Impact of a Mandatory Prescription Drug Monitoring Program on Prescription of Opioid Analgesics by Dentists

Tracking changes in opioid prescriptions dispensed following the enactment of a prescription drug monitoring program use mandate

BACKGROUND

Prescription drug monitoring programs (PDMPs) are state-based surveillance tools used to track controlled substances dispensed to patients and identify patients at-risk of misuse. Starting April 2017, Wisconsin required all prescribers access PDMP to review patient information before issuing a controlled substance prescription order for more than a 3-day supply. A primary goal of PDMP use mandates is to reduce avoidable prescribing and mitigate opioid related mortality and morbidity. Current literature has not evaluated the existence of a time point post-policy implementation, at which the trend in opioid dispensing changes, reflecting normalization/maintenance of opioid prescribing.

OBJECTIVE

We sought to evaluate the impact of the PDMP use mandate on trends in opioid prescriptions dispensed and test a hypothesis that a change or inflection in opioid prescriptions dispensed occurred post-mandate implementation.

METHODS

Interrupted Time Series Analysis (ITSA) design was used to examine whether the level (immediate impact) and trend in opioid prescribing changed significantly after the PDMP use mandate was implemented. We used a novel Change Point Analysis (CPA) approach to test the hypothesis i.e., identify if and when a change or inflection in opioid dispensing trend occurred after implementation of the PDMP use mandate.

RESULTS

ITSA model results showed a significant drop in opioid prescriptions dispensed (p < 0.05) immediately after the mandate implementation (i.e., April 2017). Results of the CPA identified a significant inflection in opioid prescriptions dispensed starting January 2019 (21-months post-policy implementation). An ITSA model using the inflection point as an interruption showed that the trend in opioid prescriptions dispensed became flatter after the inflection point, suggesting normalization.

CONCLUSION

Using a novel CPA approach, the findings showed an inflection in the trend in opioid prescriptions dispensed post-PDMP use mandate implementation, implying that most of the avoidable prescribing likely was curtailed. The results suggest that the patient information presumably accessed from the WI PDMP interface was useful in helping prescribers to make an informed clinical decision about opioid prescribing.

Associations of clinical personnel characteristics and controlled substance prescribing practices

CONTEXT

Over 68,000 deaths were attributed to opioid-related overdose in 2020. Evaluative studies have shown that states that utilized Prescription Drug Monitoring Program (PDMP) systems have decreased opioid-related deaths. With the growing use of PDMPs and an ongoing opioid epidemic, determining the demographics of physicians at risk of overprescribing can elucidate prescribing practices and inform recommendations to change prescribing behaviors.

OBJECTIVES

This study aims to assess prescribing behaviors by physicians in 2021 based on four demographics utilizing the National Electronic Health Record System (NEHRS): physician's age, sex, specialty, and degree (MD or Doctor of Osteopathic Medicine [DO]).

METHODS

We performed a cross-sectional study of the 2021 NEHRS to determine the relationship between physician characteristics and PDMP use on opioid-prescribing behaviors. Differences between groups were measured via design-based chi-square tests. We constructed multivariable logistic regression models to assess the relationships, via adjusted odds ratios (AOR), between physician characteristics and alternate prescribing patterns.

RESULTS

Compared to female physicians, male physicians were more likely to alter their original prescription to reduce morphine milligram equivalents (MMWs) prescribed for a patient (AOR: 1.60; CI: 1.06-2.39; p=0.02), to change to a nonopioid/nonpharmacologic option (AOR: 1.91; 95 % CI: 1.28-2.86; p=0.002), to prescribe naloxone (AOR=2.06; p=0.039), or to refer for additional treatment (AOR=2.07; CI: 1.36-3.16; p<0.001). Compared to younger physicians, those over the age of 50 were less likely to change their prescription to a nonopioid/nonpharmacologic option (AOR=0.63; CI: 0.44-0.90; p=0.01) or prescribe naloxone (AOR=0.56, CI: 0.33-0.92; p=0.02).

CONCLUSIONS

Our results showed a statistically significant difference between specialty category and frequency of prescribing controlled substances. After checking the PDMP, male physicians were more likely to alter their original prescription to include harm-reduction strategies. Optimizing the use of PDMP systems may serve to improve prescribing among US physicians.

Prescription drug monitoring programs evaluation: A systematic review of reviews

BACKGROUND

Prescription drug monitoring programs (PDMPs) are used to mitigate harms from high-risk medicines including misuse, prescription shopping, overdoses, and death. Previous systematic reviews report inconsistent findings. We undertook a systematic review of reviews to 1) describe and identify the methods and outcome measures used to evaluate PDMPs, 2) summarise existing evidence on outcomes and factors that influence PDMP success or benefit realisation.

METHODS

MEDLINE, EMBASE, Scopus, Cochrane Database of Systematic Reviews, and PROSPERO were used to identify systematic reviews on PDMPs. Twelve papers met the inclusion criteria. Data extracted included review aim, study designs, settings, outcome measures, and key findings. Quality was assessed using AMSTAR 2 quality assessment tool.

RESULTS

Review papers were categorised as outcome or process evaluation reviews. Process evaluation reviews described implementation processes, barriers and facilitators to PDMP use and/or implementation. Most (57%) papers described barriers which frequently included usability and data integration. Outcome evaluation papers reported impact of PDMPs on outcomes, which were opioid-focused, and findings were highly variable. Most reviews (67%) were rated as low quality, limiting the conclusions that can be drawn.

CONCLUSIONS

Inconsistent methods and outcome measures were used to evaluate PDMPs. No economic evaluations of PDMPs were found. Standardising assessment and reporting of results may improve the quality and confidence in an evidence-base to inform future roll-out and evaluation of PDMPs. Targeting barriers such as system-related challenges and negative end-user perceptions could improve sustained uptake of PDMPs, and potentially facilitate benefits realisation, including mitigating harms of high-risk prescription medicines.

The prescription drug monitoring program in a multifactorial approach to the opioid crisis: PDMP data, Pennsylvania, 2016-2020

BACKGROUND

Prescription opioids remain an important contributor to the United States opioid crisis and to the development of opioid use disorder for opioid-naïve individuals. Recent legislative actions, such as the implementation of state prescription drug monitoring programs (PDMPs), aim to reduce opioid morbidity and mortality through enhanced tracking and reporting of prescription data. The primary objective of our study was to describe the opioid prescribing trends in the state of Pennsylvania (PA) as recorded by the PA PDMP following legislative changes in reporting guidelines, and discuss the PDMP's role in a multifactorial approach to opioid harm reduction.

METHODS

State-level opioid prescription data summaries recorded by the PA PDMP for each calendar quarter from August 2016 through March 2020 were collected from the PA Department of Health. Data for oxycodone, hydrocodone, and morphine were analyzed by quarter for total prescription numbers and refills. Prescription lengths, pill quantities, and average morphine milliequivalents (MMEs) were analyzed by quarter for all 14 opioid prescription variants recorded by the PA PDMP. Linear regression was conducted for each group of variables to identify significant differences in prescribing trends.

RESULTS

For total prescriptions dispensed, the number of oxycodone, hydrocodone, and morphine prescriptions decreased by 34.4, 44.6, and 22.3% respectively (p < 0.0001). Refills fluctuated less consistently with general peaks in Q3 of 2017 and Q3 of 2018 (p = 0.2878). The rate of prescribing for all opioid prescription lengths decreased, ranging in frequency from 22 to 30 days (47.5% of prescriptions) to 31+ days of opioids (0.8% of prescriptions) (p < 0.0001). Similarly, decreased prescribing was observed for all prescription amounts, ranging in frequency from 22 to 60 pills (36.6% of prescriptions) to 60-90 pills (14.2% of prescriptions) (p < 0.0001). Overall, the average MME per opioid prescription decreased by 18.9%.

CONCLUSIONS

Per the PA PDMP database, opioid prescribing has decreased significantly in PA from 2016 to 2020. The PDMP database is an important tool for tracking opioid prescribing trends in PA, and PDMPs structured similarly in other states may enhance our ability to understand and influence the trajectory of the U.S. opioid crisis. Further research is needed to determine optimal PDMP policies and practices nationwide.

