Dentists Continue to Prescribe Opioids to Adolescents for Pain Relief

PainRelief.com Interview with:
Adriane Fugh-Berman MD
Professor, Dept. of Pharmacology and Physiology
Georgetown University Medical Center

PainRelief.com:  What is the background for this study?  What are the main findings?

Response: The first exposure of adolescents and young people to opioids is through dentists, who frequently prescribe opioids after dental procedures. Dentists are the highest prescribers of opioids to patients under 18. We conducted a national survey of dentists and received 269 responses from 30 states and 2 territories.

Four of five dentists knew that  that nonsteroidal anti-inflammatory drug (NSAID)-acetaminophen combinations are equally as effective or more effective than opioids, but 43% still  regularly prescribed opioids. There was more caution about prescribing opioids  to adolescents aged 11 through 18 years, but only half ( 48%) reported they were less likely to prescribe opioids to young adults 19 -25 years (compared to adults over 25). This is concerning  because adolescents and young adults under 25 are more likely to develop opioid use disorder than adults over 25. 

One-half of those who reported prescribing opioids reported prescribing more opioids than needed, which would result in leftover pills. Leftover pills  pose a risk for later misuse. 

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Tramadol Prescriptions for Pain Relief Linked to More Complications than Codeine

PainRelief.com Interview with:
Carlen Reyes PhD
Médico de familia
Gestora de proyectos de investigación IDIAP Jordi Gol

PainRelief.com: What is the background for this study? What are the main findings?

Response: Tramadol and codeine are two “weak” opioids frequently prescribed for different non-cancer pain indications, however, few are the studies that compare the adverse outcomes between them using large routinely collected primary care data. We aimed to fulfil this gap by analysing the risk of adverse events with the tramadol and codeine dispensations in a large primary care health care data (SIDIAP database) from Spain. 

We found that the dispensations of tramadol were associated with a greater risk of cardiovascular events, mortality and fractures compared to the dispensations of codeine. 

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Study Finds Medical Cannabis Not Likely to Solve Opioid Crisis for Pain Patients

PainRelief.com Interview with:
Carsten Hjorthøj, senior Researcher
Copenhagen Research Center for Mental Health – CORE, Mental Health Center Copenhagen, Copenhagen University Hospital
University of Copenhagen, Department of Public Health
Section of Epidemiology, Copenhagen, Denmark.

PainRelief.com:  What is the background for this study?  What are the main findings?

Response: Denmark introduced a pilot program of medical cannabis in 2018. Medical cannabis, and cannabis-based medicine, has gained a lot of both attention and controversy as a possible way to treat pain disorders, but the evidence base is still sparse. The Danish nationwide unselected registers allow us to perform a high quality pharmacoepidemiologic study with propensity score matched controls.

The main findings are that medical cannabis and cannabis-based medicine did not reduce the use of opioids in pain patients, and might actually lead to an increase in use of opioids. However, patients with neuropathic pain disorders appeared to reduce their use of gabapentin, their use of overall medication (but not opioids!), and the number of days spent in hospital, compared with controls.

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Pronounced Declines, but Regional Differences, in Hospital Use of Prescription Opioids

Sarah A. Eidbo, MS
MD Candidate
Geisinger Commonwealth School of Medicine Class of 2023
Scranton, Pennsylvania

Sarah A. Eidbo

MedicalResearch.com: What is the background for this study?

Response: The United States is still witnessing the fallout from years of a devastating, multifaceted opioid crisis. However, in the wake of this situation, healthcare providers and systems across the nation have implemented many strategies to curb the damage where they can. This study1 used reports from the Drug Enforcement Administration (DEA)2 to quantify the changes and trends in prescription opioid distribution to hospitals in the U.S .over the past two decades.

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Switching to Buprenorphine Might Provide Pain Relief for Poorly Controlled Pain

PainRelief.com Interview with:
Victoria D. Powell, MD, FACP
Clinical Lecturer – Geriatric and Palliative Medicine
University of Michigan
Staff Physician, Palliative Care
LTC Charles S. Kettles VA Medical Center
Ann Arbor, MI

Dr. Powell

PainRelief.com:  What is the background for this study?  What are the main findings?

