Opioid Prescriptions From Dental Clinicians for Young Adults and Subsequent Opioid Use and Abuse

A very interesting article titled “Association of Opioid Prescriptions From Dental Clinicians for US Adolescents and Young Adults With Subsequent Opioid Use and Abuse” written by Schroeder et al. was published online on December 3, 2018, in JAMA Internal Medicine. The article sought out to examine the association between dental opioid prescriptions from dental clinicians for adolescents and young adults and new persistent use and subsequent diagnoses of abuse.

The article states that dentists are the leading source of opioid prescriptions
for children and adolescents from age 10 to 19 and in 2009 prescribed 31% of total opioids given to this age group. A common source of dental opioid exposure is of course wisdom teeth extractions. The article states that the authors were at least partially motivated to perform their study over the controversy surrounding whether or not one should extract or retain healthy wisdom teeth in their younger years. For their research the authors used the Optum Research Database which provides claims information for a large amount of privately insured patients in the United States and contains inpatient, outpatient, and pharmaceutical claims data from millions of privately insured patients per year that has been de-identified. The claims are sourced from Optums sister company UnitedHealth Group.

opioid abuse - Opioid Prescriptions From Dental Clinicians for Young Adults and Subsequent Opioid Use and Abuse
This image is from Ajay Suresh on Flickr and has a Creative Commons License

The researchers included data in their study if patients were born between 1990 to
1999, corresponding to an approximate age range of 16 to 25 years in 2015. Dental categories included doctor of medicine in dentistry, doctor of dental surgery, general dentist, general dentist–doctor of medicine in dentistry, general dentist–doctor of dental surgery, or general surgeon–oral/maxillofacial specialist. The patients included from the data into what the authors called the index dental opioid cohort had the following three characteristics: (1) received an outpatient opioid prescription from a dental clinician in 2015 and (2) had evidence of insurance coverage in the Optum database for a minimum of 12 months preceding the opioid prescription without any evidence of opioid prescriptions, opioid abuse, or a chronic condition and (3) had evidence of continued coverage in Optum for at least 12 months following the prescription. The researchers also excluded patients who were hospitalized up to 7 days before receiving the index dental opioid prescription to attempt to limit the dataset to patients who underwent elective outpatient procedures. The researchers also created a opioid-nonexposed control cohort.

The authors measured three outcomes:  (1) at least 1 additional filled opioid prescription at 90 to 365 days after the initial prescription, (2) at least 1 subsequent health care encounter with a diagnosis code associated with opioid abuse within 365 days, (3) and death within 365 days. After accounting for the exlusions of the dataset as described above 14,888 individuals were included in the index dental opioid cohort (7,882 women with mean age 21.8 years), and 29,776
randomly selected individuals were included in the opioid nonexposed control cohort (15,764 women with mean age 21.8 years). Opioid use at 90 to 365 days occurred among 1,021 of the 14,888 individuals (6.9%) in the index dental opioid cohort compared with 30 of 29,776 individuals (0.1%) in the opioid-nonexposed cohort. The second opioid prescription was provided by a dental clinician for 276 of the 1,021 (27.0%) patients. A median of 20 pills were dispensed for the second opioid prescription. At least 1 subsequent health care encounter with a diagnosis code associated with opioid abuse within 365 days was documented for 866 patients (5.8%) in the opioid exposed cohort and 115 (0.4%) in the opioid nonexposed cohort. By peforming multivariable analysis the researchers noted that female patients were more likely to have persistent use and abuse. At 12 months follow up 1 death was reported in each cohort.

The authors state

“…the results showed that exposure to opioids through a dental clinician in a population of opioid-naive patients was associated with higher rates of opioid use at 90 to 365 days later and subsequent diagnoses associated with opioid abuse or over dose compared with controls. The results also showed that a substantial proportion of overall opioid exposure in this age group came from dental clinicians, findings that warrant close attention…”

The authors do note that they were unable to discern whether repeated opioid
prescriptions were provided for new, painful medical conditions. The researchers believe that most of the opioid prescriptions that were given to those included in their index dental opioid cohort were a result of wisdom teeth extractions although there was no way to verify this information from the Optum database.

The authors state

“If third molar extractions are the primary source of exposure to opioids, given that the potential risks and complications of the procedure extend beyond the potential for opioid use and abuse and given the lack of evidence supporting removal of asymptomatic third molars, there is also a need to focus on potentially unnecessary procedures. More studies are needed to understand when benefits are likely to exceed risks and costs.”

The authors feel their study suggest that many young patients who have never been exposed to opioids and then receive an opioid prescription from a dental clinician may be at risk for persistent opioid use and abuse. They feel heightened scrutiny regarding wisdom teeth removal and opioid prescriptions associated with the surgery is needed.