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Sharp LK, Solanki P, Boyer T, Vivo A, Kale I, Hughes AM, Gibson G, Jurasic MM, Evans CT, Suda KJ. A qualitative exploration of dentists' opioid prescribing decisions within U.S. veterans affairs facilities. Pain 2023; 164:749-757. [PMID: 35984367 PMCID: PMC10026830 DOI: 10.1097/j.pain.0000000000002759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 07/25/2022] [Accepted: 08/08/2022] [Indexed: 11/25/2022]
Abstract
ABSTRACT The U.S. Department of Veterans Affairs (VA) is the largest integrated healthcare system in the United States and provides dental care to approximately one-half million veterans annually. In response to the opioid crisis, the VA released several opioid risk mitigation strategies. Although opioid prescribing by VA dentists has decreased on the whole, the implementation experiences at the level of dentists remains unclear. Our objective was to explore the barriers and facilitators that affect opioid decision making for management of acute dental pain among VA dentists. Dentists practicing in the VA facilities with the highest and lowest volume of opioid prescriptions were recruited. Standardized qualitative interviews by telephone followed a semistructured guide designed around the Capability (C), Opportunity (O), Motivation (M), and Behaviour (B) model. Audio recordings were transcribed and independently double-coded using NVivo to identify potential targets for future guideline-based opioid interventions. Of 395 eligible general and specialty dentists, 90 (24.8%) completed an interview representing 33 VA facilities. Opportunities for prescribing opioids included 1) completion of dental procedures associated with acute dental pain, 2) caring for patients who presented with existing dental pain, and 3) responding to patient opioid requests. Capabilities included using resources (eg, electronic medical records), clinical judgement (eg, evaluation of medical history including medication use), communication skills, and ability to screen for opioid misuse. Motivation themes focused on alleviating patients' acute dental pain. Barriers and facilitators of opioid prescribing varied across facilities. The results can offer intervention targets for continued opioid risk mitigation efforts.
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Affiliation(s)
- Lisa K. Sharp
- Department of Pharmacy Systems Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, United States
| | - Pooja Solanki
- Center of Innovation for Complex Chronic Healthcare, Edward Hines JR VA Medical Center, Hines, IL, United States
| | - Taylor Boyer
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
| | - Amanda Vivo
- Center of Innovation for Complex Chronic Healthcare, Edward Hines JR VA Medical Center, Hines, IL, United States
| | - Ibuola Kale
- Center of Innovation for Complex Chronic Healthcare, Edward Hines JR VA Medical Center, Hines, IL, United States
| | - Ashley M. Hughes
- Department of Biomedical and Health Information Sciences, College of Allied Health, University of Illinois at Chicago, 1919 W. Taylor St, Chicago, IL, United States
| | - Gretchen Gibson
- Veterans Health Administration, Office of Dentistry, Washington DC, United States, United States
| | - M. Marianne Jurasic
- VA Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States
- Boston University Henry M. Goldman School of Dental Medicine, Boston, MA, United States
| | - Charlesnika T. Evans
- Center of Innovation for Complex Chronic Healthcare, Edward Hines JR VA Medical Center, Hines, IL, United States
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
- Center for Health Services & Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Katie J. Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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Evans CT, Fitzpatrick MA, Poggensee L, Gonzalez B, Gibson G, Jurasic MM, Echevarria K, McGregor JC, Gellad WF, Suda KJ. High prescribing of antibiotics is associated with high prescribing of opioids in medical and dental providers. Pharmacotherapy 2022; 42:716-723. [PMID: 35869691 PMCID: PMC9794436 DOI: 10.1002/phar.2720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/13/2022] [Indexed: 12/30/2022]
Abstract
