DULUTH, Minn.-The patient, who came in just before lunch, was well-dressed and had a disarming personality.
He said he was in terrible pain. He had tears in his eyes. He desperately needed pain medication.
But something didn't seem right to Dr. John Wainio, a Duluth dentist. He declined to prescribe opioid drugs, instead calling the oral surgeon who had extracted the patient's tooth. It was agreed the patient could see them in two hours.
Wainio later learned that the patient never showed up. It sparked his interest and - since the patient was now a patient of record at his practice - he had access to the patient's pharmacy records.
What he learned: Over the next two years, 23 Duluth dentists wrote prescriptions for the man, as did 15 emergency room physicians.
He saw the man in 2008, Wainio said in an interview this week, and it was one of his early experiences with what medical professionals call a "drug seeker" - individuals who are addicted to prescription opioids and find ways to game the system to satisfy their lust for the drugs.
Wainio, who recently retired from his practice, became a crusader on the issue of prescription pain pills. He was among the presenters on Friday as more than 50 dental professionals from the Northeastern District Dental Society gathered at the Kitchi Gammi Club for a continuing education seminar on opioids.
The centerpiece was protocols - or guidelines - on pain management that the Minnesota Dental Association approved last year. They came out of the work of an opioid task force chaired by Wainio that recommended oral and facial pain be managed without opioids.
Dr. Nathan Pedersen of Hibbing, vice president of the Northeastern District, told his fellow dental professionals that the stance on opioids has changed considerably in the 12 years he has been practicing.
In dental school, "we had zero, almost zero, addiction training," he said. Regulatory groups were telling medical professionals that they must treat pain with opioids. Now, the same groups are telling doctors and dentists to get patients off of opioids.
The problem of prescription drugs leading to addiction is well-known, but the role of dentists might not be so readily apparent. Dentists and oral surgeons prescribe 12 percent of the immediate-release opioids in the U.S., Pedersen said - more than 1 billion doses annually of hydrocodone and oxycodone.
In many cases, the first dose was prescribed by a dentist.
"We need to keep in mind that we are often prescribing patients with their first opioid when we remove their wisdom teeth," said Pedersen, who also served on the Minnesota Dental Association's opioid task force.
Like Wainio, Pedersen has had his experiences with drug seekers, including a patient who in three months across three states and 18 different providers had collected more than 500 pills. Instead of complying with the patient's wish, Pedersen handed him a pamphlet. "He swore at me and left," Pedersen said.
Wainio gave up his Drug Enforcement Agency license about five years ago, he said, voluntarily ending his ability to prescribe opioids. Quality clinical studies regarding a couple of dental procedures have shown either ibuprofen or a combination of ibuprofen and acetaminophen to be as effective as or better than prescription opioids, Wainio said.
Bridgett Anderson, who is executive director of the Minnesota Board of Dentistry, worked with Wainio in drawing up the protocols in her previous position as director of regulatory affairs for the Minnesota Dental Association.
The state group is ahead of the American Dental Association on that subject, Anderson said, and much of the impetus for that came from Northeastern Minnesota.
"Mainly it's because of the amount of diversion and drug abuse in this area, in this county," said Anderson, who attended Friday's seminar. "I know that it sparked the interest of several of the dentists in this area years ago. ... A lot of great energy and a lot of willingness to do the legwork on this came from this region, and Dr. Wainio really spearheaded a lot of this."