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    6 Comments for this article
    Seeking to reduce opioid use
    Frederick Rivara, MD, MPH | University of Washington
    This article fits in nicely with other articles we have bene publishing on sources of opiates for patients and ways to reduce addiction. The comparison of dentists in the US to those in England is very informative-a 37 fold difference in opioid prescribing. All health professionals need to address prescribing of opioids to our patients.
    CONFLICT OF INTEREST: Editor in Chief, JAMA Network Open.
    Restrictions on dentists' prescribing practices?
    Kenneth Bateman, DDS | Retired
    "Thus, US dentists and medical professionals are able to prescribe the same medications, and there are no restrictions for dentist prescribing of a specific medication."

    This statement suggests that it is surprising that dentists and medical professionals can prescribe the same medications, and that there are no restrictions on dentist prescribing. Dentistry is a completely independent healing profession; it is not an "allied health profession" subject to the control of the medical profession. The only restriction on a dentist's prescribing practice is that it be within the dentist's scope of practice. Oral pain control is definitely
    within the dentist's scope of practice.

    "Similar to England, public health and professional organizations should provide oral pain guidelines, provide educational programming focused on the treatment of oral pain, and restrict the scope, strength, and duration of opioids that can be prescribed by dentists."

    By what authority could public health and professional organizations restrict the "scope, strength, and duration" of what a dentist prescribes? Such organizations can, and rightly should, provide education, guidelines, and suggestions, but they would hit a brick wall in trying to restrict what a dentist prescribes. The only entities that could feasibly restrict a dentist's prescribing practice would be the state boards of dentistry. There is no national-level entity that could exert control over a dentist's prescribing practices. Whatever controls the DEA institutes would have to be applied equally to physicians and dentists. Dentistry is not a significant participant in Medicare, so control of prescribing practices could not be done through reimbursement incentives.

    "Curtailing opioid prescribing will require a multifaceted approach by agencies and educational programs directed at dentists and their patients. This may also involve the introduction of national or specialty-specific guidelines and consideration of formularies that limit the scope of opioid prescribing by dentists."

    What national or specialty entity could mandate a formulary for dentists that was not equally applied to physicians? Even if there were such an entity, its mandatory formulary would have to apply to anyone who prescribed for oral pain, be it dentist or physician. But if that were to happen, why stop there? Why not require a formulary for orthopedic pain? One for abdominal pain? etc.

    I agree completely that dentists need to curtail their opioid prescribing and educate themselves on equally effective alternatives. However, attempted solutions to the opioid crisis that in any way suggest that dentistry be regulated differently from medicine will only create resistance that will distract from the real problem that needs to be fixed.
    Opioids in the UK are available over the counter!
    Richard Goldman, DDS, FAGD | VP-Clinical Product Development, Dental Manufacturing Company
    Your study comparing US and UK dental opioid prescriptions fails to account for a fundamental difference between the US and UK pharmaceutical market, leading to conclusions that may not be valid.

    In the US, all opioids are controlled substances that must be prescribed by a licensed professional with a valid Drug Enforcement Administration (DEA) number. This is the only way to legally obtain opioids.

    However, in the UK, mixtures of NSAID's (acetaminophen/paracetamol, aspirin, ibuprofen) and codeine are readily available at pharmacies over the counter, and have been for decades. (https://www.bupa.co.uk/health-information/muscles-bones-joints/over-the-counter-painkillers)

    Patients in mild to moderate pain
    often believe they don't need to visit the dentist to deal with their problem. Their first stop is the local chemist, where low-dose (8 mg) OTC Co-Cadamol, an opioid pain killer, is readily available. This may be all they need to control their discomfort. If, however, their pain persists, I suspect that most patients probably just take more, rather than visiting the dentist.

    In addition, several UK internet pharmacies are advertising stronger opioid combinations of codeine or dihydrocodeine that are available simply by utilizing the services of online pharmacists and medical professionals. After only a cursory online "history" and "examination", opioids of up to 30 mg per tablet are easily obtained without the need for a face-to-face encounter. The patient pays the online retailer directly, outside of the watchful eye of the National Health Service, and outside of your statistical sample. (https://www.ukmeds.co.uk/chronic-conditions/pain-relief)

    How many English patients avail themselves of opioids directly, bypassing prescribers entirely? We have no way of knowing, as you failed to address this question. However, the answer is critical to validating your premise that "opioid prescribing by US dentists is excessive and could be contributing to the opioid epidemic".

