Persistent Opioid Use Associated With Dental Opioid Prescriptions Among Publicly and Privately Insured US Patients, 2014 to 2018 | Addiction Medicine | JAMA Network Open | JAMA Network
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Figure.  Sample Inclusion and Exclusion Criteria for Study Patients
Sample Inclusion and Exclusion Criteria for Study Patients

Patients with claims containing Current Dental Terminology codes corresponding to one of 120 dental procedures between July 1, 2014, and December 31, 2017, were included. Procedures were either invasive (eg, tooth extraction, endodontic therapy) or emergent (eg, palliative emergency treatment of dental pain). Noninvasive procedures for which opioid prescribing is extremely rare, such as tooth restorations, were not included. The study excluded patients who had surgical procedures (as defined by anesthesia-related Current Procedural Terminology codes) or additional dental procedures during the 365 days after the index date (ie, another claim with a Current Dental Terminology code corresponding to one of the 120 procedures). These groups were excluded to maximize the probability that cases of persistent opioid use were associated with initial prescriptions for the index dental procedure rather than opioid prescriptions for other procedures. Patients with subsequent emergency department visits were not excluded because many such visits are for conditions that would not result in opioid prescribing, such as asthma exacerbations. Patients who had other dental procedures during the period spanning between the 180 days prior to the index date to the 1 day prior to the index date were excluded. This exclusion affected only a small number of patients with index dates in 2014.

Table.  Risk of Persistent Opioid Use Associated With Initial Prescriptions for Dental Proceduresa
Risk of Persistent Opioid Use Associated With Initial Prescriptions for Dental Proceduresa
1.
Brummett  CM, Waljee  JF, Goesling  J,  et al.  New persistent opioid use after minor and major surgical procedures in US adults.   JAMA Surg. 2017;152(6):e170504. doi:10.1001/jamasurg.2017.0504 PubMedGoogle Scholar
2.
Harbaugh  CM, Nalliah  RP, Hu  HM, Englesbe  MJ, Waljee  JF, Brummett  CM.  Persistent opioid use after wisdom tooth extraction.   JAMA. 2018;320(5):504-506. doi:10.1001/jama.2018.9023 PubMedGoogle ScholarCrossref
3.
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.2018.5419 PubMedGoogle ScholarCrossref
4.
Suda  KJ, Durkin  MJ, Calip  GS,  et al.  Comparison of opioid prescribing by dentists in the United States and England.   JAMA Netw Open. 2019;2(5):e194303. doi:10.1001/jamanetworkopen.2019.4303 PubMedGoogle Scholar
5.
Suda  KJ, Zhou  J, Rowan  SA,  et al.  Overprescribing of opioids to adults by dentists in the U.S., 2011-2015.   Am J Prev Med. 2020;58(4):473-486. doi:10.1016/j.amepre.2019.11.006 PubMedGoogle ScholarCrossref
6.
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.e253. doi:10.1016/j.adaj.2018.02.012
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    1 Comment for this article
    EXPAND ALL
    Working Definition of Persistent Opioid Use (POU)
    Thomas Dodson, DMD, MPH, FACS | University of Washington School of Dentistry, Department of Oral and Maxillofacial Surgery
    The opioid epidemic and limiting the prescribing of opioids is and has been a topic for discussion, research, and action among oral and maxillofacial surgeons.

    I have concerns that the working definition of POU in this publication results in a biased overestimate of POU risk.

    Most patients do well with a single initial prescription of opioids for postoperative pain control. Some patients do require a second prescription within 7-10 days after the initial prescription. About 3% of our patients return for follow-up examinations due to inadequate pain control after removal of impacted wisdom teeth.

    Additionally, there
    are many legitimate reasons for receiving an opioid prescription more than 3 months after a dental procedure.

    It would be interesting to see the results if the definition of POU was revised to one or more dispensed opioid prescriptions 14-90 days after the index date and 2 or more prescriptions 91-365 days after the index date. The revised definition may help to adjust for legitimate opioid prescriptions.

