Five-Year Comparative Analysis of Medicare Opioid Prescription Volume Among Oral and Maxillofacial Surgeons

Provider-directed analgesia for dental pain

INTRODUCTION

Extraction of impacted molar teeth is a common procedure performed by oral surgeons and general dentists, with postoperative pain being a significant adverse event post-surgery. If mismanaged, pain can lead to complications that impact oral and systemic health. The current scourge of the opioid epidemic has ushered in a new era of provider-directed analgesic (PDA) therapy in dentistry.

AREAS COVERED

This article provides an in-depth review on the major pharmacological and therapeutic properties of established and alternative analgesics used to manage dental pain.

EXPERT OPINION

Substantial evidence-based literature shows combination of a non-steroidal anti-inflammatory drug (NSAID; e.g. ibuprofen) and acetaminophen provides superior pain relief than single-agent or combination opioid regimens. However, there are clinical scenarios (e.g. severe pain) when short-course opioid prescription is appropriate in select patients, in which a 2-3-day treatment duration is typically sufficient. Alternative agents (e.g. caffeine, gabapentin, phytotherapies), typically in combination with established agents, can mitigate postoperative dental pain. Some evidence suggests preemptive therapies (e.g. corticosteroids, NSAIDs) reduce amounts of postsurgical analgesic consumption and might lessen opioid prescription burden. In summary, this comprehensive review provides an opportune update on the evolving landscape of pharmacotherapy for acute postsurgical dental pain, informing best practices for PDA in the dental setting.

Opioid prescription trends among American Head and Neck Society fellowship graduates

BACKGROUND

Opioids are commonly used to manage the pain of head and neck (HN) cancer patients.

METHODS

Retrospective cohort of graduates from American Head and Neck Society accredited fellowships from 1997 to 2018. The Center for Medicare and Medicaid Services Part D Provider Utilization and Payment database 2014-2019 was cross-referenced with provider names to identify opioid prescription trends.

RESULTS

From 2014 to 2019, there was no significant difference in the average number of opioid beneficiaries per provider (18.02 vs. 18.10, p = 0.586) or opioid claims per provider (28.06 vs. 26.73, p = 0.708). The average total opioid day supply per beneficiary declined from 11.09 to 7.05 days from 2014 to 2019 (p < 0.001). In 2019, providers in the Northeast had the lowest prescribed opioid day supply (3.67 days) compared to those from the South who had the highest (10.32 days).

CONCLUSIONS

Opioid prescription length has significantly declined among HN surgeons, with variations across geographic regions.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Opioid prescribing by oral and maxillofacial surgeons in the United States, 2016-2019

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.

Do rural oral and maxillofacial surgeons prescribe more postoperative opioids?

PURPOSE

This study assesses rural-urban differences in opioid prescription practices among oral and maxillofacial surgeons (OMSs) who treated Medicare beneficiaries in 2017.

METHODS

This cross-sectional study examines the 2017 Medicare Provider Utilization and Payment Dataset. The primary predictor variable was provider Rural-Urban Commuting Area code (rural versus urban). The primary outcome variable was mean opioid claims per Medicare beneficiary. Additional outcomes include total opioid claims volume, average Medicare beneficiaries and opioid cost per provider, mean days' supply of opioids per opioid claim, and average percentage of Medicare Part D claims represented by opioid claims. Mann-Whitney U tests compared continuous variables. A least-squares regression identified correlates of opioid claims volume.

RESULTS

Rural OMSs demonstrated a higher mean opioid claims per OMS and opioid cost per provider compared to urban surgeons. Urban OMSs prescribed a greater mean days' supply of opioids per opioid claim. A larger percentage of Medicare Part D claims were represented by opioid claims for rural OMSs compared to urban OMSs. There were no differences in mean opioid claims per Medicare beneficiary. Male provider gender, female Medicare beneficiary gender, total number of beneficiaries, and a higher hierarchical condition category score were correlated with increased opioid claims per Medicare beneficiary for urban providers only.

CONCLUSION

Urban and rural OMSs prescribe a similar volume of opioids per Medicare beneficiary, with rural providers prescribing higher total volumes of opioids due to larger patient panels. This work indicates that rural and urban OMSs have similar opioid prescribing practices.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Opioid Prescribing Patterns Among Facial Plastic and Reconstructive Surgeons in the Medicare Population

Objective: To evaluate opioid prescribing patterns among American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) members in the Medicare population. Methods: Retrospective cohort study of AAFPRS members in the Medicare Part D Prescriber dataset. Results: From 2014 to 2016, there was a significant decrease in the number of days of opioids supplied per beneficiary (5.9 vs. 4.9 days, p < 0.005), as well as the opioid prescription cost per beneficiary ($14.52 vs. $11.79, p = 0.005). The highest prescription rate was found in the Midwest (20.5%) and lowest in the Northeast (14.0%), however, the difference between geographic regions was not significant (p = 0.11). There was a significant decrease in the number of total opioid days supplied per beneficiary in the South (p = 0.001), Midwest (p = 0.05), and West regions (p < 0.001). There was no significant difference in opioid prescription rate (p = 0.89) or total opioid days supplied per beneficiary (p = 0.26) when states were stratified by age-adjusted opioid-specific death rate. Conclusion: This study demonstrates a national trend toward fewer opioid days supplied and less opioid cost per Medicare beneficiary among AAFPRS members between 2014 and 2016.

Does prescription drug monitoring program usage affect opioid analgesic prescriptions by oral and maxillofacial surgeons after third molar surgery?

OBJECTIVE

To curb opioid overprescription and diversion, 49 states have implemented mandatory prescription drug monitoring programs (PDMPs). This study aims to examine the changes in analgesic prescription patterns associated with mandatory PDMP usage by oral and maxillofacial surgeons.

DESIGN

This retrospective observational cohort study analyzed analgesic prescriptions after third molar surgeries from the University of Pennsylvania from July 2016 to December 2019. Because Pennsylvania mandated PDMP usage on January 1, 2017, we analyzed prescriptions 6 months prior to and for each 6-month interval after implementation.

RESULTS

Prescriptions after 13,430 procedures on 6437 patients across 7 6-month periods were analyzed. Patients in all study periods had an average age of 40 years and there was a slight majority of females. After PDMP implementation, patients who received analgesics had an 80% lower odds of receiving an opioid option after adjusting for age, sex, and procedural severity. When an opioid was prescribed, the mean pills per script decreased from 20.18 to 10.96 1 year after PDMP implementation.

CONCLUSIONS

Mandatory PDMP usage was associated with decreased odds of a patient receiving an opioid analgesic and with a decrease in mean opioid pills per script. PDMPs may be helpful in reducing opioid prescriptions by oral and maxillofacial surgeons after third molar surgery.