The opioid epidemic has been fueled by soaring numbers of prescriptions written for pain medication. And often, those prescriptions are written by dentists.

“We’re in the pain business,” says Paul Moore, a dentist and pharmacologist at University of Pittsburgh School of Dental Medicine. “People come to see us when they’re in pain. Or after we’ve treated them, they leave in pain.”

Indeed, 12 percent of prescriptions for immediate-release opioids are written by dentists. In 2012, dentists ranked fourth among medical specialties for their opioid prescribing rates, according to data from QuintilesIMS. It has made dentists targets for people “doctor shopping” in order to get opioids.

“I have dentures,” said Shawn Bishop, who is recovering from an opioid addiction at Hope House, a treatment center in Boston. “I had went to get some legitimate work done. And I got some Percocet. I realized that by going to another dentist, I could get some more Percocets.”

Bishop, now 59, recounts the times he teamed up with others to play dentists for their opioid pills.

“He would look at our teeth or Mark’s teeth in particular,” Bishop said. “He would look at his teeth and say, ‘Yeah, we need to take this one, this one, and this one.’ And Mark will always say well, ‘I can’t do it today. Can we make an appointment for next week?’ And then the doctor will say, ‘Yeah, I need to write a prescription of Percocets.’ He kept bad teeth and toothaches just so he can do that, you know?”

For Bishop and his friends, the enterprise of getting opioid pain pills from dentists grew so routine that, he says, he became a professional at it.

“It was almost like they knew their part to play and we knew ours,” he said. “It was like actors in a little sketch there.”

Massachusetts has taken the lead in trying to reduce opioid prescription abuse. Last year, Gov. Charlie Baker’s office passed a law to prevent drug misuse. Dental schools in the state are also required to teach a set of core competencies that their students are required to meet before graduating. Students will have to demonstrate that they know how to consider nonopioid treatment options.

“At least at the medical school, the dental school, nursing school and pharmacy school level, you don’t graduate from those places without having studied this stuff and understanding both the positives and the negatives associated with using it,” Baker says. “In addition to that, making sure as a condition of relicensure, you’re getting everyone who is writing prescriptions as part of that process.”

Now, after decades of criticizing health care providers for undertreating pain and not prescribing enough pain medication, the pendulum is swinging back. Some dentists are getting back up to speed about alternatives to opioids.

“For most dental pains, the nonsteroidal anti-inflammatory drugs (NSAIDS) —that’s Advil, Aleve, Naproxen — those agents are every bit as effective as one Vicodin or one Percocet,” Moore says. “That’s been shown over and over and over again.”

This next generation of dentists is not only learning about how to prescribe opioids appropriately, but also about how to think about pain differently. At the Harvard School of Dental Medicine, students are learning how to approach pain, a world away from opioids.

“You can approach it from opioid therapy, you can approach it from different neuropathy drugs, you can approach from stretching exercises to meditation,” says Kellie Moore, a fourth-year dental student at Harvard. “And just kind of like, exhausting all the options.”

Leaning on different methods of pain treatment can yield mixed success, she says: what works with one patient might not work for another.

Dental students are also rethinking what the goal of treating pain is.

“On a scale of 0 to 10, with 10 being the worst, if we can get you to a 4 or 5, could you live with that and still function daily?” says Sam Lee, a fourth-year dental student. “If the answer is yes, then I think it’s important to the patient understand that that’s what we’re going to try to maintain as the new normal for them.”

David Keith, an oral surgeon at Massachusetts General Hospital, agrees.

“I think it does us a disservice, making us and the patients assume that we should a total smiley face and a zero level of pain,” he said. “That’s not the real world. So we take a tooth out. We do a dental implant. You’re going to be sore for a few days, but that doesn’t mean you can’t go to work.”

The changing definition of pain is part of a larger change in the profession of dentistry. And Jeff Shaefer, an orofacial pain specialist who teaches at the Harvard School of Dental Medicine, says the role of the dentist is changing as a direct result of the opioid crisis.

“Dentistry is part of the problem and I think that hurts — that we’ve been overprescribing medication,” he says. “Having a standard regimen to give every patient is not appropriate.”

Nationally, the profession of dentistry is starting to change as well. This summer, the Commission on Dental Accreditation, which sets accreditation standards for all dental schools, ordered all graduates to be competent in accessing for substance use disorder.

But currently practicing dentists may not be so eager for a change to their profession. Keith, who regularly gives lectures to dentists in the state, has heard their complaints.

“There is a reluctance to add that, as there is reluctance to check blood pressure or check a list of medication their patients are on because it adds time to the day,” he said.

