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Carrasco-Labra A, Polk DE, Urquhart O, Aghaloo T, Claytor JW, Dhar V, Dionne RA, Espinoza L, Gordon SM, Hersh EV, Law AS, Li BSK, Schwartz PJ, Suda KJ, Turturro MA, Wright ML, Dawson T, Miroshnychenko A, Pahlke S, Pilcher L, Shirey M, Tampi M, Moore PA. Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in adolescents, adults, and older adults: A report from the American Dental Association Science and Research Institute, the University of Pittsburgh, and the University of Pennsylvania. J Am Dent Assoc 2024; 155:102-117.e9. [PMID: 38325969 PMCID: PMC10919895 DOI: 10.1016/j.adaj.2023.10.009] [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: 05/29/2023] [Revised: 09/25/2023] [Accepted: 10/11/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND A panel convened by the American Dental Association Science and Research Institute, the University of Pittsburgh, and the University of Pennsylvania conducted systematic reviews and meta-analyses and formulated evidence-based recommendations for the pharmacologic management of acute dental pain after simple and surgical tooth extraction(s) and for the temporary management (ie, definitive dental treatment not immediately available) of toothache associated with pulp and periapical diseases in adolescents, adults, and older adults. TYPES OF STUDIES REVIEWED The panel conducted 4 systematic reviews to determine the effect of opioid and nonopioid analgesics, local anesthetics, corticosteroids, and topical anesthetics on acute dental pain. The panel used the Grading of Recommendations, Assessment, Development and Evaluation approach to assess the certainty of the evidence and the Grading of Recommendations, Assessment, Development and Evaluation Evidence-to-Decision Framework to formulate recommendations. RESULTS The panel formulated recommendations and good practice statements using the best available evidence. There is a beneficial net balance favoring the use of nonopioid medications compared with opioid medications. In particular, nonsteroidal anti-inflammatory drugs alone or in combination with acetaminophen likely provide superior pain relief with a more favorable safety profile than opioids. CONCLUSIONS AND PRACTICAL IMPLICATIONS Nonopioid medications are first-line therapy for managing acute dental pain after tooth extraction(s) and the temporary management of toothache. The use of opioids should be reserved for clinical situations when the first-line therapy is insufficient to reduce pain or there is contraindication of nonsteroidal anti-inflammatory drugs. Clinicians should avoid the routine use of just-in-case prescribing of opioids and should exert extreme caution when prescribing opioids to adolescents and young adults.
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Feldman C, Fredericks-Younger J, Desjardins P, Malmstrom H, Miloro M, Warburton G, Ward B, Ziccardi V, Fine D, Greenberg P, Andrews T, Matheson P, Lu SE. The Opioid Analgesic Reduction Study (OARS) Pilot: A Double-Blind Randomized Multicenter Trial. JDR Clin Trans Res 2024; 9:72-84. [PMID: 36680313 PMCID: PMC10850879 DOI: 10.1177/23800844221144031] [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] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND With addiction rates and opioid deaths increasing, health care providers are obligated to help stem the opioid crisis. As limited studies examine the comparative effectiveness of fixed-dose combination nonopioid analgesia to opioid-containing analgesia, a comparative effectiveness study was planned and refined by conducting a pilot study. METHODS The Opioid Analgesic Reduction Study (OARS) pilot, a stratified, randomized, multisite, double-blind clinical trial, was designed to test technology and procedures to be used in the full OARS trial. Participants engaged in the full protocol, enabling the collection of OARS outcome data. Eligible participants reporting to 1 of 5 sites for partial or full bony impacted mandibular third molar extraction were stratified by biologic sex and randomized to 1 of 2 treatment groups, OPIOID or NONOPIOID. OPIOID participants were provided 20 doses of hydrocodone 5 mg/acetaminophen 300 mg. NONOPIOID participants were provided 20 doses of ibuprofen 400 mg/acetaminophen 500 mg. OARS outcomes data, including pain experience, adverse effects, sleep quality, pain interference, overall satisfaction, and remaining opioid tablets available for diversion, were collected via surveys, electronic medication bottles, eDiary, and activity/sleep monitor. RESULTS Fifty-three participants were randomized with 50 completing the OARS pilot protocol. Across all outcome pain domains, in all but 1 time period, NONOPIOID was better in managing pain than OPIOID (P < 0.05 level). Other outcomes suggest less pain interference, less adverse events, better sleep quality, better overall satisfaction, and fewer opioid-containing tablets available for diversion. DISCUSSION Results suggest patients requiring impacted mandibular third molar extraction would benefit from fixed-dose combination nonopioid analgesia. KNOWLEDGE TRANSFER STATEMENT Study results suggest fixed-dose nonopioid combination ibuprofen 400 mg/acetaminophen 500 mg is superior to opioid-containing analgesic (hydrocodone 5 mg/acetaminophen 500 mg). This knowledge should inform surgeons and patients in the selection of postsurgical analgesia.
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Affiliation(s)
- C.A. Feldman
- School of Dental Medicine, Rutgers University, Newark, NJ, USA
- School of Public Health, Rutgers University, Newark, NJ, USA
| | | | - P.J. Desjardins
- School of Dental Medicine, Rutgers University, Newark, NJ, USA
| | - H. Malmstrom
- Eastman Institute for Oral Health, University of Rochester, Rochester, NY, USA
| | - M. Miloro
- College of Dentistry, University of Illinois, IL, USA
| | - G. Warburton
- School of Dentistry, University of Maryland, MD, USA
| | - B. Ward
- School of Dentistry, University of Michigan, MI, USA
| | - V. Ziccardi
- School of Dental Medicine, Rutgers University, Newark, NJ, USA
| | - D.H. Fine
- School of Dental Medicine, Rutgers University, Newark, NJ, USA
| | - P. Greenberg
- School of Public Health, Rutgers University, Newark, NJ, USA
| | - T. Andrews
- School of Public Health, Rutgers University, Newark, NJ, USA
| | - P.B. Matheson
- School of Dental Medicine, Rutgers University, Newark, NJ, USA
| | - S.-E. Lu
- School of Public Health, Rutgers University, Newark, NJ, USA
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Khouja T, Shah NH, Suda KJ, Polk DE. Trajectories of opioid prescribing by general dentists, specialists, and oral and maxillofacial surgeons in the United States, 2015-2019. J Am Dent Assoc 2024; 155:7-16.e7. [PMID: 37988047 PMCID: PMC10870999 DOI: 10.1016/j.adaj.2023.10.002] [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: 02/08/2023] [Revised: 09/28/2023] [Accepted: 10/02/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Despite decreases in opioid prescribing from 2016 through 2019, some dentists (general, specialists, oral and maxillofacial surgeons) in the United States continue to prescribe opioids at high rates. The authors' objective was to define dentists' trajectories of opioid prescribing. METHODS The authors identified actively prescribing dentists from the IQVIA Longitudinal Prescription data set, from 2015 through 2019. Group-based trajectory modeling identified opioid prescribing trajectories on the basis of dentists' annual prescribing rates for the overall sample (model 1) and for high prescribers (model 2). The authors used χ2 or Mann-Whitney U tests to characterize the model 2 trajectory groups. RESULTS In model 1 (n = 199,145 prescribers), group-based trajectory modeling identified 8 trajectories that were grouped into 5 categories. A total of 14.8% were nonprescribers who composed less than 1% of all prescriptions, low prescribers (3 groups; 46.0%) prescribed at low rates (2015: 5.5%-16.9%; 2019: 1.5%-11.9%), decliners (7.3%) decreased prescribing rapidly (2015: 29.4%; 2019: 5.1%), moderately high prescribers (2 groups; 28.5%) prescribed moderately (2015: 28.7% and 39.2%; 2019: 18.1% and 28.8%), and consistently high prescribers (3.4%) prescribed at high rates (2015: 54.6%; 2019: 44.7%). In model 2, from consistently high prescribers (n = 6,845), 4 trajectories were identified. Of these 4 groups, 1 group (7.5%) declined prescribing rapidly. The groups did not differ meaningfully; however, the rapid decliners included fewer oral and maxillofacial surgeons (13.0% vs 18.4%), saw more Medicaid patients (2.5% vs 1.0%), and had higher opioid prescribing rates in 2015 (95.5% vs 91.6%) (P < .001 for all). CONCLUSIONS The authors identified variations in dentists' opioid prescribing rates. Although 60% of dentists decreased prescribing rates by 30% through 83%, 3.4% of dentists consistently prescribed at high rates. PRACTICAL IMPLICATIONS Some dentists continue to prescribe opioids at high levels, indicating that additional information is needed to better inform policy and clinical decision making.
