R

ICHMOND, Va. — On an unseasonably warm Friday morning in October, Dr. Omar Abubaker paced in front of a small lecture hall at Virginia Commonwealth University’s dental school. The 64-year-old oral surgeon, whose sharp gray suit matched his wavy hair, quipped about his caffeine habit as he gave his third-year students a crash course on the recent history of addiction in America.

Then he took a more serious tone. Raise your hand, he said, if you’ve ever read scientific literature about addiction. The scores of scrub-clad students — white and black, mothers and fathers, former nurses and future surgeons — silently looked around the lecture hall. No one raised a hand.

“Everything you know about addiction is actually from TV, right?” Abubaker said. “Newspaper, Facebook … YouTube?” A student chuckled — a tacit acknowledgment that what she heard rang true. “There’s a disease out there that you’ll deal with that’s more likely than hypertension,” he continued. “You have no knowledge about [it].”

Four years ago, the chair of VCU’s School of Dentistry was nearly as clueless as his students about the nature of addiction. For more than two decades, he had paid little mind to his own prescribing patterns and, like many in his field, did little to train his students about exposing patients to addictive painkillers. He did so despite the fact that dentists prescribe opioids at a rate higher than nearly every other specialty, responsible for writing 1 out of every 8 prescriptions for immediate-release opioids nationwide. Prescription opioids, in turn, are widely considered the root of a national opioid crisis that’s caused more than 300,000 deaths since 2000.

On Oct. 2, 2014, however, that crisis hit home. His 21-year-old son, Adam, died after overdosing on a mixture of drugs including heroin — a path that Abubaker suspects started after a surgeon prescribed his son opioids after a shoulder procedure. “I had been consumed with keeping him alive without attempting to know more about addiction,” Abubaker recalled. Grief drove him on a search for answers, ultimately making him “more and more aware of how naïve” he was about substance use disorders.

As he grew more knowledgeable, Abubaker not only scaled back the number of pills he prescribed to patients, but also reconfigured VCU’s curriculum to include a frank discussion of how addiction can be prevented, how to spot it, and how to direct patients to treatment. Now he’s fighting to get dental schools nationwide to incorporate similar lessons into their curricula in hopes that the next generation of dentists can do better than his own.

“We got it all wrong,” he said. “It’s difficult to change patterns and behaviors of people who practice for five or 10 years. But I’m optimistic we will graduate a generation of dentists way ahead of where we are today.”

T

he Tuesday after Thanksgiving 2013, Abubaker’s three grown children made a surprise visit to his house. They asked if he could talk about a problem involving his youngest son.

“What’s the problem?” Abubaker asked.

“Adam’s using drugs,” one of them said.

“What kind?”

“Heroin.”

Abubaker was floored. The oral surgeon never expected Adam — a straight-laced volunteer firefighter who acted years beyond his age — was at risk of becoming addicted to drugs. A native of Libya, Abubaker had never used drugs because of his Islamic faith, and didn’t drink alcohol until around the age of 40.

Omar Abubaker
Abubaker with his son Adam, in their last photo together before Adam’s death.

“In my culture, touching alcohol is a sin, it’s seen as a weakness,” he said. “How do I come through Facebook to explain [Adam’s substance use disorder] to my family? They might see it at home, as reflecting poorly on me.”

Adam entered treatment, with his father’s support, and stayed off drugs for most of 2014, later enrolling in courses to become a certified emergency medical technician. But on the morning of Sept. 27, Abubaker received the call no parent wants to get. Adam was on life support after overdosing on a combination of heroin and benzodiazepine. Abubaker spent day and night at the hospital until Adam died the following week.

In the months that followed, Abubaker retraced the warning signs and second-guessed his parenting choices. He cried in the quiet of his home whenever CNN aired an opioid segment. He turned to a grief therapist to make sense of it all. But it was his wife who found his saving grace: a postgraduate degree program in addiction studies.

