opioid prescriptions by dentists

A recent large-scale data-mining study found that dental clinicians prescribed lots of opioids to US adolescents and young adults, with a substantial subsequent risk of opioid use and abuse (see opioid scripts by dentists jamaintmed2018 in dropbox, or doi:10.1001/jamainternmed.2018.5419).

Details:

-- retrospective cohort study of outpatient opioid prescriptions for patients aged 16 to 25, with continuous enrollment in the Optum Research Database in 2015 (which contains de-identified inpatient, outpatient, and pharmacy claims data for 12 to 14 million privately insured US patients per year across the 50 states), matched with clinician NPI numbers

-- 97,462 (13%) of the 754,002 individuals 16-25 yo with received one or more opioid prescriptions

    -- 29,791 (31%) received prescriptions by a dental clinician

    -- 14,888 opioid-exposed patients were enrolled, after excluding those with a record of prior opioid prescriptions, those who were hospitalized up to 7 days before the initial dental prescription, and those with no complex chronic conditions

    -- the control group included 29,776 participants who were opioid-nonexposed, meeting the same criteria

-- 53% women, 76% white/9% Hispanic/6% black/4% Asian, mean age 21.8, 40% from the south/28% north-central/rest scattered through the US,

-- index opioid prescription: median 3 days, quantity 20, 20% with at least one refill.

-- Opioids: 76% hydrocodone/acetaminophen, 21% oxycodone/acetaminophen

-- 3% had a diagnosis of non-opioid substance abuse in the previous 12 months (including cannabis, sedatives, cocaine, stimulants, inhalants, alcohol, tobacco)

-- main outcome: receipt of an opioid prescription within 90 to 365 days post-dental care, healthcare encounter with the diagnosis of opioid abuse within 365 days, and all-cause mortality within 365 days.

Results:

-- 1021 of the 14,888 in the opioid cohort (6.9%) received another opioid prescription 90 to 365 days later, compared to 30 of 29,776 opioid nonexposed people (0.1%)

    -- adjusted absolute risk difference 6.8% (6.3%-7.2%), p<0.001

    -- the 2^nd opioid prescription was prescribed by a dental clinician for 276 of the 1021 (27%), 745 were provided by emergency physicians, orthopedic surgeons, physicians assistants, otolaryngologist, family practitioners, OB/GYN, general surgeons, and general internists, with a median of 20 pills dispensed

-- 866 opioid-exposed individuals (5.8%) had one or more subsequent health encounters with an opioid abuse related diagnosis, vs 115 opioid nonexposed controls (0.4%), adjusted absolute risk difference of 5.3% (5.0%-5.7%), p<0.001

    -- in 66%, the 1^st of these encounters occurred within 90 days

-- hospitalizations associated with the diagnosis of opioid abuse were more common in the opioid exposed cohort, 74 of 14,888 (0.5%) vs the opioid nonexposed cohort, 79 of 29,776 (0.3%), with an adjusted absolute risk difference of 0.2% (0.1%-0.4%), p<0.001

-- there was one death each cohort in the 12 month period

-- one potential confounder: opioid-exposed patients had initial dental visits, whereas opioid-nonexposed individuals may not have. So they then compared individuals receiving a non-opioid prescription from dental clinicians (e.g. antibiotics) finding that only 5 of 1628 (0.3%) of them filled an opioid prescription from a non-dental clinician 90 to 365 days later compared with 745 for 14,888 (5.0%) of the opioid-exposed patients

-- individuals age 22 to 25 were less likely than those aged 16 to 18 to have persistent opioid use, adjusted odds ratio 0.7 (0.6-0.9), as well as opioid abuse, adjusted odds ratio 0.8 (0.7-1.0)

-- females were more likely to have persistent use, adjusted odds ratio 1.2 (1.0 - 1.4) and abuse, adjusted odds ratio 11.5 (9.4-14.8)

-- those with previous non-opioid substance abuse prior to the dental interaction (n=473) vs those without (n=14,415) had persistent opioid use, adjusted OR 3.7 (2.9 4.7); and opioid abuse, with adjusted OR 4.5 (3.4-5.9)

-- for those given more than 20 pills at their initial encounter, vs 20 or fewer pills, persistent use and abuse were not significantly different between the groups

Commentary:

-- in the age group of 16 to 25, dental opioid prescribing was likely largely related to the eruption and extraction of 3^rd molars

-- dentists are the leading source of opioid prescriptions for children and adolescents aged 10 to 19, accounting for 31% of opioid prescriptions in 2009

    -- dental opioid prescriptions in kids ages 11 to 18 increased from 99.7 per 1000 dental patients in 2010 to 165.9 per 1000 dental patients in 2015

-- similar results to the above dental study have been reported for persistent opioid use after surgical procedures both in adults as well as adolescents 13 to 21 years old

-- other studies have found that female sex was a risk factor for opioid exposure or persistent use (see blog tomorrow on the CDC report of dramatically increasing  drug-related deaths in women)

-- it is notable how often opioid prescriptions are given by dentists. This may change since the criteria for dental extraction of 3^rd molars is becoming narrower. Also the American Dental Association has come out with is a pretty aggressive anti-opioid campaign (see https://www.ada.org/en/advocacy/advocacy-issues/opioid-crisis )

-- it was impressive in this dental study that the risk of persistent opioid use was higher in the 16-18 yo vs 22-25 yo groups. there is the rationale that the developing adolescent brain may be more susceptible to drug addiction. one perhaps relevant study came out in 2015 of 6000 12^th-graders followed through age 23, finding that those ”legitimately” prescribed opiates by grade 12 had a 3-fold increased opioid misuse later, despite being in the lowest predicted risk strata for future opioid misuse by a validated questionnaire. See http://gmodestmedblogs.blogspot.com/2015/10/prescribed-opioids-and-future.html 

-- there are several limitations to the dental study. It is a retrospective observational analysis and therefore cannot show causation, it dealt with patients who are privately insured and may not be generalizable to others, it does not account for opioids that were acquired from nonprescription sources (though they did look at ICD diagnostic codes for subsequent opioid abuse). They also do not have specific data about diagnoses (though in this age group 3^rd molar extractions are the leading cause) or any granular data on the extensiveness of the surgery/complications

so, this study adds to the several others that have come out recently, suggesting that clinicians as a group are overprescribing opiates, and, though there are not conclusive granular data, it seems that these opiate prescriptions lead to subsequent opiate misuse. as in these prior blogs, there do seem to be pretty significant changes in clinician opiate prescribing, with pretty substantial decreased prescribing in emergency departments, and strong initiatives to decrease post-op opiate prescribing (eg see http://gmodestmedblogs.blogspot.com/2019/01/restrictive-postop-opioids-fewer-given.html ).  This is starting to address one of the important aspects of the ongoing opioid crisis…

geoff

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