Fall 2017

Three Questions for Robert Johnson III, D18

When your patient is being treated for opioid addiction.

Genevieve Rajewski

Many dentists are familiar with methadone, which has been a first-line treatment for opioid addiction and physical dependence since 1949. However, a newer drug called Suboxone is growing in popularity as a way to help people curb cravings and stay sober as they address the behavioral aspects of opioid addiction. Suboxone is both less likely to be abused and safer than methadone. Robert Johnson III, D18, recently wrote an article for the Journal of the Massachusetts Dental Society, with the assistance of Morton Rosenberg, D74, professor emeritus at the School of Dental Medicine, outlining what every dentist should know about Suboxone. Tufts Dental Medicine spoke with Johnson about how dentists can best care for patients who are using this medication-assisted treatment.

How should dentists handle pain relief in patients undergoing treatment for addiction?

This is tricky in patients being treated with either Suboxone or methadone. The goal is to limit pain without triggering a relapse. Prescribing opioids should be avoided, if possible, for obvious reasons. But undertreating pain through overly conservative pain-management plans also can put patients at risk of relapse, due to the stress and anxiety that pain causes. A combination of analgesic agents such as NSAIDS (nonsteroidal anti-inflammatory drugs), acetaminophen and long-acting local anesthetics can help keep patients ahead of the pain. Alternatively, dentists can direct the prescribing physician or addiction clinic to alter the doses of Suboxone, which has some pain-relieving effects of its own. Regardless of the ultimate pain-management plan, a dentist should stay in close communication with the patient’s Suboxone prescriber.

Are there any other oral health or medication concerns for patients taking Suboxone?

As with any medication, it’s important to minimize any possible drug-drug interactions or side effects. As Suboxone is metabolized by the liver, and it is a depressant, some drugs commonly used in dentistry—such as benzodiazepine, fluconazole and clarithromycin—should be avoided. In addition, Suboxone is dissolved under the tongue, so a moist mouth is necessary for proper absorption. Dentists should ensure that the patient is not taking any other medications that decrease saliva and also keep an eye out for tongue pain and swelling.

Are patients upfront about being in treatment for opiod addiction? How can dentists start a conversation about that?

Many patients are embarrassed about their addiction and therefore hesitant to volunteer that information. So it’s critical that dentists include questions and opportunities in their health-screening exams that encourage patients to share if they’ve ever had—or have—an opioid addiction. People who show signs of drug-seeking behavior and other patients who need to get into treatment are beyond the scope of my article’s recommendations. But it’s safe to say that having referrals on hand is helpful. Primary care physicians must go through specialized Suboxone training, so it benefits patients if dentists can point to specific doctors who practice this opioid-maintenance therapy.

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