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Teoh L, Park JS, Moses G, McCullough M, Page A. To prescribe or not to prescribe? A review of the Prescribing Competencies Framework for dentistry. J Dent 2023; 137:104654. [PMID: 37574106 DOI: 10.1016/j.jdent.2023.104654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 08/15/2023] Open
Abstract
OBJECTIVES Dentists in Australia are the second largest prescriber group, and are generally not formally taught how to prescribe. The objective of this review is to describe the Prescribing Competencies Framework and its relevance to dentistry. DATA The four-model stage of prescribing by Coombes and colleagues, and the seven competencies within the Prescribing Competencies Framework devised by the Australian National Prescribing Service MedicineWise, are discussed and applied to dentistry. SOURCES AND STUDY SELECTION Each of the seven competencies are analysed and detailed in the context of clinical dental practice. Competencies 1-5 describe the skillset and tasks required by dentists to safely prescribe, whereas Competencies 6 and 7 describe the clinical environment and recommended resources to support dentists to prescribe safely and effectively. CONCLUSIONS The Prescribing Competencies Framework provides an overview of safe and effective prescribing. Prescribing is a process, and a separate skillset to clinical dentistry. The process involves information gathering, clinical assessment, effective communication and review of the patient. Access to timely and appropriate resources and relevant electronic sources of health information for clinicians are important to provide the support required for better informed prescribing decisions. The framework describes a patient-centered prescribing process, and ultimately prescribing should be a shared decision between the dentist and the patient. CLINICAL SIGNIFICANCE Safe and effective prescribing is an integral part of dentistry and dentists are the second largest prescriber group. However, dentists display high rates of inappropriate and unnecessary prescribing, and to minimise errors, the Prescribing Competencies Framework has been established. This article details how the Framework applies to clinical practice dentistry.
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Affiliation(s)
- Leanne Teoh
- Melbourne Dental School, The University of Melbourne, Carlton, Victoria, Australia.
| | - Joon Soo Park
- UWA Dental School, The University of Western Australia, Nedlands, Western Australia, Australia
| | - Geraldine Moses
- School of Pharmacy, The University of Queensland, Woolloongabba, Queensland, Australia
| | - Michael McCullough
- Melbourne Dental School, The University of Melbourne, Carlton, Victoria, Australia
| | - Amy Page
- School of Allied Health, University of Western Australia, Western Australia, Australia
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Bavarian R, Sandhu S, Handa S, Shaefer J, Kulich RA, Keith DA. Centers for Disease Control and Prevention Clinical Practice Guideline for Prescribing Opioids: United States, 2022: What dentists need to know. J Am Dent Assoc 2023; 154:849-855. [PMID: 37097279 DOI: 10.1016/j.adaj.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 01/13/2023] [Accepted: 01/31/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND The Centers for Disease Control and Prevention (CDC) published the Clinical Practice Guideline for Prescribing Opioids for Pain-United States, 2022 (CDCCPG) to replace the 2016 guideline. This guideline was designed to serve as a clinical tool to improve communication between clinicians and patients and empower them to make informed, person-centered decisions regarding pain management and the prescribing of opioids. It is intended for primary care and other clinicians, including dentists, who provide pain management for adults with acute, subacute, and chronic pain. TYPES OF STUDIES REVIEWED This article summarizes the CDCCPG, with an emphasis on information of relevance to dentistry. RESULTS For dentists, the most important recommendations for pain management are that nonsteroidal anti-inflammatory medications are first-line medications for acute dental pain, interdisciplinary care for chronic orofacial pain is indicated, and opioids should only be prescribed for acute dental pain for a maximum of 3 days after risk assessment. PRACTICAL IMPLICATIONS The CDCCPG contains a great deal of relevant information that can help dentists and dental specialists make safe, effective, and evidence-based decisions in providing pain control for their patients.
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Myers AL, Jeske AH. Provider-directed analgesia for dental pain. Expert Rev Clin Pharmacol 2023; 16:435-451. [PMID: 37083548 DOI: 10.1080/17512433.2023.2206118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
INTRODUCTION Extraction of impacted molar teeth is a common procedure performed by oral surgeons and general dentists, with postoperative pain being a significant adverse event post-surgery. If mismanaged, pain can lead to complications that impact oral and systemic health. The current scourge of the opioid epidemic has ushered in a new era of provider-directed analgesic (PDA) therapy in dentistry. AREAS COVERED This article provides an in-depth review on the major pharmacological and therapeutic properties of established and alternative analgesics used to manage dental pain. EXPERT OPINION Substantial evidence-based literature shows combination of a non-steroidal anti-inflammatory drug (NSAID; e.g. ibuprofen) and acetaminophen provides superior pain relief than single-agent or combination opioid regimens. However, there are clinical scenarios (e.g. severe pain) when short-course opioid prescription is appropriate in select patients, in which a 2-3-day treatment duration is typically sufficient. Alternative agents (e.g. caffeine, gabapentin, phytotherapies), typically in combination with established agents, can mitigate postoperative dental pain. Some evidence suggests preemptive therapies (e.g. corticosteroids, NSAIDs) reduce amounts of postsurgical analgesic consumption and might lessen opioid prescription burden. In summary, this comprehensive review provides an opportune update on the evolving landscape of pharmacotherapy for acute postsurgical dental pain, informing best practices for PDA in the dental setting.
