Journal of Medicine - Dr. Bruce Lobitz, an attending physician in the emergency department at Upstate Carolina Medical Center in Gaffney, S.C., sees about 10 patients a week complaining of toothaches. “The bane of our existence,” he calls them.
It’s not just that doctors like him lack the training and tools to solve their dental problems. Many of these patients, he fears, complain of tooth pain simply as a ruse to get prescriptions for narcotics.
“Almost all dental patients request a prescription for narcotic pain pills,” Dr. Lobitz said. “ ‘I just need something to tide me over until I can see a dentist’ — that’s the classic line.” Sometimes, drug-seekers will show their cards: “They’ll say they’re allergic to everything except Vicodin.”
Dental patients — mostly uninsured or indigent — are not unusual in emergency rooms. Poor patients may forgo preventive care and delay treatment until they face a medical crisis. In many states, adult dental benefits under Medicaid, the government insurance program for the poor, have been scaled back or eliminated. And dentists often don’t accept Medicaid patients.
But emergency physicians like Dr. Lobitz cannot know whether someone who claims to be in agony from dental issues is telling the truth — or simply plans, he said, to “go to the next emergency room, next town over, and get another 30 Vicodin.”
Dr. Gail D’Onofrio, chairwoman of the emergency medicine department at Yale School of Medicine, has studied alcohol and drug abuse in emergency rooms. “The overuse of narcotics is a huge problem, and when a patient presents, especially for dental pain, it’s difficult to make an objective assessment,” she said. “It puts the physician in a difficult situation to assess whether or not someone truly needs pain medications. We err on the side of treating pain, and it is a huge potential for abuse.”
The frequent prescription of narcotics in emergency departments for dental pain has been quantified for the first time by research financed by the National Institutes of Health, bringing to light another way opioids get into circulation and contribute to the rampant abuse of painkillers in the United States.
From 1997 to 2007, painkillers were prescribed in three of four visits to the emergency department for dental complaints; roughly half of visits resulted in a prescription for antibiotics, according to a new analysis of the National Hospital Ambulatory Medical Care Survey by Dr. Christopher Okunseri, a practicing dentist and an associate professor of public health at the Marquette University School of Dentistry in Milwaukee.
Over that period, the number of painkiller prescriptions for dental patients in emergency departments rose 26 percent, and antibiotic prescriptions jumped 41 percent, according to the report, published online in January in the journal Medical Care.
“E.D. doctors don’t have the training or expertise to provide definitive care, so the easy way out for them is medication,” Dr. Okunseri said. “If you’re not careful, you’ll create more addicts.”
In interviews, many emergency department doctors acknowledged that they write plenty of prescriptions for opioids for patients complaining of dental pain, but they feel they face a conundrum. “I admit that some people get drugs out of me who shouldn’t get them,” said Dr. Tom Benzoni, an emergency physician who has worked for 18 years at Mercy Medical Center in Sioux City, Iowa.
Yet some patients are genuinely in pain. “Do I deny them drugs so that one person doesn’t get a little more Vicodin?” he said. “It’s emptying the ocean with a teacup to try to address our societal drug problem.”
Time pressures and heavy patient loads leave doctors with few choices. “If your goal is to get people out of the emergency room, it’s about stabilizing and shipping out,” said Dr. Nathaniel Katz, the director of the nonprofit Program on Opioid Risk Management at the Tufts Health Care Institute. “What’s the easiest way to get patients shipped out? Write them a prescription for Vicodin. How long does that take?”
Dr. Katz, a neurologist and pain specialist, added that emergency department doctors lack the tools, like dental X-ray machines, to determine whether, for example, a tooth’s nerve is infected, an excruciating problem that often requires root canal or extraction.
Relatively few emergency department workers are trained to give dental blocks, local anesthetic injections that offer immediate relief for 6 to 16 hours. In theory, the injections reduce the number of dental patients who leave the emergency room with potentially habit-forming narcotics.
Dr. Rita K. Cydulka, the vice chairwoman of the emergency medicine department at MetroHealth Medical Center in Cleveland, offers dental blocks, but she said that others in her specialty don’t want to take the time. “They find it easier to write a script for antibiotics and painkillers, and send people on their way,” she said.
Before writing a prescription, few emergency doctors use drug-monitoring programs to see whether patients have recently been given painkillers. Forty states have these programs and eight have enacted legislation to create them, said John Eadie, director of the Prescription Monitoring Program Center of Excellence at Brandeis University.
“Unfortunately many emergency physicians don’t realize the importance of a quick check of the database to see how many painkiller prescriptions a patient has filled lately,” he said.
During the first half of 2010, just one of 12 monitoring programs that reported to the Center for Excellence had 100 percent of prescribers registered to use their data. In the other states, the percentage of prescribers registered was only 9 percent to 39 percent, Mr. Eadie said.
Some doctors say the many pressures they face create other incentives to quickly prescribe remedies for patients complaining of severe pain. For example, doctors are often rated by their hospitals with patient-satisfaction surveys for how they treat pain.
“You can be faulted for not treating a patient’s pain — it’s considered the ‘fifth vital sign,’ ” said Dr. Abhi Mehrotra, the assistant director of the emergency medicine department at the University of North Carolina Hospitals. “We have to ask a patient’s pain, on a scale of 0 to 10, as well as document a reassessment of their pain after treatment.”
Dr. Benzoni, who is routinely rated on patient satisfaction and sometimes asked by management to explain a bad review, said that he feels at times as if he faces a no-win choice. “If you’re going to criticize me for not giving out narcotics, and you never praise me for correctly identifying a drug-seeker,” he said, “then I’m going to give out narcotics.”
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