Achieving Reductions in Opioid Dispensing: A Qualitative Comparative Analysis of State-Level Efforts to Improve Prescribing

OBJECTIVE

To determine whether any combinations of state-level public health activities were necessary or sufficient to reduce prescription opioid dispensing.

DESIGN

We examined 2016-2019 annual progress reports, 2014-2019 national opioid dispensing data (IQVIA), and interview data from states to categorize activities. We used crisp-set Qualitative Comparative Analysis to determine which program activities, individually or in combination, were necessary or sufficient for a better than average decrease in morphine milligram equivalent (MME) per capita.

SETTING

Twenty-nine US state health departments.

PARTICIPANTS

State health departments implementing the Centers for Disease Control and Prevention's Prevention for States (PfS) program.

MAIN OUTCOME

Combinations of prevention activities related to changes in the rate of prescription opioid MME per capita dispensing from 2014 to 2019.

RESULTS

Three combinations were sufficient for greater than average state-level reductions in MME per capita: (1) expanding and improving proactive reporting in combination with enhancing the uptake of evidence-based opioid prescribing guidelines and not moving toward a real-time Prescription Drug Monitoring Program; (2) implementing or improving prescribing interventions for insurers, health systems, or pharmacy benefit managers in combination with enhancing the uptake of evidence-based opioid prescribing guidelines; and (3) not implementing or improving prescribing interventions for insurers, health systems, or pharmacy benefit managers in combination with not enhancing the uptake of evidence-based opioid prescribing guidelines. Interview data suggested that the 3 combinations indicate how state contexts and history with addressing opioid overdose shaped programming and the ability to reduce MME per capita.

CONCLUSIONS

States successful in reducing opioid dispensing selected activities that built upon existing policies and interventions, which may indicate thoughtful use of resources. To maximize impact in addressing the opioid overdose epidemic, states and agencies may benefit from building on existing policies and interventions.

Cycles of Chronic Opioid Therapy Following Mandatory Prescription Drug Monitoring Program Legislation: A Retrospective Cohort Study

BACKGROUND

Mandates for prescriber use of prescription drug monitoring programs (PDMPs), databases tracking controlled substance prescriptions, are associated with reduced opioid analgesic (OA) prescribing but may contribute to care discontinuity and chronic opioid therapy (COT) cycling, or multiple initiations and terminations.

OBJECTIVE

To estimate risks of COT cycling in New York City (NYC) due to the New York State (NYS) PDMP mandate, compared to risks in neighboring New Jersey (NJ) counties.

DESIGN

We estimated cycling risk using Prentice, Williams, and Peterson gap-time models adjusted for age, sex, OA dose, payment type, and county population density, using a life-table difference-in-differences design. Failure time was duration between cycles. In a subgroup analysis, we estimated risk among patients receiving high-dose prescriptions. Sensitivity analyses tested robustness to cycle volume considering only first cycles using Cox proportional hazard models.

PARTICIPANTS

The cohort included 7604 patients dispensed 12,695 prescriptions.

INTERVENTIONS

The exposure was the August 2013 enactment of the NYS PDMP prescriber use mandate.

MAIN MEASURES

We used monthly, patient-level data on OA prescriptions dispensed in NYC and NJ between August 2011 and July 2015. We defined COT as three sequential months of prescriptions, permitting 1-month gaps. We defined recurrence as re-initiation of COT after at least 2 months without prescriptions. The exposure was enactment of the PDMP mandate in NYC; NJ was unexposed.

KEY RESULTS

Enactment of the NYS PDMP mandate was associated with an adjusted hazard ratio (HR) for cycling of 1.01 (95% CI, 0.94-1.08) in NYC. For high-dose prescriptions, the risk was 1.16 (95% CI, 1.01-1.34). Sensitivity analyses estimated an overall risk of 1.01 (95% CI, 0.94-1.11) and high-dose risk of 1.09 (95% CI, 0.91-1.31).

CONCLUSIONS

The PDMP mandate had no overall effect on COT cycling in NYC but increased cycling risk among patients receiving high-dose opioid prescriptions by 16%, highlighting care discontinuity.

Launching an innovative educational model addressing substance use disorders and dental pain management (Project ECHO® in dentistry)

Background

Uninformed opioid prescribing by dentists has contributed to the current opioid crisis. This report describes the development and implementation of an innovative, interactive, multidisciplinary, and participant-centric telementoring program “Pain Management and Substance Use Disorders Dental ECHO (Extension for Community Health Care Outcomes)”. We disseminated information to dentists about appropriate opioid prescribing practices and engaged them with a focus on pain management and substance use disorders. The objective of this study was to assess the effectiveness of this program for self-reported: (1) change in knowledge and confidence related to clinical skills for dental pain management of patients with substance use disorders; (2) change in clinical behavior of dentists for safe opioids prescribing; and (3) change in clinic policies regarding safe opioids prescribing.

Methods

An interdisciplinary panel of experts in medicine, pharmacy, social work, and dentistry designed and led the “Pain Management and Substance Use Disorders Dental ECHO” for invited dental care providers and dental students. Six cohorts each consisting of six, 1-h-long sessions were conducted via the Zoom videoconference platform in years 2020 and 2021. Each session included a didactic expert presentation, a participant-presented patient case and discussion. Each participant completed pre- and post-program surveys to assess the program’s influence on participant knowledge, clinical confidence and behavior change.

Results

The participants (N = 151) were dentists (n = 109), dental faculty (n = 15), dental residents (n = 6), dental hygienists/assistants (n = 13) and nurses and clinic administrators (n = 8). Self-reported perceived medication knowledge, confidence in identification, treatment and willingness to engage with substance use disorders patients, and reported compliance with Prescription Drug Monitoring Program (PDMP) checks increased significantly from before to after the sessions (p < 0.001). Overall, participants expressed high levels of satisfaction with the content and reported that the sessions provided high benefit.

Conclusion

The Project ECHO model is effective in rapidly disseminating evidence-based information. Dentists viewed this model as having a high degree of benefit for the optimal management of dental pain and the recognition and treatment of substance use disorders.

Comparison of Analgesic Prescriptions for Dental Pain and Patient Pain Outcomes Before vs After an Opioid Reduction Initiative

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.

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.

Effect of a Mandatory Prescription Drug Monitoring Program on Patient-initiated Phone Calls After Spine Surgery

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

The objective of this study was to determine the effect of a statewide, government-mandated prescription drug monitoring program (PDMP) on patient-initiated phone calls after lumbar and cervical spinal surgery.

SUMMARY OF BACKGROUND DATA

Prior studies have examined the most common reasons for a postoperative phone calls, most of which pertain to pain or prescription medications. However, no studies have investigated the effects of mandatory opioid prescription reporting on these calls.

METHODS

Patients who underwent lumbar decompression, lumbar fusion, or posterior cervical fusion were retrospectively identified. Patients were sorted into 1 of 2 cohorts based on their procedure date's relation to the initiation of the state's PDMP: "pre-PDMP" and "post-PDMP." All clinical and demographic data were obtained from electronic health records. Telephone communications from or on behalf of patients were retrospectively reviewed. Multivariable logistic regression was performed to determine independent factors associated with a postoperative phone call.

RESULTS

Five hundred and twenty-five patients (2689 phone calls) were included in the study. Average number of phone calls per patient increased significantly after PDMP implementation among lumbar (3.27 vs. 5.18, P<0.001), cervical (5.08 vs. 11.67, P<0.001), and all (3.59 vs. 6.30, P<0.001) procedures. Age [odds ratio (OR): 1.05 (1.01, 1.09), P=0.02], cervical procedure [OR: 4.65 (1.93, 11.21), P=0.001], and a post-PDMP date of surgery [OR: 6.35 (3.55, 11.35), P<0.001] were independently associated with an increased likelihood of a postoperative phone call. A higher percentage of calls were in reference to postoperative care (4.6% vs. 2.4%, P=0.01) and wound care (4.3% vs. 1.4%, P<0.001) in the post-PDMP cohort compared with the pre-PDMP cohort.

CONCLUSIONS

Patient-initiated telephone calls increased significantly after implementation of a mandatory statewide PDMP. Increasing age, operation involving the cervical spine, and surgery occurring after implementation of the state's PDMP were independently associated with an increased likelihood of postoperative phone call to health care providers.