    Before defaming American dentists, perhaps you should have more thoroughly studied the differences between the two markets being compared. They are NOT the same.
    Author Response to Availability of OTC Codeine in the UK - Part 1
    KJ Suda, PharmD, MS | University of Illinois at Chicago
    Thank you for your comment.

    I was made aware of the OTC availability of codeine-containing products in the UK post-publication. However, please note that our purpose was to describe prescribing of opioid prescriptions, not OTCs. We also did not include anti-tussives with codeine (an OTC codeine) available in the US. We did indicate that the datasets did not include OTC products as a limitation in the discussion section of the paper.

    A few details to note:
    • The UK OTC codeine containing products are lower strength/potency (max of 12.8 mg) than prescription codeine in both countries
    • These medications
    are “pharmacist only” medications. This means that pharmacists review appropriate use and will (and do) recommend alternative agents. A survey from 2014 (before our study period) indicates that UK pharmacists are limiting, some eliminating, stocking of OTC codeine products. This is similar to how OTC anti-tussives with codeine are handled in the US (kept behind the pharmacy counter, patients are screened by a pharmacist and some pharmacies have implemented policies to dispense).
    • There is a limitation of the OTC codeine quantity dispensed in the UK. Our understanding is that this is up to 3 tablets.
    • The US still consumes the vast majority of the worldwide opioid supply despite the availability of codeine OTC in the UK (and other countries, including Canada and Australia).

    The British dentist author strongly believes that dentists would not routinely recommend patients to obtain OTC opioids. His response is that if dentists perceive that a patient requires an opioid, British dentists would prescribe dihydrocodeine and not refer patients to the pharmacy to pick up the low strength OTC codeine. This is also not attractive to UK patients because they have to pay out of pocket for the OTC codeine (vs their medication copay for a dihydrocodeine through the NHS).

    In both datasets, we are unable to control if patients obtain analgesia outside of dental care. For both countries, this could be from an OTC medication purchase, legal (or illegal) purchase of prescription medications over the internet, or care from a medical provider. This is especially true for US persons where oral pain is a frequent presenting symptom in ED and urgent care settings. ED/urgent care treatment is less likely to occur in the UK because dental is part of the public benefit through the NHS. Urgent care dental clinics are also more prevalent in the UK (vs only at academic dental clinics in the US). Therefore, opioid prescribing in the US for oral pain is much larger than our results indicate.
    Response to Availability of OTC Codeine - Part 2
    KJ Suda, PharmD, M.S. | University of Illinois at Chicago
    You are likely interested in a comparison of non-codeine opioid prescribing by country. For non-codeine opioids, the magnitude of difference is even greater. This is because UK dentists did not prescribe non-codeine products and in the US 77% of opioids prescribed by US dentists were for non-codeine containing products. Importantly, 72% of all opioids prescribed by US dentists were for agents considered to be of higher potency vs codeine. This result combined with 1 in 10 opioids prescribed by US dentists being for agents at high potential misuse and diversion (oxycodone, long-acting agents) is still shocking.

    There are many
    reasons for the difference observed in our results which are described in the discussion section of our paper. Of note, the national UK guidelines mentioned in the paper are taught throughout the dental school curricula and are continuously referred to within British dentistry. Please note that there are also differences in marketing of prescription medications between the two countries (generally allowed in the US, generally not allowed in the UK).

    This paper is not the first to suggest excessive prescribing of opioids by dentists. The Pubmed links below will take you to papers published in the dental literature describing increasing prescribing rates, prescribing for nonsurgical visits (especially restorative CDTs), and other measures of unsafe opioid prescribing (high dose, repeat opioid Rx and overlapping opioid Rx). Unsafe prescribing measures were highest in adolescents, a high risk group for opioid misuse. Two of these papers were authored by ADA personnel.

    Thank you for your interest in our paper,

    Author Response - Opioid interventions customized to dentistry
    KJ Suda, PharmD, M.S. | University of Illinois at Chicago
    Thank you for your comment.

