Do Dentist Over Prescribe Opioids?

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Dentistry and the Opioid Epidemic

Scott S. De Rossi, DMD

|August 26, 2016

Pain Relief and Dental Procedures

In the United States, drug overdose is the leading cause of injury-related death. Mortality rates from drug overdose more than doubled during 1999-2013, from 6.0 per 100,000 population in 1999 to 13.8 in 2013.[1] These increases are mainly attributable to the misuse and abuse of prescription drugs, including opioid analgesics prescribed by dentists, primary care providers, and other clinicians, and the risk for overdose is escalated when a patient acquires prescriptions from multiple prescribers.[1] Most deaths (60%) occur in patients who have been given prescriptions according to prescribing guidelines by medical and dental boards.

Opioid addiction can begin with a common dental procedure that has become a rite of passage for 3.5 million young adults annually: extraction of wisdom teeth. Many clinicians prescribe 30 days of postoperative narcotic pain medications for postprocedure pain when 2 weeks is sufficient, if necessary at all. It is estimated that 61% of 14- to 17-year-olds receive opioid prescriptions from dentists following third-molar extractions.[2] Recent studies are leading many to question how and why dentists prescribe addictive painkillers when available alternatives might be safer and more effective.[1-6]

To what extent should dental providers and patients examine their reliance on narcotic analgesics to manage postoperative pain? What can dentists do to better inform their opioid prescribing decisions and guard against unintentional overdose or drug sharing? These very important questions should be asked by every clinician.

Historically, patient expectations and demands following dental surgery, evolving prescribing behaviors, and long-standing strategies for postoperative pain management are factors that have driven the prescribing of opioids by oral health professionals. In fact, many arguments in favor of opioids in dental practice are based solely on traditions, expert opinion, practical experience, and uncontrolled anecdotal observations.[2]

Despite increased attention to the roles of physicians and dentists in curbing opioid misuse, abuse, and diversion, information about prescribing practices and the frequency of multiple concurrent opioid prescriptions among dental patients is limited.[3]

Trends in Opioid Prescribing by Dentists

Jenna McCauley and colleagues[3] offer a review of data from the South Carolina prescription drug monitoring program representative of dispensed medication for patients prescribed at least one opioid by a dentist during the most recently available 2-year timeframe (2012-2013). They used descriptive analyses to examine the types and frequency of dental opioid prescriptions and the frequency of existing multiple concurrent opioid prescriptions among dental patients.

Nearly all dispensed opioid prescriptions (99.9%; n = 653,650) were for immediate-release opioids and were filled as initial prescriptions (96.2%), not refilled prescriptions. Hydrocodone (76.1%) and oxycodone (12.2%) combination products were the opioids most frequently prescribed by dentists.

Surprisingly, people younger than 21 years received more than 11% of dentist-prescribed opioids.

Surprisingly, people younger than 21 years received more than 11% of dentist-prescribed opioids. The study authors concluded that oral health professionals prescribed a large volume of the immediate-release opioids dispensed in South Carolina. A notable minority of dental patients had multiple preexisting opioid prescriptions, a situation that has been implicated in patient misuse, abuse, overdose, and diversion of opioids.[3]

Dentists: Get on Board

Many experts, including the US Surgeon General, have warned that opioid abuse has reached epidemic proportions in the United States. An innocuous prescription drug to relieve dental pain can precipitate a cycle of misuse, abuse, and addiction. An estimated 20% of patients presenting to physician or dental offices with pain symptoms or pain-related diagnoses (both acute and chronic pain) receive an opioid prescription.[4] An estimated 23% of prescribed doses are used nonmedically.[5]

Certain patients seek these drugs for nonmedical use or resale, often obtaining overlapping prescriptions from multiple prescribers. This is not surprising when you consider that in 2012, healthcare providers wrote 259 million prescriptions for opioid pain medication, and from 2007 to 2012, opioid prescriptions per capita increased more than 7%.[1] On a state-by-state basis, opioid prescribing varies greatly in ways that cannot be explained by the underlying health status of the population, stressing the lack of consensus among clinicians on how to use opioid pain medication in our patient populations.

Dentists continue to be among the leading prescribers of opioid analgesics.

Dentists continue to be among the leading prescribers of opioid analgesics, and surgical tooth extraction is one of the most frequently performed dental procedures that prompts such prescriptions.[6] As prescribers of 12% of immediate-release opioids in the United States, dentists must be part of the campaign to minimize the potential for misuse or abuse in the population through patient education, careful patient assessment, and referral for substance abuse treatment when indicated. They must make use of prescription monitoring programs in the clinical setting.[5]

Dentists can no longer assume that prescribing opioids does not affect the opioid abuse problem in the United States. Clinicians must take steps to identify problems and minimize prescription opioid abuse through greater prescriber and patient education, use of peer-reviewed recommendations for analgesia, and determining the appropriate and legitimate prescribing of opioids to adequately treat pain from dental procedures.[5]

What Can Dentists Do?

