Prescription of opioid analgesics for nontraumatic dental conditions in emergency departments
Introduction
Opioid analgesics prescribed for both acute and chronic pain management by dentists, emergency and primary care physicians, physician assistants and nurse practitioners with prescribing authority have, in recent times continued to receive attention from policymakers, clinicians and patient care advocates. This is because of their increased use and the associated potential for misuse, abuse and addiction. Studies indicate that the number of opioid prescriptions filled by pharmacies increased by 27% (from 174 million to 238 million) between 2000 and 2011 (Manchikanti et al., 2012, Maxwell, 2011, Warner et al., 2011). In addition, Mazer-Amirshahi et al., 2014 reported that the number of opioid prescriptions in emergency departments increased from 20.8% to 31.0% indicating an absolute increase of 10.2% and a relative increase of 49.0% between 2001 and 2010. Another report documented that health insurers lose about $72.5 billion annually because of opioid prescription drug diversion (Coalition Against Fraud, 2007, National Prescription Drug Abuse Prevention Strategy, 2009). These descriptive statistics clearly identify increases in opioid prescriptions and the associated healthcare costs and public health implications.
Nontraumatic dental condition (NTDC) visits to emergency departments is increasing and has become a subject of discussion by researchers, clinicians, policymakers and organized dentistry (Okunseri et al., 2012, Okunseri et al., 2014, Allareddy et al., 2014). This increase in NTDC visits is of serious concern to all stakeholders because emergency departments are not set up to provide routine dental care nor are some ED physicians trained to provide extractions or endodontic treatment (Okunseri et al., 2012). Patients who visit EDs for NTDCs (such as toothache or tooth decay) typically receive prescriptions for painkillers and antibiotics. This has led to a discussion about whether the prescription of pain medication during such visits could be contributing to the prescription drug abuse problem (Fox et al., 2013). In addition, dental care in EDs have high cost implications and do not typically afford patients a chance to build relationships with a primary dental provider and to establish a dental home (Allareddy et al., 2014, Okunseri et al., 2012).
To the best of our knowledge, only one study has attempted to document emergency physician prescribing practices of opioid analgesics and opioid combinations for nontraumatic dental conditions (Okunseri et al., 2014). In addition, there is no study based on either a convenience or a population-based representative sample that has specifically examined the different opioids prescribed in emergency departments for NTDC visits. This is particularly important given that the rationale in favor of opioid prescriptions for pain management is often based on tradition, expert opinions, specialty focused guidelines, practical experience and uncontrolled anecdotal observations (Manchikanti et al., 2012). This study examined rates of prescription of opioid analgesics and types of opioid analgesics prescribed for NTDC visits in U.S. emergency departments from 2007 to 2010.
Section snippets
Study design, settings and selection of participants
We analyzed data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for 2007–2010. NHAMCS is a cross-sectional national survey of emergency and outpatient departments of non-institutionalized general and short-stay hospitals within the 50 states of the United States of America and the District of Columbia (Ambulatory Health Care Data, 2009). A four-stage probability design was used with sampling from primary sampling units (which are geographically defined areas), hospitals
Results
Overall, NTDC was the primary diagnosis category for 1.7% of all ED visits from 2007 to 2010 (Table 1a, Table 1b). The rate of prescription of opioid analgesics was 50.3% for NTDC and 14.8% for non-NTDC visits. The rates of prescription for each specific ingredient examined (hydrocodone, oxycodone, and codeine) were significantly higher for NTDC (31.6%, 12.3%, 4.1%, respectively) than for non-NTDC visits (9.3%, 3.4%, 1.0%) in ED. The proportion of Medicaid enrollees with NTDC (29.8%) and
Discussion
Public concern over the number of deaths attributed to opioids prescribed for therapeutic indications has prompted efforts to decrease misuse, abuse and diversion of opioid analgesics. In this study, the rate of prescription of opioid analgesics was 50.3% for NTDC visits in 2007–2010. Although the rate of prescription of opioid analgesics remained fairly stable, it was, however, higher than previously reported by Okunseri et al., 2012, Okunseri et al., 2014 where 38% of NTDC patients were
Author contributions
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Christopher Okunseri, Aniko Szabo and Elaye Okunseri obtained research funding and conceived the study with Raymond A. Dionne and Sharon M. Gordon.
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Statistical advice, study design, and data analysis were provided by Aniko Szabo, Raymond A. Dionne and Sharon M. Gordon and Christopher Okunseri.
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Christopher Okunseri, Raymond A. Dionne and Sharon M. Gordon and Elaye Okunseri provided research support and drafted the initial manuscript.
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All authors contributed substantially to the interpretation of
Conflict of interest
All authors have no commercial association or sources of support that might pose a conflict of interest.
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Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in adolescents, adults, and older adults: A report from the American Dental Association Science and Research Institute, the University of Pittsburgh, and the University of Pennsylvania
2024, Journal of the American Dental AssociationEmergency department visits for dental problems among adults with private dental insurance: A national observational study
2021, American Journal of Emergency MedicineCitation Excerpt :Within 3 days of a dental-related ED visit, 38.3% of patients filled at least one opioid prescription, with the two most commonly dispensed opioids being hydrocodone (45%) and oxycodone (23.4%). Prior studies investigating nontraumatic dental complaints in the ED have found that approximately 40–53% of patients are prescribed an opioid following discharge [27-29] and approximately 55% of patients will have their prescriptions dispensed [4]. The significantly lower fill rates found in this study may indicate that dentally insured patients have lower rates of opioid prescriptions following discharge from the ED.
Opioid prescriptions in emergency departments: Findings from the 2016 National Hospital Ambulatory Medical Care Survey
2020, Preventive MedicineCitation Excerpt :A recent analysis of 2005–2015 NHAMCS found opioids to be prescribed in 24% of all ED visits (Yang et al., 2019). Another study using 2007–2010 NHAMCS data reported opioid prescription rate of 50% for dental visits and 15% for all other visits (Okunseri et al., 2015). Our study shows a rather pronounced pattern of opioid prescriptions for both dental and other visits in ED and further confirms the findings from previous studies which found dental visits to carry a high burden of opioid prescriptions (Florence et al., 2016; Kea et al., 2016; Volkow et al., 2011).
Is it time US dentistry ended its opioid dependence?
2019, Journal of the American Dental AssociationCitation Excerpt :Similarly, nontraumatic dental pain accounted for 2.18 million emergency department visits in 2012, nearly 2% of the total, and 50.3% of these patients received an opioid prescription compared with just 14.8% of all other patients in the emergency department.51 Patients who sought care at the emergency department with nontraumatic dental pain were twice as likely to receive an opioid than a nonopioid or no pain medication.51 Furthermore, most prescriptions were to keep the patient going until the patient could receive definitive dental treatment, a situation commonly associated with higher dose and longer duration of prescription and with opioid abuse and diversion.
The role of the oral health community in addressing the opioid overdose epidemic
2018, Journal of the American Dental Association