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Zhang J, Nalliah RP, Waljee JF, Brummett CM, Chua KP. Association between the COVID-19 outbreak and opioid prescribing by U.S. dentists. PLoS One 2023; 18:e0293621. [PMID: 37917644 PMCID: PMC10621808 DOI: 10.1371/journal.pone.0293621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 10/16/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND U.S. data on opioid prescribing by dentists are limited to 2019. More recent data are needed to understand the effect of the COVID-19 outbreak on dental opioid prescribing, characterize current practices, and determine if dental opioid stewardship initiatives are still warranted. OBJECTIVE To evaluate the association between the COVID-19 outbreak and the rate of opioid prescribing by U.S. dentists. METHODS During February-April 2023, the authors conducted a cross-sectional analysis of the IQVIA Longitudinal Prescription Database, which reports 92% of prescriptions dispensed in U.S. retail pharmacies. The authors calculated the monthly dental opioid dispensing rate, defined as the monthly number of dispensed opioid prescriptions from dentists per 100,000 U.S. individuals, during January 2016-February 2020 and June 2020-December 2022. To prevent distortions in trends, data from March-May 2020, when dental opioid dispensing declined sharply, were excluded. Using linear segmented regression models, the authors assessed for level and slope changes in the dental opioid dispensing rate during June 2020. RESULTS Analyses included 81,189,605 dental opioid prescriptions. The annual number of prescriptions declined from 16,105,634 in 2016 to 8,910,437 in 2022 (-44.7%). During January 2016-February 2020, the dental opioid dispensing rate declined -3.9 (95% CI: -4.3, -3.6) per month. In June 2020, this rate abruptly increased by 31.4 (95% CI: 19.3, 43.5) and the monthly decline in the dental opioid dispensing rate slowed to -2.1 (95% CI: -2.6, -1.6) per month. As a result, 6.1 million more dental opioid prescriptions were dispensed during June 2020-December 2022 than would be predicted had trends during January 2016-February 2020 continued. DISCUSSION U.S. dental opioid prescribing is declining, but the rate of this decline slowed after the COVID-19 outbreak. Findings highlight the continued importance of dental opioid stewardship initiatives.
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Affiliation(s)
- Jason Zhang
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor, MI, United States of America
| | - Romesh P. Nalliah
- University of Michigan School of Dentistry, Ann Arbor, MI, United States of America
| | - Jennifer F. Waljee
- Michigan Opioid Prescribing Engagement Network, University of Michigan Medical School, Ann Arbor, MI, United States of America
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, United States of America
| | - Chad M. Brummett
- Michigan Opioid Prescribing Engagement Network, University of Michigan Medical School, Ann Arbor, MI, United States of America
- Division of Pain Medicine, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, United States of America
| | - Kao-Ping Chua
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor, MI, United States of America
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Yan CH, Hubbard CC, Lee TA, Sharp LK, Evans CT, Calip GS, Rowan SA, McGregor JC, Gellad WF, Suda KJ. Impact of Hydrocodone Rescheduling on Dental Prescribing of Opioids. JDR Clin Trans Res 2023; 8:402-412. [PMID: 35708454 DOI: 10.1177/23800844221102830] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION In the United States, dentists frequently prescribe hydrocodone. In October 2014, the US Drug Enforcement Administration rescheduled hydrocodone from controlled substance schedule III to II, introducing more restricted prescribing and dispensing regulations, which may have changed dental prescribing of opioids. OBJECTIVE The study aim was to evaluate the impact of the hydrocodone rescheduling on dental prescribing of opioids in the United States. METHODS This was a cross-sectional study of opioids prescribed by dentists between October 2012 and October 2016, using the IQVIA Longitudinal Prescription Dataset. Monthly dentist-based opioid prescribing rate (opioid prescription [Rx]/1,000 dentists) and monthly average opioid dosages per prescription (mean morphine milligram equivalent per day [MME/d]) were measured in the 24 mo before and after hydrocodone rescheduling in October 2014 (index or interruption). An interrupted time-series analysis was conducted using segmented ordinary least square regression models, with Newey-West standard errors to handle autocorrelation. RESULTS Dentists prescribed 50,412,942 opioid prescriptions across the 49 mo. Hydrocodone was the most commonly prescribed opioid pre- and postindex (74.9% and 63.8%, respectively), followed by codeine (13.8% and 21.6%), oxycodone (8.1% and 9.5%), and tramadol (2.9% and 4.8%). At index, hydrocodone prescribing immediately decreased by -834.8 Rx/1,000 dentists (95% confidence interval [CI], -1,040.2 to -629.4), with increased prescribing of codeine (421.9; 95% CI, 369.7-474.0), oxycodone (85.3; 95% CI, 45.4-125.2), and tramadol (111.8; 95% CI, 101.4-122.3). The mean MME increased at index for all opioids except for hydrocodone, and dosages subsequently decreased during the postindex period. CONCLUSION Following the rescheduling, dentist prescribing of hydrocodone declined while prescribing of nonhydrocodone opioids increased. Understanding the impact of this regulation informs strategies to ensure appropriate prescribing of opioids for dental pain. KNOWLEDGE TRANSFER STATEMENT The study findings can be used by policy makers to make informed decisions in developing future risk mitigation strategies aimed to regulate opioid prescribing behaviors. Furthermore, dentist-specific resources and guidelines are needed subsequent to these policies in order to meet the dental population needs.
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Affiliation(s)
- C H Yan
- Department of Pharmacy Systems, Outcomes, and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - C C Hubbard
- Department of Pharmacy Systems, Outcomes, and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - T A Lee
- Department of Pharmacy Systems, Outcomes, and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - L K Sharp
- Department of Pharmacy Systems, Outcomes, and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - C T Evans
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, IL, USA
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - G S Calip
- Department of Pharmacy Systems, Outcomes, and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - S A Rowan
- College of Dentistry, University of Illinois at Chicago, Chicago, IL, USA
| | - J C McGregor
- College of Pharmacy, Oregon State University, Portland, OR, USA
| | - W F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - K J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Bavarian R, Sandhu S, Handa S, Shaefer J, Kulich RA, Keith DA. Centers for Disease Control and Prevention Clinical Practice Guideline for Prescribing Opioids: United States, 2022: What dentists need to know. J Am Dent Assoc 2023; 154:849-855. [PMID: 37097279 DOI: 10.1016/j.adaj.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 01/13/2023] [Accepted: 01/31/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND The Centers for Disease Control and Prevention (CDC) published the Clinical Practice Guideline for Prescribing Opioids for Pain-United States, 2022 (CDCCPG) to replace the 2016 guideline. This guideline was designed to serve as a clinical tool to improve communication between clinicians and patients and empower them to make informed, person-centered decisions regarding pain management and the prescribing of opioids. It is intended for primary care and other clinicians, including dentists, who provide pain management for adults with acute, subacute, and chronic pain. TYPES OF STUDIES REVIEWED This article summarizes the CDCCPG, with an emphasis on information of relevance to dentistry. RESULTS For dentists, the most important recommendations for pain management are that nonsteroidal anti-inflammatory medications are first-line medications for acute dental pain, interdisciplinary care for chronic orofacial pain is indicated, and opioids should only be prescribed for acute dental pain for a maximum of 3 days after risk assessment. PRACTICAL IMPLICATIONS The CDCCPG contains a great deal of relevant information that can help dentists and dental specialists make safe, effective, and evidence-based decisions in providing pain control for their patients.
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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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Miroshnychenko A, Ibrahim S, Azab M, Roldan Y, Martinez J, Tamilselvan D, He L, Little J, Urquhart O, Tampi M, Polk D, Moore P, Hersh E, Claytor B, Carrasco-Labra A, Brignardello-Petersen R. Acute Postoperative Pain Due to Dental Extraction in the Adult Population: A Systematic Review and Network Meta-analysis. J Dent Res 2023; 102:391-401. [PMID: 36631957 PMCID: PMC10031629 DOI: 10.1177/00220345221139230] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
This study compares the effectiveness of pharmacological treatments to develop guidelines for the management of acute pain after tooth extraction. We searched Medline, EMBASE, CENTRAL, and US Clinical Trials registry on November 21, 2020. We included randomized clinical trials (RCTs) of participants undergoing dental extractions comparing 10 interventions, including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and combinations to placebo. After duplicate screening and data abstraction, we conducted a frequentist network meta-analysis for each outcome at 6 h (i.e., pain relief, total pain relief [TOTPAR], summed pain intensity difference [SPID], global efficacy rating, rescue analgesia, and adverse effects). We assessed the risk of bias using a modified Cochrane RoB 2.0 tool and the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach. We implemented the analyses in RStudio version 3.5.3 and classified interventions from most to least beneficial or harmful. We included 82 RCTs. Fifty-six RCTs enrolling 9,095 participants found moderate- and high-certainty evidence that ibuprofen 200 to 400 mg plus acetaminophen 500 to 1,000 mg (mean difference compared to placebo [MDp], 1.68; 95% confidence interval [CI], 1.06-2.31), acetaminophen 650 mg plus oxycodone 10 mg (MDp, 1.19; 95% CI, 0.85-1.54), ibuprofen 400 mg (MDp, 1.31; 95% CI, 1.17-1.45), and naproxen 400-440 mg (MDp, 1.44; 95% CI, 1.07-1.80) were most effective for pain relief on a 0 to 4 scale. Oxycodone 5 mg, codeine 60 mg, and tramadol 37.5 mg plus acetaminophen 325 mg were no better than placebo. The results for TOTPAR, SPID, global efficacy rating, and rescue analgesia were similar. Based on low- and very low-certainty evidence, most interventions were classified as no more harmful than placebo for most adverse effects. Based on moderate- and high-certainty evidence, NSAIDs with or without acetaminophen result in better pain-related outcomes than opioids with or without acetaminophen (except acetaminophen 650 mg plus oxycodone 10 mg) or placebo.
