Survey of opioid prescribing among dentists indicates need for more effective education regarding pain management

Heron, Matthew J.; Nwokorie, Nkechi A.; O'Connor, Bonnie Blair; Brown, Ronald S.; Fugh‐Berman, Adriane

doi:10.1016/j.adaj.2021.07.018

Cited by 12 publications

(19 citation statements)

References 22 publications

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“…The major barriers reported were that both dentists and dental students expressed reservations related to medication knowledge, ability to identify patients with substance use disorders and confidence in discussing substance use disorders with patients [36]. Thus, the challenge remains to find optimal methodologies for improving dental professionals' knowledge, self-efficacy, and clinical behavior for the management of dental pain and for disseminating evidence-based best practices [37]. Our findings confirmed results of other Project ECHO studies on pain management.…”

Section: Discussionsupporting

confidence: 76%

Launching an innovative educational model addressing substance use disorders and dental pain management (Project ECHO® in dentistry)

et al. 2022

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Background: Uninformed opioid prescribing by dentists has contributed to the current opioid crisis. This report describes the development and implementation of an innovative, interactive, multidisciplinary, and participant-centric telementoring program "Pain Management and Substance Use Disorders Dental ECHO (Extension for Community Health Care Outcomes)". We disseminated information to dentists about appropriate opioid prescribing practices and engaged them with a focus on pain management and substance use disorders. The objective of this study was to assess the effectiveness of this program for self-reported: (1) change in knowledge and confidence related to clinical skills for dental pain management of patients with substance use disorders; (2) change in clinical behavior of dentists for safe opioids prescribing; and (3) change in clinic policies regarding safe opioids prescribing.Methods: An interdisciplinary panel of experts in medicine, pharmacy, social work, and dentistry designed and led the "Pain Management and Substance Use Disorders Dental ECHO" for invited dental care providers and dental students. Six cohorts each consisting of six, 1-h-long sessions were conducted via the Zoom videoconference platform in years 2020 and 2021. Each session included a didactic expert presentation, a participant-presented patient case and discussion. Each participant completed pre-and post-program surveys to assess the program's influence on participant knowledge, clinical confidence and behavior change. Results:The participants (N = 151) were dentists (n = 109), dental faculty (n = 15), dental residents (n = 6), dental hygienists/assistants (n = 13) and nurses and clinic administrators (n = 8). Self-reported perceived medication knowledge, confidence in identification, treatment and willingness to engage with substance use disorders patients, and reported compliance with Prescription Drug Monitoring Program (PDMP) checks increased significantly from before to after the sessions (p < 0.001). Overall, participants expressed high levels of satisfaction with the content and reported that the sessions provided high benefit. Conclusion:The Project ECHO model is effective in rapidly disseminating evidence-based information. Dentists viewed this model as having a high degree of benefit for the optimal management of dental pain and the recognition and treatment of substance use disorders.

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Section: Discussionsupporting

confidence: 76%

Launching an innovative educational model addressing substance use disorders and dental pain management (Project ECHO® in dentistry)

et al. 2022

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“…The reliance on opioid analgesics for dental pain in the US is more likely a cultural phenomenon than a medical necessity. The superiority of non-opioid analgesics such as APAP/ibuprofen combinations to opioids for dental pain has been common knowledge for many years 17,18,22 , yet dentists continue to rely on opioids in North America 10,20,21 . In countries where dentists have limited access to opioid drugs, very few opioids were prescribed for dental pain 40,41 .…”

Section: Discussionmentioning

confidence: 99%

“…Prescriptions for pain management after surgical tooth extractions illustrate the current problem: opioid prescription decreased only moderately from 90% in 2011 to about 70% in 2020 in dental clinics affiliated to US dental schools 7,15 , though considerable evidence demonstrates that non-opioid analgesics, such as NSAIDs or a combination of NSAIDs such as ibuprofen with acetaminophen (N-acetyl-para-aminophenol, or APAP), are superior to opioids for dental pain after dental extractions, including third molar surgeries [16][17][18] . Possible explanations include: 1) immediate-release opioids continue to be the drugs of choice in patients who cannot tolerate NSAIDs or APAP due to direct side effects or indirect effects from interaction with other medications 19 , 2) cases in which NSAIDs are ineffective, 3) dental prescribers are not convinced that short-term opioid prescription may result in opioid dependency 20 , and 4) ingrained prescription habit 21 .…”

Section: Introductionmentioning

confidence: 99%

Pain management after dental extractions – non-opioid combination analgesics minimize opioid use for acute dental pain

