Dental pain management with prescription opioids by nondental health care professionals in a health care system network

Abstract

Objectives Nondental health care professionals are often responsible for the management of dental-related complaints with use of prescription of opioids for analgesia. Prescribing patterns are influenced by prescribers’ inability to provide definitive dental treatment and limited patient access to dentists for care. The PRIMUM Group, a multidisciplinary team at our institution, formulated criteria based on peer-reviewed literature and consensus opinion to identify patients potentially at high risk for misuse, abuse, and diversion of prescription-controlled substances. These criteria have been implemented within our health care system network's electronic health records (EHRs) to generate an alert to the prescriber at the point of care should the patient meet one or more criteria. The objectives of our study are to determine the number of patients seeking treatment of dental pain from nondental health care professionals; characterize prescriptions written for these patients; identify and characterize patients at high risk for misuse, abuse, and diversion among this group based on the PRIMUM criteria; observe the ability of the EHR alert system to identify high-risk patient characteristics among the dental pain population; and develop baseline data on opioid prescribing patterns for dental pain–related encounters. Study Design We performed an in-depth retrospective data set analysis by using the EHRs from dental pain–related patient encounters within our health care system occurring between January 2016 and June 2018. Relevant encounters were identified by investigator-selected dental International Classification of Diseases (ICD)-9 and ICD-10 diagnosis codes. This case list was then linked to the PRIMUM database, which included all encounters where a prescription for an opioid was initiated. Data were collected for analysis and included prescriber, facility, date, ICD-9/ICD-10 codes, prescription details (i.e., medication, dose, date) and patient risk criteria as determined by the PRIMUM Group (3+ prescriptions in past 30 days; 2+ visits to the emergency department [ED] or urgent care with on-site treatment with opioids; history of opioid or benzodiazepine overdose; “early refill” (has open prescription with >50% remaining); and positive blood alcohol test or toxicology screen for cocaine or marijuana). Data was analyzed in order to characterize opioid prescribing patterns for dental pain-related encounters within our healthcare system. Results A total of 38,888 encounters related to dental pain ICD-9 and ICD-10 codes occurred between January 2016 and June 2018 across our expansive health care system's care locations; of these encounters, opioids were prescribed in 18,025 (46.3%). Over this period, 15.2% of patients were seen for 2 or more visits related to dental pain; and 1.6% of patients were seen for 4+ encounters related to dental pain. A total of 18,333 opioid prescriptions were written for the 18,025 opioid-prescribing encounters for dental-related pain, averaging 1 opioid prescription per encounter. The most common prescriptions written were hydrocodone–acetaminophen (58.9%), tramadol (27.3%), and oxycodone–acetaminophen (7.8%). Most prescriptions were written in the EDs and urgent care centers (90%), followed by primary care centers (8%). Advanced clinical practitioners were the most common prescribers (61.5%), followed by attending physicians (35.8%). Most patients treated for dental pain were between ages 25to 64 years (82%). This group also represented the group with the highest number of PRIMUM risk factors met, with 17.1% having at least 1 risk factor and 19.43% having greater than 1. The most common risk factor was a positive toxicology screen (14.7%), notably for marijuana (10.6%) and cocaine (4.4%). Conclusions Dental-related pain is often managed by nondental health care professionals in an ED or urgent care setting. An EHR alert may help quickly identify high-risk patients; however, the impact of alerts on prescribing patterns needs further evaluation. The decision regarding the type and quantity of medication to prescribe is complicated by lack of patient access to definitive dental treatment and lack of dental-specific training of prescribers. The limitations of this study include selective inclusion of encounters with specific ICD-9/ICD-10 codes, data limited to objectively searchable criteria, data collection for a relatively short period, and data originating from a single regional health care system. In the attempt to address the opioid epidemic, continued research may help assess the influence of improved awareness of the opioid epidemic on prescription selections over time and the ability of EHR alerts to assist prescribers in choosing alternative medications. Considerations include using EHR alerts to convey standardized guidelines and recommendations (i.e., from the American Dental Association and/or the Centers for Disease Control and Prevention for pain management and improving the collaboration between medical and dental health care professionals to formulate robust prescription guidelines for dental-related complaints. Additionally, information regarding reasons for repeat visits, such as access to care issues, needs to be explored further, and improvements need to be made so that definitive dental care may be provided rather than depending on pharmacologic management by nondental health care professionals.