Referring to a prescription drug monitoring program (PDMP) before prescribing forces a record of controlled substances dispensed to a patient and could inform prescribing, coordination of care, and screening or referral for addiction. Patient education on misuse behaviors and their risks, as well as the importance of secure storage and disposal of leftover opioid medications, are necessities in the dental practice and dental education. Although PDMPs have helped to combat prescription drug abuse and diversion, there are still deficiencies in these systems that need to be addressed with more research.[7]

In 2015, authors of two evidence-based Cochrane systematic reviews assessed the efficacy and adverse effects of nearly all oral analgesic formulations.[8,9] These comprehensive meta-analyses included results from 350 individual randomized clinical trials in which investigators assessed data in more than 45,000 participants undergoing both dental and medical surgical procedures.

The findings of these and other comprehensive reviews unequivocally confirm two important conclusions: (1) that nonsteroidal anti-inflammatory drugs (NSAIDs) are remarkably effective in relieving postoperative pain, and (2) the opioid analgesic combinations are associated with high incidences of adverse effects.[8-11]

If NSAID analgesics are at least as effective as opioid pain relievers and are associated with fewer adverse effects, why do we continue to prescribe opioid pain relievers for our patients? We must move beyond traditions, expert opinion, practical experience, and uncontrolled anecdotal observations when prescribing opioids to our patients. We need to adhere to appropriate prescribing patterns—using less medication for briefer periods of time—while we improve our knowledge of pain management and perceived safety, and change misconceptions about the undertreatment of pain.

This fall, the US Surgeon General’s office will issue a report on substance use, addiction, and health (the first on the topic since they began issuing reports in 1964), urging us to step up efforts to combat the country’s opioid epidemic.[12] Dentists, let’s join this call to action.

References

  1. Paulozzi LJ, Mack KA, Hockenberry JM. Vital signs: variation among states in prescribing of opioid pain relievers and benzodiazepines—United States, 2012. MMWR Morb Mortal Wkly Rep. 2014;63:563-568. Abstract
  2. Manchikanti L, Helm S 2nd, Fellows B, et al. Opioid epidemic in the United States. Pain Physician. 2012;15(3 Suppl):9-38.
  3. McCauley JL, Hyer JM, Ramakrishnan VR. Dental opioid prescribing and multiple opioid prescriptions among dental patients: administrative data from the South Carolina prescription drug monitoring program. J Am Dent Assoc. 2016;147:537-544. Abstract
  4. Daubresse M, Chang HY, Yu Y, et al. Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000-2010. Med Care. 2013;51:870-878. Abstract
  5. Denisco RC, Kenna GA, O’Neil MG, et al. Prevention of prescription opioid abuse: the role of the dentist. J Am Dent Assoc. 2011;142:800-810. Abstract
  6. Baker JA, Avorn J, Levin R, Bateman BT. Opioid prescribing after surgical extraction of teeth in Medicaid patients, 2000-2010. JAMA. 2016;315:1653-1654. Abstract
  7. Gabay M. Prescription drug monitoring programs. Hosp Pharm. 2015;50:277-278. Abstract
  8. Moore RA, Wiffen PJ, Derry S, Maguire T, Roy YM, Tyrrell L. Non-prescription (OTC) oral analgesics for acute pain: an overview of Cochrane reviews. Cochrane Database Syst Rev. 2015;11:CD010794.
  9. Moore RA, Derry S, Aldington D, Wiffen PJ. Adverse events associated with single dose oral analgesics for acute postoperative pain in adults: an overview of Cochrane reviews. Cochrane Database Syst Rev. 2015;10:CD011407.
  10. Au AH, Choi SW, Cheung CW, Leung YY. The efficacy and clinical safety of various analgesic combinations for post-operative pain after third molar surgery: a systematic review and meta-analysis. PLoS ONE. 2015;10:e0127611.
  11. Moore PA, Nahouraii HS, Zovko JG, Wisniewski SR. Dental therapeutic practice patterns in the U.S. II. Analgesics, corticosteroids, and antibiotics. Gen Dent. 2006;54:201-207. Abstract
  12. Ault A. Surgeon General to urge prescribers to fight opioid epidemic. Medscape Medical News. April 11, 2016. http://www.medscape.com/viewarticle/861744 Accessed August 1, 2016.
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