Discussion
In this multi-clinic, cluster randomized trial of clinical decision support strategies to de-implement opioid prescribing for dental extractions, we found that equipping dentists with clinical decision support did not lead to greater reductions in opioid prescribing compared to standard practice. Likewise, the inclusion of patient education materials in tandem with the provider’s clinical decision support did not lead to greater reductions in opioid prescribing. An important context for these findings is that opioid prescribing was already experiencing steady declines in the health system that hosted the study. As an organization, HealthPartners was already paying close attention to opioids and undertaking several actions to reduce opioid prescribing by providers. This was evidenced by a substantial reduction in opioid prescribing from the baseline study period (measured prospectively for 12 months starting in January 2019) and practices in the prior year (which informed some of our design decisions surrounding power and sample size). Our findings are consistent with recent research indicating that patterns of opioid prescribing in dentistry are influenced by type of extraction and that opioid prescribing overall has decreased in recent years in the wake of national practice guidelines and state legislation [Another important context is the COVID-19 pandemic, which resulted in a significant disruption to dental care and may have impacted workflow even after the resumption of routine services. COVID-19 shutdowns began early during the intervention period. Although clinics re-opened soon after the start of the pandemic, services were limited to addressing urgent or emergency needs in certain clinics by a limited number of providers. After several months, the clinics transitioned back to normal operations while adjusting to new workflows and dealing with anxious patients. Dentists adjusting to the challenges of delivering care in the era of COVID possibly paid less attention to the CDS resources than they would have under normal circumstances.The higher volume of opioid prescribing among oral surgeons in our sample was expected and consistent with prior literature. Research has found that the distribution of opioid prescribing by dentists differs markedly across provider characteristics, and a small minority of dentists account for high-volume and high-risk prescriptions, such as specialists in oral and maxillofacial surgery, who tend to perform more complex procedures [There is evidence that when utilized, CDS resources can change provider behavior [Although dentistry and the healthcare system as a whole are moving away from opioid prescribing, it is important to recognize that opioids can still play an important role for some patients and may be appropriate in certain circumstances [