi.org/10.15585/mmwr.mm7006a4

https://www.cdc.gov/mmwr/volumes/70/wr/mm7006a4.htm?s_cid=mm7006a4_w
Dr. Sonia Regina Bordin-Aykroyd DDS MSc
 Opioid Misuse
➢ Opioid misuse includes the
misuse of prescription opioid
pain relievers or the use of
heroin

➢ Most opioid misuse involves

the misuse of prescription pain
relievers
https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm#illicit4
Dr. Sonia Regina Bordin-Aykroyd DDS MSc
Common prescribers:

➢ internal medicine physicians,

➢ primary care physicians and
➢ dentists.

A higher number of dentists and

primary care physicians per capita is
one of the characteristics found in
counties with higher opioid
prescribing rate.

https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm#illicit4
Dr. Sonia Regina Bordin-Aykroyd DDS MSc
Dr. Sonia Regina Bordin-Aykroyd DDS MSc

Source: Annual Surveillance Report of Drug-Related Risks and Outcomes | United States CDC National Center for Injury Prevention and Control | 2018
 Opioid deaths involving Prescriptions
2013 - 2019

FIGURE 1. Age-adjusted rates of drug overdose deaths† involving prescription opioids, heroin, cocaine,
psychostimulants with abuse potential, and synthetic opioids other than methadone¶ — United States, 2013–2019
https://www.cdc.gov/mmwr/volumes/70/wr/mm7006a4.htm?s_cid=mm7006a4_w
Source: National Vital Statistics System, Mortality File. https://wonder.cdc.gov/
Dr. Sonia Regina Bordin-Aykroyd DDS MSc
 Number of opioid prescriptions - USA (2016 to 2019)

• 19% reduction in annual prescribing

rate from 2006 to 2017.

• declines in opioid high-dose

prescribing rates (≥90 MME) since 2008.

• the dose (MME) prescribed per person

continues to increase (for the lower
dose prescribers) and the average is
still 3 X higher than it was in 1999.

• the average number of days per

prescription for each patient continues
to increase, with an average of 18 days
reported in 20172. https://www.cdc.gov/drugoverdose/deaths/prescription/maps.html

https://www.cdc.gov/mmwr/volumes/70/wr/mm7006a4.htm?s_cid=mm7006a4_w Dr. Sonia Regina Bordin-Aykroyd DDS MSc

Dr. Sonia Regina Bordin-Aykroyd DDS MSc

Source: Annual Surveillance Report of Drug-Related Risks and Outcomes | United States CDC National Center for Injury Prevention and Control | 2018
 Prescriptions x Opioid addiction

“Taking prescription opioids for longer

The overall opioid prescribing rate in the United States peaked and leveled off from 2010-2012 and has been
declining since 2012, but the at of opioids in morphine milligram equivalents (MME) prescribed per person is still
periods of time or in higher dosages can
around three times higher than it was in 1999.1 MME is a way to calculate the total amount of opioids, accounting
for differences in opioid drug type and strength.
There was a more than 19% reduction in annual prescribing rate from 2006 to 2017. The declines in opioid
increase the risk of opioid use disorder
prescribing rates since 2012 and high-dose prescribing rates (≥90 MME) since 2008 suggest that healthcare
providers have become more cautious in their opioid prescribing practices.
(addiction), overdose, and death”.

Dr. Sonia Regina Bordin-Aykroyd DDS MSc Source: National Vital Statistics System, Mortality File. https://wonder.cdc.gov/
https://www.cdc.gov/mmwr/volumes/70/wr/mm7006a4.htm?s_cid=mm7006a4_w
 Over Prescription
➢Over-prescription of opioid
analgesics by health professionals
triggered the opioid crisis helping to
expedite their diversion and misuse,
extending it to hard drugs, such as
heroin and illicit artificial opioids
(fentanyl and its analogs).
Dr. Sonia Regina Bordin-Aykroyd DDS MSc
 Opioid Misuse

https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm#illicit4 Dr. Sonia Regina Bordin-Aykroyd DDS MSc

Dr. Sonia Regina Bordin-Aykroyd DDS MSc
Dr. Sonia Regina Bordin-Aykroyd DDS MSc
 Opioid Misuse
Pain reliever only

8.2 million or (3.9%) adults

881,000 or (3.5 %) adolescents > 26 y.o.
aged 12 - 17 y.o.

2.5 million or (7.1 % ) young adults

aged 18 - 25 y.o. https://www.samhsa.gov/data/sites/default/files/NSDUH-
FFR1-2016/NSDUH-FFR1-2016.htm#illicit4 Dr. Sonia Regina Bordin-Aykroyd DDS MSc
 Types of prescription pain relievers people misused
> 12 y. o. of the population

https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-
Dr. Sonia Regina Bordin-Aykroyd DDS MSc % 2016/NSDUH-FFR1-2016.htm#illicit4
Main Reasons for the Misuse of Pain Relievers

Most commonly reported

reason for misuse of a
pain reliever was to
relieve physical pain,
which is the reason pain
relievers are prescribed, if
there are no alternatives
to pharmacological
therapy

https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm#illicit4 Dr. Sonia Regina Bordin-Aykroyd DDS MSc

 Pain Reliever Use Disorder

Dr. Sonia Regina Bordin-Aykroyd DDS MSc

https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm#illicit4
Source of the Last Pain Reliever That Was Misused

https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm#illicit4 Dr. Sonia Regina Bordin-Aykroyd DDS MSc

 Patients prescribed higher opioid
dosages are at higher risk of death
from overdose.
Dosage

**CDC - Centers for Disease Control and Prevention. 2018 Annual Surveillance Report of Drug-Related Risks and
Outcomes — United States. Surveillance Special Report 2. Centers for Disease Control and Prevention, U.S.
Department of Health and Human Services. Published August 31, 2018.

