Dental opioid prescribing rates after the up-scheduling of codeine in Australia

To prescribe or not to prescribe? A review of the Prescribing Competencies Framework for dentistry

OBJECTIVES

Dentists in Australia are the second largest prescriber group, and are generally not formally taught how to prescribe. The objective of this review is to describe the Prescribing Competencies Framework and its relevance to dentistry.

DATA

The four-model stage of prescribing by Coombes and colleagues, and the seven competencies within the Prescribing Competencies Framework devised by the Australian National Prescribing Service MedicineWise, are discussed and applied to dentistry.

SOURCES AND STUDY SELECTION

Each of the seven competencies are analysed and detailed in the context of clinical dental practice. Competencies 1-5 describe the skillset and tasks required by dentists to safely prescribe, whereas Competencies 6 and 7 describe the clinical environment and recommended resources to support dentists to prescribe safely and effectively.

CONCLUSIONS

The Prescribing Competencies Framework provides an overview of safe and effective prescribing. Prescribing is a process, and a separate skillset to clinical dentistry. The process involves information gathering, clinical assessment, effective communication and review of the patient. Access to timely and appropriate resources and relevant electronic sources of health information for clinicians are important to provide the support required for better informed prescribing decisions. The framework describes a patient-centered prescribing process, and ultimately prescribing should be a shared decision between the dentist and the patient.

CLINICAL SIGNIFICANCE

Safe and effective prescribing is an integral part of dentistry and dentists are the second largest prescriber group. However, dentists display high rates of inappropriate and unnecessary prescribing, and to minimise errors, the Prescribing Competencies Framework has been established. This article details how the Framework applies to clinical practice dentistry.

Opioid prescribing patterns among medical practitioners in New South Wales, Australia

INTRODUCTION

Prescriber behaviour is important for understanding opioid use patterns. We described variations in practitioner-level opioid prescribing in New South Wales, Australia (2013-2018).

METHODS

We quantified opioid prescribing patterns among medical practitioners using population-level dispensing claims data, and used partitioning around medoids to identify clusters of practitioners who prescribe opioids based on prescribing patterns and patient characteristics identified from linked dispensing claims, hospitalisations and mortality data.

RESULTS

The number of opioid prescribers ranged from 20,179 in 2013 to 23,408 in 2018. The top 1% of practitioners prescribed 15% of all oral morphine equivalent (OME) milligrams dispensed annually, with a median of 1382 OME grams (interquartile range [IQR], 1234-1654) per practitioner; the bottom 50% prescribed 1% of OMEs dispensed, with a median of 0.9 OME grams (IQR 0.2-2.6). Based on 63.6% of practitioners with ≥10 patients filling opioid prescriptions in 2018, we identified four distinct practitioner clusters. The largest cluster prescribed multiple analgesic medicines for older patients (23.7% of practitioners) accounted for 76.7% of all OMEs dispensed and comprised 93.0% of the top 1% of practitioners by opioid volume dispensed. The cluster prescribing analgesics for younger patients with high rates of surgery (18.7% of practitioners) prescribed only 1.6% of OMEs. The remaining two clusters comprised 21.2% of prescribers and 20.9% of OMEs dispensed.

DISCUSSION AND CONCLUSION

We observed substantial variation in opioid prescribing among practitioners, clustered around four general patterns. We did not assess appropriateness but some prescribing patterns are concerning. Our findings provide insights for targeted interventions to curb potentially harmful practices.

A wastewater-based evaluation of the effectiveness of codeine control measures in Australia

BACKGROUND AND AIM

From 1 February 2018, codeine was rescheduled from an over-the-counter (OTC) to a prescription-only medicine in Australia. We used wastewater-based epidemiology to measure changes in population codeine consumption before and after rescheduling.

METHODS

We analysed 3703 wastewater samples from 48 wastewater treatment plants, taken between August 2016 and August 2019. Our samples represented 10.6 million people, 45% of the Australian population in state capitals and regional areas in each state or territory. Codeine concentrations were determined by liquid chromatography-tandem mass spectrometry and converted to per-capita consumption estimates using the site daily wastewater volume, catchment populations and codeine excretion kinetics.

RESULTS

Average per-capita consumption of codeine decreased by 37% nationally immediately after the rescheduling in February 2018 [95% confidence interval (CI) = 35.3-39.4%] and substantially in all states between 24 and 51% (95% CI = 22.4-27.0% and 41.8-59.4%). The decrease was sustained at the lower level to August 2019. Locations with least pharmacy access decreased by 51% (95% CI = 41.7-61.7%), a greater decrease than 37% observed for those with greater pharmacy access (95% CI = 35.1-39.4%). Regional areas decreased by a smaller margin to cities (32 versus 38%, 95% CI = 30.2-34.1% versus 34.9-40.4%, respectively) from a base per-capita usage approximately 40% higher than cities.

