HYANNIS, Mass. — It was an unsavory bargain: Nelson Wood, a dentist, would write opioid prescriptions for patients who agreed to give him some of the pills to feed his own addiction.
The prescribing came to an abrupt end when Wood was arrested during a drug deal with one of those patients: in the parking lot of a Gold’s Gym.
That was nearly a decade ago in Western Massachusetts, and since then Wood has entered treatment, regained his dental license, and worked diligently to remove any temptations that could lead to a relapse — and almost certainly end his career. He’s gone so far as to ask the government to not grant him the authority to write prescriptions for powerful opioids such as Percocet, Vicodin, and OxyContin that are classified as having “a high potential for abuse.”
Yet Wood’s attempt to do the right thing — for himself but also, he believes, for his patients — has collided with an unnerving reality: Opioids are ingrained in the culture of dentistry, and his decision has been bad for business.
Wood’s story is a case study of the pressures dentists face to prescribe potent pain pills, even as research shows most of their patients would do just fine with over-the-counter medications such as ibuprofen. Many patients have come to expect strong narcotics after having a tooth removed or undergoing a root canal.
The pressures go well beyond anxious patients: A major insurance company was hesitant to add Wood to its network because of his limited prescribing license.
“It’s almost like they’re telling me to prescribe opiates,” Wood told STAT. “Drugs are ruining this country and they want me to add to it. And I’ve basically said, ‘No, I won’t do it. You know, I will not do it.’”
Dentists have become a significant source of opioid prescribing — especially for younger patients undergoing wisdom teeth extractions. They prescribe about 8 percent of the opioids in this country, according to government researchers, but are the top prescribers of these drugs to adolescents, accounting for 31 percent of all opioids given to patients aged 10 to 19 years old. That’s particularly concerning because that age group is among the most likely to abuse drugs and develop addictions.
“Most patients get along just fine without opioids,” said Dr. Paul Moore, a dentist and a professor of pharmacology at the University of Pittsburgh. “We’ve found that a combination of Advil and Tylenol provide a lot of relief. It’s pretty remarkable with that combination.”
He said prescription painkillers such as Percocet and Vicodin are not very effective at treating acute dental pain and often come with side effects such as nausea, to say nothing of the risk of addiction.
Moore said there is growing support to reduce opioid prescribing in dentistry. He said he knows two dentists who have decided to operate without any kind of Drug Enforcement Administration prescribing license, essentially deciding they could practice without the ability to offer patients prescription painkillers. The rate of opioid prescribing by dentists declined a modest 6 percent from 2007 to 2012. And in October, the American Dental Association issued a statement on the use of opioids that recommends dentists consider over-the-counter pain relievers such as Motrin and Advil as “first-line therapy for acute pain management.”
Yet as the case of Wood shows, the pain treatment paradigm in dentistry likely won’t change quickly.
30 tablets for a tooth extraction
In 2014, when the DEA moved to tighten restrictions on the prescribing of opioids like Vicodin, the leading dental societies banded together in an unsuccessful challenge to the proposal. Six groups representing dentists and oral surgeons, including the American Dental Association, argued that the stricter rules would make it harder for patients to get needed pain relief.
“It is the inertia of the provider,” said Dr. David Keith, an oral surgeon at Massachusetts General Hospital who co-chaired a group that recommended additional training on opioid misuse for dental students in Massachusetts. “It does take a little bit to change the Titanic’s direction here.”
Many dentists prescribe “very, very large amounts” of opioids — far in excess of what would be expected for patients following a tooth extraction, said Dr. Brian Bateman, associate professor of anaesthesia at Brigham and Women’s Hospital and Harvard Medical School who studied the use of opioids following tooth extractions. In many cases, dentists prescribe 20 to 30 tablets of a narcotic painkiller, when a patient in all likelihood will only require a handful of pills before any pain subsides.
Bateman said that was troubling because many of those patients likely have leftover medication that could be abused. Keith estimates as many as 30 million prescription pain pills given to dental patients each year fall into this category.
Opioid prescribing is so prevalent in the profession that magazines for dentists carry advertisements promoting drugs that treat opioid-produced nausea and vomiting, Keith said.
The persistent belief in dentistry that drugs such as Vicodin are more effective than over-the-counter medications — despite evidence to the contrary — is reinforced by outside pressures. Some insurers and hospital systems take into account complaints from patients upset they were not prescribed an opioid when reviewing the work of dentists. Angry patients not prescribed an opioid also take to social media, potentially damaging a practice’s reputation by making claims the dentist doesn’t care about the pain of patients.
Moore said after a lecture he gave in Montana, an oral surgeon approached him to say he knew many of his patients didn’t need Vicodin, but he prescribed the drug anyway.
“He said I have looked at the numbers and you are absolutely right,” Moore said. “But he said he was one of only three oral surgeons in his area and if he got a reputation for not prescribing Vicodin he would be out of business.”
In a precarious position
Now 62, Wood moves slowly around his office in a converted house near Hyannis Harbor. He is a solo practitioner working six days a week in a physically demanding job. Years of alcohol and drug abuse have taken a toll. His back and knees hurt. He suffers from osteoarthritis. He fits in frequent cigarette breaks and then sprays himself with a little cologne to mask the tobacco smell from patients.
Asked whether he has thought about using opioids to get relief from his pain, he answers quickly: “It’s very tempting.”
It’s a precarious position. Wood’s struggle with addiction has cost him financially and personally. His dental license was suspended and he lost his house. He was arrested several times, and a girlfriend died of an overdose.
