Episode Description

In the latest podcast episode featuring Dr. William Claytor, the discussion centers on the opioid crisis, specifically its historical context, alarming addiction rates, and the impact of prescription practices. Dr. Claytor highlights the tragic peak of overdose deaths reaching 112,000 in May 2023 and the recent 25% decline in North Carolina. The episode delves into the transition from prescription opioids to dangerous street drugs like fentanyl, emphasizing the risks faced by adolescents who are given opioids for dental procedures, often leading to long-term use. Alternatives to opioids, such as NSAIDs and acetaminophen for pain management, are recommended, along with improved patient communication strategies. The conversation also touches on the mental health challenges faced by dentists, with a significant number considering leaving the profession due to stress, underscoring the need for better support and education in dental practices.

Episode Navigation

  • 00:33 – Historical context of the opioid crisis
  • 02:23 – Current statistics on overdose deaths
  • 03:54 – Transition from prescription to street drugs
  • 07:22 – Dental prescribing patterns and changes
  • 13:52 – Adolescent susceptibility to addiction
  • 21:00 – Alternative pain management solutions
  • 29:34 – Pre-procedural anxiety management
  • 38:18 – Dental professional stress and substance abuse

Key Takeaways

Understanding the Crisis

  • Opioid overdose deaths peaked at 112,000 in May 2023
  • Dental prescriptions have decreased from 18% to 4-6% of total opioid prescriptions
  • First exposure to opioids often occurs during dental procedures

Alternative Pain Management

  • NSAIDs and acetaminophen combinations prove equally or more effective than opioids
  • Long-acting anesthetics provide extended post-operative pain control
  • Patient preparation and communication are crucial for successful pain management

Featured Guest

Dr. William Claytor: Director of the North Carolina Dental Opioid Course with extensive experience in dental practice and addiction prevention. Leading expert in developing protocols for responsible pain management in dentistry.

Featured Discussion Topics

  • Evolution of opioid prescribing practices
  • Adolescent vulnerability to addiction
  • Alternative pain management strategies
  • Patient communication and preparation
  • Professional stress management
  • Pre-operative anxiety management

Connect With Simplify Dentistry

  • Website: simplifydds.com
  • Facebook: Simplify Dentistry Community

Topics: dental opioids, pain management, addiction prevention, dental prescribing, patient care, dental anxiety, practice management, dental education, professional wellbeing, dental procedures

Transcript

00:13
Dr. Richard Offutt
Welcome to the Simplify Dentistry Podcast. I’m Richard Offutt and I’m joined by Dr. Murtuza Shah-Khan. Our guest today is Dr. William Claytor. Dr. Claytor has been a dentist in North Carolina for many years and is currently the director of the North Carolina Dental Opioid Course. We are thrilled to have him join us today. Welcome, Bill.

00:33
Dr. William Claytor
Thank you.

00:35
Dr. Murtuza Shah-Khan
Thanks for joining us.

00:36
Dr. Richard Offutt
We appreciate your coming and joining us today. And just to kind of start off the top, talk to us about the scale and scope of the problem we’re facing with opioids.

00:46
Dr. William Claytor
Back in 1980, when doctors made the comment that less than 1% of people had adverse reactions or had a problem with opioids if they had no history of addiction. In fact, it was a 11 line editorial in the New England Journal of Medicine where they made this statement and it became the new mantra because of the 12,000 or so patients they treated or observed in the study, they found that only about 5 developed in addictions. And then by 1996, the American Pain Society identified pain as the fifth vital sign. And I can remember back early in practice when I got into dental practice, hearing these advertisements on TV and, you know, magazines about, we have Americans in pain. We ought to be giving them these opioids that are safe to take. Let’s get Americans out of pain.

01:40
Dr. William Claytor
And consequently, the turn of the century came and here we are in 2000. And then from 2000 to 2010, it kind of took off. We had a, just, you know, kind of crested the wave of the number of prescriptions being written somewhere between 2010 and 2013. And then due to what they called advertising abuse, deterrence, we saw a decrease in the amount of prescribing. And it went down almost from 2 or 300 million prescriptions in the US down to maybe like in 2020. I think we’re down to something like 142 million prescriptions written each year. The numbers have gone down. The physicians and dentists have done their part. Yeah, the scope is tremendous.

