Substance abuse and the dental patient ... What's the connection?

Statistically, more than 10.5 million Americans are affected by substance abuse, which includes the use of alcohol and other drugs, including prescribed medications. Approximately 2 million of them have participated in some form of Alcoholics Anonymous or Cocaine Anonymous programs (1). The January 2002 issue of Mental Health Report states that "the demand for alcohol and drug treatment is up in at least 13 states since the September 11 terrorist attacks according to a recent survey" by the National Center on Addiction and Substance Abuse (CASA) at Columbia University. (2) "Exposure to trauma puts an individual at four to five times greater risk of substance abuse, and stress is considered the number one cause of relapse to alcohol, drug abuse, and smoking." (2)

The mental health impact of terrorism, disaster, and economic uncertainty in the workplace has increased the need for substance abuse and addiction treatment. With these statistical numbers on the rise and resulting behavioral health issues, the dental team must be increasingly more alert to recognize patients who need special care and possible referral for alcohol, tobacco, and other drug (ATOD) services. Understanding the definitions of substance abuse and dependency, prevention concepts, rationale for substance abuse screening, dental team alerts, clinical interview skills, awareness of medical and legal implications, and the referral process are techniques needed for delivering quality dental care to these substance abusing patients.

Definition of Substance Abuse and Dependency

The dentist, office personnel, dental hygienist, and dental assistant are all professionals that can make a difference in their practice and the community by recognizing patient substance abuse.

What is substance abuse? Substance abuse can be defined as "the use of a substance to modify or control mood or state of mind in a manner that is illegal or harmful to oneself or others". (3)

It can be described as problematic. Substance dependency is a response to a substance characterized by three features: tendency to use more substance, physiological and psychological changes when the substance is withdrawn, and an overwhelming desire to continue using the substance despite negative consequences. A patient can be experiencing substance abuse problems before it becomes a dependency. Many drugs have addictive potential and for some substances the dependency can be physical or psychological or both. Some of the most common substance abusing patients seen in a dental practice would involve the use of alcohol, tobacco, sedative/hypnotics, barbiturates, and narcotics. As a dental team we can provide education, early intervention and effective motivation for the patient to seek help before abuse becomes dependency.

Prevention Concepts

Prevention has become an important part of the dental practice of most health care professionals. Patients expect health care providers to focus a part of their visit on prevention activities or messages. Effective prevention messages that are easy to deliver and do not interfere with busy office routines are available and, with careful team treatment planning, easy to implement. A general approach to prevention messages may include supporting healthy lifestyle choices. Life consequences related to ATOD use, allowing patients to describe their understanding or concerns about problems related to ATOD, correcting misunderstandings with evidence-based information, and establishing a trusting partnership with your patients are all very important aspects of office-based prevention. (4) Patients often express their concerns to the staff more than to the dentist, therefore, having an educated dental team can make the difference for increased quality dental care for patients.

Substance Abuse Screening

Screening for substance abuse is a brief verbal interaction that brings focus to the potential harm substance use brings to the quality of dental care. Careful screening of patients for substance abuse or dependency serves as a basis for giving prevention messages, assists in management of clinical problems, helps to minimize drug interaction effects, helps to prevent domestic violence, child abuse, and malpractice suits, and allows the dental team the ability to change community norms and community health. Identifying alcohol, tobacco, and other drug issues and people at-risk for dependency, understanding the source of abnormal behavior in some patients, and prevention of possible diversion of controlled substances are ethical issues involving ATOD abuse. Prevention of complication from conscious sedation, local, and general anesthesia is essential for patient safety and dental practice risk management. Statistics support that alcohol, tobacco and other drug use is identified as the third largest healthcare hazard in the United States after cancer and cardiovascular disease. (1) With these statistical reminders, dentistry has a responsibility to guide these patients to resources specifically designed to address substance abuse and dependency.

