The ADA Practical Guide toSubstance Use Disorders andSafe Prescribing

Andrew Taylor O’Neil (September 2, 1991–September 9, 2014)

This book is dedicated to Andrew – high-school valedictorian, Eagle Scout with highest honors, nat-uralist, intellectual, humorist, friend and teacher to all, brother, and most importantly an amazing,caring, giving, and loving son. No parent could ever be more proud of a son than I am of you. Youare forever in the hearts of all that ever met you.

Dad

The ADA PracticalGuide to SubstanceUse Disorders andSafe Prescribing

Edited by

Michael O’Neil, PharmDProfessor and Vice-Chair, Department of Pharmacy PracticeDrug Diversion, Substance Abuse, Pain Management ConsultantSouth College School of PharmacyKnoxville, TN, USA

Copyright © 2015 by American Dental Association. All rights reserved

Published by John Wiley & Sons, Inc., Hoboken, New JerseyPublished simultaneously in Canada

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by anymeans, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the Publisher, orauthorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, Inc., 222Rosewood Drive, Danvers, MA 01923, (978) 750-8400, fax (978) 750-4470, or on the web at www.copyright.com.Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons,Inc., 111 River Street, Hoboken, NJ 07030, (201) 748-6011, fax (201) 748-6008, or online athttp://www.wiley.com/go/permission.

The contents of this work are intended to further general scientific research, understanding, and discussion only andare not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, ortreatment by health science practitioners for any particular patient. The publisher and the author make norepresentations or warranties with respect to the accuracy or completeness of the contents of this work andspecifically disclaim all warranties, including without limitation any implied warranties of fitness for a particularpurpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and theconstant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to reviewand evaluate the information provided in the package insert or instructions for each medicine, equipment, or devicefor, among other things, any changes in the instructions or indication of usage and for added warnings andprecautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website isreferred to in this work as a citation and/or a potential source of further information does not mean that the author orthe publisher endorses the information the organization or Website may provide or recommendations it may make.Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared betweenwhen this work was written and when it is read. No warranty may be created or extended by any promotionalstatements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.

For general information on our other products and services or for technical support, please contact our CustomerCare Department within the United States at (800) 762-2974, outside the United States at (317) 572-3993 or fax (317)572-4002.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not beavailable in electronic formats. For more information about Wiley products, visit our web site at www.wiley.com.

Library of Congress Cataloging-in-Publication Data

The ADA practical guide to substance use disorders and safe prescribing / edited by Michael O’Neil.p. ; cm.

Practical guide to substance use disorders and safe prescribingAmerican Dental Association practical guide to substance use disorders and safe prescribingIncludes bibliographical references and index.Summary: “This is in addition to a variety of legal regulations dentists must follow regarding the storage and

record keeping of controlled substances”—Provided by publisher.ISBN 978-1-118-88601-4 (paperback)I. O’Neil, Michael (Pharmacist), editor. II. American Dental Association, issuing body. III. Title: Practical guide

to substance use disorders and safe prescribing. IV. Title: American Dental Association practical guide to substanceuse disorders and safe prescribing.

[DNLM: 1. Dental Care–United States. 2. Substance-Related Disorders–United States. 3. DentalOffices–organization & administration–United States. 4. Dentist-Patient Relations–United States.5. Drug Prescriptions–standards–United States. 6. Drug and Narcotic Control–United States. WM 270]

RK701617.6061–dc23 2015006921

Cover images (clockwise from top middle): © iStockphoto/JurgaR; © iStockphoto/mphillips007;© iStockphoto/KarenMower; © iStockphoto/Bunyos; © Stephen Wagner, used with permission

Set in 9.5/12pt Palatino LT Std by Aptara Inc., New Delhi, India

Printed in Singapore

10 9 8 7 6 5 4 3 2 1

Contents

Contributors xi

Preface xiii

Acknowledgments xv

1 Substance Use Disorders, Drug Diversion, and Pain Management:The Scope of the Problem 1Michael O’Neil, PharmDIntroduction 1Definitions 2Substance Use Disorder, Drug Misuse, Drug Diversion,and Pain Management in the Dental Community 4Understanding the Cultures of Substance Use Disorder, Drug Misuse, and Drug Diversion 8Summary 9References 10

