Recent changes to North Carolina’s Controlled Substances Reporting System (CSRS) now permit licensed delegates, including registered dental hygienists, to run PDMP queries on behalf of a supervising prescriber. While this option may be appropriate in certain institutional or high-volume environments, our practice has made a deliberate decision not to delegate CSRS access.
This decision reflects clinical responsibility, operational logic, and alignment with current public-health data — not resistance to oversight or patient safety.
The Opioid Landscape Has Changed — the Control Framework Has Not
Dentistry responded early and decisively to concerns surrounding prescription opioid misuse. Over the past decade, dental opioid prescribing has declined sharply, short-course protocols are now standard, and non-opioid analgesic strategies are widely adopted.
At the same time, the epidemiology of opioid-related harm has shifted. Current overdose morbidity and mortality are driven overwhelmingly by illicit fentanyl and polypharmacy, not by prescription opioids issued in regulated healthcare settings. In this sense, the prescription-driven opioid crisis has largely sunset, even as broader substance-use harms persist.
Yet regulatory intensity continues to increase — not because dental prescribing has re-emerged as a driver of harm, but because the oversight infrastructure built during the crisis has not contracted. Instead, it has adapted.
PDMP Expansion Serves Oversight Objectives, Not Clinical Ones
PDMP systems were originally designed as targeted tools to identify outlier prescribing and diversion. Increasingly, they function as normalized surveillance infrastructure — producing audit-ready records that exist independently of clinical outcomes.
Expanding access through licensed delegates does not meaningfully improve clinical decision-making in dentistry, where prescribing is infrequent and procedure-based. What it does improve is coverage, traceability, and institutional defensibility.
From a control standpoint, this expansion ensures:
- more access points
- more licensed touchpoints
- clearer attribution of activity
- reduced ambiguity during audits or investigations
These outcomes serve oversight needs. They do not address a current clinical deficiency.
The Operational Contradiction
Registered dental hygienists are among the most economically productive and operationally essential members of a dental practice. Their chairside time is scarce, patient-facing, and central to practice viability. Redirecting that time to low-frequency administrative surveillance tasks does not improve care, efficiency, or safety.
At the same time, regulators have chosen to sunset unlicensed administrative access — roles better suited for clerical functions — while expanding access to licensed clinical personnel who carry personal credential risk.
From a practice perspective, this is illogical.
From a control perspective, it is coherent.
Licensed professionals:
- are individually identifiable
- carry disciplinary exposure
- generate cleaner audit trails
- reduce ambiguity about responsibility
This change optimizes accountability architecture, not workflow.
A Disproportionate Impact on Dental Specialists
There is an additional structural consequence that deserves explicit attention.
While general dentists outnumber all other dental licensees, many dental specialists — including oral and maxillofacial surgeons, periodontists, endodontists, prosthodontists, pediatric dentists, and orthodontists — do not employ registered dental hygienists. These practices have historically relied on trained but unlicensed clinical or administrative staff to support non-clinical functions.
With the sunsetting of unlicensed delegate access, specialists are left without a practical delegation pathway. They must either:
- personally perform all CSRS queries, or
- forego queries except when absolutely unavoidable
A policy framed as “expanding access” therefore functions, in practice, as a contraction of flexibility for a significant segment of the profession — particularly for high-acuity, procedure-dense practices that already operate under greater regulatory scrutiny.
This is not a neutral effect. It is a disproportionate operational burden imposed by design.
Delegation Consolidates Responsibility Rather Than Distributes It
Even when a licensed delegate performs a CSRS query:
- the supervising dentist remains fully responsible
- interpretation and clinical judgment remain unchanged
- liability does not diffuse — it concentrates
Delegation shifts the mechanics of access while preserving a single point of accountability.
For our practice, it is more coherent and defensible for the individual who bears clinical and legal responsibility to perform the query directly.
Preventing Compliance Drift and Opportunistic CE
There is another concern that should be stated plainly.
When regulatory options expand without clear clinical necessity, they often become fertile ground for secondary compliance industries — particularly continuing education programs framed as “required,” “protective,” or “best practice,” even when no such mandate exists.
Our practice is intentionally cautious about allowing optional regulatory tools to evolve into:
- implied obligations
- fear-based education
- or revenue-generating compliance narratives disconnected from clinical need
PDMP use should remain clinically motivated and proportionate — not a vehicle for opportunistic CE offerings that capitalize on ambiguity rather than improve patient care.
Clerical Surveillance Should Not Be Detached from Clinical Judgment
Licensed delegates do not have prescribing authority and are not trained to evaluate prescription histories for clinical relevance or risk stratification. Their role in PDMP access is administrative.
We believe PDMP use should remain a clinically driven action, not a routinized compliance exercise performed to satisfy oversight expectations rather than patient-specific need.
Optional Access Is Not a Mandate
Delegate access to CSRS is an option, not a requirement. Choosing not to delegate is not non-compliance.
Our practice continues to:
- use CSRS when clinically appropriate
- prescribe conservatively
- follow evidence-based pain-management protocols
- document rationale for PDMP queries
We simply do so directly, without introducing additional licensed access points that do not improve care.
A Proportionate Response to a Shifted Reality
Oversight mechanisms should evolve alongside the risks they were created to address. When regulatory structures expand after the original clinical driver has diminished, it is reasonable to question whether the objective has shifted from safety to system preservation.
For our practice — and for many specialty practices — direct prescriber access to CSRS remains the most proportionate, clinically coherent, and defensible approach.
In Summary
We support patient safety, responsible prescribing, and appropriate oversight. We also recognize that regulatory systems are designed to optimize traceability and defensibility — not practice efficiency — and that secondary compliance markets often arise in their wake.
Understanding those dynamics allows practices to make intentional, informed decisions.
For these reasons, our practice has chosen not to delegate CSRS queries. We believe this decision reflects sound clinical judgment, operational realism, and professional responsibility.