Dr. Sonia Regina Bordin-Aykroyd DDS MSc www.cdc.gov/drugoverdose/prescribing/guideline.html

The role of dentistry on the opioid epidemics

➢ Dental pain may lead to the first

encounter with opioids for adolescent
and young adults [1].
Nearly 60% of adolescents
and young adults who
➢ Dentists have historically represented the visited an Emergency
largest source of opioid prescriptions for Department for a dental
pain were prescribed
young age groups, often for third molar opioids.

extractions [2],[3].

https://www.cdc.gov/acute-pain/dental-pain/
Dr. Sonia Regina Bordin-Aykroyd DDS MSc
➢ “Dentists are among the most frequent prescribers
of opioids in the United States, second to family
physicians18,19.

➢ While per capita prescribing of opioids is

decreasing nationally20, dental prescribing rates are
increasing21.

➢ Studies in the United States have shown that

dentists recommend and prescribe opioids over
nonsteroidal anti-inflammatory drugs, in greater
quantities, and for longer than necessary to control
dental pain22,23 ”.

https://www.cdc.gov/acute-pain/dental-pain/ Dr. Sonia Regina Bordin-Aykroyd DDS MSc

➢ An estimated 1 million opioid pills prescribed
following tooth extractions remain unused in
the USA26.

➢ Dentists are responsible for one-third of

opioid prescriptions to adolescents, a
vulnerable population for opioid misuse18,27.

➢ In 2016, dentists prescribed > 11.4 million opioid prescriptions in the

USA vs 28,082 opioid prescriptions in England (37 x higher)25.

Dr. Sonia Regina Bordin-Aykroyd DDS MSc

https://www.cdc.gov/acute-pain/dental-pain/
25. JAMA Network Open. 2019;2(5):e194303. doi:10.1001/jamanetworkopen.2019.4303
 Effectiveness of opioids on pain relief
➢ Studies have demonstrated that oral opioids do not provide superior pain
control compared with non-opioid analgesics for acute and chronic
pain12.

➢ Systematic reviews and randomized clinical trials of acute oral pain

found that patients who received acetaminophen combined with
ibuprofen reported pain relief similar or better to opioid and nonopioid
combination analgesic31,32.

25. JAMA Network Open. 2019;2(5):e194303. doi:10.1001/jamanetworkopen.2019.4303

Dr. Sonia Regina Bordin-Aykroyd DDS MSc
 Effectiveness of opioids on pain relief

25. JAMA Network Open. 2019;2(5):e194303. doi:10.1001/jamanetworkopen.2019.4303

Dr. Sonia Regina Bordin-Aykroyd DDS MSc
 2018 - HR6, Public Law 115-271 that mandates examination of current evidences
(clinical practice guidelines, insurance), further research and funding on alternative
pain treatments…………

Opioid Prescription:
CDC published a new guideline, providing recommendations for prescribing opioid pain medication:
“Prescription opioids are often used to treat chronic and acute pain and, when used appropriately, can be an
important component of treatment. However, serious risks are associated with their use, and it is essential to
carefully consider the risks of using prescription opioids alongside their benefits. These risks include
misuse, opioid use disorder (addiction), overdoses, and death”12.
“The FDA is committed to supporting the development of novel treatments, both drugs and devices,
that can be used to address opioid dependence or addiction, as well as new, non-addictive treatments
for pain that can serve as alternatives to opioids13.”

In April 2018 - scientific review Journal of the American Dental Association concluded that NSAIDs
alone or in combination with acetaminophen are generally more effective and are associated with
fewer side effects compared to opioids14.”
ADA Statement May 25, 2019: “To combat opioid abuse, the ADA has urged all 163,000 member dentists
to double down on their efforts to prevent opioids from harming patients and their families.” Dentists
should consider prescribing non-steroidal anti-inflammatory drugs (NSAIDs) alone or in combination
with acetaminophen over opioids as first-line therapy for acute pain management15.
https://www.nidcr.nih.gov/grants-funding/funding-priorities/future-research-initiatives/role-dentistry-
prevention-opioid-drug-misuse-abuse Dr. Sonia Regina Bordin-Aykroyd DDS MSc
 Conclusion
• Worldwide, opioid use varies greatly by country. The USA consumes most of the
global opioid supply despite representing only 4% of the world’s population28.

• Opioid prescriptions and opioid-related deaths in the USA is much greater than in
other countries24.

• Parallel strategies for the prevention of addiction, including non-pharmacological

alternatives have the potential to reduce postoperative pain and opioid consumption.

• Evidence-based literature supports the use of photobiomodulation and lasers in the

prevention and management of pain.

admin@aaofh.org
Dr. Sonia Regina Bordin-Aykroyd DDS MSc
 Dr. Sonia Regina Bordin-Aykroyd, De Montford University, UK

Reference
1. https://www.cdc.gov/drugoverdose/data/prescribing.html.
2. http://wonder.cdc.gov.
3. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/previous
Releases
4. https://www.gov.uk/government/statistics/substance-misuse-treatment-for-adults-statistics-2018-to-2019
5. https://www.cdc.gov/drugoverdose/data/prescribing/overdose-death-maps.html
6. https://www.cdc.gov/drugoverdose/prevention/index.html
7. https://www.texmed.org/Template.aspx?id=51222
8. https://www.cdc.gov/mmwr/volumes/66/wr/mm6626a4.htm
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15. https://www.ada.org/en/press-room/news-releases/2019-archives/may/ada-statement-on-new-study-in-the-journal-of-the-american-medical-association
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Special Report 2. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Published August 31, 2018.
17. www.cdc.gov/drugoverdose/prescribing/guideline.html
 Dr. Sonia Regina Bordin-Aykroyd, De Montford University, UK

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