Association of Opioid Use With Pain and Satisfaction After Dental Extraction

Alternatives to dental opioid prescribing after tooth extraction (ADOPT): protocol for a stepped wedge cluster randomized trial

BACKGROUND

Dentists and oral surgeons are leading prescribers of opioids to adolescents and young adults (AYA), who are at high risk for developing problematic opioid use after an initial exposure. Most opioids are prescribed after tooth extraction, but non-opioid analgesics provide similar analgesia and are recommended by multiple professional organizations.

METHODS

This multi-site stepped wedge cluster-randomized trial will assess whether a multicomponent behavioral intervention can influence opioid prescribing behavior among dentists and oral surgeons compared to usual practice. Across up to 12 clinical practices (clusters), up to 33 dentists/oral surgeons (provider participants) who perform tooth extractions for individuals 12-25 years old will be enrolled. After enrollment, all provider participants will receive the intervention at a time based on the sequence to which their cluster is randomized. The intervention consists of prescriber education via academic detailing plus provision of standardized patient post-extraction instructions and blister packs of acetaminophen and ibuprofen. Provider participants will dispense the blister packs and distribute the patient instructions at their discretion to AYA undergoing tooth extraction, with or without additional analgesics. The primary outcome is a binary, patient-level indicator of electronic post-extraction opioid prescription. Data for the primary outcome will be collected from the provider participant's electronic health records quarterly throughout the study. Provider participants will complete a survey before and approximately 3 months after transitioning into the intervention condition to assess implementation outcomes. AYA patients undergoing tooth extraction will be offered a survey to assess pain control and satisfaction with pain management in the week after their extraction. Primary analyses will use generalized estimating equations to compare the binary patient-level indicator of being prescribed a post-extraction opioid in the intervention condition compared to usual practice. Secondary analyses will assess provider participants' perceptions of feasibility and appropriateness of the intervention, and patient-reported pain control and satisfaction with pain management. Analyses will adjust for patient-level factors (e.g., sex, number of teeth extracted, etc.).

DISCUSSION

This real-world study will address an important need, providing information on the effectiveness of a multicomponent intervention at modifying dental prescribing behavior and reducing opioid prescriptions to AYA.

CLINICALTRIALS

GOV: NCT06275191.

Post-Procedure Analgesic Management

During the development of multimodal pain management protocols, practitioners need to consider the potential risks each treatment modality inherently carries in order to prevent or diminish harmful outcomes. As an example, the part dentists played in the early stages of the opioid epidemic in the United States of America should serve as a cautionary account. By understanding the roots of this crisis, as practitioners we are better equipped to implement the novel analgesic agents available today to optimize post-operative pain control while minimizing any risk of addiction and harm to our communities. It is therefore critical that our colleagues understand the variety of accessible options for pain management to assure that our profession is able to seek adequate and sustainable relief for our post-operative patients. This article will go in depth to explain the analgesic tools practitioners can implement for an effective low-risk protocol, including a combination of NSAIDS and acetaminophen approach, using long-acting local anesthetics such as Exparel, pregabalin, gabapentin, ketamine, dexmedetomidine, and corticosteroids, and enhanced recovery after surgery protocols.

Pain management following dental trauma and surgical procedures

Surgical procedures and post-traumatic management of dental patients require effective pain management during treatment, but being considerably more invasive than conservative treatments, pain management is required into the postoperative period. Clinical trials on pain intensity following dental surgical procedures (e.g., 3rd molar extraction, implant placement, periodontal, and endodontic surgery) have shown that pain is most intense approximately 5-6 h after completion of the procedure, reaching its peak levels during the first postoperative day. Greatest consumption of analgesics occurs during the first 48-72 h after 3rd molar extraction. For the management of perioperative pain associated with either conservative or surgical dental treatment, the local anesthetics articaine, lidocaine, mepivacaine, and prilocaine are preferred. These drugs, with a vasoconstrictor, provide a rapid onset and a duration of pulpal anesthesia adequate to complete most dental and surgical procedures painlessly. For management of post-traumatic and postsurgical pain, bupivacaine-administered by an appropriate nerve block-near the conclusion of a surgical procedure, can provide the patient with a pain-free period of up to 12 h. Nonsteroidal anti-inflammatory drugs represent the most effective drugs for the management of dental postsurgical pain. NSAIDs, as a group in therapeutic doses, have numbers needed to treat (NNTs) ranging from 2 to 3, while opioid analgesics do not approach those for NSAIDs. A protocol for management of pain following surgical procedures and traumatic injuries is discussed in this paper and includes preemptive NSAID; perioperative pain management; postoperative pain management-local anesthesia; postoperative pain management-analgesics; postoperative telephone call.

