June 9, 2021

Congresswoman Annie Kuster
Co-ChairBipartisan Addiction and Mental Health Task Force
Cannon House Office Building 320
Washington, D.C. 20515
Congressman David Trone
Co-ChairBipartisan Addiction and Mental Health Task Force
1213 Longworth House Office Building
Washington, D.C. 20515

Congressman Brian Fitzpatrick
Co-ChairBipartisan Addiction and Mental Health Task Force
1722 Longworth House Office Building
Washington, D.C. 20515

Congresswoman Jaime Herrera Beutler
Co-ChairBipartisan Addiction and Mental Health Task Force
2352 Rayburn House Office Building
Washington, D.C. 20515

Dear Bipartisan Addiction and Mental Health Task Force Co-Chairs:

On behalf of the American Association of Oral and Maxillofacial Surgeons (AAOMS), the professional
association that represents more than 9,000 oral and maxillofacial surgeons (OMSs) in the United States, I
applaud your work to create the Bipartisan Addiction and Mental Health Task Force. AAOMS supports yourefforts to reduce opioid addiction and looks forward to working with you to achieve this goal.

Oral and maxillofacial surgery is the surgical specialty of dentistry. As such, management of our patients’
pain following invasive procedures is an important aspect of providing the best quality patient care. As
lawful prescribers, we know, when used appropriately, prescription opiates enable individuals with acuteand chronic pain to lead productive lives and recover more comfortably from surgical procedures. We also
recognize, however, that pain medication prescribed following oral and maxillofacial surgery is frequently
the first exposure many American adolescents have to opioids, and roughly 12 percent of all immediaterelease opioid prescriptions in the United States are related to dental procedures. 1

Dentists, including OMSs, have a responsibility to ensure we do not exacerbate a growing public health risk
while ensuring our patients receive the relief they need following complex dental procedures. We believe
OMSs must demonstrate safe and responsible opioid prescribing for acute and postoperative pain in theirpatients, which includes accessing the state’s prescription-drug monitoring program as well as educating
the patient and family about potential risks – and the safe use, storage and disposal – of opioid analgesics.
1 Denisco R, Kenna C, O’Neil M, et al. Prevention of prescription opioid abuse: The role of the dentist. JADA. 2011; 142(7):800–810.

We are pleased to share with the task force the initiatives that AAOMS has taken over the last several years
to ensure we are doing our part to reduce opioid abuse.

We believe the most important step to reduce usage of opioids for dental procedures is to educate our own
membership about the potential for opioid abuse. These educational efforts implemented by AAOMS
include:••••••Published prescribing recommendations that urge non-narcotic pain medicine – rather than opioids– be utilized as a first-line therapy to manage a patient’s acute and post-surgical pain.
Partnered with SAMHSA and NIDAMED to create continuing education (CE) on opioid abuse andmake it available to AAOMS members.
Provide CE webinars and CE programs on opioid misuse and abuse.
Promote the DEA's National Prescription Drug Take Back Days to AAOMS members.
Developed an information card on the Safe Use and Disposal of Prescription Medications.
Participate in and promote to AAOMS membership the Partnership for Drug-Free Kids Medicine
Abuse Project.

Data, provided in the attached document, suggest these educational efforts are working. More specifically,
89 percent of OMSs surveyed have reduced the number of opioids prescribed for wisdom teeth extraction,
while 97 percent of OMSs report that they do not refill a prescription following wisdom teeth extraction.

Despite the progress we have made as a specialty, we recognize that the country still faces huge challenges
in overcoming the opioid epidemic and that new initiatives and policy changes will be needed. As you may
be aware, the National Center for Health Statistics recently reported provisional data that showed thereported number of drug overdose deaths occurring in the United States increased by 26.8 percent from the12 months ending in September 2019 to the 12 months ending in September 2020. 2 Clearly, the COVID-19
pandemic has worsened the opioid epidemic and now is not time to rest on our laurels.

