The ADA Practical Guide to Substance Use Disorders and Safe Prescribing

Michael O'Neil

• Publisher: Wiley-Blackwell
• Year: 2015
• Print ISBN: 9781118886014
• eBook ISBN: 9781118925270
• Edition: 1
• Topic: Medicine
• Subtopic: Dentistry

Dentists have been inundated by patients with an array of complicated medical conditions and pain/sedation management issues. This is in addition to a variety of legal regulations dentists must follow regarding the storage and recordkeeping of controlled substances. Avoid unknowingly putting your practice at risk by becoming victim to a scam or violating a recordkeeping requirement with The ADA Practical Guide to Substance Use Disorders and Safe Prescribing.

This Practical Guide is ideal for dentists and staff as they navigate:

•Detecting and deterring substance use disorders (SUD) and drug diversion in the dental office (drug-seeking patients)
•Prescribing complexities
•Treating patients with SUD and complex analgesic and sedation (pain/sedation management) needs and the best use of sedation anxiety medication
•Interviewing and counselling options for SUD
•Federal drug regulations
Commonly used illicit, prescription, and over-the-counter drugs, as well as alcohol and tobacco, are also covered.

Special features include:

•Clinical tools proven to aid in the identification, interviewing, intervention, referral and treatment of SUD
•Basic elements of SUD, acute pain/sedation management, and drug diversion
•Summary of evidence-based literature that supports what, when and how to prescribe controlled substances to patients with SUD
•Discussion of key federal controlled substance regulations that frequently impact dental practitioners
•Checklists to help prevent drug diversion in dental practices
•Chapter on impaired dental professionals
•Case studies that examine safe prescribing and due diligence

1
Substance Use Disorders, Drug Diversion, and Pain Management: The Scope of the Problem

Michael O'Neil, PHARMD

Introduction

The practice of dentistry has become increasingly complicated by multiple factors, including increasing numbers of patients with substance use disorder (SUD), patients receiving chronic pain medications, and prescription drug-related crime (see Box 1.1). In January 2012, the Centers for Disease Control (CDC) announced that the USA is experiencing an epidemic of prescription drug-related overdoses with the majority of these involving prescription opioids.¹ Findings from the 2011 National Health and Aging Trends Study reported bothersome pain afflicts half of the community-dwelling US older adult population and is associated with significant reduction in physical function, particularly in those with multisite pain.² National Survey on Drug Use and Health (NSDUH) 2012 data indicate that 6.8 million people aged 12 or older are current nonmedical users of psychotherapeutic drugs and that 4.9 million of these were users of pain relievers.³ The NSDUH 2012 data also indicate that the rate of current illicit drug (e.g., cocaine, marijuana, inhalants) use among persons aged 12 or older was 9.2%. In 2012, the NSDUH survey revealed an estimated 22.2 million persons aged 12 or older were classified as having an SUD in the past year (8.5% of the population aged 12 or older). Other results from this survey are include 2.8 million people were classified as having an SUD of both alcohol and illicit drugs, 4.5 million had an SUD associated with illicit drugs but not alcohol, and 14.9 million an SUD associated with alcohol but not illicit drugs. Overall, 17.7 million had an SUD associated with alcohol and 7.3 million had an SUD associated with illicit drugs.³

---

Box 1.1 Factors Complicating the Practice of General Dentistry

• Chronic pain management.
• Misuse of prescription medication.
• SUD associated with prescription medications.
• SUD associated with illicit substances.
• SUD associated with alcohol.
• Psychiatric disorders (diagnosed and undiagnosed).
• Opioid maintenance treatment programs (methadone, buprenorphine).
• Aging population.
• Polypharmacy (use of multiple medications to treat the same condition).
• Patient criminal activity.

---

The extent of the overlap of pain management, SUD, prescription drug misuse, and drug diversion in the same patient has not been well defined. However, patients commonly present with more than one of these clinical and ethical challenges at any given office visit or hospital admission. Individual motivations and behaviors leading to the abuse, misuse, and diversion of prescription drugs, illicit drugs, and alcohol vary significantly. This chapter will provide an overview of SUD, prescription drug misuse, drug diversion, pain management, and cultural considerations in patients involved in these activities. Key terminology used throughout this book is also defined.

