Prescribing Patterns for Opioid Pain Relievers

While healthcare providers in the United States have decreased their opioid prescribing since its peak in 2012, physician-prescribed opioids are still higher in the US than in other countries around the world.⁴⁹ Further, opioid prescribing patterns vary widely among states and regions, with greater decreases in opioid prescribing associated with introduction of state laws that mandate prescriber training and use of the PDMP, among other factors.^63,64 The contributions of dental opioid prescriptions to this number is substantial. The number of opioid prescriptions per 1000 dental patients increased from 130.58 in 2010 to 147.44 in 2015.⁶ These prescriptions represented approximately 12% of all immediate-release opioid prescriptions.⁵ It has also been estimated that approximately two-thirds of opioid prescriptions written in dental offices were prescribed during/following surgical dental visits and approximately one-third during non-surgical visits, the majority of which were operative procedures.⁶ It should be noted that a marked decrease in opioid prescriptions has been noted in dental settings after 2016, when updated prescribing recommendations and guidelines were published by the American Dental Association and other entities.^65-67 This development is encouraging and indicates that education and processes can improve prescribing patterns and reduce high-risk prescribing. It has also been suggested that prompts within the electronic health records may further reduce high-risk prescribing by identifying patients with opioid misuse risk factors and automatically notifying prescribers if they write an opioid prescription.⁶⁸

Focus has been put over the last few years on identifying high-risk populations for future misuse after initial opioid prescriptions. It has been established that adolescents are particularly vulnerable to future risk of opioid misuse and these patients have a high risk to be exposed to opioids as a prescription after dental care.^14-16 It is estimated that 61% of 14- to 17-year-olds receive opioid prescriptions from dentists following extraction of third molars.¹⁶ This is particularly concerning given the body of literature that associates age of first exposure to opioids to an increased risk of nonmedical use, misuse, and substance abuse of opioids in patients.⁴ Among high school seniors, 36.9% of nonmedical users of prescription opioids used the drugs from their previous prescriptions and 27% of those prescriptions were written by dentists.^4,69 Non-medical use of opioids in adolescents and young adults parallels the prescribing rates for these medications, with male non-medical users having higher peer-to-peer diversion rates and rates of non-pain relief (recreational) use.⁴ Younger adults (18-25 years) have higher rates of opioid misuse (8.1%) than older adults (2.0%), despite more opioid prescriptions being written for older individuals.⁷⁰ Further, in adolescents predictors of prolonged opioid use after surgery and potential misuse included duration of opioid prescriptions, daily MME of opioid prescriptions, as well as indicators of socio-economic status.⁵ These factors may indicate that younger people are more vulnerable to opioid misuse and additional care should be given to opioid prescribing in that group.