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Affiliation(s)
- A. Miroshnychenko
- Department of Health Research Methods,
Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - S. Ibrahim
- Faculty of Health Sciences, McMaster
University, Hamilton, Ontario, Canada
| | - M. Azab
- Faculty of Health Sciences, McMaster
University, Hamilton, Ontario, Canada
| | - Y. Roldan
- Department of Health Research Methods,
Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - J.P.D. Martinez
- Department of Health Research Methods,
Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - D. Tamilselvan
- Faculty of Health Sciences, McMaster
University, Hamilton, Ontario, Canada
| | - L. He
- Faculty of Health Sciences, McMaster
University, Hamilton, Ontario, Canada
| | - J.W. Little
- Division of Oral and Craniofacial
Health Sciences, Adams School of Dentistry, Chapel Hill, NC, USA
| | - O. Urquhart
- ADA Science and Research Institute,
Chicago, Illinois, USA
| | - M. Tampi
- Department of Cariology, University of
Michigan School of Dentistry, Ann Arbor, MI, USA
| | - D.E. Polk
- Department of Dental Public Health,
University of Pittsburgh, Pittsburgh, PA, USA
| | - P.A. Moore
- Department of Dental Public Health,
University of Pittsburgh, Pittsburgh, PA, USA
| | - E.V. Hersh
- Department of Oral Surgery and
Pharmacology, University of Pennsylvania, Philadelphia, PA, USA
| | - B. Claytor
- N.C. Caring Dental Professionals,
Aberdeen, NC, USA
| | - A. Carrasco-Labra
- Department of Preventative and
Restorative Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - R. Brignardello-Petersen
- Department of Health Research Methods,
Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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9
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Solanki PA, Hubbard CC, Poggensee L, Evans CT, Suda KJ. Adverse outcomes associated with opioid prescription by dentists in the Veterans Health Administration: A national cross-sectional study from 2015 to 2018. J Public Health Dent 2023. [PMID: 36799865 DOI: 10.1111/jphd.12560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 12/01/2022] [Accepted: 01/26/2023] [Indexed: 02/18/2023]
Abstract
OBJECTIVES Opioids prescribed by dentists have been associated with serious adverse events, including opioid-related overdose and mortality. However, the downstream outcomes of opioids prescribed by dentists to Veterans who are at high risk for opioid misuse and overdose have yet to be determined. METHODS This was a national cross-sectional analysis of opioids associated with dental visits within the Veterans Health Administration from 2015 to 2018. Overprescribing was defined per guidelines as >120 morphine milligram equivalents (MME) or >3 days supply. The association of dental visit and patient characteristics was modeled separately for opioid-related poisoning and all-cause mortality using logistic regression. RESULTS Of 137,273 Veterans prescribed an opioid by a dentist, 0.1% and 1.1% were associated with opioid-related poisoning and mortality, respectively. There was no difference in opioid poisoning within 6 months for Veterans with opioid prescriptions >120 MME (aOR = 1.25 [CI: 0.89-1.78]), but poisoning decreased in Veterans prescribed opioids >3-days supply (aOR = 0.68 [CI: 0.49-0.96]). However, Veterans with opioids >120 MME were associated with higher odds of mortality within 6 months (aOR = 1.17 [95% CI: 1.05-1.32]) while there was no difference in prescriptions >3-days supply (aOR = 1.12 [CI: 0.99-1.25]). CONCLUSION Serious opioid-related adverse events were rare in Veterans and lower than other reports in the literature. Since nonopioid analgesics have superior efficacy for the treatment of acute dental pain, prescribing opioid alternatives may decrease opioid-related poisoning. Strategies for dentists to identify patients at high risk should be incorporated into the dental record.
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Affiliation(s)
- Pooja A Solanki
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr VA Hospital, Hines, Illinois, USA
| | - Colin C Hubbard
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Linda Poggensee
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr VA Hospital, Hines, Illinois, USA
| | - Charlesnika T Evans
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr VA Hospital, Hines, Illinois, USA.,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, USA
| | - Katie J Suda
- Department of Veterans Affairs, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Department of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Gryczynski J, Mitchell SG, Asche SE, Truitt AR, Worley DC, Rindal DB. De-Implementing Opioids for Dental Extractions (DIODE): a multi-clinic, cluster-randomized trial of clinical decision support strategies in dentistry. Implement Sci 2023; 18:5. [PMID: 36765414 PMCID: PMC9913004 DOI: 10.1186/s13012-023-01262-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 01/25/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Opioid pain relievers are commonly prescribed following dental extractions, but evidence shows that non-opioid analgesics often provide adequate pain relief with fewer risks. The current study examined clinical decision support (CDS) as a tool for de-implementing opioid prescribing in dentistry. METHODS This prospective, cluster-randomized trial examined CDS for dental pain management at 22 HealthPartners Dental Group clinics in Minnesota. Dental providers (n = 49) were randomized to deliver care using CDS, CDS with patient education materials (CDS-E), or standard practice (SP). Randomization was stratified by provider type (dentist vs. oral surgeon) and baseline opioid prescribing volume. Patient records of dental extractions were examined for January 2019 through May 2021, representing a 12-month baseline and 15-month intervention period (N = 12,924). Opioid prescription at the visit (no vs. yes) was the primary outcome. Data were analyzed using generalized linear mixed models, adjusting for patient sex and age, extraction complexity, and baseline prescribing strata (volume and provider type). RESULTS Patients were 56.2% female, with a mean age of 46.7 (SD = 20.0) years. Providers were 8% oral surgeons, 57% female, and with a mean age of 43.7 (SD = 11.2) years. There were significant decreases in opioid prescribing during the study (P < 0.001), representing a continuation of pre-existing trends to reduce opioid prescribing in these dental practices. There were no significant differences in opioid prescribing between CDS and SP (OR = 1.29; 97.5% CI = 0.93, 1.79; P = 0.08), or CDS-E and SP arms (OR = 1.27; 97.5% CI = 0.86, 1.79; P = 0.18). The direction of the association favored greater reductions in opioid prescribing in the SP arm. Despite training and implementation support, utilization of the CDS was low, particularly among oral surgeons, who were significantly more likely than other dentists to prescribe opioids. Among non-oral surgeon providers with the opportunity to access it, CDS utilization was not significantly associated with opioid prescribing. CONCLUSIONS Equipping dentists with CDS resources, whether alone or accompanied by patient education materials, did not accelerate reductions in opioid prescribing beyond those observed in standard practice. Strategies are needed to enhance CDS utilization for patient care and safety surrounding analgesia following dental extractions. TRIAL REGISTRATION Clinicaltrials.gov, NCT03584789.
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Affiliation(s)
| | | | - Stephen E. Asche
- grid.280625.b0000 0004 0461 4886HealthPartners, Minneapolis, MN USA
| | - Anjali R. Truitt
- grid.280625.b0000 0004 0461 4886HealthPartners, Minneapolis, MN USA
| | - Donald C. Worley
- grid.280625.b0000 0004 0461 4886HealthPartners, Minneapolis, MN USA
| | - D. Brad Rindal
- grid.280625.b0000 0004 0461 4886HealthPartners, Minneapolis, MN USA
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Hughes AM, Lin E, Hussain RA, Gibson G, Jurasic MM, Sharp LK, Hubbard CC, Poggensee LE, Evans CT, McGregor JC, Gellad WF, Suda KJ. The feasibility of academic detailing for acute oral pain management in outpatient dentistry: A pilot study. J Am Pharm Assoc (2003) 2023; 63:158-163.e6. [PMID: 36031546 PMCID: PMC10807693 DOI: 10.1016/j.japh.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Opioids are overprescribed in the outpatient dental setting. Therefore, opportunities exist for opioid stewardship. OBJECTIVES The purpose of this pilot study was to test the feasibility of an academic detailing (AD) intervention to promote appropriate prescribing of opioids in outpatient dentistry. METHODS We implemented an AD intervention targeting management of acute oral pain in a Midwestern Veterans Affairs outpatient dental facility. The intervention targeted dentists who actively prescribed opioids at the time of the study. The pilot study tested feasibility, adoption, and acceptance of the AD campaign. Visit-based prescribing rates were obtained from the Veterans Health Administration's Corporate Data Warehouse for baseline and postintervention using difference-in-differences analyses to detect potential changes in health service outcomes. RESULTS Results indicate moderate levels of feasibility through participation rates (n = 5, 55.5%) and high levels of organizational readiness for change (average of 88.6% agree to strongly agree). Furthermore, fidelity of the AD intervention was high. Adoption measures show moderate indication of motivation to change, and trends suggest that participating dentists decreased their visit-based opioid prescribing rates (P > 0.05). CONCLUSION The intervention demonstrated feasibility with some indications of adoption of intervention techniques and decrease in opioid prescribing. We further recommend working closely with frontline providers to gather feedback and buy-in before scaling and implementing the AD campaign.
