December 03, 2018
Teens and young adults who are prescribed opioids by dental clinicians are at increased risk for persistent use and for abuse in the subsequent year, a retrospective cohort study suggests.
Investigators used claims data from 2015 to identify 14,888 privately insured 16- to 25-year-olds who obtained their first opioid prescription from a dentist or oral surgeon, likely mainly to manage pain after extraction of third molars (wisdom teeth). The investigators then matched this group by sex and age with 29,776 youths who had not filled an opioid prescription.
Study results, published online December 3 in JAMA Internal Medicine, showed that the opioid-exposed group had an adjusted absolute 6.8% higher risk of receiving another opioid prescription 90 to 365 days later and an adjusted absolute 5.3% higher risk of having a healthcare encounter with an opioid abuse–related diagnosis within the year.
"The findings suggest that dental opioid prescriptions, which may be driven by third molar extractions in this age group, may be associated with subsequent opioid use and opioid abuse," conclude Alan R. Schroeder, MD, a clinical professor of pediatrics in the Division of Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine, California, and colleagues.
"This work raises two really important related but separate questions: Do we need opioids, and do we need the procedure?" Schroeder said in a press release.
"One proposed solution to limit opioid exposure following dental procedures has been to use nonopioid alternatives such as nonsteroidal anti-inflammatory medications or long-acting local anesthesia," the investigators note. "Another solution is to limit the quantity of opioids dispensed," to minimize the prescribing of extra pills, which may go unused or be given to others. (The youths studied were given a median of 20 pills.)
The authors also suggest that the medical community reconsider whether extraction of wisdom teeth is necessary. They note that a recent Cochrane review concluded that it is not clear whether the practice of removing disease-free, asymptomatic wisdom teeth benefits patients.
To obtain a likely opioid-naive population of patients undergoing elective outpatient procedures for their study, Schroeder and colleagues excluded patients who had been hospitalized in the week before receiving prescribed dental opioids, as well as patients who had received other opioid prescriptions or who had been diagnosed with opioid abuse in the past year.
Of all youths in the cohort who received at least one opioid prescription during 2015, 30.6% were given the prescription by a dental clinician. Of these, 84.6% received their prescription from a doctor of medicine in dentistry or a doctor of dental surgery, 13.0% from a general dentist, and 2.4% from a general surgeon–oral/maxillofacial specialist.
Overall, 6.9% of those in the dental-opioid-prescribed group received another opioid prescription 90 to 365 days later, compared with just 0.1% of the control patients (P < .001).
Among those who received a second opioid prescription, 27.0% received it from a dental clinician. The remainder obtained it from either a nonspecified provider (18.0%), an emergency medicine physician (17.7%), an orthopedic surgeon (9.2%), a physician assistant (7.8%), an otolaryngologist (7.3%), a family practitioner (6.7%), an obstetrician/gynecologist (4.6%), a general surgeon (3.4%), or a general internist (3.2%).
In addition, 5.8% of the opioid-exposed youth had at least one subsequent healthcare encounter (office visit, emergency department visit, or hospitalization) with an opioid abuse–related diagnosis code, compared with just 0.4% of those in the control group (P < .001).
"Almost 7 percent of these patients had new, persistent use at least three months after the initial prescription and almost 6 percent had an opioid abuse diagnosis," Schroeder said. "That's pretty alarming."
Multivariate odds of both persistent opioid use and abuse were higher for female patients and those who had abused nonopioid substances. They were lower for 22- to 25-year-olds compared with 16- to 18-year-olds and for Asian patients relative to white patients.
The patients who received opioids did not differ significantly with respect to all-cause mortality in the year after receiving the prescription compared to the patients who were not prescribed opioids. A single death occurred in each group.
The authors have disclosed no relevant financial relationships.