2 Understanding the Disease of Substance Use Disorders 11James H. Berry, DO and Carl Rollynn Sullivan, MDIntroduction 11Definitions 11Epidemiology: Drug/Alcohol 13Pathophysiology/Brain Pathways 14Signs, Symptoms, Behavior 15Treatment Methods 20Summary 26

v

vi Contents

Appendix 2.A: Common Opioid Analgesics and their Brand Names 27References 29Resources and Further Readings 30

3 Principles of Pain Management in Dentistry 31Paul A. Moore, DMD, PhD, MPH and Elliot V. Hersh, DMD, MS, PhDIntroduction 31Definitions 32Neurophysiology and Neuroanatomy of Acute Inflammatory Pain 32Orally Administered Analgesic Agents 33Medication-Assisted Therapies for Treating Drug-Dependent Patients 41Adjunctive Drugs Used to Limit Pain in Dentistry 41Guidelines for Analgesic Therapy 43Summary 45References 45Resources and Further Readings 46

4 Special Pain Management Considerations: (1) Chronic Methadone,Buprenorphine, and Naltrexone Therapy; (2) Chronic Opioids forNonmalignant Pain 47Michael O’Neil, PharmDIntroduction 47Definitions 48Interviewing the Patient: Establishing Goals of Treatment 49Pharmacological Treatment of Opioid Addiction 49Treating Acute Dental Pain 51Acute Pain in Patients Receiving Opioid Maintenance Therapy 51The Active Opioid Addict 55Acute Pain Management in Patients Receiving Naltrexone Therapy 56Acute Pain Management in Patients Receiving Opioids for Chronic Pain 57Summary 57References 58

5 Sedation and Anxiolysis 61Matthew Cooke, DDS, MD, MPHIntroduction 61Definitions 61Spectrum of Anesthesia and Sedation 62Preoperative Evaluation 64Physical Status Classification 65Sedation 65Medications Available for Sedation of Patients with Substance Use Disorder 68The Concept of Balanced Anesthesia 76Monitoring and Documentation 76Summary 78Disclaimer 78References 79Resources and Further Readings 82

Contents vii

6 Common Substances and Medications of Abuse 83William J. Maloney, DDS and George F. Raymond, DDSIntroduction 83Definitions 83Signs and Symptoms of Substance Use Disorder 85Common Substances of Abuse 86Prescription Medications 100Over-the-Counter Medications 111Summary 112References 112Resources and Further Readings 118

7 Tobacco Cessation: Behavioral and PharmacologicalConsiderations 119Frank Vitale, MA and Amanda Eades, PharmDIntroduction 119Definitions 119Forms of Tobacco 121Oral Effects of Tobacco Use 121Dental Practitioner Management of Tobacco Use 122Spit Tobacco Interventions 124Oral Substitutes 125Social Support/Disapproval 125Medication Management for Smoking Cessation 126The Role of Nicotine 126Pharmacotherapy Options 127Summary 138References 138Resources and Further Readings 140

8 Detection and Deterrence of Substance Use Disordersand Drug Diversion in Dental Practice 141Sarah T. Melton, PharmD, BCPP, BCACP, CGP, FASCP and Ralph A. OrrIntroduction 141Definitions 141Screening Patients for Substance Use Disorder 142Schemes and Scams to Obtain Prescription Drugs 144Dental Practitioner- and Office Personnel-Related Prescription Drug Diversion 147Prescription Drug Monitoring Programs 148Disposal of Controlled Substances 153Universal Precautions in Prescribing Controlled Substances 154Summary 157References 157Resources and Further Readings 158

viii Contents

9 Interviewing and Counseling Patients with Known or SuspectedSubstance Use Disorders: Dealing with Drug-seeking Patients 159George F. Raymond, DDS and William J. Maloney, DDSIntroduction 159Definitions 160Preinterview Considerations 160Patient Interview Considerations 161Interviewing and Counseling Techniques 162What Questions Should Be Asked? 163Screening Tools 164Documentation 165Summary 166References 166Resources and Further Readings 167

10 Office Management of Controlled Substances 169Carlos M. AquinoIntroduction 169Federal Statutes and Regulations 169Definitions 169Common Violations by Dental Practitioners 170Surviving a Drug Enforcement Administration Inspection 173Practice Due Diligence Program 175Management of Noncontrolled Substances in the Office 176Summary 176Resources and Further Readings 176

