Evaluating Opioid Prescribing by Dentists in the United States: A Mixed Methods Approach

Evidence suggests that United States (US) dentists were excessively prescribing opioids. Risk mitigation strategies aimed to minimize overprescribing of opioids across all prescribers, inclusive of dentists, have been implemented. There is limited understanding how dentists’ prescribing of opioids have changed in response. This mixed methods dissertation aimed to address this evidence gap. First, a time-series approach was used to describe changes in dentists’ opioid prescribing from 2012-2019 using a comprehensive nationally-representative prescription claims dataset. Over the eight years, dentists prescribed >87.2 million opioid prescriptions. Autoregressive integrated moving average models demonstrated that population- and dentist-based prescribing rates, and opioid dosages (morphine milligram equivalents [MME]) significantly declined monthly from 2012-2019. Joinpoint regressions identified four time-points (February-2016, May-2017, December-2018, and March-2019) at which monthly prescribing rate trends were decreasing in higher magnitude compared to the prior time-segments. Second, an interrupted time-series analysis was used to understand how the 2014 federal rescheduling of hydrocodone impacted dentists’ prescribing of opioids. Immediately following the implementation of the federal regulation (index), hydrocodone prescribing immediately decreased, with increased prescribing of codeine, oxycodone, and tramadol. The average MME/day increased at index for all opioids except for hydrocodone. Third, interviews with a national sample of US dentists was conducted to identify barriers and facilitators to opioids prescribing. Seventy-three interviews were qualitatively analyzed. Eleven themes were identified within the Capability, Opportunity and Motivation Model of Behavior. Findings suggested that dentists were judicious prescribers of opioids if they were knowledgeable of analgesics, able to identify patients demonstrating behaviors of substance use disorders, capable of communicating to patients the pain management plans, or prescribed opioids within clinic policies or state/federal regulations. Dentists reported prescribing an opioid if they determined clinical necessity or feared patients’ negative perception if they refused to prescribe an opioid. Dentists’ opioid decision-making processes are influenced by a range of real-world practice experiences, and patient and clinic factors. Education/training that target the knowledge gap in dentists and changes in the dentist practice culture can encourage dentists to prescribe non-opioids as first-line analgesics, while conserving opioid use. US dentists’ have become more conservative in prescribing opioids. While regulations are capable of restricting dentists’ prescribing of opioids, other strategies targeting the knowledge gap in dentists may ensure dentists’ are capable of appropriately prescribing analgesics for dental-related pain.