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Affiliation(s)
- Alan L Myers
- Department of Diagnostic & Biomedical Sciences, School of Dentistry, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Arthur H Jeske
- Office of the Dean, School of Dentistry, The University of Texas Health Science Center at Houston, Houston, TX, USA
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Are there differences in opioid prescriptions to urban and rural patients by oral-maxillofacial surgeons in Massachusetts from 2011-2021? J Oral Maxillofac Surg 2023:S0278-2391(23)00300-2. [PMID: 37004839 DOI: 10.1016/j.joms.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/08/2023] [Accepted: 03/09/2023] [Indexed: 03/17/2023]
Abstract
PURPOSE Oral-maxillofacial surgeons (OMSs) are frequent prescribers of opioid analgesics. It remains unclear if prescription patterns differ for urban versus rural patients, given potential differences in access to and delivery of care. This study aimed to characterize urban-rural differences in opioid analgesic prescriptions to patients in Massachusetts by OMSs from 2011 to 2021. METHODS This retrospective cohort study used the Massachusetts Prescription Monitoring Program database to identify Schedule II and III opioid prescriptions by providers with specialty of "oral and maxillofacial surgery" from 2011 to 2021. The primary predictor variable was patient geography (urban/rural) and secondary predictor was year (2011-2021). The primary outcome variable was milligram morphine equivalent (MME) per prescription. Secondary outcome variables were days' supply per prescription and number of prescriptions received per patient. Descriptive and linear regression statistics were performed to analyze differences in prescriptions to urban and rural patients each year and throughout the study period. RESULTS The study data, which includes OMS opioid prescriptions (n = 1,057,412) in Massachusetts from 2011 to 2021, ranged annually between 63,678 and 116,000 prescriptions to between 58,000 and 100,000 unique patients. The cohorts each year ranged between 48 and 56% female with mean ages between 37 and 44 years. There were no differences in the mean number of patients per provider in urban and rural populations in any year. The study sample had a large majority of urban patients (>98%). MME per prescription, days' supply per prescription, and prescriptions received per patient were all generally similar between urban and rural patients each year, with the largest MME per prescription difference in 2019 (87.3 for rural to 73.9 for urban patients, P < .01). From 2011 to 2021, all patients had a steady decrease in MME per prescription (β = -6.64, 95% confidence interval: -6.81, -6.48; R2 = 0.39) and day's supply per prescription (β = -0.1, 95% confidence interval: -0.1, -0.09; R2 = 0.37). CONCLUSION In Massachusetts, there were similar opioid prescribing patterns by OMSs to urban and rural patients from 2011 to 2021. There has also been a steady decrease in the duration and total dosage of opioid prescriptions to all patients. These results are consistent with multiple statewide policies over the last several years aimed at curbing opioid overprescribing.
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Dyson MP, Dong K, Sevcik W, Graham SZ, Saba S, Hartling L, Ali S. Quantifying unused opioids following emergency and ambulatory care: A systematic review and meta-analysis. J Am Coll Emerg Physicians Open 2022; 3:e12822. [PMID: 36203538 PMCID: PMC9523453 DOI: 10.1002/emp2.12822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/24/2022] [Accepted: 08/31/2022] [Indexed: 11/08/2022] Open
Abstract
Objective To quantify unused opioids among adult and pediatric patients discharged from the emergency department (ED) or ambulatory care settings with a prescription for acute pain. Methods We searched MEDLINE, Embase, CINHAL, PsycINFO, the Cochrane Library, and the gray literature from inception to April 29, 2021. We included observational studies in which any patient with an acutely painful condition received a prescription for an opioid on discharge from an outpatient care setting, and unused opioids were quantified. Two reviewers screened records for eligibility, extracted data, and conducted the quality assessment. Where possible, we pooled data and otherwise described the results of studies narratively. Total unused prescriptions were synthesized using a weighted average. Random effects models were used, and heterogeneity was measured by the I2 statistic. Our primary outcome was the quantity of unused opioid medication available after receiving a prescription for acute pain. Secondary outcomes were the proportion of patients with unused opioids following a prescription, the proportion of patients using no opioids, morphine equivalents of unused opioids, and factors associated with leftover opioids. Results In this systematic review and meta-analysis of 9 studies in emergency and ambulatory care settings, 59.6% of prescribed opioids remained unused; pediatric patients had 69.3% of their prescriptions remaining, compared to 54.6% among adult patients. The highest proportion of unused opioids was found following dental extractions (82.6%). Conclusions and Relevance More than 50% of opioids remain unused following prescriptions for acute pain. Responsible prescribing must be accompanied by education on safer use, storage, and disposal.