    Thank you for your research efforts in helping providers limit the overprescribing of opioids.
    CONFLICT OF INTEREST: Consultant, Associate Editor of JOMS, American Association of Oral and Maxillofacial Surgeons
    READ MORE
    Research Letter
    Substance Use and Addiction
    April 16, 2021

    Persistent Opioid Use Associated With Dental Opioid Prescriptions Among Publicly and Privately Insured US Patients, 2014 to 2018

    Author Affiliations
    • 1Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor
    • 2Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
    • 3Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan
    • 4Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
    • 5University of Michigan School of Dentistry, Ann Arbor
    • 6Division of Pain Medicine, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
    JAMA Netw Open. 2021;4(4):e216464. doi:10.1001/jamanetworkopen.2021.6464
    Introduction

    Persistent opioid use (POU) occurs when patients who receive opioid prescriptions after procedures continue to use opioids after acute pain typically resolves.1-3 In dentistry, the risk of POU has been assessed among privately insured patients.2,3 Whether the risk of POU differs among publicly insured patients is unknown. The goal of this study was to compare the risk of POU among privately and publicly insured dental patients aged 13 to 64 years in the United States.

    Methods

    This retrospective cohort study used data from the 2014-2018 IBM MarketScan Dental, Commercial, and Multi-State Medicaid research databases. The Dental database contains dental claims from 1 million to 1.5 million nonelderly patients with employer-sponsored dental insurance; most claims can be linked to medical and pharmacy claims in the Commercial database. The Multi-State Medicaid database includes dental, medical, and pharmacy claims from 10 million to 12 million patients in several unidentified states. Because the data were deidentified, the University of Michigan Institutional Review Board deemed this study exempt from institutional review board review and patient informed consent. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

    Patients aged 13 through 64 years who had dental procedures between July 1, 2014, and December 31, 2017, were included in the study. Analyses were limited to each patient’s earliest procedure, the date of which was the index date. We excluded the following groups of patients: those lacking continuous enrollment during the 180 days before through 365 days after the index date, those who were not opioid naive, those who had dental procedures before the index date, and those who had subsequent surgical or dental procedures.

    The exposure variable was set to 1 if there were 1 or more dispensed opioid prescriptions between 7 days before and 3 days after the index date (initial prescription).2 Persistent opioid use was defined as 1 or more dispensed opioid prescriptions 4 to 90 days after the index date and 1 or more prescriptions 91 to 365 days after the index date.2 Using logistic regression, we modeled the occurrence of POU as a function of the exposure, payer type, and their interaction. Models controlled for demographic and clinical characteristics. We calculated the average marginal effect (AME) of the exposure—the change in risk of POU if all patients did and did not have initial prescriptions—overall and by payer type. SAS version 9.4 (SAS Institute Inc) and Stata 14.2 MP (StataCorp) were used for statistical analysis. Two-sided hypothesis tests were conducted with α = .05.

    Results

    A total of 1 691 878 patients were included in the study sample (Figure). Among these patients, 934 883 (55.3%) were female, 756 995 (44.7%) were male, and the mean (SD) age was 34.7 (16.3) years (Table). Among these patients, 38.5% were aged 13 to 25 years, and 37.0% were publicly insured; almost a third of patients (31.3%) had 1 or more initial prescriptions. The risk of POU was 1.3% overall and 2.1% vs 1.0% among those with and without 1 or more initial prescriptions (AME, 1.5 percentage points; 95% CI, 1.5-1.6 percentage points). Among publicly insured patients, the risk of POU was 2.0% overall and 3.2% vs 1.3% among those with vs without 1 or more initial prescriptions (AME, 2.3 percentage points; 95% CI, 2.1-2.4 percentage points). Among privately insured patients, the risk of POU was 0.9% overall and 2.0% vs 0.6% among those with vs without 1 or more initial prescriptions (AME, 1.3 percentage points; 95% CI, 1.2-1.3 percentage points). The AME of 1 or more initial prescriptions was 1.0 percentage point higher in publicly insured patients (95% CI, 0.9-1.1 percentage points).

    Discussion

    Dental opioid prescriptions were associated with a 1.0–percentage point higher risk of POU among publicly insured patients compared with privately insured patients. This difference translates to a substantial excess number of POU cases, as US dentists accounted for 11.4 million opioid prescriptions in 2016.4 One potential explanation is that publicly insured patients may have higher rates of undiagnosed substance use disorders, a risk factor for POU.1 Because of access barriers, including the lack of adult Medicaid dental benefits in some states, patients may be prescribed opioids instead of receiving definitive dental care.

