Addressing the high rate of opioid prescriptions for dental pain in the emergency department

138 Correspondence / American Journal of Emergency Medicine 36 (2018) 134168


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    Addressing the high rate of Opioid prescriptions for Dental pain in the

    emergency department ?,??,???

    Over two million people in the United States face an addiction to Prescription opioids and over twelve million reported abusing opioid medications in 2015 [1]. A common site of analgesic opioid prescription is for patients presenting with acute pain in the emergency department (ED). Approximately 50.3% of patients who present with non-traumatic dental pain in the ED receive a prescription for opioid drugs [2]. In con- trast, opioid analgesics were prescribed for just 14.8% of all other ED pa- tients [2]. Patients presenting with non-traumatic dental pain were also

    ? The authors have no potential conflicts of interest to disclose.

    ?? No sources of support were provided, including in the form of equipment, drugs, or grants.

    ??? This research did not receive any specific grant from funding agencies in the public,

    commercial, or not-for-profit sectors.

    twice as likely to be prescribed an opioid drug over a non-opioid drug or no painkillers [2]. There were over 2.18 million visits to emergency de- partments for dental pain in 2012 alone, approximately 1.7% of total ED visits [3]. Additionally, Uninsured patients had the highest likelihood of receiving an opioid prescription (57.1%) [2]. Evidence suggests that opi- oid analgesic prescription by physicians in the emergency department may contribute to the development of long-term opioid use or addiction in some patients [4,5]. The high frequency of recurrent ED visits for acute dental pain [6] may be contributing to the increased availability of opioid drugs, addiction, and morbidity and mortality associated with prescription Opioid abuse. It’s imperative that emergency depart- ment physicians and researchers acknowledge this discrepancy in opi- oid prescription rates and consider non-traumatic dental pain as they develop and implement guidelines for safe prescribing of opioid analgesics.

    For most patients presenting with non-traumatic dental pain, emer- gency department physicians provide antibiotics and analgesics to tem- porize the condition until a dentist can provide definitive treatment. The time consumed to evaluate and treat patients with dental pain may contribute to longer ED Waiting times and overcrowding, as well as take up time and space that could have been used for patients with more seri- ous, urgent conditions. The immense pressure on ED physicians to con- serve time and manage heavy patient loads isn’t frequently conducive to conducting thorough oral health examinations or reviewing prescrip- tion drug monitoring data.

    We propose two workflow solutions to reduce the rate of opioid pre- scribing to patients presenting with non-traumatic dental pain in the emergency department. First, many emergency department physicians and staff have received training to administer bupivacaine dental blocks, local anesthesia injections that offer relief from dental pain for up to 11 h [7]. Encouraging physicians and nurses to utilize dental blocks more fre- quently may reduce the number of prescribed opioids. Additionally, we suggest that ED staff that have not received training in this simple proce- dure utilize publicly available online medical videos for self-training [8]. Second, evidence suggests that over-the-counter non-steroidal anti-in- flammatory drugs (NSAIDs) and acetaminophen alone may provide ef- fective analgesia for most non-traumatic dental pain and Dental procedures, including third molar extractions [9]. Research suggests that the use of controlled substance Prescribing guidelines that encourage the use of Non-steroidal anti-inflammatory drugs and dental nerve blocks before opioids for patients presenting with dental pain in the ED leads to a reduction in opioid analgesic prescription rates [10].

    Emergency department treatment of non-traumatic dental pain may represent an important, possibly overlooked, area of high opioid prescrib- ing in the United States. As new approaches to curb opioid prescription rates, including novel guidelines and checklists to standardize best prac- tices, are implemented in health care organizations across the United States, it will be important to examine the incidence of opioid prescribing for dental conditions that present in medical settings.

    Nisarg A. Patel, BS, BA

    Harvard School of DentalMedicine, 188 Longwood Ave,

    Boston, MA 02115, USA

    E-mail address: [email protected]

    Salim Afshar, DMD, MD

    Department of Plastic and Oral Surgery, Boston Children’s Hospital, 300

    Longwood Ave, Boston, MA 02115, USA Corresponding author at: Department of Plastic & Oral Surgery, 300 Longwood Avenue, Hunnewell, 1st Floor, Boston, MA 02115, USA.

    E-mail address: [email protected]

    3 May 2017

    Correspondence / American Journal of Emergency Medicine 36 (2018) 134168 139


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    Acuity, treatment times, and patient experience in Freestanding Emergency Departments affiliated with academic institutions

    The first goal of the Institute for Healthcare Improvement (IHI) Tri- ple Aim Initiative is to “improve the patient experience of care (includ- ing quality and satisfaction).” Our goal was to evaluate and compare common ED quality metrics, and patient satisfaction scores specifically

    Table 1

    Average triage level of patients seen in FEDs compared to national averages.a

    Triage level

    Study FED average % for 2014 (“n” = 114,053)

    National ED average % for 2014b (“n” = 136.3 M)

    Level 1 (resuscitation)



    Level 2 (emergent)



    Level 3 (urgent)



    Level 4 (semi-urgent)



    Level 5 (non-urgent)



    a Indicates a statistically significant difference between study FED and national ED, p b


    b Medicare hospital outpatient and physician claims.

    at 8 Freestanding Emergency Departments (FEDs) affiliated with aca- demic institutions to both national Emergency Department (ED) data and to EDs with similar volume.

    While there are few FEDs affiliated with academic institutions at this time, several institutions have plans to build them in order to expand pa- tient coverage and increase training opportunities. Regarding all FEDs, Jere- miah Schuur, et al., had noted that between five and 10% of all emergency care is now provided in FEDs [1]. Patidar et al. noted a 121% increase in FEDs and an 1129% increase in independent FEDs from 2007 to 2013 [2].

    The FEDs in our study represent three affiliated with Cleveland Clin- ic, three from Baylor College of Medicine, one from the University of Utah, and one from Northwell Health.1 Data were derived from Elec- tronic Health Record (EHR) data of 147,053 patient visits for these facil- ities in 2013 and 2014. All facilities are staffed almost exclusively (99%) by BC/BE Emergency Physicians. FEDs affiliated with Cleveland Clinic, Northwell, and Utah all receive ambulances. Northwell’s Lenox Health FED receives 46% of their patients from ambulance services, which is one of the highest percentages in New York City.

    Chart 1. Average triage level of patients seen in academic FEDs compared to national averages*.

    We evaluated Acuity levels, wait times, treatment times, and patient satisfaction data. We performed a retrospective chart review using EHRs and Hospital Outpatient Quality Reports (HOQR) submitted to the Cen-

    ter for Medicare and Medicaid Services (CMS). These results were 1 Affiliated with Hofstra Northwell School of Medicine at Hofstra University.

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