Dental Team Alerts

The dental receptionist is a key person for alerting the dentist and staff to potential problems. Receptionist observations can include noticing the general appearance of patients when they check in for a visit, noticing a history of broken appointments, dramatic unexpected complaints, or repeated requests for unusual prescriptions. The dental auxiliary observations should include reviewing the patient's general health, reviewing the medical history to include the use of prescription, over-the-counter, and illicit drugs and observing clinical or unusual behavioral signs. Common patient management issues of substance abusers may include irregular attendance or compliance with treatment, anxiety, fear, cravings for sweets, increased hazards of cross-infection with the hepatitis virus, HIV and increasing occurrence of tuberculosis. The common oral problems are oral neglect, increased caries, periodontal disease, smoker's keratoses, gingival or buccal ulcerations or pigmentations, and the feigning of oral diseases, such as pain or even self-inflicted injuries to obtain narcotic prescriptions. (5) Be aware of someone walking in near closing time claiming severe pain and hoping the dentist will provide a quick pain prescription until the patient can return for a next day appointment. The patient may request specific drugs or make a self-diagnosis, or have no interest in discussing the diagnosis, investigations or a second opinion. (5) Remember, prescription pads should be stored out of sight in the patient area.

Clinical Interview

All office visits should begin with updating the original health history. Patients may be reluctant to share information, as shame and guilt are primary issues with substance abusers. Be empathetic, neutral, and nonjudgemental in determining if a patient has a problem with alcohol, tobacco, or other drugs. The patient could also be recovering from the recent use of alcohol or other drugs. Confidentiality is a must for all patients and when requesting information reinforce the concept that this information is used to improve dental health. Remember to ask if there is a family history of alcohol or other drug dependence or if a patient has a past history of treatment or is currently under treatment. The name of the treatment facility, attending physician, length of abstinence, and current status, should be established and recorded in the medical history. (4) Remember, there is no stereotypical profile, and substance abuse can affect all age groups, the young, middle aged, and the older adult.

Alcoholism

What is the definition of alcoholism? The consumption of alcohol in a manner that it causes deterioration in social behavior and physical/psychological dependence where withdrawal is difficult, causes adverse effects, and can be life threatening.

Signs of alcoholism include the smell of alcohol on the patient's breath, signs of self-neglect of mouth, clinical signs of acute necrotizing ulcerative gingivitis, poor personal hygiene, and over-boisterous or facetious manners. Patients may complain of indigestion, anxiety, tremor of hands, malnutrition, and slurred speech. They may have a history of liver disease, and social difficulties.

Occupational risk factors for alcohol abuse include: workers in the alcohol industry, entertainers, commercial travelers, bored housewives, bachelors over the age of 40, armed forces personnel, and health care professionals. Social problems may include absenteeism, frequent job changes, and marital disharmony. There could be an increase in accidents, assaults, violence, or occurrence of cirrhosis. A family history of alcoholism is also a contributing factor. (5)

A positive screening for alcoholism would be for men who drink 15 or more drinks per week (180 grams of alcohol) or women who drink 12 or more drinks per week (144 grams of alcohol). Persons who drink more than five drinks per occasion one or more times per week are at risk. Use of the CAGE screening process can aid the dental professional by asking the patient the following questions for alcohol or other drug abuse:

* Have you felt you ought to Cut down or Control your drinking or drug use?

* Do you get Annoyed or Angry when people ask you about you alcohol or drug use?

* Have you felt bad or Guilty about your drinking or drug use?

* Have you ever had a drink or used drugs first thing in the morning (Eye opener) to steady your nerves, or get rid of a hangover, or get the day started?

A score of two or more positive answers indicate a need for more in-depth assessment. (4,6,7) Remember, it is not unusual for patients to become defensive or even a bit upset when you ask these questions. Remain calm and reinforce that this is designed to help the dental team provide effective dental care.