Mapping the research addressing prescription drug monitoring programs: A scoping review

ISSUES

Prescription drug monitoring programs are a harm minimisation intervention and clinical decision support tool that address the public health concern surrounding prescription drug misuse. Given the large number of studies published to date and the ongoing implementation of these programs, it is important to map the literature and identify areas for further research to improve practice.

APPROACH

A scoping review was undertaken to identify the research on prescription drug monitoring programs published between January 2015 and April 2021.

KEY FINDINGS

A total of 153 citations were included in this scoping review. The majority of the studies originated from the USA and were quantitative. Results on program effectiveness are mixed and mainly examine their association with opioid-related outcomes. Unintended consequences are revealed in the literature and this review also highlights barriers to program use.

IMPLICATIONS

Overall, findings are mixed despite the large number of studies published to date. Mapping the literature identifies priority areas for further research that can advise policymakers and clinicians on practice improvement.

CONCLUSION

Results on prescription drug monitoring program effectiveness are mixed and mainly examine their association with opioid-related outcomes. This review highlights barriers to prescription drug monitoring program effectiveness related to program use and system integration. Further research is needed in these areas to improve prescription drug monitoring program use and patient outcomes.

Primary care provider perspectives on and utilization of a mandatory prescription drug monitoring program in New York City

BACKGROUND

The ways in which prescription drug monitoring programs (PDMPs) have been integrated into primary care practice remain understudied, and research into physician utilization of PDMPs in states where PDMP use is mandated remains scant.

OBJECTIVES

To characterize primary care physician perspectives on and utilization of a mandatory PDMP in New York City.

METHODS

We conducted face-to-face, in-depth interviews with primary care physicians who reported that they currently prescribed opioid analgesic medication. We used a thematic analytic approach to characterize physician perspectives on the PDMP mandate and physician integration of mandatory PDMP use into primary care practice.

RESULTS

Primary care providers demonstrated a continuum of PDMP utilization, ranging from consistent use to the specifications of the mandate to inconsistent use to no use. Providers reported a range of perspectives on the purpose and function of the PDMP mandate, as well as a lack of clarity about the mandate and its enforcement.

CONCLUSION

Findings suggest a need for increased clinical and public health education about the use of PDMPs as clinical tools to identify and treat patients with potential substance use disorders in primary care.

Opioids and older adults: Increasing trends in opioid usage in a dental population compared to a National Database (NHANES)

Aim

To examine self‐reported opioid prevalence at a dental school clinic for patients ≥65 years old as compared to national data, comparing gender, ethnicity/race and older adult age groupings.

Methods and results

Self‐reported prescription opioid medication use was extracted from the medical record for dental patients ≥65 years old who visited the school's general dental clinic (GDC) in 2012 or 2017. This data was compared to the National Health and Nutrition Examination Survey (NHANES) data for 2011–2012 and 2017–18. There was a significant increase in prevalence of opioid use in adults ≥65 between 2012 (4.5%) and 2017 (6.5%) and for ages 65–79 (from 4.7% to 6.3%) and ≥80 (3.4% to 7.9%), women (4.8% to 7.0%), and African Americans (4.7% to 8.4%) in the GDC. Older adults at the GDC reported less opioid use than the NHANES national average for both periods no matter the gender or the age with variable results for race/ethnicity.

Conclusion

The prevalence of older adults taking opioids in our general dental school clinic population increased significantly in 2017 as compared to 2012 but was lower than the national average for the respective periods. Awareness of existing opioid usage in older adult patients and its higher adverse risk potential is critical when prescribing analgesics for dental pain for this age group.

Effectiveness of online training of first and second year AEGD residents in identifying, referring, and managing patients at-risk for substance use and opioid disorders

BACKGROUND AND OBJECTIVES

Dentists have contributed greatly to the opioid epidemic, dispensing roughly 8.6% of opioids totaling over 18 million prescriptions in a 12-month period from July 2016 to June 2017 and report educational gaps regarding screening techniques for substance misuse and an unfamiliarity with available referral resources. The purpose of this study was to determine the knowledge and comfort level of residents in identifying, referring, and managing patients who are at risk for opioid use or substance use disorder in the dental setting before and after an online case-based training course.

METHODS

Thirty-five first year (PGY1) and 11 second year (PGY2) advanced education in general dentistry (AEGD) residents participated in an online training course that aimed to assess knowledge in the domains of identifying, referring, and managing patients at risk for substance abuse disorder and opioid use in an academic setting. There were nine subdomains within the three major domains that further assessed resident comfort and knowledge. Before and after training, data were collected and analyzed.

RESULTS

Analysis of the results indicated that (1) the training modules increased resident comfort in identifying (p = 0.011), referring (p = 0.032), and managing (p = 0.002) patients at risk for opioid substance use. (2) PGY1 residents benefited more than PGY2 residents in identifying (p = 0.034) and the manage domains (p < 0.001). (3) Residents viewed the module quality, usefulness, and applicability favorably. Further analysis of the nine subdomains is presented.

CONCLUSION

Our study suggests that dental curricula would benefit from incorporating training of residents in identifying, referring, and managing patients at risk for substance use disorder and opioid use.

Distribution of Opioid Prescribing and High-Risk Prescribing Among U.S. Dentists in 2019

INTRODUCTION

It is unknown whether certain dentists account for disproportionate shares of dental opioid prescriptions and high-risk prescriptions. Identifying and characterizing such dentists could inform the targeting of initiatives to improve the appropriateness and safety of dental opioid prescribing.

METHODS

In May 2021, the authors conducted a cross-sectional analysis using the IQVIA Longitudinal Prescription Database, which reports dispensing from 92% of U.S. pharmacies, and 2 provider databases (IQVIA OneKey, National Plan and Provider Enumeration System). Analyses included opioid prescriptions from dentists dispensed in 2019 to patients aged >12 years. High-risk prescriptions were those considered high risk by any of 3 metrics (prescriptions to opioid-naïve patients exceeding a 3-day supply, prescriptions with daily opioid dosage ≥50 morphine milligram equivalents, opioid prescriptions with benzodiazepine overlap). Among all prescriptions and high-risk prescriptions, the authors calculated the proportion accounted for by high-volume dentists -- those with prescription counts in the 95th percentile or higher. Using logistic regression, the characteristics associated with being a high-volume dentist were identified.

RESULTS

In 2019, a total of 141,345 dentists accounted for 10,736,743 opioid prescriptions dispensed to patients aged >12 years; 4,242,634 (39.5%) were high-risk prescriptions. The 7,079 high-volume dentists, a group representing 5.0% of the 141,345 dentists, accounted for 46.9% of all prescriptions and 47.5% of high-risk prescriptions. Male sex, younger age, non‒Northeast location, and specialization in oral and maxillofacial surgery were associated with a higher risk of being a high-volume dentist.

CONCLUSIONS

In 2019, high-volume dentists accounted for almost half of dental opioid prescriptions and high-risk prescriptions. Quality improvement initiatives targeting these dentists may be warranted.

Flipping the script: The effects of opioid prescription monitoring on specialty-specific provider behavior

Mandatory access Prescription Drug Monitoring Programs (MA-PDMPs) aim to curb the epidemic at a common point of initiation of use, the prescription. However, there is recent concern about whether opioid policies have been too restrictive and reduced appropriate access to patients with the most need for opioid pharmaceuticals. We assess MA-PDMP's effect on specialty-specific opioid prescribing behavior of Medicare providers. Our findings suggest that requiring providers to query a PDMP differentially affects opioid prescribing across provider specialties. We find a three to four percent decrease in prescribing for Primary Care and Internal Medicine providers. This result is driven by healthcare providers at the lower end of the prescribing distribution. There is also suggestive evidence of an increase in opioid use disorder treatment drugs prescribed by these same providers. We also find no evidence for the hypothesis that MA-PDMPs restrict prescribing by providers who treat patients with potentially high levels of pain, few drug substitutes, or urgency for pain treatment (e.g., Oncology/Palliative care). This result is not dependent on whether a state provides exemptions for these providers. Our results indicate that MA-PDMPs may help close provider-patient informational gaps while retaining a provider's ability to supply these drugs to patients with a need for opioids.

