U.S. dentists prescribe 37 times more opioid than in England

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Researchers from the University of Illinois at Chicago have found that dentists practicing in the U.S. write 37 times more opioid prescriptions than dentists practicing in England.

And, the type of opioids they prescribe has a higher potential for abuse.

Their findings, which are reported in JAMA Network Open, suggest that measures to reduce opioid prescribing by dentists, who are among the top prescribers of opioids in the U.S., should be discussed by policymakers and professional associations.

The study was, in part, a collaboration between UIC’s Colleges of Pharmacy and Dentistry, and the University of Sheffield.

UIC’s Katie Suda, the corresponding author of the study, says that the degree to which prescribing patterns differ between dentists in the two countries, which have similar oral health and dental utilization, is eye-opening.

“To see such a difference between two groups of dentists in countries with similar oral health and use of dentists is an indicator that opioid prescribing practices in the U.S. warrant a second look,” said Suda, associate professor of pharmacy systems, outcomes and policy at the UIC College of Pharmacy.

“This study tells us that efforts to adopt national guidelines for treating dental pain and for promoting conservative opioid prescribing practices among dentists in the U.S. should be a priority and should be included as part of more comprehensive judicious opioid prescribing strategies.”

To study dental provider opioid prescribing practices in the two countries, Suda and her colleagues analyzed nationally-representative databases from both countries of prescriptions dispensed from retail pharmacies, including community and mail service pharmacies, and outpatient clinic pharmacies in 2016, which is considered to be a peak point in the U.S. opioid crisis.

They found U.S. dentists wrote 37 times more opioid prescriptions in 2016 – 1.4 million in the U.S. compared to only 28,000 in England.


The impact of the opioid epidemic has been felt in communities in all 50 U.S. states. Curbing the epidemic’s exponential trajectory requires special attention from dental educators.

Academic dental institutions are using a variety of methods to mitigate substance misuse, including curriculum and clinical protocol changes.

Dental educators are key to teaching best practices in prescribing to the next generation of practicing dentists. This policy brief highlights strategies that demonstrate academic dentistry’s contributions to combating the opioid epidemic. 

CONTEXT OF THE PROBLEM


The opioid epidemic is a major public health concern.

In 2016, more than 42,000 deaths were attributed to substance overdose related to opioids.1 

More than 11.5 million Americans misused prescription pain relievers, such as hydrocodone, oxycodone, heroin, and fentanyl,2 and opioid overdose-related death continue to soar (Figure 1). On Oct. 26, 2017, President Trump declared the opioid epidemic a national public health emergency under federal law.

According to the President’s Council of Economic Advisers, the opioid epidemic has resulted in an economic burden of $504 billion, or 2.8% of the U.S. gross domestic product.3 

The  President’s Commission on Combating Drug Addiction and the Opioid Crisis 4 outlined a comprehensive set of recommendation that will help dental educators, clinicians, addiction treatment providers, researchers and other allied community members combat opioid abuse.

While these recommendations are important, the increase in opioid misuse stemming from dental settings has also prompted dentists and dental educators to take a stand against this epidemic.

Dentists have been identified as among the leading prescribers of opioids.5 Used to alleviate pain, dental practitioners have commonly prescribed opioids after tooth extractions or surgical procedures.

In particular, the removal of third molars, most routinely performed during the teen years, has received significant focus since dentists were reported to be the highest prescribers of opioids for this vulnerable age group.6,7

 In 2009, dentists wrote 12% of the opioid prescriptions in the United States, and family physicians accounted for 15% of opioid prescriptions.8 

Similar patterns were observed in South Carolina (Figure 2), where dentists are among the most frequent opioid prescribers.

To address this trend, dental schools have reassessed and updated pain management curricula and clinical protocols to further ensure their graduates are competent and safe prescribers.

Changes include using alternative methods for pain management, such as nonsteroidal anti-inflammatory drugs (NSAIDs), and recognizing the symptoms of addiction and substance misuse problems.

For example, the University of Minnesota School of Dentistry established a mandatory protocol to teach dental students to prescribe NSAIDs as the first-line pain treatment for dental procedures.9 

Dental schools play a pivotal role in shaping the future of dental practice and preparing faculty and dental students to effectively address pain management and respond to the opioid public health emergency. 

CURRENT SETTING AND RATIONALE FOR POLICY


In 2015, Massachusetts Governor Charles D. Baker and his Working Group on Dental Education on Prescription Drug Misuse challenged the three dental schools in the Commonwealth to develop an evidence-based curriculum with a set of core competencies to prepare and train the next generation of practicing dentists in three realms:10

  1. Primary prevention domain: Preventing opioid prescription misuse, screening at-risk patients and performing evaluative measures to assess a patient’s pain to determine pharmacological and nonpharmacological treatment.
  2. Secondary prevention domain: Identifying patients at risk for substance abuse and systematically referring them to evidence-based pain management centers, and developing treatment plans for people with acute and chronic pain.
  3. Tertiary prevention domain: Managing substance use disorders as a chronic disease.