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Dreyer M, Shukla A, Sabadee J, Bibireddy M, Borner K, Thyvalikakath T, Simon K. Opioid Prescriptions Prior to Emergency Department Dental Visits: A Comparison of Dental Health Professional Shortage Areas (DPSAs) and Non-DPSAs Using Electronic Health Records. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2023; 60:469580231218440. [PMID: 38142365 PMCID: PMC10749523 DOI: 10.1177/00469580231218440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 12/25/2023]
Abstract
Although prior research has linked dental conditions and opioid prescribing in the U.S., it is not yet known whether the receipt of opioid prescriptions prior to seeking emergency care for dental conditions differs in geographical areas that are underserved by health care professionals (Dental Professional Shortage Areas, DPSAs) compared to other areas. Using Indiana's state-wide electronic health records from January 1, 2016 to October 31, 2020, we examine if patients from DPSAs presenting at the emergency department (ED) for dental conditions are more likely to have received opioid prescriptions in the 30 days prior to their visit, compared to patients from other areas. A higher rate of opioid receipt among DPSA individuals may indicate an association between lower availability of dental professionals and the use of opioids as a coping strategy. We note that our study design has several limitations (such as a lack of data on prescription use after the ED visit) and does not prove causation. We find that individuals experiencing dental condition ED visits in DPSAs are 16% more likely (than those in non-DPSAs) to have filled an opioid prescription in the 30 days prior to the ED visit, after controlling for age, gender, and race/ethnicity. This result is statistically significant at the 1% level. The baseline rate of opioid filling in the 30 days prior to the ED visit is 12% in DPSAs. These correlational results suggest that unmet dental needs might be substantially connected to opioid prescriptions, although further research is needed to establish whether this relationship is causal.
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Affiliation(s)
| | | | | | - Meghana Bibireddy
- Luddy School of Informatics, Computing and Engineering, Indianapolis, IN
| | - Katy Borner
- Luddy School of Informatics, Computing, and Engineering, Bloomington, IN
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13
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Yan CH, Ramanathan S, Suda KJ, Khouja T, Rowan S, Evans CT, Lee TA, Calip GS, Gellad WF, Sharp LK. Barriers to and facilitators of opioid prescribing by dentists in the United States: A qualitative study. J Am Dent Assoc 2022; 153:957-969.e1. [PMID: 35863973 PMCID: PMC10644785 DOI: 10.1016/j.adaj.2022.05.009] [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: 01/04/2022] [Revised: 05/08/2022] [Accepted: 05/23/2022] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Connie H. Yan
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Swetha Ramanathan
- School of Public Health, University of Illinois at Chicago, Chicago, IL, USA
| | - Katie J. Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Medicine, Pittsburgh, University of Pittsburgh, PA, USA
| | - Tumader Khouja
- Department of Medicine, Pittsburgh, University of Pittsburgh, PA, USA
| | - Susan Rowan
- College of Dentistry, University of Illinois at Chicago, Chicago, IL, USA
| | - Charlesnika T. Evans
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, IL, USA
- Northwestern University Feinberg School of Medicine, Department of Preventive Medicine and Center for Health Services and Outcomes Research, Chicago, IL, USA
| | - Todd A. Lee
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Gregory S. Calip
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Walid F. Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Medicine, Pittsburgh, University of Pittsburgh, PA, USA
| | - Lisa K. Sharp
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
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Kohli R, Replogle K, Gough-Goldman A, Taylor B, Maughan B, Sehgal HS, Herink MC, Hemmings R, Mahoney S, McDonnell MM, McLemore K, Schwarz E. Launching an innovative educational model addressing substance use disorders and dental pain management (Project ECHO® in dentistry). BMC Oral Health 2022; 22:402. [PMID: 36109782 PMCID: PMC9479263 DOI: 10.1186/s12903-022-02417-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 08/25/2022] [Indexed: 11/28/2022] Open
Abstract
Background Uninformed opioid prescribing by dentists has contributed to the current opioid crisis. This report describes the development and implementation of an innovative, interactive, multidisciplinary, and participant-centric telementoring program “Pain Management and Substance Use Disorders Dental ECHO (Extension for Community Health Care Outcomes)”. We disseminated information to dentists about appropriate opioid prescribing practices and engaged them with a focus on pain management and substance use disorders. The objective of this study was to assess the effectiveness of this program for self-reported: (1) change in knowledge and confidence related to clinical skills for dental pain management of patients with substance use disorders; (2) change in clinical behavior of dentists for safe opioids prescribing; and (3) change in clinic policies regarding safe opioids prescribing. Methods An interdisciplinary panel of experts in medicine, pharmacy, social work, and dentistry designed and led the “Pain Management and Substance Use Disorders Dental ECHO” for invited dental care providers and dental students. Six cohorts each consisting of six, 1-h-long sessions were conducted via the Zoom videoconference platform in years 2020 and 2021. Each session included a didactic expert presentation, a participant-presented patient case and discussion. Each participant completed pre- and post-program surveys to assess the program’s influence on participant knowledge, clinical confidence and behavior change. Results The participants (N = 151) were dentists (n = 109), dental faculty (n = 15), dental residents (n = 6), dental hygienists/assistants (n = 13) and nurses and clinic administrators (n = 8). Self-reported perceived medication knowledge, confidence in identification, treatment and willingness to engage with substance use disorders patients, and reported compliance with Prescription Drug Monitoring Program (PDMP) checks increased significantly from before to after the sessions (p < 0.001). Overall, participants expressed high levels of satisfaction with the content and reported that the sessions provided high benefit. Conclusion The Project ECHO model is effective in rapidly disseminating evidence-based information. Dentists viewed this model as having a high degree of benefit for the optimal management of dental pain and the recognition and treatment of substance use disorders.
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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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16
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Khouja T, Polk DE, Suda KJ. Opioid prescribing by oral and maxillofacial surgeons in the United States, 2016-2019. J Public Health Dent 2022; 82:491-494. [PMID: 36210548 PMCID: PMC10919295 DOI: 10.1111/jphd.12544] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 07/01/2022] [Accepted: 08/05/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To describe opioid prescribing trends among oral and maxillofacial surgeons (OMFS). METHODS Prescriptions by OMFS were identified from IQVIA Longitudinal Prescription Dataset, 2016-2019. OMFS-based, patient-based and population-based prescribing rates and changes in high-risk opioid prescribing were calculated annually. We used linear regression to describe trends. RESULTS There were 13.9 million opioid prescriptions among 12.5 million patients (627 prescriptions/OMFS/year). Hydrocodone and oxycodone decreased by 20.9% and 39.2% (p < 0.05), while tramadol and codeine increased by 24.3% and 6.1% (p < 0.05), respectively. Opioid prescribing rates significantly decreased by 27 prescriptions/OMFS/year, 18.6 patients/OMFS/year and by 0.9 prescriptions/100,000 population/year (p < 0.05 for all). From 2016 to 2019, the proportion of opioids >3 days decreased by 54.2% (p < 0.05) and prescriptions ≥50 MME/day decreased by 66.3% (p < 0.05). Although the number of opioid prescriptions by OMFS decreased in most states, 12% of states experienced increases. CONCLUSION Opioid prescribing, especially high-risk prescribing, by OMFS has decreased. However, targeted interventions are warranted in some areas.
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Affiliation(s)
- Tumader Khouja
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Deborah E. Polk
- Department of Dental Public Health, University of Pittsburgh School of Dental Medicine, Pittsburgh, Pennsylvania, USA
| | - Katie J. Suda
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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17
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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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18
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Khouja T, Zhou J, Gellad WF, Mitsantisuk K, Hubbard CC, Yan CH, Sharp LK, Calip GS, Evans CT, Suda KJ. Serious opioid-related adverse outcomes associated with opioids prescribed by dentists. Pain 2022; 163:1571-1580. [PMID: 35838648 PMCID: PMC9803557 DOI: 10.1097/j.pain.0000000000002545] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/18/2021] [Indexed: 01/03/2023]
Abstract
ABSTRACT Although nonsteroidal anti inflammatory drugs are superior to opioids in dental pain management, opioids are still prescribed for dental pain in the United States. Little is known about the serious adverse outcomes of short-acting opioids within the context of dental prescribing. The objective of this study was to evaluate adverse outcomes and persistent opioid use (POU) after opioid prescriptions by dentists, based on whether opioids were overprescribed or within recommendations. A cross-sectional analysis of adults with a dental visit and corresponding opioid prescription (index) from 2011 to 2018 within a nationwide commercial claims database was conducted. Opioid overprescribing was defined as >120 morphine milligram equivalents per Centers for Disease Control and Prevention guidelines. Generalized estimating equation models were used to assess adverse outcomes (emergency department visits, hospitalizations, newly diagnosed substance use disorder, naloxone administration, or death within 30 days from index) and POU (≥1 prescription 4-90 days postindex). Predicted probabilities are reported. Of 633,387 visits, 2.6% experienced an adverse outcome and 16.6% had POU. Adverse outcome risk was not different whether opioids were overprescribed or within recommendations (predicted probability 9.0%, confidence interval [CI]: 8.0%-10.2% vs 9.1%, CI: 8.1-10.3), but POU was higher when opioids were overprescribed (predicted probability 27.4%, CI: 26.1%-28.8% vs 25.2%, CI: 24.0%-26.5%). Visits associated with mild pain and those with substance use disorders had the highest risk of both outcomes. Findings from this study demonstrate that dental prescribing of opioids was associated with adverse outcomes and POU, even when prescriptions were concordant with guidelines. Additional efforts are required to improve analgesic prescribing in dentistry, especially in groups at high risk of opioid-related adverse outcomes.
