Presentation Transcript

1. Substance Abuse: Your Patients, Your Practice, Your Family

   Dennis P. Bohlin DDS NYSDA Committee on Chemical Dependency
2. Why I hate statistics. Accidental Deaths over last four years From motor vehicle accidents - 32,000 Homicides by firearms - 10,000 Overdose deaths from opiates - 38,000 Prescription drugs - 16,000 Heroin - 22,000 Fatalities from MVAs - 89/day Fatalities from overdoses - 100/day Four out of five heroin addicts start with prescription opiates CDC, NIDA,NHTSA
3. Why is the disease concept of addiction important? For practical therapeutic reasons Everybody stays angry and the addict never recovers Love the alcoholic/addict. Hate the disease Shame V. Guilt
4. What is a Disease? Defect or impairment in a target organ that produces symptoms. Target organ: midbrain (mesolimbic system) Symptom: involuntary craving ( obsessive, compulsive, and visceral Craving preferred to psychological dependence
5. Disease Model vs. Moral Model Undeclared war Moral model believes in free choice Craving limits degrees of freedom Sick people receive care; evil people receive condemnation We are responsible. There is no pardon for bad behavior.
6. Chemical Dependency Primary illness A chronic, progressive disease Fatal, if not arrested Family-centered Treatable Preventable
7. Everyone Uses Substances To soothe, reward, or pleasure oneself Carbohydrates, chocolate, dessert Tobacco Caffeine Alcohol Drugs Are substances bad?
8. Predictors of Chemical Dependency: Biologic risk factors (Tolerance) Genetic risk factors (Serotonin receptors) Social risk factors (cultural differences) Consumption patterns Familial influences Non-familial influences
9. Barriers to Understanding Unpleasant past experience with chemically dependent individuals Abusers may be manipulative and noncompliant Doctors may feel coerced in carrying out their professional and ethical responsibility Addicts may pose a real threat of disease, theft, assault, etc. Our emotional response must be examined
10. Addiction Continued Use of Alcohol or Drug Despite Repeated Adverse Consequences Substance use continues even when it disrupts and or destroys aspects of life that are personally important. Reward Deficiency Syndrome
11. Reward Deficiency Syndrome The reward pathway in the brain is located in the mesolimbic system This is a dopamine system arising from the ventral tegmental area and flows to the nucleus accumbens and then to the prefrontal cortex Drugs and alcohol hijack this system
12. PET Scan
13. ASAM Definition Addiction: A primary, chronic, neurobiological disease, with genetic, psychosocial and environmental factors influencing its development and manifestations; it is characterized by behaviors that include impaired control over drug use, compulsive use, continued use despite harm, and craving or a combination of these. April 2011
14. Abuse and Addiction are Different Abuse: recreational or periodic use beyond the level that is good for the body and its ability to function psychologically, socially, and physically Men: alcoholic beverages exceeding 2-3 a day Women: alcoholic beverages exceeding 1-2 a day Any non-prescribed use of mood-altering substances other than alcohol
15. Symptoms of addiction: Increased tolerance/Cross tolerance Ever increasing craving for ever diminishing pleasure Denial – Frontal hypofunctionality Loss of control Personality changes Guilt and remorse Blackouts Hangovers
16. “I CAN CONTROL IT.” WHAT HAPPENS AFTER THE FIRST DRINK OR THE FIRST DRUG? DO YOU HAVE A CHOICE?

17. It’s not how much you use…

    It’s what it does to you when you use. Chasing the first high
18. Myths About Alcoholism: A sign of weakness or lack of will power All alcoholism is the same Alcoholics may resume social drinking You can’t help alcoholics until they decide that they want help