Growing up in the Boston suburb of Brookline, Wood was around age 13 when he began experimenting with drugs, and eventually alcohol. His parents had survived the Auschwitz concentration camp, he said, and his father, who owned a construction business, was emotionally distant and an alcoholic. Other family members also battled addiction.
When Wood was 20, he was arrested as part of a DEA cocaine investigation. He avoided jail by entering a treatment program. It was the beginning of a cycle of drug and alcohol abuse, followed by periods of sobriety that ended with several relapses.
After earning a dental degree at the University of Pennsylvania, he joined a prestigious dental practice in Boston. But in 1992, State Police investigated Wood for inappropriately writing prescriptions for Percocet, Valium, and Xanax, according to an investigative report. The state board of dentistry placed him on probation for five years.
By 1999, he was out of dentistry and in a treatment facility in Mississippi, following an overdose. The best job he could find was working as a cashier at a supermarket for $7.20 an hour. Several months later, he started cleaning the teeth of dogs as part of a research project at the University of Mississippi. The pay was $50 per dog.
Wood returned to Massachusetts in 2006 to open an office for a national denture company. He said he soon relapsed again, after undergoing back surgery and receiving painkillers. In 2007, he was arrested following an alleged drug deal in the parking lot of a Gold’s Gym. Wood allegedly had an arrangement with two patients — a husband and a wife — where he would write them prescriptions for Vicodin and Percocet in exchange for the couple providing him with some of the pills in return.
He entered the Massachusetts Professional Recovery System, a treatment program for medical professionals dealing with substance abuse issues. He credits the program with saving his life. Wood said he does well when he is being closely monitored — be it by the DEA, the board of dentistry, or a treatment program. He said he has been sober since 2008.
In 2011, he saw an advertisement for a dental practice for sale on Cape Cod. Wood jumped on the opportunity, borrowing money from his brother to make a down payment. Later, when two DEA agents visited his office to tell him he was cleared to get a full prescribing license, Wood told them he wanted only a limited license, to avoid any temptations if he had the ability to prescribe Vicodin or Percocet. He can still prescribe milder narcotics, with less potential for abuse.
Wood said his past drug use and his refusal to prescribe highly addictive opioids has caused problems for him with insurance companies. Blue Cross Blue Shield of Massachusetts approved him as a member of its network, but only after an extended review, Wood said. He said the doctor who reviewed his case said the insurer usually does not credential dentists who do not have a full DEA license. To assuage concerns of insurers, Wood said he arranged for an emergency room doctor at a local hospital to prescribe more powerful opioids to his patients who may need them.
Blue Cross declined to discuss the case of Wood. In general, the insurer said it credentials dentists on a case-by-case basis and that one of many factors it considers is what kind of license the dentist has from the DEA.
The Guardian Life Insurance Company of America last month notified Wood it would not allow him in its network because of his “history of license sanctions.”
Wood said most of his patients are insured by Medicaid, the government insurer for the poor, or pay cash. About a quarter are covered by a handful of private insurers that have included Wood in their network.
Beach towns awash in opioids
Wood has another reason for limiting his prescribing license: He doesn’t want to be a target.
Cape Cod may be best known for its beaches and as the summer home of the Kennedy family, but it is also awash in illicit opioids. Massachusetts has the seventh highest rate of overdose deaths in the country — and within the state, the Cape Cod region experiences overdoses at a rate that exceeds urban areas like Boston.
Last month, police here broke up a fentanyl ring that allegedly operated out of a multi-million-dollar home owned by the Shriver family. Eunice Shriver was the sister of President John F. Kennedy. Police said the family was unaware of the drug dealing and the property’s caretaker was arrested for allegedly allowing dealers to use the sprawling home.
It didn’t take long for opioid addicts to find Wood. One of his first patients was a young man complaining of tooth pain. Wood told him the tooth needed to be pulled, but the patient said he didn’t want the tooth removed; he just wanted oxycodone for the pain. That is an opioid Wood can’t prescribe, and he told the patient he didn’t need it.
Wood said he then noticed the man signaling someone outside. He went around back where he caught the man’s girlfriend trying to break into the rear of his office, presumably in search of opioids.
After that incident, Wood hung a sign in his reception area: “This office DOES NOT prescribe nor have narcotic medication on the premises.”
Another time, a mother dropped her daughter off for a procedure and Wood wrote a prescription for a mild pain reliever when he was done. After the young woman left, the mother stormed into the office to demand Wood write a prescription for something stronger. It was clear, he said, the mother wanted the more powerful drugs for herself.
One patient offered him sex in exchange for an opioid prescription, he said. Another changed a prescription for four Valium to 24.
In the past year, three doctors practicing within two miles of Wood’s office gave up their medical license or had it taken away for charges related to illegal prescribing of opioids. The incidents are proof to Wood he is doing the right thing.
“I don’t want the hamster running around in my head when I’m in pain, trying to get pain relief using my own license,” he said.
After starting out with just a few dozen patients, Wood has several hundred regular patients today. He said many of them know of his past. Some have talked to him about their own struggle with addiction or that of family members. Several patients have died of overdoses. It’s a constant reminder of what is at stake if he uses drugs again: His dental license, his practice, and his ongoing redemption would be gone.
“If I don’t stay sober, I’m going to lose everything,” he said. “But I’ll stay clean and sober. I’ve been there before. I lost everything twice.”