Response: People with chronic pain who use long-term opioids face a number of health risks, and often do not have optimally controlled pain.

Buprenorphine acts on the opioid receptor with a different effect than drugs like morphine or oxycodone, and as a result is less associated with the risks of long-term opioid use, such as accidental overdose. While buprenorphine has been successfully used in patients with opioid use disorder for several years, certain experts have proposed using buprenorphine for pain management in people with chronic pain. We found low quality evidence supporting pain control that may be superior to traditional opioids, but much more research is needed to confirm.

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Physicians Differently Prescribe Pain Relief Medications to White and Minority Patients

PainRelief.com Interview with:
Dan P. Ly M.D., M.P.P., Ph.D.
Division of General Internal Medicine and Health Services Research
David Geffen School of Medicine
University of California, Los Angeles

PainRelief.com:  What is the background for this study?  What are the main findings?

Response: We know that minority patients were less likely to receive opioids than white patients, but this could have been due to minority patients seeing lower opioid-prescribing physicians. As far as I could tell, nobody had been able to examine whether the same physician prescribed opioids differently to their minority patients.

I find that this is the case: the same physician was less likely to prescribe opioids to their minority patients with new low back pain, and instead was more likely to prescribe NSAIDs to their minority patients. And unfortunately, this differential prescribing may have had the consequence of leading to more chronic opioid use in white patients.  

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Overdose Rates Increased When Pain Meds Prescribed by Multiple Providers

PainRelief.com Interview with:
Kao-Ping Chua, MD, PhD
Department of Pediatrics
Susan B. Meister Child Health Evaluation and Research Center,
Department of Health Management and Policy, School of Public Health,
University of Michigan Ann Arbor

Dr. Kao-Ping Chua

PainRelief.com:  What is the background for this study?  What are the main findings?

Response: Having overlapping opioid and benzodiazepine prescriptions is a strong risk factor for opioid overdose even if these prescriptions are written by the same prescriber.

In this study of privately insured and Medicare Advantage patients, we show that the risk of overdose is even greater when the prescriptions are written by multiple prescribers. Specifically, the unadjusted risk of overdose on a day of overlap was 1.8 times higher when the prescriptions were written by multiple prescribers. After controlling for patient demographic characteristics, clinical co-morbidities, and prescribing patterns, the adjusted odds of overdose was 1.2 times higher, corresponding roughly to a 20% higher adjusted risk.

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Opioid Use Disorder: Treatment Among US Medicaid Enrollees

PainRelief.com Interview with:
Julie Donohue, Ph.D., Chair and Professor
University of Pittsburgh Graduate School of Public Health Department of Health Policy and Management.
Lead, Medicaid Outcomes Distributed Research Network

Dr. Donohue

PainRelief.com:  What is the background for this study?

Response: Medicaid plays an incredibly important role in our health system, and the population it serves overlaps with those most likely to have opioid use disorder. But Medicaid is 50-plus separate programs that can’t easily share data, so it can be difficult to draw evidence-based conclusions about the impact of interventions to prevent and treat opioid use disorder in this population.

PainRelief.com: What are the main findings?

Response: For the first time, we’ve pooled a large part of that data, enabling us to draw powerful conclusions that could better enable our country to address the opioid epidemic, which has only grown more intense during the COVID-19 pandemic. We found that the prevalence of opioid use disorder increased from 3.3% of enrollees in 2014 to 5% in 2018. Notably, the share of enrollees with opioid use disorder enrolled in Medicaid due to the ACA expansion grew from 27.3% to 50.7% in the same time period.

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Multimodal Analgesia For Pain Relief After Joint Replacement

PainRelief.com Interview with:

Joseph Albert Karam, MD
Assistant Professor of Clinical Orthopaedic Surgery
Associate Program Director, Orthopaedic Surgery Residency
The University of Illinois at Chicago

Joseph-Karam
Dr. Karam

PainRelief.com:  What is the background for this study?Would you describe the multimodal pain plan?

Response: Pain after joint replacement surgery has been historically managed by protocols centered on opioid medication. Given the side effects associated with these medications, the risk for long term addiction and evidence showing that opioids are not necessarily the best at treating pain perioperatively in joint replacement, multimodal pain management protocols have been established. These protocols utilize different families of medications that target pain at different steps in the pain pathway.