11 Addiction and Impairment in the Dental Professional 177William T. Kane, DDS, MBA, FAGD, FACDIntroduction 177Definitions 178The Complexity of Addiction 178The Neurobiology of Addiction 179The Stigma of Addiction 180Epidemiology of Addiction in Dentistry 180Risk Factors for Substance Use Disorder 180Substances of Choice 182Identifying Addiction 183“The Conspiracy of Silence” 183Intervention 184Evaluation/Assessment 185Treatment 186Family and Staff 186Relapse 187Monitoring 187Peer Assistance or Dental Well-being Committee Programs 187

Contents ix

Summary 189References 189Resources and Further Readings 190

12 Due Diligence and Safe Prescribing 191Michael O’Neil, PharmDIntroduction 191Definitions 191Case Scenarios 192Summary 205References 206

Continuing Education Examination 207

Index 213

Contributors

Carlos M. AquinoDEA Compliance ConsultantMilford, MA, USARetired Police Department OfficerRetired Drug Enforcement Agent, DEA

James H. Berry, DOAddiction PsychiatristMedical Director – Chestnut Ridge CenterInpatient ServicesAssistant Professor – Department ofBehavioral Medicine and PsychiatryWest Virginia UniversityMorgantown, WV, USA

Matthew Cooke, DDS, MD, MPHAssistant ProfessorDepartments of Dental Anesthesiology &Pediatric DentistryUniversity of Pittsburgh School of DentalMedicinePittsburgh, PA, USAandDepartments of Oral & Maxillofacial Surgery &Pediatric DentistryVirginia Commonwealth University School ofDentistryRichmond, VA, USA

Amanda Eades, PharmDAssistant Professor/Clinical PharmacistUniversity of Illinois at ChicagoChicago, IL, USA

Elliot V. Hersh, DMD, MS, PhDProfessor PharmacologyDirector – Division of Pharmacology andTherapeuticsUniversity of Pennsylvania School of DentalMedicinePhiladelphia, PA, USA

William T. Kane, DDS, MBA, FAGD, FACDGeneral DentistryDexter, MI, USA

William J. Maloney, DDSClinical Associate ProfessorDepartment of Cariology and ComprehensiveCareNew York University College of DentistryNew York, NY, USA

Sarah T. Melton, PharmD, BCPP, BCACP,CGP, FASCPAssociate Professor of Pharmacy PracticeGatton College of Pharmacy at ETSUJohnson City, TN, USA

xi

xii Contributors

Paul A. Moore, DMD, PhD, MPHProfessor – Pharmacology and Dental PublicHealthUniversity of Pittsburgh School of DentalMedicinePittsburgh, PA, USA

Michael O’Neil, PharmDProfessor and Vice-ChairDepartment of Pharmacy PracticeDrug Diversion, Substance Abuse and PainManagement ConsultantSouth College School of PharmacyKnoxville, TN, USA

Ralph A. OrrDirectorVirginia’s Prescription Monitoring ProgramHenrico, VA, USA

George F. Raymond, DDSClinical InstructorDepartment of Cariology and ComprehensiveCareNew York University College of DentistryNew York, NY, USA

Carl Rollynn Sullivan, MDProfessor and Vice-ChairmanDirector, Addictions ProgramsWVU School of MedicineDepartment of Behavioral Medicine &PsychiatryMorgantown, WV, USA

Frank Vitale, MANational DirectorPharmacy Partnership for Tobacco CessationPittsburgh, PA, USA

Preface

Health-care practitioners have become inun-dated by an array of patients with multiplemedical conditions that are further compli-cated by pain/sedation management issues,substance use disorders (SUDs), and worriesof drug diversion. Pain management, whetherfor acute or chronic pain, has become a pri-mary concern for dental practitioners. Prac-titioners often feel pressured by patient sur-vey results and patients to “overprescribe”controlled substances. With the rise in opioidaddiction there has been a significant increase inmedication-assisted treatment, including use ofmethadone and buprenorphine products. Theseagents have proven efficacy in both the treat-ment of opioid addiction and pain. However,evidence-based studies evaluating treatment ofpatients with concurrent opioid addiction and acuteor chronic pain are lacking. Opioid or alcoholaddiction treatment medications, such as nal-trexone, have complicated opioid analgesia inmany patients.

The plethora of substances being abused insociety today includes household products suchas paints and “cleaners” to combinations ofheroin, cocaine, and other medicinal agents.Public health risks of medication misuse and

substance abuse have reached epidemic propor-tions. When patients present to the dental prac-titioner with a history of SUD or recent sub-stance abuse, routine procedures are no longerroutine. Dental practitioners treating patientsunder the influence of substances may put boththe patients and themselves at unnecessary riskof complications. Use of routine local anesthet-ics, such as lidocaine with epinephrine, nowhas the potential to put the methamphetamineaddict in a life-compromising situation. Datasupporting definitive management of patientswith acute pain and SUD are limited. Recogniz-ing patients with SUD, intervening, and direct-ing them to appropriate treatment require timeand expertise.