02:25
Dr. William Claytor
We’ve, to date, the largest number of total overdose deaths peaked out in May of 2023 at 112,000, a little bit over 112,000 total deaths, about 70% of those due to fentanyl or other synthetic opioids. And it’s important to realize that in 2023, when I say 2023, and you see these numbers like 108,000 deaths, 109,000, 112,000. They’re not a calendar year, they’re more of a fiscal year. So it’s like From May of 2023, going back a year, there was over 112,000 deaths. The good news, if there is any silver lining to this cloud or whatever, is that we have seen a, About A 3% decrease since peak in May of 2023 of total overdose deaths in the nation. And even better news for the state we live in North Carolina.

03:24
Dr. William Claytor
The North Carolina Department of Health and Human Services said that in around 2021, somewhere in there, we had a total of over 4,000 total drug overdose deaths. But in 2022, 2023, that number has dropped down to under 3,000. So we’ve had about a. North Carolina and Nebraska both have had about a 25% decrease in the total number of overdose deaths, with 70% of those being attributed to usually fentanyl or other opioids.

03:55
Dr. Richard Offutt
That was where I was going with this. Next, next question, a line of question is the, the transition from using prescription drugs to using street drugs.

04:07
Dr. William Claytor
If you’ve never seen these TV shows or movies where drug dealers, you know, mix fentanyl together, they all take their base powder, whatever that may be, flour or saccharine or whatever they mix it with, and they may incorporate fentanyl in it and oftentimes they’ll take a spatula, just kind of mix it together or credit card or something. And so it’s not a uniform mix. And so when they press the powder into a pill, they get what they call clumping. So that’s what we’re seeing like a, the, the, the. Excuse me. The, the nation has a, the dea, I believe it is Department of Justice has a national campaign going on called One Pill Can Kill Campaign, which is trying to stress to the youth that, you know, it could just be a one time event and it’s over.

04:55
Dr. William Claytor
Especially if you take a pill where the concentration of the fentanyl is in one part of that pill that you take. And they call that phenomenon clumping. So but yeah, I mean it’s, it’s gone from like 2010 where we kind of peeked out at where they thought, you know, I can remember back in the day, you know, a few years ago, everyone was trying to point their finger at who was responsible for this opioid crisis. Was it the, was it the manufacturers, the distributors, the pharmacists, the doctors, you Know everybody. And so they all took polls and had. Everybody had about 15 or 20% responsibilities. Everybody was pointing their fingers, everybody. But one of the areas that they were really pointing their fingers at, not surprisingly, were doctors and dentists, physicians and dentists.

05:45
Dr. William Claytor
The meth is coming back mixed together with fentanyl today for the first time in the opioid epidemic. We have, for the first time, more people use fentanyl by smoking it than they do injected it because of fear of hep C and, you know, HIV and things like that from needle use. But they’re smoking it thinking it’s going to be a safer route of taking it in. And nothing could be further from the truth. You can still die from it, you know, if it’s a mixture. But you’ll see fentanyl and you’ll see meth and you’ll see a lot of autopsy reports. You’ll see a lot of benzos, not surprisingly, playing a factor in respiratory depression. And then the big three can be associated. Cannabis, tobacco and alcohol typically are in there somewhere. So it’s a polypharmacy kind elixir that people are dying from.

06:39
Dr. William Claytor
You, you can occasionally find the pure, as they say, the pure alcoholic that just drank and died maybe from, you know, alcoholism, but you don’t really see a pure death anymore. But those that are attributed mainly to prescription opioids that dentists and physicians are writing have gone way down. And we know that, I mean, and that’s a good thing. But at the same time, dentists still prescribe more opioids than probably we need to. Back in the 2004, 5 and 6 era, it was thought that dentists wrote about 18% of all opioid prescriptions in America. Of all healthcare professionals, that number has gone down to probably somewhere between 4 and 6% now, which is good. But we still are the number one prescriber for teenagers for that, what I call the rite of passage, getting your wisdom teeth out or other surgeries.