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Affiliation(s)
- Michele P. Dyson
- Department of PediatricsUniversity of AlbertaEdmontonAlbertaCanada
| | - Kathryn Dong
- Department of Emergency MedicineUniversity of AlbertaEdmontonAlbertaCanada
- Inner City Health and Wellness ProgramRoyal Alexandra HospitalEdmontonAlbertaCanada
| | - William Sevcik
- Department of PediatricsUniversity of AlbertaEdmontonAlbertaCanada
- Department of Emergency MedicineUniversity of AlbertaEdmontonAlbertaCanada
| | - Samir Z. Graham
- Department of PediatricsUniversity of AlbertaEdmontonAlbertaCanada
| | - Sabrina Saba
- Department of PediatricsUniversity of AlbertaEdmontonAlbertaCanada
| | - Lisa Hartling
- Department of PediatricsUniversity of AlbertaEdmontonAlbertaCanada
| | - Samina Ali
- Department of PediatricsUniversity of AlbertaEdmontonAlbertaCanada
- Department of Emergency MedicineUniversity of AlbertaEdmontonAlbertaCanada
- Women and Children's Health Research InstituteUniversity of AlbertaEdmontonAlbertaCanada
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de Carvalho MF, de Matos Silveira G, de Carvalho PAR, Leite ICG, da Graça Naclério-Homem M. Analgesia and Side Effects of Codeine Phosphate Associated with Paracetamol Versus Oxycodone After the Extraction of Mandibular Third Molars: A Randomized Double-Blind Clinical Trial Using the Split-Mouth Model. J Maxillofac Oral Surg 2022; 21:1038-1043. [PMID: 36274876 PMCID: PMC9474989 DOI: 10.1007/s12663-022-01717-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 04/03/2022] [Indexed: 10/18/2022] Open
Abstract
Purpose To assess the analgesia and side effects of 10 mg oxycodone as compared to 30 mg of codeine phosphate associated with 500 mg of paracetamol after bilateral lower third molar extraction. Methods This is a prospective, randomized, double-blind study applied to a sample of 16 patients. They were evaluated for seven days postoperatively, and the mean score of the visual analogue scale (VAS) of pain between test and control medications was assessed by the Wilcoxon distribution. The side effects of these medications were assessed by the Q Cochran test. A p value of < .05 was considered statistically significant. Results The mean score of the VAS of pain was higher in the oxycodone side, where few patients reported the use of rescue analgesic. There was no report of rescue medication in codeine phosphate associated with paracetamol side. The most common side effects reported in both groups, predominantly in patients using the oxycodone, were drowsiness, dizziness, and headache. Conclusion The use of codeine phosphate associated with paracetamol after the extraction of impacted mandibular third molars is a better choice than oxycodone for controlling postoperative pain. Trial Registration Number and Date of Registration RBR-8ntwmyq 07/07/2021.