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The Senate is again trying to tackle the politics of health care. Rather than going for sweeping changes, lawmakers are acting more like handymen this time, looking for tweaks and fixes that will make the system that’s already in place work better.

Sen. Lamar Alexander, R-Tenn., is leading the effort to stabilize the Affordable Care Act’s insurance markets for next year. He’s trying to get a bipartisan bill together in the next 10 days, he said Thursday. He’s working against the clock; insurance companies have only until Sept. 27 to commit to selling policies on the ACA exchanges, and to set their final prices for health plans.

It’s a big ask. And Alexander, who is chairman of the Senate’s Health, Education, Labor and Pensions Committee, was frank about what needed to happen.

“To get a Republican president and a Republican House and a Republican Senate just to vote for more money won’t happen in the next two or three weeks, unless there’s some restructuring,” he told a group of five governors who testified before his committee Thursday.

It was the second of four hearings the committee is holding while developing a new health bill.

All of the governors and most of the senators in the room agreed that the top priority was for Congress to appropriate money for what are called cost-sharing reductions. These reimburse insurance companies for discounts they’re required by law to give low-income customers.

President Trump has threatened to cut off the payments, and insurance companies have responded to that uncertainty by proposing higher premiums for next year.

Funding CSR’s is the easy part, Alexander said.

He was looking for tweaks that will appease conservative Republicans who for years have told their constituents that Obamacare is a failure. They would be hard-pressed to appropriate money to fund it without some substantive changes.

Alexander presented the dilemma to the governors as an opportunity to ask for specific changes they’d like to see happen fast.

“This train may move through the station, and this is the chance to change those things,” he said near the end of the hearing. “And so if you want to tell us exactly what those are, and we got it by the middle of next week, we could use it and it would help us get a result.”

The governors had plenty of ideas.

Massachusetts Governor Charlie Baker, a Republican, said establishing reinsurance plans — pools of money to help insurers when they face huge costs from severely ill patients — can cut premiums for everyone.

Alaska last year created a reinsurance program that almost immediately slowed down the inflation in health insurance premiums in that state, Lori Wing-Heier, the director of the Alaska’s Division of Insurance, told the committee in testimony Wednesday.

Democratic Sen. Maggie Hassan of New Hampshire thinks Washington should put up some of the money for such programs.

“I’d be making the argument that at least some of the seed money should be coming from the feds because the feds are going to save money,” she told the governors at Thursday’s hearing.

And the governors unanimously supported Alexander’s proposal to give states waivers that would allow them out of some of Obamacare’s regulations, and enable states to design their own health care systems.

“What we’re really focused on is, how do you make the bureaucracy easier so that you can get these various waivers that pretty much all of us agree offer not only cost savings but in many cases will improve the actual outcomes of health care delivered,” Gov. Steve Bullock, of Montana, told the committee.

Sen. Chris Murphy, D-Conn., said he was concerned that giving too much flexibility would diminish the quality of the insurance policies.

Gov. Bill Haslam, of Tennessee, took issue with that.

“There’s an assumption from the federal government, that’s a little offensive to be honest, that ‘you won’t care for the least of these unless we tell you exactly how to do it,’ ” he said.

The governors were divided on a suggestion by Alexander that catastrophic health plans — which have high deductibles and don’t cover routine health care — should be more widely available. Under the Affordable Care Act such policies are only available to people under age 30.

Alexander said expanding the role of such policies could help gain the support of conservative Republicans in the House and Senate who want consumers to have more and cheaper choices in their insurance plans.

Baker, of Massachusetts, said he opposed expanding such policies, but Gov. Gary Herbert of Utah said he liked the idea.

In the end, Alexander suggested the bill he’ll pursue will likely include funding for cost-sharing payments and a more flexible waiver program. But he says he’s open to ideas.

“The reason for the hearings is for me to learn and listen,” Alexander said.

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A popular federal-state program that provides health coverage to millions of children in lower- and middle-class families is up for renewal Sept. 30.

But with a deeply divided Congress, some health advocates fear that the Children’s Health Insurance Program could be in jeopardy or that conservative lawmakers will seek changes to limit the program’s reach. Other financial priorities this month include extending the nation’s debt ceiling, finding money for the Hurricane Harvey cleanup and keeping the government open.

“With all that is on Congress’ plate, I am very worried that a strong, wildly successful program with strong public support will get lost in the shuffle and force states to begin the process of winding down CHIP,” said Bruce Lesley, president of the advocacy group First Focus.