As the Task Force works towards new policy goals, we would like to make the following recommendations
should new legislation at the federal level be considered:••2Continuing Education (CE)o AAOMS supports CE, but to be most effective, it should be managed at the state level because
CE has traditionally been under the purview of the states.
o Any CE requirement should be appropriately proportionate to CE requirements for othertopics and customized so it is relevant to each type of prescribing situation.
o Any federal requirement should either exempt prescribers in states with existing
requirements or supersede those state requirements so prescribers are not subject toduplicative requirements.
o Provider specialty organizations (such as AAOMS) should be included as accepted
practitioner training organizations for CE requirements.
Prescription Drug Monitoring Programs (PDMPs)o AAOMS supports properly funded PDMPs that are updated in real time by dispensers andinteroperate between states.

Provisional Monthly Drug Overdose Deaths from September 2019 to September 2020. National Center for Health Statistics.
Available at: https://nchstats.com/2021/04/14/provisional-monthly-drug-overdose-deaths-from-september-2019-to-september2020/. Accessed June 5, 2021.

o•Approved auxiliary personnel should be authorized to access the system on thepractitioner’s behalf.

Prescribing Initiatives
o AAOMS appreciates the development of prescribing guidelines. In 2017, AAOMS publishedprescribing recommendations for the management of acute and postoperative pain for theOMS patient that urge non-narcotic pain management – rather than opioids – be utilized as afirst-line therapy to manage a patient’s acute and post-surgical pain.
o Any effort by government entities to develop prescribing guidelines should recognize theunique care provided by OMSs by involving them in the development process and avoiding a
one-size-fits-all approach as pain management needs vary patient to patient.
o Partially filling a prescription with the option to acquire the remaining amount only whennecessary should be encouraged because this would lessen the risk of diversion of unused
medications.
o Any dosage limitation restrictions should allow provider discretion because the managementof pain severity varies by procedure and patient.
o Collaboration should occur with appropriate agencies to secure approval of innovative
solutions for alternative pain management options, reducing the need for opioids. This
would include pharmaceuticals, such as bupivacaine HCL, that extend the length of surgicalsite anesthesia.
o Allow dentists to refer their Medicare patients directly to physical therapy. Current law
requires that OMSs seek a referral from an allopathic or osteopathic physician and/or workwith such a physician to establish a therapy plan when an OMS believes physical therapy
should be part of a patient’s treatment. Such consultation not only is inefficient andunnecessary, but costly to both Medicare and beneficiaries while delaying patient access toalternative pain management therapies.

AAOMS commends the task force on its efforts to curb the misuse of prescription drugs. As attachments tothis letter, we have included our prescribing recommendations, Opioid Prescribing: Acute and Postoperative
Pain Management, and survey data on prescribing trends among our membership. We welcome an
opportunity to discuss these issues in detail and work with you to explore all possible solutions. Pleasecontact Jeanne Tuerk, manager of the AAOMS Department of Governmental Affairs, at 800-822-6637 or
jtuerk@aaoms.org for additional information.
Sincerely,B.D. Tiner, DDS, MD, FACSAAOMS President
Attachments

American Association of Oral and Maxillofacial SurgeonsWhite Paper

Opioid Prescribing: Acute and Postoperative Pain Management
Oral and maxillofacial surgeons must demonstrate safe andcompetent opioid prescribing for acute and postoperative
pain in their patients. Responsible prescribing of opioids
must be a priority, including accessing the state’sprescription-drug monitoring program as well as educating
the patient and family about potential risks – and the safe
use, storage and disposal – of opioid analgesics. Because
prescribing protocols evolve over time, practitioners also
should stay informed of the latest public health trends,
including possible alternatives to opioid pain treatment.

• Providers should prescribe non-steroidal
anti-inflammatory drugs (NSAIDs) as first-line
analgesic therapy, unless contraindicated. If NSAIDs
are contraindicated, providers should prescribe
acetaminophen (N-acetyl-p-aminophenol [APAP])
as first-line analgesic therapy.

