The ADA Practical Guide to Substance Use Disorders and Safe Prescribing

Michael O’Neil, Pharm.D., is Professor and Vice Chair of the Department of Pharmacy Practice at South College School of Pharmacy in Knoxville, Tennessee. Dr. O’Neil has more than 25 years’ experience as a critical care and pain specialist and has taught pharmacy students, pharmacy residents, nursing students, surgery/medical students, and medical residents in the classroom and at the bedside. He has completed research and published in several leading health professional journals including pharmacy, dentistry, and nursing. Dr. O’Neil has also served as a consultant and expert on prescription drug abuse, substance abuse, and drug diversion for the U.S. Drug Enforcement Agency, the Bureau of Criminal Investigation, the U.S. Attorney’s Office, the West Virginia Board of Dental Examiners, the American Association of Dental Boards, and several law enforcement agencies. Dr. O’Neil developed the West Virginia Pharmacists Recovery Network where he served as Executive Director and head investigator. Dr. O’Neil helped initiate other professional recovery networks in medicine, dentistry and nursing.

Contributors xi

Preface xiii

Acknowledgments xv

1 Substance Use Disorders, Drug Diversion, and Pain Management: The Scope of the Problem 1
Michael O’Neil, PharmD

Introduction 1

Definitions 2

Substance Use Disorder, Drug Misuse, Drug Diversion, and Pain Management in the Dental Community 4

Understanding the Cultures of Substance Use Disorder, Drug Misuse, and Drug Diversion 8

Summary 9

References 10

2 Understanding the Disease of Substance Use Disorders 11
James H. Berry, DO and Carl Rollynn Sullivan, MD

Introduction 11

Definitions 11

Epidemiology: Drug/Alcohol 13

Pathophysiology/Brain Pathways 14

Signs, Symptoms, Behavior 15

Treatment Methods 20

Summary 26

Appendix 2.A: Common Opioid Analgesics and their Brand Names 27

References 29

Resources and Further Readings 30

3 Principles of Pain Management in Dentistry 31
Paul A. Moore, DMD, PhD, MPH and Elliot V. Hersh, DMD, MS, PhD

Introduction 31

Definitions 32

Neurophysiology and Neuroanatomy of Acute Inflammatory Pain 32

Orally Administered Analgesic Agents 33

Medication-Assisted Therapies for Treating Drug-Dependent Patients 41

Adjunctive Drugs Used to Limit Pain in Dentistry 41

Guidelines for Analgesic Therapy 43

Summary 45

References 45

Resources and Further Readings 46

4 Special Pain Management Considerations: (1) Chronic Methadone, Buprenorphine, and Naltrexone Therapy; (2) Chronic Opioids for Nonmalignant Pain 47
Michael O’Neil, PharmD

Introduction 47

Definitions 48

Interviewing the Patient: Establishing Goals of Treatment 49

Pharmacological Treatment of Opioid Addiction 49

Treating Acute Dental Pain 51

Acute Pain in Patients Receiving Opioid Maintenance Therapy 51

The Active Opioid Addict 55

Acute Pain Management in Patients Receiving Naltrexone Therapy 56

Acute Pain Management in Patients Receiving Opioids for Chronic Pain 57

Summary 57

References 58

5 Sedation and Anxiolysis 61
Matthew Cooke, DDS, MD, MPH

Introduction 61

Definitions 61

Spectrum of Anesthesia and Sedation 62

Preoperative Evaluation 64

Physical Status Classification 65

Sedation 65

Medications Available for Sedation of Patients with Substance Use Disorder 68

The Concept of Balanced Anesthesia 76

Monitoring and Documentation 76

Summary 78

Disclaimer 78

References 79

Resources and Further Readings 82

6 Common Substances and Medications of Abuse 83
William J. Maloney, DDS and George F. Raymond, DDS

Introduction 83

Definitions 83

Signs and Symptoms of Substance Use Disorder 85

Common Substances of Abuse 86

Prescription Medications 100

Over-the-Counter Medications 111

Summary 112

References 112

Resources and Further Readings 118

7 Tobacco Cessation: Behavioral and Pharmacological Considerations 119
Frank Vitale, MA and Amanda Eades, PharmD

Introduction 119

Definitions 119

Forms of Tobacco 121

Oral Effects of Tobacco Use 121

Dental Practitioner Management of Tobacco Use 122

Spit Tobacco Interventions 124

Oral Substitutes 125

Social Support/Disapproval 125

Medication Management for Smoking Cessation 126

The Role of Nicotine 126

Pharmacotherapy Options 127

Summary 138

References 138

Resources and Further Readings 140

8 Detection and Deterrence of Substance Use Disorders and Drug Diversion in Dental Practice 141
Sarah T. Melton, PharmD, BCPP, BCACP, CGP, FASCP and Ralph A. Orr

Introduction 141

Definitions 141

Screening Patients for Substance Use Disorder 142

Schemes and Scams to Obtain Prescription Drugs 144

Dental Practitioner- and Office Personnel-Related Prescription Drug Diversion 147

Prescription Drug Monitoring Programs 148

Disposal of Controlled Substances 153

Universal Precautions in Prescribing Controlled Substances 154

Summary 157

References 157

Resources and Further Readings 158

9 Interviewing and Counseling Patients with Known or Suspected Substance Use Disorders: Dealing with Drug-seeking Patients 159
George F. Raymond, DDS and William J. Maloney, DDS

Introduction 159

Definitions 160

Preinterview Considerations 160

Patient Interview Considerations 161

Interviewing and Counseling Techniques 162

What Questions Should Be Asked? 163

Screening Tools 164

Documentation 165

Summary 166

References 166

Resources and Further Readings 167

10 Office Management of Controlled Substances 169
Carlos M. Aquino

Introduction 169

Federal Statutes and Regulations 169

Definitions 169

Common Violations by Dental Practitioners 170

Surviving a Drug Enforcement Administration Inspection 173

Practice Due Diligence Program 175

Management of Noncontrolled Substances in the Office 176

Summary 176

Resources and Further Readings 176

11 Addiction and Impairment in the Dental Professional 177
William T. Kane, DDS, MBA, FAGD, FACD

Introduction 177

Definitions 178

The Complexity of Addiction 178

The Neurobiology of Addiction 179

The Stigma of Addiction 180

Epidemiology of Addiction in Dentistry 180

Risk Factors for Substance Use Disorder 180

Substances of Choice 182

Identifying Addiction 183

“The Conspiracy of Silence” 183

Intervention 184

Evaluation/Assessment 185

Treatment 186

Family and Staff 186

Relapse 187

Monitoring 187

Peer Assistance or Dental Well-being Committee Programs 187

Summary 189

References 189

Resources and Further Readings 190

12 Due Diligence and Safe Prescribing 191
Michael O’Neil, PharmD

Introduction 191

Definitions 191

Case Scenarios 192

Summary 205

References 206

Continuing Education Examination 207

Index 213