Are there differences in opioid prescriptions to urban and rural patients by oral-maxillofacial surgeons in Massachusetts from 2011-2021?

PURPOSE

Oral-maxillofacial surgeons (OMSs) are frequent prescribers of opioid analgesics. It remains unclear if prescription patterns differ for urban versus rural patients, given potential differences in access to and delivery of care. This study aimed to characterize urban-rural differences in opioid analgesic prescriptions to patients in Massachusetts by OMSs from 2011 to 2021.

METHODS

This retrospective cohort study used the Massachusetts Prescription Monitoring Program database to identify Schedule II and III opioid prescriptions by providers with specialty of "oral and maxillofacial surgery" from 2011 to 2021. The primary predictor variable was patient geography (urban/rural) and secondary predictor was year (2011-2021). The primary outcome variable was milligram morphine equivalent (MME) per prescription. Secondary outcome variables were days' supply per prescription and number of prescriptions received per patient. Descriptive and linear regression statistics were performed to analyze differences in prescriptions to urban and rural patients each year and throughout the study period.

RESULTS

The study data, which includes OMS opioid prescriptions (n = 1,057,412) in Massachusetts from 2011 to 2021, ranged annually between 63,678 and 116,000 prescriptions to between 58,000 and 100,000 unique patients. The cohorts each year ranged between 48 and 56% female with mean ages between 37 and 44 years. There were no differences in the mean number of patients per provider in urban and rural populations in any year. The study sample had a large majority of urban patients (>98%). MME per prescription, days' supply per prescription, and prescriptions received per patient were all generally similar between urban and rural patients each year, with the largest MME per prescription difference in 2019 (87.3 for rural to 73.9 for urban patients, P < .01). From 2011 to 2021, all patients had a steady decrease in MME per prescription (β = -6.64, 95% confidence interval: -6.81, -6.48; R² = 0.39) and day's supply per prescription (β = -0.1, 95% confidence interval: -0.1, -0.09; R² = 0.37).

CONCLUSION

In Massachusetts, there were similar opioid prescribing patterns by OMSs to urban and rural patients from 2011 to 2021. There has also been a steady decrease in the duration and total dosage of opioid prescriptions to all patients. These results are consistent with multiple statewide policies over the last several years aimed at curbing opioid overprescribing.

Association of Postoperative Opioid Prescription Size and Patient Satisfaction

OBJECTIVE

To evaluate the association between postoperative opioid prescription size and patient-reported satisfaction among surgical patients.

SUMMARY BACKGROUND DATA

Opioids are overprescribed after surgery, which negatively impacts patient outcomes. The assumption that larger prescriptions increase patient satisfaction has been suggested as an important driver of excessive prescribing.

METHODS

This prospective cohort study evaluated opioid-naive adult patients undergoing laparoscopic cholecystectomy, laparoscopic appendectomy, and minor hernia repair between January 1 and May 31, 2018. The primary outcome was patient satisfaction, collected via a 30-day postoperative survey. Satisfaction was measured on a scale of 0 to 10 and dichotomized into "highly satisfied" (9-10) and "not highly satisfied" (0-8). The explanatory variable of interest was size of opioid prescription at discharge from surgery, converted into milligrams of oral morphine equivalents (OME). Hierarchical logistic regression was performed to evaluate the association between prescription size and satisfaction while adjusting for clinical covariates.

RESULTS

One thousand five hundred twenty patients met the inclusion criteria. Mean age was 53 years and 43% of patients were female. One thousand two hundred seventy-nine (84.1%) patients were highly satisfied and 241 (15.9%) were not highly satisfied. After multivariable adjustment, there was no significant association between opioid prescription size and satisfaction (OR 1.00, 95% CI 0.99-1.00). The predicted probability of being highly satisfied ranged from 83% for the smallest prescription (25 mg OME) to 85% for the largest prescription (750 mg OME).

