Heroes of the Addiction Crisis: How Dr. Coty Hulgan is Helping to Reduce Opioid Dependencies
The first time I implemented an opioid sparing protocol in our office, I was meticulous on follow-up to make sure my patient was comfortable following her procedure. It was profoundly impactful to me to speak with the patient at the 24- and 48-hour marks to find that there was no significant discomfort. This truly gave me the confidence to take this protocol to my practice and know that my patients are going to respond well to treatment without a concern for handing out prescriptions for narcotics.
I had the pleasure of interviewing Dr. Coty Hulgan. Dr. Hulgan is a native of Albertville, Alabama and a graduate of Birmingham-Southern College. He completed a Master’s in Public Health and dental school at the University of Alabama at Birmingham. Following dental school, Dr. Hulgan finished a three-year program to receive specialty training in Periodontics. Dr. Hulgan maintains an adjunct faculty position at the UAB School of Dentistry. Dr. Hulgan and his wife, Tara, have lived in Birmingham since 2004 and have one daughter, Mary Garner. Outside of the office, he enjoys running and maintains a lifelong passion for music in the form of guitar.
Thank you so much for joining us! Is there a particular story or incident that inspired you to get involved in your work with opioid and drug addiction?
Prior to dental school, I worked as a surgical technician to retrieve corneas and eyes for donation and research from patients who were organ donors. I recall seeing so many patients in the emergency room that had passed away from drug related complications. Every time I saw a case, it impacted me to see these lives taken on a potentially preventable problem.
While in dental school, I was assigned a patient that was 17-years old with an entire mouth of non-restorable teeth due to cavities. The patient arrived at this point due to a narcotic addiction that caused dry mouth and a diet profoundly high in sugar. His mom accompanied him to the initial appointment, and I had the task to tell them that he would be losing all of his teeth and placed in a set of dentures before he was old enough to be considered an adult.
Can you explain what brought us to this place? Where did this epidemic come from?
As a periodontist who performs dental procedures, I know all too well the risks opioids can present to patients after surgery. A 2017 report revealed that nearly 1-in-10 patients prescribed opioids to manage postsurgical pain went on to persistent use of the medications, meaning they were still taking opioids three to six months after their procedure. And while the opioid epidemic has affected the entire nation, my home state of Alabama, has been hit especially hard. In 2017, Alabama had the highest prescribing rate in the country with providers writing more than 107 opioid prescriptions for every 100 persons — nearly two-times the average U.S. rate.
While overprescribing opioids after surgery isn’t the sole cause of the epidemic, it is considered an unintentional gateway to opioid addiction and dependence as millions of patients prescribed opioids after surgery each year become persistent opioid users, still taking opioid medication three to six months after surgery.
Can you describe how your work is making an impact battling this epidemic?
My struggle as a clinician is to find a balance of making sure my patients are comfortable in the post-operative phase of treatment, while limiting the amount of narcotics that go into my community.
A large portion of my patients are young adults (ages 18–30) and dental surgery is often this population’s first exposure to opioids. I have an opioid sparing protocol in my office to limit opioid use that includes pre-op NSAIDs and by using a non-opioid option called EXPAREL. This long-acting local anesthetic is placed into the surgical site during a procedure and slowly releases a numbing medication to provide pain relief for the first two-to-three days after surgery. This is the window when patients need it the most.
Since implementing this approach, I’ve decreased opioid prescriptions by over 85% in our practice.
Without sharing real names, can you tell us a story about a particular individual/patient who was impacted by your initiative?
The first time I implemented an opioid sparing protocol in our office, I was meticulous on follow-up to make sure my patient was comfortable following her procedure. It was profoundly impactful to me to speak with the patient at the 24- and 48-hour marks to find that there was no significant discomfort. This truly gave me the confidence to take this protocol to my practice and know that my patients are going to respond well to treatment without a concern for handing out prescriptions for narcotics.
Can you share something about your work makes you most proud? Is there a particular story or incident that you found most uplifting?