Nicotine and Other Drugs

Statistics reveal that more than 400,000 deaths in the United States each year may be attributed to cigarette smoking, making it the nation's leading preventable cause of premature mortality. Half of the cases of adult periodontitis, in this country may also be attributable to cigarette smoking. Tobacco use is responsible for more than 75% of the cases of oral and pharyngeal cancer in the United States. (8) Nicotine and tobacco use present dental management problems in patients, which may include chronic obstructive airway disease, ischemic heart disease, resistance to sedation, and associated disorders such as alcoholism or peptic ulcer. The affects of tobacco affects decrease success rates of periodontal therapy and dental implants. It impairs oral wound healing, and increases the risk for a wide range of oral soft tissue changes. This includes gingival recession and dental caries on tooth roots and crowns with the use of smokeless tobacco. Smokeless tobacco users should be aware that both chew and snuff are addictive substances and can cause oral disease. (9)

What are some clinical signs of nicotine abuse? Oral cancers, smoker's keratosis or pigmentation changes, predisposes to periodontal disease, ie acute necrotizing gingivitis, candidosis, and xerostomia.

Extrinic staining of the teeth is also present. Screening questions about nicotine and illicit drugs should include:

* Have you used any tobacco products, such as cigarettes, cigars, or smokeless tobacco in the past three months? If yes, what and how much and how often?

* Have you used marijuana more than five times in your lifetime? If yes, when was the last time? (4)

Preventive advice should be given to nicotine and marijuana users. They should be advised to stop smoking to reduce risk of oral cancer so that within five years, the oral mucosa will return to the normalcy of a non-smoker. Explain to the patient that if they stop smoking, the reduction in the risk of periodontal disease, risk of oral cancer, and a decrease in caries due to a dry mouth from smoking will be beneficial to their dental care and overall health. Persons who have used marijuana, cocaine and narcotics more than five times within the past year require more extensive assessment by an ATOD specialist. (4)

Barbiturates and Narcotics

The use of barbiturates by dental patients may be prescribed for severe insomnia or control of epilepsy. Examples of barbiturates are: Amytal, Florinal, Nembutal, Tuinal, Seconal, and Phenobarbital. The effects of using barbiturates are sedation, depression of respiration and heart rate, as well as impairment of thought processes and memory. Barbiturates also cause impaired coordination and ataxia. With chronic use, addicts begin to think slowly, have increasing emotional liability, and signs of self-neglect.

Dental management of barbiturate abusers may be complicated by altered drug metabolism, hepatitis B and C, sexually transmitted disease, epilepsy, maxillofacial injuries, tetanus, and HIV infection. (5) Barbiturates induce liver drug-metabolizing enzymes and cause resistance to anesthetics, but enhance (potentiate) the sedative effects of some drugs. An "at-risk" population, middle-aged women, often living alone and isolated, may take large quantities and/or drink alcohol and form the largest group of high-risk patients abusing barbiturates. Young addicts, who take barbiturates or "sleepers" like the effects of calmness and relaxation. Oral complications of barbiturate abuse are rare, however, one must be aware of the increased sedation effects used in various dental procedures. If a patient is suspected of abusing barbiturates, remember that barbiturates are a controlled drug and patients who stop taking large doses abruptly can experience withdrawal symptoms, including anxiety, insomnia, tremors, delirium, convulsions, and possible death. (5) Barbiturates must be withdrawn under strict medical supervision.

Narcotics, a type of opiate, are often prescribed for pain and produce a feeling of euphoria or feeling of extreme well being. "Narcotic drugs decrease the user's perception of pain and alter his or her reaction to pain. For this reason, narcotics--primarily codeine and morphine--are prescribed legitimately as pain killers". (9) Tolerance to narcotics develops rapidly and dependence is likely. Examples of narcotics would be the use of heroin, morphine, codeine, hydrocodone (Lorcet, Vicodin, Hycodan, Tussionex), hydromorphone (Dilaudid), oxycodone (Oxycontin, Percodan, Percocet, Tylox, Roxicet, Roxicodone), methadone (Dolophine, Methadase), fentanyl and analogs (Innovar, Sublimaze, Alfenta, Sufenta, Duragesic), and other narcotics (opium, Darvon, Talwin, Buprenorphine, Meperidine or Pethidine, Demerol). "Narcotic drugs are among those substances used illegally, or abused, by adolescents. Some estimate that as many as 90% of adult drug addicts began a pattern of substance abuse during adolescence." (9) If substance abuse or addiction to a narcotic is suspected, encourage and assist the patient with referral to appropriate addiction professionals.

