Impact of Hydrocodone Rescheduling on Dental Prescribing of Opioids.

INTRODUCTION: In the United States, dentists frequently prescribe hydrocodone. In October 2014, the US Drug Enforcement Administration rescheduled hydrocodone from controlled substance schedule III to II, introducing more restricted prescribing and dispensing regulations, which may have changed dental prescribing of opioids. OBJECTIVE: The study aim was to evaluate the impact of the hydrocodone rescheduling on dental prescribing of opioids in the United States. METHODS: This was a cross-sectional study of opioids prescribed by dentists between October 2012 and October 2016, using the IQVIA Longitudinal Prescription Dataset. Monthly dentist-based opioid prescribing rate (opioid prescription [Rx]/1,000 dentists) and monthly average opioid dosages per prescription (mean morphine milligram equivalent per day [MME/d]) were measured in the 24 mo before and after hydrocodone rescheduling in October 2014 (index or interruption). An interrupted time-series analysis was conducted using segmented ordinary least square regression models, with Newey-West standard errors to handle autocorrelation. RESULTS: Dentists prescribed 50,412,942 opioid prescriptions across the 49 mo. Hydrocodone was the most commonly prescribed opioid pre- and postindex (74.9% and 63.8%, respectively), followed by codeine (13.8% and 21.6%), oxycodone (8.1% and 9.5%), and tramadol (2.9% and 4.8%). At index, hydrocodone prescribing immediately decreased by -834.8 Rx/1,000 dentists (95% confidence interval [CI], -1,040.2 to -629.4), with increased prescribing of codeine (421.9; 95% CI, 369.7-474.0), oxycodone (85.3; 95% CI, 45.4-125.2), and tramadol (111.8; 95% CI, 101.4-122.3). The mean MME increased at index for all opioids except for hydrocodone, and dosages subsequently decreased during the postindex period. CONCLUSION: Following the rescheduling, dentist prescribing of hydrocodone declined while prescribing of nonhydrocodone opioids increased. Understanding the impact of this regulation informs strategies to ensure appropriate prescribing of opioids for dental pain. KNOWLEDGE TRANSFER STATEMENT: The study findings can be used by policy makers to make informed decisions in developing future risk mitigation strategies aimed to regulate opioid prescribing behaviors. Furthermore, dentist-specific resources and guidelines are needed subsequent to these policies in order to meet the dental population needs.

The effects of chronic alcohol consumption or thiamin deficiency on radial-arm maze performance in the rat.

Experiment 1 tested the hypothesis that chronic consumption of ethanol, in the presence of good nutrition, is associated with impairments in memory. Rats were fed a vitamin-fortified ethanol-Sustagen diet with 35% ethanol-derived calories for 150 days. Two control groups were used. The first was pair fed a Sustagen mix in which sucrose had been substituted for ethanol. The second control group received ad lib access to standard laboratory chow and water. All animals were then placed on the chow and water diet for six weeks prior to testing in an eight-arm radial maze. There was a significant, but modest, difference between groups in the number of trials to reach a criterion level of seven correct from the first eight choices and all eight correct in ten choices. However, there were no differences between the groups when delays (0, 5, 20, 60, 120 and 240 minutes) were imposed between the 4th and 5th choices. In Experiment 2, a thiamin-deficient group was compared with pair-fed and ad lib control groups on the same task. The thiamin-deficient group took more trials to reach criterion but the groups did not differ in the delay testing phase. The results are discussed in the context of reference/working memory distinctions, and the literature on remediation of cognitive deficits associated with alcoholism.

Burns in the elderly in the south east of Scotland: review of 176 patients treated in the Bangour Burns Unit (1982-91) and burn inpatients in the region (1975-91).

One hundred and seventy-six patients aged 65 years and above, treated in Bangour Burns Unit during a 10-year period between 1982 and 1991 were studied in detail. Annual number of burn cases treated as inpatients in the South East of Scotland, within or outwith the Bangour burns unit, and all deaths due to burns, during the period from 1975 to 1991, among the estimated population were analysed to assess the trend in incidence and rates of burns in elderly persons in the community.

Cement-related burns.

Burns caused by prolonged contact of wet cement with skin are common in this country. Recent literature has highlighted other ways in which the use and manufacture of cement can lead to burn injuries, notably through explosion and contact with hot powder during manufacturing. These injuries are uncommon in this country and potentially very serious. Case studies are presented of two men injured in such a way in the same incident at a cement-manufacturing plant.

Burn injuries caused by chip-pan fires: the Edinburgh experience.

Thirty-two patients were admitted to the South-East Scotland Burn Unit over a 4-year period (1990-94), with burns sustained as a consequence of chip-pan fires. This represented 7 per cent of all admissions to the unit. Fourteen patients came from the Edinburgh city area, and 18 from surrounding countries. There were 14 males and 18 females, and an average age of 51.6 years. The average burn surface area was 4.7 per cent. Eighteen patients had burns to their hands, this being the most common area involved. Fourteen patients were managed conservatively, and 18 needed operative intervention. The patients spent an average of 19.4 days in hospital, and they required 46.3 days for complete healing to take place. Prevention by increased community awareness and widespread education is necessary to minimize the incidence, morbidity and cost of this relatively common and preventable type of burn.

Colonic perforation following prolonged hypovolaemia in a major burns injury.

