Case 4

Initial Presentation: A 52-year-old male presents for emergent care on a Friday at noon prior to a long weekend. He states that he is in town visiting his family and he has an established dentist where he lives. He states that he developed excruciating pain on the upper right quadrant during the previous night that prevented him from sleeping and that he is scheduled for a root canal when he returns home next week. Examination reveals a grossly carious #3 with a buccal cusp fracture. He asks for antibiotics and pain medication to “get him through the weekend” so that he can return home and receive care in his dentist’s office. Upon querying the PDMP, it is noted that he has had 58 prescriptions for opioids in the past year written by 46 providers, including 16 emergency room physicians and 20 dentists in 3 states. The prescriptions were filled at 18 pharmacies in all 3 states.

Action Plan: This is potentially an instance of doctor/pharmacy shopping and taking advantage of dental practice vulnerabilities, including the likelihood of Friday closure and the limited communication between dental practices and across state lines. In many states, patients have the responsibility of informing their healthcare providers if they are receiving care, including being prescribed medication, by other healthcare providers. The patient should be asked about symptoms and verification with his dentist that he is an established patient with the treatment plan that he described. Prescribers can refuse to write a prescription if they feel that the patient is not being truthful.

Conclusion: The dentist was unable to be contacted while the patient was present. This patient refused to stay and receive treatment and no prescription was given. Upon follow up after the holiday, no patient of record with the name provided had been seen in the dentist office described. This type of behavior was recounted in a recent National Public Radio broadcast where two individuals in recovery for opioid treatment described seeking consultation for broken teeth and received opioid prescriptions without follow-up.¹⁰⁶