Those who fill an opioid prescription for wisdom tooth removal are nearly three times as likely to keep using

A new study recently published in JAMA by Michigan OPEN researchers finds a link between filling an opioid prescription after wisdom tooth extraction and long-term opioid use

Young people ages 13 to 30 who filled an opioid prescription immediately before or after they had their wisdom teeth out were nearly three times as likely as their peers to still be filling opioid prescriptions weeks or months later.

Those in their late teens and twenties had the highest odds of persistent opioid use, compared with those of middle school and high school age

Led by Calista Harbaugh, M.D., a Michigan OPEN research fellow and University of Michigan surgical resident, the researchers used insurance data to focus on young people who were ‘opioid naïve’ — who hadn’t had an opioid prescription in the six months before their wisdom teeth came out, and who didn’t have any other procedures requiring anesthesia in the following year.

“Wisdom tooth extraction is performed 3.5 million times a year in the United States, and many dentists routinely prescribe opioids in case patients need it for post-procedure pain. Until now, we haven’t had data on the long-term risks of opioid use after wisdom tooth extraction. We now see that a sizable number go on to fill opioid prescriptions long after we would expect they would need for recovery, and the main predictor of persistent use is whether or not they fill that initial prescription.”

Dr. Harbaugh

Other factors also predicted risk of long-term opioid use. Teens and young adults who had a history of mental health issues such as depression and anxiety, or chronic pain conditions, were more likely than others to go on to persistent use after filling their initial wisdom tooth-related prescription.

More about the study

In all, 1.3 percent of 56,686 wisdom tooth patients who filled their opioid prescription between 2009 and 2015 went on to persistent opioid use, defined as two or more prescriptions filled in the next year written by any provider for any reason. That’s compared with 0.5 percent of the 14,256 wisdom tooth patients who didn’t fill a prescription.

Though those numbers may seem small, the high number of wisdom teeth procedures every year mean a large number of young people are at risk, notes Harbaugh.

The team used data from employer-based insurance plans, available through the Truven MarketScan database. Chad Brummett, MD, co-director of Michigan OPEN and is senior author of the new research. The team also includes U-M School of Dentistry professor Romesh Nalliah, DDS, MHCM.

The data show opioid prescriptions filled, but not actual use of opioid pills by patients. Leftover opioids pose a risk of their own, because they can be misused by the individual who received the prescription, or by a member of their household or a visitor. The researchers also couldn’t tell the reason for the later opioid prescription fills by those who went on to persistent use.

Importance for providers

The authors suggest that dentists and oral surgeons should consider prescribing non-opioid painkillers before opioids to their wisdom tooth patients. If pain is acute, they should prescribe less than the seven-day opioid supply recently recommended by the American Dental Association for any acute dental pain.

“There are no prescribing recommendations specifically for wisdom tooth extraction,” says Harbaugh. “With evidence that nonsteroidal anti-inflammatories may be just as, if not more, effective, a seven-day opioid recommendation may still be too much.”

Brummett adds, “These are some of the first data to the show long-term ill effects of routine opioid prescribing after tooth extractions. When taken together with the previous studies showing that opioids are not helpful in these cases, dentists and oral surgeons should stop routinely prescribing opioids for wisdom tooth extractions and likely other common dental procedures.”

Nalliah, the dentist on the Michigan OPEN research team, agrees. “I believe that opioid prescribing for dental procedures can be cut to a fraction of what it is today,” he says. “Through wisdom tooth extraction, the dental profession has an enormous opportunity to fight the opioid crisis by preventing early introduction of opioids to America’s young people. We hope that our study will make my fellow dentists think twice about removing wisdom teeth, and to more strongly consider non-opioid solutions.”

Michigan OPEN has created patient educational materials for dentists and oral surgeons to use, free of charge, within their practice. Information within these brochures include facts about opioids, questions for the patient to ask the doctor, and information about safe opioid medication storage and disposal. Michigan OPEN will co-brand these brochures with the dentist’s logo, free of charge, should they request it.

Importance for patients and parents

Getting a prescription for an opioid painkiller around the time of a wisdom tooth procedure comes with many decision points, Harbaugh says.

“Patients must decide whether to fill the prescription and take the medication, and where to store and dispose of the unused pills. All of these decision points need to be discussed with patients,” she says. “Patients should talk to their dentists about how to control pain without opioids first. If needed, opioids should only be used for breakthrough pain, as backup if the pain’s not controlled with other medications.”

The Michigan-OPEN team is currently studying the wisdom tooth extraction population further, by speaking with patients and parents about their experience and how many opioid pills they actually took. This will allow them to create evidence-based prescribing guidelines just like the ones they’ve developed for other operations.

The research was funded by the federal Substance Abuse and Mental Health Services Administration, the Michigan Department of Health and Human Services, and University of Michigan Precision Health.

Nearly 5 percent of patients ages 13 to 21 who had common surgical procedures continued to receive opioid prescription refills three to six months after surgery, according to new data presented by Michigan OPEN research fellow Calista Harbaugh at the American Academy of Pediatrics National Conference & Exhibition and published in Pediatrics.

This is the first known study to show that long-term opioid use after surgery may be a significant problem for teens and young adults. Researchers analyzed data using commercial claims from the Truven MarketScan research databases between January 1, 2010, and June 30, 2015.

