A Qualitative Assessment of the Role of Dental Specialists in U.S. Opioid Epidemic

A Qualitative Assessment of the Role of Dental Specialists in U.S. Opioid Epidemic

Dental School Faculty and Postdoctoral Trainee Perspectives

Rochisha S. Marwaha, D.D.S., M.P.H., FICD; Gunnar Hasselgren, D.D.S., Ph.D.; Sarah Douglas-Broten, D.M.D., M.P.H.; Sidney B. Eisig, D.D.S.; Kavita P. Ahluwalia, D.D.S., M.P.H.

ABSTRACT

This research used qualitative methods to compare the prescription opioid-related knowledge, opinions and behaviors of oral surgery (OS) and endodontics (E) faculty and postdoctoral trainees. Semi-structured interview guides were used to conduct 10 key-informant interviews with faculty and focus group discussions with 18 postdoctoral trainees. Interviews and focus group discussions were recorded, transcribed and coded for thematic content. E faculty reported infrequent use of opioids for dental pain management, while OS faculty frequently prescribed opioids. Conversely, E faculty were more likely to use prescription drug monitoring programs to track patients’ potential for addiction compared to OS. In conclusion, the frequency of opioid prescribing for dental pain management varies among the two dental specialties.

The United States is in the midst of an opioid epidemic predicated on both illegal and prescription drug abuse. Forty-four people die each day due to prescription opioid overdoses, and the mortality has increased by a factor of five over the past 17 years, resulting in the declaration of an opioid epidemic by the U.S. Department of Health and Human Services.[1,2] Prescription opioids are efficacious pain relievers used to manage acute and chronic pain. Individuals misuse prescription opioids by taking doses other than prescribed, using a family member/friends’ prescription, or taking the medicine for the euphoric effect that may result.[3,4] Dentists (12%) are the second highest prescribers of immediate-release opioids after family physicians (15%),[5] and reports suggest that 45% of the initial-fill opioid prescriptions were written by dentists.[5,6] While the role of dentists in prescribing opioids is documented, there is limited information regarding their opioid prescribing knowledge, opinions and behaviors among dental specialists, and how their dental training impacts future practice.[5] Among dentists, oral and maxillofacial surgeons (oral surgeons) and endodontists are more likely to prescribe opioids postoperatively for management of acute pain.[5,7]

The most common dental procedures for which oral surgeons prescribe opioid analgesics are third molar and surgical extractions.[5,6,8,9] Historically, oral surgeons routinely prescribed approximately 20 opioid tablets for impacted third molar extractions. Prescriptions of these many tablets may result in leftover doses, with increased potential for abuse.[9,10] However, these prescribing practices have changed since the recent implementation of prescription drug monitoring programs (PDMPs).

Endodontists are most likely to prescribe narcotics for severe pain associated with a necrotic pulp, acute periradicular abscess, postoperative flare-up and postsurgical pain.[11] A Canadian study revealed that a significant proportion of endodontists prescribed opioid analgesics to manage postoperative endodontic pain when not indicated.[12] Also, a combination of opioid analgesics and acetaminophen is usually prescribed for treating odontogenic pain in patients for whom nonsteroidal anti-inflammatory drugs (NSAIDs) may be contraindicated.[7,13,14]

Prescription drug monitoring programs (PDMPs) are statewide databases that monitor the prescription of controlled substances such as opioid analgesics and can, therefore, be used to determine if a patient is seeking opioid drugs.[6,15] In New York State, the use of PDMPs was mandated on Aug. 27, 2013; however, there are no penalties for a practitioner who does not consult the PDMP before prescribing an opioid medication.[16]

Furthermore, only a five- or more day supply of a controlled substance prescribed from a dental office, private practice or urgent care facility requires PDMP consultation before prescription.[16] Since a five-day supply would cover much of the prescribing by dentists, it would seem the PDMP system would rarely apply to them. Also, a recent study indicated that the frequency of opioid prescriptions almost halved, and the number of opioid pills prescribed was reduced by 78% when the PDMP system was implemented; however, whether PDMPs were utilized by dentists before prescribing opioids was not assessed.[15]

