Opioid prescribing by oral and maxillofacial surgeons in the United States: trends and opportunities for intervention

Introduction

Prescription opioids play a major role in the opioid epidemic in the United States (1). Over the past decade, there have been concerted research efforts and policy interventions at various levels of government to promote responsible opioid prescribing. Oral and maxillofacial surgeons are important stakeholders in this discussion because they frequently employ opioid analgesics to manage intra- and post-operative pain.

Research shows that opioid prescribing in healthcare has decreased in recent years (2-5). For oral and maxillofacial surgeries (OMSs), opioid prescribing patterns have also followed this trend, becoming increasingly responsible and evidence-based. One national level study found that all dental providers decreased opioid prescribing between 30% and 83% between 2015 and 2019 (5). Similarly, another study demonstrated that OMSs prescribed fewer quantities opioids for shorter durations to Medicare beneficiaries from 2014 to 2018 (6). At the state level, a study of Massachusetts OMSs found steady decreases in quantity and duration of opioids from 2011 to 2021 (7). These trends are encouraging and have occurred in the context of multifaceted interventions at the federal, state, and institutional levels to promote responsible prescribing in healthcare. This has led to a marked decrease in prescribing habits among many OMSs (5,7).

Nevertheless, there remains much work to be done. There are still some dental providers who continue to prescribe opioids, such as hydrocodone (Vicodin^®) and oxycodone (Oxycontin, Percocet^®), at a high rate (5,6). In addition, opioid diversion, which occurs when opioids are used by individuals for whom they were not prescribed, is another major challenge. Studies have shown that the majority of opioids prescribed after OMS procedures are unused. A randomized controlled trial found that more than half of the opioids prescribed after dental extractions were unused (8). Further, an institutional study at a large children’s hospital found that 93% of patients did not use any opioids after third molar surgeries (9). Unused opioids present a tremendous risk of opioid diversion despite increasing efforts by governmental and public health agencies to improve mechanisms for safe opioid disposal.

The following will provide an overview of the pharmacology of opioid analgesics as relevant to OMS, trends in the opioid epidemic, notable policy interventions in response, and possible next steps to combat the opioid crisis.

Pharmacology of opioid analgesics

Opioid analgesics are used to manage both acute and chronic pain in oral healthcare (3). Acute pain occurs after surgical procedures or during odontogenic infections (10). Chronic pain involves a wide range of complex neurologic changes, leading to increased sensitivity and persistent discomfort, and can often stem from temporomandibular disorders (TMDs) (11).

Opioids exert the majority of their analgesic effects by binding to mu (µ) receptors in the central and peripheral nervous systems (12). Activation of these receptors results in potent analgesia, as well as other effects, such as euphoria and sedation by inhibiting neurotransmitter release and reducing neuronal excitability (13).

However, there are also drawbacks to using opioid analgesics. In the short term, opioids can cause respiratory depression by decreasing the brainstem’s chemical receptors (14), and can also cause nausea, vomiting, constipation, pruritus, and orthostatic hypotension (15,16). In the long term, opioids can cause addiction. Opioid reward occurs through the reduction of gamma-aminobutyric acid (GABA)’s inhibition on dopamine neurons in the ventral tegmental area (17), creating strong positive reinforcement and leading to increased tolerance, requiring higher doses to achieve the same pleasurable effects (18). This process can lead to opioid addiction due to the brain’s adaptation and subsequent cravings. Despite efforts to prescribe the lowest effective dosage for the shortest duration, there is a risk of long-term addiction when opioids are used for either acute or chronic pain management. One study found that patients who use opioids consistently for more than a single week can develop some degree of dependency (19,20).

Chronic pain is notoriously difficult to treat, particularly neuropathic pain that follows neuronal injury. This type of pain is challenging to diagnose and manage because it can persist long after the original tissue injury has healed, making it hard to pinpoint specific areas of damage (21,22). Common conditions managed by oral and maxillofacial surgeons include temporomandibular disorders, trigeminal neuralgia, and myofascial pain—each of which can be persistent and difficult to control (23). Several opioids have been effectively used to treat neuropathic pain, including morphine, methadone, hydromorphone, levorphanol, and transdermal fentanyl (24).