Specific to my branch of dentistry, I see a portion of my practice dedicated to long term management of helping patients to keep his or her teeth. It is also extremely rewarding when I have a patient come in with a specific, identifiable problem that I feel confident I can fix. Gingival recession is one of the most common referrals that I see in our clinic. There are a multitude of approaches to address this problem based on severity and tissue quality and it is very exciting to approach these cases with creativity and a mindset of minimally invasive surgery for treatment.
One patient in particular had teeth taken out at a young age and was left with poor tissue quality across the top arch. Her denture had no foundation for retention. We were able to take a creative approach to her case to increase the amount of fixed tissue in the top area of her mouth. She returned with tears in her eyes with a hug to both myself and my surgical assistant, thankful that she could finally eat the way she wanted to eat.
Can you share three things that the community and society can do to help you address the root of this problem? Can you give some examples?
A lot is already being done in communities across the country, but there is always more we can do. First, patients and caregivers need to have conversations with their doctors prior to surgery about non-opioid options to manage pain. I would encourage someone thinking about having any type of surgery to talk with their doctor and develop a plan that’s personal for their recovery.
Additionally, those who have prescription opioids in their homes should consider discarding them at an authorized drop-off facility such as your local law enforcement agency. This is extremely important as a recent report found that nearly 90% of patients with leftover opioid pills didn’t dispose of them properly, with many keeping them in their homes and some sharing them with family or friends.
If you had the power to influence legislation, which three laws would you like to see introduced that might help you in your work?
If I had the power to influence legislation, three laws I would like introduced would be 1) to mandate and reimburse healthcare professionals for having proactive discussions about pain management with patients before surgery, 2) institute patient consent forms that allows a patient to “opt-out” of opioids and 3) passing H.R. 5172, Non-Opioids Prevent Addiction in the Nation (NOPAIN) Act.
It’s important for doctors to discuss the risks of opioids with patients before their surgery takes place, and educate them on opioid alternatives so they understand what options are available and best for them. Patient consent forms are used in some states already, but not all. These forms are especially paramount for individuals in recovery who cannot take opioids but often find themselves walking out of a doctor’s office with a prescription anyway. It would allow individuals to carry a permanent record indicating that they should not be administered an opioid. Finally, representatives and Senators in Alabama and West Virginia recently introduced the bipartisan NOPAIN Act, which would eliminate technical barriers that make it hard, and many times impossible, for clinicians and patients to access safe, effective non-opioids for surgery or other acute pain.
I know that this is not easy work. What keeps you going?
We are all in a process of improving. I try to keep a mindset of leaving a place better than you found it and this is a very practical way that I can impact my community.
Do you have hope that one day this leading cause of death can be defeated?
Certainly, I believe that if we all work together, we can combat this issue.
How do you define “Leadership”? Can you explain what you mean or give an example?
Leadership is accomplished by example and empowering the people around you. Any team member that is hired at my practice is asked “what are your goals outside of this office?” I understand that we will not have the same team forever and by encouraging the team around you, we are all working towards a bigger purpose.
What are your “5 things I wish someone told me when I first started” and why. Please share a story or example for each.
- Learning is hard.
- Treat others the way you want to be treated.
- Fake it ’til you make it. Assert yourself as the person you want to be and learn about how to become that person.
- Take advantage of the opportunities you have to understand the people around you. Everyone you interact with throughout your day has a story.
- Learn from others’ mistakes so you don’t have to make them.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
“Keep being brave.” When I started my first practice out of residency, a close friend sent this in a text to me. I was overwhelmed with the amount of things I needed to accomplish to even get the doors open. One day when I had spoken with him about the amount of stress I was taking on, he sent me this simple message that has stayed with me throughout my career.
Is there a person in the world, or in the US whom you would love to have a private breakfast or lunch with, and why?
When I was younger, my grandfather spent a great deal of time to take me outside and share his life experience with me. He passed away when I was 11 and I recall he had such insight to life. I wish that I could spend some time with him as an adult to be able to truly take this in and share it with my daughter.
How can our readers follow you on social media?
Southern Periodontics Facebook Page
Southern Periodontics Instagram Page
Thank you for all of these great insights!
