Archive | 2021
Cost savings from averted prescription opioidattributable dental diseases in the United States between 2013 and 2019
Abstract
INTRODUCTION Between 2013 and 2019, opioid prescriptions in the US declined by about 7% per year. However, little is known about the health and economic impacts of this decline on common dental diseases in adults (i.e. periodontitis, untreated dental caries and edentulism). We sought to assess relationships between prescription opioid use and indicated dental diseases, and to estimate associated epidemiologic and economic impacts of the decline in opioid prescriptions. METHODS We evaluated NHANES data (2009, 2011, 2013 and 2015 cycles) to measure associations between recent prescription opioid use and indicated dental diseases. We then used an empirical modeling approach to estimate: a) the number of patients directly affected by withheld opioid prescriptions, b) associated changes in the number of patients with indicated dental diseases, and c) associated changes in direct and indirect costs of care. RESULTS Estimated one-year risks of untreated caries and edentulism were 1.5% (95% CI: 0.2–2.8, p<0.05) and 2.6% (95% CI: 1.2–4.1, p<0.05) higher in NHANES participants with recent prescription opioid use compared to those without. About 102 million opioid prescriptions were withheld from about 91 million individuals between 2013 and 2019; this may have averted over 1.3 million cases of untreated caries and 2.3 million cases of edentulism, and may have saved up to $1.4 billion in direct and indirect costs. CONCLUSIONS The decline in opioid prescriptions between 2013 and 2019 may have averted over 3.6 million combined cases of untreated caries and edentulism, and may have saved the US economy over $1.4 billion. INTRODUCTION The US has been experiencing an opioid epidemic driven by prescription opioids1. With annual opioid prescriptions averaging over 200 million in the last decade, there are about 2 million substance use disorder diagnoses and 50000 overdose deaths each year1. The opioid epidemic cost the US over $1 trillion between 2001 and 2007, and the annual cost to society ranges between $89 billion and $117 billion (2018 US$)2. This economic burden results from criminal justice involvement (about 9%), direct and indirect healthcare costs (up to 45%), and workplace productivity loss (up to 46%)3. Between 2013 and 2019, the previously rising trend in annual opioid prescriptions underwent a reversal. With growing awareness of the opioid epidemic, increasing adoption of safer prescribing practices, and implementation of Prescription Drug Monitoring Programs, annual opioid prescriptions declined by about 7% per year between 2013 and 20194,5. Expectedly, fewer opioid prescriptions should reduce the number of new opioid-attributable health conditions and associated costs6. Indeed, early reports indicate that in 2018, overdose deaths decreased for the first time in almost three decades7. However, little is known about other opioid-related health conditions that may have been averted by the decline in opioids prescriptions. In the oral health landscape, this knowledge gap is compounded by unclear associations between prescription opioid use and common dental diseases (i.e. periodontitis, untreated caries and edentulism)8,9. To fill these gaps, this study’s goals were: a) to evaluate associations between prescription opioid use and common dental diseases, and b) to estimate averted new cases of common dental diseases (and associated cost savings) from the indicated decline in opioid prescriptions. Research Paper| Population Medicine Popul. Med. 2021;3(May):13 https://doi.org/10.18332/popmed/136488 2 This study’s findings are expected to contribute to the national discourse on impacts of the opioid epidemic. METHODS Data sources National Health and Nutrition Examination Survey (NHANES) NHANES is a nationally representative survey of the noninstitutionalized US civilian population to assess the health and nutritional status of adults and children in the United States10. The survey combines interviews with physical examinations, and oral health outcomes are usually assessed by calibrated examiners to minimize measurement error in self-reported outcomes11. Other characteristics of NHANES have been previously described10. For adequate statistical power, we created two pooled datasets across three NHANES cycles: 2009–2010, 2011–2012, and 2013–2014 cycles to study periodontitis among persons aged ≥30 years; and 2011–2012, 2013–2014, and 2015–2016 cycles to study untreated caries and edentulism among individuals aged ≥20 years. Opioid Prescriptions in the US Data on the total number of opioid prescriptions dispensed in the United States between 2012–2019 were obtained from the Centers for Disease Control and Prevention and are presented in Table 112. We estimated the decline in opioid prescriptions as year-on-year differences between 2013 and 2019. Measures Oral health outcomes Oral health measurements in the NHANES datasets include probing depth, gingival recession, attachment loss, and indices of periodontal disease (mild, moderate, severe, or any periodontitis). We used available oral health measures to create binary indicators of periodontitis (present or absent based on CDC/American Academy of Periodontology case definitions), untreated caries (≥1 tooth affected vs none) and edentulism (≥1 tooth missing vs none)13. Indicator of prescription opioid use Recent (i.e. in the past 30 days) use of hydrocodone, oxycodone, propoxyphene, codeine, tramadol, opium, morphine, fentanyl, hydromorphone, meperidine, pentazocine, oxymorphone, or tapentadol was also assessed in the indicated NHANES cycles; these data were used to create a binary indicator of recent prescription opioid use. Others Control covariates of interest (based on plausible associations with the key independent and/or outcome variables) in the NHANES datasets were gender, age, race/ethnicity, educational level, poverty level, health insurance status, country of birth, veteran status, depressive symptoms, cigarette smoking, alcohol use, marijuana use, methamphetamine use, cocaine use, heroin use, comorbidities (including arthritis, diabetes, thyroid disorders, hypertension, hypercholesterolemia, angina, coronary arterial disease, heart attack, stroke, asthma, bronchitis, emphysema, liver diseases and cancer) and NHANES cycle. Analyses Evaluating associations between prescription opioid use and common dental diseases Logistic regression was used to evaluate each indicator of common dental diseases as a function of recent prescription opioid use and control covariates specified above. An alpha of 0.05 was used to determine statistical significance. The logistic regression models were also used to predict the six-year (i.e. 2009–2014 and 2011–2016) risk differences of indicated dental diseases across respondents with and without recent prescription opioid use (i.e. as differences in respective six-year cumulative incidences). These sixyear risk differences were then converted to one-year risk differences using methods described by Fleurence et al.14. Averted cases of common dental diseases and associated costsavings First, we estimated the number of individuals that would have received the averted opioid prescriptions by assuming that 29% of adults with an opioid prescription have refills within the same year (about 1.6 refills per patient)15. We then estimated the number of common dental disease cases affected by the decline in opioid prescriptions as the product of respective one-year risk differences and number of individuals that would have received opioid prescriptions Table 1. Total number of opioid prescriptions dispensed in the United States 2012–2019 Annual opioid prescriptions (observed)ƒ Reductions in annual opioid prescriptions†