Update: The Dental Profession and the Opioid Epidemic

Ira Lamster DDS, MMSc

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Update: The Dental Profession and the Opioid Epidemic

The abuse of opioid medications in the United States has reached epidemic proportions. Since 1996, deaths related to opioid overdose in the United States exceed 200,000. Furthermore, major pharmaceutical corporations have been directly or indirectly involved in this epidemic, related either to a failure to control unauthorized or inappropriate distribution of these drugs, or by incentives offered to corporate representatives to promote their use by providers. Stories about these corporations, their sales practices and proposed financial settlements to compensate the families of the thousands upon thousands who have died, appear in the lay press on an almost daily basis1Washington Post Staff. "The Opioid Files: Follow the Post's Investigation of the Opiod Epidemic." The Washington Post. 13 Sep 2013. https://www.washingtonpost.com/national/2019/07/20/opioid-files/?arc404=true. Therefore, an update on the role of the dental profession regarding clinical practice and its impact on the opioid crisis is warranted. Here we review data from the last two years (2018 and 2019).

For the dental profession, the use of opioid prescription is related primarily to pain management following invasive surgical procedures (endodontic therapy, extraction of 3rd molar teeth). Furthermore, emergency management of acute oral infection, often in a non-dental setting (i.e. hospital emergency department) may also be a contributing factor.

In the past two years, several studies in the medical literature have illustrated the potential impact of opioid prescriptions written by dentists on the opioid crises. Using the Optimum Research Database (a private insurance claims database in the United States), the relationship between opioid prescriptions written by dentists for adolescents and young adults following extraction of 3rd molar teeth was associated with a 6.8% increase in continued opioid use, and a 5.4% increase in future opioid abuse, as compared to age and sex-matched controls2Schroeder AR, Dehghan M, Newman TB, Bentley JP, Park KT. Association of Opioid Prescriptions From Dental Clinicians for US Adolescents and Young Adults With Subsequent Opioid Use and Abuse. JAMA Intern Med 2019;179:145-152.. The authors concluded that for 2015, opioid prescriptions written by dentists for pain management contributed to opioid abuse. A recent study compared opioid prescriptions by dentists in the United States with prescriptions written by dentists in England3Suda KJ, Durkin MJ, Calip GS, et al. Comparison of opioid prescribing by dentists in the united states and england. JAMA Netw Open 2019;2:e194303.. For data from the United States, the IQVIA L Rx database was used, which includes outpatient prescription data from commercial insurers, as well as the Medicare and Medicaid programs. Data from England was obtained from the National Health Service. Remarkably, in the United States nearly one-quarter (22.3%) of prescriptions written by dentists were for opioids, versus less than 1% (0.6%) of prescriptions written by dentists in England. Expressed as the number of prescriptions per dentists, in the U.S. the number was 58.2 versus 1.2 prescriptions in England. Other differences were observed between the two countries. In the U.S., dentists prescribed a wide variety of opioids, and used long-acting drugs. In England, only dihydrocodeine was prescribed, and long-acting opioids were not prescribed (see Tables 1 and 2). The authors included several suggestions. The first and most obvious was the need to reduce opioid prescriptions by dentists in the United States. They also focused on “persons without dental insurance and of lower socioeconomic status” to determine if there is an association between limited access to dental services and abuse of opioid drugs. They also stressed the need for educational programs for dentists regarding opioid prescribing as well as the role of oversight agencies in developing specific guidelines for dentists prescribing opioid analgesics.

A review of the prescribing of opioids and antibiotics as part of dental treatment serves as a reminder that overprescribing of both types of drugs are associated with very significant public health problems4Dana R, Azarpazhooh A, Laghapour N, Suda KJ, Okunseri C. Role of dentists in prescribing opioid analgesics and antibiotics: an overview. Dent Clin North Am 2018;62:279-294.. While both types of drugs should be utilized judiciously and only when needed, cultural changes and oversight may be required. Dental practitioners should participate in prescription drug monitoring programs for opioids and consider development guidelines for antibiotic stewardship.