Medical and Legal Implications

As healthcare providers, remember that there may be the possibility of drug interactions when patients deliberately or innocently combine certain medications. The Federal Drug Administration reported that over half of 100 drugs classified as" most frequently prescribed" were known to contain ingredients that react adversely with alcohol. Twenty-five hundred (2500) deaths are reported annually from this lethal combination. To protect the dental practice from potential malpractice suits, always document patient records accurately and review at every dental visit. If a patient is suspected of ATOD use or abuse, to the extent possible, monitor the frequency and amount of alcohol that a patient consumes, the use of nicotine, over-the-counter drugs and prescriptions containing narcotics, depressants, sedatives, or stimulants. The use and abuse of cannabis (marijuana and hashish), hallucinogens (LSD, mescal, peyote, Ibogaine, Ecstasy), stimulants (speed, crack/cocaine, crank, methamphetamine), and inhalants (gasoline, paint thinner, solvents, aerosol sprays, cleaning fluids, nitrous oxide), should be documented, if possible. Offer the patient advice regarding restrictions on alcohol consumption with possible drug interactions and the medical and social dangers of all psychoactive drug use.

Referral Methods

Refer patients who have positive screenings or who have evidence of alcohol, tobacco, or other drug problems to an ATOD specialist. Patients who are struggling and unable to change their alcohol, tobacco, and other drug use behaviors should be encouraged to consider an office visit to a professional who can provide in-depth assessment and recommendations. If there are patients who are concerned about a family member with an alcohol, tobacco, and other drug problem, refer them to an addiction specialist, usually available in your area telephone book.

What if the patient is reluctant to see a counselor? Tell the patient that this is a normal reaction but remind them that this is an important step towards improving their health and well being. Let the patient know that you will be working cooperatively with the addictions professional to coordinate effective dental care. Make the phone call while the patient is in the office and have them make an appointment before they leave your office. Ask the specialist to call you after they have completed the assessment so you can participate in treatment planning and support. Remember, necessary "release of information" forms are required for effective consultation. In some dental practice settings, an ATOD Addiction Counselor performs the assessment in the dental professional's office. Also, a referral to a social worker or psychologist who uses alternatives to standard ATOD addictions treatment may be more appealing to persons who have had negative experiences with alcohol or other drug treatment programs in the past. (4)

What's the Connection?

The identification and screening of dental patients with ATOD issues is becoming an important function of behavioral dentistry. Dentistry not only should concern itself with dental health care, but take an active role in screening patients for general overall health issues. A well informed and educated dental team can be alert to recognizing ATOD issues in their patients. Reviewing medical histories carefully and noting suspicious findings is essential.

Patients may not always be open about substance abuse or addiction, or may not realize they have a problem at all. A primary barrier to helping ATOD patients is denial, the primitive psychological defense mechanism that protects the patient from information that is too painful to accept about themselves. When genuine, empathic, nonjudgmental, and educated concern is expressed in terms of overall health and well being by health care professionals, the impact can be significant. The office personnel, dental assistant and dental hygienist can be observant at all times and alert the dentist to questionable behaviors or symptoms. The dentist should talk privately with the patient for further assessment and encourage the patient to seek professional help if needed.

Preventive dental health care can not only save teeth, but can save a life. Dentistry can make the connection between substance abuse and the dental patient. The dental team can make a significant difference!

Additional Information and Resources

The National Clearinghouse for Alcohol and Drug Abuse Information (800-729-6686) provides valuable resources on substance abuse prevention and treatment. Links from the website [e-mail] connect to the Centers for Substance Abuse Treatment (CSAT) and Prevention (CSAP). Links are also available to the National Institutes on Drug Abuse (NIDA) and Alcohol & Alcohol Abuse (NIAAA). Listings are available of licensed ATOD treatment facilities and professionals nationwide through the "treatment locator system".