19. IS MY PATIENT AN ALCOHOLIC / DRUG ADDICT?

20. Opportunity for dentists to refer addicted patients for treatment Know your resources
21. The Dental Management of Patients Who Present with Substance Abuse Problems Patient behavior is your main issue in treatment and not what particular substance(s) is abused A drug is a drug is a drug What substances pose the biggest problems?
22. Substances Commonly Abused by Young People Alcohol – CNS depressant 185 billion dollar annual loss to US economy Marijuana – From 3% THC to almost 40% THC (very addictive) Marijuana abuse more common in young people than opiate abuse No contraindication to dental treatment Synthetic marijuana, salvia, bath salts, inhalants
23. Narcotic Analgesics Heroin – Very available, very pure, inexpensive Prescription drugs: Oxy/Hydrocodone Expensive Check the medicine cabinet Xerostomia, rampant caries, poor oral hygiene, pinpoint pupils, sedated affect
24. Benzodiazepines Xanax: widely abused, difficult and dangerous withdrawal Klonopin: Burning mouth Anti-anxiety meds are big relapse potential for recovering patients Beware of using opiate pain medications for patients who are prescribed benzodiazepines
25. CNS Stimulants Cocaine: freebase or powder Ecstasy/MDMA (Molly) Methamphetamine (Meth-mouth) Ritalin Adderall Xerostomia, rampant caries, periodontal disease, extreme bruxism, dilated pupils, paranoia
26. Dentists prescribe 12% of all IR opioid medication in the US That is 1.0-1.5 billion doses Non-medical use of prescription opiates is a national health crisis. The crack of the 2010s
27. Current Pain Management Philosophy “Opioid analgesics are useful in managing severe acute or chronic pain. They are often underused, resulting in needless pain and suffering, because clinicians often underestimate the required dosage, overestimate the duration of action and risks of adverse effects, and have unreasonable concerns about addiction.” – The Merck Manual 18th Edition
28. Availability May be main reason for increase in non-medical use of opioids Definite risk factor for healthcare professionals (Anesthesiologists) Education is key to increasing respect for these medications Begs the question for legalization Lessons from Prohibition
29. Issues for Our Patients Patients like to save medications Patients illegally divert their medicine to family and friends 70% of opiates used for non-medical reasons are unused prescribed medication found in our patients’ homes Real estate agents caution homeowners to check their medicine cabinets before open house visits
30. Recommendations for Prescribing IR Opiates Standard of care is shifting to three day supply of opiates No refills of opiates are recommended Three day supply generally seen as 12 doses Patient visits are encouraged for moderate to severe pain beyond three days NSAIDs and/or acetaminophen are encouraged after three days We are generally encouraged to use NSAIDs as first-line pain medication
31. Recommendations Continued Avoid prescribing opiates to patients taking benzodiazepines such as Xanax to prevent respiratory depression Consider prescribing opiates with less abuse potential Tylenol with codeine #3 Tramadol 50mg with 325mg Acetaminophen
32. Recommendations for Prescribing Dentists If storing opiates in the office, use bolted safe for storage Prescription pads should be locked away Street value of one blank Rx is $600 Report stolen pads to local police and Bureau of Narcotic Enforcement Never prescribe opiates over the phone if you are the covering doctor. We can only write narcotic prescriptions for patients of record
33. Using “I STOP” Practical guide to safely prescribed pain medications What is my responsibility if a significant number of pain medication prescriptions show up in the database? Pathology present? – Real or self-inflicted Previous prescriptions for benzodiazepines Use a designee. Must have HCS account No snooping! Print report, reference number, and place in chart
34. Patient Education Patients need to appreciate and respect dangers of prescribed medications Patients need careful instruction on storage and disposal of unused medication Use of drop-off and lock boxes for unused medication I am recommending an attachment to all pain prescriptions for opiates given to patients.
35. Attachment to Pain Prescriptions Your unused pain medication is a potential threat to family and friends. An important patient responsibility. The Federal government has declared abuse of prescription pain medicine a health crisis of epidemic proportions. A main source of abused pain medication is the unused pills from your prescription. Younger family members and their friends are especially at risk. Please take unused pills, mix with and dispose with your solid waste. Your community may also take back and dispose of unused medication. Check with your pharmacy. Please do not flush medications down any drains, as medication may find its way into the water supply. Thank you for your help in fighting this serious national problem.
36. Professional Issues in Treating Substance Abusing Patients Substance abusing patients may respond differently to medications than would most other patients (respiratory depression) Patients may be unable to benefit from pain medication due to tolerance Patients may be injured as a result of inappropriate medications (cardiac arrhythmia, hypertensive crisis) Patients who are substance abusers may have associated pathology (hepatitis, TB, HIV, etc.) Patients may have difficulty meeting financial obligations due to substance abusing lifestyles
37. Recognition of Substance Abuse Medical history “do no harm” We are concerned about drug interactions with non-prescribed substances Disease may present as early, middle, and end stage Disease knows no socio-economic barriers Physical signs Behavioral clues
38. Physical Signs Alcohol Husky voice, spider vein angioma, irritated tissues, smell on breath, bleeding, CA Psychotropic Substances Injection tracks, emotional lability, confusion, slurred speech, pupil size, high N2O tolerance
39. Behavioral Clues Inappropriate behavior Seductive and ingratiating Needy “prodigal son” Emergency orientation Unreliable with appointments Knows exactly which drug to ask for Enraged when frustrated Needle phobic
40. Behavioral Characteristics of Addicts Obsessive Control and Manipulation Preoccupation with Supply Heightened Perception Extraordinary sensitivity to attitudes of the professional Extreme anxiety about pain
41. Management Strategies Obtain clear picture of substances used and pattern of use (patient will minimize) Complete treatment if possible in one visit Payment in advance Patient should demonstrate reliability
42. Can We Prescribe Opiates to Substance Abusers? We are legally bound not to contribute to addiction. There are circumstances where NSAIDs will not be enough in moderate to severe pain Prescribe as medically necessary for 3-4 days Realize tolerance is an issue Strict boundaries on second prescription Medication given to “trusted other” There will be no third prescription Use NSAIDs subsequently
43. Can you treat patients who are high? Can they give informed consent? Can they comply with treatment and post-op instructions? How necessary is treatment? How compliant is patient during treatment? When in doubt…Reschedule Have NARCAN in your medical kit in case of overdose
44. Doctor Shopping Only patients of record may receive prescriptions without being seen These folks are exceptionally good scam artists May be evidence of self-mutilation and/or unfinished dental work Carefully double indicate amounts on prescriptions. Use number and word to indicate amount dispensed