Definitions

Acute Pain

Acute pain comes on quickly, can be moderate to severe in intensity, and generally lasts a short period of time (e.g., from days up to 3 months). Acute pain is considered a beneficial process, warning of potential harm to the body from injury or medical conditions. Acute pain is most commonly nociceptive, modulated by mediators such as prostaglandins, substance P, and histamines, or neuropathic, characterized by alterations in the transmission pathways of nerves.

Addiction

Addiction is a primary chronic disease of brain reward, motivation, memory, judgment, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations that frequently result in destructive and life-threatening behaviors.⁴ Addiction is influenced by multiple factors, including, but not limited to, genetics, environment, sociology, physiology, and individual behaviors.

Addiction is characterized by the inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems in behavior and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.⁴

Chronic Pain

Chronic pain generally refers to intractable pain that exists for 3 months or more and does not resolve in response to treatment. Some conditions may become chronic in as little as 1 month. Chronic pain may be continuous or reoccurring, persisting for months or even a lifetime. While the exact duration and characteristics of acute and chronic pain may overlap considerably depending on a patient's medical condition, dental practitioners should recognize that specific timelines for the diagnosis of acute versus chronic pain may be integrated into federal and state legislation and into state board regulations to promote safe pain management practices and safe medication prescribing guidelines.

Drug Diversion

Drug diversion may be defined as the intentional transfer of a substance, or possession of a substance, or alteration of legitimate medication orders outside the boundaries designated by the Food and Drug Administration, federal Drug Enforcement Administration (DEA), or state regulatory board. Drug diversion may involve prescription or over-the counter (OTC) medications or illicit substances. These illegal activities are usually motivated by financial incentives, SUD behaviors, or other activities, such as sharing medications with the intent to help. Examples include a patient selling or giving their prescription medication to someone else, altering the original information on a prescription without the prescriber's consent, or theft of medications.

Drug Misuse

Drug misuse may be defined as taking a prescribed or OTC medication for nonprescribed purposes, in excessive doses, shorter intervals than prescribed or recommended, or for reasons other than the original intent of the prescription. Examples include doubling the dosage, shortening dosing intervals, or treating disorders for which the medication was not prescribed.

Opiates and Opioids

Opiates refer to natural substances derived from the poppy plant. Opioids function in a similar manner to opiates but are either synthetic or partially synthetic derivatives of opiates. For the purpose of this text, the term opioid will be used interchangeably for opiate.

Prescriber–Patient Mismatch

Prescriber–patient mismatch is defined as the inconsistency in treatment goals or expectations of treatment between the prescriber and the patient. Examples include analgesia, sedation, or anxiolysis.

Substance Abuse

Substance Abuse is a maladaptive pattern of chemical use (e.g. alcohol, medications, marijuana, cocaine, solvents, etc.) leading to clinically significant impair...

Table of contents

• Cover
• Dedication
• Title page
• Copyright
• Contributors
• Preface
• Acknowledgments
• 1 Substance Use Disorders, Drug Diversion, and Pain Management: The Scope of the Problem
• 2 Understanding the Disease of Substance Use Disorders
• 3 Principles of Pain Management in Dentistry
• 4 Special Pain Management Considerations: (1) Chronic Methadone, Buprenorphine, and Naltrexone Therapy; (2) Chronic Opioids for Nonmalignant Pain
• 5 Sedation and Anxiolysis
• 6 Common Substances and Medications of Abuse
• 7 Tobacco Cessation: Behavioral and Pharmacological Considerations
• 8 Detection and Deterrence of Substance Use Disorders and Drug Diversion in Dental Practice
• 9 Interviewing and Counseling Patients with Known or Suspected Substance Use Disorders: Dealing with Drug-seeking Patients
• 10 Office Management of Controlled Substances
• 11 Addiction and Impairment in the Dental Professional
• 12 Due Diligence and Safe Prescribing
• The ADA Practical Guide to Substance Use Disorders and Safe Prescribing
• Index
• EULA