Opioid Prescription Trends in a US Dental School Clinic, 2014-2018: A Retrospective Study Using Electronic Health Record Data

OBJECTIVES

Opioid misuse and abuse continues to be a grave public health concern in the United States. The aim of this study was to use electronic health records (EHRs) from a US dental school clinic to retrospectively analyze trends in opioid prescription frequencies.

DESIGN

A database review was conducted using EHR data from 20 patient care clinics in a dental school over a 5-year period during which local, state, and national policies and guidelines to mitigate harm from opioid misuse were introduced.

SETTING

University of Michigan School of Dentistry, state of Michigan.

OUTCOME MEASURE

Descriptive statistics using measures of frequency and distribution of opioid prescriptions written were compared over a 5-year period by dental school clinic specialty, CDT (Code on Dental Procedures and Nomenclature) procedure, drug type, and patient age/gender.

RESULTS

From 2014 to 2018, a total of 12 401 opioid-based prescriptions were written by dental providers in the school's patient care clinics. An ARIMA (autoregressive integrated moving average) model time trend analysis demonstrated a significant decrease in the number of prescribed opioids after 2016.

CONCLUSIONS

While causal relationships cannot be drawn between drug abuse and prescription trends alone, this exploratory study provided a better understanding of prescription frequency patterns that can help monitor distribution of opioids and identify areas where future public health interventions may be needed. Dental education institutions have an obligation to ensure a competent health care workforce as well as unique opportunities to support regional and national public health strategies aimed at reducing misuse of opioids.

Faculty and dental student knowledge, attitudes, and practices concerning the prescribing of opioids: Informing curricular change

OBJECTIVES

This study aimed to assess the knowledge, attitudes, and practices surrounding the prescribing of opioids and addiction in a dental school population.

METHODS

Predoctoral dental students, residents, and dental faculty were surveyed about their beliefs, awareness, opinions about, and prior training in the prescribing of opioids, current prescribing practices, and confidence with risk mitigation strategies. Demographic information collected included gender, race/ethnicity, faculty/student role, year of birth, and year of graduation.

RESULTS

Responses were received from 220 faculty and students (n = 47 and n = 173, respectively). Both faculty and students agreed that opioids were overprescribed for the treatment of dental pain. A majority of faculty and dental students (DS)3 + DS4 and DS1 + DS2 students expressed no or limited prior training in (1) the approved state opioid guidelines (75%, 79%, and 95%, respectively), (2) the identification/assessment of substance use disorders (68%, 81%, and 92%, respectively), and (3) patient education to accompany the prescribing of opioids (71%, 80%, and 92%, respectively). A majority of faculty reported moderate or extreme confidence in their clinical skills related to the prescribing of opioids (75%), their ability to identify patients with substance use disorders (55%), and their ability to discuss addiction risk and secure storage of opioids (65%). In contrast, DS3 + DS4 and DS1 + DS2 students expressed significantly less confidence and training. Faculty and students agreed that the role of a dentist included risk mitigation, but reported actions did not match their beliefs, reportedly due to lack of time, less confidence, and the assumption that a pharmacist would assume risk mitigation conversations.

CONCLUSIONS

A cohesive curriculum across the four predoctoral years is needed focusing on factual knowledge about the prescribing of opioids, safe prescribing, and confidence with patient communication and risk mitigation strategies. In addition, a need for parallel faculty development synchronized with and reinforced by curricular content was identified.

Association Between Statewide Opioid Prescribing Interventions and Opioid Prescribing Patterns in North Carolina, 2006-2018

OBJECTIVE

To examine the impact of three sequential statewide policy and legislative interventions on opioid prescribing practices among privately insured individuals in North Carolina.

METHODS

An interrupted time series approach was used to examine level and trajectory changes of new and prevalent opioid prescription rates, days' supply, and daily morphine milligram equivalents before and after implementation of a 1) prescription drug monitoring program, 2) state medical board initiative, and 3) legislative action. Analyses were conducted using individual-level claims data from a large private health insurance provider serving North Carolina residents, ages 18-64 years, from January 2006 to August 2018.

RESULTS

Rates of new and prevalent prescription opioid patients were relatively unaffected by the prescription monitoring program but sharply declined in the months immediately following both medical board (-3.7 new and -19.3 prevalent patients per 10,000 person months) and legislative (-14.1 new and -26.7 prevalent patients) actions. Among all opioid prescriptions, days' supply steadily increased on average over the study period but declined after legislative action (-1.5 days' supply per year).

CONCLUSIONS

The voluntary prescription drug monitoring program launched in 2010 only marginally affected opioid prescribing patterns on its own, but its redeployment as an investigative and clinical tool in multifaceted public policy approaches by the state medical board and legislature later in the decade plausibly contributed to notable declines in prescription rates and days' supply. This study lends new emphasis to the importance of enforcement mechanisms for state and national policies seeking to reverse this critical public health crisis.

An Interrupted Time-series Evaluation of the Association Between State Laws Mandating Prescriber Use of Prescription Drug Monitoring Programs and Discontinuation of Chronic Opioid Therapy in US Veterans

BACKGROUND

Most states have recently passed laws requiring prescribers to use prescription drug monitoring programs (PDMPs) before prescribing opioid medications. The impact of these mandates on discontinuing chronic opioid therapy among Veterans managed in the Veterans Health Administration (VA) is unknown. We assess the association between the earliest of these laws and discontinuation of chronic opioid therapy in Veterans receiving VA health care.

METHODS

We conducted a comparative interrupted time-series study in the 5 states mandating PDMP use before August 2013 (Ohio, West Virginia, Kentucky, New Mexico, and Tennessee), adjusting for trends in the 17 neighboring control states without such mandates. We modeled 25 months of prescribing for each state centered on the month the mandate became effective. We included Veterans prescribed long-term outpatient opioid therapy (305 of the preceding 365 d). Our outcomes were discontinuation of chronic opioid therapy (primary outcome) and the average daily quantity of opioids per Veteran over the following 6 months (secondary outcome).

RESULTS

We included 250 monthly cohorts with 225,665 unique Veterans and 3.4 million Veteran-months. Baseline discontinuation rates before the PDMP mandates were 0.4%-2.7% per month. Kentucky saw a discontinuation increase of 1 absolute percentage point following its PDMP mandate which decreased over time. The other 4 states had no significant association between their mandates and change in opioid discontinuation. There was no evidence of decreasing opioid quantities following PDMP mandates.

CONCLUSION

We did not find consistent evidence that state laws mandating provider PDMP use were associated with the discontinuation of chronic opioid therapy within the VA for the time period studied.

Pain relief with combination acetaminophen/codeine or ibuprofen following third-molar extraction: A systematic review and meta-analysis

OBJECTIVE

The purpose of our study was to perform a systematic review and meta-analysis of randomized, blinded, placebo-controlled studies that, following third-molar extraction, utilized either a combination of acetaminophen (600 mg) with codeine (60 mg) or ibuprofen (400 mg) for pain management.

DESIGN

We searched PubMed, and the trial registry ClinicalTrials.gov databases with the keywords "molar or molars", "tooth or teeth", "extraction" and "pain". Selected studies were: (1) randomized, blinded, placebo controlled, (2) utilized either a single-dose combination acetaminophen (600 mg) with codeine (60 mg) (A/C) or ibuprofen, and (3) recorded standardized pain relief (PR) at 6 hours, or summed total pain relief over 6 hours (TOTPAR6). Of the 2,949 articles that were identified, 79 were retrieved for full-text analysis, and 20 of these studies met our inclusion criteria.

RESULTS

For A/C, the weighted, standardized mean difference (SMD) for TOTPAR6 was 0.796 (0.597-0.995, 95% confidence interval), P < 0.001, and for PR at 6 h, the SMD was 0.0186 (0.007 to 0.378; P = 0.059), whereas for ibuprofen the SMD for TOTPAR6 was 3.009 (1.283 to 4.735; P = 0.001), and for PR at 6 h, the SMD was 0.854 (95% CI, 0.712 to 0.996; P < 0.001). A SMD of 0.8 or larger is indicative of a large effect.