CONCLUSIONS

In a large cohort of patients undergoing common surgical procedures, there was no association between opioid prescription size at discharge after surgery and patient satisfaction. This implies that surgeons can provide significantly smaller opioid prescriptions after surgery without negatively affecting patient satisfaction.

Effects of Systemic Lidocaine Versus Dexmedetomidine on the Recovery Quality and Analgesia After Thyroid Cancer Surgery: A Randomized Controlled Trial

INTRODUCTION

Surgical management is commonly used for thyroid cancer. We evaluated the effects of systemic lidocaine versus dexmedetomidine on the recovery quality and analgesia after thyroid cancer surgery.

METHODS

A total of 120 patients with thyroid cancer were randomly allocated to group L (received lidocaine 1.5 mg/kg loading, continuously infused 1.5 mg/kg per hour), group D (received dexmedetomidine 0.5 µg/kg loading, continuously infused 0.5 µg/kg per hour) and group C (received normal saline), with 40 cases in each group. Anaesthesia induction and maintenance were performed using target-controlled infusions (TCIs) of propofol and remifentanil. The primary outcome of the quality of recovery-15 (QoR-15) score was recorded on the day before surgery and postoperative day 1 (POD1). Secondary outcomes included the consumption of remifentanil during surgery, time to first required rescue analgesia, number of patients requiring rescue analgesia, postoperative cumulative consumption of tramadol, visual analogue scale (VAS) pain score, incidence of postoperative nausea or vomiting (PONV) and side effects.

RESULTS

The total score of the QoR-15 at POD1 (median, IQR) was higher in group L (128.0, 122.0-132.8) and group D (127.5, 122.5-132.5) compared to group C (118.5, 113.0-123.5) (P = 0.000). Compared to group C, systemic lidocaine and dexmedetomidine reduced cumulative consumption of remifentanil and VAS pain score (P = 0.000). The time to first required rescue analgesia (mean, SD) was longer in group L (8.1 h, 1.2 h) and group D (8.5 h, 1.9 h) than group C (5.9 h, 0.9 h) (P = 0.000). The number of patients requiring rescue analgesia was lower in group L (8/40, 20%) and group D (6/40, 15%) than group C (16/40, 40%) (P = 0.029), and cumulative consumption of tramadol (mean, SD) was lower in group L (44.0 mg, 17.1 mg) and group D (51.7 mg, 14.1 mg) than group C (73.9 mg, 18.4 mg) (P = 0.000). The incidence of PONV in group L (7/40, 17.5%) and group D (9/40, 22.5%) was lower than group C (18/40, 45.0%) (P = 0.016). Bradycardia (heart rate  less than 50 beats/min or lower) was noted in 25 patients (25/40, 62.5%), which was reversed by intravenous administration of atropine 0.5 mg.

CONCLUSION

Systemic lidocaine and dexmedetomidine had similar effects on enhancing the quality of recovery, alleviating the intensity of pain and reducing the incidence of PONV after thyroid cancer surgery. However, dexmedetomidine may result in bradycardia. Therefore, lidocaine was superior to dexmedetomidine.

TRIAL REGISTRATION

ChiCTR.org.cn (ChiCTR2000038442). Registered on September 22, 2020.

Barriers to and facilitators of opioid prescribing by dentists in the United States: A qualitative study

BACKGROUND

Dentists in the United States frequently prescribe opioids for dental-related pain, although evidence shows superior efficacy of nonopioids for pain management. A national sample of US dentists was interviewed to understand the barriers and facilitators to opioid prescribing.

METHODS

Semistructured one-on-one telephone interviews were conducted with dentists sampled from the 6 regions of The National Dental Practice-Based Research Network. Responses were coded into the domains of the Capability, Opportunity and Motivation Model of Behavior. Potential behavior change interventions were identified for targeted themes.

RESULTS

Seventy-three interviews were qualitatively analyzed. Most of those interviewed were general dentists (86.3%) and on average (SD) were in practice for 24.3 (13.0) years. Ten themes were identified within the Capability, Opportunity and Motivation Model of Behavior. Dentists' knowledge of opioid risk, ability to identify substance use disorder behavior, and capability of communicating pain management plans to patients or following clinic policies or state and federal regulations were linked with judicious opioid prescribing. Dentists reported prescribing opioids if they determined clinical necessity or feared negative consequences for refusing to prescribe opioids.