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Affiliation(s)
- Tumader Khouja
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jifang Zhou
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
| | - Walid F. Gellad
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kannop Mitsantisuk
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Colin C. Hubbard
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA
| | - Connie H. Yan
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA
| | - Lisa K. Sharp
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA
| | - Gregory S. Calip
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Katie J. Suda
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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19
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Yan CH, Lee TA, Sharp LK, Hubbard CC, Evans CT, Calip GS, Rowan SA, McGregor JC, Gellad WF, Suda KJ. Trends in Opioid Prescribing by General Dentists and Dental Specialists in the U.S., 2012-2019. Am J Prev Med 2022; 63:3-12. [PMID: 35232618 PMCID: PMC9233039 DOI: 10.1016/j.amepre.2022.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 12/22/2021] [Accepted: 01/07/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Evidence suggests that U.S. dentists prescribe opioids excessively. There are limited national data on recent trends in opioid prescriptions by U.S. dentists. In this study, we examined trends in opioid prescribing by general dentists and dental specialists in the U.S. from 2012 to 2019. METHODS Dispensed prescriptions for oral opioid analgesics written by dentists were identified from IQVIA Longitudinal Prescription Data from January 2012 through December 2019. Autoregressive integrated moving average and joinpoint regression models described monthly population-based prescribing rates (prescriptions/100,000 individuals), dentist-based prescribing rates (prescriptions/1,000 dentists), and opioid dosages (mean daily morphine milligram equivalents/day). All analyses were performed in 2020. RESULTS Over the 8 years, dentists prescribed >87.2 million opioid prescriptions. Population- and dentist-based prescribing rates declined monthly by -1.97 prescriptions/100,000 individuals (95% CI= -9.98, -0.97) and -39.12 prescriptions/1,000 dentists (95% CI= -58.63, -17.65), respectively. Opioid dosages declined monthly by -0.08 morphine milligram equivalents/day (95% CI= -0.13, -0.04). Joinpoint regression identified 4 timepoints (February 2016, May 2017, December 2018, and March 2019) at which monthly prescribing rate trends were often decreasing in greater magnitude than those in the previous time segment. CONCLUSIONS Following national trends, dentists became more conservative in prescribing opioids. A greater magnitude of decline occurred post 2016 following the implementation of strategies aimed to further regulate opioid prescribing. Understanding the factors that influence prescribing trends can aid in development of tailored resources to encourage and support a conservative approach by dentists, to prescribing opioids.
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Affiliation(s)
- Connie H Yan
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois.
| | - Todd A Lee
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Lisa K Sharp
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Colin C Hubbard
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Charlesnika T Evans
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr VA Hospital, Hines, Illinois; Department of Preventive Medicine, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Gregory S Calip
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Susan A Rowan
- College of Dentistry, University of Illinois at Chicago, Chicago, Illinois
| | | | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Valdes IL, Possinger MC, Hincapie-Castillo JM, Goodin AJ, Dewar MA, Sumfest JM, Vouri SM. Changes in Prescribing by Provider Type Following a State Prescription Opioid Restriction Law. J Gen Intern Med 2022; 37:1838-1844. [PMID: 34236602 PMCID: PMC9198141 DOI: 10.1007/s11606-021-06966-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/04/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Many states have implemented opioid days' supply restriction policies, leading to reductions in opioid prescribing. Although research within certain provider types exist, no study has evaluated a restriction policy by various provider types. OBJECTIVE To evaluate changes in opioid utilization following a days' supply restriction policy stratified by provider type: surgery, emergency medicine, primary care, specialty care, and dentistry. DESIGN Interrupted time series (ITS) PARTICIPANTS: Opioid prescription claims of patients in a private health plan serving a large Florida employer from 1/1/2015 to 3/31/2019. Provider types were determined using the Healthcare Provider Taxonomy Code associated with the national provider identifier (NPI). INTERVENTIONS Florida's opioid restriction policy implemented on July 1, 2018. MAIN MEASURES Changes in mean morphine milligram equivalent (MMEs), mean days' supply, and mean number of units dispensed per opioid prescription before and after policy implementation. KEY RESULTS There were 10,583 opioid initial prescriptions dispensed. Treating providers were classified as surgery (16.4%; n = 1732), emergency care (14.3%; n = 1516), primary care (21.2%; n = 2241), specialty care (11.4%; n = 1207), and dentistry providers (23.7%; n = 2511). Significant reductions in mean days' supply were observed across most provider types ranging from 14% reduction for dentistry providers to 41% reduction for specialty care providers. Significant changes were observed for emergency care and specialty care providers with a 30% (p = 0.001)and 29% (p < 0.001) reduction in mean MME, respectively, and a 27% (p = 0.040) reduction in mean number of units dispensed in emergency care providers, after implementation. Pre-implementation trends in opioid prescribing varied by provider type impacting the effects of the opioid days' supply restriction policy. CONCLUSIONS Pre-policy opioid prescribing varied by provider type with a differential impact on mean MMEs, mean days' supply, and mean number of units dispensed per prescription following implementation.
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Affiliation(s)
- Ivelisse L Valdes
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, USA
| | - Marie-Christin Possinger
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Juan M Hincapie-Castillo
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, USA
- Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, USA
| | - Amie J Goodin
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, USA
| | - Marvin A Dewar
- University of Florida Health Physicians, Gainesville, FL, USA
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jill M Sumfest
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Scott M Vouri
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA.
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, USA.
- University of Florida Health Physicians, Gainesville, FL, USA.
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Abstract
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).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY, 11367, United States.
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22
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Tempe DK. Opioid stewardship in cardiac anesthesia practice. J Cardiothorac Vasc Anesth 2022; 36:2262-2264. [DOI: 10.1053/j.jvca.2022.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 04/24/2022] [Indexed: 11/11/2022]
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Chua KP, Waljee JF, Gunaseelan V, Nalliah RP, Brummett CM. Distribution of Opioid Prescribing and High-Risk Prescribing Among U.S. Dentists in 2019. Am J Prev Med 2022; 62:317-325. [PMID: 35190099 PMCID: PMC8867916 DOI: 10.1016/j.amepre.2021.09.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/10/2021] [Accepted: 09/14/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION It is unknown whether certain dentists account for disproportionate shares of dental opioid prescriptions and high-risk prescriptions. Identifying and characterizing such dentists could inform the targeting of initiatives to improve the appropriateness and safety of dental opioid prescribing. METHODS In May 2021, the authors conducted a cross-sectional analysis using the IQVIA Longitudinal Prescription Database, which reports dispensing from 92% of U.S. pharmacies, and 2 provider databases (IQVIA OneKey, National Plan and Provider Enumeration System). Analyses included opioid prescriptions from dentists dispensed in 2019 to patients aged >12 years. High-risk prescriptions were those considered high risk by any of 3 metrics (prescriptions to opioid-naïve patients exceeding a 3-day supply, prescriptions with daily opioid dosage ≥50 morphine milligram equivalents, opioid prescriptions with benzodiazepine overlap). Among all prescriptions and high-risk prescriptions, the authors calculated the proportion accounted for by high-volume dentists -- those with prescription counts in the 95th percentile or higher. Using logistic regression, the characteristics associated with being a high-volume dentist were identified. RESULTS In 2019, a total of 141,345 dentists accounted for 10,736,743 opioid prescriptions dispensed to patients aged >12 years; 4,242,634 (39.5%) were high-risk prescriptions. The 7,079 high-volume dentists, a group representing 5.0% of the 141,345 dentists, accounted for 46.9% of all prescriptions and 47.5% of high-risk prescriptions. Male sex, younger age, non‒Northeast location, and specialization in oral and maxillofacial surgery were associated with a higher risk of being a high-volume dentist. CONCLUSIONS In 2019, high-volume dentists accounted for almost half of dental opioid prescriptions and high-risk prescriptions. Quality improvement initiatives targeting these dentists may be warranted.
