Long-Term Opioid Use Rare After Wisdom Teeth Removed

By Pat Anson, Editor

Anti-opioid activists have long claimed that thousands of young people have become addicted to opioid pain medication after having their wisdom teeth removed.

“Would you give your child heroin to remove a wisdom tooth?” is how a provocative 2016 anti-opioid billboard in New York City’s Times Square put it.

But a large new study published in JAMA found that the risk of long-term opioid use after wisdom tooth removal is relatively rare – although still a cause for concern.

The study of over 70,000 teens and young adults found that only 1.3% were still being prescribed opioids months after their initial prescription by a dentist. The risk of long-term use was nearly 3 times higher for young people prescribed opioids than for those who were not (0.5%).

Although the overall risk of long-term use is small, researchers say the sheer number of wisdom tooth removals warrants caution when prescribing opioids.

"Wisdom tooth extraction is performed 3.5 million times a year in the United States, and many dentists routinely prescribe opioids in case patients need it for post-procedure pain," said lead author Calista Harbaugh, MD, a research fellow and surgical resident at the University of Michigan’s Institute for Healthcare Policy and Innovation.

"Until now, we haven't had data on the long-term risks of opioid use after wisdom tooth extraction. We now see that a sizable number go on to fill opioid prescriptions long after we would expect they would need for recovery, and the main predictor of persistent use is whether or not they fill that initial prescription."

Harbaugh and her colleagues looked at insurance claims for opioid prescriptions between 2009 and 2015. Hydrocodone (70%) was the most common opioid prescribed after wisdom tooth removal, followed by oxycodone (24%). Long-term opioid use was defined as two or more prescriptions filled in the year after wisdom tooth removal.

But other factors besides dental surgery raised the risk of long-term opioid use. Teens and young adults who had a history of chronic pain or mental health issues such as depression and anxiety were more likely to go on to regular use after filling their initial opioid prescription.

"These are some of the first data to the show long-term ill effects of routine opioid prescribing after tooth extractions. When taken together with the previous studies showing that opioids are not helpful in these cases, dentists and oral surgeons should stop routinely prescribing opioids for wisdom tooth extractions and likely other common dental procedures," said senior author Chad Brummett, MD, co-director of the Michigan Opioid Prescribing and Engagement Network.

There are no specific prescribing guidelines for wisdom tooth removal. The American Dental Association recommends that dentists first consider non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief. It also supports the CDC opioid guidelines, which recommend that opioids be limited to no more than 7 days' supply for acute pain.

A small 2016 study found that over half the opioids prescribed to patients after wisdom tooth removal or dental surgery go unused, with many of the leftover pills being abused or stolen by friends and family members. On average, dental patients received 28 opioid pills and – three weeks later – most had pills leftover.

100 Million Pain Pills Unused After Dental Surgery

By Pat Anson, Editor

Over half the opioids prescribed to patients following dental surgery go unused, according to a small study by researchers who say the leftover pills could be abused or stolen by friends and family members.

Researchers affiliated with the University of Pennsylvania’s Perelman School of Medicine and School of Dental Medicine followed 79 patients who had their wisdom teeth removed or some other type of surgical tooth extraction. Seventy-two of them were given opioid pain medication after the surgery.

On average, patients received 28 opioid pills and – three weeks later -- had 15 pills (54%) leftover. Only five patients used all of the prescribed pills.

From that small sample, researchers project that as many as 100 million excess pain pills are prescribed annually by dentists.

 “When translated to the broad U.S. population, our findings suggest that more than 100 million opioid pills prescribed to patients following surgical removal of impacted wisdom teeth are not used, leaving the door open for possible abuse or misuse by patients, or their friends or family,” said lead author Brandon Maughan, MD, an emergency physician and health services researcher at The Lewin Group, a health policy consulting firm.

“Given the increasing concern about prescription opioid abuse in the United States, all prescribers – including physicians, oral surgeons and dental clinicians – have a responsibility to limit opioid exposure, to explain the risks of opioid misuse, and educate patients on proper drug disposal.”

Twenty-four hours after surgery, patients in the study reported an average pain score of 5 out of 10 while taking pain medication. By the second day, more than half (51%) reported a low pain score (0-3 out of 10), and by the fifth day, almost 80 percent had a low pain score.

“Results of our study show within five days of surgery, most patients are experiencing relatively little pain, and yet, most still had well over half of their opioid prescription left,” said co-author Elliot Hersh, DMD, a professor in the department of Oral & Maxillofacial Surgery and Pharmacology at Penn Dental Medicine.

“Research shows that prescription-strength NSAIDs, like ibuprofen, combined with acetaminophen, can offer more effective pain relief and fewer adverse effects than opioid-containing medications. While opioids can play a role in acute pain management after surgery, they should only be added in limited quantities for more severe pain.”

The study, published in the journal Drug and Alcohol Dependence, also found that drug disposal kiosks in pharmacies and small financial incentives may encourage patients to properly dispose of their unwanted pain medication.

Patients in the study received a debit card preloaded with $10. If they completed surveys assessing their pain and medication use after surgery, they received an addition $3 credit on the debit card. Patients who completed a follow-up health interview received an additional $10.

Patients were also provided with information about pharmacy based drug disposal programs, which led to a 22% increase in the number of patients who had either disposed or planned to properly dispose of their leftover opioids.

“Expanding the availability of drug disposal mechanisms to community locations that patients regularly visit – such as grocery stores and retail pharmacies – may substantially increase the use of these programs,” Maughan said.

Reducing the excess prescribing of opioids for acute pain is one of the goals of the Centers for Disease Control and Prevention. The CDC's prescribing guidelines state that three days or less supply of opioids “often will be sufficient” for acute pain caused by trauma or surgery, and that 7 days supply “will rarely be needed.”  Those guidelines, however, were developed for primary care physicians, not dentists.