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Empowering Dentists to Reduce Opioid Prescriptions to Young People

Despite lowering opioid prescription rates, dentists in the US prescribe more opioids than dentists in any other country. [1-4]





While a new prescription to any opioid-naïve individual carries short- and long-term risks, prescriptions for adolescents and young adults are particularly problematic.



Research shows that taking prescription opioids before high school graduation increases the risk of future opioid misuse, [5] illicit drug use, [6-8] and drug overdose. [9]

Additionally, nearly 60% of opioids prescribed for acutely painful conditions in outpatient settings remain unused, and most unused opioids come from dental procedures and prescriptions to children.[10] These leftover tablets are a risk for misuse, diversion, and accidental ingestion.



This study will test a new multi-component approach to reduce opioid prescriptions for acute dental pain after tooth extraction. The intervention will use techniques that are designed to modify dentist decision-making behavior towards evidence-based practices for acute dental pain management.

By The Numbers

40.9%

Between 2013 and 2020, 40.9% of adolescent and young adult patients received opioid prescriptions compared to 23% of patients across other age groups.[11]

3x

A filled opioid prescription following wisdom teeth extraction nearly triples the likelihood of persistent opioid use among opioid-naïve patients aged 13-30 years. [12]

1/3

Over 1/3 of high school seniors who misuse opioids use a leftover prescription. [13]

The ADOPT Study Multi-Component Intervention Includes:

Academic Detailing

Academic detailing is a peer-to-peer interactive education methodology and is an evidence-based, effective way to reduce opioid prescribing. [14-18] Dentists will participate in sessions led by a trained pharmacist to discuss strategies for safer opioid prescribing tailored specifically to the provider’s practice. [19] Key messages include efficacy and adverse events associated with nonopioids compared to opioids, risks of opioids specific to adolescent and young adult patients, setting realistic pain expectations, and best practices when opioids are prescribed. 

Two male providers talking

Post-Procedure Instructions

The ADOPT team will provide standardized patient education materials for clinics to give to their patients. The materials emphasize expectation setting, using non-opioid analgesics as first-line pain management, and safe storage/disposal of opioids when prescribed. Materials will include QR codes linking to the Kentucky Office of Drug Control Policy county-specific drug disposal locations. Patients will be invited to complete a survey that monitors the pain management experience and medication usage behaviors.

dentist working on patient

Non-Opioid Analgesic Blister Packs

The third component of the intervention is a pre-packaged, labeled blister pack of acetaminophen and ibuprofen for distribution by the clinic/provider. The goal of the blister packs is to provide tangible resources to clinicians to reduce “just-in-case” prescribing.

blisterpack

Meet The Team

Doug Oyler

Doug Oyler College of Pharmacy

Douglas Oyler, PharmD, is an assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky’s College of Pharmacy. His research focuses on safe opioid prescribing and other strategies to mitigate harm from the opioid crisis in Kentucky and beyond. He has served as principal or co-investigator on numerous projects funded by NIH, FDA, DOJ, DOD, and others.

Dr. Oyler is one of the primary investigators and, along with Dr. Rojas-Ramirez, will oversee all aspects of the study. 

Marcia Rojas Ramirez

Marcia Rojas-Ramirez College of Dentistry

Dr. Marcia Rojas-Ramirez is an Assistant Professor at the University of Kentucky’s College of Dentistry with a background in Public Health. She is a Diplomate of the American Board of Orofacial Pain and has over 10 years of experience in the field of chronic pain management.

Dr. Rojas-Ramirez will work closely with Dr. Oyler to ensure the study is successfully implemented by overseeing all aspects of the trial, including harmonization of the processes, recruitment, and retention of the clinical sites.

Aaron Begley headshot

Aaron Begley COLLEGE OF PHARMACY

Aaron L. Begley, BPH, is the Assistant Research Coordinator for the ADOPT study. He has 2 years of experience working at the University of Kentucky within the Substance Use Priority Research Area, including the HEALing Communities Study. He received his BPH from the UK College of Public Health, and his research interests include Health Disparities in Kentucky, Social/Behavioral Theories pertaining to behavior change, and substance use/Opioid Prescribing practices. 


Mr. Begley will serve as the principal contact for managing supply inventory and assist with invoicing, reporting, and site coordination.