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Affiliation(s)
- Matheus Furtado de Carvalho
- Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Federal University of Juiz de Fora, Rua José Lourenço Kelmer, s/n, São Pedro, Juiz de Fora, MG CEP: 36036-900 Brazil
| | - Gabriela de Matos Silveira
- Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Federal University of Juiz de Fora, Rua José Lourenço Kelmer, s/n, São Pedro, Juiz de Fora, MG CEP: 36036-900 Brazil
| | - Paula Afonso Rodrigues de Carvalho
- Faculty of Medicine, Department of Public Health, Federal University of Juiz de Fora, Rua José Lourenço Kelmer, s/n, São Pedro, Juiz de Fora, MG CEP: 36036-900 Brazil
| | - Isabel Cristina Gonçalves Leite
- Faculty of Medicine, Department of Public Health, Federal University of Juiz de Fora, Rua José Lourenço Kelmer, s/n, São Pedro, Juiz de Fora, MG CEP: 36036-900 Brazil
| | - Maria da Graça Naclério-Homem
- Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Traumatology and Prosthesis, University of São Paulo, São Paulo, Brazil
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Teoh L, McCullough M, Taing MW. Efficacy of oxycodone for postoperative dental pain: A systematic review and meta-analysis. J Dent 2022; 125:104254. [PMID: 35977697 DOI: 10.1016/j.jdent.2022.104254] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 07/25/2022] [Accepted: 08/13/2022] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Dental pain is a commonly managed presentation in medicine and dentistry, where oxycodone is often prescribed. The aim of this systematic review and meta-analysis was to determine and quantify the effectiveness of oxycodone for acute dental pain. DATA Randomised controlled trials, controlled trials and comparative studies were included involving patients >12 years, where oxycodone was trialled for dental pain. SOURCES Three databases were searched: Medline Ovid, Embase Ovid and Web of Science. Two authors independently screened title and abstracts for relevance, extracted data and performed bias assessments. STUDY SELECTION Of 148 potentially relevant studies, 13 articles met the inclusion criteria for the systematic review and of the 13, nine studies were included in the meta-analysis. All studies were single-dose analgesia for surgical third molar extractions. CONCLUSIONS Oxycodone produced more effective analgesia in combination with paracetamol. In the meta-analysis, monotherapy etoricoxib and rofecoxib showed significant pain relief compared to combination oxycodone/paracetamol (SPID6 mean difference=-2.13, CI=-3.29, -0.98; TOTPAR6 mean difference=-2.98, CI=-4.90, -1.06). Non-steroidal anti-inflammatory drugs (NSAIDs) were more effective than oxycodone/paracetamol combinations, however, the evidence would become weak in a future study with a similar patient setting due to substantial statistical heterogeneity (SPID6 and TOTPAR6 prediction interval -4.471, 0.207 and -7.28, 1.32 respectively). CLINICAL SIGNIFICANCE Non-steroidal anti-inflammatory drugs were superior than oxycodone/paracetamol combinations, although some patient populations may experience similar effects to the combined oxycodone/paracetamol combination.
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Affiliation(s)
- Leanne Teoh
- Melbourne Dental School, The University of Melbourne, Carlton, Victoria, Australia.
| | - Michael McCullough
- Melbourne Dental School, The University of Melbourne, Carlton, Victoria, Australia
| | - Meng-Wong Taing
- School of Pharmacy, The University of Queensland, Woolloongabba, Queensland, Australia
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Oyler DR, Rojas-Ramirez MV, Nakamura A, Quesinberry D, Bernard P, Surratt H, Miller CS. Factors influencing opioid prescribing after tooth extraction. J Am Dent Assoc 2022; 153:868-877. [PMID: 35691709 DOI: 10.1016/j.adaj.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 05/01/2022] [Accepted: 05/04/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Tooth extractions account for most opioid prescriptions from dentists, but specific characteristics that influence likelihood are less established. Improving understanding can facilitate development of tailored interventions to reduce unnecessary opioid prescribing. METHODS The authors performed a retrospective review of patients 12 years and older undergoing tooth extraction at the College of Dentistry at the University of Kentucky from 2013 through 2020. The primary end point was issuance of an opioid prescription related to the encounter. RESULTS In 44,387 eligible records analyzed, 10,628 (23.9%) patients received an opioid prescription. Results of multivariable logistic regression found that the factors associated with an opioid prescription included receipt of a nonopioid analgesic prescription (adjusted odds ratio [aOR], 11.36; 95% CI, 10.37 to 12.44), receipt of an antibiotic prescription (aOR, 8.29; 95% CI, 7.57 to 9.08), procedural sedation (aOR, 2.11; 95% CI, 1.93 to 2.31), surgical extraction (aOR, 1.96; 95% CI, 1.84 to 2.10), and third molar extractions (1 tooth: aOR, 1.14; 95% CI 1.04 to 1.25; 2 teeth: aOR, 2.09; 95% CI, 2.87 to 2.34; 3 teeth: aOR, 2.73; 95% CI, 2.36 to 3.15; 4 teeth: aOR, 3.45; 95% CI, 3.10 to 3.83). Factors that decreased risk included having an appointment in 2018 or later (aOR, 0.31; 95% CI, 0.29 to 0.33), in a student (aOR, 0.57; 95% CI, 0.51 to 0.65) or resident (aOR, 0.33; 95% CI, 0.31 to 0.36) clinic, and on any day other than Friday (Monday: aOR, 0.83; 95% CI, 0.76 to 0.91; Tuesday: aOR, 0.90; 95% CI, 0.83 to 0.99; Wednesday: aOR, 0.89; 95% CI, 0.81 to 0.97; Thursday: aOR, 0.88; 95% CI 0.81 to 0.97). CONCLUSIONS Opioid prescriptions after tooth extraction were common in patients undergoing more extensive procedures. Provider perceptions, habits, and several clinical factors appeared to influence prescribing patterns. PRACTICAL IMPLICATIONS The decision to prescribe an opioid appears to be associated with habits and factors perceived to modulate postoperative pain, which may serve as targets for opioid reduction strategies.
