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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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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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Dyson MP, Dong K, Sevcik W, Graham SZ, Saba S, Hartling L, Ali S. Quantifying unused opioids following emergency and ambulatory care: A systematic review and meta‐analysis. J Am Coll Emerg Physicians Open 2022; 3:e12822. [PMID: 36203538 PMCID: PMC9523453 DOI: 10.1002/emp2.12822] [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: 04/29/2022] [Revised: 08/24/2022] [Accepted: 08/31/2022] [Indexed: 11/08/2022] Open
Abstract
Objective To quantify unused opioids among adult and pediatric patients discharged from the emergency department (ED) or ambulatory care settings with a prescription for acute pain. Methods We searched MEDLINE, Embase, CINHAL, PsycINFO, the Cochrane Library, and the gray literature from inception to April 29, 2021. We included observational studies in which any patient with an acutely painful condition received a prescription for an opioid on discharge from an outpatient care setting, and unused opioids were quantified. Two reviewers screened records for eligibility, extracted data, and conducted the quality assessment. Where possible, we pooled data and otherwise described the results of studies narratively. Total unused prescriptions were synthesized using a weighted average. Random effects models were used, and heterogeneity was measured by the I2 statistic. Our primary outcome was the quantity of unused opioid medication available after receiving a prescription for acute pain. Secondary outcomes were the proportion of patients with unused opioids following a prescription, the proportion of patients using no opioids, morphine equivalents of unused opioids, and factors associated with leftover opioids. Results In this systematic review and meta‐analysis of 9 studies in emergency and ambulatory care settings, 59.6% of prescribed opioids remained unused; pediatric patients had 69.3% of their prescriptions remaining, compared to 54.6% among adult patients. The highest proportion of unused opioids was found following dental extractions (82.6%). Conclusions and Relevance More than 50% of opioids remain unused following prescriptions for acute pain. Responsible prescribing must be accompanied by education on safer use, storage, and disposal.
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Affiliation(s)
- Michele P. Dyson
- Department of Pediatrics University of Alberta Edmonton Alberta Canada
| | - Kathryn Dong
- Department of Emergency Medicine University of Alberta Edmonton Alberta Canada
- Inner City Health and Wellness Program Royal Alexandra Hospital Edmonton Alberta Canada
| | - William Sevcik
- Department of Pediatrics University of Alberta Edmonton Alberta Canada
- Department of Emergency Medicine University of Alberta Edmonton Alberta Canada
| | - Samir Z. Graham
- Department of Pediatrics University of Alberta Edmonton Alberta Canada
| | - Sabrina Saba
- Department of Pediatrics University of Alberta Edmonton Alberta Canada
| | - Lisa Hartling
- Department of Pediatrics University of Alberta Edmonton Alberta Canada
| | - Samina Ali
- Department of Pediatrics University of Alberta Edmonton Alberta Canada
- Department of Emergency Medicine University of Alberta Edmonton Alberta Canada
- Women and Children's Health Research Institute University of Alberta Edmonton Alberta Canada
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Cruz AJS, Abreu LG, da Rocha Mendes S, de Castilho LS, de Abreu MHNG. Association of sociodemographic factors with the prescription pattern of opioids for dental patients: a systematic review. Evid Based Dent 2022:10.1038/s41432-022-0282-7. [PMID: 36068264 DOI: 10.1038/s41432-022-0282-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Aim To evaluate the association of patients' sociodemographic factors (sex, age, ethnicity, income, educational level, living environment and health insurance) with the prescription pattern of opioids provided by oral health practitioners.Methods Observational studies that evaluated the association of patients' sociodemographic factors and the likelihood of receiving an opioid prescription provided by an oral health practitioner were eligible. Electronic searches were conducted in Medline (PubMed), Embase, Scopus, Web of Science, LILACS, SciELO, Google Scholar, and OpenGrey up to March 2021. Two authors independently screened the studies, performed data extraction, and assessed the risk-of-bias using the critical appraisal tools developed by the Joanna Briggs Institute (JBI). Certainty of the evidence was assessed with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE).Results Eight studies were included in this systematic review. Publication year ranged from 2011 to 2021. Narrative synthesis showed with very low certainty of evidence that younger individuals were more likely to receive a prescription of opioids than older individuals. Regarding the other sociodemographic factors and the prescriptions of opioids in dentistry, the evidence is controversial. Risk of bias was low for most items assessed in the included studies.Conclusion The available evidence suggests that there is an association between patients' sociodemographic factors and the prescription patterns of opioids provided by oral health practitioners.