STUDY OBJECTIVE High prescribers of antibiotics and opioids are an important target for stewardship interventions. The goal of this study was to assess the association between high antibiotic and high opioid prescribing by provider type. DESIGN A national cross-sectional study. SETTING 2015-2017 Department of Veterans Affairs (VA) electronic health record data. POPULATION Prescribers were identified as dentists (2017: n = 1346) and medical providers (physicians n = 23,072; advanced practice providers [APP] n = 7705; and other providers [pharmacists/chiropractors] n = 3674) (2017: n = 34,451). MEASUREMENTS High prescribing was defined as being in the top 25% of visit-based rates of antibiotic or opioid prescribing (number of prescriptions/number of dental or medical visits). Multivariable random effects logistic regression with clustering by facility was used to assess the adjusted association between high antibiotic and opioid prescribing. RESULTS Medical providers prescribed 4,348,670 antibiotic and 10,256,706 opioid prescriptions; dentists prescribed 277,170 antibiotic and 124,103 opioid prescriptions. Among all high prescribers of antibiotics, 40% were also high prescribers of opioids as compared to 18% of those who were not high antibiotic prescribers (p < 0.0001). High prescribing of antibiotics was associated with high prescribing of opioids in medical providers (adjusted odds ratio [aOR] = 2.87, 95% confidence interval [CI] = 2.72-3.04) and dentists (aOR = 8.40, 95% CI 6.00-11.76). Older provider age, specific US geographic regions, and lower VA facility complexity and rurality were also associated with high opioid prescribing by medical providers. In dentists, younger provider age, male gender, specific regions of the United States, and lower number of dentists in a facility were associated with high opioid prescribing. At the facility level, high dental prescribers of antibiotics or opioids were not at the same facilities as high medical prescribers, respectively (p < 0.0001). CONCLUSIONS High antibiotic prescribing was associated with high opioid prescribing. Thus, stewardship interventions targeting both medication classes may have higher impact to efficiently reduce prescribing of medications with high public health impact. Provider-targeted interventions are needed to improve antibiotic and opioid prescribing in both dentists and medical providers.
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Affiliation(s)
- Charlesnika T. Evans
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr VA Hospital, Hines, Illinois
- Department of Preventive Medicine, Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Margaret A. Fitzpatrick
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr VA Hospital, Hines, Illinois
- Department of Medicine, Division of Infectious Diseases, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - Linda Poggensee
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr VA Hospital, Hines, Illinois
| | - Beverly Gonzalez
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr VA Hospital, Hines, Illinois
- Department of Psychiatry & Behavioral Sciences, Northwestern University, Chicago, Illinois
| | - Gretchen Gibson
- Veterans Health Administration Office of Dentistry, Washington, District of Columbia
| | - M. Marianne Jurasic
- Boston University Henry M. Goldman School of Dental Medicine, Boston, Massachusetts
- VA Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts
| | - Kelly Echevarria
- Antimicrobial Stewardship Task Force, Pharmacy Benefits Management Program, Department of Veterans Affairs, Washington, District of Columbia
| | | | - Walid F. Gellad
- Department of Veterans Affairs, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Katie J. Suda
- Department of Veterans Affairs, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Suda KJ, Evans CT, Gibson G, Jurasic MM, Poggensee L, Gonzalez B, Hubbard CC, Vivo A, Cunningham FE, McGregor JC, Gellad WF. Opioid Prescribing by Dentists in the Veterans Health Administration. Am J Prev Med 2022; 63:371-383. [PMID: 35341616 PMCID: PMC9780026 DOI: 10.1016/j.amepre.2022.01.