May 19, 2016
Among the leading prescribers of opioids for pain relief, a new study has found that dentists’ prescriptions for opioids after tooth extractions are often for too long and for too many pills.
“The reason a lot of people go to the dentist is because they have pain or they undergo a procedure that causes some pain, for which the dentists are responding,” said study co-author Brian Bateman, MD, associate professor of anesthesia at Harvard Medical School, in Boston. “But I believe we have gotten away from thinking about opioids as dangerous medications. Dentists may not be as conservative as they need to be with respect to using these medications, and reserving them only for patients with truly severe pain for which other treatment approaches are not adequate.”
The study found that the median amount of opioids prescribed corresponds to 24 tablets of 5 mg of hydrocodone, “so half of the patients are getting more than that,” Dr. Bateman said. The study also found that 61% of adolescents filled a prescription for opioids.
“For patients taking four tablets a day, that is about a one-week supply, which I think for most cases is too long,” he said. A better option might be a few pills to get through the first day, according to Dr. Bateman, after which patients could be transitioned to nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen.
Opioid prescriptions were filled by 42% of patients within seven days after surgical tooth extraction.
The study also noted that the two most commonly dispensed opioids were hydrocodone (75%) and oxycodone (15.4%), based on Medicaid database cases from 2000 to 2010, representing a total of 2,757,273 patients (JAMA 2016 Apr. 19 [Epub ahead of print]).
Dr. Bateman noted that for cases when opioids are deemed appropriate, they should be prescribed at the lowest dose possible and for the shortest duration.
“Certainly when medications are prescribed in excess of what patients actually need, it creates leftover pills, which we know is a major source for opioids that are misused or diverted,” he said. Therefore, dentists as well as physicians “need to reevaluate the indications for prescribing opioids.”
Roger Fillingim, PhD, a professor in the College of Dentistry at the University of Florida, in Gainesville, is not surprised by any of the study results. “It is fairly well known that dentists are among the more prolific prescribers of opioids because of the many acute procedures they perform that result in some level of post-procedure pain,” he said.
All prescribers should tailor their prescriptions to the patient’s needs, according to Dr. Fillingim, former president of the American Pain Society. “However, what is relatively new is the increased awareness of the societal consequences of opioids beyond an individual patient that may occur if opioids are prescribed unnecessarily or in larger amounts than needed.”
Dr. Fillingim advocates that dentists become aware of the latest evidence on what medications are available and known to effectively treat the pain caused by a particular procedure. “Dentists should prescribe the least potentially harmful medication possible,” he said. “As the study authors cite, there are findings to show that opioids are not necessarily the best medication for the vast majority of dental extraction and other dental surgical procedures.”
Dr. Fillingim pointed out that some studies appear to support that the NSAID ibuprofen alone provides fairly similar efficacy to ibuprofen combined with an opioid medication. “You want to prescribe the best thing for that particular patient at that particular time that will have the least side effects for the patient, and ultimately the least side effects for society,” he said.
A study of surveyed dentists about opioid prescribing practices and risk mitigation strategy that appeared in the January-March 2016 edition of Substance Abuse found, among respondents, that only 44% reported regularly screening for current prescription drug abuse and only 5.8% requested patient medical records. Furthermore, only 38% of dentists had ever accessed a prescription drug monitoring program and only 4.7% consistently used one (Substance Abuse 2016;37:9-14).
“These findings highlight some areas where we could potentially improve prescribing practices for dentists,” said Dr. Fillingim, who co-authored the Substance Abuse article. “Many providers are not receiving ideal education and training.”