The courses were revelatory. He learned how drugs altered the brain, and how dependency can lead to substance use disorder. And he thought back on all the prescriptions for Percocet he’d written over the years, after extracting teeth or performing corrective jaw surgeries.

“I started looking at my pattern of prescriptions first, then my colleagues, then my residents,” he said. “[And I remember] how I used to [think] people deserved as many pain meds as they wanted. My God.”

Newsletters

Sign up for our Daily Recap newsletter

Please enter a valid email address.

Since completing his addiction studies program last year, Abubaker has spoken to hundreds of dentists at conferences and smaller professional association meetings. He’s also conducted research on whether prescribers’ knowledge of addiction impacts the size of their prescriptions. And he’s retooled VCU’s four-year curriculum to focus more heavily on addiction.

Today, Abubaker teaches second-year students about nerve damage, the expected duration of pain, and non-narcotic pain relievers — far beyond past courses’ simple focus on “what you give and how many,” he said. Third-year students learn to understand addiction, identify potential signs in their patients, and make addiction treatment referrals. Opioids can be effective for some patients, Abubaker stresses to students, but should be used with the utmost caution. And sometimes, if the tenor of the classroom feels right, Abubaker will share the story of his son, to underscore just how much is at stake.

Omar Abubaker
Abubaker sees patients at the clinic at VCU. Julia Rendleman for STAT

A

bubaker has grown into a zealous advocate against overprescribing at the same time as his field has reckoned with the subject.

For instance, after only modest declines in opioid prescribing between 2007 and 2012, dentists and oral surgeons in New York have scaled back their use of opioid painkillers in part due to policies like prescription drug monitoring programs, studies found.

And universities are increasingly pressing those lessons upon students. In Massachusetts, Ronald Kulich, a professor at Tufts University School of Dental Medicine, and Dr. David Keith, an oral surgeon at Massachusetts General Hospital who teaches at Harvard, have helped insert lessons on skills like preventing opioid misuse or providing referrals to patients struggling with substance use disorder. In other states like Illinois and Minnesota, dental schools are testing out different ways to educate students on opioids.

Historically, the risks of treating pain have been “minimally covered,” said Kulich. “It’s starting to change in dentistry, as it is in medicine, from being covered minimally in the curriculum.”

“It’s difficult to change patterns and behaviors of people who practice for five or 10 years. But I’m optimistic we will graduate a generation of dentists way ahead of where we are today.”

Dr. Omar Abubaker

There’s some movement on a national level as well. In August 2017, the Commission on Dental Accreditation, the body responsible for dental education curriculum standards, ruled that it would immediately require dental school graduates to be competent in considering “the impact of prescribing practices and substance use disorder” on their patients. Later that month, Abubaker, Kulich, and a handful of other dental school professors met with the Substance Abuse and Mental Health Services Administration officials to figure out how best to manage pain without unnecessarily exposing patients to opioids — and how to potentially implement this education in dental school classrooms nationwide.

But there’s a long way to go. A study published last year in Substance Abuse found that fewer than half of dentists conducted screenings for substance abuse or relied on prescription drug monitoring programs. And a national survey of dentists published in Addiction in 2015 found that two-thirds said screening patients for substance use shouldn’t be part of their job.

“The public is moving fast in changing their mindset,” Abubaker said. “It’s practitioners that are dragging behind.”

Omar Abubaker
Abubaker checks patient John Strickland’s teeth a couple of weeks after his oral surgery. Julia Rendleman for STAT

A

fter his Friday morning lecture, Abubaker strolls over to the VCU School of Dentistry’s clinic. In addition to teaching, he still sees patients at least twice a week — meaning he has had plenty of opportunity to put his new prescribing philosophy into practice.

He pops in and out of exam rooms wearing his blue gown and mask. In one room he greets 21-year-old college student John Strickland, whose cheeks are still swollen two weeks after his corrective jaw surgery. “How was the pain?” Abubaker asked.