CONCLUSIONS

Dentists' opioid decision making is influenced by a range of real-world practice experiences and patient and clinic factors. Education and training that target dentists' knowledge gaps and changes in dentists' practice environment can encourage effective communication of pain management strategies with patients and prescribing of nonopioids as first-line analgesics while conserving opioid use.

PRACTICAL IMPLICATIONS

Identified knowledge gaps in dentistry can be targets for education, clinical guidelines, and policy interventions to ensure safe and appropriate prescribing of opioids.

Association of sociodemographic factors with the prescription pattern of opioids for dental patients: a systematic review

Aim To evaluate the association of patients' sociodemographic factors (sex, age, ethnicity, income, educational level, living environment and health insurance) with the prescription pattern of opioids provided by oral health practitioners.Methods Observational studies that evaluated the association of patients' sociodemographic factors and the likelihood of receiving an opioid prescription provided by an oral health practitioner were eligible. Electronic searches were conducted in Medline (PubMed), Embase, Scopus, Web of Science, LILACS, SciELO, Google Scholar, and OpenGrey up to March 2021. Two authors independently screened the studies, performed data extraction, and assessed the risk-of-bias using the critical appraisal tools developed by the Joanna Briggs Institute (JBI). Certainty of the evidence was assessed with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE).Results Eight studies were included in this systematic review. Publication year ranged from 2011 to 2021. Narrative synthesis showed with very low certainty of evidence that younger individuals were more likely to receive a prescription of opioids than older individuals. Regarding the other sociodemographic factors and the prescriptions of opioids in dentistry, the evidence is controversial. Risk of bias was low for most items assessed in the included studies.Conclusion The available evidence suggests that there is an association between patients' sociodemographic factors and the prescription patterns of opioids provided by oral health practitioners.

Factors influencing opioid prescribing after tooth extraction

BACKGROUND

Tooth extractions account for most opioid prescriptions from dentists, but specific characteristics that influence likelihood are less established. Improving understanding can facilitate development of tailored interventions to reduce unnecessary opioid prescribing.

METHODS

The authors performed a retrospective review of patients 12 years and older undergoing tooth extraction at the College of Dentistry at the University of Kentucky from 2013 through 2020. The primary end point was issuance of an opioid prescription related to the encounter.

RESULTS

In 44,387 eligible records analyzed, 10,628 (23.9%) patients received an opioid prescription. Results of multivariable logistic regression found that the factors associated with an opioid prescription included receipt of a nonopioid analgesic prescription (adjusted odds ratio [aOR], 11.36; 95% CI, 10.37 to 12.44), receipt of an antibiotic prescription (aOR, 8.29; 95% CI, 7.57 to 9.08), procedural sedation (aOR, 2.11; 95% CI, 1.93 to 2.31), surgical extraction (aOR, 1.96; 95% CI, 1.84 to 2.10), and third molar extractions (1 tooth: aOR, 1.14; 95% CI 1.04 to 1.25; 2 teeth: aOR, 2.09; 95% CI, 2.87 to 2.34; 3 teeth: aOR, 2.73; 95% CI, 2.36 to 3.15; 4 teeth: aOR, 3.45; 95% CI, 3.10 to 3.83). Factors that decreased risk included having an appointment in 2018 or later (aOR, 0.31; 95% CI, 0.29 to 0.33), in a student (aOR, 0.57; 95% CI, 0.51 to 0.65) or resident (aOR, 0.33; 95% CI, 0.31 to 0.36) clinic, and on any day other than Friday (Monday: aOR, 0.83; 95% CI, 0.76 to 0.91; Tuesday: aOR, 0.90; 95% CI, 0.83 to 0.99; Wednesday: aOR, 0.89; 95% CI, 0.81 to 0.97; Thursday: aOR, 0.88; 95% CI 0.81 to 0.97).

CONCLUSIONS

Opioid prescriptions after tooth extraction were common in patients undergoing more extensive procedures. Provider perceptions, habits, and several clinical factors appeared to influence prescribing patterns.

PRACTICAL IMPLICATIONS

The decision to prescribe an opioid appears to be associated with habits and factors perceived to modulate postoperative pain, which may serve as targets for opioid reduction strategies.

Dean reported opioid and pain management curriculum in US dental schools

PURPOSE

Dental students learn to prescribe pain management medications in dental school, including opioids. Given the current state of opioid-related morbidity and mortality in the US, dental schools should evaluate the context and implementation of opioid prescribing in their dental school clinics (DSCs).