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Tang C, Buckley J, Burcal R. Opioid Prescription Reduction after Dentoalveolar Surgery-A Success Story in the Recruit Training Environment. Mil Med 2022; 187:261-263. [PMID: 35446946 DOI: 10.1093/milmed/usac103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/15/2022] [Accepted: 03/31/2022] [Indexed: 11/15/2022] Open
Abstract
Given the public health toll exacted by the Opioid Crisis, it is important for providers in all disciplines to examine their opioid prescribing patterns to see where opioid reduction strategies can be effectively employed. Limiting the impact of the Opioid Crisis on active duty service members is a critical component of maintaining a ready fighting force. One avenue for reducing the potential for opioid diversion and abuse is developing and implementing non-opioid postsurgical pain management strategies that both provide adequate pain relief and also ensure an expedient return to full duty. Dentoalveolar surgeries performed by oral and maxillofacial surgeons to maintain operational dental readiness are a good example of common procedures necessitating post-procedural pain medications and convalescent days impacting availability for full duty. The providers at US Navy Recruit Training Command's oral surgery clinic undertook a process improvement initiative to reduce opioid prescriptions after dentoalveolar surgery. This change was accompanied by a concerted education effort aimed at both providers and patients on the benefits of avoiding opioids as well as the importance of strict adherence to a standardized medication dosing regimen for efficacious non-opioid pain control consisting of maximum doses of ibuprofen and acetaminophen taken every six hours. No increase in convalescent time off and no increase in postoperative visits related to pain control were noted. In our experience, eliminating routine post-procedure opioids for dentoalveolar surgery was a viable strategy for reducing the potential for opioid diversion and abuse among our patients with no negative impact on the operational and training tempo of the associated command.
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Affiliation(s)
- Clarence Tang
- NMRTC Great Lakes, Bldg 1017 Department of Dentistry, Division of Oral Surgery, Great Lakes, IL 60064, USA
| | - James Buckley
- NMRTC Great Lakes, Bldg 1017 Department of Dentistry, Division of Oral Surgery, Great Lakes, IL 60064, USA
| | - Robert Burcal
- NMRTC Great Lakes, Bldg 1017 Department of Dentistry, Division of Oral Surgery, Great Lakes, IL 60064, USA
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How Much Opioid Medication Do Patients Need After Orthognathic Surgery? J Oral Maxillofac Surg 2022; 80:1174-1182. [DOI: 10.1016/j.joms.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 04/03/2022] [Accepted: 04/03/2022] [Indexed: 11/22/2022]
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Donado C, Solodiuk JC, Mahan ST, Difazio RL, Heeney MM, Starmer AJ, Cravero JP, Berde CB, Greco CD. Standardizing Opioid Prescribing in a Pediatric Hospital: A Quality Improvement Effort. Hosp Pediatr 2022; 12:164-173. [PMID: 35059711 DOI: 10.1542/hpeds.2021-005990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Opioids are indicated for moderate-to-severe pain caused by trauma, ischemia, surgery, cancer and sickle cell disease, and vaso-occlusive episodes (SCD-VOC). There is only limited evidence regarding the appropriate number of doses to prescribe for specific indications. Therefore, we developed and implemented an opioid prescribing algorithm with dosing guidelines for specific procedures and conditions. We aimed to reach and sustain 90% compliance within 1 year of implementation. METHODS We conducted this quality improvement effort at a pediatric academic quaternary care institution. In 2018, a multidisciplinary team identified the need for a standard approach to opioid prescribing. The algorithm guides prescribers to evaluate the medical history, physical examination, red flags, pain type, and to initiate opioid-sparing interventions before prescribing opioids. Opioid prescriptions written between January 2015 and September 2020 were included. Examples from 2 hospital departments will be highlighted. Control charts for compliance with guidelines and variability in the doses prescribed are presented for selected procedures and conditions. RESULTS Over 5 years, 83 037 opioid prescriptions in 53 804 unique patients were entered electronically. The encounters with ≥1 opioid prescription decreased from 48% to 25% between 2015 and 2019. Compliance with the specific guidelines increased to ∼85% for periacetabular osteotomies and SCD-VOC and close to 100% for anterior-cruciate ligament surgery. In all 3 procedures and conditions, variability in the number of doses prescribed decreased significantly. CONCLUSION We developed an algorithm, guidelines, and a process for improvement. The number of opioid prescriptions and variability in opioid prescribing decreased. Future evaluation of specific initiatives within departments is needed.