“It’s good,” said Strickland, who is taking liquid ibuprofen twice a day after finishing a small number of opioids, back when his pain was more severe. Before the surgery, Abubaker discussed with Strickland what sort of pain he might feel and why he’ll limit his opioid prescription. “I didn’t need more,” Strickland said.

A little later in the day Abubaker examines Jeyda Tolliver, a 15-year-old high school student whose underbite limits her ability to chew food and causes her jaw to pop frequently. She’s nervous — her feet fidget at first — because she’d heard from her orthodontist that surgery would require “breaking” her jaw for the purposes of repositioning it. Don’t worry, Abubaker said. He assures the procedure known as an orthognathic surgery — requiring one-millimeter incisions to her jaw followed by the insertion of titanium plates and screws — won’t be that painful.

Dental resident Bryan Wheeler sits in the exam room and observes the conversation. Abubaker likes to have students stay in the room so that they can learn from the way he establishes patients’ expectations about pain management.

“We don’t give as much medication,” Abubaker told Tolliver. “You’ve probably heard about people having problems …”

“Yes,” Tolliver said. “The opioids …”

Abubaker urges her to try a non-narcotic painkiller after her surgery first. If it doesn’t work, he’d write her a prescription for around five opioid pills, noting that some of his patients only take one or two to avoid the risks. She won’t suffer, he assured her. He wants her to stay safe.

“People from all walks of life — blacks and whites, yellow and brown like me — have had problems” with opioids, he explained. “It has nothing to do with where you live, or where you came from. You could be the president. You could be the son of a doctor.”

Leave a Comment

Please enter your name.
Please enter a comment.

  • I lost my son also to substance use disorder. I work in a dental office and opioids are prescribed after a procedure “just in case”. It’s so necessary to teach medical & dental students about addiction and it’s not a moral issue. It can happen to ANYONE!!

  • I wonder why they aren’t doing more with medical marijuana to treat pain? It’s not addictive, never an overdose from it. Is it just that big Pharma has the market cornered?

  • For JLN: I do not wish to be rude with you, but you clearly haven’t checked your facts. Heroin is cheaper on the street than stolen prescription drugs. Likewise my source for the statistic on origins of addiction in teens is from a senior MD who spoke before the Presidents’ Commission on Combating Addiction and the Opioid Crisis, in June of this year. Teens don’t commonly get treated for chronic pain. Articles recently published in the New England Journal of Medicine report that addiction is uncommon among opined-niave patients treated on short durations.

    Finally, I’m not a medical doctor and I don’t prescribe. I’m a technically trained patient advocate and healthcare writer who communicates with thousands of pain patients in ~50 Facebook groups, every week. So I see “the other side of the opioid crisis” from up close among people who are living the experience. I am also careful to make clear the limitations of my background when patients come to me with their stories of agony imposed on them by their doctors who will no longer prescribe, no matter how severe or intractable the pain is.

    What is your background, if I may ask — and what circumstances put you in touch with large numbers of addicts?

  • My sincere condolences to Dr Abubaker on the loss of his son. Thank God someone is finally taking a leadership role with the dentists. Oral surgeons gave both my teenaged college student 30 days of Vicodin when they had their wisdom teeth pulled 10 years and 12 years ago. One of them, despite the pain, didn’t take even take one pill; the other thought he was supposed to take a Vicodin every time he took the prescribed antibiotic, ended up completing the whole prescription and went on to a 10-year problem with opioids that derailed his college education and could have cost him his life.
    I continue to be amazed at how nurses, physicians and dentists can go to school to learn about how to administer drugs, without knowing the potency and potential for addiction that prescription opioids have.
    It would seem that by now every nursing, medical and dental school should have a strong curricular component on the analgesic drugs that cause addiction, and the brain science of addiction.
    It is just adding to the tragedy of addiction to do anything less.
    If every one of us could check with our own almae matres and be sure the curricula have been adapted to reflect this crucial information, we can help direct the future of the education of healthcare professionals and start saving more lives.