Data regarding opioid prescribing by dentists is also available from other countries. Studies from Canada indicate that prescription of opioids by dentists in that country appears to be decreasing5Jimoh KO, Matthews DC, Brillant M, Sketris I. Pattern of opioid analgesic prescription for adults by dentists in Nova Scotia, Canada. JDR Clin Trans Res 2018;3:203-211.. Analyzing data on opioid prescriptions by dentists in Nova Scotia between 2011 and 2015, they observed that more than two-thirds of dentists (70%) wrote a prescription for an opioid, and that was equivalent to 17% of all providers who wrote such a prescription. However, during this interval, opioid prescriptions written by dentists accounted for only 4% of all opioid prescriptions in this province, and the total amount of opioid prescribed (morphine milligram equivalent) was only 0.5% over the 5-year period. Furthermore, a reduction in the total amount of opioid prescribed by dentists was seen from 2011 to 2015. These data indicate an overall reduction in opioid prescriptions written by dentists in this province. A study from Manitoba Canada that examined opioid prescriptions by dentists from 2014 through 2017 found very similar results6Falk J, Friesen KJ, Magnusson C, Schroth RJ, Bugden S. Opioid prescribing by dentists in Manitoba, Canada: A longitudinal analysis. J Am Dent Assoc 2019;150:122-129.. Dentists were responsible for 3.8% of all opioid prescriptions, and the milligram morphine equivalent amounted to 0.58%. The authors concluded that dentists were not overly responsible for the overuse of opioids, and as a group did not disproportionately contribute to overuse of these drugs.

A similar analysis of opioid prescriptions by all German dentists from 2012 to 2013 indicated a 3.4% decrease in prescriptions during this period7Halling F, Heymann P, Ziebart T, Neff A. Analgesic prescribing patterns of dental practitioners in Germany. J Craniomaxillofac Surg 2018;46:1731-1736.. In contrast, during these 5 years there was a 10.4% increase in the number of prescriptions written by physicians.

The trend towards decreased utilization of opioids outside of the United States was not seen in recently published reports from all countries. In Australia, data from 2013 to 2016 indicated a 30% increase in opioid prescriptions by Australian dentists8Teoh L, Stewart K, Marino RJ, McCullough MJ. Part 2. Current prescribing trends of dental non-antibacterial medicines in Australia from 2013 to 2016. Aust Dent J 2018.. Opioid prescribing by dentists in Brazil for the year 2012 has also been published9Lino PA, Sohn W, Singhal A, Martins MAP, Silva M, Abreu M. A national study on the use of opioid analgesics in dentistry. Braz Oral Res 2019;33:e076.. This study did not report changes over time, but rather the total number of prescriptions (141,161 prescribed by 36,929 dentists) and variables associated with opioid prescriptions. An increased in the use of opioids was associated with visiting the dentist, and increasingly associated with poverty. They also observed variation in rates for different states within Brazil.

The prescribing habits of dentists in the United States continue to be a concern, and studies have examined prescriptions provided by certain groups of healthcare providers to better understand how to develop targeted interventions for reduction in the use of opioids. These studies are geographical (certain states), by provider, and by patient-recipient.

A report from Washington State examined opioid prescribing by dentists from 2014 and 2015. Opioid prescriptions were provided during 10.3% of all dental visits, and two-thirds of these opioid-prescribed visits were associated with an invasive dental procedure. There was also some indication that a greater total amount of opioid medication was associated with individuals who had a prior history of “high-risk prescription use”10Obadan-Udoh E, Lupulescu-Mann N, Charlesworth CJ, et al. Opioid prescribing patterns after dental visits among beneficiaries of Medicaid in Washington state in 2014 and 2015. J Am Dent Assoc 2019;150:259-268 e251.. These data are considered as baseline for what will be a statewide program to monitor use of opioid prescriptions.

Data is available regarding opioid prescriptions written for certain groups of dental patients. These data provide insight into how these drugs are utilized by dental providers. A study of Medicaid patients with a dental visit during the period between 2013 and 2015 indicated that of the 890,000 patients, 23% received a prescription for opioids within two weeks of that visit11Janakiram C, Chalmers NI, Fontelo P, et al. Sex and race or ethnicity disparities in opioid prescriptions for dental diagnoses among patients receiving Medicaid. J Am Dent Assoc 2018;149:246-255.. Patients at increased risk of receiving a prescription for opioid medication were females (50% increased likelihood) and a patient was twice as likely if they were non-Hispanic white or African American versus Hispanic. If patients were seen in a hospital emergency department, they were at almost 5 times the risk of having received a prescription for opioids as compared to patients seen in a dental office. Further, if seen by a nurse practitioner, the chance of receiving an opioid prescription was about two and half times greater than if seen by a dentist.