45. “I AM A RECOVERING ALCOHOLIC / DRUG ADDICT”

    Legal Problems
46. Legal Problems We may be liable if we contribute to the addiction problem (NYSDJ May 2002) We have an obligation to protect ourselves and our staff, but we cannot discriminate against someone with this illness (ADA) We have to guard against contributing to relapse in recovering patients
47. Recovering Patients and Pain Control Avoid mood altering drugs Coordinate with family and physician opiate prescriptions (AA/NA Sponsor) NSAIDS - 3 Advil and 1 Tylenol q4h - 4 Advil one hour pre-op Long acting local anesthesia Do dentistry—don’t medicate Coordinate with treatment center for methadone and buprenorphine maintenance
48. How Prevalent is this Disease? Alcoholism (NCA) 10-13% Male/Female 2:1 Abuse of Drugs Other than Alcohol General Population (NIMH) 2% Physicians (NEJM) 5-10%
49. Rate Estimates of Chemical Dependency Among Professionals 10-17% Bowermaster 19.6% Bissell

50. Factors Responsible For Increased Drug Abuse Among Dentists

    Psychological, Genetic, and Professional Factors
51. Psychological Risks Dentistry is a high stress profession. An obsessive, compulsive, driving personality often emerges from our training and practice. We have a tendency to deny emotional and social problems.
52. Genetic Risks Doctors have the same genetic susceptibility as the lay population. There are 50 or 60 genomes with markers for alcoholism Gene splicing not an option.
53. Professional Risks Lack of respect for the dangers of medications The tendency to self-prescribe and self-medicate The mistaken belief that pharmacological knowledge will enable control of substance usage The ready availability of potent psychotropic substances
54. Substances Most Commonly Abused by Dentists Alcohol Hydrocodone Nitrous oxide Benzodiazepines
55. Changes Noted in Substance-Abusing Dentists Increasing isolation Family and relationship problems Business and employee problems Clinical skills may persist into late-stage disease
56. Dentists Respond Very Well to Treatment License enhances recovery Social supports are usually in place Peer support
57. Treatment Total abstinence 12 Step Programs of Recovery Insurance companies may require out-patient treatment first Preferably in-patient followed by after-care and monitoring (polydrug abusers) Dual diagnosis—psychological and medical support Anti-craving medication (e.g. Suboxone for opiate addiction)
58. What is Sobriety? Includes abstinence Positive change Emotional balance Accepting life on life’s terms One day at a time Gratitude
59. NYSDA Committee on Chemical Dependency Confidentiality Referral for treatment Peer Support Coordinator Advocacy Professional Assistance Program
60. The Disease Affects the Whole Family Alanon Alateen Narcanon Dealing with issues of codependency and enabling
61. Codependency Addicted to the addict Denial Family history Low self-esteem Control issues Alanon handshake
62. Prevention “There’s nothing wrong with not drinking.” Abstinence Education and awareness of family history Alternate activities and strategies for stress management Confidence building
63. Fact Checking Resources NYS Office of Alcoholism and Substance Abuse Services (OASAS) NYS Bureau of Narcotic Enforcement NYSDA Committee on Chemical Dependency Journals “The Prevention of Opioid Abuse: The Role of the Dentist” JADA 2011;142;800-810 City Health Information: NYC Department of Health and Mental Hygiene (December 2011)
64. Follow Up Dennis P. BohlinDDS 200 W. 57th Street Ste. 1110 New York, NY 10019 212-586-2333 E-mail request for PowerPoint DPBOHL@aol.com