JDP

Jennifer Dolly Prothro College of Pharmacy

Jennifer M. Dolly Prothro, MPH, CCRP, is the Project Manager for the ADOPT study and has over 10 years of experience working in research at the University of Kentucky (UK).  She received her MPH from the UK College of Public Health, with a focus on Health, Behavior & Society.  Her research interests include clinical research in substance use disorders, behavioral methodology, and implementation science.

Ms. Dolly Prothro will work closely with the project team to guide research activities conducted at the dental clinic sites and will oversee research coordination, regulatory oversight, and network operations.

Enif Dominguez Fernandez headshot

Enif Dominguez-Fernandez College of Dentistry

Enif A. Dominguez-Fernandez, DDS, graduated from dental school at the Central University of Venezuela (Universidad Central de Venezuela, Caracas-Venezuela). After nine years as a chief surgical assistant in a nationally well-recognized oral and maxillofacial surgery center (Caracas-Venezuela), she received her oral and maxillofacial surgery training at the University of Kentucky. Her clinical interests include dental implants, zygomatic implants, distraction osteogenesis, orthognathic surgery, oral and maxillofacial reconstruction, and sleep apnea surgery. She is currently an Assistant Professor of Dentistry at the University of Kentucky’s College of Dentistry.

Dr. Dominguez-Fernandez will collaborate with MPI Dr. Rojas-Ramirez to ensure the harmonization of study procedures across sites
and aid in the recruitment of dentists and oral surgeons.

Trish Freeman

Trish Freeman College of Pharmacy

Patricia (Trish) Freeman, Ph.D., is the Earl Platt Slone Endowed Professor of Pharmacy Practice and Science and University Research Professor at the University of Kentucky’s College of Pharmacy. She has substantial experience leading and coordinating pharmacist-initiated prevention and opioid-related harm reduction efforts, including academic detailing to reduce opioid prescribing. Dr. Freeman has authored more than 100 publications.

Dr. Freeman will oversee the study’s academic detailing initiatives and aid in evaluation and dissemination. 

Hannah Knudsen

Hannah Knudsen College of Medicine

Hannah K. Knudsen, PhD, is a Professor of Behavioral Science at the University of Kentucky’s College of Medicine. Her area of specialization is addiction health services research and implementation science. Much of her work has focused on the adoption and implementation of evidence-based practices (EBPs) for the treatment of substance use disorders (SUDs), and she has published more than 130 peer-reviewed publications.

Dr. Knudsen will oversee implementation-related design and analysis, specifically examining key implementation outcomes of the intervention. Knudsen will also ensure scientific and ethical standards are met and aid in evaluation and dissemination.

Maggie Lang

Maggie Lang College of Public Health

Maggie Lang, MMC, MS, is a Biomedical Data Scientist within the Biostatistics Consulting and Interdisciplinary Research Collaboration Lab (Biostat CIRCL) at the University of Kentucky’s Department of Biostatistics. She leverages her extensive experience working with large-scale biomedical data to collaborate with researchers across various disciplines.

Ms. Lang will serve as a Staff Statistician, working closely with Dr. Westgate on all required statistical analyses.

Craig Miller

Craig Miller College of Dentistry

Craig S. Miller, DMD, MS, is the Alvin L. Morris Professor of Oral Health Research and Associate Dean for Faculty Affairs and Development at the University of Kentucky’s College of Dentistry. He is board-certified in Oral Medicine, with 35 years of experience in the diagnosis and management of complex oral health issues and medically compromised patients. Dr. Miller has authored more than 200 publications, co-authored four internationally recognized textbooks, and has maintained funding from the National Institutes of Health for more than 30 years.

Dr. Miller will facilitate the recruitment of dentists and oral surgeons, assist in ensuring protocol adherence, manage communication with clinical site providers, and aid in the evaluation and dissemination of the findings.

Monica Roberts

Monica Roberts College of Pharmacy

Monica F. Roberts, PharmD, is an academic detailing pharmacist with experience providing education to physicians, pharmacists, and dentists. She developed and delivered the prescription opioid safety educational outreach program for the University of Kentucky’s HEALing Communities Study.

Dr. Roberts graduated from the University of Kentucky College of Pharmacy in 2017 and completed the University of Kentucky College of Pharmacy Community Pharmacy Residency Program with the Kroger Louisville Division in 2018. She has over 6 years of experience working in various roles in community pharmacies. Prior to her pharmacy career, she worked in journalism and publishing as a copy editor, page designer, and technical writer.