Another study examined antibiotic and opioid prescriptions for patients with Medicare. Only individuals with Medicare Part D (pharmacy benefits) could be included12Koppen L, Suda KJ, Rowan S, McGregor J, Evans CT. Dentists' prescribing of antibiotics and opioids to Medicare Part D beneficiaries: Medications of high impact to public health. J Am Dent Assoc 2018;149:721-730.. For the year 2014, of the nearly 7 million prescriptions, about 60% were for an antibiotic and nearly 20% were for an opioid. 57% of the prescriptions for opioids exceeded the recommended prescription duration, which is 3 days.

An interesting group of dental providers to examine are those practitioners who participate in a Practice-Based Research Network (PBRN). Dentists who are members of a PBRN participate in clinical research projects while providing care in their offices and then feedback regarding a range of clinical activities. A series of papers13McCauley JL, Reyes S, Meyerowitz C, et al. Training experiences regarding pain management, addiction, and drug diversion of dentists enrolled in the National Dental Practice-Based Research Network. Subst Abus 2019:1-6.,14McCauley JL, Gilbert GH, Cochran DL, et al. Prescription Drug Monitoring Program use: National Dental PBRN results. JDR Clin Trans Res 2019;4:178-186.,15McCauley JL, Leite RS, Gordan VV, et al. Opioid prescribing and risk mitigation implementation in the management of acute pain: results from The National Dental Practice-Based Research Network. J Am Dent Assoc 2018;149:353-362.,16McCauley JL, Nelson JD, Gilbert GH, et al. Prescription drug abuse among patients in rural dental practices reported by members of the National Dental PBRN. J Rural Health 2019. examined opioid prescription writing characteristics of dentists in a PBRN. Two-thirds of dentists in this network had previous training in appropriate pain management, while almost half (48%) reported training in identification of patterns suggestive of abuse. Major sources of training were continuing education programs, as well as dental school courses for younger dentists13McCauley JL, Reyes S, Meyerowitz C, et al. Training experiences regarding pain management, addiction, and drug diversion of dentists enrolled in the National Dental Practice-Based Research Network. Subst Abus 2019:1-6.. A recent study reported on participating dentists' experience with a prescription drug monitoring program (PDMP)14McCauley JL, Gilbert GH, Cochran DL, et al. Prescription Drug Monitoring Program use: National Dental PBRN results. JDR Clin Trans Res 2019;4:178-186.. Fifty-three percent (53%) of responders reporting accessing a PDMP, 47% did not. The reasons for not accessing a program included lack of familiarity (57%) and lack of knowledge about how to register (25%). Nearly 60% of those who used a PDMP found it to be a value, and approximately 60% stated that the program changed their prescribing pattern (no opioid prescriptions or fewer doses).

A subsequent study indicated that nearly 30% of practicing dentists prescribed opioids or opioids with another non-narcotic analgesics to at least half of their patients who required pain management15McCauley JL, Leite RS, Gordan VV, et al. Opioid prescribing and risk mitigation implementation in the management of acute pain: results from The National Dental Practice-Based Research Network. J Am Dent Assoc 2018;149:353-362.. Not surprisingly, this behavior was associated with non-adherence to PDMP guidelines. Another study examined differences between dentists in the PBRN who practiced in rural verses non-rural settings16McCauley JL, Nelson JD, Gilbert GH, et al. Prescription drug abuse among patients in rural dental practices reported by members of the National Dental PBRN. J Rural Health 2019.. Dentists practicing in rural areas reported a higher frequency of suspected opioid abuse, and as a result were more likely to avoid writing a prescription for an opioid if they believed there was the potential for abuse. Another study reported relatively low use of PDMP by dentists in Washington state for the year 201417Sun BC, Lupulescu-Mann N, Charlesworth CJ, et al. Variations in prescription drug monitoring program use by prescriber specialty. J Subst Abuse Treat 2018;94:35-40..