REFERENCES

(1.) Sandoval VA. The Drug Dependent Patient: In Williams (ed): Dentistry Faces Addiction: How to Be Part of the Solutions. Mosby Year Book, Inc. St. Louis 1992, pp 98-101.

(2.) Mental Health Report: Responding to Terrorism, Demand for Substance Abuse Treatment Has Risen Since Sept 11, CASA Reports, January 4, 2002, pp 2.

(3.) GSC Home Study Courses: Drug Abuse-Dental Concerns, p 5, 2001.

(4.) Scully C, Cawson RA. Medical Problems in Dentistry, Fourth Edition: Chemical Dependency, pp 490-491. The Bath Press, Great Britain, 1998.

(5.) Substance Abuse and Mental Health Services Administration, Dental Team Curriculum: ATOD Problems, Prevention, p 7. Website: http://p2001.health.org

(6.) Bush B, Shaw S, Clear, P, Delbanco TL, Aronson MD. Screening for Alcohol Abuse Using the CAGE Questionnaire. Am J Med 82:231-235, 1987.

(7.) Tomar SL. Tobacco and Oral Health: What Are We Doing? Dental Abstracts, Volume 46. Issue 1, 4-6, 2001.

(8.) National Institute News Release: Chewing Tobacco Use Linked to Dental Caries. Website: http://www.nih.gov/news/pr/nov 99

(9.) Gale Encyclopedia of Psychology: Narcotic Drugs. Website: http:www.findarticles.com

RELATED ARTICLE: Dentists urged to refer patients who use tobacco to American Cancer Society Quitline.

Provided by the American Cancer Society

Dentists are urged to refer their patients who use tobacco to the American Cancer Society Quitline--a toll-free telephone support program offering personal assistance for those ready to make a quit attempt. The service, 1-877-YES-QUIT, is part of an effort available in most states to eliminate tobacco-related illness, the single-most preventable cause of disease and death.

Health care professionals play a critical role in helping patients quit. The U.S. Department of Health and Human Services Clinical Practice Guideline titled Treating Tobacco Use and Dependence recommends that healthcare providers ask their patients if they use tobacco, advise them to quit and arrange for follow-up care.

Arranging for follow-up care is easy. Simply give patients who smoke the Quitline toll-free number--877-YES-QUIT (877-937-7848). All callers ready to make a serious quit attempt will be mailed a three-book packet that lends direct advice, real-life examples and skill-building exercises to help smokers progress through the three main steps in quitting: 1) contemplation; 2) preparation/ action; and 3) maintenance.

Callers also may receive advice on a combination of cessation aids and self-help techniques, including medications, stress reduction techniques, and self-control skills.

The American Cancer Society Quitline was launched in May 2000. In addition to providing assistance to smokers who are ready to quit, the Quitline can help smokers who are just starting to prepare for a "quit attempt" as well as answer questions for friends and families of smokers.

Protocols tailored to special populations like spit tobacco users and pregnant women are currently being developed.

The American Cancer Society is the nationwide community-based voluntary health organization dedicated to eliminating cancer as a major health problem by preventing cancer, saving lives and diminishing suffering from cancer, through research, education, advocacy and service.

For information about cancer, call toll-free anytime 1-800-ACS-2345 or visit the American Cancer Society website at www.cancer.org.

Carolyn C. Newman, CDA, is a graduate of University of North Carolina School of Dentistry, Dental Assistant Program and currently a Program Assistant/Office Manager with the Behavioral Healthcare Resource Program, Substance Abuse Certificate Program at University of North Carolina-Chapel Hill, School of Social Work. She has served as ADAA Fourth District Trustee, President of the NCDAA and Durham-Orange DAS.

Worth Bolton is a Licensed Clinical Social Worker and Certified Clinical Addictions Specialist working as Clinical Instructor in the Behavioral Healthcare Resource Program at the School of Social Work, University of North Carolina-Chapel Hill. For over 25 years he has provided substance abuse services and is past Chair and Board Member of the North Carolina Substance Abuse Professional Substance Abuse Certification Board and the North Carolina Foundation for Alcohol and Drug Studies.