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Affiliation(s)
- Alex Junio Silva Cruz
- Graduate Program in Dentistry, School of Dentistry, Universidade Federal de Minas Gerais, Brazil.
| | - Lucas Guimarães Abreu
- Department of Child´s and Adolescent´s Oral Health, School of Dentistry, Universidade Federal de Minas Gerais, Brazil
| | - Suellen da Rocha Mendes
- Graduate Program in Dentistry, School of Dentistry, Universidade Federal de Minas Gerais, Brazil
| | - Lia Silva de Castilho
- Department of Operative Dentistry, School of Dentistry, Universidade Federal de Minas Gerais, Brazil
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Huang Q, Rasubala L, Gracely RH, Khan J, Eliav E, Ren Y. Comparison of Analgesic Prescriptions for Dental Pain and Patient Pain Outcomes Before vs After an Opioid Reduction Initiative. JAMA Netw Open 2022; 5:e2227219. [PMID: 35976651 PMCID: PMC9386536 DOI: 10.1001/jamanetworkopen.2022.27219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This cross-sectional study compares prescribing patterns of opioid and nonopioid analgesics and patients’ dental pain outcomes before vs after implementation of an opioid reduction initiative at a single dental clinic.
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Affiliation(s)
- Qirong Huang
- Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, New York
| | - Linda Rasubala
- Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, New York
| | - Richard H. Gracely
- Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, New York
| | - Junad Khan
- Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, New York
| | - Eli Eliav
- Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, New York
| | - Yanfang Ren
- Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, New York
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Oyler DR, Rojas-Ramirez MV, Nakamura A, Quesinberry D, Bernard P, Surratt H, Miller CS. Factors influencing opioid prescribing after tooth extraction. J Am Dent Assoc 2022; 153:868-877. [PMID: 35691709 DOI: 10.1016/j.adaj.2022.05.001] [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: 11/15/2021] [Revised: 05/01/2022] [Accepted: 05/04/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Tooth extractions account for most opioid prescriptions from dentists, but specific characteristics that influence likelihood are less established. Improving understanding can facilitate development of tailored interventions to reduce unnecessary opioid prescribing. METHODS The authors performed a retrospective review of patients 12 years and older undergoing tooth extraction at the College of Dentistry at the University of Kentucky from 2013 through 2020. The primary end point was issuance of an opioid prescription related to the encounter. RESULTS In 44,387 eligible records analyzed, 10,628 (23.9%) patients received an opioid prescription. Results of multivariable logistic regression found that the factors associated with an opioid prescription included receipt of a nonopioid analgesic prescription (adjusted odds ratio [aOR], 11.36; 95% CI, 10.37 to 12.44), receipt of an antibiotic prescription (aOR, 8.29; 95% CI, 7.57 to 9.08), procedural sedation (aOR, 2.11; 95% CI, 1.93 to 2.31), surgical extraction (aOR, 1.96; 95% CI, 1.84 to 2.10), and third molar extractions (1 tooth: aOR, 1.14; 95% CI 1.04 to 1.25; 2 teeth: aOR, 2.09; 95% CI, 2.87 to 2.34; 3 teeth: aOR, 2.73; 95% CI, 2.36 to 3.15; 4 teeth: aOR, 3.45; 95% CI, 3.10 to 3.83). Factors that decreased risk included having an appointment in 2018 or later (aOR, 0.31; 95% CI, 0.29 to 0.33), in a student (aOR, 0.57; 95% CI, 0.51 to 0.65) or resident (aOR, 0.33; 95% CI, 0.31 to 0.36) clinic, and on any day other than Friday (Monday: aOR, 0.83; 95% CI, 0.76 to 0.91; Tuesday: aOR, 0.90; 95% CI, 0.83 to 0.99; Wednesday: aOR, 0.89; 95% CI, 0.81 to 0.97; Thursday: aOR, 0.88; 95% CI 0.81 to 0.97). CONCLUSIONS Opioid prescriptions after tooth extraction were common in patients undergoing more extensive procedures. Provider perceptions, habits, and several clinical factors appeared to influence prescribing patterns. PRACTICAL IMPLICATIONS The decision to prescribe an opioid appears to be associated with habits and factors perceived to modulate postoperative pain, which may serve as targets for opioid reduction strategies.
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Cruz AJS, Abreu LG, Mendes SDR, de Castilho LS, de Abreu MHNG. Association of sociodemographic factors with the prescription pattern of opioids for dental patients: A systematic review protocol. PLoS One 2021; 16:e0255743. [PMID: 34352025 PMCID: PMC8341526 DOI: 10.1371/journal.pone.0255743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 07/20/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Oral health practitioners are responsible for a significant share of opioid prescriptions that seem to be influenced by many aspects, including sociodemographic factors. However, there is no consensus on the factors associated with opioid prescription in Dentistry. OBJECTIVE To identify whether patients' sociodemographic factors are associated with the prescription pattern of opioids in Dentistry. MATERIALS AND METHODS This systematic review will include observational studies (cross-sectional, case-control, and cohort). Electronic searches will be conducted in MEDLINE (PubMed), EMBASE, Scopus, Web of science, LILACS, SciELO, and Google Scholar. Grey literature will also be consulted. Two independent reviewers will screen all retrieved articles for eligibility, extract data, and assess the methodological quality of the included studies. The results will be presented as a narrative synthesis and, where possible, a meta-analysis will be conducted. Certainty of the evidence will be assessed with the Grading of Recommendations, Assessment, Development, and Evaluation approach. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42020211226.