Perforation of the lower gastrointestinal tract is rare in burns patients. A 41-year-old male, who sustained 40% total body surface area burns and subsequently developed an acute abdomen on day 15 postburn, is presented. Emergency management included a subtotal colectomy and ileostomy formation performed to repair a perforated transverse colon found at laparotomy. The burns were debrided and grafted and the patient required cardiac, renal and respiratory support initially in the ITU setting before making a complete recovery. It is suggested that ischaemia caused the perforated transverse colon due to a prolonged low flow state. This was not detected until invasive cardiovascular catheterisation was performed and revealed a hypovolaemic state, which was corrected by fluids and noradrenaline. Both the previous cardiac history of the patient (Fallot's Tetralogy repair) and the noradrenaline may have exacerbated the low flow state within the mesenteric circulation leading to ultimate perforation. This case highlights the difficulties that may arise in resuscitating a patient who has previously had a cardiac defect repaired. Despite repair, abnormal physiology may persist resulting in misleading observations that produce undetected hypovolaemia with subsequent adverse events, as in this case. In such patients, early invasive cardiovascular monitoring should be considered.

The diagnosis and assessment of abdominal aortic aneurysms by ultrasonography.

A study of 150 patients examined by ultrasonography is described. It was designed specifically to diagnose and investigate abdominal aortic aneurysms. Sixty-four aneurysms were found. Ultrasonography was useful in distinguishing aneurysms from other conditions and there was a high degree of correlation between size measured by scanning and operative size. In addition to the demonstration of rupture it was possible to perform serial measurements. The technique is simple and quick and causes minimal disturbance to the patient.

Skin cancer referrals--could prioritization be a reasonable approach in the new millennium?

With the increasing and ageing population and concomitant increased referral of skin lesions and skin cancer in particular, problems with regard to waiting times to be seen as well as waiting lists currently face us. While several other specialties including radiotherapists, dermatologists, general surgeons, general practitioners may perform surgical and other treatments, there may be some confusion as well as some inefficiencies in the services provided. With a better understanding of the different grades and types of skin cancer, it should be possible to provide a more efficient and fairer service even without a major increase in resources. The question is whether or not the general practitioners and their patients are ready for prioritization?

Trilucent breast implants--a personal review of the current controversies (May 1999).

Trilucent ("Soya Bean") breast implants were marketed as a safe alternative to silicon implants. Following their use in the UK for the past four years, a reassessment of this has currently been announced (March 1999) and further implantation has been suspended by the Trilucent company in conjunction with the MDA (Medical Devices Agency). This has been the result of some reports of adverse reactions to the triglyceride filling material when the implant ruptures. All patients with trilucent implants were advised to return to their respective surgeons for review and advice. A personal review has been undertaken by the author of this paper. The results obtained are discussed. The majority of patients were concerned, but were happy with cosmetic results, and did not at present wish their implants removed. None appeared as yet to have had serious complications that could be attributed to the implants.

Plastic surgery waiting list--the numbers game fact or fiction?

Previous studies have indicated the importance of work load and operating time in helping to manage a waiting list. While analysis of a waiting list based solely on numbers cannot give an accurate assessment it is only this and "the waiting time" to surgery (apparently irrespective of clinical priorities) that seem to matter to the government, the Trust Hospitals, and to the public. This study examines case numbers on a waiting list over a two year period and links this to the preceding six months elective operations. Further insight into a waiting list construction can be obtained because of the clinical need for some degree of prioritisation, particularly because of malignancies, it is obvious why the bare waiting list numbers and composition can give a false impression of the true situation. The secondary effect on waiting time for less urgent cases can thus be more readily explained. Some form of rationing may be the answer.

A review of injuries to professional footballers in a premier football team (1990-93).

A prospective study of injuries sustained by first team professional foot-ballers either in training or in competition was undertaken over a 3 year period. These were injuries which resulted in loss of availability for playing. In a total of 27 players, 94 significant injuries occurred resulting in 364 weeks "out of action". 79% of these injuries were sustained in matches. Midfield players suffered the most injuries (39%). A prospective study in Heart of Midlothian Football Club's first team players over a 3 year period 1990-3 revealed that significant injuries resulting in loss of availability for playing occurred in 27 players. The majority of injuries occurred in match play (79%) with the average time "out of action" per player being 13 weeks (overall total = 364 weeks). Midfield players suffered the most injuries (39%) and the most common anatomical site of injury was the thigh followed by the knee. Muscle and ligament injuries were the commonest soft tissue problem. 6% of injuries were skeletal. Players older than 26 years of age appeared to be more prone to injury. No good correlation could be found between the number of games played and increased likelihood of injuries.

Polaroid photographic referral for skin cancer--a potentially useful method of reducing time to surgery.

A prospective trial was conducted on twenty-five patients referred by dermatologists during 1998 using a referral letter and an accompanying polaroid photograph for prospective plastic surgical management of skin cancers. Using the description and the photograph, suitable patients were given dates for operation without requiring a plastic surgery out-patient clinic appointment. This enabled, not only a saving in the cost of an out-patient appointment, but a significant reduction in waiting time to surgery.

A three year review of injuries to professional footballers (1995-98) and comparison with previous observations (1990-93).

A prospective study over a three year period (1995-8) of footballers' injuries in first team players was undertaken in a similar fashion to a previous study (1990-3). During the present study the Club had a major cup success and appeared to have a younger squad with less major injury and subsequent time out of action. As a result of the earlier paper it would appear that some lessons and observations may have been put into action and helped produce a more consistent standard for the club. Increasing recognition of the need to reduce and monitor the levels and types of injuries seems now to be established.

The value of ultrasonography in the diagnosis of abdominal aortic aneurysm.

An evaluation of ultrasonography in early dilatation and aneurysm is presented. Fifty-nine patients with prominent abdominal pulsation were examined and aneurysm was demonstrated in 22. There was a high degree of correlation between the size of the aneurysm demonstrated by ultrasound and the size displayed at operation. It was also possible to demonstrate increasing dilatation by measurement on subsequent occasions.