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Original Investigation
December 3, 2018

Association of Opioid Prescriptions From Dental Clinicians for US Adolescents and Young Adults With Subsequent Opioid Use and Abuse

Author Affiliations
  • 1Division of Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
  • 2Division of Critical Care, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
  • 3Division of Gastroenterology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
  • 4Department of Epidemiology and Biostatistics, University of California, San Francisco
  • 5Department of Pediatrics, University of California, San Francisco
  • 6Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
JAMA Intern Med. 2019;179(2):145-152. doi:10.1001/jamainternmed.2018.5419
Key Points

Question  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?

Findings  In this cohort analysis of claims data, index opioid prescriptions in opioid-naive adolescents and young adults compared with age- and sex-matched controls were associated with a statistically significant 6.8% absolute risk increase in persistent opioid use and a 5.4% increase in the subsequent diagnosis of opioid abuse.

Meaning  The findings suggest that dental opioid prescriptions, which may be driven by third molar extractions in this age group, may be associated with subsequent opioid use and opioid abuse.

Abstract

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.

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    1 Comment for this article
    EXPAND ALL
    Association of Opioid Prescriptions From Dental Clinicians for US Adolescents and Young Adults
    Thomas Dodson, DMD, MPH, FACS | University of Washington School of Dentistry
    The article by Schroeder et al1 measured an association between opioid exposure in a susceptible population (adolescents and young adults) and an increased risk for subsequent opioid abuse in a sample of dental patients. When compared to an opioid-naïve sample, 1) subjects receiving an opioid prescription were 69 times more likely to receive a second opioid prescription and 2) 14.5 times more likely to be diagnosed with an opioid abuse condition between 90 and 365 days after the initial prescription.
    Balancing postoperative pain control using opioids with the measurable risk for opioid abuse is challenging. Numerous randomized clinical trials (RCTs)
    report equivalent pain control after wisdom tooth operations between non-steroidal anti-inflammatory medications and opioids. Extrapolating findings from RCTs to the general population needs to be done cautiously. Because investigators design RCTs with homogeneous samples, it begs the question: “Are the subjects who enroll in a RCT similar to patients seen in community practice?”
    The investigators raised questions about the management of impacted wisdom teeth, this unnecessarily confounding their paper. They incompletely referenced a Cochrane study on the management of wisdom teeth, stating "... given the lack of evidence supporting the removal of asymptomatic third molars, there is also a need to focus on potentially unnecessary procedures." The full sentence is "Insufficient evidence is available to determine whether or not asymptomatic disease‐free impacted wisdom teeth should be removed."2
    The American Association of Oral and Maxillofacial Surgeons (AAOMS) is actively engaging its membership regarding the risks of opioid exposure and our role in limiting opioid exposure in this susceptible population.3 Oral and maxillofacial surgeons played a key role working with the Bree Collaborative in developing opioid prescribing guidelines for Washington state.4
    Oral and maxillofacial surgeons continue to address the issues of opioid use in our country by incorporating multi-modal aspects of pain control as noted by Schroeder et al1. It is also notable that while dentists may have a high incidence of initial opioid prescriptions, they are the least likely health professional to prescribe a subsequent one5, emphasizing that opioid reduction in this population needs to be a collaborative effort among all health care professionals.

    Thomas Dodson, DMD, MPH, FACS
    Stuart Lieblich, DMD
    A. Thomas Indresano, DMD, FACS

    References
    1. Schroeder AR, Dehgan M, Newman TB, Bentley JP, et al.: Association of opioid prescriptions from dental clinicians for US adolescents and young adults with subsequent opioid use and abuse. JAMA Intern Med. doi:10.1001/jamainternmed.2018.5419.
    2. Ghaeminia H, Perry J, Nienhuijs ME, et al: Surgical removal versus retention for the management of asymptomatic disease-free impacted wisdom teeth. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003879.pub4/epdf/full (last accessed December 16, 2018).
    3. Opioid prescribing: Acute and postoperative pain management. Amer Assoc Oral Maxillofac Surg white paper, 2017. (https://www.aaoms.org/docs/govt_affairs/advocacy_white_papers/opioid_prescribing.pdf (last accessed December 16, 2018)
    4. Dental Guideline on Prescribing Opioids for Acute Pain Management. The Bree Collaborative, September 2017 http://www.breecollaborative.org/wp-content/uploads/2017-10-26-FINAL-Dental-Opioid-Recommendations_Web.pdf (last accessed January 19, 2019)
    CONFLICT OF INTEREST: Associate Editor, Journal of Oral and Maxillofacial Surgery
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