CONCLUSION

Wastewater analysis shows that codeine consumption in Australia decreased by approximately 37% following its rescheduling as a prescription-only medicine in 2018. Wastewater-based epidemiology can be used to evaluate changes in population pharmaceutical consumption in responses to changes in drug scheduling.

Efficacy of oxycodone for postoperative dental pain: A systematic review and meta-analysis

OBJECTIVES

Dental pain is a commonly managed presentation in medicine and dentistry, where oxycodone is often prescribed. The aim of this systematic review and meta-analysis was to determine and quantify the effectiveness of oxycodone for acute dental pain.

DATA

Randomised controlled trials, controlled trials and comparative studies were included involving patients >12 years, where oxycodone was trialled for dental pain.

SOURCES

Three databases were searched: Medline Ovid, Embase Ovid and Web of Science. Two authors independently screened title and abstracts for relevance, extracted data and performed bias assessments.

STUDY SELECTION

Of 148 potentially relevant studies, 13 articles met the inclusion criteria for the systematic review and of the 13, nine studies were included in the meta-analysis. All studies were single-dose analgesia for surgical third molar extractions.

CONCLUSIONS

Oxycodone produced more effective analgesia in combination with paracetamol. In the meta-analysis, monotherapy etoricoxib and rofecoxib showed significant pain relief compared to combination oxycodone/paracetamol (SPID6 mean difference=-2.13, CI=-3.29, -0.98; TOTPAR6 mean difference=-2.98, CI=-4.90, -1.06). Non-steroidal anti-inflammatory drugs (NSAIDs) were more effective than oxycodone/paracetamol combinations, however, the evidence would become weak in a future study with a similar patient setting due to substantial statistical heterogeneity (SPID6 and TOTPAR6 prediction interval -4.471, 0.207 and -7.28, 1.32 respectively).

CLINICAL SIGNIFICANCE

Non-steroidal anti-inflammatory drugs were superior than oxycodone/paracetamol combinations, although some patient populations may experience similar effects to the combined oxycodone/paracetamol combination.

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.

Endogenous opiates and behavior: 2020

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).

Outcomes to evaluate care for adults with acute dental pain and infection: a systematic narrative review

OBJECTIVE

To identify outcomes reported in peer-reviewed literature for evaluating the care of adults with acute dental pain or infection.DesignSystematic narrative review.

SETTING/PARTICIPANTS

Primary research studies published in peer-reviewed literature and reporting care for adults with acute dental pain or infection across healthcare settings. Reports not in English language were excluded.

STUDY SELECTION

Seven databases (CINAHL Plus, Dentistry and Oral Sciences Source, EMBASE, MEDLINE, PsycINFO, Scopus, Web of Science) were searched from inception to December 2020. Risk of bias assessment used the Critical Appraisal Skills Programme checklist for randomised controlled trials and Quality Assessment Tool for Studies of Diverse Design for other study types.

OUTCOMES

Narrative synthesis included all outcomes of care for adults with acute dental pain or infection. Excluded were outcomes about pain management to facilitate treatment, prophylaxis of postsurgical pain/infection or traumatic injuries.

RESULTS

Searches identified 19 438 records, and 27 studies (dating from 1993 to 2020) were selected for inclusion. Across dental, pharmacy, hospital emergency and rural clinic settings, the studies were undertaken in high-income (n=20) and low/middle-income (n=7) countries. Two clinical outcome categories were identified: signs and symptoms of pain/infection and complications following treatment (including adverse drug reactions and reattendance for the same problem). Patient-reported outcomes included satisfaction with the care. Data collection methods included patient diaries, interviews and in-person reviews.

DISCUSSION

A heterogeneous range of study types and qualities were included: one study, published in 1947, was excluded only due to lacking outcome details. Studies from dentistry reported just clinical outcomes; across wider healthcare more outcomes were included.

CONCLUSIONS

A combination of clinical and patient-reported outcomes are recommended to evaluate care for adults with acute dental pain or infection. Further research is recommended to develop core outcomes aligned with the international consensus on oral health outcomes.

PROSPERO REGISTRATION NUMBER

CRD42020210183.

Comparison of Dental Benzodiazepine Prescriptions From the U.S., England, and Australia From 2013 to 2018

INTRODUCTION

Benzodiazepines contribute to substance use disorder and are often part of polydrug abuse, most frequently with opioids. Although dental opioid prescribing differs significantly between countries, little is known about the patterns of dental benzodiazepine prescribing. The aim of this study is to compare dental prescribing of benzodiazepines among the U.S., England, and Australia in 2013-2018.

METHODS

Population-level data were accessed from national data sets for each country for dental benzodiazepine prescriptions. Outcome measures of dental benzodiazepine prescribing included: (1) prescribing rates by population for each year and (2) the quantity and relative proportion of benzodiazepines by type for each country. The analysis was conducted in 2020.

