State-Level and Urban-Rural Differences in Opioid Prescribing Following Toothache Diagnoses in the USA

Toothache is a common reason for dental visits, and opioid prescriptions for toothache have been linked to increased risk of misuse, addiction, and regulatory scrutiny, underscoring the need to understand prescribing patterns.

This study quantified prevalence of opioid prescribing after toothache diagnoses comparing (1) US states versus the national average; and (2) US rural versus urban areas.

We conducted a cross-sectional analysis of Epic Cosmos electronic health record database, covering patients in all US states (except Alaska) between August 2020 and July 2024. The outcome was the prevalence of opioid prescriptions issued within 3 days of a toothache diagnosis. Predictor variables were US state of residence, and rural-urban classification (based on Rural-Urban Commuting Area codes). State-level prevalences were compared to the US national average, and US rural prevalence was compared to urban using prevalence ratios (PRs) and 95% confidence intervals (CIs), with PR > 1 indicating higher prescribing.

For 1,382,711 toothache diagnoses, 49,190 (3.6%) opioid prescriptions were issued (20.2% females, 12.3% males, 67.5% unavailable). Opioid prescriptions following toothache diagnoses exceeded the national average in 15 states, highest in Virginia (PR = 2.31, 95%CI 2.24, 2.39), Georgia (PR = 1.51, 95%CI 1.44, 1.57), and Maryland (PR = 1.37, 95%CI 1.38, 1.56). Conversely, 27 states had below-average prescribing, lowest in South Dakota (PR = 0.20, 95%CI 0.12, 0.34), Hawaii (PR = 0.35, 95%CI 0.26, 0.39), and California (PR = 0.38, 95%CI 0.36, 0.40). Opioid prescribing following toothache diagnosis was slightly lower in rural than in urban areas (PR = 0.89, 95%CI 0.87, 0.92).

Opioid prescribing following toothache diagnoses in the USA differed by state and rurality, with 15 states overrepresented and 27 states underrepresented relative to national average, and a slight underrepresentation in US rural areas. Context-specific analyses of contributing factors can guide targeted interventions and promote evidence-based pain management.