All dental office staff must now look for drugdiversion behaviors on a daily basis. Unknow-ingly, dental practitioners may become victimsof various scams and schemes. Recognition,prevention, deterrence, detection, and report-ing of potential criminal behaviors interruptthe daily work flow for many dental practices.Prescription drug fraud and “Dr Shopping”are only two of the many diversion activitiesdental practitioners must address. A signifi-cant rise in prescription fraud has created an

xiii

xiv Preface

environment of fear and frustrations for pre-scribers, patients, law enforcement agencies,and local communities.

Dental practitioners must be fully preparedto manage a variety of patients with complexanalgesic/sedation needs and SUD and, at thesame time, protect themselves and their stafffrom drug diversion activities.

The purpose of this book is multifactorial:

1. Review basic elements of SUD, acutepain/sedation management, and drugdiversion.

2. Provide clinical tools proven to aid inthe identification, interviewing, interven-tion, referral, and treatment of SUD.

3. Summarize evidence-based literature thatsupports what, when, and how to prescribecontrolled substances to patients with SUD(e.g., analgesia, sedation).

4. Discuss key federal controlled-substanceregulations that frequently impact dentalpractitioners.

5. Provide checklists that will help preventdrug diversion in dental practices.

In completing this challenge, dental prac-titioners will be better prepared to care forpatients, protect the community, and safeguardtheir own practices.

Michael O’Neil

Acknowledgments

I am forever indebted to the chapter authors ofthis book. Their work, patience, and commit-ment to excellence are nothing less than excep-tional. Managing patients in an environmentof increasing frequency of substance use dis-orders, drug diversion, and pain is often anoverwhelming endeavor. The expertise offeredby the chapters is practical and evidence basedand will guide dental practitioners in their day-to-day practices. I wish to acknowledge theAmerican Dental Association (ADA) staff edi-tors of this book for their excellent and timelywork. These include Amy Lund, Senior Editor,Kathryn Pulkrabek, Manager/Editor Profes-sional Products, Alison Siwek, Manager, DentistHealth and Wellness, and Carolyn Tatar, Senior

Manager of Product Development and Man-agement. I wish to thank Carolyn Tatar for herdirection in this project.

I would also like to thank the Wiley pub-lishing team of Rick Blanchette, Nancy Turner,and Jennifer Seward for their due diligence andcommitments to making this book a success.

I am indebted to Alison Siwek for herinsights and perspectives regarding the manyconcerns of dental practitioners working withthe ADA. The authors and I would like tothank the ADA leadership for their recognitionof the need to create this book to educate theirmembers.

Michael O’Neil

xv

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

Michael O’Neil, PHARMD

Introduction

The practice of dentistry has become increas-ingly complicated by multiple factors, includ-ing increasing numbers of patients withsubstance use disorder (SUD), patients receiv-ing chronic pain medications, and prescriptiondrug-related crime (see Box 1.1). In January2012, the Centers for Disease Control (CDC)announced that the USA is experiencing anepidemic of prescription drug-related over-doses with the majority of these involvingprescription opioids.1 Findings from the 2011National Health and Aging Trends Studyreported bothersome pain afflicts half of thecommunity-dwelling US older adult popula-tion and is associated with significant reductionin physical function, particularly in those withmultisite pain.2 National Survey on Drug Useand Health (NSDUH) 2012 data indicate that6.8 million people aged 12 or older are currentnonmedical users of psychotherapeutic drugsand that 4.9 million of these were users of painrelievers.3 The NSDUH 2012 data also indicate

Box 1.1 Factors Complicating thePractice 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.

that the rate of current illicit drug (e.g., cocaine,marijuana, inhalants) use among persons aged12 or older was 9.2%. In 2012, the NSDUHsurvey revealed an estimated 22.2 million per-sons aged 12 or older were classified as havingan SUD in the past year (8.5% of the popula-tion aged 12 or older). Other results from this

The ADA Practical Guide to Substance Use Disorders and Safe Prescribing, First Edition. Edited by Michael O’Neil.© 2015 American Dental Association. Published 2015 by John Wiley & Sons, Inc.