Courtney Rogers

Courtney Rogers COLLEGE OF PHARMACY

Courtney Rogers, BA Sociology & Spanish, is the Administrative Research Coordinator for the ADOPT study and is earning an MSW at the University of Kentucky. She has a combined ten years of experience implementing programs pertaining to opioid use disorder treatment (UK’s HEALing Communities Study), health insurance (Kynect), transportation access (Broke Spoke Community Bike Shop), and nutrition/food security (UKY SNAP-Ed).

Ms. Rogers will be the principal contact for regulatory compliance, ensure protocol adherence, and assist with site coordination.  

Sharon Walsh

Sharon Walsh College of Medicine

Sharon Walsh, Ph.D. is a Professor of Behavioral Science, Psychiatry, Pharmacology, and Pharmaceutical Sciences in the Colleges of Medicine and Pharmacy at the University of Kentucky and serves as Director of the Center on Drug and Alcohol Research and the Substance Use Disorder Priority Research Area.   Her clinical research focuses on pharmacological and behavioral issues in opioid use disorder, including studies on the efficacy of pharmacotherapies for opioid use disorder, abuse liability of psychoactive drugs, and the pharmacology of widely used opioid analgesics. She has published more than 170 manuscripts and book chapters.  She is presently the Principal Investigator of the HEALing Communities Study, which is a large-scale implementation science project aimed at reducing opioid overdose deaths.

Dr. Walsh will provide scientific guidance and administrative support to this trial to ensure its integrity, successful implementation, and compliance within the relevant regulatory frameworks.  She will also ensure that ethical standards will be met with regard to clinical research and clinical trial conduct and assist in disseminating the outcomes.

Philip Westgate

Philip Westgate College of Public Health

Philip Westgate, Ph.D., is a Professor and Acting Chair of the Department of Biostatistics at the University of Kentucky’s College of Public Health. His methodological areas of interest include cluster, group, or community randomized trials, longitudinal studies, and clustered data in general. Furthermore, he has applied interests in a variety of areas, including the substance use area.

Dr. Westgate will serve as the statistical lead and oversee statistical planning/design, measurement of variables, and development of study-specific data entry user guides. Dr. Westgate will also oversee monthly data quality and completeness reporting as well as analysis of all outcomes.

References

1. Fadare JO, Oshikoya KA, Obimakinde OS, et al. Patterns of drugs prescribed for dental outpatients in Nigeria: findings and implications. Acta Odontol Scand. Oct 2017;75(7):496-506. doi:10.1080/00016357.2017.1347822

2. Suda KJ, Durkin MJ, Calip GS, et al. Comparison of Opioid Prescribing by Dentists in the United States and England. JAMA Netw Open. May 3 2019;2(5):e194303. doi:10.1001/jamanetworkopen.2019.4303

3. Hollingworth SA, Chan R, Pham J, Shi S, Ford PJ. Prescribing patterns of analgesics and other medicines by dental practitioners in Australia from 2001 to 2012. Community Dent Oral Epidemiol. Aug 2017;45(4):303-309. doi:10.1111/cdoe.12291

4. Teoh L, Hollingworth S, Marino R, McCullough MJ. Dental opioid prescribing rates after the up-scheduling of codeine in Australia. Sci Rep. May 21 2020;10(1):8463. doi:10.1038/s41598-020-65390-6

5. Miech R, Johnston L, O'Malley PM, Keyes KM, Heard K. Prescription Opioids in Adolescence and Future Opioid Misuse. Pediatrics. Nov 2015;136(5):e1169-77. doi:10.1542/peds.2015-1364

6. Hudgins JD, Porter JJ, Monuteaux MC, Bourgeois FT. Prescription opioid use and misuse among adolescents and young adults in the United States: A national survey study. PLoS Med. Nov 2019;16(11):e1002922. doi:10.1371/journal.pmed.1002922

7. Muhuri P, Gfroerer J, Davies M. Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States. SAMHSA CBHSQ Data Review. 2013

8. Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers -United States, 2002-2004 and 2008-2010. Drug Alcohol Depend. Sep 1 2013;132(1-2):95-100. doi:10.1016/j.drugalcdep.2013.01.007