METHODS

A nationwide survey of deans of clinical operations at all US dental schools was conducted in 2020 related to pain management in their DSC. The Michigan Medicine Institutional Review Board deemed this study unregulated (HUM00151607).

RESULTS

Of the 68 accredited dental schools in the United States, 26 deans of DSCs responded to the survey, yielding a 40% response rate. The survey results showed differences in the levels of education for dental students on opioid prescribing and patient education requirements. A comprehensive curriculum regarding safe opioid prescribing and patient education training was reported by 12 schools. Four dental programs did not have a single guideline or policy in relation to opioids for their dental students.

CONCLUSION

The implementation of opioid prescribing guidelines and the surrounding context are different among DSCs, which could result in knowledge gaps and confusion for novice providers. Although many dental programs provide extensive opioid safety training, there is room for improvement and standardization to further advance patient care.

Endogenous opiates and behavior: 2020

This paper is the forty-third consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2020 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Effectiveness of online training of first and second year AEGD residents in identifying, referring, and managing patients at-risk for substance use and opioid disorders

BACKGROUND AND OBJECTIVES

Dentists have contributed greatly to the opioid epidemic, dispensing roughly 8.6% of opioids totaling over 18 million prescriptions in a 12-month period from July 2016 to June 2017 and report educational gaps regarding screening techniques for substance misuse and an unfamiliarity with available referral resources. The purpose of this study was to determine the knowledge and comfort level of residents in identifying, referring, and managing patients who are at risk for opioid use or substance use disorder in the dental setting before and after an online case-based training course.

METHODS

Thirty-five first year (PGY1) and 11 second year (PGY2) advanced education in general dentistry (AEGD) residents participated in an online training course that aimed to assess knowledge in the domains of identifying, referring, and managing patients at risk for substance abuse disorder and opioid use in an academic setting. There were nine subdomains within the three major domains that further assessed resident comfort and knowledge. Before and after training, data were collected and analyzed.

RESULTS

Analysis of the results indicated that (1) the training modules increased resident comfort in identifying (p = 0.011), referring (p = 0.032), and managing (p = 0.002) patients at risk for opioid substance use. (2) PGY1 residents benefited more than PGY2 residents in identifying (p = 0.034) and the manage domains (p < 0.001). (3) Residents viewed the module quality, usefulness, and applicability favorably. Further analysis of the nine subdomains is presented.

CONCLUSION

Our study suggests that dental curricula would benefit from incorporating training of residents in identifying, referring, and managing patients at risk for substance use disorder and opioid use.

Do Patterns of Opioid Prescriptions to Medicare Beneficiaries Differ Between Oral and Maxillofacial Surgeons Practicing in Urban and Rural Settings?

PURPOSE

This study compared opioid prescription patterns among oral and maxillofacial surgeons (OMSs) treating Medicare beneficiaries in urban and rural settings, in an effort to identify avenues to further promote responsible opioid prescribing in a patient demographic vulnerable to opioid diversion.

MATERIALS AND METHODS

This study used Medicare Provider Utilization and Payment Data from 2014 to 2018, focusing on providers labeled as an OMS. Rural-urban commuting area codes were used to categorize each OMS as urban or rural. The demographic variables included total number of OMSs, provider gender, beneficiaries per provider, beneficiaries' age, and beneficiary hierarchal condition category (proxy for clinical complexity). The outcome variables included opioid prescribing rate, opioid claims per provider, opioid claims per beneficiary, and number of days' supply of opioids per claim. Descriptive statistics, χ² tests, 2-tailed t tests, and Wilcoxon rank-sum tests were used as appropriate.

RESULTS

Across all years, the data consisted of mostly urban and male OMSs. The mean number of Medicare beneficiaries prescribed opioids per OMS varied widely, and the mean age of beneficiaries was 70.4 ± 4.4 and 69.9 ± 4.1 years for urban and rural OMSs, respectively. Mean opioid claims per provider were higher among rural OMSs, with large standard deviations among both rural and urban OMSs. However, there were no significant differences in the opioid prescribing rate or in the mean opioid claims per beneficiary in all 5 years included in the study. There were also no clinically significant differences between urban and rural OMSs in the number of days' supply per claim (between 3 and 4 days in all periods). However, in each year, there was a significantly higher proportion of urban OMSs who prescribed more than 7 days' supply per claim.