The cohort study included 88,637 privately insured adolescents (with an average age of about 17) who had never used opioids before and who had one of 12 common surgical procedures, including tonsil or adenoid removal, hernia repair, cholecystectomy and scoliosis repair.

Of the total, more than 4,343 patients still got opioid refills 90 to 180 days after surgery, according to pharmacy claims.

“One of the most common things we hear when we raise this issue is ‘doctors don’t give kids opioids,’ but we know that’s not accurate. We found that nearly 90,000 young people in this study received opioids, and almost 1 in 20 of them continued to receive these medications months later. Doctors need to be aware that refilling opioid prescriptions for teens can be a problem by either increasing the risk of dependence or increasing access to medications that may be distributed to other youth,” says Calista Harbaugh, MD.

Harbaugh notes that researchers looked at opioid prescriptions, not necessarily opioid use. But refills indicate the medications were used, stored or diverted into the community, she says.

A new study, published in JAMA Surgery, reveals an interesting breakthrough from the Michigan OPEN team at the University of Michigan, in efforts to stop the national crisis of opioid addiction. The study found that reducing opioid prescribing by nearly sixty-six percent did not affect the patient’s level of postoperative pain control, which would mean less opioids left over to be pushed into potential diversion.

Currently, no national guidelines exist for surgery-related pain control with opioids. The idea of creating guidelines on prescribing surgery-related pain prescriptions focuses on how patients actually use the medications, and then educating providers and the rest of the community based on this research.This study will provide evidence to support such guidelines.

The study reveals insight on post-op opiate use for a common operation: gallbladder removal. Patients undergoing this surgery receive an average prescription of 250 milligrams of opioids for the treatment of post-op pain. After interviewing a large portion of the patients, the researchers discovered that most of the patients used an average of 30 milligrams after their surgery. Many patients interviewed before the guidelines took effect said they wanted to know how many pills to expect to take, and the guide laid it out: “Most patients take about five or fewer, and they stop taking pain medicine by the fifth day after surgery”, one-fifth of what the average patient is prescribed!

As a result of these findings, Michigan Medicine lowered the average prescription given to their patients for gallbladder surgery to 75 milligrams of opioids (approximately 15 pills) in the 200 patients treated in the first five months after the guideline went into effect. Requests for opioid refills did not increase and the percentage of patients getting a prescription for nonopioid painkillers such as acetaminophen or ibuprofen more than doubled. These findings contribute to and support the recommendations created by Michigan OPEN and MSQC earlier this year.

More than 10 percent of people who had never taken opioids prior to curative-intent surgery for cancer continued to take the drugs three to six months later, according to a new Michigan OPEN study, published in the Journal of Clinical Oncology. The risk is even greater for those who are treated with chemotherapy after surgery.

“We wanted to look at patients who had potentially curable disease, such as early stage breast cancer, colon cancer or melanoma. These patients deserve special attention, because if they’re going to be free from cancer, we’d also like them not to be on opioids long term,” says lead study author Jay Lee, M.D., a general surgery resident at Michigan Medicine and Michigan OPEN research fellow.

The team used a national data set of insurance claims to identify 39,877 cancer patients who had never previously used opioids and were prescribed the drugs after undergoing curative-intent surgery from 2010 to 2014.

Of this group, 10 percent continued to fill opioid prescriptions with high daily opioid dose — equivalent to six tablets per day of 5-milligram hydrocodone — three months after surgery. Daily opioid doses remained at this level even one year after surgery.

A new study from Michigan OPEN researchers suggests that having surgery may come with an additional risk: the risk of becoming a long-term opioid user.

The team reviewed data from more than 36,000 nonelderly adults with private insurance who had only one operation in a two-year period from 2013 to 2014. None had an opioid prescription in the year preceding the operation.

About 6 percent of people who hadn’t been taking opioids before an operation but were prescribed the drugs to ease postoperative pain still refilled the drugs three to six months later. The average number of postoperative prescriptions was 3.3, adding up to about 125 pills. The rate didn’t differ between patients who had minor or major surgery.  It was also 12 times higher than the rate of long-term opioid prescription filling seen in a control group of similar adults who didn’t have surgery during the study period.

The Michigan OPEN team found that certain factors made some “opioid-naïve” surgery patients more likely to refill opioid prescriptions for months afterward.

Those who had been smokers or were diagnosed with alcohol, drug, depression, anxiety or chronic pain conditions before their operations had a higher rate of persistent prescriptions.

This suggests other reasons that patients might keep up opioid use months after an operation — despite a lack of evidence that the drugs help chronic pain or other long-term issues.

“This points to an under recognized problem among surgical patients,” says Chad Brummett MD, the first author of the study and one of the co-directors of Michigan OPEN. “This is not about the surgery itself, but about the individual who is having the procedure and some predisposition they may have. And we know that continued opioid use is probably not the right answer for them.”

The team continues to study the issue in hopes of developing better processes for surgical teams to predict and manage the risk of long-term opioid use among their patients. The researchers launched an effort to help surgical teams prescribe opioids appropriately in the weeks immediately before and after an operation or procedure which can be found at opioidprescribing.info. The team plans to update these recommendations regularly.