Predictive Factors in Opioid Administration for Acute Odontalgia; A Pilot Study

PURPOSE:  The use of non-steroidal anti-inflammatory drugs (NSAIDs) after third molar surgery has been shown to be superior to the use of combination opioid narcotics (1).  However, most oral surgeons frequently prescribe these narcotics to their patients.  Unlike NSAIDs, opioids have significant addiction potential and prescription drug abuse has reached epidemic proportions (2).  Prescribing patterns are often based on providers’ preferences without clear scientific evidence as to which modality of postoperative pain management is best.  A better understanding of the prescribing patterns after third molar surgery may help focus provider behavior and alter the management of acute odontalgia.

HYPOTHESIS:  Patient, provider, and surgical factors are related to the prescribing of opioids analgesics by oral surgeons.

MATERIALS AND METHODS:  Using a historical cohort study design, 300 charts were reviewed from patients who underwent mandibular third molar extractions in the New York University College of Dentistry’s Oral and Maxillofacial Surgery Clinic in 2011.   Ultimately, 260 charts were included in the study.  The presence or absence of specific patient predictor risk factors and outcomes were identified and recorded.  Patient predictors included: age, gender, ethnicity, and American Dental Association (ADA) procedure code.  ADA code is related to the difficulty of extraction.  Outcomes included: positive or negative combination opioid narcotic prescription, type of opioid prescribed, dosage of opioid prescribed, number of subsequent visits to the clinic for postoperative pain, number of additional combination opioid prescriptions given, type of additional opioid prescribed, and dosage of additional opioid prescribed.  Provider experience was also recorded.  20 charts were reviewed by two independent examiners to calculate inter-examiner reliability. 

RESULTS:  Overall, 78.8% of the sample was prescribed a combination opioid narcotic.  Risk ratios were calculated for the relationship between individual risk factors and the prescription of a combination opioid narcotic.  The presence of preoperative pain (OR=2.10, p<.05) and patients’ age (younger or older than 40-60 years old) (OR=12.30, p<.001) were significantly associated with the prescribing of an opioid after mandibular third molar surgery.  Multiple logistic regression analysis was used to develop a preliminary overall predictive model of risk factors for the prescription of combination opioid narcotics.  Both risk factors were independent predictors of the prescription of a combination opioid narcotic (preoperative pain, p<.05), (age, p<.001).  Gender, ethnicity and ADA code were not related to prescribing patterns. 

CONCLUSIONS: The presence of preoperative pain predicts the prescribing of opioid medications after mandibular third molar surgery.  Younger patients (under 40) and older patients (over 60) are more likely to be prescribed narcotics after mandibular third molar extractions.  Provider prescribing patterns may be based on factors that are independent of patients’ presentations for third molar surgery.  Future studies are needed to better understand why surgeons prescribe opioids in an effort to more accurately manage postoperative pain after third molar surgery, reduce the potential for prescription drug abuse, and set the stage for targeted educational interventions. 

 REFERENCES:

1. Barasch A, Safford MM, et al. Patterns of postoperative pain medication prescribing after invasive dental procedures. Spec Care Dentist. 2011;31(2):53-57.
2. Hernandez SH, Nelson LS.  Prescription drug abuse: insight into the epidemic.  Clin Pharmacol Thera. 2010; 88(3):307-317.