CONCLUSIONS

Opioid prescription practices were generally similar between rural and urban OMSs treating Medicare beneficiaries. The small subset of longer-term opioid prescribers, which were more prevalent in urban areas, warrants further investigation.

Survey of opioid prescribing among dentists indicates need for more effective education regarding pain management

BACKGROUND

Dentists commonly prescribe opioids and are the highest prescribers of opioids to patients 18 years and younger. Little is known about dentists' beliefs regarding opioids and other analgesics.

METHODS

The authors conducted a national survey of dentists about their opioid prescribing habits, perceptions regarding opioid effectiveness, beliefs about patient behaviors, and relationships with drug and equipment manufacturers.

RESULTS

The authors received 291 responses from 30 states and 2 territories and analyzed 269 completed surveys. Although 84% of respondents reported believing that nonsteroidal anti-inflammatory drug (NSAID)-acetaminophen combinations are equally as effective or more effective than opioids, 43% of respondents also reported regularly prescribing opioid medications. Of those who reported prescribing opioids, 9 of 10 reported they were less likely to prescribe opioids to adolescents aged 11 through 18 years, but only 48% reported they were less likely to prescribe opioids to young adults aged 19 through 25 years. One-half of those who reported prescribing opioids reported prescribing in amounts that would result in unused medication, and 69% reported having had patients divert or misuse opioids. Few dentists reported industry interactions.

CONCLUSIONS

The continued prescription of opioids contradicts mounting evidence about the superiority of NSAIDs over opioids in dentistry. Continuing dental education, increased use of prescription drug monitoring programs, and the development of national guidelines are necessary to align clinical practice with current evidence.

PRACTICAL IMPLICATIONS

Dentists should seek to minimize opioid prescribing and pill counts and instead opt for safer, more effective NSAID-acetaminophen combinations. Dentists also should refrain from prescribing opioids to patients younger than 25 years because of the high risk of experiencing addiction in this population.

Opioid Prescribing to US Children and Young Adults in 2019

BACKGROUND

Recent national data are lacking on the prevalence, safety, and prescribers of opioid prescriptions dispensed to children and young adults aged 0 to 21 years.

METHODS

We identified opioid prescriptions dispensed to children and young adults in 2019 in the IQVIA Longitudinal Prescription Database, which captures 92% of US pharmacies. We calculated the proportion of all US children and young adults with ≥1 dispensed opioid prescription in 2019. We calculated performance on 6 metrics of high-risk prescribing and the proportion of prescriptions written by each specialty. Of all prescriptions and those classified as high risk by ≥1 metric, we calculated the proportion written by high-volume prescribers with prescription counts at the ≥95th percentile.

RESULTS

Analyses included 4 027 701 prescriptions. In 2019, 3.5% of US children and young adults had ≥1 dispensed opioid prescription. Of prescriptions for opioid-naive patients, 41.8% and 3.8% exceeded a 3-day and 7-day supply, respectively. Of prescriptions for young children, 8.4% and 7.7% were for codeine and tramadol. Of prescriptions for adolescents and young adults, 11.5% had daily dosages of ≥50 morphine milligram equivalents; 4.6% had benzodiazepine overlap. Overall, 45.6% of prescriptions were high risk by ≥1 metric. Dentists and surgeons wrote 61.4% of prescriptions. High-volume prescribers wrote 53.3% of prescriptions and 53.1% of high-risk prescriptions.

CONCLUSIONS

Almost half of pediatric opioid prescriptions are high risk. To reduce high-risk prescribing, initiatives targeting high-volume prescribers may be warranted. However, broad-based initiatives are also needed to address the large share of high-risk prescribing attributable to other prescribers.

Pain Management for Dental Medicine in 2021: Opioids, Coronavirus and Beyond

Over the past year our attention has inevitably been on the coronavirus pandemic, the health and welfare of our families, patients, and office staffs as well as the re-opening of our dental practices. In addition, the opioid crisis continues, is very likely to worsen as a result of the pandemic and continues to be a challenge to Dentistry. National public health issues and healthcare disparities continue and have created a global concern for providing evidence-based, adequate pain management in the dental setting. We have brought together a group of national thought leaders and experts in this field who will share their insights on the current state of opioid prescribing in Dentistry and describe some of the exciting work being done in advancing pain management. The learning objectives for this conference proceedings were: Describing the implications of current public health concerns for safe and effective pain management in dental medicine.Identifying risk factors and understanding the current guidelines for the use of opioid and non-opioid medications in dental medicine.Analyzing the interprofessional collaborations necessary for effective pain management in dental medicine.Recognizing the challenges and opportunities brought about by the COVID-19 pandemic for the dental profession.Applying evidence-based strategies for managing the complex pain patient in the dental setting.Appraising new and future modalities for the assessment and management of orofacial pain.