9. Friedman J, Godvin M, Shover CL, Gone JP, Hansen H, Schriger DL. Trends in Drug Overdose Deaths Among US Adolescents, January 2010 to June 2021. JAMA. Apr 12 2022;327(14):1398-1400. doi:10.1001/jama.2022.2847

10. Dyson MP, et al. Quantifying unused opioids following emergency and ambulatory care: A systematic review and meta-analysis. J Am Coll Emerg Physicians Open. 2022;3(5):e12822. doi:10.1002/emp2.12822

11. Oyler DR, Rojas-Ramirez MV, Nakamura A, Quesinberry D, Bernard P, Surratt HL, Miller CS. Factors influencing opioid prescribing after tooth extraction. JAm Dent Assoc. 2022 [accepted; in press]

12. Harbaugh CM, Nalliah RP, Hu HM, Englesbe MJ, Waljee JF, Brummett CM. Persistent opioid use after wisdom tooth extraction. JAMA. 2018;320(5):504-506. doi:10.1001/jama.2018.9023 

13. McCabe SE, West BT, Boyd CJ. Leftover prescription opioids and nonmedical use among high school seniors: a multi-cohort national study. J Adolesc Health. Apr 2013;52(4):480-5. doi:10.1016/j.jadohealth.2012.08.007

14. Bounthavong M, Devine EB, Christopher MLD, Harvey MA, Veenstra DL, Basu A. Implementation evaluation of academic detailing on naloxone prescribing trends at the United States Veterans Health Administration. Health Serv Res. Oct 2019;54(5):1055-1064. doi:10.1111/1475-6773.13194

15. Bounthavong M, Harvey MA, Wells DL, et al. Trends in naloxone prescriptions prescribed after implementation of a National Academic Detailing Service in the Veterans Health Administration: A preliminary analysis. J Am Pharm Assoc.Mar -Apr 2017;57(2S):S68-S72. doi:10.1016/j.japh.2016.11.003

16. Smart MH, Mandava MR, Lee TA, Pickard AS. Feasibility and acceptability of virtual academic detailing on opioid prescribing. Int J Med Inform. Mar 2021;147:104365. doi:10.1016/j.ijmedinf.2020.104365

17. May F, Simpson D, Hart L, Rowett D, Perrier D. Experience with academic detailing services for quality improvement in primary care practice. Qual Saf Health Care. Jun 2009;18(3):225-31. doi:10.1136/qshc.2006.021956

18. Saffore CD, Pickard AS, Crawford SY, Fischer MA, Sharp LK, Lee TA. Practice change intentions after academic detailing align with subsequent opioid prescribing. J Am Pharm Assoc. Nov-Dec 2020;60(6):1001-1008. doi:10.1016/j.japh.2020.08.011

19. Walsh SL, El-Bassel N, Jackson RD, et al. for The HEALing Communities Study Consortium. The HEALing (Helping to End Addiction Long-term (SM)) Communities Study: Protocol for a cluster randomized trial at the community level to reduce opioid overdose deaths through implementation of an integrated set of evidence-based practices. Drug Alcohol Depend. Dec 1 2020;217:108335. doi:10.1016/j.drugalcdep.2020.108335

NIH/NIDCR Support

​​​This research is supported by the National Institute of Dental and Craniofacial Research (NIDCR) under award number UG3DE032621. The content is solely the responsibility of the authors and does not necessarily represent the official views of NIDCR or the National Institutes of Health.

We wish to remember and honor those who inhabited this Commonwealth before the arrival of the Europeans. Briefly occupying these lands were the Osage, Wyndott tribe, and Miami peoples. The Adena and Hopewell peoples, who are recognized by the naming of the time period in which they resided here, were here more permanently. Some of their mounds remain in the Lexington area, including at UK’s Adena Park.

In more recent years, the Cherokee occupied southeast Kentucky, the Yuchi southwest Kentucky, the Chickasaw extreme western Kentucky and the Shawnee central Kentucky including what is now the city of Lexington. The Shawnee left when colonization pushed through the Appalachian Mountains. Lower Shawnee Town ceremonial grounds are still visible in Greenup County.

We honor the first inhabitants who were here, respect their culture, and acknowledge the presence of their descendants who are here today in all walks of life including fellow pharmacists and healthcare professionals.