Both acute and chronic orofacial pain are currently treated with opioid analgesics. One study looking at prescribing practices from 2010 to 2015 found that restorative procedures accounted for 55.57% of all nonsurgical dental visits with opioid prescriptions, while OMSs comprised 59.11% and implants 1.99% of surgical visits requiring opioids (4). This highlights the necessity for careful opioid management across all dental practices. In light of the risks of opioid use, the Centers for Disease Control and Prevention (CDC) published the “Clinical Practice Guideline for Prescribing Opioids for Pain—United States, 2022”, which advocates for optimizing non-opioid therapies for pain control, prior to employing opioids (25). A review of analgesics for dental pain concluded that non-steroidal anti-inflammatory drugs (NSAIDs) particularly when combined with acetaminophen, were superior to opioids for post-operative inflammatory pain (21). Further, studies support that employing long-acting local anesthetics, perioperative/preemptive medications, and home care measures (ice pack, liquid diet, head elevation) can reduce the need for opioid pain medications postoperatively (11). Another review article found that various non-opioid alternatives, such as gabapentin, ketamine, and corticosteroids, can also help relieve pain following third molar extraction (26).

A unique characteristic of opioids, unlike NSAIDs, is their ability to cause temporary anterograde and retrograde memory impairments (27). While such memory effects could potentially impact cognitive function long term, in the short term, they help patients forget the experience of pain. Consequently, there are situations where non-opioid treatments may be insufficient. In those cases, opioid analgesics should be used judiciously, for the shortest amount of time necessary.

In following with the CDC, the American Dental Association (ADA) recommends dentists limit prescription of opioids to 7 days or less (28). Another possible alternative could be the use of opioids containing abuse-deterrent properties, such as inclusion of aversive substances or the use of prodrugs (29). The objective of these opioids is to mitigate illegal and unintended misuse of oral formulations. Although abuse-deterrent properties may benefit a limited cohort of patients, a more comprehensive and effective framework is essential to address the opioid crisis.

Epidemiology of the United States opioid crisis

Opioids are undeniably addictive medications, a fact that has significant implications for healthcare. Concerns about opioid misuse have existed before the United States government officially labeled the crisis as an epidemic in April 2011 (30). Understanding the complex history of opioid use and its inherent risks is crucial to addressing the ongoing challenges in managing pain and preventing addiction.

While opioids have been employed for various analgesic purposes for centuries, their use in the United States during the 1990s was primarily focused on managing cancer pain and providing end-of-life care (10). In 1986, the World Health Organization (WHO) introduced its analgesic ladder, a stepwise approach to pain management that recommended non-opioids for mild pain, mild opioids for moderate pain, and strong opioids for severe pain, primarily for cancer patients (31). This model aimed to ensure appropriate pain control while minimizing risks. However, during the 1990s, this structured approach became more widely applied to non-cancer pain, and the perceived safety of newer opioids, along with the emphasis on aggressive pain control, led to a sharp increase in prescriptions. One study found that an estimated 233.7 million opioid prescriptions were filled in retail pharmacies in the United States each year between 2006 and 2017 (32). Due to regulatory changes and evolving clinical guidelines, opioid-related overdose deaths decreased in 2023, for the first time since 2018 (33). However, overdose deaths caused by opioids continue to be an ongoing problem in the United States. The exact prevalence of addiction among chronic pain patients treated with opioids in the United States remains uncertain and could potentially exceed reported levels due to diversion and illicit drug use (34,35).

While difficult to quantify, it is increasingly evident that prescribers have played a significant role in the opioid crisis. A comprehensive review highlighted that patients prescribed higher doses of opioids face increased risk of overdose (34). Given that OMSs and other dental specialists are frequent prescribers of opioids and often prescribe to younger patients, there has been an emphasis by the entire oral healthcare field to promote responsible opioid prescribing (36,37). A significant driver of opioid misuse and diversion is the surplus of unused prescription opioids. A randomized controlled trial following outpatient dental surgery found that more than half of the opioids prescribed after tooth extractions were unused (8). Moreover, opioids prescribed after wisdom tooth extractions are linked to increased likelihood of continued opioid use in patients who have not previously used opioids (37,38). These findings illustrate how leftover opioids exacerbate misuse and diversion. In 2007, a national survey revealed that more than half (56.5%) of the misuse of prescription opioids occurred through sharing among friends or family members (39).

