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BackgroundOverdose deaths from prescription opioid analgesics are a continuing crisis in the United States. Opioid analgesics are among the most frequently prescribed drugs by dentists. An estimated 5 million people undergo third-molar extractions in the United States each year, resulting in postoperative pain. Studies show that, in most cases, the combination of ibuprofen and acetaminophen is an effective alternative to commonly prescribed opioid analgesics for the management of postextraction pain. Nevertheless, many dentists routinely prescribe opioids after dental extractions. ObjectiveWe describe the rationale, design, and methods for a randomized trial of interventions designed to de-implement opioid prescribing by dentists while implementing effective nonopioid analgesics following dental extractions. MethodsUsing a prospective, 3-arm, cluster randomized trial design with dentists as the unit randomized and patient-level prescribing data as the primary outcome, we will compare different strategies to reduce the reliance on opioids and increase the use of alternative pain management approaches utilizing information support tools aimed at both providers and their patients. The study will test the efficacy of 2 interventions to decrease opioid prescribing following dental extractions: clinical decision support with (CDS-E) and without patient education (CDS). Providers will be randomized to CDS, CDS-E, or standard practice. Patient-level outcomes will be determined via review of comprehensive electronic health records. We will compare study arms on differential change in prescribing patterns from pre- to postimplementation of the intervention. The primary outcome of interest is a binary indicator of whether or not the patient received an opioid prescription on the day of the extraction encounter. We will also examine recommendations or prescriptions for nonopioid analgesics, patients’ perceptions of shared decision making, and patients’ pain experiences following the extraction. ResultsThe HealthPartners Institutional Review Board approved the study. All study materials including the CDS and patient education materials have been developed and pilot tested, and the protocol has been approved by the National Institute of Dental and Craniofacial Research. The intervention was implemented in February 2020, with 51 dentists who were randomized to 1 of the 3 arms. ConclusionsIf the intervention strategies are shown to be effective, they could be implemented more broadly in dental settings with high levels of opioid prescribing. Trial RegistrationClinicalTrials.gov NCT03584789, https://clinicaltrials.gov/ct2/show/NCT03584789 International Registered Report Identifier (IRRID)DERR1-10.2196/24342

Background: Clinical decision support (CDS) has the potential to improve clinical decision-making consistent with evidence-based care. CDS can be designed to save health care providers time and help them provide safe and personalized analgesic prescribing., Objective: The aim of this report is to describe the development of a CDS system designed to provide dentists with personalized pain management recommendations to reduce opioid prescribing following extractions. The use of CDS is also examined., Methods: This study was conducted in HealthPartners, which uses an electronic health record (EHR) system that integrates both medical and dental information upon which the CDS application was developed based on SMART (Substitutable Medical Applications and Reusable Technologies) on FHIR (Fast Healthcare Interoperability Resources). The various tools used to bring relevant medical conditions, medications, patient history, and other relevant data into the CDS interface are described. The CDS application runs a drug interaction algorithm developed by our organization and provides patient-specific recommendations. The CDS included access to the state Prescription Monitoring Program database., Implementation (results): The pain management CDS was implemented as part of a study examining opioid prescribing among patients undergoing dental extraction procedures from February 17, 2020, to May 14, 2021. Provider-level use of CDS at extraction encounters ranged from 0% to 87.4% with 12.1% of providers opening the CDS for no encounters, 39.4% opening the CDS for 1%-20% of encounters, 36.4% opening it for 21%-50% of encounters, and 12.1% opening it for 51%-87% of encounters., Conclusions: The pain management CDS is an EHR-embedded, provider-facing tool to help dentists make personalized pain management recommendations following dental extractions. The SMART on FHIR-based pain management CDS adapted well to the point-of-care dental setting and led to the design of a scalable CDS tool that is EHR vendor agnostic., Trial Registration: ClinicalTrials.gov NCT03584789; https://clinicaltrials.gov/study/NCT03584789., (©D Brad Rindal, Dhavan Prasad Pasumarthi, Vijayakumar Thirumalai, Anjali R Truitt, Stephen E Asche, Donald C Worley, Sheryl M Kane, Jan Gryczynski, Shannon G Mitchell. Originally published in JMIR Medical Informatics (https://medinform.jmir.org), 07.11.2023.)