07:35
Dr. William Claytor
And so I cannot tell you the number of oral surgeons that have contacted me over time and said, you know, I’ve heard this lecture, I’ve heard your lecture, I’ve heard other people’s lectures saying, try acetaminophen and ibuprofen. And they do that. And it says, it’s amazing. In a year they may write five, six, a dozen, maybe opioids. It’s not like four or five a day like they were.

07:57
Dr. Richard Offutt
Yeah, that takes me to my next question kind of going along Our area to discuss is with the prescribers. And you’ve kind of, you just topped that off with the prescribers becoming acutely aware of the problem and reducing. And I know you have story after story that doctors have told you that I’m sure, but I think it is important to talk about what you started to talk maybe before I spoke over you is the initial exposure so many times comes from dental experiences for young folks. You know, the first time that they ever are sedated or the first time that they ever have a prescription drug, pain medicine, I think so. Can you talk to that a little bit? I think that’s very informative for all of all the practitioners.

08:49
Dr. William Claytor
Yes. And that is the area that when I do my courses around, people will say, well, what more can we do as dentists? We’ve been, you know, talking about opioids for seven, eight years now. I mean, what more can we do? And that’s the area the adolescent. Because there are good studies now and more studies coming out, but one in particular, it was in JAMA Network that was, came out a few years ago about a huge study of about 190,000 youth between the ages of 10 and 19. And, and they show that even a low dose or a one time dose of an opioid can actually lead to further and persistent use. Now I get the question all the time.

09:31
Dr. William Claytor
Does that mean they go home and they take the bottle that the dentist or physician wrote them of, 10 or 15 tablets and turn it up and take the whole bottle in the overdose and die? No, I mean, I guess that’s possible, but that’s not normally what is indicated that’s happening. What’s happening is, and I use the scenario of like, you know, your teenager goes and say, you know, has a soccer injury and has ankle injury and they prescribe opioids, or maybe they have their wisdom teeth taken out and they prescribe an opioid and for a day or two, you know, we’re okay. But the child keeps coming back to mom or dad saying I, I really need another pain pill. And you know, the question comes up, well, are you still in pain?

10:16
Dr. William Claytor
Well, you know, sometimes they’ll say, yeah, I’m definitely in pain. And other times they’ll say, well, not really, but you know, I think I might need it, you know, that kind of stuff. So it’s one of those in case doses, if you will. But the parent, let’s say the parent doesn’t give them the medication. Well, the child today has avenues as we know through social media and contacts at school and the Internet and, you know, cryptocurrency accounts and on, if they like the way it makes them feel, they’re going to maybe find a resource for that. And they have older friends, younger friends, that maybe contacts at school that can help them get that same feeling again. I have a good friend of mine who’s a counselor up in Kentucky and he works with a lot of adolescents and he says the adolescent brain.

11:03
Dr. William Claytor
The best description I’ve ever heard of the adolescent brain is that it’s a wonderful gas pedal, a terrible break. And, you know, during that experimental time when kids are, you know, being social media pressure and peer pressure to smoke or to drink a beer or whatever, they do, they want to impress, they don’t want to disappoint, and sometimes they get into things that they shouldn’t be. And then they say, you know, I like that feeling. I can get it today because I know how to, I have resources to get it. But that’s sort of what the studies are kind of indicating that either a low dose or single dose of an opioid can actually lead to persistent or further use. Dentistry, is that what I call the 72 hour profession?

11:49
Dr. William Claytor
In other words, we deal with the inflammatory response over that two or three day period on procedures that we do in dentistry. If our patients aren’t getting better, we see them back in two or three days. We don’t give them a bottle of 30 tablet, 30 days of opioids. And I know they can’t do that anymore, but, you know, for the most part you can’t. But like physicians deal with more chronic pain, dealing with long term issues where we’re more of a in and out kind of, you know, detailed procedural kind of surgery kind of in and out kind of thing. And if our patients aren’t better in two or three days. Dentists are traditionally great caregivers. I feel like most, for the most part, we do a great job with our patients.