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Affiliation(s)
- Carolina Donado
- Departments of Anesthesiology, Critical Care and Pain Medicine and
- Departments of Anestheasia
| | - Jean C Solodiuk
- Departments of Anesthesiology, Critical Care and Pain Medicine and
- Departments of Anestheasia
| | | | | | - Matthew M Heeney
- Pediatrics, Harvard Medical School, Boston, Massachusetts
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Amy J Starmer
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
- Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Joseph P Cravero
- Departments of Anesthesiology, Critical Care and Pain Medicine and
- Departments of Anestheasia
| | - Charles B Berde
- Departments of Anesthesiology, Critical Care and Pain Medicine and
- Departments of Anestheasia
| | - Christine D Greco
- Departments of Anesthesiology, Critical Care and Pain Medicine and
- Departments of Anestheasia
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Wang TT, Nadella S, Lee CC, Hersh EV, Tannyhill RJ, Panchal N. Do Patterns of Opioid Prescriptions to Medicare Beneficiaries Differ Between Oral and Maxillofacial Surgeons Practicing in Urban and Rural Settings? J Oral Maxillofac Surg 2021; 80:614-619. [PMID: 34856159 DOI: 10.1016/j.joms.2021.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 10/25/2021] [Accepted: 10/27/2021] [Indexed: 11/20/2022]
Abstract
PURPOSE This study compared opioid prescription patterns among oral and maxillofacial surgeons (OMSs) treating Medicare beneficiaries in urban and rural settings, in an effort to identify avenues to further promote responsible opioid prescribing in a patient demographic vulnerable to opioid diversion. MATERIALS AND METHODS This study used Medicare Provider Utilization and Payment Data from 2014 to 2018, focusing on providers labeled as an OMS. Rural-urban commuting area codes were used to categorize each OMS as urban or rural. The demographic variables included total number of OMSs, provider gender, beneficiaries per provider, beneficiaries' age, and beneficiary hierarchal condition category (proxy for clinical complexity). The outcome variables included opioid prescribing rate, opioid claims per provider, opioid claims per beneficiary, and number of days' supply of opioids per claim. Descriptive statistics, χ2 tests, 2-tailed t tests, and Wilcoxon rank-sum tests were used as appropriate. RESULTS Across all years, the data consisted of mostly urban and male OMSs. The mean number of Medicare beneficiaries prescribed opioids per OMS varied widely, and the mean age of beneficiaries was 70.4 ± 4.4 and 69.9 ± 4.1 years for urban and rural OMSs, respectively. Mean opioid claims per provider were higher among rural OMSs, with large standard deviations among both rural and urban OMSs. However, there were no significant differences in the opioid prescribing rate or in the mean opioid claims per beneficiary in all 5 years included in the study. There were also no clinically significant differences between urban and rural OMSs in the number of days' supply per claim (between 3 and 4 days in all periods). However, in each year, there was a significantly higher proportion of urban OMSs who prescribed more than 7 days' supply per claim. CONCLUSIONS Opioid prescription practices were generally similar between rural and urban OMSs treating Medicare beneficiaries. The small subset of longer-term opioid prescribers, which were more prevalent in urban areas, warrants further investigation.
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Affiliation(s)
- Tim T Wang
- Resident, Oral & Maxillofacial Surgery, Massachusetts General Hospital and Clinical Fellow, Harvard School of Dental Medicine, Boston, MA
| | - Srighana Nadella
- DMD Candidate, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA
| | - Cameron C Lee
- Resident, Oral & Maxillofacial Surgery, Massachusetts General Hospital and Clinical Fellow, Harvard School of Dental Medicine, Boston, MA
| | - Elliot V Hersh
- Professor, Department of Oral and Maxillofacial Surgery and Pharmacology, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA
| | - R John Tannyhill
- Program Director and Assistant Professor, Oral & Maxillofacial Surgery, Massachusetts General Hospital and Harvard School of Dental Medicine, Boston, MA
| | - Neeraj Panchal
- Assistant Professor and Section Chief of Oral and Maxillofacial Surgery, Philadelphia Veterans Affairs Medical Center, Penn Presbyterian Medical Center, University of Pennsylvania School of Dental Medicine, Philadelphia, PA.
