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Comment & Response
May 20, 2019

Dangers of Opioid Prescribing for Young Adults After Dental Procedures—Reply

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
  • 3Department of Epidemiology and Biostatistics, University of California, San Francisco
  • 4Department of Pediatrics, University of California, San Francisco
  • 5Division of Gastroenterology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
  • 6Genentech, South San Francisco, California
JAMA Intern Med. 2019;179(7):998. doi:10.1001/jamainternmed.2019.0213

In Reply We thank Hersh and colleagues for their comments regarding our recent investigation on dental opioid use in adolescents and young adults,1 and also for their multiple contributions in this area. We agree that most of the dental opioid prescriptions documented in our study were likely to come from oral surgeons who possess either doctor of dental medicine or doctor of dental surgery degrees and perform the vast majority of third molar extractions, the procedure most likely to be driving the high frequency of opioid prescriptions. We opted to include general surgeon–oral/maxillofacial specialists as a health care provider category (composing 2.4% of first prescribers of opioids) to capture all health care provider types that might be performing dental procedures, but we acknowledge that oral surgeons generally fall into the doctor of dental medicine/doctor of dental surgery category.

We also agree that third molar extractions are painful procedures and that nonsteroidal anti-inflammatory drugs and acetaminophen should be used as first-line therapy, as suggested recently in the overview of systematic reviews published by Moore and colleagues.2 However, given the high likelihood of subsequent use, abuse, and diversion, especially in this vulnerable age range, we disagree that 20 opioid pills should be prescribed routinely to all patients under the premise that a small proportion of patients might wind up needing them. Although the inability to predict the need for postoperative opioids certainly poses some challenges, creative solutions that emphasize judicious opioid prescribing are needed, as is heightened scrutiny of the need for the extractions that are driving the opioids in the first place.

Finally, we noticed a methodologic error relating to our unexposed cohort. Because this cohort, by definition, could not have received a subsequent opioid prescription from a dental clinician in 2015, an immortal time bias was introduced, which deflates the apparent risk of subsequent use in this cohort. A revised estimate of new persistent use in the unexposed cohort of 0.111% is not meaningfully different than the original estimate of 0.1%, and the absolute risk difference between the exposed and unexposed cohorts remains 6.8%. We have requested a correction of the published article to add discussion of this bias to the Limitations section.3

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Article Information

Corresponding Author: Alan R. Schroeder, MD, Division of Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine, 300 Pasteur Dr, MC 5776, Stanford, CA 94305 (aschroe@stanford.edu).

Published Online: May 20, 2019. doi:10.1001/jamainternmed.2019.0213

Conflict of Interest Disclosures: None reported.

References
1.
Schroeder  AR, Dehghan  M, Newman  TB, Bentley  JP, Park  KT.  Association of opioid prescriptions from dental clinicians for US adolescents and young adults with subsequent opioid use and abuse.  JAMA Intern Med. 2019;179(2):145-152. doi:10.1001/jamainternmed.2018.5419PubMedGoogle ScholarCrossref
2.
Moore  PA, Ziegler  KM, Lipman  RD, Aminoshariae  A, Carrasco-Labra  A, Mariotti  A.  Benefits and harms associated with analgesic medications used in the management of acute dental pain: An overview of systematic reviews.  J Am Dent Assoc. 2018;149(4):256-265.e3. doi:10.1016/j.adaj.2018.02.012PubMedGoogle ScholarCrossref
3.
 Data reporting error  [published online May 20, 2019].  JAMA Intern Med. doi:10.1001/jamainternmed.2019.1547Google Scholar
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