The program covers more than 9 million kids — typically from families not poor enough to qualify for Medicaid, the state-federal program that covers health care for people with low incomes.

Income eligibility levels for CHIP vary widely among states, though most set thresholds at or below 200 percent of the poverty level — about $49,000 for a family of four. Unlike Medicaid, CHIP is usually not free to participants. Enrolled families pay an average premium of about $127 a year.

Since CHIP’s enactment, the share of uninsured children in the U.S. fell from 13.9 percent in 1997 to 4.5 percent in 2015, according to the Medicaid and CHIP Payment and Access Commission.

The 20-year-old program has bipartisan support. One of its original sponsors is Sen. Orrin Hatch, R-Utah, chairman of the Finance Committee, which has scheduled a hearing on reauthorization Thursday.

It’s possible in the jam-packed legislative calendar this month that other health-related provisions could be attached to a CHIP reauthorization bill — such as Republican-sponsored changes to the Affordable Care Act. Those changes could keep the resulting bill from getting enough support from Democrats and some Republicans in the Senate for passage.

“It’s the only vehicle in health care policy other than the federal budget that’s going to be moving, so it’s likely extraneous items are likely to be added to it,” says Christopher Pope, a health policy researcher and senior fellow at the conservative Manhattan Institute.

Supporters of CHIP also worry about changes in eligibility for the program that could dampen enrollment.

The Affordable Care Act bumped up federal funding of CHIP by 23 percentage points and forbids states to restrict eligibility rules that were in place in 2010. Both of those requirements continue through September 2019.

The added funding means a dozen states have their entire CHIP programs paid for by the federal government. In the fiscal year that ended last September, states contributed less than $2 billion, compared with the federal government’s $13.6 billion contribution, according to the conservative Heritage Foundation. States should pay a higher share of the program’s costs, the foundation argues.

President Trump’s budget request this spring called for immediately eliminating the ACA bump in funding and ending the restriction on a state’s ability to curtail eligibility — often referred to as the “maintenance of effort” provision.

But that provision has kept CHIP stable at a time when the individual insurance market faces uncertainty, says Joan Alker, director of Georgetown University’s Center for Children and Families in Washington, D.C.

Advocates note that if children have to leave CHIP and move to marketplace coverage, their families may be forced to pay higher out-of-pocket costs for their kids’ health care.

Without the maintenance-of-effort requirement, advocates fear that states would be more likely to do what Arizona did during the last economic downturn: It froze enrollment from December 2009 until last June. The move was allowed because it took effect before the ACA’s restriction began in March 2010.

Meanwhile, Republicans are not united in their views of the maintenance-of-effort requirement. Some favor it because, they say, it shifts more authority of the program to states. Others say it would very likely lead some states to move many CHIP enrollees into either Medicaid or private insurance policies sold on the Obamacare exchanges — both areas where the federal government may pay an even higher share of the costs, Pope says.

“It’s not a simple win for anything, but you can see why some governors would like it,” he says.

At a House subcommittee hearing in June, some Republican lawmakers expressed concerns about extending the enhanced federal funding for CHIP.

“This increase in funding has challenged the program by both shifting the nature of shared responsibility of the state Children’s Health Insurance Program to the federal government and making states more dependent on federal dollars,” said Rep. Michael Burgess, R-Texas, who heads the Energy and Commerce subcommittee on health.

A committee staff memo prepared for the hearing suggested that taking away the extra funding (as some Republicans would like to do), but leaving the maintenance-of-effort requirement in place, would not result in fewer children having coverage.

Without renewal of the program, Arizona, Minnesota, North Carolina and the District of Columbia would run out of their federal CHIP funding by the end of this year. By March 2018, an additional 27 states would exhaust their funds.

Minnesota and D.C. officials say all children in those two regions who are covered by CHIP will transition to Medicaid if the federal funding is cut.

Alker says the enhanced funding included in CHIP’s 2009 reauthorization has helped several states, including Nevada and Utah. The states were able to expand coverage to legal immigrant children immediately; before that extra money came in, these kids faced a five-year wait for insurance.

Given the complexity of making major changes and the tight congressional timeline, some experts say Congress may opt to pass a clean CHIP bill — without major changes to the program.

“Congress is in [session] this month so few days that I can easily see CHIP simply being reauthorized without strings attached,” says Joe Antos, a health economist with the conservative American Enterprise Institute. Lawmakers’ attention is more likely to focus on the debt-limit deadline, the budget resolution and tax reform, Antos says.

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Phil Galewitz is a senior correspondent for KHN.

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