CONCLUSIONS

Our data indicate that single dose of ibuprofen (400 mg) is an effective pain reducer for post third molar extraction pain.

Outpatient Prescribing of Antibiotics and Opioids by Veterans Health Administration Providers, 2015-2017

INTRODUCTION

Antibiotics and opioids are targeted by public health and stewardship communities for reductions in prescribing across the country. This study evaluates trends and factors associated with outpatient prescribing by dental and medical providers in a large integrated health system.

METHODS

This was a cross-sectional study of national dental and medical outpatient visits from Department of Veterans Affairs facilities in 2015-2017; analyzed in 2019-2020. Antibiotic and opioid prescribing rates were assessed by provider and facility characteristics. Multivariable Poisson regression adjusted for repeated measures by the provider was used to assess the independent association between facility and provider characteristics and rate of prescribing.

RESULTS

Over the study period, 4,625,840 antibiotic and 10,380,809 opioid prescriptions were identified for 115,625,890 visits. Physicians prescribed most antibiotics (67%). Dentists prescribed 6% of the antibiotics but had the highest per-visit antibiotic prescribing rate compared to medical providers (6.75 vs 3.90 prescriptions per 100 visits, p<0.0001), which was largely driven by dental specialists. By contrast, dentists had lower opioid prescribing than medical providers (3.02 vs 9.20 prescriptions per 100 visits, p<0.0001). Overall, antibiotic and opioid prescribing decreased over time, with opioids having the greatest decreases (-28.0%). In multivariable analyses, U.S. geographic region, rurality, and complexity were associated with prescribing for both drug classes. Opioid and antibiotic prescribing were positively correlated.

CONCLUSIONS

Although antibiotic and opioid prescribing has decreased, there are still important target areas for improvement. Interventions need to be tailored to community characteristics such as rurality and provider type.

Primary Care Implementation of a Mandatory Prescription Drug Monitoring Program in New York City

The ways in which prescription drug monitoring programs (PDMPs) have been integrated into clinical practice remain understudied, and research into PDMP implementation in states where PDMP use by providers is mandated remains scant. This qualitative study describes how use of a state-mandated PDMP influenced clinical practice and opioid analgesic prescribing. We conducted face-to-face, in-depth interviews with 53 New York State-licensed primary care physicians who reported that they currently prescribed opioid analgesic medication, including those providers who reported consistent use of the PDMP (n = 38) in this sample. We used a thematic analytic approach to identify patterns of PDMP implementation into practice following enactment of the New York State legislative usage mandate. Among physicians who consistently used the PDMP, we found two distinct groups: (1) physicians who reported no change in their clinical practice and (2) physicians who acknowledged changes to both clinical practice and administrative management. In the latter group, most physicians felt the PDMP had benefited their patient relationships by fostering dialogue around patient substance use; however, some used the PDMP to dismiss patients from care. Findings suggest that increased education for providers relating to judicious prescribing, opioid use disorder, and best practice for PDMP utilization are needed.

The Effectiveness of Stewardship Interventions to Reduce the Prescribing of Extended-Release Opioids for Acute Pain: A Systematic Review

OBJECTIVE

To evaluate the effectiveness of stewardship interventions in reducing the prescribing of extended-release opioids for acute pain.

DESIGN

Systematic review of randomized controlled trials, pre-post intervention studies, cohort studies and case-control studies.

METHODS

A search was conducted using Medline, Scopus, Cochrane Central Register of Controlled Trials, International Pharmaceutical Abstracts, and PsycINFO from inception to March 24, 2019. Search terms included opioids, interventions, extended-release, and acute pain. Included articles were original research articles outlining the impact of stewardship interventions on reducing the prescribing of extended-release opioids for acute pain.

RESULTS

The search resulted in 1,264 articles after the removal of duplicates. Of these, 141 full texts were assessed, with three eligible for inclusion. One additional article was obtained via a manual search. Three studies explored forcing function interventions; two included prior authorization policies, which saw decreases in extended-release/long-acting scripts by 18-36%, while another evaluated order restrictions producing increased adherence to guidelines by 36%. One study explored the impact of education targeting prescribers and patients through a risk mitigation and evaluation strategy, which decreased extended-release/long-acting quarterly script volumes by 4.3%. All studies were performed at system levels. Forcing function interventions decreased extended-release/long-acting prescriptions and increased adherence to guidelines to a greater extent than less restrictive interventions such as education.

CONCLUSIONS

Forcing function interventions implemented at system levels show promise in decreasing the prescribing of extended-release opioids for acute pain. The current lack of literature warrants future research to increase understanding of the effectiveness of such interventions.

Characteristics Associated With Opioid and Antibiotic Prescribing by Dentists

INTRODUCTION

The objective of this study is to identify county-level characteristics that may be high-impact targets for opioid and antibiotic interventions to improve dental prescribing.

METHODS

Prescriptions during 2012-2017 were extracted from the IQVIA Longitudinal Prescription database. Primary outcomes were yearly county-level antibiotic and opioid prescribing rates. Multivariable negative binomial regression identified associations between prescribing rates and county-level characteristics. All analyses occurred in 2020.

RESULTS

Over time, dental opioid prescribing rates decreased by 20% (from 4.02 to 3.22 per 100 people), whereas antibiotic rates increased by 5% (from 6.85 to 7.19 per 100 people). Higher number of dentists per capita, higher proportion of female residents, and higher proportion of residents aged <65 years were associated with increased opioid rates. Relative to location in the West, location in the Northeast (59%, 95% CI=52, 65) and Midwest (64%, 95% CI=60, 70) was associated with lower opioid prescribing rates. Higher clinician density, median household income, proportion female, and proportion White were all independently associated with higher antibiotic rates. Location in the Northeast (149%, 95% CI=137, 162) and Midwest (118%, 95% CI=111, 125) was associated with higher antibiotic rates. Opioid and antibiotic prescribing rates were positively associated.

CONCLUSIONS

Dental prescribing of opioids is decreasing, whereas dental antibiotic prescribing is increasing. High prescribing of antibiotics is associated with high prescribing of opioids. Strategies focused on optimizing dental antibiotics and opioids are needed given their impact on population health.

Plan Type and Opioid Prescriptions for Children in Medicaid

BACKGROUND

Opioids are generally an inappropriate acute pain management strategy in children, particularly because of the risk for diversion and subsequent misuse and abuse.

OBJECTIVES

To examine associations between Medicaid plan type [coordinated care organization (CCO), managed care (MC), fee-for-service (FFS)] and whether a child received an opioid prescription.

RESEARCH DESIGN

Secondary analysis of Oregon Medicaid data (January 1, 2016 to December 31, 2017).

SUBJECTS

Medicaid-enrolled children ages 0-17 (N=200,169).

MEASURES

There were 2 outcomes: whether a child received an opioid prescription from (a) any health provider or (b) from a visit to the dentist. Predictor variables included Medicaid plan type, age, sex, race, and ethnicity.

RESULTS

About 6.7% of children received an opioid from any health provider and 1.2% received an opioid from a dentist visit. Children in a CCO were significantly more likely than children in a MC (P<0.01) or FFS (P=0.02) plan to receive an opioid from any health provider. Children in a CCO were also significantly more likely than children in MC or FFS to receive an opioid from a dentist visit (P<0.01).

CONCLUSIONS

Pediatric opioid prescriptions vary by plan type. Future efforts should identify reasons why Medicaid-enrolled children in a CCO plan are more likely to be prescribed opioids.

Barriers and facilitators to PDMP IS Success in the US: A systematic review

INTRODUCTION

Prescription Drug Monitoring Programs (PDMP) help prevent prescription drug misuse and promote appropriate pain management. Despite these benefits and PDMP mandates in most states, PDMPs face challenges that hinder their success. This paper uses the Delone and McLean Information Success (IS) Model to review the current literature for barriers and facilitators to PDMP quality, use, intention to use and user satisfaction in the United States (U.S.).

MATERIAL AND METHODS

Scopus, PubMed and Embase databases were searched due to their relevance to information technology, education and research.