Additionally, what is not known is the proportion of dental specialists, specifically oral surgeons and endodontists, who use PDMPs and their effectiveness and impact on practice. Furthermore, oral surgeons’ and endodontists’ opinions and knowledge, all of which may impact their propensity to screen and educate patients regarding abuse, are not known.[5,6,17,18]

The objective of this study was to compare the prescription opioid-related knowledge, opinions and practices of oral surgery and endodontic faculty and postdoctoral trainees at Columbia University, College of Dental Medicine. Since oral surgeons and endodontists are key dental specialties involved in acute pain management secondary to oral interventions, targeting them can play an important role in promoting non-narcotic pain management.[5,7]

Materials and Methods

This qualitative study was approved by Columbia University Medical Center’s Institutional Review Board (Protocols: AAAR5513 & AAAR5572). Data were collected through (a) key-informant interviews with faculty and (b) focus group discussions (FGDs) with oral surgery and endodontics postdoctoral trainees. Data were recorded, transcribed and coded for thematic content.

Development of semi-structured guides:

Semi-structured guides were developed by conducting literature reviews and interviews with oral surgery and endodontics faculty.

Data collection:

• Key-informant interviews: All attending oral surgery and endodontics faculty were requested to participate in the project via email by the chair of their respective departments. A semi-structured interview guide was used to conduct the interviews in a private space. Interviews were recorded and transcribed.

• Focus group discussions (FGDs): The study team worked with chief residents to recruit postdoctoral trainees in each dental specialty. One FGD was conducted for each of the specialties. FGDs, which were led by a moderator, were conducted in an enclosed, private space and were recorded and transcribed.

Analysis:

Transcriptions were hand-coded by two individual coders and compared for agreement. Themes gleaned from the key-informant interviews and FGDs were explored among team members and were followed by a discussion for quality assurance purposes. Additionally, themes were examined for patterns; quotes were used for interpretive purposes.

Results

Key-informant interviews were conducted with oral surgery (n=5) and endodontic (n=5) faculty; two focus group discussions (FGDs), which were restricted by specialty, were conducted with oral surgery (n=8) and endodontics (n=11) postdoctoral trainees.

Oral surgery faculty and postdoctoral trainees report that third molar and surgical extractions are the most common procedures for which opioids are prescribed; the opioid of choice is Percocet (oxycodone and acetaminophen).

Oral surgery faculty and trainees say they overprescribed opioid analgesics in the past as they were not aware of the CDC guidelines for acute pain management but are less likely to overprescribe now. Endodontics faculty and postdoctoral trainees report prescribing opioids for periapical flare-ups, pain due to severe pulpitis and surgical endodontics; Vicodin (hydrocodone bitartrate and acetaminophen) is their opioid of choice[15] (Table 1). Both endodontics faculty and trainees believe they rarely prescribe opioids and are not contributing to the opioid epidemic.

Nine themes emerged from the data and received consensus among the study team. The themes were segregated by specialty and faculty/trainee status for clarity and comparison (Table 2).

Theme 1: Patient Expectations

Faculty and trainees in both specialties consider managing patient expectations to be challenging; they believe that patients expect opioids following a surgical procedure and feel pressured to fulfill these expectations both to mitigate pain and build their practices.

Theme 2: Finger-Pointing

“Finger-pointing” or blame-shifting is a common theme among all interviews and focus group discussions. While endodontists blame oral surgeons for overprescribing, the oral surgeons, in turn, suggest that all surgical specialties in medicine and dentistry overprescribe. Additionally, both specialties believe that general dentists overprescribe due to lack of adequate training for acute pain management.

Theme 3: Private versus Academic Practice

Although both specialties concede they don’t overprescribe in their academic practices, faculty say they prescribe more frequently in private practice to retain patients. Trainees in

both specialties find prescribing opioids inconvenient due to faculty oversight. Endodontics postdoctoral trainees say they would be more likely to prescribe opioids in private practice.