In response to the opioid crisis, tightening regulations on prescription opioids have inadvertently led to a rise in illegal fentanyl use. According to a study published in 2023, the increased presence of illicit fentanyl in the drug supply has significantly heightened the risk of fatal overdoses, emphasizing the need for a balanced approach to managing pain while preventing misuse (40). Addressing the opioid crisis demands a carefully balanced strategy that prioritizes effective pain management while minimizing the potential for misuse, diversion, and fatal overdoses.

Policy interventions

Over the past decade, the shift towards increasingly responsible opioid prescribing has been associated with the implementation of numerous policies (41). These interventions span across federal, state, local, and institutional levels as well as guidelines from organized bodies such as the ADA, American Medical Association (AMA), American Association of Oral and Maxillofacial Surgeons (AAOMS), and the CDC. For example, in 2014, the United States Congress passed a bill that reclassified hydrocodone, which at the time was widely prescribed for dental pain, from a Schedule III to a Schedule II substance, which made it more restrictive (42). More recently in guidelines regarding opioid prescribing for acute and postoperative pain management, authors representing AAOMS recommended that providers prescribe NSAIDs as first-line analgesic therapy, unless contraindicated. In addition to encouraging the use of PDMPs, the authors also stated that “if opioid analgesics are considered, start with the lowest possible effective dose and the shortest duration possible” (43).

One of the most significant policies that has been widely adopted across states is PDMPs (44). PDMPs are electronic databases that track dispensing of controlled substances to provide healthcare providers, including dentists and OMSs, with relevant patient prescription data (45). By providing prescribers with access to prescription histories of patients, PDMPs help identify and mitigate potential cases of prescription drug misuse. In a 2020 study utilizing Medicaid prescription data across the United States between 2011 and 2016, Wen et al. found that state implementation of PDMP mandates was associated with a decrease in opioid prescription rate from 161.47 to 147.07 prescriptions per quarter per 1,000 enrollees (46). PDMPs are managed at the state level but are impacted by federal regulations as well. Section 5042 of the United States SUPPORT Act mandates that all Medicaid providers reference relevant information from PDMPs prior to prescribing a controlled substance (47). Electronic prescribing (e-prescribing) systems allow providers to send prescriptions directly to pharmacies electronically, decreasing the risk of prescription fraud. Both PDMPs and e-prescribing capabilities can be integrated into electronic health records (EHRs), allowing providers to have real-time access to their patients’ opioid prescription histories.

Several state Boards of Registration in Dentistry (BORID) have implemented strict continuing education (CE) requirements and licensure regulations to promote responsible opioid prescribing (48). In addition, federal legislation, titled the Medication Access and Training Expansion (MATE) Act, requires healthcare providers who prescribe controlled substances to complete structured training on the treatment and management of patients with opioid or other substance use disorders (49). Through AAOMS’s CE offerings, OMSs can attend courses to count towards this requirement.

Other regulatory measures include EHR system defaults, days’ supply limits, and peer comparisons. EHR systems for opioid prescriptions often include default settings, such as limiting the quantity of opioids that can be prescribed at one time, which can prevent excessive prescribing. A recent study found that reducing the default number of tablets for opioid prescriptions in the EHR can modestly reduce prescribing (50). For opioid-naïve patients, many states have passed laws restricting the initial opioid prescription to a 7-day supply, aiming to mitigate the risk of long-term opioid use and dependence (51). However, important concerns have been raised about this standardization of prescribing policies, specifically because it does not account for variations in patient presentations and can unintentionally cause harm by decreasing patients’ access to therapeutic opioid analgesics (51). As opioid prescribing policies evolve, they must address these concerns while developing targeted interventions to mitigate opioid misuse and diversion. Regarding peer comparisons, some states have reports, such as in the form of report cards, which provide prescribers with data on their opioid prescribing patterns compared to their peers of the same medical specialty, adding to the opioid surveillance by identifying outliers and encouraging adherence to best practices (52). Given the small number of dentists and OMSs in most states in comparison to physicians, these comparisons may not be of specific value as the comparison groups may not be realistic. The “dentist” category may include double degree OMSs and double degree OMSs practicing under their medical licenses who may be excluded altogether. A more useful comparison may be the individuals prescribing habits over time.

