The ADA's 2018 opioid policy: seven days, mandatory CE and PDMPs, and what the ADA has added since

What it says#

On March 26, 2018 the American Dental Association announced what it called a new policy on opioids "supporting mandates on prescription limits and continuing education in what could be the first of its kind among major health care professional organizations." The press release states the policy in three sentences. The ADA supports mandatory continuing education in prescribing opioids and other controlled substances. The ADA supports statutory limits on opioid dosage and duration of no more than seven days for the treatment of acute pain, consistent with the CDC's evidence-based guidelines. And the ADA supports dentists registering with and utilizing prescription drug monitoring programs to promote the appropriate use of opioids and deter misuse and abuse. ADA President Joseph P. Crowley called on dentists "to double down on their efforts to prevent opioids from harming our patients and their families."

The policy text as recorded by the House of Delegates (Resolution 2018:310, October 2018) is longer than the release. The CE resolution says any mandatory requirement should provide credit acceptable for both DEA registration and state dental board requirements, provide coursework tailored to dentists and dental practice, and include a phase-in period so affected dentists have a reasonable time to comply. The dosage resolution repeats the seven-day sentence. The third resolution, in the recorded text, supports "improving the quality, integrity, and interoperability of state prescription drug monitoring programs." The instruction to register with and use a PDMP sits in the ADA's older Statement on the Use of Opioids in the Treatment of Dental Pain, adopted in 2005 and revised in 2012 and 2016.

That 2016 statement is the clinical half of the ADA's position. It says dentists should take a medical and dental history for current medications, interactions and substance abuse before prescribing; should follow and keep reviewing CDC and state board recommendations; should register with and use the PDMP; should talk with patients about preventing misuse, and about storage and disposal; should "consider nonsteroidal anti-inflammatory analgesics as the first-line therapy for acute pain management"; should recognize multimodal strategies that spare opioids; should coordinate with other treating doctors, including pain specialists, for chronic orofacial pain; and should not be held responsible for the willful and deceptive behavior of patients who obtain opioids for non-dental purposes when practicing in good faith. Dental students, residents and dentists are encouraged to seek CE in addictive disease and pain management.

The release published the numbers behind the policy. In 1998 dentists wrote 15.5 percent of all U.S. opioid prescriptions; by 2012 the share was 6.4 percent. Three articles in the April 2018 JADA were cited: an overview of five systematic reviews found that for adults 400 mg of ibuprofen plus 1,000 mg of acetaminophen "was superior to any opioid-containing medications studied"; an ADA Health Policy Institute analysis of about 1.1 million privately insured dental patients from 2010 through 2015 found a median opioid supply of three days, an increase of 17 opioid prescriptions per 1,000 dental patients over the six years, the largest increase among patients aged 11 to 18, and higher median doses in the 11 to 18 and 19 to 25 age groups; and a third article walked through ten clinical scenarios for reading PDMP data.

What the ADA has said since sits on the same site. Its current-policies page lists the "ADA Policy on Opioid Prescribing (2023)" and the "Statement on the Use of Opioids in the Treatment of Dental Pain (2024)," the years of the most recent House action on each; the seven-day sentence, the CE criteria and the PDMP resolution read the same as in 2018. On February 5, 2024 the ADA endorsed a clinical practice guideline, developed with the University of Pittsburgh and the University of Pennsylvania under a three-year, $1.5 million FDA grant awarded in 2020, that recommends NSAIDs alone or with acetaminophen as first-line treatment for short-term dental pain in adolescents 12 and older and adults, reserves opioids for when first-line therapy is insufficient or NSAIDs are contraindicated, and tells clinicians to avoid "just in case" prescriptions and to "exert extreme caution when prescribing opioids to adolescents and young adults." A pediatric guideline had been published in 2023; the ADA's topic page notes that codeine and tramadol are contraindicated for acute pain in children per the FDA.

Who it applies to#

No dentist is bound by an ADA policy. It is the profession's stated position, and its purpose was to give state legislatures, dental boards and Congress something to cite; on the day of the announcement the ADA sent letters describing the policy to the House Energy and Commerce and Ways and Means committees and the Senate HELP committee, and four days later to HHS. Where a state has since written a day limit, a CE requirement or a PDMP mandate into law, that law binds you, and its numbers may differ from the ADA's. The policy applies to acute pain, which is nearly all dental prescribing; for chronic orofacial pain the 2016 statement asks for coordination with other treating doctors rather than a limit. The policy says nothing about milligram strength or morphine milligram equivalents; seven days is its only number.

What changed#

Before 2018 the ADA's position was the 2016 statement: consider NSAIDs first, use the PDMP, seek CE. The 2018 policy was the first time the ADA supported mandates, a statutory ceiling and required CE, rather than recommendations, which is why the release called it possibly the first of its kind among major health professional organizations. Since then the ADA has kept the policy and moved the clinical bar higher through the 2023 and 2024 endorsed guidelines, which no longer say "consider" NSAIDs but recommend them as first-line and describe opioids as reserved for the cases where that fails. The federal MATE Act training requirement, covered in its own entry here, arrived after the policy and is the mandatory CE the ADA said it would support.

Where the source is#

The March 26, 2018 press release is in the ADA's press release archive on ada.org and is free. The policy text, the 2016 statement and the 2024 guideline summary are on the ADA's Oral Analgesics for Acute Dental Pain topic page, and the current wording with its 2023 and 2024 dates is on the ADA's current-policies page under Substance Use Disorders. The February 5, 2024 press release and the opioid education page are also on ada.org. The JADA articles cited in the release and the 2023 and 2024 guidelines themselves sit behind the journal's site, which requires a subscription or ADA membership for full text.