Huang

Rasubala

Gracely

et al. 2022

Preprint

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ObjectiveTo evaluate long-term changes in pain management strategies and assess the outcomes of opioids and non-opioid combination analgesics after dental extractions.MethodsThis is a cross-sectional study of patients who received dental extractions and analgesic prescriptions in a large dental urgent care center in two 12-month periods: January 2012 to December 2012 (Year-2012) and March 2021 to February 2022 (Year-2022). Data extracted from electronic records include type of dental extractions, analgesics prescribed, and follow-up visits. The primary outcome was failure rate measured by the proportions of patients who returned to the clinic for management of pain after receiving dental extractions and analgesic prescriptions.ResultsA total of 3,357 patients in Year-2012 and 3,785 patients in Year-2022 received analgesic prescriptions in conjunction with dental extractions. Combination analgesics were significantly higher in Year-2022 (62.5%) than in Year-2012 (34.9%) (RR=1.79, 95% CI 1.70-1.89. p<0.0001). Combinations analgesics were almost exclusively opioids and 1,166 patients, or 34.7%, received opioids in Year-2012, compared to none received opioids, 49.4% received ibuprofen/ acetaminophen and 13.1% received gabapentin combinations in Year-2022. After surgical extractions, a majority were prescribed opioids (52.4%), followed by ibuprofen (46.2%) in Year-2012. In contrast, a majority received ibuprofen/acetaminophen (56.2%) or gabapentin combinations (17.3%) in Year-2022. Ibuprofen/acetaminophen had a failure rate (2.2%) lower than gabapentin combinations (4.4%) (RR=0.50, 95%CI 0.31-0.83. p=0.01), or opioid combinations (21.4%) (RR=0.10, 95%CI 0.08-0.14. p<0.0001). Failure rate for gabapentin combinations was lower than opioids (RR=0.21, 95%CI 0.14-0.31. p<0.0001).Conclusions and RelevanceThis study showed a paradigm shift from opioids and single medication analgesics to non-opioids and combination analgesics with ibuprofen, acetaminophen and gabapentin as components in prescribing for pain after dental extractions, which presents an opportunity to minimize or eliminate our reliance on opioids for dental pain.

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“…As in other specialties, prescribing in dentistry has been declining over time 45 ; however, rates remain high. 46 , 47 Miller et al 46 found that 74.9% of analgesic prescriptions written between 2013 and 2018 were for opioids; in an American national survey of dentists, 47 50% of those reporting prescribing opioids were doing so in amounts exceeding what was required, and 69% reported having had patients who had diverted or used their opioids non‐medically. These numbers are alarming and can have significant consequences for the safety of patients and the community.…”

Section: Discussionmentioning

confidence: 99%

“…As in other specialties, prescribing in dentistry has been declining over time 45 ; however, rates remain high. 46,47 and disposal, and daily dispensing and/or delayed prescriptions. [48][49][50] These guidelines provide a practical and safe approach that could also be applied in other settings, such as in the ED.…”

Section: Discussionmentioning

confidence: 99%

Quantifying unused opioids following emergency and ambulatory care: A systematic review and meta‐analysis

et al. 2022

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Objective To quantify unused opioids among adult and pediatric patients discharged from the emergency department (ED) or ambulatory care settings with a prescription for acute pain. Methods We searched MEDLINE, Embase, CINHAL, PsycINFO, the Cochrane Library, and the gray literature from inception to April 29, 2021. We included observational studies in which any patient with an acutely painful condition received a prescription for an opioid on discharge from an outpatient care setting, and unused opioids were quantified. Two reviewers screened records for eligibility, extracted data, and conducted the quality assessment. Where possible, we pooled data and otherwise described the results of studies narratively. Total unused prescriptions were synthesized using a weighted average. Random effects models were used, and heterogeneity was measured by the I 2 statistic. Our primary outcome was the quantity of unused opioid medication available after receiving a prescription for acute pain. Secondary outcomes were the proportion of patients with unused opioids following a prescription, the proportion of patients using no opioids, morphine equivalents of unused opioids, and factors associated with leftover opioids. Results In this systematic review and meta‐analysis of 9 studies in emergency and ambulatory care settings, 59.6% of prescribed opioids remained unused; pediatric patients had 69.3% of their prescriptions remaining, compared to 54.6% among adult patients. The highest proportion of unused opioids was found following dental extractions (82.6%). Conclusions and Relevance More than 50% of opioids remain unused following prescriptions for acute pain. Responsible prescribing must be accompanied by education on safer use, storage, and disposal.

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Survey of opioid prescribing among dentists indicates need for more effective education regarding pain management

Cited by 12 publications

References 22 publications

Launching an innovative educational model addressing substance use disorders and dental pain management (Project ECHO® in dentistry)

Launching an innovative educational model addressing substance use disorders and dental pain management (Project ECHO® in dentistry)

Pain management after dental extractions – non-opioid combination analgesics minimize opioid use for acute dental pain

Quantifying unused opioids following emergency and ambulatory care: A systematic review and meta‐analysis

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