As the first of their kind, the Massachusetts crossinstitutional core competencies can serve as a model for other academic dental institutions that are revising their curricula. The Commission on Dental Accreditation (CODA) amended its Standard 2-23e (now Standard 2-24e) for Dental Education Programs 11 during winter 2017 to emphasize dental students’ competency in local anesthesia, pain and anxiety control in the prescription practices on substance use disorders. CODA’s initiative ensures that dental schools enforce these newly established accrediting standards to promote education on opioid abuse and dependence. 

Figure 1:

March 2018 Opioid Policy Brief Figure 1
CDC logo

Source: CDC/NCHS, National Vital Statistics System, Mortality. CDC WONDER, Atlanta, GA: US Department of Health and Human Services, CDC; 2016. https://wonder.cdc.gov/.


In addition to the competencies, dental schools are collaborating with community and grassroots organizations; other health professions schools; and local, state and federal governments to develop and implement interventions and propose state-level policies to limit opioid prescription by supply and length of the prescription.

5 For instance, the American Dental Association’s (ADA) Statement on the Use of Opioids in the Treatment of Dental Pain and the Centers for Disease Control and Prevention’s Guideline for Prescribing Opioids for Chronic Pain encourage practicing dentists and other clinicians to obtain continuing education that promotes safe prescription practices and ensures that patients with substance use disorders limit their opioid intake.6

Moreover, dental students are being taught to use electronic health records and prescription drug monitoring programs (PDMPs) to assess and treat patients at risk for substance misuse. PDMPs are state-level electronic databases that provide health authorities with real-time data on behavior and prescription patterns for patients who are vulnerable to substance abuse.

Although each state regulates its own PDMP (except for Missouri), a number of dental schools across the country have integrated training on PDMPs into their curricula and clinics to improve opioid prescribing.

For example, dental students are taught during their pharmacology courses and clinical rotations to assess and consider the patient’s history by using PDMPs in patient evaluations.

However, despite the value of the PDMPs, there is no standardization across the 50 states, which presents a challenge for health authorities to monitor patients who may shop for opioids across state lines.

Curtailing the opioid epidemic requires a multifaceted and collective approach.

On Aug. 30, 2017, ADEA and the Substance Abuse and Mental Health Services Administration (SAMHSA) co-hosted the Dental Schools Addiction Education Summit on the Opioid Epidemic  to discuss opioid epidemic trends and share strategies for preventing prescription drug misuse and addiction.

Seventeen dental schools and stakeholders from 11 states and the District of Columbia, alongside agencies such as the Health Resources and Service Administration, Uniformed Services University of the Health Sciences, ADA, and the Association of American Medical Colleges, identified opportunities to improve addiction awareness in academic dental institutions. Examples include:

  • Collaborate with other or neighboring dental schools in the state to generate plans/modules to enhance students’ educational training about opioid prescription and addiction.
  • Form an opioid task force as a subgroup of the school’s curriculum committee charged with revising dental school pedagogy on substance abuse.
  • Establish baseline information concerning prescription patterns, including all dental and advanced dental education programs, with an emphasis on pain and anxiety control.
  • Create toolkits for prescribing dentists that include patient education materials on opioid addiction. 

This finding remained even when the researchers adjusted for differences in population size and number of dentists.

They also found that U.S. dentists prescribed a much wider range of opioids, where dentists in England only prescribed one – a codeine derivative called dihydrocodeine, which is the only opioid included in the formulary used by their National Health Service.

In the U.S., the most commonly prescribed opioids were hydrocodone-based, followed by codeine, oxycodone and tramadol.

One in ten opioids prescribed by U.S. dentists were opioids with a high potential for abuse and diversion, such as oxycodone and long-acting opioids. Dentists in England did not prescribe these opioids.

“Dentists need to be part of the opioid conversation,” said co-author Dr. Susan Rowan, executive associate dean and associate dean for clinical affairs at the UIC College of Dentistry.

“It is common for people to overlook dental issues until pain becomes severe and major interventions are needed.

Pain killers are often an essential part of dental care and provider flexibility in choice is important, but this study shows us there is room for dental care providers to contribute to and inform abuse reduction programs.

“This data should be a wakeup call to individual dental practices and collaborative organizations of dental care providers to push the envelope towards greater efforts to reduce opioid prescribing or patients’ potential for abuse,” Rowan said.

“I was shocked to discover the high level of opioid prescribing of my U.S. dental colleagues.

Particularly, when there is good evidence that NSAIDs and acetaminophen are as good or better than opioids for treating dental pain and don’t cause the unpleasant side-effects, addiction and misuse problems associated with opioids,” said co-author Dr. Martin Thornhill, professor of translational research in dentistry at the University of Sheffield.

“UK dentists manage exactly the same pain problems as their U.S. colleagues and achieve high levels of patient satisfaction using NSAIDs and acetaminophen, without the need to resort to opioids.”

More information:JAMA Network Open (2019). DOI: 10.1001/jamanetworkopen.2019.4303

Journal information: JAMA Network Open
Provided by University of Illinois at Chicago

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