The exact protocol varies from one institution to the other but typically include systemic agents such as acetaminophen, non-steroidal anti-inflammatories/COX-2 inhibitors, gabapentinoids, corticosteroids, as well as loco-regional interventions such as local infiltration analgesia and regional nerve blocks. ‘Pre-emptive analgesia’ which most commonly uses a nonsteroidal anti-inflammatory, acetaminophen and/or a gabapentinoid has also been demonstrated to play a key role. Additional measures such as NMDA antagonists and epidural catheters can also be used in select cases. Non-pharmacological treatments such as cryotherapy, cryoneurolysis and electrical nerve stimulation have also been described. Our preferred institutional protocol is detailed in the paper.

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Prescription Opioids for Pain Relief in Youth Decreased in Recent Years

PainRelief.com Interview with:

Madeline H. Renny, MD
Postdoctoral Fellow, Department of Population Health
Clinical Instructor, Department of Emergency Medicine and Pediatrics
New York University Grossman School of Medicine
New York, New York

Dr. Renny

PainRelief.com:  What is the background for this study?

Response: Prescription opioids are involved in over half of opioid overdoses among youth.  Additionally, prescription opioid use is associated with risks of future misuse, adverse events, and unintentional exposures by young children.  While there are several studies on opioid prescribing in adults, few studies have focused on the pediatric and adolescent population.  In the last year, postoperative guidelines for opioid prescribing for children and adolescents were released, but there remain no national guidelines on general opioid prescribing for youth. 

To our knowledge, no prior national studies have examined trends in important opioid prescribing practices, including amount prescribed, duration, high-dosage, and extended-release/long-acting (ER/LA) opioid prescriptions, in this subset of the population; a necessary step in understanding the opioid epidemic and in developing targeted interventions for youth. 

Therefore, we performed a cross-sectional analysis of U.S. opioid prescription data to investigate temporal trends in several key opioid prescribing practices in children, adolescents, and younger adults in the U.S. from 2006-2018.


PainRelief.com: What are the main findings?

Response: We found that opioid dispensing rates declined significantly for children, adolescents, and younger adults since 2013. When examining trends in opioid prescribing practices, there were differences based on age group. For adolescents and young adults, rates of long-duration and high-dosage opioid prescriptions decreased during the study period, whereas there were increases in these rates for younger children.  

PainRelief.com: What should readers take away from your report?

Response: Dispensed opioid prescriptions for youth have significantly decreased in recent years.  These findings are consistent with prior studies in children and adults, suggesting that opioid prescribing practices may be improving. Additionally, the decrease in rates of high-dosage and long-duration prescriptions in adolescents and young adults is encouraging in the context of research showing associations with these prescribing practices and opioid use disorder and overdose. However, opioids remain commonly dispensed to youth and potential high-risk prescribing practices (long-duration, high-dosage, and ER/LA prescriptions) appear to be common, especially in younger children.  

PainRelief.com: What recommendations do you have for future research as a result of this work?

Response: The increase in rates of potential high-risk prescribing practices in young children was an unexpected finding and warrants future study. Due to the limitations of our database (no clinical information, including diagnoses or indications for prescription), we were unable to determine the appropriateness of opioid prescribing practices (e.g., whether a prescription was for a child with cancer or for a child with an acute injury).  Our two sensitivity analyses were performed to try to identify a subset of patients with chronic illness and both showed no differences in trends.  However, it will be important to further investigate these opioid prescribing practices using a database with clinical information to better understand these findings in young children.

Further research investigating specific opioid prescribing practices may inform targeted interventions, including pediatric and adolescent-specific opioid prescribing guidelines, to ensure appropriate opioid prescribing in this population. 

No disclosures

Citation:

Renny MH, Yin HS, Jent V, Hadland SE, Cerdá M. Temporal Trends in Opioid Prescribing Practices in Children, Adolescents, and Younger Adults in the US From 2006 to 2018. JAMA Pediatr. Published online June 28, 2021. doi:10.1001/jamapediatrics.2021.1832

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