GP4c - Do Oral and Maxillofacial Surgeons Prescribe More Opioids after Third Molar Removal for Patients with Substance Use History?

Abstract: Statement of the problem:
In 2018, an estimated 53.2 million (19.4%) people 12 years or older in the United States (US) used an illicit drug within the previous year. As such, oral and maxillofacial surgeons (OMSs) must be prepared to recognize patients with a substance abuse history (SUH) and may need to be prepared to adjust analgesic management for these patients. Although substance use may be associated with increased opioid requirements and delayed recovery, few recommendations exist to guide postoperative pain management in this population. Specifically, no data exist to guide postoperative outpatient opioid dosing quantitatively for patients with SUH. The purpose of this study was to measure and compare the amount of opioids prescribed by OMSs to patients with and without a self-reported SUH after third molar (M3) removal.

Materials, methods and data analysis:
The investigators implemented a retrospective cohort study and enrolled a sample derived from the population of patients who had their M3s removed between January 1, 2019, and December 31, 2019, at the OMS faculty/resident outpatient clinic, University of Washington (UW) School of Dentistry. Subjects were included in the study were male or female, age > 13 years, having had M3s removed under any type of anesthesia, in an outpatient setting with postoperative medications prescribed for analgesia. Subjects were excluded if they did not meet these inclusion criteria, had other procedures done concurrently with M3 removal, or if no postoperative analgesics were prescribed.

The primary predictor variable was SUH status coded as yes (SUH+) or no (SUH-). Subjects were categorized as SUH+ if the documented social history reflected SUH, or when selected on self-reporting health questionnaires. For this study, substances, as defined by the Centers for Disease Control and Prevention (CDC), included marijuana, cocaine (including crack), heroin, hallucinogens, and prescription psychotherapeutic drugs (including pain relievers, tranquilizers, stimulants, and sedatives). The primary and secondary outcome variables were: 1) prescribed morphine milligram equivalents (MMEs) and 2) number of postoperative visits due to inadequate pain control, respectively. Other variables were age, gender, payor (government [Medicare/Medicaid] or nongovernment [private insurance or self-pay]), provider (faculty or resident), anesthesia technique (local anesthesia [LA], nitrous oxide [N2O], moderate sedation [MS], or deep sedation/general anesthesia [DS/GA]), and procedure specific (erupted or impacted).

Institutional Review Board approval was obtained. Descriptive, bivariate, and multivariate statistics were computed.

Results and outcomes data:
The sample included 1112 subjects with a mean age of 25 +/- 9 years; 61.2% were female. Of the 1112 subjects, 198 (17.8%) were SUH+. Mean prescribed postoperative analgesics MMEs were 70.9 +/- 27.9 and 63.4 +/- 28.8 in the SUH+ and SUH- groups, respectively (P < .001). An adjusted linear regression model showed a non-significant association between SUH status and MMEs prescribed (P = .12). The study showed a non-significant increase (P = .15) in the proportion of patients with inadequate pain control in the SUH- group (4.1%) versus the SUH+ group (2.0%).

Conclusion:
The results suggest that 10% more opioids were prescribed for postoperative pain after M3 removal for patients with SUH, though after adjustment, the amount may not be clinically significant. The amount of MMEs prescribed for postoperative pain management after M3 removal in patients with SUH, on average, may be similar as for patients without SUH.

References:
1. U.S. Department of Health and Human Services. The national survey on drug use and health (NSDUH) report: 2018 NSDUH annual national report. Available at: SAMHSA.gov/data/report/2018-nsduh-annual-national-report. Accessed June 5, 2020.
2. Moran S, Isa J, Steinemann S: Perioperative management in the patient with substance abuse. Surg Clin North Am 95(2):417-28, 2015