opiate scripts by dentists: US vs England

A few recent articles highlighted the continuing problem in the US with opioid prescriptions. This blog will deal with a study showing much higher prescribing of opioids overall by dentists in the US vs England, and much stronger ones at that (see opioid scripts by dentists jamaintmed2018 in dropbox, or doi:10.1001/jamanetworkopen.2019.4303). another blog tomorrow....

Details:

-- cross-sectional study of prescriptions for opioids dispensed from outpatient pharmacies in healthcare settings in 2016, by dentists in the US and England

    -- the US data source was the IQVIA LRx database, which captures 85% of all outpatient prescriptions, including people commercially insured, Medicare, Medicaid, and cash payment (but not the VA)

    -- the English data are from the NHS Digital Prescription Cost Analysis database, but were only available for England and not the whole UK

Results:

-- US dentists wrote 37 times greater proportion of opioid prescriptions vs English dentists:

    -- US: 22.3% of dental prescriptions were for opioids (11.4 million prescriptions)

    -- England: 0.6% of dental prescriptions were for opioids (20,082 prescriptions)

-- number of opioid prescriptions per 1000 population

    -- US: 35.4 per 1000

    -- England: 0.5 per 1000

-- opioid prescriptions written per dentist:

    -- US: 58.2

    -- England: 1.2

-- types of opioid prescriptions:

    -- US: hydrocodone (62.3%), codeine (23.2%), oxycodone (9.1%), tramadol (4.8%); long-acting opioids (0.06%)

    -- England: dihydrocodeine, a codeine derivative (100%); long-acting opioids (not prescribed)

Commentary:

-- most of the opioids prescribed internationally are written in the US, despite the fact that the US represents only 4% of the world’s population

-- dentists are the 2^nd most frequent prescriber of opioids in the US (after family physicians...)

    -- dentists prescribe one third of opioid prescriptions for adolescents

-- per capita prescribing of opioids has been decreasing nationally (see http://gmodestmedblogs.blogspot.com/2017/07/decreasing-opiate-prescriptions.html ), though dental prescription rates are increasing (e.g. the opioid prescription rate by dentists in 2010 was 130.58 prescriptions per thousand dental patients, increasing to 147.44 per thousand in 2015 (see https://jada.ada.org/pb/assets/raw/Health%20Advance/journals/adaj/05_ADAJ1009.pdf )

-- US studies have suggested that dentists prescribe opioids over NSAIDs, greater quantities, and for longer than necessary to control dental pain

-- an estimated 1 million opioid pills prescribed following tooth extractions are unused in the US

    --unused opiates create a ready source of opiates in the community; more than half of those who misuse prescription opioids get them from a friend or relative

--studies have shown that combinations of acetaminophen and ibuprofen are associated with pain relief at least as good as opiates

--this study complements a recent one finding lots of opiate prescriptions by dentists to US adolescents and young adults (see https://gmodestmedblogs.blogspot.com/2019/01/opioid-prescriptions-by-dentists.html  ), and puts this problem in the larger context of a large discrepancy with the UK, where dental health may well be lacking and there may be even greater need for stronger medications (see https://www.newsweek.com/english-peoples-teeth-are-international-disgrace-and-national-health-disaster-769635 )

    -- though, that being said, 23% of US population does not have dental insurance, whereas dental care is part of the public benefit in the UK National Health Service

    -- and there are studies suggesting that actual oral health US and UK are pretty similar

-- it is pretty striking that not only are many more prescriptions written in the US, but that much higher potency ones are dominant, increasing the likelihood of addiction or diversion

-- the American Dental Association did come out with guidelines suggesting options to decrease opiate prescriptions, but there are no specific recommendations for treating oral pain (vs England where there are guidelines, recommending NSAIDs over opiates). See http://gmodestmedblogs.blogspot.com/2018/04/new-opioid-guidelines-or-directives.html

-- England also has a national formulary, and dihydrocodeine is the only opiate that dentists can prescribe

-- a clear limitation of this comparative study is that the numbers come from data-mining, without patient-specific information regarding clinical condition. 

-- it is impressive that dentists prescribe a large number of opiates for adolescents (although many do have 3^rd molar extractions likely leading to these prescriptions, it does seem that NSAIDs and acetaminophen combined does typically provide adequate dental pain).  

    -- But the risk of persistent opioid use tends to be higher in adolescents than adults: 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 have been many studies in prior blogs which looked at ways to decrease opiate prescriptions. For example, a very restrictive post-op opioid prescription at a cancer center led to many fewer opiates used yet no difference in patient-reported pain, see http://gmodestmedblogs.blogspot.com/2019/01/restrictive-postop-opioids-fewer-given.html , which also reviews several earlier blogs on limiting opioid prescriptions. and other studies suggest that only 28% of prescribed doses of opiates for post-op pain are actually taken (see http://gmodestmedblogs.blogspot.com/2018/12/post-op-opiates-too-many-pills-too-many.html )!!!! (leaving more unused ones in the house, more available for others to get/take/become addicted to, as noted above)

So, this comparison between US and English dentists brings up a few issues:

-- England is able to have a more consistent approach to clinician-prescribed opiates since they have a more far-reaching and comprehensive health plan. And, with clear-cut guidelines on care. It is much harder to implement a rigorous approach in the US given how fragmented our system of care is

-- one advantage of clear-cut guidelines is that they can be more prescriptive: the American Dental Association guidelines for a “new policy to combat opioid epidemic”does include 5 systematic reviews finding that ibuprofen 400 mg plus acetaminophen 1000 mg was superior to any opioid-containing medication", but their guidelines state that dentists  “consider NSAIDs is the first-line therapy for acute pain management”. Not a very compelling guideline…

-- so, all of this does suggest that this is a pretty low-hanging fruit: if we know that opiates are usually not needed in dental work (those 5 studies showing NSAIDs/acetminophen are as good or better), and we know that huge numbers of scripts go to kids/young adults who seem to be more susceptible to future drug addiction, and we know that huge numbers of opiate pills are not needed and remain unused at home, and we know that is a significant source for friends and family to get/misuse opiates, and we know that some reasonably similar countries (England) prescribe way fewer opiates for dental procedures, and we know that the opioid issue in the US has such profound effects on individuals/familiies/communities/nationally, a reasonable conclusion is that we could impose reasonable restrictions here...???!!!

geoff

If you would like to be on the regular email list for upcoming blogs, please contact me atgmodest@uphams.org

For access to the dropbox, go to link: https://www.dropbox.com/sh/0bmvtita8mzms11/XDTwHySFFg

Then go to "clinic", then to either "clinical stuff" for articles, or "powerpt presentations" for the powerpoint presentations

to get access to all of the blogs:

1. go to http://gmodestmedblogs.blogspot.com/
 to see them in reverse chronological order

2. click on 3 parallel lines top left, if you want to see blogs by category, then click on "labels" and choose a category

3. or you can just click on the magnifying glass on top right, then  type in a name in the search box and get all the blogs with that name in them

please feel free to circulate this to others. also, if you send me their emails, i can add them to the list