Finally, the National Prescription Drug Take Back Day, organized twice a year by the Drug Enforcement Agency (DEA), is an initiative that encourages safe and responsible means to dispose of unused or expired prescription medications at designated locations in communities across the country (53). In April 2024 alone, Take Back Day brought in 670,136 pounds (335 tons) of medication (54). Other disposal programs include on-site disposal boxes in pharmacies (including CVS, Walgreens, independent and medical affiliates) and at-home drug deactivation and disposal systems such as Deterra (55,56). By reducing the availability of unused opioids in households, this initiative aims to mitigate drug abuse and diversion.

Conclusions

Much progress has been made to increase responsible opioid prescribing in healthcare over the last decade (52,53). Many high-volume prescribers and drug-seeking patients have been identified and addressed through provider education and public policies. Although opioid-related deaths have recently decreased as of 2023, there remains significant work to be done in addressing the opioid epidemic. Even though healthcare is only a part of the overall issue, recent research on opioid diversion and unused opioids prescribed post-operatively serves as a reminder that there is more to be done.

Looking forward, there are several avenues that warrant particular attention in terms of research and possible intervention. First, poor pain management may stem from the lack of uniform pain education during dental training. Pain education is often reliant on faculty in multiple departments who themselves may not have been trained on current standards. In a study that interviewed patients, medical students, and educators, Tellier et al. found that all participants recognized a need for additional medical education about pain assessment and management (57). In addition, the Commission on Dental Accreditation (CODA) has only recently added competency requirements for predoctoral students in management of orofacial pain and temporomandibular disorders. A robust, coordinated pre-doctoral curriculum will over time help to ensure that practitioners graduate with the necessary educational background to provide evidence-based pain management and may limit some of the causes of the current opioid crisis.

Beyond the pre-doctoral level training, practicing OMSs should be actively involved in staying up to date on opioid policies and best practices to optimize patient care. BORIDs should continue to mandate CE training. To this end, planners should be mindful regarding the involvement of commercial sponsors in pain education to avoid potential conflicts of interest. Another consideration is that high-cost and in-person CE courses can limit accessibility and create barriers for underserved populations (58). Evidence-based, conflict-free, high-quality programs tailored to the specific needs of the target audience should be promoted. Specialty societies, such as the ADA and AAOMS, should also be more proactive in endorsing best practice guidelines for pain management.

Furthermore, because the majority of OMSs treat patients in the private practice setting, the prescribing practices of these practitioners deserve additional attention (59,60). While the prescribing habits of these practitioners are captured by state and national level data, the more granular studies, particularly randomized clinical trials involving prospective interventions tend to be conducted in academic surgery settings. Collaboration with private practitioners, particularly those who practice in larger groups, can help shed light into prescribing differences between them and academic surgeons.

Also, the phenomenon of “just in case” prescribing (61) should be further explored. Some OMSs presumably understand that most of their patients will not use all, or even most, of the opioids prescribed. However, they will still prescribe a standard quantity of opioids perhaps because of the minority of patients who may require that amount or simply out of habit. This naturally risks opioid diversion. Insight into these practices can help inform interventions to curb diversion. Relatedly, clinical studies to assess patients for biomarkers that can help predict post-operative pain response may also be helpful to reduce the amount of opioids prescribed post-operatively (62).

Finally, a promising area that is underexplored is opioid disposal and drug take-back programs. Efforts by institutions and national public health agencies on this front remain in the fledgling phase (54,63). Clinical trials offering various incentives to patients who return unused opioids at follow-up appointments or local pharmacies could be conducted. While these would require an upfront investment in terms of financial resources and personnel, successful efforts for drug returns could be scaled regionally or nationally to reduce diversion. Looking forward, there is no imminent end to the opioid epidemic in the United States. Therefore, continued attention and investment in the aforementioned efforts are warranted.

Acknowledgments

None.

Footnote

Peer Review File: Available at https://joma.amegroups.com/article/view/10.21037/joma-24-22/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-24-22/coif). The authors have no conflicts of interest to declare.

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