It is the position of AAOMS that the practitioner-patient
relationship must be upheld, allowing for practitioner
judgment in the management of a patient’s pain –including drug types, dosages and treatment durations.
Pain management decisions should be individualized andonly determined after a careful assessment of the levelof risk to – and condition of – the patient. While oral
and maxillofacial surgeons should ultimately make all
final prescribing decisions, the recommendations in thisAAOMS White Paper are intended to provide direction
and serve as a supportive resource.

• When indicated for acute breakthrough pain, consider
short-acting opioid analgesics. If opioid analgesics areconsidered, start with the lowest possible effective dose
and the shortest duration possible.

Considerations and recommendations for the managementof acute and postoperative pain include the following:• A nonsteroidal anti-inflammatory drug administeredpre-emptively may decrease the severity ofpostoperative pain.
• A perioperative corticosteroid (dexamethasone) may
limit swelling and decrease postoperative discomfort
after third-molar extractions.
• A long-acting local anesthetic (e.g., bupivacaine,etidocaine, liposomal bupivacaine) may delay onset
and severity of postoperative pain.
• The oral and maxillofacial surgeon should avoid starting
treatment with long-acting or extended-release opioid
analgesics.

• NSAIDs and APAP, taken simultaneously, work
synergistically to rival opioids in their analgesic
effect, but dosage levels and times of administration
should be carefully documented to prevent overdosage.

• When prescribing opioids, state law may requireprescribers to access the state prescription drugmonitoring program (PDMP). If there is any suspicionof patient drug misuse, abuse and/or addiction, the OMS
should access the PDMP. To assess for opioid misuseor addiction, use targeted history or validated screening
tools.
• All instructions for patient analgesia and analgesic
prescriptions should be carefully documented.
• When deviating from these prescribing
recommendations – or those required by statelaws or institutions – the oral and maxillofacial
surgeon should document the justification for
doing so.
Oral and maxillofacial surgeons also should:• Address exacerbations of chronic or recurrent
pain conditions with non-opioid analgesics,
non-pharmacological therapies and/or referralto specialists for follow-up, as clinically appropriate.
• Limit the prescriptions of opioid analgesics to patientscurrently taking benzodiazepines and/or other opioids
because of the risk factors for respiratory depression.

PAGE 1 Opioid Prescribing: Acute and Postoperative Pain Management• Inform patients that the recommended maximum daily
dose of acetaminophen should not exceed 3,000 mg. To
avoid potential APAP toxicity, an oral and maxillofacial
surgeon choosing to prescribe an opioid should consider
one that is ibuprofen-based.
• Counsel patients that the recommended maximum daily
dose of ibuprofen is 3,200 mg. Note: Higher maximal
daily doses have been reported for osteoarthritis while
under the direction of a physician.
• Educate patients on the expectations of postoperative
pain management and the anticipated levels of relief.
• Not prescribe acetaminophen with codeine to treat pain
in children younger than 12. For more information, visit
the FDA Drug Safety site.
For management of chronic pain, refer to the Centers
for Disease Control’s Guideline for Prescribing Opioids
for Chronic Pain.
© 2020 American Association of Oral and Maxillofacial Surgeons.
No portion of this publication may be used or reproduced without
the express written consent of the American Association of Oraland Maxillofacial Surgeons.

PAGE 2 Opioid Prescribing: Acute and Postoperative Pain ManagementWhite Paper

OMS Efforts to Prevent
Prescription Drug Abuse
Oral and maxillofacial surgeons are part of the solution.

89%

97%

Reduced opioidprescribing for wisdom
teeth extractions
89 percent of OMSs have
reduced the number ofopioids prescribed for
wisdom teeth extraction.

Do not refill aprescription
97 percent of OMSs
report they do not refill
a prescription following
wisdom teeth extraction.

72%

93%

Prescribe
ibuprofen

Prescribe less than a
3-day supply

72 percent of OMSs
report they prescribe
ibuprofen alone or with
an emergency supplyof opioids for all OMS
surgical procedures.

93 percent of OMSs
prescribe less than a
3-day supply – up from
74 percent in 2017.

Source: 2017, 2018 and 2019 AAOMS membership surveys