Theme 4: Training

Currently, there are no specific courses on opioid prescribing at university, but postdoctoral trainees receive experiential training through practice with faculty. Recently, online training and courses provided by the American Association of Oral and Maxillofacial Surgery (AAOMS) and American Association of Endodontics (AAE) have increased awareness among some faculty and postdoctoral trainees.

Theme 5: Utilization of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) over Opioids

Both specialties are more likely to use NSAIDs as their firstline medication, with opioids being prescribed as a rescue drug for breakthrough pain. However, the two medications are frequently prescribed simultaneously, and instructions to take the opioid as needed for pain if the NSAIDs alone do not provide adequate relief are provided.

Theme 6: Use of PDMPs

Both oral surgery and endodontics faculty are aware of the PDMP policy in New York State. However, endodontists are more likely to use them compared to oral surgeons, who report time to be a deterrent to the use of PDMPs. Both specialties feel that the process of using PDMPs should be made less cumbersome in order to track patients’ previous use of opioids.

Theme 7: Screening Patients for Addiction before Prescribing Opioids

Both specialties report screening patients for addiction before prescribing opioids. Oral surgeons use patients’ medical and social histories, and endodontists examine their prescription histories through PDMPs. Additionally, oral surgeons mentioned that even if their patients’ histories indicate drug-seeking behaviors, they are entitled to receive an opioid for pain management following a painful procedure.

Theme 8: Identifying “Red Flags”

Both oral surgeons and endodontists focus on noticing warning signs of drug-seeking behaviors among patients, including reviewing prescription history through PDMPs, and a history of switching providers.

Theme 9: Contribution to the Opioid Epidemic

Oral surgery faculty and postdoctoral trainees report overprescribing opioids in the past but have changed their practices post-declaration of the epidemic. Endodontics faculty and postdoctoral trainees believe they are more conservative in prescribing opioids for pain management compared to other surgical specialties. Additionally, endodontics trainees believe that opioid addiction has more to do with chronic pain and long-term prescription.

Discussion

To the best of our knowledge, this study is the first qualitative assessment of prescription opioid-related knowledge, opinions and practices among oral surgery and endodontics faculty and postdoctoral trainees in an academic setting. While not generalizable, this pilot data presents valuable insights into opioid-related prescribing practices among dental specialists in practice and training. The study provides information that is worth exploring in a subsequent hypothesis-driven effort that could, in fact, contribute more robust data that might be used to address gaps in knowledge and practice among oral surgeons and endodontists in practice.

To the best of our knowledge, this study is the first qualitative assessment of prescription opioid-related knowledge, opinions and practices among oral surgery and endodontics faculty and postdoctoral trainees in an academic setting. While not generalizable, this pilot data presents valuable insights into opioid-related prescribing practices among dental specialists in practice and training. The study provides information that is worth exploring in a subsequent hypothesis-driven effort that could, in fact, contribute more robust data that might be used to address gaps in knowledge and practice among oral surgeons and endodontists in practice.

Patient expectations and demands emerge as a major challenge for faculty and trainees in both specialties; prescribing opioids in many cases is equally about patient and pain management. Finger-pointing is a common phenomenon among both dental specialties—while the oral surgeons blame all surgical specialties for overprescribing, endodontists pointed to general dentists and oral surgeons. Both finger-pointing and perceived pressure from patients shift ownership, precluding the need for action.

Our data suggests that there are no specific courses that target acute pain management using non-opioid alternatives; the primary model used for postdoctoral training is an apprenticeship model in which trainees learn experientially. Professional specialty groups, however, have provided online continuing education courses for dentists and specialists in practice. Additionally, the pain management and prescription opioid courses required to renew Drug Enforcement Administration (DEA) licenses have helped dentists and specialists keep their knowledge updated. While these courses may be useful in targeting specialists in practice, given the rise in opioid abuse in the United States, including pain management and prescription opioid training in advanced education dental program curriculum would be important for trainees.