Agreement in Medications Reported in Medical and Dental Electronic Health Records

INTRODUCTION

The historical separation between medicine and dentistry has resulted in the creation of separate health records, which have the potential to negatively impact patient care and safety. Of particular importance, errors or omissions in medication lists in separate electronic health records (EHRs) may lead to medical errors and serious adverse outcomes.

OBJECTIVE

This study aimed to compare medication lists reported in the EHRs of active patients treated by both the University of Michigan School of Dentistry and Michigan Medicine to determine if differences exist.

METHODS

In this cohort study, EHRs of a population of 159,733 patients that the University of Michigan medical and dental clinics share in common were investigated for agreement in the reporting of 16 medications. After exclusion of minors and patients not seen in the last 5 y, records of 27,277 patients were examined.

RESULTS

The maximum percentage of agreement in medications reported in both records was 52% for levothyroxine, and the minimum was 7% for sildenafil. The medical record had a significantly higher number of unique medications than the dental record, suggesting higher underreporting in the dental setting.

CONCLUSION

The lack of agreement in the report of medications with serious dental and medical implications argues in favor of unification of records and use of available technology to increase accurate medication reporting.

KNOWLEDGE TRANSFER STATEMENT

The results demonstrate a lack of agreement between medications reported in medical and dental records, which can have serious implications to patients' health. A unified health record, employing available technology to increase accurate medication reporting, would mitigate this problem.

Patterns of opioid prescribing in an Appalachian college of dentistry

BACKGROUND

Nonopioids provide sufficient analgesia with less risk after most dental procedures, but opioid prescriptions are still common. This study analyzed opioid prescribing characteristics on the basis of patient demographics and procedure types.

METHODS

The authors conducted a secondary analysis of an existing data set of opioid prescriptions issued from 2013 through 2018 from a college of dentistry in central Appalachia. Opioid prescriptions for young children or liquids were excluded. The authors analyzed prescriptions according to patient age group and sedation level required for surgical procedures.

RESULTS

Of 12,464 opioid prescriptions analyzed, 70% were written after extractions or surgical procedures. More than one-half (57.3%) were written for patients younger than 45 years. Adolescent and young adult (AYA) patients received prescriptions of higher quantities (mean [standard deviation], 20.9 [6.4] pills; 95% confidence interval, 20.6 to 21.1) and of longer durations (mean [standard deviation], 3.3 [1.5] days; 95% confidence interval, 3.2 to 3.4) than other groups (P < .001; 1-way analysis of variance).

CONCLUSIONS

AYA patients received more opioids than older patients after dental procedures, which is concerning given the high risk associated with AYA opioid exposure. Faculty in colleges of dentistry should educate students and residents on the risks and benefits of opioid therapy as well as alternative analgesics and via exemplifying appropriate prescribing behavior.

PRACTICAL IMPLICATIONS

AYA patients represent a seemingly unidentified high-risk age group for dentists. Dentists who perform invasive procedures must examine carefully opioid prescription necessity and prescribe in a manner consistent with best practices.

Opioid prescribing patterns by dental procedure among US publicly and privately insured patients, 2013 through 2018

BACKGROUND

It is unknown which procedures account for the most US dental opioid prescriptions. Moreover, few national studies have assessed opioid prescribing patterns for these procedures. These knowledge gaps impede the optimal targeting of dental opioid stewardship initiatives.

METHODS

The authors analyzed claims data from the 2013 through 2018 IBM MarketScan Dental, Commercial, and Medicaid Multi-State Databases. Patients aged 13 through 64 years undergoing 1 of 120 procedures were identified. "Initial prescriptions" were opioid prescriptions dispensed on the date of procedures to 3 days afterward. For the procedures accounting for the 5 highest proportions of initial prescriptions, the authors fitted linear regression models assessing trends in the probability of 1 or more initial prescriptions and mean total morphine milligram equivalents prescribed-a standardized measure of opioid amount. Regressions were adjusted for demographic characteristics and comorbidities.