RESULTS

There were 142 and 183 barriers and facilitators, respectively, found in 44 peer reviewed articles. Barriers to PDMP quality, use and user satisfaction include lack of interstate data sharing, access difficulties, lack of time, inability to delegate access, lack of knowledge or awareness of the PMDP, and lack of EHR integration. Facilitators to PDMP quality, use and user satisfaction include interstate data connections, real-time data updates, EHR integration, and access delegation.

DISCUSSION

Interstate data sharing, EHR integration and expanding access to delegates were common themes found. Some results were found to be contradictory such as mandating use.

CONCLUSION

PDMP users can use these findings to assess current barriers to PDMP success in the U.S. and draw possible solutions from the list of facilitators. Practitioners should consider the context of their state and organization when determining which facilitators would most promote PDMP IS success. Combining facilitators may be the best route to PDMP IS success in certain situations.

Analgesic and Antibiotic Prescription Pattern among Dentists in Guangzhou: A Cross-Sectional Study

Aim

To assess the rational use of drugs and the pattern of prescribing of analgesics and antibiotics for dental management and the information given by dentists in Guangzhou to their patients about the use of these drugs.

Methods

A questionnaire was distributed to 225 dentists working in Guangzhou. The questionnaires consisted of open-ended questions and were given to dentists about analgesic and antibiotic use in dentistry. The questionnaires were analyzed, and absolute frequencies were expressed in the answers to each question. The cases, the analgesics, and the antibiotics recommended by the dentists for each case were determined by the frequency analysis method of descriptive statistics.

Results

Responses to the questionnaire were received from 164 (72.9%) dentists. Paracetamol and diclofenac were the most widely prescribed analgesics. It is also estimated that selective COX-2 inhibitors or opioid analgesics have not been administered by dentists. The antibiotics primarily used for treatment were amoxicillin and metronidazole, and amoxicillin was used for prophylaxis. While more than 80% of dentists indicated that they provided their patients with information on the use of antibiotics, the quality of the information was limited. Patients were primarily instructed by dentists to observe the dosage and dose intervals of the prescription drugs.

Conclusions

The results of the present study demonstrated that dentists most commonly prescribe paracetamol and diclofenac as analgesics, amoxicillin, and metronidazole for the therapy of periodontal, endodontic, and surgical procedures. The results also showed that dentists informed their patients inadequately about analgesic and antibiotic use.

A Rapid Review of the Impact of Systems-Level Policies and Interventions on Population-Level Outcomes Related to the Opioid Epidemic, United States and Canada, 2014-2018

OBJECTIVES

In the United States, rising rates of overdose deaths and recent outbreaks of hepatitis C virus and HIV infection are associated with injection drug use. We updated a 2014 review of systems-level opioid policy interventions by focusing on evidence published during 2014-2018 and new and expanded opioid policies.

METHODS

We searched the MEDLINE database, consistent with the 2014 review. We included articles that provided original empirical evidence on the effects of systems-level interventions on opioid use, overdose, or death; were from the United States or Canada; had a clear comparison group; and were published from January 1, 2014, through July 19, 2018. Two raters screened articles and extracted full-text data for qualitative synthesis of consistent or contradictory findings across studies. Given the rapidly evolving field, the review was supplemented with a search of additional articles through November 17, 2019, to assess consistency of more recent findings.

RESULTS

The keyword search yielded 535 studies, 66 of which met inclusion criteria. The most studied interventions were prescription drug monitoring programs (PDMPs) (59.1%), and the least studied interventions were clinical guideline changes (7.6%). The most common outcome was opioid use (77.3%). Few articles evaluated combination interventions (18.2%). Study findings included the following: PDMP effectiveness depends on policy design, with robust PDMPs needed for impact; health insurer and pharmacy benefit management strategies, pill-mill laws, pain clinic regulations, and patient/health care provider educational interventions reduced inappropriate prescribing; and marijuana laws led to a decrease in adverse opioid-related outcomes. Naloxone distribution programs were understudied, and evidence of their effectiveness was mixed. In the evidence published after our search's 4-year window, findings on opioid guidelines and education were consistent and findings for other policies differed.

CONCLUSIONS

Although robust PDMPs and marijuana laws are promising, they do not target all outcomes, and multipronged interventions are needed. Future research should address marijuana laws, harm-reduction interventions, health insurer policies, patient/health care provider education, and the effects of simultaneous interventions on opioid-related outcomes.

Prescription drug monitoring programs in the US: A systematic literature review on its strength and weakness

Prescription Drug Monitoring Program (PDMP) is an electronic database that tracks the prescriptions of controlled drugs with its aims to combat the incidence of drug abuse. Although the establishment of PDMP in the US was since 2003, evidence of the impact of PDMP's strength and weakness towards its implementation is still scarce. A systematic literature review according to Preferred Reporting Items for Systematic Review (PRISMA) standard was conducted to investigate the influence of PDMP's strength in combating the incidence of drug abuse and also to review the weaknesses of PDMP that prohibit its implementation. Results from this study reveal that the implementation of PDMP has mitigated the issue of drug abuse and has increased work efficiency among healthcare practitioners. However, the implementation rate of this system is low due to its weaknesses such as limited internet access and limited access to the PDMP system. Therefore, efforts to overcome the weaknesses of PDMP need to be instituted to ensure the healthcare system could fully optimize PDMP's benefits.

Special Screening Resources: Strategies to Identify Substance Use Disorders, Including Opioid Misuse and Abuse

The prescription drug crisis has affected all sectors of the population, and so it is inevitable that dentists will increasingly see at-risk patients or those with substance use disorders in the course of their professional activities. Recognizing these patients and the special needs that they may have is now part of the standard of care for the profession. Screening for substance misuse involves a thorough history and review of the patient's medical record and, as appropriate, reviewing prior records and use of available screening tools.

Effect of short-term prescription opioids on DNA methylation of the OPRM1 promoter

Background

A long-term opioid use has been associated with hypermethylation of the opioid receptor mu 1 (OPRM1) promoter. Very little is currently known about the early epigenetic response to therapeutic opioids. Here, we examine whether we can detect DNA methylation changes associated with a few days’ use of prescribed opioids. Genome-wide DNA methylation was assayed in a cohort of 33 opioid-naïve participants who underwent standard dental surgery followed by opioid self-administration. Saliva samples were collected before surgery (visit 1), and at two postsurgery visits at 2.7 ± 1.5 days (visit 2), and 39 ± 10 days (visit 3) after the discontinuation of opioid analgesics.

Results

The perioperative methylome underwent significant changes over the three visits that were primarily due to postoperative inflammatory response and cell heterogeneity. To specifically examine the effect of opioids, we started with a candidate gene approach and evaluated 10 CpGs located in the OPRM1 promoter. There was a significant cross-sectional variability in opioid use, and for participants who self-administered the prescribed drugs, the total dosage ranged from 5–210 morphine milligram equivalent (MME). Participants were categorized by cumulative dosage into three groups: < 25 MME, 25–90 MME, and ≥ 90 MME. Using mixed-effects modeling, 4 CpGs had significant positive associations with opioid dose at two-tailed p value < 0.05, and overall, 9 of the 10 OPRM1 promoter CpGs showed the predicted higher methylation in the higher dose groups relative to the lowest dose group. After adjustment for age, cellular heterogeneity, and past tobacco use, the promoter mean methylation also had positive associations with cumulative MME (regression coefficient = 0.0002, one-tailed p value = 0.02) and duration of opioid use (regression coefficient = 0.003, one-tailed p value = 0.001), but this effect was significant only for visit 3. A preliminary epigenome-wide association study identified a significant CpG in the promoter of the RAS-related signaling gene, RASL10A, that may be predictive of opioid dosage.

Conclusion

The present study provides evidence that the hypermethylation of the OPRM1 promoter is in response to opioid use and that epigenetic differences in OPRM1 and other sites are associated with a short-term use of therapeutic opioids.

Opioid Use During the Six Months After an Emergency Department Visit for Acute Pain: A Prospective Cohort Study

STUDY OBJECTIVE

Despite the frequent use of opioids to treat acute pain, the long-term risks and analgesic benefits of an opioid prescription for an individual emergency department (ED) patient with acute pain are still poorly understood and inadequately quantified. Our objective was to determine the frequency of recurrent or persistent opioid use during the 6 months after the ED visit METHODS: This was a prospective, observational cohort study of opioid-naive patients presenting to 2 EDs for acute pain who were prescribed an opioid at discharge. Patients were followed by telephone 6 months after the ED visit. Additionally, we reviewed the statewide prescription monitoring program database. Outcomes included frequency of recurrent and persistent opioid use and frequency of persistent moderate or severe pain 6 months after the ED visit. Persistent opioid use was defined as filling greater than or equal to 6 prescriptions during the 6-month study period.

