Written by: Chad Wagner
Chad is a second-year student at University of Minnesota Dental School and an advocate for opioid research and policy reform. He recently sponsored a successful resolution at ASDA's House of Delegates and presented his research at the American Association for Dental Research conference.
Hello, I'm Chad Wagner and I'm a second year dental student at the University of Minnesota. I have an interest in pathology, pain and addiction, and clinical research. I hope to pursue an academic career where I can practice at a high level while pursuing answers to questions relevant to dentistry.
Health professionals are searching for answers to the devastating wake left behind by the opioid abuse epidemic. Even with decreased opioid prescriptions, more legislation, and increased education efforts; opioid deaths continue to rise. The most recent data from the CDC reported over 64,000 deaths in 2016, an average of 175 per day. While the majority were from heroin, a significant portion (22.4%) were attributed to semi-synthetic schedule II opioids such as Hydrocodone and Oxycodone. These analgesics are commonly prescribed by dentists for various procedures associated with post-operative pain. While dentists prescribe less than 10% of total opioids, this figure is misleading. Dentists are the leading prescriber to patients age 10-19, an age where the developing brain is susceptible to addictive medications. Knowing the deadly side effects of opioids, it is imperative that we as a profession strive to limit opioids prescriptions to educate those patients who truly need them.
Our research was based on the emerging evidence that non-steroidal anti-inflammatory (NSAIDs) medications along with acetaminophen can be as effective, if not more effective, in treating acute postoperative pain. My specific project was to quantify the change in provider behavior following the implementation of the [University of Minnesota School of Dentistry’s] prescribing protocol which was accepted by the clinical affairs committee and implemented in 2016. The protocol calls for preemptive and postoperative NSAIDs, use of a long-acting local anesthetic, and non-opioid analgesics be the first-line treatment for post-operative pain. When opioids are indicated, the provider must document the indications, consult the prescription drug monitoring program, and opt for the lowest dose and quantity they believe will effectively manage their patient's pain. The protocol maintains provider autonomy and authority to make decisions they believe are best for their patients. The guidelines closely mimic the ADAs recommendation for opioid prescribing and the AAMOS white paper on opioid prescribing.
Our retrospective analysis compared overall opioid prescriptions, the number of tablets per prescription, and non-opioid analgesic prescriptions in the year prior to the protocol and the quarters following its implementation. We observed a 70% decrease in total opioid prescriptions across the school of dentistry and a 25% decrease in the average tablets per prescription.
Our conclusion was that the prescribing protocol was effective in reducing the total number of prescriptions and average tablets per prescription. This is important as we estimate we have decreased the number of opioid tablets by nearly 16,000 per quarter or around 80,000 tablets overall. This significantly decreases access to these medications and protects many opioid naive patients from these highly addictive substances. While these numbers are promising, a significant more work needs to be done, such as whether we are currently addressing the question if we are adequately treating postoperative pain. Our results also showed a completed switch in the ratio of opioid to non-opioid analgesics prescribed; in 2015 65% of analgesics were opioids compared to 35% non-opioids, by the end of 2017 29% of analgesics were opioids and 71% were non-opioids. These results highlight the shift in providers now opting to prescribe NSAIDs and Acetaminophen for post-operative pain. Results from a retrospective cohort study report that less than 1% of patients treated with a non-opioid for post-operative pain following extractions of 3rd molars went on to receive an opioid prescription.
We are encouraged by these results and believe this protocol could be implemented in dental schools across the nation and similar decreases could be observed. My personal motivation to work on this research was that my cousin, like 2 million Americans currently, was addicted to opioid prescription medications. Unfortunately, my cousin proceeded to heroin abuse and after unsuccessful rehabilitation, passed away in 2015. The ability to work on this project and present at the AADR meeting was a true honor and a special experience for me. Meeting with colleagues who share the passion to help people and motivation to better our profession is inspiring and excited me about the future of dentistry.
Center for Health Statistics N. PROVISIONAL COUNTS OF DRUG OVERDOSE DEATHS, as of 8/6/2017. 2016. https://www.cdc.gov/nchs/data/health_policy/monthly-drug-overdose-death-estimates.pdf. Accessed January 21, 2018.
School of Dentistry Guideline Acute Postoperative Pain Opioid Prescribing Guidelines I. Purpose. https://www.dentalclinics.umn.edu/sites/dentalclinics.umn.edu/files/acute_pain_opiod_prescribing_guidelines.pdf. Accessed January 21, 2018.
Statement on the Use of Opioids in the Treatment of Dental Pain. http://www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/statement-on-opioids-dental-pain. Accessed November 22, 2017.
Opioid Prescribing: Acute and Postoperative Pain Management. https://www.aaoms.org/docs/govt_affairs/advocacy_white_papers/opioid_prescribing.pdf.
Contact Chad at email@example.com