    • In fairness, I find the statement “it’s always the person and never the drug that is at fault” to be too simplistic. We know that 90% of addicts begin abusing drugs and alcohol in their teens. This is a phase of life when the adolescent brain is still forming — and one in which young people are much more vulnerable to suggestion, rebellion, and risk taking that people in their 20s and older have begun to recognize as involving unacceptable risks.

      It might not be going too far to suggest that many teens operate with a kind of diminished mental capacity which their adults are morally obligated to help them survive if they are to grow up and become competent. Of course, some adults are also without a clue (there is no universal rule in human behavior). But given all of that, we can’t make sweeping statements about “bad choices” being the only root of this catastrophe. Adult disengagement from guiding teens almost certainly also plays a serious role when they mess up their lives. Most of us live in two-earner urban families, with all of the distractions and time competition that involves. So we all have some degree of responsibility for the addiction crisis. And we must all become involved if that crisis is to have solutions.

  • We seem to be seeing a pendulum in the practice of pain relief, both dental and medical. From a situation of perhaps over-prescribing opioids, the pendulum has swung much too far in the opposite direction. Now patients are being deserted by doctors who are afraid of being persecuted by the DEA and losing their license if they meet the real needs of people in agony.

    While there is some truth in this article, there are also profound misconceptions.

    It is true that dentists are likely to be the first medical professionals that a teenager will see, who will prescribe opioids for pain. However it is grossly untrue that the great majority of patients treated for a few days with an opioid for dental pain are at any serious risk of opioid abuse disorder. The exception to this observation may be that a small percentage of the population seems to be genetically disposed toward addiction on short exposure. I’ve heard numbers around 2%., which is consistent with a 2010 Cochrane Review on effectiveness and risks of opioid pain relievers. The Review found that less than 0.5% of patients prescribed opioids for the first time for a medical disorder were diagnosed with opioid abuse disorder within one year.

    Another truth that is largely being ignored is from the National Institutes On Drug Abuse: 90% of all addicts first begin abusing drugs and alcohol in their teens. But only a small percentage of teens will see a doctor for pain severe enough to warrant prescription of opioid pain relief for more than a few days. Thus we can say with confidence that the teen who becomes addicted after treatment for chronic pain is not a representative sample — and drug control policy should not be founded on this non-representative group.

    In reality, the author’s son didn’t get heroin from a doctor or dentist. He got it on the street — the same place where most addicts get pain pills that have been stolen from home medicine closets or diverted from pharmacies and dispensaries. According to the stats of the CDC itself, opioid-related deaths are now dominated by drugs that nobody can get from a doctor or dentist: heroin, synthetic fentanyl, morphine stolen from hospitals, and methadone diverted from community treatment programs. Drugs commonly used in prescriptions place a distant fifth in this statistic. And the great majority of addicts who use prescription drugs don’t have a prescription for them.

    One more reality of the opioid crisis should also be mentioned. We know that the most effective means of harm reduction for people who are already addicted is drug replacement therapy with Methadone or perhaps Suboxone. In established addicts, 30-day detox and Narcotics Anonymous don’t work without intensive follow-on programs of community reintegration and therapy. Both have horrendous relapse rates. And community reintegration means placing addicts in safe housing, training them for jobs that they must have to live independently, and helping them get sober again when they relapse, which many will. Prison flat out doesn’t work AT ALL as a deterent to addiction or relapse, as demonstrated by a Pew Charitable Trust major study released this July.

    If we are ever to see a reduction in the carnage of addiction, then we must begin educating our kids as young as Middle School, and reducing the incentives for addicts to become pushers in order to feed their habit. Addiction is a real public health crisis. But restricting pain treatment won’t solve it. Since 2010, prescription rates of opioids have dropped steadily while drug-related deaths have continued to climb. Pill counting or coerced reduction of analgesic therapy in people who have long been stable and well managed on high doses of opioids don’t work. Such measures only add more victims to the butcher’s bill.