    Beside the English model, we are only aware of two published interventions focused on opioid prescribing by dentists. These interventions include mandatory query of the state prescription drug monitoring program (PDMP) and audit and feedback delivered from a pharmacist embedded in a dental practice. There are a few other pilot projects ongoing. However, we are open to your suggestions of other implementation strategies that may be effective for dentists.

    Thank you for your interest in our paper,
    Original Investigation
    Health Policy
    May 24, 2019

    Comparison of Opioid Prescribing by Dentists in the United States and England

    Author Affiliations
    • 1Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr Veterans Administration Hospital, Chicago, Illinois
    • 2College of Pharmacy, University of Illinois at Chicago
    • 3School of Medicine, Washington University in St Louis, St Louis, Missouri
    • 4Center for Health Equity Research and Promotion, Pittsburgh Veterans Administration Healthcare System, Pittsburgh, Pennsylvania
    • 5School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
    • 6Center for Clinical and Translational Science, University of Illinois at Chicago
    • 7Department of Oral Medicine, Carolinas Medical Center, Charlotte, North Carolina
    • 8College of Dentistry, University of Illinois at Chicago
    • 9School of Clinical Dentistry, University of Sheffield, Sheffield, United Kingdom
    JAMA Netw Open. 2019;2(5):e194303. doi:10.1001/jamanetworkopen.2019.4303
    Key Points español 中文 (chinese)

    Question  How do opioid prescribing patterns differ between dentists in the United States and dentists in England?

    Findings  In this cross-sectional study of opioid prescribing by dentists in 2016, the proportion of dental prescriptions that were opioids was 37 times greater in the United States than in England.

    Meaning  In light of similar oral health and dentist use between the 2 countries, it is likely that opioid prescribing by US dentists is excessive and could be reduced.


    Importance  The United States consumes most of the opioids worldwide despite representing a small portion of the world’s population. Dentists are one of the most frequent US prescribers of opioids despite data suggesting that nonopioid analgesics are similarly effective for oral pain. While oral health and dentist use are generally similar between the United States and England, it is unclear how opioid prescribing by dentists varies between the 2 countries.

    Objective  To compare opioid prescribing by dentists in the United States and England.

    Design, Setting, and Participants  Cross-sectional study of prescriptions for opioids dispensed from outpatient pharmacies and health care settings between January 1 and December 31, 2016, by dentists in the United States and England. Data were analyzed from October 2018 to January 2019.

    Exposures  Opioids prescribed by dentists.

    Main Outcomes and Measures  Proportion and prescribing rates of opioid prescriptions.

    Results  In 2016, the proportion of prescriptions written by US dentists that were for opioids was 37 times greater than the proportion written by English dentists. In all, 22.3% of US dental prescriptions were opioids (11.4 million prescriptions) compared with 0.6% of English dental prescriptions (28 082 prescriptions) (difference, 21.7%; 95% CI, 13.8%-32.1%; P < .001). Dentists in the United States also had a higher number of opioid prescriptions per 1000 population (35.4 per 1000 US population [95% CI, 25.2-48.7 per 1000 population] vs 0.5 per 1000 England population [95% CI, 0.03-3.7 per 1000 population]) and number of opioid prescriptions per dentist (58.2 prescriptions per dentist [95% CI, 44.9-75.0 prescriptions per dentist] vs 1.2 prescriptions per dentist [95% CI, 0.2-5.6 prescriptions per dentist]). While the codeine derivative dihydrocodeine was the sole opioid prescribed by English dentists, US dentists prescribed a range of opioids containing hydrocodone (62.3%), codeine (23.2%), oxycodone (9.1%), and tramadol (4.8%). Dentists in the United States also prescribed long-acting opioids (0.06% of opioids prescribed by US dentists [6425 prescriptions]). Long-acting opioids were not prescribed by English dentists.

    Conclusions and Relevance  This study found that in 2016, dentists in the United States prescribed opioids with significantly greater frequency than their English counterparts. Opioids with a high potential for abuse, such as oxycodone, were frequently prescribed by US dentists but not prescribed in England. These results illustrate how 1 source of opioids differs substantially in the United States vs England. To reduce dental opioid prescribing in the United States, dentists could adopt measures similar to those used in England, including national guidelines for treating dental pain that emphasize prescribing opioids conservatively.