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