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PAINSCAN LITERATURE REVIEW
Issue 1, Volume 4
Addiction Medicine and Relapse Prevention
8 Articles in this Series
Introduction
The Krebs SPACE Trial
Association of opioid prescriptions from dental clinicians for US adolescents and young adults with subsequent opioid and abuse
The influence of anxiety sensitivity on opioid use disorder treatment outcomes.
Draft Report on Pain Management Best Practices: Updates, Gaps, Inconsistencies, and Recommendations
The Addiction Patient
What the SUPPORT Act Means for Providers
Inside the NCASA Report: Ending the Opioid Crisis
The role of opioid prescription in incident opioid abuse and dependence among individuals which chronic non-cancer pain

Association of opioid prescriptions from dental clinicians for US adolescents and young adults with subsequent opioid and abuse

JAMA Intern Med
2019;179(2):145-152

IMPORTANCE: Through prescription writing, dental clinicians are a potential source of initial opioid exposure and subsequent abuse for adolescents and young adults.

OBJECTIVE: To examine the association between index dental opioid prescriptions from dental clinicians for opioid-naive adolescents and young adults in 2015 and new persistent use and subsequent diagnoses of abuse in this population.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study examined outpatient opioid prescriptions for patients aged 16 to 25 years in the Optum Research Database in 2015. Prescriptions were linked by National Provider Identifier number to a clinician category.

EXPOSURES: Individuals were included in the index dental opioid (opioid-exposed) cohort if they filled an opioid prescription from a dental clinician in 2015, had continuous health plan coverage and no record of opioid prescriptions for 12 months before receiving the prescription, and had 12 months of health plan coverage after receiving the prescription. Two age- and sex-matched opioid-nonexposed control individuals were selected for each opioid-exposed individual and were assigned a corresponding phantom prescription date.

MAIN OUTCOMES AND MEASURES: Receipt of an opioid prescription within 90 to 365 days, a health care encounter diagnosis associated with opioid abuse within 365 days, and all-cause mortality within 365 days of the index opioid or phantom prescription date.

RESULTS: Among 754,002 individuals with continuous enrollment in 2015, 97,462 patients (12.9%) received 1 or more opioid prescriptions, of whom 29,791 (30.6%) received prescriptions supplied by a dental clinician. The opioid-exposed cohort included 14,888 participants (7882 women [52.9%], 11,273 white [75.7%], with mean [SD] age, 21.8 [2.4] years), and the randomly selected opioid-nonexposed cohort included 29,776 participants (15,764 women [52.9%], 20,078 [67.4%] white, with mean [SD] age, 21.8 [2.4] years). Among the 14,888 individuals in the index dental opioid cohort, 1021 (6.9%) received another opioid prescription 90 to 365 days later compared with 30 of 29 776 (0.1%) opioid-nonexposed controls (adjusted absolute risk difference, 6.8%; 95%CI, 6.3%-7.2%), and 866 opioid-exposed individuals (5.8%) experienced 1 or more subsequent health care encounters with an opioid abuse–related diagnosis compared with 115 opioid-nonexposed controls (0.4%) (adjusted absolute risk difference, 5.3%; 95%CI, 5.0%-5.7%). There was only 1 death in each cohort.

CONCLUSIONS AND RELEVANCE: The findings suggest that a substantial proportion of adolescents and young adults are exposed to opioids through dental clinicians. Use of these prescriptions may be associated with an increased risk of subsequent opioid use and abuse.

Commentary

Because molar extractions are common in young people, many of whom are given post-operative prescriptions for opioids, the possibility exists that some percentage of these patients will abuse or become addicted to opioids. The key question, according to the Schroeder paper, is: “Are opioid prescriptions from dental clinicians that are written for pain management of third-molar extractions from adolescents and young adults associated with subsequent opioid use and abuse?” This is indeed an interesting question, and it is of concern that 6.9% of those who received opioids post-op received another prescription 90 to 365 days later, compared with only 0.1% of those who had not. In addition, 5.8% of the opioid-treated group experienced one or more subsequent healthcare encounters with an opioid-related diagnosis.