    Our study has some limitations, including the lack of patient location information in Medicaid claims. Dental opioid prescribing rates vary regionally.5 Estimates would be confounded if the risk of POU similarly varies regionally, although we are unaware of data supporting this possibility.

    Our findings suggest that studies of the privately insured underestimate the risk of POU associated with dental opioid prescribing.2,3 The results further highlight the importance of avoiding dental opioid prescribing when nonopioids provide effective analgesia, which is the case for most dental procedures.6 More broadly, prior studies of POU have largely excluded publicly insured patients.1-3 If the findings of this study are generalizable to other procedures, the risks of perioperative dental opioid prescribing may be greater than previously appreciated.

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    Article Information

    Accepted for Publication: February 23, 2021.

    Published: April 16, 2021. doi:10.1001/jamanetworkopen.2021.6464

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Chua K-P et al. JAMA Network Open.

    Corresponding Author: Kao-Ping Chua, MD, PhD, Department of Pediatrics, University of Michigan, 300 N Ingalls St, SPC 5456, Room 6E18, Ann Arbor, MI 48109-5456 (chuak@med.umich.edu).

    Author Contributions: Dr Chua had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Chua, Waljee, Brummett.

    Acquisition, analysis, or interpretation of data: Chua, Hu, Nalliah, Brummett.

    Drafting of the manuscript: Chua, Waljee.

    Critical revision of the manuscript for important intellectual content: Hu, Nalliah, Brummett.

    Statistical analysis: Chua, Hu.

    Administrative, technical, or material support: Waljee, Nalliah.

    Supervision: Brummett.

    Conflict of Interest Disclosures: Dr Nalliah reported receiving grants from the Michigan Department of Health and Human Services during the conduct of the study. Dr Brummett reported receiving grants from the State of Michigan, Benter Foundation, SAMHSA State Opioid Response, the Opioid Harm Reduction and Treatment Quality in Acute Care project, and the University of Michigan Precision Health Initiative, Opioid Use Case. He also reported receiving personal fees as a consultant for Heron Therapeutics, Vertex Pharmaceuticals, and Alosa Health. He has received fees for providing expert testimony. No other disclosures were reported.

    Funding/Support: This work was funded by grant 2020-02 from the Benter Foundation. Further support was provided by grant 19-PAF06837 from SAMSHA and a grant from the University of Michigan Precision Health research initiative. Dr Chua’s work was supported by a career development award 1K08DA048110-01 from the National Institute on Drug Abuse.

    Role of the Funder/Sponsor: The funding sources played no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication.

    References
    1.
    Brummett  CM, Waljee  JF, Goesling  J,  et al.  New persistent opioid use after minor and major surgical procedures in US adults.   JAMA Surg. 2017;152(6):e170504. doi:10.1001/jamasurg.2017.0504 PubMedGoogle Scholar
    2.
    Harbaugh  CM, Nalliah  RP, Hu  HM, Englesbe  MJ, Waljee  JF, Brummett  CM.  Persistent opioid use after wisdom tooth extraction.   JAMA. 2018;320(5):504-506. doi:10.1001/jama.2018.9023 PubMedGoogle ScholarCrossref
    3.
    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.2018.5419 PubMedGoogle ScholarCrossref
    4.
    Suda  KJ, Durkin  MJ, Calip  GS,  et al.  Comparison of opioid prescribing by dentists in the United States and England.   JAMA Netw Open. 2019;2(5):e194303. doi:10.1001/jamanetworkopen.2019.4303 PubMedGoogle Scholar
    5.
    Suda  KJ, Zhou  J, Rowan  SA,  et al.  Overprescribing of opioids to adults by dentists in the U.S., 2011-2015.   Am J Prev Med. 2020;58(4):473-486. doi:10.1016/j.amepre.2019.11.006 PubMedGoogle ScholarCrossref
    6.
    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.e253. doi:10.1016/j.adaj.2018.02.012
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