During this recent period, a few studies reported on the prescribing habits of dental specialists in North America. A study of opioid prescriptions provided after removal of third molars by oral surgeons at the University of Minnesota School of Dentistry revealed that following introduction of an opioid prescription protocol, the number of opioid prescriptions decreased from 2015 to 2017, as did the average number of tablets (15.9 to 11.5). Further, opioid prescriptions tended to be provided for more complex surgery18Tompach PC, Wagner CL, Sunstrum AB, Nadeau RA, Tu HK. Investigation of an opioid prescribing protocol after third molar extraction procedures. J Oral Maxillofac Surg 2019;77:705-714.. Similarly, in a pediatric population in Nova Scotia, Canada, there was a decrease in opioid prescription written (primarily by oral surgeons for following a tooth extraction) when comparing 2011/2012 to 2017/201819Matthews DC, Brillant MGS, Jimoh KO, Singleton W, McLean-Veysey P, Sketris I. Patterns of opioid prescribing by dentists in a pediatric population: a retrospective observational study. CMAJ Open 2019;7:E497-E503.. The amount of drugs dispensed was reduced (in terms of the cumulative amount of drugs dispensed and the length in days of the prescription). Lastly, a study of opioid prescribing habits by endodontists utilized an on-line survey20Alghofaily M, Romberg E, Aldahmash S, Tordik PA. Opioid-prescribing habits of practitioner and educator members of the American Association of Endodontists: report of a national survey. J Endod 2019;45:1265-1271.. The responders indicated a preference for non-opioid analgesics (non-steroidal anti-inflammatory, and acetaminophen), with hydrocodone as a secondary choice. When opioids were provided, the length of the prescription was 4 days or less.

Conclusions that can be drawn from this recent data concerning opioid prescriptions provided by dentists to patients after treatment are the following:

  1. In response to the opioid abuse crisis, dental providers are more aware of the need to control the number of opioid prescriptions given to patients, and when prescribed are writing prescriptions for less total drug, and for fewer days. However, additional efforts to reduce the number of opioid prescriptions written by dentists are required.
  2. Prescription drug monitoring programs are helpful, and lead to a more appropriate approach to opioid prescriptions. Participation by members of the dental profession in these programs, as reported in the literature, is only fair.
  3. It is important to remember that the published literature reports on data from prior years, often 5-6 years before the year of publication. Current prescribing trends, and participation in various monitoring and education programs, is likely to be better today than what is reported in the recent literature.
  4. With the increased coverage in the lay press and scientific literature of the enormous personal impact of the opioid crisis, it is expected that the dental profession will continue to reduce the number of opioid prescriptions that are written and thereby help to control abuse of these drugs.

Table 1. Dental Opioid Prescriptions in the United States and England, 2016

Prescribing Outcomes United States England
Number of dental opioid prescriptions 11,440,198 28,082
Population-based opioid prescribing rate, number of prescriptions per 1000 population (95% CI) 35.4 (25.2-48.7) 0.5 (0.03-3.7)

Adapted from Suda, KJ et al (2019)

Table 2. Dental Prescriptions for Selected Opioids in the United States and England by Drug, 2016

Prescription United States England
Codeine
Number of dental codeine prescriptions 2,657,486 28,082
Population-based codeine prescribing rate, number of prescriptions per 1000 population (95% CI) 8.2 (4.1-15.8) 0.5 (0.03-3.7)
Hydrocodone
Number of dental hydrocodone prescriptions 7,126,867 0
Population-based hydrocodone prescribing rate, No. of prescriptions per 1000 population (95% CI) 22.0 (13.8-33.3) 0 (0-3.7)
Oxycodone
Number of dental oxycodone prescriptions 1,044,611 0
Population-based oxycodone prescribing rate, number of prescriptions per 1000 population (95% CI) 3.2 (1.1-8.8) 0 (0-3.7)
Tramadol
Number of dental tramadol prescriptions 543,630 0
Population-based tramadol prescribing rate, number of prescriptions per 1000 population (95% CI) 1.7 (0.2-5.6) 0 (0-3.7)

Adapted from Suda, KJ et al (2019)

