Why are dentists still overprescribing opioids?
It’s no secret that prescribing opioids to adolescents and young adults carries a high risk of subsequent addiction and abuse — there’s even a new tv series about it. But among dentists, who are the most likely specialists to prescribe opioids for adolescents, opioid prescribing is still alarmingly common.
In 2015, dentists prescribed 67% more opioids to patients age 11-18 in 2015 than they did in 2010. And as many as half of the opioids prescribed by dentists from 2011-2015 exceeded the dose or days worth of pills recommended by the CDC’s guidelines.
Why are dentists still prescribing so many opioids? A new study in the The Journal of the American Dental Association examined dentists’ beliefs about opioids and other pain relievers, as well as their industry ties. The survey for the study was conducted by PharmedOut, a Georgetown University Medical Center project that advances evidence-based prescribing and educates health care professionals and students about pharmaceutical and medical device marketing practices. Here are some takeaways from the piece.
The good news
The survey revealed a lot of encouraging progress on opioid education and prescribing. Among the 269 dentists surveyed, most (84%) were aware that pain relievers like ibuprofen or acetaminophen work just as well or better than opioids for pain after dental procedures. One respondent wrote, “[I] have been very surprised at how well nonopioid pain management combinations work in situations where I previously would almost automatically prescribe opioids.” Additionally, the vast majority of respondents who prescribed opioids reported they were less likely to prescribe them to patients age 11-18.
Many dentists said they decreased their opioid prescribing in recent years, which is encouraging. Among the respondents, 71% said they prescribed fewer opioids in the past decade than they used to, and 34% stopped prescribing them entirely. One dental surgeon reported: “After wisdom tooth procedures, I used to prescribe 30 Vicodin with one refill…I now prescribe 6-10 Vicodin tablets after third molar surgery and am getting close to just prescribing NSAIDs [ibuprofen].”
The bad news
However, the survey showed that opioid prescribing, even for young adults, was still prevalent. A little less than half (43%) of respondents prescribed at least one opioid per month, and 13% reported more than 5 opioid prescriptions per month. Less than half of dentists who prescribed opioids reported that they were less likely to prescribe opioids to young adults (aged 19-25 years) than to older patients.
Dentists also tended to prescribe more pills than necessary. Despite being aware of the risks of opioid diversion and misuse, half of the dentists who reported prescribing opioids said that they prescribe enough to leave leftover pills.
Behind the pattern
Why are dentists still prescribing more opioids than necessary to high-risk groups when they are aware of the risks?
One possibility is the financial influence of pharmaceutical companies. Previous research reveals a strong correlation between opioid prescribing and industry payments to doctors. A 2019 analysis found that among doctors who wrote at least one opioid prescription between 2014 and 2015, doctors who prescribed more opioids were more likely to receive money from a pharmaceutical company than doctors who prescribed the median amount. Additionally, the more opioids doctors prescribed, the more money they received from pharma, on average.
However, dentists do not appear to have the same relationships with industry as doctors do. In the recent study, about 22% of dentists reported receiving a payment from a drug or device company (about half of all physicians receive payments from industry). “I don’t think this is due to industry, especially as [dentists] are mainly prescribing generic opioids,” said Adriane Fugh-Berman, director of PharmedOut and one of the study authors. Typically, drug companies devote their resources to increasing sales of their expensive branded drugs, not generics.
The study authors point to education as a potential blind spot for dentists. More than half of the survey respondents (54%) said that the pain management education they received in dental school was outdated, and 14% said they received no pain management education in dental school at all. Also, the American Dental Association (ADA) does not provide guidelines for opioid prescribing, which misses an opportunity to standardize prescribing and reduce overprescribing.
The lack of up-to-date education and guidelines may make some dentists susceptible to demands from patients. Among respondents, the vast majority (83%) believed that patients think that opioids are better for dental pain than other pain relievers. For some dentists it may be easier to just prescribe opioids, rather than have to explain to patients why they’re not prescribing them. The idea that patients want prescriptions is common among doctors, but not always founded; research has shown that many patients would be happy to reduce their medication burden if their doctor said it was possible.
Dentists are also affected by incentives within their practice. For example, some dentists reported that they gave patients extra pills so the practice wouldn’t get calls on weekends or holidays to refill the prescription. One general dentist wrote, “Opioids were given in abundance especially on Fridays so patients didn’t call on the weekends. Our [outpatient surgery] department preached this constantly.” In this case, the administrative demands of the department outweighed the dentist’s concerns about the risk of pill diversion.
Even though relatively few dentists had industry ties, some dentists had adopted talking points about pain popularized by the pharmaceutical industry. “Pain control is one of our hallmarks in patient management. Failure of adequate post-op pain control is a failure of your practice,” one dentist said. This framing of pain as a “vital sign,” which started in the late 1980s, was one of the drivers of the opioid epidemic. Another dentist said they were taught that patients with pain could not get addicted to opioids, another narrative pushed by opioid manufacturers.
The study authors recommend more independent (non-industry funded) education for dentists on pain management, more emphasis on the dangers of opioid addiction for young adults and teens, and that the ADA develop prescribing guidelines for dental pain that establish non-opioid pain relievers as the standard of care and highlight the risks of prescribing opioids.