RESULTS

Between 2013 and 2018, U.S. dentists prescribed 23 times more than English dentists and 7 times more than Australian dentists by population. During the study period, the rate of dental benzodiazepine prescribing decreased in England and the U.S. but increased in Australia. Despite these trends, U.S. dental prescribing rates remained 28 times more than English dentists and 6 times more than Australian dentists in 2018 (U.S., 3.10 prescriptions/1,000 population; England, 0.11 prescriptions/1,000 population; Australia, 0.50 prescriptions/1,000 population). U.S. dentists prescribed a wider variety of benzodiazepines than English and Australian dentists. Diazepam was most commonly prescribed in all countries. In the U.S., triazolam, lorazepam, and alprazolam were next most commonly prescribed. Temazepam was next most frequent in England and Australia.

CONCLUSIONS

Significant variation in benzodiazepine prescribing rates and types were seen among the countries. To improve patient safety, further investigation into the appropriate use and choices of benzodiazepines in dentistry is needed.

Prescribing drugs of dependence in dentistry: a review of␣legal and regulatory considerations

The misuse of drugs of dependence is a major public health issue in Australia, and prescribing of these medications by dentists has increased in recent years. While there has been much focus on the appropriate indications and clinical use of these medicines in dental practice, the legal requirements of prescribing are equally important. Dental practitioners need to be aware of their legal obligations, as inappropriate prescription practices may lead to regulatory or criminal prosecution. Although dentists hold registration through the National Scheme␣and there is nationally standardised scheduling of drugs in Australia, the legislation governing drug laws differs for each state and territory, especially when prescribing drugs of dependence. This article summarises the legislation governing the prescription of drugs of dependence in Australia that is relevant to dental practice, providing insights into how dentists might contribute to the appropriate, safe and legal use and management of these medications.

Trends in Dental Medication Prescribing in Australia during the COVID-19 Pandemic

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic and subsequent restrictions on dental services have had a significant impact on the provision of dental care in Australia and around the world.

OBJECTIVES

To investigate the impact of COVID-19 on medications prescribed by dentists under the Australian Pharmaceutical Benefits Scheme (PBS).

METHODS

Data on the number of dental prescriptions dispensed for all medications listed on the PBS Dental Schedule, from January 2019 to June 2020, were extracted from publicly available data sets. Analysis of prescription trends was performed for 1) total medications, 2) each major medication class, and 3) individual medications. The number of prescriptions dispensed in each month from January 2020 to June 2020 was compared to the same month in 2019 to determine the relative (percentage) change, and z statistics were used to determine whether changes were statistically significant.

RESULTS

There was a significant decrease in dental prescriptions in April 2020 compared to April 2019 (14,785, 18%; P < 0.05). Decreases in prescriptions for antibiotics (10,512, 16%; P < 0.05) and opioid analgesics (3,129, 18%; P < 0.05) were smaller compared to other major medication classes. There was a significant increase in June 2020, compared with June 2019, for prescriptions of amoxicillin with clavulanic acid (4,903, 20%; P < 0.05), tramadol (89, 46%; P < 0.05), and oxycodone (381, 73%; P < 0.05).

CONCLUSION

Dental service restrictions during COVID-19 likely drove an unmet need for routine dental treatment, which had significant implications for public oral health following easing of restrictions. During the initial surge and subsequent lockdown, antibiotics and opioid analgesics may have been used an as alternative to routine operative treatment. Continued professional guidance is required to ensure dental prescribing remains evidence based during the pandemic period.

KNOWLEDGE TRANSFER STATEMENT

The COVID-19 pandemic and subsequent restrictions on dental practice have had a profound impact on the provision of dental care in Australia and elsewhere in the world. In this context, population-level medication surveillance is important to identify and respond to changes in prescribing patterns that have arisen due to COVID-19 and restrictions on the provision of dental care. This research is particularly important for governments, regulators, and professional associations to ensure therapeutic guidelines and recommendations during the pandemic period remain relevant and evidence based.

Outcomes associated with scheduling or up-scheduling controlled substances

BACKGROUND

Many nations place drugs into various "schedules" according to their risk of abuse and/or recognized medical value that vary in terms of their restrictions. To mitigate diversion or abuse, drugs sometimes get rescheduled or are scheduled for the first time. Until now, there have not been efforts to integrate lessons from across the range of such past events.

METHODS AND DATA

We searched for peer-reviewed evaluations of instances of (re-)scheduling drugs in the United States after 1969 and a comparably large set of instances from other countries. Those 109 articles were supplemented by 30 others found in other ways but not meeting those search criteria (e.g., because the information on rescheduling was a minor part of a more general article).

FINDINGS

Findings are reported for many outcomes and with diverse measures over different timelines, making standardization of outcomes difficult. For more than half of the events for which quantitative outcomes were reported, there were declines in use-related measures by at least 40 percent. It is common for there to be reports of increases in indicators pertaining to other substances, sometimes more dangerous but sometimes less dangerous; overall, substitution appears to occur, but be partial.

CONCLUSION

Scheduling and up-scheduling can - though does not always - have substantial effects on a range of outcomes. Substitution to other substances is a possibility and so should be anticipated.