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Affiliation(s)
- Kao-Ping Chua
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor, Michigan; Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan.
| | - Jennifer F Waljee
- Michigan Opioid Prescribing Engagement Network, Institute for Healthcare Policy & Innovation, University of Michigan Medical School, Ann Arbor, Michigan; Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Vidhya Gunaseelan
- Michigan Opioid Prescribing Engagement Network, Institute for Healthcare Policy & Innovation, University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Chad M Brummett
- Michigan Opioid Prescribing Engagement Network, Institute for Healthcare Policy & Innovation, University of Michigan Medical School, Ann Arbor, Michigan; Division of Pain Medicine, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
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Humphreys K, Shover CL, Andrews CM, Bohnert ASB, Brandeau ML, Caulkins JP, Chen JH, Cuéllar MF, Hurd YL, Juurlink DN, Koh HK, Krebs EE, Lembke A, Mackey SC, Larrimore Ouellette L, Suffoletto B, Timko C. Responding to the opioid crisis in North America and beyond: recommendations of the Stanford-Lancet Commission. Lancet 2022; 399:555-604. [PMID: 35122753 PMCID: PMC9261968 DOI: 10.1016/s0140-6736(21)02252-2] [Citation(s) in RCA: 182] [Impact Index Per Article: 91.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 08/01/2021] [Accepted: 10/06/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Keith Humphreys
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.
| | - Chelsea L Shover
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Christina M Andrews
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Amy S B Bohnert
- Department of Psychiatry and Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA; Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Margaret L Brandeau
- Department of Management Science and Engineering, Huang Engineering Center, Stanford University, Stanford, CA USA
| | | | - Jonathan H Chen
- Stanford Center for Biomedical Informatics Research, Stanford University School of Medicine, Stanford, CA, USA; Division of Hospital Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Yasmin L Hurd
- Addiction Institute, Icahn School of Medicine, New York, NY, USA
| | - David N Juurlink
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Howard K Koh
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Erin E Krebs
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA; Center for Care Delivery and Outcomes Research, Veterans Affairs Minneapolis Health Care System, Minneapolis, MN, USA
| | - Anna Lembke
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Sean C Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | | | - Brian Suffoletto
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Christine Timko
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
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A Cross Sectional Survey of Attitudes and Barriers toward Pharmacist Services at Pre-Doctoral Academic Dental Institutions. J Am Pharm Assoc (2003) 2022; 62:1232-1238.e2. [DOI: 10.1016/j.japh.2022.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 01/28/2022] [Accepted: 01/29/2022] [Indexed: 11/22/2022]
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Obadan-Udoh E, Jura M, Wang S, Werts M, Martiniano R, Muench U, Mertz E. A longitudinal cohort study of opioid prescriptions associated with nonsurgical dental visits among Oregon and New York state Medicaid beneficiaries, 2014-2016. J Am Dent Assoc 2022; 153:460-469. [DOI: 10.1016/j.adaj.2021.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 10/18/2021] [Accepted: 10/21/2021] [Indexed: 11/27/2022]
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Evans CT, Fitzpatrick MA, Poggensee L, Gonzalez B, Gibson G, Jurasic MM, Echevarria K, McGregor JC, Cunningham F, Gellad WF, Suda KJ. Outpatient Prescribing of Antibiotics and Opioids by Veterans Health Administration Providers, 2015-2017. Am J Prev Med 2021; 61:e235-e244. [PMID: 34376291 PMCID: PMC8541933 DOI: 10.1016/j.amepre.2021.05.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 05/04/2021] [Accepted: 05/06/2021] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Antibiotics and opioids are targeted by public health and stewardship communities for reductions in prescribing across the country. This study evaluates trends and factors associated with outpatient prescribing by dental and medical providers in a large integrated health system. METHODS This was a cross-sectional study of national dental and medical outpatient visits from Department of Veterans Affairs facilities in 2015-2017; analyzed in 2019-2020. Antibiotic and opioid prescribing rates were assessed by provider and facility characteristics. Multivariable Poisson regression adjusted for repeated measures by the provider was used to assess the independent association between facility and provider characteristics and rate of prescribing. RESULTS Over the study period, 4,625,840 antibiotic and 10,380,809 opioid prescriptions were identified for 115,625,890 visits. Physicians prescribed most antibiotics (67%). Dentists prescribed 6% of the antibiotics but had the highest per-visit antibiotic prescribing rate compared to medical providers (6.75 vs 3.90 prescriptions per 100 visits, p<0.0001), which was largely driven by dental specialists. By contrast, dentists had lower opioid prescribing than medical providers (3.02 vs 9.20 prescriptions per 100 visits, p<0.0001). Overall, antibiotic and opioid prescribing decreased over time, with opioids having the greatest decreases (-28.0%). In multivariable analyses, U.S. geographic region, rurality, and complexity were associated with prescribing for both drug classes. Opioid and antibiotic prescribing were positively correlated. CONCLUSIONS Although antibiotic and opioid prescribing has decreased, there are still important target areas for improvement. Interventions need to be tailored to community characteristics such as rurality and provider type.
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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, 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.
| | - Margaret A Fitzpatrick
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr VA Hospital, Hines, Illinois; Division of Infectious Diseases, Department of Medicine, Stritch School of Medicine, Loyola University Chicago, 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 & Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts
| | - Kelly Echevarria
- Antimicrobial Stewardship Task Force, Pharmacy Benefits Management Program, U.S. Department of Veterans Affairs, Washington, District of Columbia
| | | | - Fran 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, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - 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, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Okunev I, Frantsve-Hawley J, Tranby E. Trends in national opioid prescribing for dental procedures among patients enrolled in Medicaid. J Am Dent Assoc 2021; 152:622-630.e3. [PMID: 34325778 DOI: 10.1016/j.adaj.2021.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 03/16/2021] [Accepted: 04/18/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The authors examined trends in opioid prescriptions by dentists for children and nonsenior adults enrolled in Medicaid. METHODS The authors used the IBM Watson Medicaid claims databases for 2012 through 2019 and the Centers for Disease Control and Prevention conversion data set. Opioid prescriptions were linked to a dental visit when prescribed within 3 days of the dental visit and if the patient had no medical visit reported during that period. The authors conducted descriptive analyses for age, procedures performed, treatment history, and prescription strength. RESULTS The results of the study showed consistent decreases in opioid prescription rates in dentistry during the study period from 2.7% to 1.6% among children (aged 0-20 years) and from 28.6% to 12.2% for adults (aged 21-64 years). The adult opioid prescription rate decreased for nonsurgical dental procedures from 9.7% to 2.9%. For surgical procedures, the adult prescription rate decreased from 48.0% to 28.7%. Most dental-related opioids were prescribed for oral surgeries (children, 70.8%; adults, 58.6%). By 2019, 23% of all opioid prescriptions for children were dental related. CONCLUSIONS The authors found that opioid prescription rates in dentistry for people enrolled in Medicaid declined substantially from 2012 through 2019 for both children and adults. The percentage of prescriptions written for nonsurgical visits consistently declined over the observed time. During the same time, opioid prescription rates for both dental surgical procedures and dental nonsurgical procedures. PRACTICAL IMPLICATIONS Although the trends revealed in the analysis show declining opioid prescription patterns, these results suggest that the overall rate is still too high and prescriptions are being written unnecessarily.
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Harnett P, Hindman J, Duenas M, Coogan M, Misicko H. Answering a Call to Action on American Workplace and Community Opioid Concerns. New Solut 2021; 31:229-238. [PMID: 34353132 PMCID: PMC8505779 DOI: 10.1177/10482911211037573] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Leidos, Inc. is a large government science and technology company. When a Leidos employee lost his son to an opioid overdose, he wrote an impassioned email to the CEO, asking him to take action related to the growing societal problem of opioid use disorders. The CEO understood and accepted this important call to action. Leidos’ subsequent efforts included supporting employees and families, as well as community outreach, eventually broadening to include mental health and well-being. This paper outlines the company’s efforts to combat opioid use disorders, understanding that they sit within a larger total worker health umbrella inclusive of mental health and well-being. The hope is that this ongoing journey and its exemplars are helpful for other organizations seeking to make an impact for their employees and society.
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Chua KP, Kenney BC, Waljee JF, Brummett CM, Nalliah RP. Dental Opioid Prescriptions and Overdose Risk in Patients and Their Families. Am J Prev Med 2021; 61:165-173. [PMID: 33975766 PMCID: PMC8319034 DOI: 10.1016/j.amepre.2021.02.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 01/29/2021] [Accepted: 02/14/2021] [Indexed: 02/08/2023]
Abstract
INTRODUCTION It is unknown whether dental opioid prescriptions are associated with opioid overdose in patients or their family members, who may have access to patients' opioids. METHODS During July-October 2020, the 2011-2018 IBM MarketScan Dental, IBM MarketScan Commercial, and Medicaid Multi-State Databases were analyzed. Two analyses were conducted. In the patient analysis, dental procedures for privately and publicly insured patients aged 13-64 years were identified. The exposure was ≥1 initial prescription (dispensed opioid prescription within 3 days of the procedure). The association between the exposure and ≥1 overdose within 90 days of the procedure was evaluated using logistic regression. In the family analysis, procedures for privately insured patients in family plans were identified. The association between the exposure and ≥1 overdose in a family member within 90 days was evaluated using logistic regression. In both analyses, the average marginal effect of the exposure was calculated, representing the change in the probability of the outcome if all versus if no procedures were associated with ≥1 initial prescription. RESULTS The patient analysis included 8,544,098 procedures. When ≥1 initial prescription did and did not occur, the 90-day risk of overdose was 5.8 versus 2.2 per 10,000 procedures (average marginal effect=1.5, 95% CI=1.2, 1.8). The family analysis included 3,461,469 procedures. When ≥1 initial prescription did and did not occur, the 90-day risk of overdose in a family member was 1.7 versus 1.0 per 10,000 procedures (average marginal effect=0.4, 95% CI=0.1, 0.7). CONCLUSIONS Findings further highlight the importance of avoiding unnecessary dental opioid prescribing.