12:32
Dr. William Claytor
You know, we’ll get them back and adjust a cusp or extract the tooth, open a tooth, the root canal, whatever it takes to get them out of pain. So we don’t really have a need for opioids in most cases. And so is the first choice always, if there are no contraindications, I say NSAIDs. And then the combination of NSAIDs and acetaminophen, certainly you could consider that as a first choice. You can always, you know, your clinical judgment always overrides my comment. If you feel like Opioids are necessary in this particular case, then I would definitely say limit it maybe to a day, but keep them on the NSAIDs and then reevaluate and, you know, preoperatively prepare the patient for what to expect and give them that call 24 hours later to let them know that we’re there for them. We haven’t abandoned them.

13:24
Dr. William Claytor
We’re here to make sure they’re comfortable. And it’s amazing, as we know, that patients do quite well with NSAIDs.

13:33
Dr. Richard Offutt
And talk a little bit about the adolescent brain and susceptibility to addiction. I think that, that’s something that we, that you have to really kind of get very detailed on because doesn’t, you know, lots of times people believe that it’s the chronic use of opioids that lead to, whereas in the adolescent that’s not necessarily the case. It can be, you know, a single event. And can you talk to that a second for us?

14:05
Dr. William Claytor
Yes. There are multiple studies out there showing this, but the one I always Refer to is Dr. Lander at Columbia University did a, you know, he reminds us in this article he published that the brain doesn’t fully develop, you know, until the mid, early mid-20s. And that the earlier you start using substances, like if you started using mood altering substances at age 20 versus age 10. At age 10, some studies show up to five times greater risk for addiction development if the earlier you start using that drug. With that being said, we know for the most part the adolescent brain doesn’t make sound good decisions.

14:51
Dr. William Claytor
I mean, there’s a lot of stuff going on in the adolescent brain, from hormonal to, you know, growing 4 or 5 inches in a summer, to dealing with social media, to dealing with, you know, acne, with, dealing with, you know, peer pressure, you know, all this stuff. It’s a rough time, it’s a very torturous time, if you will. But when you throw drugs on top of it doesn’t help any. And in fact, surveys that he refers to in his study was that 90, almost 97% of people who had a substance use disorder that was diagnosed started using prescription opioids or prescription mood altering drugs before, you know, in their teenage years. So the earlier you start using, the more likely you are to develop substance use disorders or addiction.

15:41
Dr. William Claytor
The Addiction Professionals of North Carolina has a little statement that says for every year you can delay use of substances, mood altering substances, you decrease the chances of developing a disorder. 4 to 5%. Well said. Another way, if you could raise a generation of kids from birth to age 25 and not a single one of them ever smoked a cigarette, ever used alcohol or ever used any mood altering chemicals like opioids or benzos or anything like that. If you had that population, you had the ability to do that. And then after age 25 you expose them to these drugs, you know, cigarettes, alcohol, whatever. Yeah, they can develop an addiction still, but the chances go way, way down. I mean, I don’t know what the percentages are, but they’re in the single digits, I’m sure.

16:34
Dr. William Claytor
And, and because you know this, we’ve developed the synaptic connections, we developed this center of our brain for executive functioning. We’ve had some emotion regulation in the amygdala. We have had issues come up in our lives where we’ve had to deal with stress and deal with conflict.

16:54
Dr. Richard Offutt
Thank you. And that kind of leads me to, and you touched on it, the alternative, and the alternatives to it as prescribers are, you know, if you’re doing surgery and you’re in your practice every day and you know, people are going to have to manage this post op, manage them postoperatively. And you have, I’ve heard you before talk about the phenomenal database and studies that show the alternatives to opioid prescribing is equally if not superior in many, many types of surgery. Can you, can you talk a little bit about that? And then maybe even go into the, the, the placebo, no placebo sort of research on that. I think that’s fascinating.

