A dentist's decision whether or not they will prescribe opioids is influenced by several factors and their personal experiences. Researchers identified 10 major factors that impact dental opioid prescriptions in a recent study published in the Journal of the American Dental Association.
The study was based on one-on-one interviews with dozens of dentists to better understand the nuances of opioid prescribing. It was a collaboration with the National Dental Practice-Based Research Network, which has more than 7,500 member dentists in six regions (JADA, July 18, 2022).
Based on the interviews, the authors identified 10 key themes that impact the capability, opportunity, and motivation of dentists to prescribe opioids.
1. Clinical and patient factors
Dentists generally agree that the existing guidelines are sufficient for writing appropriate opioid prescriptions, but they differ on which surgeries for which they prescribe opioids as pain management. Many note the decision of whether to prescribe opioids is a subjective judgment call based on patients' pain tolerance.
When prescribing opioids, dentists consider several clinical factors, including the type of surgery performed, patient considerations and requests, and for a few dentists, in case of breakthrough pain.
"If it's a Friday, or if I'm about to go out of town, a lot of times I'll give people a paper prescription for Norco or hydrocodone in case they need it," one dentist told researchers in the study.
2. Witnessing the risks of opioids firsthand
Many dentists recognize the high risk of opioid addiction, diversion, and overdose, which in turn affect their prescribing habits. About a dozen dentists said they were more hesitant to prescribe opioids after they witnessed patients or family members with substance use disorders. Additionally, two dentists stopped prescribing opioids after their license numbers were fraudulently used to obtain the prescription drugs.
"In worst-case [scenarios], opioid dependence can lead to death," said a dentist with seven years of experience. "I certainly don't want to start patients down that road."
3. Suspicion of a substance use disorder
Suspicion of a substance use disorder can impact whether dentists prescribe opioids for a patient. When dentists suspect a patient may have a substance use disorder, they trust their gut feeling based on suspicious behaviors, like a patient demanding a specific opioid brand or repeatedly requesting refills. Dentists will also use a prescription drug monitoring program (PDMP) to check for current and past opioid prescriptions that can indicate a patient is misusing opioids.
"If I have a patient that's asking for opioids and there's not a reason for it ... we will consult [the PDMP] program and find out if there's history," said a dentist in a suburban area.
4. Laws and regulations
State laws influence dentists' opioid prescribing habits, such as limiting the number of tablets that can be prescribed or requiring the use of specific prescription pads. Some institutions also require dentists to document checking the PDMP in patient charts.
"Unless legally required, a lot of us may consider our practice marketability beyond everything else," said a dentist in a rural area. "If it's considered illegal, you will think twice, because some of us will not cross that line just to get the patient."
5. Perceived business impact
Dentists worry that not prescribing opioids will hurt their practice's bottom line. Some dentists, especially those in areas with more competition, are concerned that fewer patients will visit their clinics if they do not prescribe opioids for procedures. Others worry that not prescribing opioids will lead to negative reviews or accusations of incompetent pain management.
"If I do a large surgical procedure and I'm not willing to prescribe the appropriate meds to help manage the patient's pain afterwards, fact of the matter is patients aren't gonna come to me," said a dentist with 10 years of experience.
6. Knowledge of opioid alternatives
Dentists' knowledge and beliefs about the effectiveness of opioid alternatives for dental pain management play a role in opioid prescribing. In the survey, dentists showed that they're knowledgeable that analgesics can effectively help manage pain after dental surgery, and they are willing to share their knowledge with patients.
"Usually, ibuprofen 800 milligrams is my go-to choice, and I give the patient 10 tabs in an envelope ... after the procedure," said a dentist in a city. "That way, they don't bother asking me for a prescription."
7. Ability to educate patients
Dentists routinely inform patients about the effectiveness of nonopioid analgesics for pain and work with them on a plan to address any breakthrough pain they may experience after surgery. While dentists acknowledge patients' pain concerns, they also have to set the expectation that some discomfort will occur, which can be a challenge.
"Pain-free is a really distorted expectation," a dentist with seven years of experience said. "We explain to patients that they're gonna be uncomfortable."
8. Capability of addressing substance abuse
Dentists differ in their beliefs regarding their responsibility to help patients manage substance use. Some want to refer patients to care and discuss risks, while others feel substance use disorder management is outside their scope of practice, which can make them reluctant to prescribe opioids at all.
"We're not trained in dental school to handle that at all," said a dentist with 30 years of experience.
9. Practice policies
The dental practice's setting can influence opioid prescribing. Having clinic policies or a standard of care for opioid prescriptions influences the types of prescriptions that dentists write.
"At our clinic here, we only prescribe three different types of medications," said a dentist with 33 years of experience. "We try to use ibuprofen when we can, and Tylenol, and the other one is tramadol."
10. Thoughts on the opioid crisis
Dentists generally do not perceive their profession to be the main contributor to the opioid crisis, instead citing physicians as the main providers of excess opioid prescriptions. Others place the blame on the tactics of pharmaceutical companies and even patients.
"The patients need to be responsible," said a dentist in an urban area. "If you know taking pain pills is bad for you when you're not in pain, then you know you need to have the responsibility for managing that. But the doctors are responsible too."
Key takeaways
The study was conducted with 73 members of the National Dental Practice-Based Research Network who practiced in U.S. counties with high or low opioid prescription rates. All participants were actively practicing dentistry in an outpatient clinic mainly serving adults, and the vast majority were general dentists. They were given a $50 gift card for their participation.
The interviews revealed that many real-world experiences influence how dentists prescribe opioids. Understanding the factors that affect opioid prescribing habits can ultimately help researchers create strategies for safe and effective opioid use, according to the authors.
"There is ... the need for the dental culture to integrate the norm of nonopioids in dental pain management," wrote the authors, led by Connie H. Yan, PharmD, PhD, a pharmacy graduate student at the University of Illinois at Chicago. "Improvements in system-level factors can ensure dentists can practice in environments that support the safe prescribing of opioids."
Based on the study design, the authors cautioned the findings may be only reflective of the opinions of dentists interested in the topic of opioids. Still, the survey shows that additional guidance, education, and training may be required for some dentists who are not as knowledgeable about current guidelines.
"Dentists who excessively prescribe opioids need to be identified, with the aim to understand knowledge gaps and to inform targeted interventions, such as revisions to education and training or refinement of dentist-specific guidance," the authors wrote.