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/17/2021] [Accepted: 01/05/2022] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Nonopioid analgesics are more effective for most oral pain, but data suggest that dental prescribing of opioids is excessive. This study evaluates the extent to which opioids exceed recommendations and the characteristics associated with opioid overprescribing by Veterans Health Administration dentists. METHODS This was a national cross-sectional study of Veterans' dental visits from 2015 to 2018. Overprescribing was defined per national guidelines as >120 morphine milligram equivalents (primary outcome). The association of dental visit and patient demographic and medical characteristics was modeled with overprescribing (defined as >120 morphine milligram equivalents) using Poisson regression with clustering by facility and patient. A secondary analysis assessed opioid prescriptions >3 days' supply. The dates of analysis were January 2020‒May 2021. RESULTS Of the 196,595 visits, 28.7% exceeded 120 morphine milligram equivalents. Friday visits and people with chronic oral pain or substance misuse were associated with a higher prevalence of overprescribing. Women, older Veterans, and Black and Latinx Veterans were less likely to be overprescribed than men, younger Veterans, and White Veterans, respectively. Routine dental visits had a higher prevalence of opioid overprescribing than invasive visits. Opioid overprescribing decreased over time. White Veterans were more likely to receive oxycodone and hydrocodone, whereas people of Black race and Latinx ethnicity were more likely to receive codeine and tramadol. In the secondary analysis, 68.5% of opioid prescriptions exceeded a 3-day supply. CONCLUSIONS Nearly 1 in 3 opioids prescribed by Veterans Health Administration dentists exceed guidelines. Prescribing higher potency and quantities of opioids, especially on Fridays and to certain demographic groups, should be addressed as part of dental opioid stewardship programs.
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Affiliation(s)
- Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, U.S. Department of Veterans Affairs, Pittsburgh, Pennsylvania; Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Charlesnika T Evans
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Center for Health Services & Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Gretchen Gibson
- Veterans Health Administration Office of Dentistry, U.S. Department of Veterans Affairs, Washington, District of Columbia
| | - M Marianne Jurasic
- Veterans Health Administration Office of Dentistry, U.S. Department of Veterans Affairs, Washington, District of Columbia; Boston University Henry M. Goldman School of Dental Medicine, Boston, Massachusetts; Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, U.S. Department of Veterans Affairs, Bedford, Massachusetts
| | - Linda Poggensee
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, U.S. Department of Veterans Affairs, Hines, Illinois
| | - Beverly Gonzalez
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, U.S. Department of Veterans Affairs, Hines, Illinois
| | - Colin C Hubbard
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Amanda Vivo
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, U.S. Department of Veterans Affairs, Hines, Illinois
| | - Fran E Cunningham
- Pharmacy Benefits Management Services, U.S. Department of Veterans Affairs, Hines, Illinois
| | | | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, U.S. Department of Veterans Affairs, Pittsburgh, Pennsylvania; Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Wang TT, Nadella S, Lee CC, Hersh EV, Tannyhill RJ, Panchal N. Do Patterns of Opioid Prescriptions to Medicare Beneficiaries Differ Between Oral and Maxillofacial Surgeons Practicing in Urban and Rural Settings? J Oral Maxillofac Surg 2021; 80:614-619. [PMID: 34856159 DOI: 10.1016/j.joms.2021.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 10/25/2021] [Accepted: 10/27/2021] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Tim T Wang
- Resident, Oral & Maxillofacial Surgery, Massachusetts General Hospital and Clinical Fellow, Harvard School of Dental Medicine, Boston, MA
| | - Srighana Nadella
- DMD Candidate, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA
| | - Cameron C Lee
- Resident, Oral & Maxillofacial Surgery, Massachusetts General Hospital and Clinical Fellow, Harvard School of Dental Medicine, Boston, MA
| | - Elliot V Hersh
- Professor, Department of Oral and Maxillofacial Surgery and Pharmacology, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA
| | - R John Tannyhill
- Program Director and Assistant Professor, Oral & Maxillofacial Surgery, Massachusetts General Hospital and Harvard School of Dental Medicine, Boston, MA
| | - Neeraj Panchal
- Assistant Professor and Section Chief of Oral and Maxillofacial Surgery, Philadelphia Veterans Affairs Medical Center, Penn Presbyterian Medical Center, University of Pennsylvania School of Dental Medicine, Philadelphia, PA.
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