17:43
Dr. William Claytor
So the first part I always refer to the Cochrane Review that was done by the Cochrane Group out of England who gathers, you know, meta analysis of different areas of medicine, by the way, just as a little side here, as a plug. I found out that Cochrane has now opened up a center in the United States, the first one, and it’s going to be at the University of Pennsylvania. So at the Dental school there, I think, or at the Penn. I don’t know if it’s dental school, but it’s, I know it’s at the University of Penn. That’s something in the works right now. So that’s good. But Cochrane, yeah, they talk about the value of, and the statement that you’ve heard NSAIDs are as effective, if not more effective than opioids.

18:29
Dr. William Claytor
Where that came from in the Cochrane Review just basically showed that ibuprofen, either 200 milligrams or even 400 milligrams topped out at about 38, 39% of the patients got at least 50% pain relief, which was equivalent to oxycodone 10 milligrams with two extra strength acetaminophen. Interestingly enough, for those who still think that opioids are a great painkiller, they’re really not, they’re not that great of analgesic. They mask the brain, they treat the brain, they don’t treat the pain as well as NSAIDs in most cases. In this world we live in early or I should say mild pain up to early, moderate, severe pain. That’s our dental world. NSAIDs, acetaminophen, more combinations work great together.

19:26
Dr. William Claytor
But the opioids, when you actually decrease the opioid amount from 15 milligrams of oxycodone down to 10 milligrams, the Cochrane report showed, and add two extra strength acetaminophen, that number goes up to the equivalent of the, of the NSAIDs. So when you have oxycodone 10 milligrams plus two extra strength acetaminophen, its analgesic effect is about the same as taking 2, 1 or 2 ibuprofen for post op discomfort. So my question or my concern is that if that’s the case, why would we, as a kind of a first knee jerk kind of reaction, give an opioid with acetaminophen as our first response? Why wouldn’t we respond with an NSAID first?

20:15
Dr. William Claytor
And if that doesn’t work, because we know it says at least equally effective, why then if that was not quite as effective, you could add acetaminophen in with the ibuprofen, either 200 and 500 or 400 and a thousand, you know, with the ibuprofen and acetaminophen. And you can show studies as high as 60% got at least 50 pain relief, which is a lot better than the opioids. You don’t get the side effects of the opioids.

20:44
Dr. William Claytor
But again, in our world as dentists, for most of what we do, including extractions, third molars, bone grafts, implants, we don’t need that heavy duty, you know, fentanyl based medication like for severe pain in cancer patients or trauma or post op surgery childbirth, where opioids are really made for those, because they want to mess with your brain, they want to make you forget the pain, you know, that’s fine. But in most cases we don’t have to do that in dentistry for those dental Procedures that do require something more. And you’re, you’ve done the NSAIDs and acetaminophen and it’s still not quote unquote working. I look at two avenues you can go. One is that you can use some long acting anesthetics such as, you know, I don’t, you know, these bupivacade, liposomal injection suspension things. There’s several of them out there now.

21:45
Dr. William Claytor
You know, I, I have no vested interest in Exparel, but that’s one that kind of comes to mind. There’s a new combination of lidocaine and tetracaine with EPI called Endurocain or Endura kit and it’s a combination of an amide and a ester together that tends to have a lingering effect too of anesthetic. So it gives you anesthetic effect after the procedure. Marcaine, don’t Forget Marcaine.5% with 1 to 200 epi. That’s a good one. You have another one called Zenrelief which is a combination of bupivacaine and Meloxicam or mobic anti inflammatory. All these are infiltrated right around the surgical site. They’re not, they’re not used as blocks except for you can use Marcaine as a block for surgery and also for post anesthetic, post surgery anesthesia.

22:43
Dr. William Claytor
So you have this realm of like if you’re wanting to get the lingering effect more than just maybe lidocaine or septicane or whatever can give you, and you want to have a lingering effect of maybe four to six hours of anesthetic. You could actually use Marcaine and give a block with that and you can get that effect. You can also use Marcaine and Exparel and endurocaine or Endura kit and Zenrelief by infiltrating as a post surgery anesthetic that will kind of linger on and give patients some claims are up to 24 hours. I know with Exparel it can go up to two to three, maybe even four days of some type of relief while they’re still on their NSAIDs, you know, trying to get the inflammation down.

