RICHMOND, 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.
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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.”
The 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.
“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.”
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.
Abubaker 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.”
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.”
After 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.
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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.”
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