Opioid abuse has reached epidemic proportions in the United States1,2 and often begins with a prescription for a pain medication. Dentists are among the leading prescribers of opioid analgesics,3 and surgical tooth extraction is one of the most frequently performed dental procedures. Surveys suggest that dental practitioners commonly prescribe opioids following this procedure,4 despite evidence that a combination of nonsteroidal medications and acetaminophen may provide more effective analgesia for postextraction pain.5 Little information is available on nationwide patterns of opioid prescribing following tooth extraction.
Methods
The use of the Medicaid database for research was approved by Partners’ institutional review board and the need for informed consent was waived. We collected data from the Medicaid Analytic eXtract—a national database of deidentified health claims drawn from Medicaid transactions for the years 2000–2010, which were combined for this analysis.6 All patients who underwent surgical dental extraction were included, identified by Current Dental Terminology codes. The cohort was restricted to patients with continuous Medicaid coverage from 90 days before through 7 days following extraction, allowing for up to a 7-day lapse in coverage. We determined the frequency of opioid prescriptions filled within 7 days of extraction and the nature and amount of opioids dispensed. Patients were stratified by age, sex, and type of extraction. Patients who filled an opioid prescription in the 90 days prior to extraction were excluded.
The opioids studied included codeine, hydrocodone, hydromorphone, levorphanol, meperidine, methadone, morphine, oxycodone, oxymorphone, pentazocine, propoxyphene, tramadol, and fentanyl. To examine the amount of opioids dispensed, the dose prescribed was converted into morphine equivalents. Patients younger than 18 years were excluded from the analysis of quantity dispensed, as pediatric dosing is often weight-based. Patients receiving nontablet or noncapsule formulations (eg, liquids) were also excluded. All analyses were performed in SAS (SAS Institute), version 9.4.
Results
There were 2 757 273 patients in the cohort. The mean age was 24.9 years (SD, 13.3) and 64% were women. Within 7 days of extraction, 1 161 747 patients (42%) filled a prescription for an opioid medication. The most commonly dispensed opioid was hydrocodone (78% of all prescriptions), followed by oxycodone (15.4%), propoxyphene (3.5%), and codeine (1.6%). Patients aged 14 to 17 years had the highest proportion of filled opioid prescriptions (61%), followed by patients aged 18 to 24 years (52%) (Table 1).
Table 1.
Proportion of Medicaid Patients Dispensed Opioids Following Surgical Extraction of Teeth, 2000–2010a
| No. of Patients | Dispensed Opioid, No. (%) | |
|---|---|---|
| Overall cohort | 2 757 273 | 1 161 747 (42) |
| Age group, y | ||
| ≤13 | 367 219 | 52 528 (14) |
| 14–17 | 657 535 | 400 549 (61) |
| 18–24 | 646 370 | 339 386 (52) |
| 25–34 | 492 104 | 196 051 (40) |
| 35–44 | 302 048 | 97 703 (32) |
| 45–54 | 184 500 | 51 557 (28) |
| ≥55 | 107 497 | 23 973 (22) |
| Sex | ||
| Men | 979 352 | 405 120 (41) |
| Women | 1 777 921 | 756 627 (43) |
| Procedure type | ||
| Surgical extraction of nonimpacted tooth | 1 718 053 | 544 971 (32) |
| Removal of impacted tooth | ||
| Soft tissue | 245 505 | 140 514 (57) |
| Partially bony | 475 053 | 301 706 (64) |
| Completely bony | 669 199 | 466 616 (70) |
| Completely bony with unusual surgical complications | 60 478 | 41 280 (68) |
| Surgical removal of residual tooth roots | 169 613 | 53 853 (32) |
Data were from the Medicaid Analytic eXtract.
The median number of milligrams of morphine equivalents dispensed to adults following extraction was 120 (interquartile range [IQR], 90–150; 10th–90th percentile range, 75–225) (Table 2), representing 24 5-mg tablets of hydrocodone (IQR, 18–30) or 16 5-mg tablets of oxycodone (IQR, 12–20). The median number of morphine equivalents dispensed was highest for patients who underwent more invasive procedures (extraction of impacted teeth rather than nonimpacted teeth).
Table 2.
Amount of Oral Morphine Equivalents Dispensed Following Tooth Extraction by Procedure Type Among Medicaid Patients (N = 693 702)a,b
| Dispensed Morphine Equivalents, mg | |
|---|---|
| Median (IQR) [10th–90th Percentile] | |
| Overall cohort | 120 (90–150) [75–225] |
| By procedure | |
| Surgical extraction of nonimpacted tooth | 113 (90–150) [68–225] |
| Removal of impacted tooth | |
| Soft tissue | 120 (100–150) [75–225] |
| Partially bony | 140 (100–160) [75–225] |
| Completely bony | 150 (100–188) [80–225] |
| Completely bony with unusual surgical complications | 150 (113–210) [90–250] |
| Surgical removal of residual tooth roots | 125 (98–180) [75–276] |
Data were from the Medicaid Analytic eXtract.1
Oral morphine equivalents calculated based on the following study: Von Korff M, Saunders K, Thomas Ray G, et al. De facto long-term opioid therapy for noncancer pain. Clin J Pain. 2008;24(6):521–527.
Discussion
In this large cohort of Medicaid patients from throughout the United States, prescriptions for opioids were filled by 42% of patients within 7 days following surgical tooth extraction. There was great variability in the amount of opioids dispensed for a given procedure, with an approximately 3-fold difference between the 10th and 90th percentile in the oral morphine equivalents prescribed. Although a limited supply of opioids may be required for some patients following tooth extraction, these data suggest that disproportionally large amounts of opioids are frequently prescribed given the expected intensity and duration of postextraction pain, particularly as nonopioid analgesics may be more effective in this setting.5
This study has limitations. Findings based on data from Medicaid claims may not generalize to a commercially insured population. Also, the final year of the study was 2010, and it is possible that dental prescribing practices have changed somewhat since that time.
This common dental procedure may represent an important area of excessive opioid prescribing in the United States. As the nation implements programs to reduce excessive prescribing of opioid medications, it will be important to include dental care in these approaches.
Acknowledgments
Funding/Support: Research reported in this publication was supported by grant K08HD075831 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health.
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Footnotes
Author Contributions: Dr Bateman and Ms Levin had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Baker, Avorn, Bateman.
Acquisition, analysis, or interpretation of data: Baker, Avorn, Levin, Bateman.
Drafting of the manuscript: Baker, Bateman.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Levin.
Obtained funding: Avorn.
Administrative, technical, or material support: Avorn, Bateman.
Study supervision: Avorn, Bateman.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
References
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