Our data suggest that although practitioners are aware of PDMPs, there are differences in utilization and perceived utility of PDMPs by specialty. Oral surgery faculty and trainees report time constraints as a deterrent to using PDMPs, but endodontics faculty use PDMPs whenever they prescribe opioids. Additionally, endodontics trainees indicate that since faculty oversight restricts opioid prescribing in academic settings, they almost never prescribe opioids, and their use of PDMPs is, therefore, limited.

Oral surgery faculty and postdoctoral trainees in both specialties report that using PDMPs is time-consuming— efforts to streamline the use of PDMPs, and easy integration with electronic medical and dental records, could be considered. Alternatively, opportunities for more effective utilization of auxiliaries to monitor patient use of opioids should be explored. The utilization of PDMPs is not standardized across the United States; efforts to develop standard policy regarding their utilization across states should be considered because their consistent utilization has successfully been used to reduce the frequency of opioid prescribing among dentists and physicians.[16]

Our data suggest that endodontists believe they do not specifically contribute to the opioid epidemic because they feel that long-term opioid abuse is a consequence of chronic pain management. Recent studies indicate, however, that acute pain management can lead to long-term opioid use.[16,26,27] A study conducted by the Centers for Disease Control (CDC) suggests that the chance of long-term opioid use increases within the first days of therapy, including among individuals whose first episode of use was less than/equal to eight days.[27] It is, therefore, essential to increase awareness among dental specialists regarding the addictive potential of short-term opioid use for acute pain management and, in turn, educate their patients regarding the risks of opioids before prescribing.[16,27]

It is important to note that this pilot study included a sample of oral surgery and endodontics faculty and postdoctoral trainees from one dental school; therefore, this qualitative work is not generalizable to oral surgeons and endodontists at other dental schools, or providers in practice. Regardless, these data do provide important insight into the opioid prescribing behaviors of oral surgery and endodontics specialties both at the faculty and trainee levels and suggest that training is not standardized across specialties and time constraints, patient expectations, and state and local policies targeting the use of PDMPs impact opioid prescribing among specialists. Furthermore, the information gathered can be used to inform the development of instruments for quantitative studies of provider prescribing knowledge, opinions and practices, and, potentially, to then implement and test future educational interventions targeting dental specialists in training and practice.

This pilot qualitative research, while not generalizable, provides initial interesting data that requires further study and could eventually have implications for academia, policy and research. The disparity in utilization of prescription drug monitoring programs (PDMPs) among the oral surgery and endodontics specialties, and perceived impact on the epidemic by specialty, suggests that a more unified approach towards training and education of postdoctoral trainees and dentists-in-practice may be an important first step in mitigating the role of dentistry in the current epidemic. Additionally, if these results are confirmed by more generalizable studies, training that specifically addresses pain management, use of opioids, addiction and alternative therapies should be incorporated in the dental curriculum at the pre- and postdoctoral levels. Since sustained use of PDMPs can result in lowered rates of prescription, incorporation of the use of PDMPs in dental training and practice should be explored, and a single national PDMP policy should be considered. p

Queries about this article can be sent to Dr. Marwaha at marwaha@uthscsa.edu.

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Rochisha Singh Marwaha, D.D.S., M.P.H., FICD, is clinical associate professor, Comprehensive Dentistry, and assistant director, postdoctoral DPH residency program, University of Texas Health, San Antonio, School of Dentistry. She was a postdoctoral resident, Columbia University, College of Dental Medicine, New York, NY.

Dr. Marwaha

Gunnar Hasselgren, D.D.S., Ph.D., is professor of dental medicine, interim director of endodontics and chair, Section of Cariology and Restorative Sciences, Columbia University College of Dental Medicine, New York, NY.

Sarah Douglas-Broten, D.M.D., M.P.H., is a postdoctoral trainee, Section of Population Oral Health, Columbia University College of Dental Medicine, New York, NY.

Sidney B. Eisig, D.D.S., is chair, Section of Hospital Dentistry, and director, Division of Oral and Maxillofacial Surgery, Columbia University College of Dental Medicine, New York, NY.

Kavita P. Ahluwalia, D.D.S., M.P.H., is associate professor of dental medicine and director, postdoctoral program in dental public health, Columbia University College of Dental Medicine, New York, NY.