RESULTS

During 9 months beginning in November 2017, 733 patients were approached for participation. Four hundred eighty-four met inclusion criteria and consented to participate. Four hundred ten patients (85%) provided 6-month telephone data. The prescription monitoring database was reviewed for all 484 patients (100%). Most patients (317/484, 66%; 95% confidence interval 61% to 70%) filled only the initial prescription they received in the ED. One in 5 patients (102/484, 21%; 95% confidence interval 18% to 25%) filled at least 2 prescriptions within the 6-month period. Five patients (1%; 95% confidence interval 0% to 2%) met criteria for persistent opioid use. Of these 5 patients, all but 1 reported moderate or severe pain in the affected body part 6 months later.

CONCLUSION

Although 1 in 5 opioid-naive ED patients who received an opioid prescription for acute pain on ED discharge filled at least 2 opioid prescriptions in 6 months, only 1% had persistent opioid use. These patients with persistent opioid use were likely to report moderate or severe pain 6 months after the ED visit.

Nonsteroidal Anti-Inflammatory Drugs and Opioids in Postsurgical Dental Pain

Postsurgical dental pain is mainly driven by inflammation, particularly through the generation of prostaglandins via the cyclooxygenase system. Thus, it is no surprise that numerous randomized placebo-controlled trials studying acute pain following the surgical extraction of impacted third molars have demonstrated the remarkable efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen sodium, etodolac, diclofenac, and ketorolac in this prototypic condition of acute inflammatory pain. Combining an optimal dose of an NSAID with an appropriate dose of acetaminophen appears to further enhance analgesic efficacy and potentially reduce the need for opioids. In addition to being on average inferior to NSAIDs as analgesics in postsurgical dental pain, opioids produce a higher incidence of side effects in dental outpatients, including dizziness, drowsiness, psychomotor impairment, nausea/vomiting, and constipation. Unused opioids are also subject to misuse and diversion, and they may cause addiction. Despite these risks, some dental surgical outpatients may benefit from a 1- or 2-d course of opioids added to their NSAID regimen. NSAID use may carry significant risks in certain patient populations, in which a short course of an acetaminophen/opioid combination may provide a more favorable benefit versus risk ratio than an NSAID regimen.

Prescription Drug Monitoring Programs and Prescription Opioid-Related Outcomes in the United States

Prescription drug monitoring programs (PDMPs) are a crucial component of federal and state governments' response to the opioid epidemic. Evidence about the effectiveness of PDMPs in reducing prescription opioid-related adverse outcomes is mixed. We conducted a systematic review to examine whether PDMP implementation within the United States is associated with changes in 4 prescription opioid-related outcome domains: opioid prescribing behaviors, opioid diversion and supply, opioid-related morbidity and substance-use disorders, and opioid-related deaths. We searched for eligible publications in Embase, Google Scholar, MEDLINE, and Web of Science. A total of 29 studies, published between 2009 and 2019, met the inclusion criteria. Of the 16 studies examining PDMPs and prescribing behaviors, 11 found that implementing PDMPs reduced prescribing behaviors. All 3 studies on opioid diversion and supply reported reductions in the examined outcomes. In the opioid-related morbidity and substance-use disorders domain, 7 of 8 studies found associations with prescription opioid-related outcomes. Four of 8 studies in the opioid-related deaths domain reported reduced mortality rates. Despite the mixed findings, emerging evidence supports that the implementation of state PDMPs reduces opioid prescriptions, opioid diversion and supply, and opioid-related morbidity and substance-use disorder outcomes. When PDMP characteristics were examined, mandatory access provisions were associated with reductions in prescribing behaviors, diversion outcomes, hospital admissions, substance-use disorders, and mortality rates. Inconsistencies in the evidence base across outcome domains are due to analytical approaches across studies and, to some extent, heterogeneities in PDMP policies implemented across states and over time.

Overprescribing of Opioids to Adults by Dentists in the U.S., 2011-2015

INTRODUCTION

Dentists prescribe 1 in 10 opioid prescriptions in the U.S. When opioids are necessary, national guidelines recommend the prescription of low-dose opioids for a short duration. This study assesses the appropriate prescribing of opioids by dentists before guideline implementation.

METHODS

The authors performed a cross-sectional analysis of a population-based sample of 542,958 U.S. commercial dental patient visits between 2011 and 2015 within the Truven Health MarketScan Research Databases (data analysis October 2018‒April 2019). Patients with recent hospitalization, active cancer treatment, or chronic pain conditions were excluded. Prescription opioids were ascertained using pharmacy claims data with standardized morphine equivalents and recorded days' supply. Appropriate prescribing was determined from the 2016 Centers for Disease Control and Prevention guidelines for pain management based on a recommended 3 days' supply of opioid medication and anticipated post-procedural pain.

RESULTS

Twenty-nine percent of prescribed opioids exceeded the recommended morphine equivalents for appropriate management of acute pain. Approximately half (53%) exceeded the recommended days' supply. Patients aged 18-34 years, men, patients residing in the Southern U.S., and those receiving oxycodone were most likely to have opioids prescribed inappropriately. The proportion of opioids that exceed the recommended morphine equivalents increased over the study period, whereas opioids exceeding the recommended days' supply remained unchanged.

CONCLUSIONS

Between 1 in 4 and 1 in 2 opioids prescribed to adult dental patients are overprescribed. Judicious opioid-prescribing interventions should be tailored to oral health conditions and dentists.

The Association of State Opioid Misuse Prevention Policies With Patient- and Provider-Related Outcomes: A Scoping Review

Policy Points This scoping review reveals a growing literature on the effects of certain state opioid misuse prevention policies, but persistent gaps in evidence on other prevalent state policies remain. Policymakers interested in reducing the volume and dosage of opioids prescribed and dispensed can consider adopting robust prescription drug monitoring programs with mandatory access provisions and drug supply management policies, such as prior authorization policies for high-risk prescription opioids. Further research should concentrate on potential unintended consequences of opioid misuse prevention policies, differential policy effects across populations, interventions that have not received sufficient evaluation (eg, Good Samaritan laws, naloxone access laws), and patient-related outcomes.

CONTEXT

In the midst of an opioid crisis in the United States, an influx of state opioid misuse prevention policies has provided new opportunities to generate evidence of policy effectiveness that can inform policy decisions. We conducted a scoping review to synthesize the available evidence on the effectiveness of US state interventions to improve patient and provider outcomes related to opioid misuse and addiction.

METHODS

We searched six online databases to identify evaluations of state opioid policies. Eligible studies examined legislative and administrative policy interventions that evaluated (a) prescribing and dispensing, (b) patient behavior, or (c) patient health.

FINDINGS

Seventy-one articles met our inclusion criteria, including 41 studies published between 2016 and 2018. These articles evaluated nine types of state policies targeting opioid misuse. While prescription drug monitoring programs (PDMPs) have received considerable attention in the literature, far fewer studies addressed other types of state policy. Overall, evidence quality is very low for the majority of policies due to a small number of evaluations. Of interventions that have been the subject of considerable research, promising means of reducing the volume and dosages of opioids prescribed and dispensed include drug supply management policies and robust PDMPs. Due to low study number and quality, evidence is insufficient to draw conclusions regarding interventions targeting patient behavior and health outcomes, including naloxone access laws and Good Samaritan laws.

CONCLUSIONS

Recent research has improved the evidence base on several state interventions targeting opioid misuse. Specifically, moderate evidence suggests that drug supply management policies and robust PDMPs reduce opioid prescribing. Despite the increase in rigorous evaluations, evidence remains limited for the majority of policies, particularly those targeting patient health-related outcomes.