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Affiliation(s)
- Alex Junio Silva Cruz
- Graduate Programme in Dentistry, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Lucas Guimarães Abreu
- Department of Child’s and Adolescent’s Oral Health, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Suellen da Rocha Mendes
- Graduate Programme in Dentistry, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Lia Silva de Castilho
- Department of Operative Dentistry, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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Nagarajan R, Talbert J, Miller CS, Ebersole J. Variations in Schedule III prescription patterns in a Medicaid population pre- and post-policy. Sci Rep 2021; 11:7142. [PMID: 33785767 PMCID: PMC8010045 DOI: 10.1038/s41598-021-86409-6] [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: 01/09/2020] [Accepted: 03/01/2021] [Indexed: 11/09/2022] Open
Abstract
The present study investigated variations in patient movement patterns between prescribers before and after House Bill 1 (HB1) implementation in Kentucky using network abstractions (PPN: prescriber-prescriber networks) from a one-month cross-sectional Schedule III prescription data in a Medicaid population. Network characteristics such as degree centrality distribution of PPN was positively skewed and revealed Dental Practitioners to be the highly connected specialty with opioid analgesic hydrocodone-acetaminophen to be the most commonly prescribed drug. Taxonomy enrichment of the prescriber specialties in PPN using chi-square test revealed a reduction in the enriched taxonomies Post-HB1 compared to Pre-HB1 with Dental practitioners being constitutively enriched (p < 0.05). PPNs were also found to exhibit rich community structure revealing inherent clustering of prescribers as a result of patient movement, and were markedly different from those generated by random graph models. The magnitude of deviation from random graphs decreased Post-HB1 relative to Pre-HB1. The proposed network approach provides system-level insights into prescribers with potential to complement classical reductionist approaches and aggregate statistical measures used in assessing changes in prescription patterns pre- and post- policy implementation. It can provide preliminary cues into drug seeking behavior, and facilitate targeted surveillance of prescriber communities.
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Affiliation(s)
- Radhakrishnan Nagarajan
- Center for Oral and Systemic Health, Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, WI, USA.
| | - Jeffery Talbert
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Craig S Miller
- Department of Oral Health Practice, College of Dentistry, University of Kentucky, Lexington, KY, USA
| | - Jeffrey Ebersole
- School of Dental Medicine, University of Nevada Las Vegas, Las Vegas, NV, USA
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Oyler DR, Miller CS. Patterns of opioid prescribing in an Appalachian college of dentistry. J Am Dent Assoc 2021; 152:209-214. [PMID: 33632410 DOI: 10.1016/j.adaj.2020.12.002] [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: 07/08/2020] [Revised: 11/11/2020] [Accepted: 12/09/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Nonopioids provide sufficient analgesia with less risk after most dental procedures, but opioid prescriptions are still common. This study analyzed opioid prescribing characteristics on the basis of patient demographics and procedure types. METHODS The authors conducted a secondary analysis of an existing data set of opioid prescriptions issued from 2013 through 2018 from a college of dentistry in central Appalachia. Opioid prescriptions for young children or liquids were excluded. The authors analyzed prescriptions according to patient age group and sedation level required for surgical procedures. RESULTS Of 12,464 opioid prescriptions analyzed, 70% were written after extractions or surgical procedures. More than one-half (57.3%) were written for patients younger than 45 years. Adolescent and young adult (AYA) patients received prescriptions of higher quantities (mean [standard deviation], 20.9 [6.4] pills; 95% confidence interval, 20.6 to 21.1) and of longer durations (mean [standard deviation], 3.3 [1.5] days; 95% confidence interval, 3.2 to 3.4) than other groups (P < .001; 1-way analysis of variance). CONCLUSIONS AYA patients received more opioids than older patients after dental procedures, which is concerning given the high risk associated with AYA opioid exposure. Faculty in colleges of dentistry should educate students and residents on the risks and benefits of opioid therapy as well as alternative analgesics and via exemplifying appropriate prescribing behavior. PRACTICAL IMPLICATIONS AYA patients represent a seemingly unidentified high-risk age group for dentists. Dentists who perform invasive procedures must examine carefully opioid prescription necessity and prescribe in a manner consistent with best practices.
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Escontrías OA, Istrate E, Stewart DC. Curricular and clinical approaches to addressing the opioid epidemic: Results from the 2019 ADEA opioid dental school survey. J Dent Educ 2020; 84:1359-1367. [DOI: 10.1002/jdd.12452] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/25/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Omar A. Escontrías
- American Dental Education Association Office of Policy and Educational Research 655 K St NW, Suite 800 Washington District of Columbia 20001 USA
| | - Emilia Istrate
- American Dental Education Association Office of Policy and Educational Research 655 K St NW, Suite 800 Washington District of Columbia 20001 USA
| | - Denice C.L. Stewart
- American Dental Education Association Office of Policy and Educational Research 655 K St NW, Suite 800 Washington District of Columbia 20001 USA
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