References

  • 1.Washington Post Staff. "The Opioid Files: Follow the Post's Investigation of the Opiod Epidemic." The Washington Post. 13 Sep 2013. https://www.washingtonpost.com/national/2019/07/20/opioid-files/?arc404=true.
  • 2.Schroeder AR, Dehghan M, Newman TB, Bentley JP, Park KT. Association of Opioid Prescriptions From Dental Clinicians for US Adolescents and Young Adults With Subsequent Opioid Use and Abuse. JAMA Intern Med 2019;179:145-152.
  • 3.Suda KJ, Durkin MJ, Calip GS, et al. Comparison of opioid prescribing by dentists in the united states and england. JAMA Netw Open 2019;2:e194303.
  • 4.Dana R, Azarpazhooh A, Laghapour N, Suda KJ, Okunseri C. Role of dentists in prescribing opioid analgesics and antibiotics: an overview. Dent Clin North Am 2018;62:279-294.
  • 5.Jimoh KO, Matthews DC, Brillant M, Sketris I. Pattern of opioid analgesic prescription for adults by dentists in Nova Scotia, Canada. JDR Clin Trans Res 2018;3:203-211.
  • 6.Falk J, Friesen KJ, Magnusson C, Schroth RJ, Bugden S. Opioid prescribing by dentists in Manitoba, Canada: A longitudinal analysis. J Am Dent Assoc 2019;150:122-129.
  • 7.Halling F, Heymann P, Ziebart T, Neff A. Analgesic prescribing patterns of dental practitioners in Germany. J Craniomaxillofac Surg 2018;46:1731-1736.
  • 8.Teoh L, Stewart K, Marino RJ, McCullough MJ. Part 2. Current prescribing trends of dental non-antibacterial medicines in Australia from 2013 to 2016. Aust Dent J 2018.
  • 9.Lino PA, Sohn W, Singhal A, Martins MAP, Silva M, Abreu M. A national study on the use of opioid analgesics in dentistry. Braz Oral Res 2019;33:e076.
  • 10.Obadan-Udoh E, Lupulescu-Mann N, Charlesworth CJ, et al. Opioid prescribing patterns after dental visits among beneficiaries of Medicaid in Washington state in 2014 and 2015. J Am Dent Assoc 2019;150:259-268 e251.
  • 11.Janakiram C, Chalmers NI, Fontelo P, et al. Sex and race or ethnicity disparities in opioid prescriptions for dental diagnoses among patients receiving Medicaid. J Am Dent Assoc 2018;149:246-255.
  • 12.Koppen L, Suda KJ, Rowan S, McGregor J, Evans CT. Dentists' prescribing of antibiotics and opioids to Medicare Part D beneficiaries: Medications of high impact to public health. J Am Dent Assoc 2018;149:721-730.
  • 13.McCauley JL, Reyes S, Meyerowitz C, et al. Training experiences regarding pain management, addiction, and drug diversion of dentists enrolled in the National Dental Practice-Based Research Network. Subst Abus 2019:1-6.
  • 14.McCauley JL, Gilbert GH, Cochran DL, et al. Prescription Drug Monitoring Program use: National Dental PBRN results. JDR Clin Trans Res 2019;4:178-186.
  • 15.McCauley JL, Leite RS, Gordan VV, et al. Opioid prescribing and risk mitigation implementation in the management of acute pain: results from The National Dental Practice-Based Research Network. J Am Dent Assoc 2018;149:353-362.
  • 16.McCauley JL, Nelson JD, Gilbert GH, et al. Prescription drug abuse among patients in rural dental practices reported by members of the National Dental PBRN. J Rural Health 2019.
  • 17.Sun BC, Lupulescu-Mann N, Charlesworth CJ, et al. Variations in prescription drug monitoring program use by prescriber specialty. J Subst Abuse Treat 2018;94:35-40.
  • 18.Tompach PC, Wagner CL, Sunstrum AB, Nadeau RA, Tu HK. Investigation of an opioid prescribing protocol after third molar extraction procedures. J Oral Maxillofac Surg 2019;77:705-714.
  • 19.Matthews DC, Brillant MGS, Jimoh KO, Singleton W, McLean-Veysey P, Sketris I. Patterns of opioid prescribing by dentists in a pediatric population: a retrospective observational study. CMAJ Open 2019;7:E497-E503.
  • 20.Alghofaily M, Romberg E, Aldahmash S, Tordik PA. Opioid-prescribing habits of practitioner and educator members of the American Association of Endodontists: report of a national survey. J Endod 2019;45:1265-1271.