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Scrivani SJ, Keith DA, Kulich RJ, DaSilva AF, Donoff RB, Handa S, Holland N, Lerman MA, McCauley JL, Reisner L, Resnick CM, Stohler CS, Vasciannie A, Fortino M, Schatman ME. Pain Management for Dental Medicine in 2021: Opioids, Coronavirus and Beyond. J Pain Res 2021; 14:1371-1387. [PMID: 34079355 PMCID: PMC8164473 DOI: 10.2147/jpr.s319373] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 05/12/2021] [Indexed: 12/15/2022] Open
Abstract
Over the past year our attention has inevitably been on the coronavirus pandemic, the health and welfare of our families, patients, and office staffs as well as the re-opening of our dental practices. In addition, the opioid crisis continues, is very likely to worsen as a result of the pandemic and continues to be a challenge to Dentistry. National public health issues and healthcare disparities continue and have created a global concern for providing evidence-based, adequate pain management in the dental setting. We have brought together a group of national thought leaders and experts in this field who will share their insights on the current state of opioid prescribing in Dentistry and describe some of the exciting work being done in advancing pain management. The learning objectives for this conference proceedings were: Describing the implications of current public health concerns for safe and effective pain management in dental medicine.Identifying risk factors and understanding the current guidelines for the use of opioid and non-opioid medications in dental medicine.Analyzing the interprofessional collaborations necessary for effective pain management in dental medicine.Recognizing the challenges and opportunities brought about by the COVID-19 pandemic for the dental profession.Applying evidence-based strategies for managing the complex pain patient in the dental setting.Appraising new and future modalities for the assessment and management of orofacial pain.
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Affiliation(s)
- Steven J Scrivani
- Department of Diagnostic Sciences, Craniofacial Pain and Headache Center, Tufts University School of Dental Medicine, Boston, MA, USA
| | - David A Keith
- Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Ronald J Kulich
- Department of Diagnostic Sciences, Craniofacial Pain and Headache Center, Tufts University School of Dental Medicine, Boston, MA, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Alexandre F DaSilva
- Department of Biological and Material Sciences & Prosthodontics, University of Michigan School of Dentistry, Headache and Orofacial Pain Effort, University of Michigan, Ann Harbor, MI, USA
- fNIRS Laboratory, University of Michigan, Ann Harbor, MI, USA
| | - R Bruce Donoff
- Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Shruti Handa
- Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Nicole Holland
- Department of Public Health and Community Service, Tufts University School of Dental Medicine, Boston, MA, USA
| | - Mark A Lerman
- Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA
| | - Jenna L McCauley
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Lori Reisner
- Department of Pharmaceutical Services, School of Pharmacy University of California, San Francisco, CA, USA
- Department of Clinical Pharmacy, San Francisco Medical Center, San Francisco, CA, USA
| | - Cory M Resnick
- Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, MA, USA
- Harvard School of Dental Medicine, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Christian S Stohler
- Columbia University College of Dental Medicine, New York, NY, USA
- Columbia University Medical Center, New York, NY, USA
| | - Alexis Vasciannie
- Department of Diagnostic Sciences, Craniofacial Pain and Headache Center, Tufts University School of Dental Medicine, Boston, MA, USA
| | - Matthew Fortino
- Department of Diagnostic Sciences, Craniofacial Pain and Headache Center, Tufts University School of Dental Medicine, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Michael E Schatman
- Department of Diagnostic Sciences, Craniofacial Pain and Headache Center, Tufts University School of Dental Medicine, Boston, MA, USA
- Department of Public Health & Community Medicine, Tufts University School of Medicine, Boston, MA, USA
- School of Social Work, North Carolina State University, Raleigh, NC, USA
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14
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Wang TT, Tong J, Hersh EV, Chuang SK, Panchal N. Does prescription drug monitoring program usage affect opioid analgesic prescriptions by oral and maxillofacial surgeons after third molar surgery? Oral Surg Oral Med Oral Pathol Oral Radiol 2021; 132:26-31. [PMID: 33741285 DOI: 10.1016/j.oooo.2021.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/08/2020] [Accepted: 01/13/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To curb opioid overprescription and diversion, 49 states have implemented mandatory prescription drug monitoring programs (PDMPs). This study aims to examine the changes in analgesic prescription patterns associated with mandatory PDMP usage by oral and maxillofacial surgeons. DESIGN This retrospective observational cohort study analyzed analgesic prescriptions after third molar surgeries from the University of Pennsylvania from July 2016 to December 2019. Because Pennsylvania mandated PDMP usage on January 1, 2017, we analyzed prescriptions 6 months prior to and for each 6-month interval after implementation. RESULTS Prescriptions after 13,430 procedures on 6437 patients across 7 6-month periods were analyzed. Patients in all study periods had an average age of 40 years and there was a slight majority of females. After PDMP implementation, patients who received analgesics had an 80% lower odds of receiving an opioid option after adjusting for age, sex, and procedural severity. When an opioid was prescribed, the mean pills per script decreased from 20.18 to 10.96 1 year after PDMP implementation. CONCLUSIONS Mandatory PDMP usage was associated with decreased odds of a patient receiving an opioid analgesic and with a decrease in mean opioid pills per script. PDMPs may be helpful in reducing opioid prescriptions by oral and maxillofacial surgeons after third molar surgery.