23:34
Dr. William Claytor
Because most of what we deal with in dentistry as y’all you guys know, is inflammatory in nature. That’s one way, the anesthetics the second way. And I used to use this before we had all these long acting anesthetics. I used to use this in practice when I was in full time practice, an oral surgeon reminded me that the formulation, I don’t know if you guys remember the old drug Mepragan Fortis, it was a combination of opioid and Finnegan that when they found that in this combination that when you add Finnegan to an opioid, in some cases it has the potential to double the analgesic effect of the opioid without reducing respiration.

24:18
Dr. William Claytor
So what I would do, I would prescribe maybe an opioid and 25 milligrams of Finnegan maybe for one day, like four tablets of each for one day to try to get them through with a real acute phase of pain. If it’s continuing to be a really very noticeable pain with, instead of like I used to do before all that, give two opioids. And so if you took one, I’d say, well, just take two. And it’s probably safe in a short period of time, but why do it if you got other alternatives that might work better?

24:51
Dr. Richard Offutt
So, so, Bill, for our listeners that are, that they hear this podcast and they go, I want to go into my practice tomorrow and I want to reduce the number of opioid tablets that I prescribe. Can you talk a little bit about the, that you have to prepare your patient for this, you have to prepare your patient that you’re not going to prescribe their child a narcotic and the reasons why. And can you talk a little bit about that, about the preparation of the parent, of the, of the patient or the patient themselves with what needs to happen? This, this has to be a bigger thing than just the doctor deciding it.

25:37
Dr. William Claytor
Right. And I’ll start out by answering that, by telling you a personal story. You know, someone asked me back in 2017 when we started really talking and lecturing about opioids. They said, well, why did you prescribe opioids? And I got to thinking about that and I thought, well, when I was in dental school and this was just right after the dinosaurs had become extinct, when I was in dental school, I.

26:07
Dr. Richard Offutt
Think I remember seeing you then.

26:08
Dr. William Claytor
So, yeah, I think so. Yeah. The, the, you know, we, as I said, we gloved up, numbed up, took a tooth out and wrote a prescription like a real doctor because it was the mantra. It was less than 1% have a problem with opioids. We thought it was a standard of care. We thought it was a thing to do. And at the time, in retrospect, it was the thing to Do. That’s what everybody did. Then people started questioning, wait a minute, what’s going on here? Do we really need this? And so with that being said, I, you know, I really feel like we’ve gotten to the point to where we need to kind of rethink what we’re treating here. And this is inflammatory pain. And we do know that.

26:59
Dr. William Claytor
You know, I think your question was more along the lines of, why did I change? Ask your question one more time.

27:07
Dr. Richard Offutt
That, that just the practitioner, our listener, that wants tomorrow go into their practice and change about. It’s, they can stop prescribing or reduce their, the number of tablets, but they have to manage the patients a little differently.

27:24
Dr. William Claytor
Right. So, so there are two, there are two words. One we’re probably familiar with, one we’re probably a lot of us aren’t. I know I wasn’t that familiar with it, but we’ve all heard of the word placebo and we know that patients have estimates depending on the circumstance, go between 20 and 30% of the people are placebo, potentially affected by placebo. So, you know, that’s where you use a pill or drug or whatever and you tell them it’s going to do this and it does it, but it’s nothing but an innocuous substance and it really has no potential to do that. But in their mind, they think about, you know, it worked just like the doc said. But nocebo is that. And, and some people estimate this can be as high as 25 to 30% of our patients.

28:13
Dr. William Claytor
And you know them, you have them in your practice. I had them in my practice. You’ve heard the comments from them, things like, oh, I, I know if it’s going to happen to me. You know, it’s going to be the worst kind of pain. I’ll end up in the emergency room. They catastrophize out to the nth degree of what the outcome, what it’s going to look like if they have a procedure done, you know, telling the patient that it’s normal to have some discomfort for a day or two, maybe lingering on for, you know, 48, 72 hours, that most of the time it can be dealt with very effectively with medicines we already have in our medicine cabinet and that we’re here for them and this is what to expect.

