Opioids Overprescribed for Low-Risk Procedures
Common low-risk surgical procedures, like tooth extraction and knee arthroscopy, are frequently the setting of opioid overprescribing by dentists and clinicians. Two articles in JAMA explore the trends in opioid prescribing among dentists and surgeons for postoperative pain.1,2
[Editor's Note: The study period of the 2 articles is from 2000 to 2012, during the height of increased awareness about pain as the Fifth Vital Sign and corresponding increase in opioid prescribing. Recently, the American Pain Society released new guidelines on Postoperative Pain Management. In addition, the CDC also released New Guidelines for Opioid Prescribing for Chronic Pain.]
The first of the JAMA articles examined nationwide patterns of opioids prescribed after tooth extraction procedures.1 Using health claims data drawn from Medicaid transactions occurring from 2000-2010, a large cohort of 2,757,273 patients were included in the analysis. Of those patients, 42% filled an opioid prescription within the 7 days following the extraction procedure.
Hydrocodone/acetaminophen (ie, Vicodin) was the most commonly prescribed drug, accounting for 78% of all prescriptions, followed by oxycodone/acetaminophen (ie, Percocet, 15.4%), propoxyphene (3.5%), and codeine (1.6%). While the mean age of patients was 24.9 years (SD, 13.3) (64% female), teenagers (aged 14 to 17 years) had the highest proportion of filled opioid prescriptions compared with patients aged 18 to 24 years (61% and 52%, respectively).
Following a tooth extraction procedure, adult patients were dispensed a median number of 120 milligrams of morphine equivalent opioids (interquartile range [IQR], 90-150; 10th-90th percentile range, 75-225), which equals 24 5-mg hydrocodone tablets (IQR, 18-30) or 16 5-mg oxycodone tablets (IQR, 12-20). The highest morphine equivalents were for patients who underwent more invasive procedures, such as extraction of impacted teeth.
“There was great variability in the amount of opioids dispensed for a given procedure, with an approximately 3-fold difference between the 10th and 90th percentile in the oral morphine equivalents prescribed,” the authors wrote. Patients typically require a limited supply of opioids for acute pain following a tooth extraction procedure, so the numbers suggest that disproportionately large amounts of opioids commonly are prescribed to patients.
This inference could be further distressing given the fact that systematic reviews have found non-opioid therapies, particularly a combination approach of ibuprofen and acetaminophen, provide more effective pain relief and less side effects compared to the currently-available opioid-containing formulations.3
The spotlight on opioid abuse in the U.S. has sparked a discussion over proper opioid prescribing practices, a topic that has largely focused on practitioners in primary care settings. But according to Brian T. Bateman, MD, MSc, of Brigham and Women's Hospital in Boston, Massachusetts, and co-author of the JAMA study, dentists should not be left out of the conversation.
“We know that dentist are among the leading prescribers of opioids in the United States—this is particularly true in age groups vulnerable to the risks of addiction, like adolescents and young adults. Just as physicians need to strive to become more responsible in the way they prescribe opioids, dentists also need to be more cautious about prescribing large amounts of these dangerous medications,” he said.
Prescribing Opioids After Surgical Procedures
The second study analyzed data from around 14 million commercially insured patients, looking for possible trends in postoperative opioid prescribing.2 The study focused its cohort on 155,297 opioid-naïve adults who underwent some kind of low-risk surgical procedure, such as the following:
- Carpal tunnel release
- Laparoscopic cholecystectomy
- Inguinal hernia repair
- Knee arthroscopy
Within 7 days, the majority of patients (80.0%) filled a prescription for an opioid. Somewhat similar to Bateman et al’s findings, 86.4% of these prescriptions were for hydrocodone/acetaminophen or oxycodone/acetaminophen. Because the researchers examined data from 2004, 2008, and 2012, they found the proportions of patients filling prescriptions for opioids following these low-risk surgical procedures steadily increased over the years—similar to the rise in opioid prescribing in general.
For patients that filled a prescriptions for hydrocodone/acetaminophen or oxycodone/acetaminophen, mean morphine equivalents (for all years) included:
- Laparoscopic cholecystectomy - 203.0 (95% CI, 202.1-204.0)
- Carpal tunnel release - 213.1 (95% CI, 211.1-215.1)
- Inguinal hernia repair – 221.5 (95% CI, 220.1-222.9)
- Knee arthroscopy - 268.8 (95% CI, 267.6-270.0)
Interestingly, the mean morphine equivalent of opioids dispensed for every procedure steadily increased from 2004 through 2012 by 29.71 (95% CI, 28.08-31.35; P < 0.001). This was most noticeable for knee arthroscopy procedures, at 45.16 morphine equivalents (95% CI 42.26-48.07; P < 0.001). And yet, the duration of days for prescriptions remained unchanged, even decreasing slightly. The rising prescribing levels could be a sign of increasing reliance on opioid prescriptions over alternative therapies to manage postoperative pain, the authors wrote.
"It is also important to recognize that filling a prescription for opioids and taking the medication are two different things,” said Hannah Wunsch, MD, MSc, from the Sunnybrook Health Sciences Centre in Toronto, Ontario, Canada. “We don’t know from this study how many patients are making use of these pills or are keeping them as a last resort after trying other appropriate alternatives,” Dr. Wunsch told Practical Pain Management.
Another explanation could be an increased focus on pain treatment. According to Dr. Bateman, this could very well be the case. “My sense is that many practitioners, whether doctors or dentist, prescribe extra medication ‘just in case.’ They don't want the patient to run out and have to come back for a refill or end up having pain that is untreated," he noted.
“The problem with that approach is that it leads to a lot of leftover opioid medication out there in the community," he added. "We know leftover medication is a major source for opioids that are misused or diverted. It is also possible, although we don't have good data on the issue, that patients who are prescribed and take more opioid medications for an acute pain condition have a higher chance of becoming addicted.”