RESULTS

The 9,482,976 procedures in the sample were associated with 2,721,688 initial prescriptions. Of these prescriptions, 5 procedures accounted for 95.2%: tooth extraction (65.2%), problem-focused limited oral evaluation (17.2%), endodontic therapy (8.4%), alveoloplasty (2.9%), and surgical implant services (1.5%). Among the 5 procedures, the median adjusted annual change in the probability of 1 or more initial prescriptions was -1.3 percentage points. The median adjusted annual change in mean total morphine milligram equivalents was -4.5 (roughly 1 pill containing 5 mg of hydrocodone). In 2018, 45.3% of tooth extractions resulted in 1 or more initial prescriptions.

CONCLUSIONS

Five procedures accounted for 95.2% of dental opioid prescriptions, and tooth extraction accounted for almost two-thirds of those. Opioid prescribing for tooth extractions is declining but remains common, despite the availability of equally effective nonopioid alternatives.

PRACTICAL IMPLICATIONS

Eliminating routine opioid prescribing for tooth extraction could reduce dental opioid exposure substantially.

Receipt of opioids and patient care experiences among nonsurgical hospitalized adults

OBJECTIVE

To examine the association between receipt of opioids and patient care experiences among nonsurgical hospitalized adults.

DATA SOURCES

A total of 17 691 patient-level responses to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient care experience survey linked to medical records from nonsurgical hospitalizations in an 11-hospital health care system in a Midwestern state, years 2011-2016.

STUDY DESIGN

We conducted a pooled cross-sectional study that used propensity score matching analyses and logistic regression to estimate the relationship between patients' care experience measures (overall and pain-specific) and their receipt of opioids while hospitalized. In supplementary analyses, we used the same propensity score matching methods to estimate the relationship between patient care experience measures and receipt of opioids in four patient subgroups based on average patient-reported pain during hospitalization (no pain; mild pain; moderate pain; and severe pain).

PRINCIPAL FINDINGS

Receipt of opioids was not associated with patient care experience measures in our main analysis. In our supplementary analysis, we found lower ratings for pain control among hospitalizations for patients who reported moderate pain (Marginal Effects = -4.5 percent; P value = .015).

CONCLUSIONS

Counter to some previous studies, we observed that receipt of opioids was not associated with patient care experience measures for nonsurgical hospitalized adults. These findings may be due to different pain experiences of adults hospitalized for nonsurgical versus surgical reasons.

Prescription and Prescriber Specialty Characteristics of Initial Opioid Prescriptions Associated with Chronic Use

OBJECTIVE

This study evaluated the characteristics of opioid prescriptions, including prescriber specialty, given to opioid-naïve patients and their association with chronic use.

DESIGN

Cross-sectional analysis of the Ohio prescription drug monitoring program from January 2010 to November 2017.

SETTING

Ohio, USA.

SUBJECTS

Patients who had no opioid prescriptions from 2010 to 2012 and a first-time prescription from January 2013 to November 2016.

METHODS

Chronic use was defined as at least six opioid prescriptions in one year and either one or more years between the first and last prescription or an average of ≤30 days not covered by an opioid during that year.

RESULTS

A total of 4,252,809 opioid-naïve patients received their first opioid prescription between 2013 and 2016; 364,947 (8.6%) met the definition for chronic use. Those who developed chronic use were older (51.7 vs 45.6 years) and more likely to be female (53.6% vs 52.8%), and their first prescription had higher pill quantities (44.9 vs 30.2), higher morphine milligram equivalents (MME; 355.3 vs 200.0), and was more likely to be an extended-release formulation (2.9% vs 0.7%, all P < 0.001). When compared with internal medicine, the adjusted odds of chronic use were highest with anesthesiology (odds ratio [OR] = 1.46) and neurology (OR = 1.43) and lowest with ophthalmology (OR = 0.33) and gynecology (OR = 0.37).

CONCLUSIONS

Eight point six percent of opioid-naïve individuals who received an opioid prescription developed chronic use. This rate varied depending on the specialty of the provider who wrote the prescription. The risk of chronic use increased with higher MME content of the initial prescription and use of extended-release opioids.