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Affiliation(s)
- Kao-Ping Chua
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan; Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan.
| | - Brooke C Kenney
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan
| | - Jennifer F Waljee
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan; Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Chad M Brummett
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan; Division of Pain Medicine, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
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Geiger CK, Cohen JL, Sommers BD. Association Between Medicaid Prescription Drug Limits and Access to Medications and Health Care Use Among Young Adults With Disabilities. JAMA HEALTH FORUM 2021; 2:e211048. [PMID: 35977173 PMCID: PMC8796920 DOI: 10.1001/jamahealthforum.2021.1048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/17/2021] [Indexed: 11/22/2022] Open
Abstract
Question Are policies that cap monthly prescriptions in Medicaid associated with access to medication and health care use among young adults with disabilities in Arkansas and Texas? Findings In this cohort study using difference-in-differences analysis of 28 046 young adults with disabilities, including 8214 in states with a 3-drug limit at age 21 years, the 3-drug limit was associated with lower monthly prescriptions for medications used to treat mental health conditions and higher inpatient admissions among all individuals with disabilities in states with the drug cap policy compared with those in states without this policy. Meaning In this study, state drug cap policies in Medicaid were associated with lower access to medications and higher use of inpatient care. Importance Prescription drugs are necessary for managing complex physical and mental health conditions for more than 10 million Medicaid beneficiaries with disabilities. However, some state Medicaid programs limit the number of prescription drugs that beneficiaries can obtain monthly, which may decrease access to essential medications. Objective To examine the association between exposure to the 3-drug limit at age 21 years in Arkansas and Texas and prescription drug and health care use among beneficiaries with disabilities enrolled in Medicaid. Design, Setting, and Participants In this cohort study of 28 046 young adults with disabilities, difference-in-differences analysis was performed using Medicaid Analytic eXtract claims data from January 1, 2007, to December 31, 2012. Analyses were completed December 1, 2020. The analyses included Medicaid beneficiaries with disabilities in Arkansas and Texas (ie, drug cap states) or 15 comparison states without drug cap policies who became age 21 years during the study period and were continuously enrolled in fee-for-service Medicaid in the year before and after that point. Exposures Exposure to the 3-drug prescription limit at age 21 years in 2 drug cap states. Main Outcomes and Measures Monthly total prescriptions and prescriptions for drugs to treat mental health conditions, total prescription drug spending, and inpatient and emergency department visits and spending in the 12 months before and after becoming age 21 years. Results Among 28 046 young adults with disabilities, 8214 (29.3%) resided in drug cap states and were subject to the 3-drug limit at age 21 years. Most individuals were male (drug cap states: 61.4%, comparison states: 60.6%), and the minority were White individuals (drug cap states: 36.7%, comparison states: 49.4%). More than one-half of individuals with disabilities were diagnosed with a mental health condition before age 21 years (drug cap states: 57.0%, comparison states: 60.0%). In the year before the analyzed individuals became aged 21 years, the mean (SD) number of prescriptions per beneficiary per month was 1.58 (2.16) in drug cap states vs 1.82 (1.91) in comparison states. The drug cap policy was associated with 19.6% (95% CI, −21.3% to −17.8%; P < .001) fewer monthly prescriptions and 16.5% (95% CI, −21.9% to −10.8%; P < .001) fewer prescriptions for drugs for mental health conditions but was not associated with total prescription drug spending. The drug cap policy was associated with 13.6% (95% CI, 1.9% to 26.6%; P = .02) more inpatient admissions. Conclusions and Relevance In this cohort study of young adults with disabilities, drug cap policies were associated with lower rates of access to important medications and higher rates of hospitalization among individuals in states with drug cap policies vs those without these policies.
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Affiliation(s)
- Caroline K. Geiger
- Harvard University, Interfaculty Initiative in Health Policy, Cambridge, Massachusetts
- Genentech, Inc, South San Francisco, California
| | - Jessica L. Cohen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Benjamin D. Sommers
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Harvard Medical School/Brigham & Women’s Hospital, Boston, Massachusetts
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Campbell TJ, Martins D, Tadrous M, Juurlink DN, Paterson JM, Mamdani MM, Mock D, Gomes T. Dental Opioid Prescription Characteristics and the Risk of New, Persistent Use. Am J Prev Med 2021; 60:831-839. [PMID: 33744063 DOI: 10.1016/j.amepre.2021.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 11/24/2020] [Accepted: 01/07/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Dentists are a common source of opioid exposure. This study investigates the association between initial dental opioid prescription characteristics and subsequent persistent use and examines the rate of opioid overdose after initiation. METHODS A retrospective cohort study was conducted among Ontario residents who were dispensed an initial opioid prescription originating from a dentist between October 2014 and September 2018 (data were analyzed in October 2019-May 2020). Exposures were characterized on the basis of the average daily dose in milligram morphine equivalents and the duration and formulation (long versus short acting) of the initial prescription. New, persistent use was defined as ≥1 opioid prescription within 90 days and another within 91-365 days after the initial prescription. The rate of an opioid overdose within 90 days after initiation was examined. RESULTS Among 786,125 Ontarians who initiated a dentist-prescribed opioid, 34,880 (4.4%) developed persistent use, whereas 140 (0.72 per 1,000 person-years) had evidence of an overdose within 90 days. People dispensed an initial daily dose >90 milligram morphine equivalents (n=5,644, 0.7%) had significantly greater odds of persistence (AOR=1.20, 95% CI=1.07, 1.34) than those dispensed ≤20 milligram morphine equivalents (n=179,884, 22.9%). Persistence was also significantly associated with receiving longer prescription durations and a long-acting opioid on initiation. CONCLUSIONS Among people who initiated a dentist-prescribed opioid, 1 in 23 experienced persistent use, and persistence was associated with the characteristics of the prescription. Prescribing lower doses, prescribing for shorter durations, and avoiding long-acting formulations may be an opportunity to lessen the risk of persistent opioid use.
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Affiliation(s)
| | - Diana Martins
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Unity Health Toronto, Toronto, Ontario, Canada
| | - Mina Tadrous
- ICES, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; Women's College Hospital Research Institute, Toronto, Ontario, Canada
| | - David N Juurlink
- ICES, Toronto, Ontario, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Research Institute, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - J Michael Paterson
- ICES, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Muhammad M Mamdani
- ICES, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Unity Health Toronto, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - David Mock
- Royal College of Dental Surgeons of Ontario, Toronto, Ontario, Canada; Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
| | - Tara Gomes
- ICES, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Unity Health Toronto, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
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Scrivani SJ, Keith DA, Kulich RJ, DaSilva AF, Donoff RB, Handa S, Holland N, Lerman MA, McCauley JL, Reisner L, Resnick CM, Stohler CS, Vasciannie A, Fortino M, Schatman ME. Pain Management for Dental Medicine in 2021: Opioids, Coronavirus and Beyond. J Pain Res 2021; 14:1371-1387. [PMID: 34079355 PMCID: PMC8164473 DOI: 10.2147/jpr.s319373] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 05/12/2021] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Steven J Scrivani
- Department of Diagnostic Sciences, Craniofacial Pain and Headache Center, Tufts University School of Dental Medicine, Boston, MA, USA
| | - David A Keith
- Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Ronald J Kulich
- Department of Diagnostic Sciences, Craniofacial Pain and Headache Center, Tufts University School of Dental Medicine, Boston, MA, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Alexandre F DaSilva
- Department of Biological and Material Sciences & Prosthodontics, University of Michigan School of Dentistry, Headache and Orofacial Pain Effort, University of Michigan, Ann Harbor, MI, USA
- fNIRS Laboratory, University of Michigan, Ann Harbor, MI, USA
| | - R Bruce Donoff
- Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Shruti Handa
- Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Nicole Holland
- Department of Public Health and Community Service, Tufts University School of Dental Medicine, Boston, MA, USA
| | - Mark A Lerman
- Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA
| | - Jenna L McCauley
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Lori Reisner
- Department of Pharmaceutical Services, School of Pharmacy University of California, San Francisco, CA, USA
- Department of Clinical Pharmacy, San Francisco Medical Center, San Francisco, CA, USA
| | - Cory M Resnick
- Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, MA, USA
- Harvard School of Dental Medicine, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Christian S Stohler
- Columbia University College of Dental Medicine, New York, NY, USA
- Columbia University Medical Center, New York, NY, USA
| | - Alexis Vasciannie
- Department of Diagnostic Sciences, Craniofacial Pain and Headache Center, Tufts University School of Dental Medicine, Boston, MA, USA
| | - Matthew Fortino
- Department of Diagnostic Sciences, Craniofacial Pain and Headache Center, Tufts University School of Dental Medicine, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Michael E Schatman
- Department of Diagnostic Sciences, Craniofacial Pain and Headache Center, Tufts University School of Dental Medicine, Boston, MA, USA
- Department of Public Health & Community Medicine, Tufts University School of Medicine, Boston, MA, USA
- School of Social Work, North Carolina State University, Raleigh, NC, USA
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Hubbard CC, Evans CT, Calip GS, Rowan SA, Gellad WF, Campbell A, Gross AE, Hershow RC, McGregor JC, Sharp LK, Suda KJ. Characteristics Associated With Opioid and Antibiotic Prescribing by Dentists. Am J Prev Med 2021; 60:648-657. [PMID: 33745816 PMCID: PMC8549405 DOI: 10.1016/j.amepre.2020.11.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/31/2020] [Accepted: 11/19/2020] [Indexed: 01/15/2023]
Abstract
INTRODUCTION The objective of this study is to identify county-level characteristics that may be high-impact targets for opioid and antibiotic interventions to improve dental prescribing. METHODS Prescriptions during 2012-2017 were extracted from the IQVIA Longitudinal Prescription database. Primary outcomes were yearly county-level antibiotic and opioid prescribing rates. Multivariable negative binomial regression identified associations between prescribing rates and county-level characteristics. All analyses occurred in 2020. RESULTS Over time, dental opioid prescribing rates decreased by 20% (from 4.02 to 3.22 per 100 people), whereas antibiotic rates increased by 5% (from 6.85 to 7.19 per 100 people). Higher number of dentists per capita, higher proportion of female residents, and higher proportion of residents aged <65 years were associated with increased opioid rates. Relative to location in the West, location in the Northeast (59%, 95% CI=52, 65) and Midwest (64%, 95% CI=60, 70) was associated with lower opioid prescribing rates. Higher clinician density, median household income, proportion female, and proportion White were all independently associated with higher antibiotic rates. Location in the Northeast (149%, 95% CI=137, 162) and Midwest (118%, 95% CI=111, 125) was associated with higher antibiotic rates. Opioid and antibiotic prescribing rates were positively associated. CONCLUSIONS Dental prescribing of opioids is decreasing, whereas dental antibiotic prescribing is increasing. High prescribing of antibiotics is associated with high prescribing of opioids. Strategies focused on optimizing dental antibiotics and opioids are needed given their impact on population health.