28:56
Dr. William Claytor
And my thing I did, I know, last several years in practice was I would tell the patient, I’m going to call you in 24 hours to see how you’re doing. I always refer and highly for those in North Carolina. I know we’re not talking only to North Carolina, but in North Carolina, the North Carolina Dental Society has a video that we helped develop years ago about what to expect post op. It’s in English and Spanish I believe, and you can download it from the website. But it’s a two and a half media, two and a half minute video of exactly for the patient to listen to, which is another way to prepare the patient of what to expect.

29:37
Dr. William Claytor
Oftentimes when we get our patients on an emergency basis and they’re in acute pain and they have to have it done right away, it’s hard to have that discussion because they’re just wanting out of pain so you can go ahead and anesthetize them and then have that conversation, try to help them understand, you know, that this is going to be okay. And just talking is so important because dentists have improved on that, but we still got a lot of improvement to do. I think as a profession.

30:07
Dr. Murtuza Shah-Khan
Yeah, Bill, we’ve touched on a lot of post op stuff and a little bit of this preparation. One thing I wanted to kind of get your take on was talking about more kind of pre procedural things like you know, the anxiety patient, the you know, anxiolytic meds that we can prescribe. I know, you know, we’re talking to a broader audience, but recently in North Carolina they’ve changed some of, you know, what general practitioners and general dentists can prescribe for angio lytic needs. So I wanted to get your take on that and see what you thought of.

30:39
Dr. William Claytor
Right. And I’m certainly, I would say upfront, I’m not really an expert on that, but I do know they’ve changed it from the day when I would give like say for instance, 5 milligrams of a Valium the night before for people to go to sleep, you know, help them sleep and then 5 milligrams an hour before the procedure. Now I know it’s a one time bolus, I think it is of anxiolytic drug. Like different. Well, it depends on your permit level of what you know, whether you have moderate or whatever. And so I think, I mean if you’re asking do I think that’s a good thing to do. Certainly if it’s, you know, done according to your, up to the level of your permit and it’s a one time bolus, I Have no problem with that.

31:30
Dr. William Claytor
One thing along those lines though, that I would caution patients or dentists to be aware of and make their staff aware of it is to make sure in your health history form ahead of time that you ask questions not only about tobacco and alcohol, but you asked questions about opioid use and cannabis use. And the reason for that is there are some good studies coming out now showing that men under the age of 50 that have some level of ischemic heart disease, which most of us do to some level, are higher risk of having a myocardial infarction within an hour after vaping a high concentration of cannabis product and a chronic use of it, I should say, not just maybe a one time use, but chronic being several times a month or several times a week.

32:19
Dr. William Claytor
And the reason I mentioned that is that your patient may not be asking for halcyon or Valium or whatever you prescribe and they seem pretty chilled out. Just make sure that they’re not vaping ahead of time, sitting out in your parking lot, vaping, coming in. Because there have been some, as you know, cannabis in and of itself has a sympathetic potential, sympathetic response to the heart where you can have tachycardia for not just 10 or 15 minutes like an epi rush, but you can have it for up to several hours. You can, they can throw arrhythmias, they can have, you know, increased blood pressure, the whole works. It can be very scary event in the office. So rule out cannabis use and other drug use if you’re going to give a pre op medication.

33:09
Dr. William Claytor
I mean, not that you wouldn’t, but you just, we need to be asking these questions because in and of itself, cannabis has the potential to increase heart rate. But when we, if we’re going to use epinephrine on top of that, no, it’s not going to cause necessarily the event, but it’s going to exacerbate the potential that cannabis could already have on the heart. And I always say it doesn’t have to happen in dental office. You could be walking in Walmart and somebody that’s been vaping could have a sympathetic reaction. So it’s not so much the epi, even though that doesn’t help it any. So a lot of people don’t know that and a lot of people think it’s, you know, not really true.

33:49
Dr. William Claytor
But I’ve taken some calls from dentists and oral surgeons in the state and they’re going like, what in the world’s going on here? You know, they had no idea until they asked that question. I was in Michigan, heard stories about this event happening. So it’s very real. And we need to be asking.

