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

Surgeons' knowledge regarding perioperative pain management in patients with opioid use disorder: a survey among 260 members of the American College of Surgeons

BACKGROUND

Patients with opioid use disorder (OUD) are increasing, challenging surgeons to adjust post-operative pain management guidelines. A literature review identified limited information on how to best care for these patients. The purpose of this study was to determine surgical perioperative management of OUD, challenges, and support needed for optimal care.

METHODS

This study utilized an anonymous voluntary survey that was distributed to members of the American College of Surgeons through the association's electronic weekly newsletter. The survey was advertised weekly for three consecutive weeks. The survey included questions regarding surgeons' management of perioperative pain in patients with opioid use disorder and perceived barriers in treatment.

RESULTS

A total of 260 surgeons responded representing all specialties except ophthalmology. General surgery (66.5%) and plastic and reconstructive surgery (7.5%) represented the majority of responders. Ninety-five percent of surgeons reported treating a patient who used opioids in the past month and 86% encountered a patient with OUD. Nearly half (46%) reported being uncomfortable managing postoperative pain in patients with OUD. Most (67%) were not aware of any guidelines or standards pertaining to perioperative management of patients with OUD. While consultation was sought by 86% of surgeons, analyses identified lack of timely response and a lack of care coordination among specialists. Lack of knowledge and fear of harm (contributing further to addiction) were the most common themes.

CONCLUSION

Nearly half of surgeons report discomfort caring for patients with OUD with the vast majority involving a consulting service to assist with their care. Most surgeons believe that it would be helpful to have guidelines regarding the care of these patients. This provides an opportunity for increased education and training on the perioperative management of patients with OUD and further collaboration with addiction medicine, psychiatry and pain management colleagues.

Trajectories of opioid prescribing by general dentists, specialists, and oral and maxillofacial surgeons in the United States, 2015-2019

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.

Analgesics for the management of acute dental pain in the pediatric population: A systematic review and meta-analysis

BACKGROUND

The authors assessed the clinical effectiveness of analgesics to manage acute pain after dental extractions and pain associated with irreversible pulpitis in children.

TYPES OF STUDIES REVIEWED

The authors searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and US Clinical Trials registry from inception through November 2020. They included randomized controlled trials comparing any pharmacologic interventions with each other and a placebo in pediatric participants undergoing dental extractions or experiencing irreversible pulpitis. After duplicate screening and data abstraction, the authors conducted random-effects meta-analyses. They assessed risk of bias using the Cochrane Risk of Bias 2.0 tool and certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

The authors included 6 randomized controlled trials reporting 8 comparisons. Ibuprofen may reduce pain intensity compared with acetaminophen (mean difference [MD], 0.27 points; 95% CI, -0.13 to 0.68; low certainty) and a placebo (MD, -0.19 points; 95% CI, -0.58 to 0.21; low certainty). Acetaminophen may reduce pain intensity compared with a placebo (MD, -0.13 points; 95% CI, -0.52 to 0.26; low certainty). Acetaminophen and ibuprofen combined probably reduce pain intensity compared with acetaminophen alone (MD, -0.75 points; 95% CI, -1.22 to -0.27; moderate certainty) and ibuprofen alone (MD, -0.01 points; 95% CI, -0.53 to 0.51; moderate certainty). There was very low certainty evidence regarding adverse effects.

PRACTICAL IMPLICATIONS

Several pharmacologic interventions alone or in combination may provide a beneficial effect when managing acute dental pain in children. There is a paucity of evidence regarding the use of analgesics to manage irreversible pulpitis.

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.

Factors influencing opioid prescribing after tooth extraction

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.