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Affiliation(s)
- Colin C Hubbard
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois Chicago, Chicago, Illinois
| | - Charlesnika T Evans
- Department of Preventive Medicine, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, Illinois
| | - Gregory S Calip
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois Chicago, Chicago, Illinois
| | - Susan A Rowan
- Department of Restorative Dentistry, College of Dentistry, University of Illinois Chicago, Chicago, Illinois
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania; Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Alan E Gross
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois Chicago, Chicago, Illinois
| | - Ronald C Hershow
- Department of Epidemiology, School of Public Health, University of Illinois Chicago, Chicago, Illinois
| | - Jessina C McGregor
- Department of Pharmacy Practice, College of Pharmacy, Oregon State University, Corvallis, Oregon
| | - Lisa K Sharp
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois Chicago, Chicago, Illinois
| | - Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania; Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
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Chua KP, Hu HM, Waljee JF, Nalliah RP, Brummett CM. Persistent Opioid Use Associated With Dental Opioid Prescriptions Among Publicly and Privately Insured US Patients, 2014 to 2018. JAMA Netw Open 2021; 4:e216464. [PMID: 33861332 PMCID: PMC8052591 DOI: 10.1001/jamanetworkopen.2021.6464] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This cohort study uses data from 3 MarketScan databases to compare the association of persistent opioid use with dental opioid prescriptions among publicly and privately insured patients in the United States from 2014 through 2018.
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Affiliation(s)
- Kao-Ping Chua
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
| | - Hsou-Mei Hu
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan
| | - Jennifer F. Waljee
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | | | - Chad M. Brummett
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan
- Division of Pain Medicine, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
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36
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Chua KP, Hu HM, Waljee JF, Brummett CM, Nalliah RP. Opioid prescribing patterns by dental procedure among US publicly and privately insured patients, 2013 through 2018. J Am Dent Assoc 2021; 152:309-317. [PMID: 33637299 DOI: 10.1016/j.adaj.2021.01.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/11/2020] [Accepted: 01/06/2021] [Indexed: 10/22/2022]
Abstract
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.
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37
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Weiner SG, Chou SC, Chang CY, Garner C, El Ibrahimi S, Hallvik S, Hendricks M, Baker O. Prescription and Prescriber Specialty Characteristics of Initial Opioid Prescriptions Associated with Chronic Use. PAIN MEDICINE 2020; 21:3669-3678. [PMID: 33094313 DOI: 10.1093/pm/pnaa293] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Shih-Chuan Chou
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Cindy Y Chang
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Chad Garner
- State of Ohio Board of Pharmacy, Columbus, Ohio
| | - Sanae El Ibrahimi
- Comagine Health, Portland, Oregon.,University of Nevada, Las Vegas, Nevada
| | | | | | - Olesya Baker
- Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Piper BJ, McCall KL, Kogan LR, Hellyer P. Assessment of Controlled Substance Distribution to U.S. Veterinary Teaching Institutions From 2006 to 2019. Front Vet Sci 2020; 7:615646. [PMID: 33392300 PMCID: PMC7775551 DOI: 10.3389/fvets.2020.615646] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 11/24/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: To evaluate the changing pattern of distribution of Schedule II and III opioids, barbiturates, and stimulants to veterinary educational institutions in the United States. Design: Longitudinal study. Sample: Veterinary teaching institutions that use Schedule II and III drugs. Procedures: Distribution of controlled substances to veterinary teaching institutions was obtained from the Drug Enforcement Administration's Automated Reports and Consolidated Orders System (ARCOS) for opioids (e.g., methadone, fentanyl, codeine), barbiturates (pentobarbital, butalbital), and stimulants (amphetamine, methylphenidate, lisdexamfetamine) from 2006–2019. Opioids were converted to their morphine milligram equivalents (MME) for evaluation over time. Results: Controlled substance distribution to veterinary schools exhibited dynamic, and agent specific, changes. The total MME for 11 opioids peaked in 2013 and decreased by 17.3% in 2019. Methadone accounted for two-fifths (42.3%) and fentanyl over one-third (35.4%) of the total MME in 2019. Pentobarbital distribution was greatest by weight of all substances studied and peaked in 2011 at 69.4 kg. Stimulants underwent a pronounced decline and were very modest by 2014. Conclusions and Clinical Relevance: Opioids by total MME in veterinary teaching practice have undergone more modest changes than opioids used with humans. Hydrocodone, codeine and recently fentanyl use have declined while methadone increased. Stimulant distribution decreased to become negligible. Together, this pattern of findings warrant continued monitoring.
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Affiliation(s)
- Brian J Piper
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA, United States.,Center for Pharmacy Innovation and Outcomes, Geisinger Precision Health Center, Forty Fort, PA, United States
| | - Kenneth L McCall
- Department of Pharmacy Practice, University of New England, Portland, ME, United States
| | - Lori R Kogan
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO, United States
| | - Peter Hellyer
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO, United States
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Zhou J, Calip GS, Rowan S, McGregor JC, Perez RI, Evans CT, Gellad WF, Suda KJ. Potentially Inappropriate Medication Combination with Opioids among Older Dental Patients: A Retrospective Review of Insurance Claims Data. Pharmacotherapy 2020; 40:992-1001. [PMID: 32767780 PMCID: PMC8483014 DOI: 10.1002/phar.2452] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/30/2020] [Accepted: 06/30/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Opioid prescribing by dentists for older patients receiving medications with potential contraindications and the subsequent impact on acute care outcomes is not well described. OBJECTIVES Our objective of this paper was to evaluate the use of potentially inappropriate medication combinations (PIMCs) involving opioids prescribed by dentists according to the Beers Criteria and risks of 30-day emergency department (ED) visits and all-cause hospitalization among commercially insured dental patients ages 65 years and older. METHODS We conducted a retrospective cohort study of 40,800 older dental patient visits in which opioids were prescribed between 2011 and 2015 using the IBM MarketScan databases. Data collection from dental, medical, and pharmacy claims included information on the concurrent use of PIMCs and outcomes of all-cause acute care utilization over the 30-day period after dental encounters. RESULTS For the overall cohort, the median age was 69 years, and 45% were women. The prevalence of PIMCs per Beers Criteria was 10.4%. A total of 947 all-cause acute care events were observed in the 30 days post-dental visit. Patients with PIMCs involving opioids prescribed by dentists according to the Beers Criteria had higher rates of acute care use (3.3% vs 2.2%, p<0.001), which were associated with an increased risk of all-cause acute care utilization (adjusted risk ratio [RR] 1.23, 95% confidence interval [CI] 1.02-1.48). A dose-response relationship was seen with increasing oral morphine equivalents prescribed and increased acute care utilization (p<0.001). CONCLUSION A significant proportion of older patients receiving opioids at dental visits use psychotropic medications that in combination should be avoided according to the American Geriatric Society Beers Criteria.
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Affiliation(s)
- Jifang Zhou
- University of Illinois at Chicago, College of Pharmacy, Chicago, IL
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Gregory S. Calip
- University of Illinois at Chicago, College of Pharmacy, Chicago, IL
- Flatiron Health, New York, NY
| | - Susan Rowan
- University of Illinois at Chicago, College of Dentistry, Chicago, IL
| | | | - Rosanne I. Perez
- University of Illinois at Chicago, College of Medicine, Chicago, IL
| | - Charlesnika T. Evans
- Northwestern University Feinberg School of Medicine, Chicago, IL
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, IL
| | - Walid F. Gellad
- University of Pittsburgh, Department of Medicine, Pittsburgh, PA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Katie J. Suda
- University of Pittsburgh, Department of Medicine, Pittsburgh, PA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
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