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Affiliation(s)
- Tim T Wang
- DMD Candidate, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA, USA; MPH Candidate, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Associate Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Jason Tong
- DMD Candidate, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Elliot V Hersh
- Professor, Department of Oral & Maxillofacial Surgery/Pharmacology, University of Pennsylvania School of Dental Medicine, Philadelphia, PA, USA
| | - Sung-Kiang Chuang
- Clinical Professor, Department of Oral and Maxillofacial Surgery/Pharmacology, University of Pennsylvania School of Dental Medicine, Philadelphia, PA, USA; Private Practice, Brockton Oral and Maxillofacial Surgery Inc.; Attending, Department of Oral and Maxillofacial Surgery, Good Samaritan Medical Center, Brockton, MA, USA
| | - Neeraj Panchal
- Assistant Professor, Department of Oral and Maxillofacial Surgery, University of Pennsylvania School of Dental Medicine, Philadelphia, PA, USA.
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15
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Annual review of selected scientific literature: A report of the Committee on Scientific Investigation of the American Academy of Restorative Dentistry. J Prosthet Dent 2020; 124:274-349. [PMID: 32811666 DOI: 10.1016/j.prosdent.2020.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 01/20/2023]
Abstract
This comprehensive review of the 2019 restorative dental literature is offered to inform busy dentists regarding remarkable publications and noteworthy progress made in the profession. Developed by the Scientific Investigation Committee of the American Academy of Restorative Dentistry, each author brings discipline-specific expertise to 1 of 8 sections of the report: (1) prosthodontics; (2) periodontics, alveolar bone, and peri-implant tissues; (3) implant dentistry; (4) dental materials and therapeutics; (5) occlusion and temporomandibular disorders; (6) sleep-related breathing disorders; (7) oral medicine and oral and maxillofacial surgery; and (8) dental caries and cariology. The report targets important information likely to influence day-to-day dental treatment decisions. Each review is not intended to stand alone but to update interested readers so that they may visit source material when greater detail is desired. As the profession moves toward evidence-based clinical decision-making, an incredible volume of potentially valuable dental literature continues to increase. It is the intention of this review and its authors to provide assistance in negotiating the extensive dental literature published in 2019. It is our hope that readers find this work useful in the clinical management of dental patients.
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Miller CS, Ke C, Witty JT, Nagarajan R. Prescribing patterns of opioid analgesics in a dental setting: 2013-2018. Oral Surg Oral Med Oral Pathol Oral Radiol 2020; 130:402-410. [PMID: 32660860 DOI: 10.1016/j.oooo.2020.06.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/11/2020] [Accepted: 06/14/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Analgesic prescribing patterns are influenced by internal and external factors. Understanding these factors could help improve prescribing practices. STUDY DESIGN We conducted a retrospective analysis of electronic health records with regard to analgesic prescriptions written from 2013 through 2018 at the University of Kentucky College of Dentistry. Deidentified information (age, gender, dental procedures, analgesic drug, quantity, and refills) were recorded and studied with respect to national guidelines and recent state legislation using the χ2 test, analysis of variance, logistic regression, and multiple linear regression. RESULTS Opioids comprised 74.9% of the 17,099 analgesic prescriptions written. Extractions were most commonly associated with opioid prescriptions. Multivariate analysis showed that (1) older patients were more likely to receive an opioid prescription (P < .01) but with fewer pills (P < .01); (2) surgical extractions were associated with a lower opioid prescription rate (P < .01) but more opioid pills per prescription compared with nonsurgical extractions (P < .01); and (3) the odds of receiving an opioid prescription and the number of opioid pills prescribed decreased over year after release of the national guideline (P < .01) and after enactment of state legislation (P < .01). CONCLUSIONS Regulations and guidelines were associated with reduction in opioid prescriptions.
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Affiliation(s)
- Craig S Miller
- Division of Oral Diagnosis, Oral Medicine and Oral Radiology, University of Kentucky, College of Dentistry, Lexington, KY, USA.
| | - Chenlu Ke
- Department of Statistical Sciences and Operations Research, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, Virginia
| | - Jeffrey T Witty
- Information Technology, University of Kentucky, College of Dentistry, Lexington, KY, USA
| | - Radha Nagarajan
- Center for Oral and Systemic Health, Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, WI, USA
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17
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Subramanian G, Quek SYP. Opioid Prescription Following Third Molar Extractions. J Oral Maxillofac Surg 2019; 77:1527. [PMID: 31039357 DOI: 10.1016/j.joms.2019.03.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 03/27/2019] [Indexed: 10/26/2022]
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