    • Methadone and suboxone “therapy” just replace one opiate with another. There is a reason that addicts refer to methadone as “liquid handcuffs”.

      Your statement that “In reality, the [doctor’s] son didn’t get heroin from a doctor or dentist” shows the depths of your rationalization and your refusal to accept responsibility for your part in this epidemic.

      Your statement is literally correct — he didn’t get the heroin from a doctor or dentist. Instead, he got prescription opiates from a doctor or dentist and became addicted to opiates. At that point, he needed opiates just to stave off withdrawal. Most likely, he then purchased prescription opiates from a drug dealer. But prescription opiates are a lot more expensive than heroin. Most likely, he told himself he would never do heroin. But once his money ran low, he rationalized his way into snorting heroin, telling himself he would never inject it. A few weeks later, he likely had a needle in his arm. Did he get the heroin from a doctor or dentist? No, but he got his addiction from the prescription opiates prescribed by that doctor or dentist.

      So stop the rationalization and accept the fact that most likely some of your patients became addicted to the medications that you prescribed, and then went down the path of addiction to their deaths.

      There is no easy solution to reducing the chance of addiction while managing patients’ pain. But until dentists and physicians like yourself accept that they have been part of the problem and are willing to help work towards a solution, we will continue to have an enormous amount of addiction and many more people are going to die. And the solution isn’t “continue to prescribe as in the past and then put anyone who gets addicted on suboxone or methadone.”

      I’ve spoken to many addicts and most all have followed this path of starting with pain medication that was prescribed to them. I’ve also spoken to addicts on suboxone and methadone. None of the ones that I’ve known who took that path for any length of time ever got off opiates and most ended up back on heroin. Prescribing suboxone and methadone sure is a good way to keep one’s waiting room full, however.

      And more than a few addicts abuse suboxone.

    • I am a recovering addict, clean for ten years. One of the main reason I was able to get clean, was first my time using Methadone, and second my time using Suboxone. MAT is the treatment showing the best result by far and as a country we need to move beyond 12 Step programs that have shown to be ineffective in helping heroin addicts stay clean. The reason Methadone is referred to as “liquid handcuffs” is because you need to go and take your dose everyday, It was a huge pain, but it taught me to be proactive in my recovery, I had to find my way there and back.

      To the point where addicts get pills on the street. I started using pills that people got legally prescribed to them and didn’t finish. Isn’t that the exact type of over medicating the article speaks of?

      Addicts misuse all drugs that is what makes them an addict, I came off heroin and started using Cocaine, not because I liked it, but because I was an addict and couldn’t stop.

  • Millions of people have taken “opioids,” prescription pain medication such as Percocet and Vicodin, for three of four days after surgery for pain, and they didn’t get addicted and they didn’t bounce to heroin and they didn’t die. The drugs are perfectly safe if taken sensibly.

    My sympathies to the doctor and his late son, but his son was a heroin addict. He was not killed by “opioids,” he was killed by overdosing on heroin.

    Soon, when it’s all but impossible to get pain medication, all so the DEA can get drugs out of circulation so addicts can’t get to them, the people who support the “opioid” panic now may one day experience sever pain and wish they had thought this through.

  • Omg only 5 pills after surgery. What a terrible dentist! I wouldn’t let him clean my dogs teeth. Oral pain is some of the worst to experience

  • I recently had a root canal, and the endodontist gave me an RX for 12 Vicodin- I didn’t even need one. Tomorrow when I go back I will be asking him if this is really a 12 Vicodin event for his patients, and as a nurse and pt known to him will be expressing my concerns.

    • My dentist completely ignored my anxiety during a root canal, when an Ativan would have been super-useful. Then he gave me 30 Vicodins after for pain! I needed one, for that evening.

      It was ridiculous and showed how little he really understood pain. Kudos to this guy for trying to understand what patients really need.

    • Well then why not refuse it, and give the script back, thats what you could have done, obviously you did not want or think you needed it.

Sign up for our Morning Rounds newsletter

Your daily dose of news in health and medicine.