Are Oral and Maxillofacial Surgeons Prescribing Fewer Opioids and More Non-Narcotic Analgesics for Postoperative Pain After Third Molar Removal?

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.

Analgesia and Side Effects of Codeine Phosphate Associated with Paracetamol Versus Oxycodone After the Extraction of Mandibular Third Molars: A Randomized Double-Blind Clinical Trial Using the Split-Mouth Model

Purpose

To assess the analgesia and side effects of 10 mg oxycodone as compared to 30 mg of codeine phosphate associated with 500 mg of paracetamol after bilateral lower third molar extraction.

Methods

This is a prospective, randomized, double-blind study applied to a sample of 16 patients. They were evaluated for seven days postoperatively, and the mean score of the visual analogue scale (VAS) of pain between test and control medications was assessed by the Wilcoxon distribution. The side effects of these medications were assessed by the Q Cochran test. A p value of < .05 was considered statistically significant.

Results

The mean score of the VAS of pain was higher in the oxycodone side, where few patients reported the use of rescue analgesic. There was no report of rescue medication in codeine phosphate associated with paracetamol side. The most common side effects reported in both groups, predominantly in patients using the oxycodone, were drowsiness, dizziness, and headache.

Conclusion

The use of codeine phosphate associated with paracetamol after the extraction of impacted mandibular third molars is a better choice than oxycodone for controlling postoperative pain.

Trial Registration Number and Date of Registration

RBR-8ntwmyq 07/07/2021.

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.

Do Oral and Maxillofacial Surgeons Prescribe More Opioids After Third Molar Removal for Patients with Substance Use History?

PURPOSE

Oral and maxillofacial surgeons (OMSs) must manage postoperative pain control for patients who take illicit substances. The purpose of this study was to measure and compare the amount of opioid prescribing between patients with and without self-reported substance use history (SUH) by OMSs after third molar (M3) removal.

MATERIALS AND METHODS

The investigators implemented a retrospective cohort study and enrolled a sample of subjects who had M3 removal between January 1, 2019 through December 31, 2019. The primary predictor variable was SUH coded as yes (SUH+) or no (SUH-). The primary and secondary outcome variables were prescribed morphine milligram equivalents (MMEs) and number of post-operative visits due to inadequate pain control (IPC), respectively. Other variables were age, gender, payor, provider, anesthesia, and procedure specific. Descriptive, bivariate, and multiple linear regression models were computed.

RESULTS

The sample included 1,112 subjects with a mean age of 25 ± 9 years; 61.2% were female. Of the 1,112 subjects, 198 (17.8%) reported a SUH. Mean MMEs were 70.9 ± 27.9 and 63.4 ± 28.8 in the SUH+ and SUH- groups, respectively (P ≤ .001). An adjusted linear regression model showed a non-significant association between SUH and MMEs prescribed (P = .50). The study showed a non-significant increase (P = .15) in the proportion of patients with IPC in the SUH- group (4.1%) versus the SUH+ group (2.0%).

CONCLUSIONS

The results suggest that 10% more opioids were prescribed for postoperative pain after M3 removal for patients with SUH, though after adjustment, the amount may not be clinically significant. Postoperative pain management after M3 removal in patients with SUH, on average, can be managed in a similar manner as for patients without SUH.

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.