Strengths and weaknesses of existing data sources to support research to address the opioids crisis

Better opioid prescribing practices, promoting effective opioid use disorder treatment, improving naloxone access, and enhancing public health surveillance are strategies central to reducing opioid-related morbidity and mortality. Successfully advancing and evaluating these strategies requires leveraging and linking existing secondary data sources. We conducted a scoping study in Fall 2017 at RAND, including a literature search (updated in December 2018) complemented by semi-structured interviews with policymakers and researchers, to identify data sources and linking strategies commonly used in opioid studies, describe data source strengths and limitations, and highlight opportunities to use data to address high-priority public health research questions. We identified 306 articles, published between 2005 and 2018, that conducted secondary analyses of existing data to examine one or more public health strategies. Multiple secondary data sources, available at national, state, and local levels, support such research, with substantial breadth in data availability, data contents, and the data's ability to support multi-level analyses over time. Interviewees identified opportunities to expand existing capabilities through systematic enhancements, including greater support to states for creating and facilitating data use, as well as key data challenges, such as data availability lags and difficulties matching individual-level data over time or across datasets. Multiple secondary data sources exist that can be used to examine the impact of public health approaches to addressing the opioid crisis. Greater data access, improved usability for research purposes, and data element standardization can enhance their value, as can improved data availability timeliness and better data comparability across jurisdictions.

Opioid guidelines for common dental surgical procedures: a multidisciplinary panel consensus

One in 16 patients prescribed opioids after a surgical procedure will become a long-term user. The lack of procedure-specific guidelines after common dental procedures contributes to the opioid overprescribing problem. We convened a multidisciplinary panel to develop consensus recommendations for opioid prescribing after common dental procedures. We used a three-step modified Delphi method to develop a consensus recommendation for outpatient opioid prescribing for 14 common dental procedures. The multi-institution, multidisciplinary panel represented seven relevant stakeholder groups (oral surgeons, periodontists, endodontists, general dentists, general surgeons, oral surgery residents, and oral surgery patients). The panel determined the minimum and maximum number of opioid tablets a clinician should consider prescribing. For all 14 surgical procedures, ibuprofen was recommended as initial therapy. The maximum number of opioid tablets recommended varied by procedure (overall median = 5 tablets, range = 0-15 tablets). Zero opioid tablets were recommended as the maximum number for six of 14 (43%) procedures, one to 10 opioid tablets was the maximum for four of 14 (27%) procedures, and 11-15 tablets was the maximum for four of 14 (27%) procedures. Procedure-specific prescribing recommendations may help provide guidance to clinicians and help address the opioid overprescribing problem.

Substance Use Stigma, Primary Care, and the New York State Prescription Drug Monitoring Program

Prescription drug monitoring programs (PDMPs) are databases that track controlled substances at the provider, patient, and pharmacy levels. While these databases are widely available at the state level throughout the United States, several jurisdictions in recent years have mandated the use of these systems by health care providers. This study explores the implementation of mandatory PDMP technology in primary care practice and the effects on treatment of people with possible substance use disorders. Findings are based on 53 in-depth interviews with primary care providers in New York City, collected shortly following the passage of legislation mandating use of a PDMP by health care providers in New York State. Findings suggest that use of the PDMP highlighted tensions between provider stigma toward substance use disorders and the clinical care of people who use drugs, challenging their stereotypes and biases. The parallel clinical and law enforcement purposes of PDMP technology placed providers in dual roles as clinicians and enforcers and encouraged the punitive treatment of patients. Finally, PDMP technology standardized the clinical assessment process toward a "diagnosis first" approach, consistent with prior scholarship on the implementation of emerging medical technologies.

Opioid prescribing patterns after dental visits among beneficiaries of Medicaid in Washington state in 2014 and 2015

BACKGROUND

Dentists contribute to the prevailing opioid epidemic in the United States. Concerning the population enrolled in Medicaid, little is known about dentists' opioid prescribing.

METHODS

The authors performed a retrospective cohort study of beneficiaries of Medicaid in Washington state with dental claims in 2014 and 2015. The primary outcome was the proportion of dental visits associated with an opioid prescription. The authors categorized visits as invasive or noninvasive by using procedure codes and each beneficiary as being at low or high risk by using his or her prescription history from the prescription drug monitoring program.

RESULTS

A total of 126,660 (10.3%) of all dental visits, most of which were invasive (66.9%), among the population enrolled in Medicaid in Washington state was associated with opioid prescriptions. However, noninvasive dental visits and visits for beneficiaries who had prior high-risk prescription use were associated with significantly higher mean days' supply and mean quantity of opioids prescribed. Results from the multivariate logistic regression showed that the probability of having an opioid-associated visit increased by 35.6 percentage points when the procedures were invasive and by 11.1 percentage points when the beneficiary had prior high-risk prescription use.

CONCLUSIONS

This baseline of opioid prescribing patterns after dental visits among the population enrolled in Medicaid in Washington state in 2014 and 2015 can inform future studies in which the investigators examine the effect of policies on opioid prescribing patterns and reasons for the variability in the dosage and duration of opioid prescriptions associated with noninvasive visits.

PRACTICAL IMPLICATIONS

Dentists must exercise caution when prescribing opioids during invasive visits and to patients with prior high-risk prescription use.

Do prescription drug monitoring programs encourage prescription - or illicit - opioid abuse?

BACKGROUND

Prescription drug monitoring programs (PDMPs) are tools that states can use to fight prescription opioid misuse within their jurisdiction. However, because PDMPs make prescription opioids more difficult to access, these programs may have the unintended consequence of increasing deaths related to illicit opioids. Methods: This study uses fixed effects models to estimate how PDMP regulatory strength is associated with both prescription opioid- and heroin-related deaths between 1999 and 2016. PDMP regulatory strength is measured by creating a score using multiple correspondence analysis (MCA). Additional models replace the MCA score with a binary indicator for the presence of one particular regulation requiring physicians to access the system before writing opioid prescriptions. Results: Results show that continuous measures of PDMP strength are not generally associated with prescription opioid- or heroin-related death rates. Yet, one model does show that PDMP scores are positively associated with the heroin-related death rate. The models using the binary mandatory access variable show a strong positive association with both prescription opioid and heroin deaths. Conclusions: This study supports the theory that more stringent state PDMPs are associated with higher rates of heroin-related deaths, potentially due to decreases in prescription opioid availability.

Pattern of Opioid Analgesic Prescription for Adults by Dentists in Nova Scotia, Canada

Global consumption of prescription opioid analgesics has increased dramatically in the past 2 decades, outpacing that of illicit drugs in some countries. The increase has been partly ascribed to the widespread availability of prescription opioid analgesics and their subsequent nonmedical use, which may have contributed to the epidemic of opioid abuse, addiction, and overdose-related deaths. International studies report that dentists may be among the leading prescribers of opioid analgesics, thus adding to the societal impact of this epidemic. Between 2009 and 2011, dentists in the United States prescribed 8% to 12% of opioid analgesics dispensed. There is little information on the pattern of opioid analgesic prescription by dentists in Canada. The aim of this study was to examine the pattern of opioid analgesics prescription by dentists in Nova Scotia (NS), Canada. This retrospective observational study used the provincial prescription monitoring program's record of oral opioid analgesics and combinations dispensed to persons 16 y and older at community pharmacies that were prescribed by dentists from January 2011 to December 2015. During the study period, more than 70% of licensed dentists in NS wrote a prescription for dispensed opioid analgesics, comprising about 17% of all opioid analgesic prescribers. However, dentists were responsible for less than 4% of all prescriptions for dispensed opioid analgesics, prescribing less than 0.5% of the total morphine milligram equivalent (MMEq) of opioid analgesics dispensed over the 5 y. There was a significant downward trend in total MMEq of dispensed opioid analgesics prescribed by dentists from about 2.23 million MMEq in 2011 to 1.93 million MMEq in 2015 (r = -0.97; P = 0.006). Opioid prescription is common among dentists, but their contribution to the overall availability of opioid analgesics is low. Furthermore, there has been a downward trend in total dispensed MMEq of opioid analgesics prescribed by dentists. Knowledge Transfer Statement: This study will serve to inform dentists and policy makers on the types and dosage of opioid analgesics being prescribed by dentists. The study may prompt dentists to reflect on and adjust their practice of opioid analgesic prescription in view of the current opioid analgesic epidemic.