34:07
Dr. Richard Offutt
You know, Bill, you mentioned something that I think, you know, we, we forget. You know, you get in the day to day practice and you know, your dentists are constantly busy. They’re going from room to patient to patient. And, and one of the things that I think is so important is that thing of knowing your patient, right. Knowing who you’re treating. And you know, we have some things now with controlled substance reporting, PMP wear and can you touch on that a little bit? Just, just to kind of. It’s a tool, it’s a tool to know your patient better.

34:44
Dr. William Claytor
Right. And, and its efforts were lofty when it first came out, you know, to help kind of mitigate the, the over prescribing to help people that might have a problem, maybe find some resources for help. But in 2017, when we, and that’s some of the first data when I first started looking at it, every state had some level of I guess you say accountability as looking into, you know, what patients were taking as far as opioids. And I know except for Missouri just came on board recently. But sometimes if you looked at, say you were in Idaho or something, you would look up to see if a patient was on what medication it may be two to three days, up to a week before a prescription actually showed up on that report because it took time.

35:38
Dr. William Claytor
Some states were within 24 hours, some were a week.

35:41
Dr. Richard Offutt
I think when we talk and talk about our colleagues in dentistry and you know, we spend most of our time helping people solve, solving other people’s problems. But then sometimes we as Dennis, we’re under a lot of stress and we have, we have to adopt coping mechanisms of, and some people become compulsive exercisers. Some people do things to kind of mitigate some of that self imposed pressure. Can you talk a little bit about, you know, substance abuse, mental health and burnout in our profession as a result of not having effective coping mechanisms.

36:23
Dr. William Claytor
That’s, that’s a big topic, right?

36:25
Dr. Richard Offutt
Yeah, I know it’s unfair, unfair being that I’m giving you two minutes to do it right?

36:30
Dr. William Claytor
No, no, I’ll try. Well, I will just say that, you know, the, the thing with the stress levels at the ADA just did a, they do their communication trends report every year or so and they came out in October of last year, in 2023. And they asked dentists, Is your profession stressful? And 90% said yes. So immediately when I saw that information come in, I thought I want to meet the 10% who say it’s not stressful. I mean, that’s right.

37:05
Dr. Richard Offutt
Who are those, who are those people?

37:07
Dr. William Claytor
I’ve never met a person like that. But with 90% they broke it down a little bit further and they found that, you know, that mid career dentists were so concerned about continuing good reinsurance reimbursement and also retaining patients because a lot of the patients were leaving to go to the new dentist coming out because you know, they were trying to maintain their patient base. And of course the young dentist was more just totally in some ways paralyzed with fear of maybe being in a situation where they don’t feel like they have a future or control of where they’re going with their careers. The debts and ever looming problem.

37:47
Dr. William Claytor
You know, this average according to asda, American Student Dental Associations said that when you can average private and public school dental education in 2020 it was around 306,000 was the average debt they come out of school with. I know some schools are, have over a million dollars after four years and some like in our state are under somewhere under 200,000. So you know, it’s all over the place. And that same study, they found that 41% of dentists said they either wanted to quit dentistry, not go to work or just didn’t like what they did anymore. That’s a, that’s a dangerous place because you’re like you said, we don’t have coping skills. And a lot of that has to do not only with dentistry, but people in general.

38:39
Dr. William Claytor
We’re not, we don’t come out of the womb as a, as a human being with coping skills. It has to be taught to us. And with most a lot of dentists in on the Myers Briggs scale being introvert, processing, getting their energy through introversion and we tend to be overthinkers.

38:56
Dr. Richard Offutt
Well, Bill, I want to thank you for joining us on Simplify and I’ve enjoyed our relationship over the years and I hope I know all of our listeners will as well And I will be sure to post the graphics that you provided me. I’ll put those, they’ll be on our Facebook site today and I appreciate very much and I want to thank you.

39:18
Dr. William Claytor
Thank you so much and I hope everyone has a good rest of the day.

39:22
Dr. Richard Offutt
Thank you. Thank you sir. Bill, thank you.

39:24
Dr. William Claytor
Bye.