However, the authors did not actually answer this question in their paper. As they explained, “Although the indication for these opioid prescriptions is not obtainable in the Optum data set, given the available data on the frequency of third-molar extractions ... it is likely that this procedure is responsible for most of these prescriptions.” All we know about the treated group was that they received at least one opioid prescription by a dental clinician, presumably for some procedure. There is no information about the diagnosis. The assumption is that most had third-molar extractions, but it is certainly possible that a small percentage of the patients had a different dental problem and a surgical procedure that may have resulted in more prolonged pain and a prolonged need for opioids.

 Just a few months before the Schroeder study was published, another study by Harbaugh, et al, using a different database1 – this one specifically of patients who had “Persistent Opioid Use After Wisdom Tooth Extraction” – compared the outcome in two groups of patients aged 13 to 30 who all had undergone a wisdom tooth extraction. They found that 1.3% of the group who had been given an initial opioid prescription filled another prescription at 90 to 365 days, compared with 0.5% of those who were not initially prescribed an opioid. Compared to the Schroeder study, this one found a significantly smaller likelihood of repeated opioid use more than 90 days after tooth extraction, and a greater percentage of the control group. These studies are not totally comparable because the Schroeder study did not specify why the study group received opioids in the first place, and likely assumed that it was for tooth extraction and not some other dental surgery. In addition, the dental diagnoses of the Schroeder control group were not made clear, meaning they are not a comparable control group. Another limitation, this one of both studies, was that neither provided information on why some patients requested an opioid prescription more than 90 days after the dental procedure. 

In the Schroeder study, it was not clear how the diagnosis of opioid abuse was obtained. The supplemental table provided online includes a lengthy list of ICD-9 and ICD-10 diagnostic codes related to abuse or dependence but gives no information about the specific diagnoses made in any of the patients. In the absence of chart reviews, there is no way to confirm the diagnosis of opioid abuse or addiction. Among the opioid-exposed group, 0.5% had subsequent hospitalizations associated with a diagnosis of opioid abuse, compared with the non-exposed group (0.3%).  Thus, the absolute risk difference in hospitalization between the two groups was only 0.2%, and there was one death in each group in the following year (again, a diagnosis not given) with no significant difference between the two groups. These results indicate that whatever the “opioid-related diagnosis,” the likelihood of serious consequences was small.

Nonetheless, the results of the Schroeder study (and the Harbaugh study) do support the need for awareness among dental health personnel regarding how prescribing opioids to young people may lead to adverse consequences. The question then arises, how can these consequences be minimized?

Schroder, et al’s, discussion consisted only of solutions intended to limit opioid exposure following a dental procedure: use non-steroid alternatives such as NSAIDs or long-acting local anesthesia; limit the quantity of opioid pills prescribed; and, consider not removing asymptomatic third molars. This approach did not consider the patients as individuals who need to be understood in order to provide risk assessment relevant to making decisions about providing opioids.

Interestingly, the Harbaugh study (which did not examine the likelihood of subsequent opioid abuse or addiction), compared the opioid-treated and control groups (all of whom underwent molar removal) regarding pre-existing behavioral health issues. They found that a significantly greater percentage of opioid-treated patients (compared with the non-opioid group) had chronic pain, depression, or anxiety, as well as significantly more pre-operative prescriptions for benzodiazepines, stimulants, sedatives or hypnotics, and antidepressants. This suggests that screening for these diagnoses and medications may be useful in a dental worker’s risk assessment regarding post-op care for the anticipated pain. It may be argued, therefore, that these decisions are not clear-cut and, instead, should be influenced by “getting to know your patient.”

Next Article:
The influence of anxiety sensitivity on opioid use disorder treatment outcomes.
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