1

2 The ADA Practical Guide to Substance Use Disorders and Safe Prescribing

survey are include 2.8 million people were clas-sified as having an SUD of both alcohol andillicit drugs, 4.5 million had an SUD associatedwith illicit drugs but not alcohol, and 14.9 mil-lion an SUD associated with alcohol but notillicit drugs. Overall, 17.7 million had an SUDassociated with alcohol and 7.3 million had anSUD associated with illicit drugs.3

The extent of the overlap of pain manage-ment, SUD, prescription drug misuse, and drugdiversion in the same patient has not been welldefined. However, patients commonly presentwith more than one of these clinical and ethicalchallenges at any given office visit or hospitaladmission. Individual motivations and behav-iors leading to the abuse, misuse, and diversionof prescription drugs, illicit drugs, and alco-hol vary significantly. This chapter will pro-vide an overview of SUD, prescription drugmisuse, drug diversion, pain management, andcultural considerations in patients involved inthese activities. Key terminology used through-out this book is also defined.

Definitions

Acute PainAcute pain comes on quickly, can be moderateto severe in intensity, and generally lasts a shortperiod of time (e.g., from days up to 3 months).Acute pain is considered a beneficial process,warning of potential harm to the body frominjury or medical conditions. Acute pain ismost commonly nociceptive, modulated bymediators such as prostaglandins, substance P,and histamines, or neuropathic, characterizedby alterations in the transmission pathways ofnerves.

AddictionAddiction is a primary chronic disease ofbrain reward, motivation, memory, judgment,

and related circuitry. Dysfunction in these cir-cuits leads to characteristic biological, psy-chological, social, and spiritual manifestationsthat frequently result in destructive and life-threatening behaviors.4 Addiction is influencedby multiple factors, including, but not limitedto, genetics, environment, sociology, physiol-ogy, and individual behaviors.

Addiction is characterized by the inabilityto consistently abstain, impairment in behav-ioral control, craving, diminished recognition ofsignificant problems in behavior and interper-sonal relationships, and a dysfunctional emo-tional response. Like other chronic diseases,addiction often involves cycles of relapse andremission. Without treatment or engagement inrecovery activities, addiction is progressive andcan result in disability or premature death.4

Chronic PainChronic pain generally refers to intractable painthat exists for 3 months or more and does notresolve in response to treatment. Some condi-tions may become chronic in as little as 1 month.Chronic pain may be continuous or reoccurring,persisting for months or even a lifetime. Whilethe exact duration and characteristics of acuteand chronic pain may overlap considerablydepending on a patient’s medical condition,dental practitioners should recognize that spe-cific timelines for the diagnosis of acute versuschronic pain may be integrated into federal andstate legislation and into state board regulationsto promote safe pain management practices andsafe medication prescribing guidelines.

Drug DiversionDrug diversion may be defined as the inten-tional transfer of a substance, or possession ofa substance, or alteration of legitimate medica-tion orders outside the boundaries designatedby the Food and Drug Administration, fed-eral Drug Enforcement Administration (DEA),

Substance Use Disorders, Drug Diversion, and Pain Management: The Scope of the Problem 3

or state regulatory board. Drug diversion mayinvolve prescription or over-the counter (OTC)medications or illicit substances. These illegalactivities are usually motivated by financialincentives, SUD behaviors, or other activities,such as sharing medications with the intent tohelp. Examples include a patient selling or giv-ing their prescription medication to someoneelse, altering the original information on a pre-scription without the prescriber’s consent, ortheft of medications.

Drug MisuseDrug misuse may be defined as taking a pre-scribed or OTC medication for nonprescribedpurposes, in excessive doses, shorter intervalsthan prescribed or recommended, or for reasonsother than the original intent of the prescription.Examples include doubling the dosage, short-ening dosing intervals, or treating disorders forwhich the medication was not prescribed.

Opiates and OpioidsOpiates refer to natural substances derivedfrom the poppy plant. Opioids function in asimilar manner to opiates but are either syn-thetic or partially synthetic derivatives of opi-ates. For the purpose of this text, the term opioidwill be used interchangeably for opiate.

Prescriber–Patient MismatchPrescriber–patient mismatch is defined as theinconsistency in treatment goals or expectationsof treatment between the prescriber and thepatient. Examples include analgesia, sedation,or anxiolysis.

Substance AbuseSubstance Abuse is a maladaptive pat-tern of chemical use (e.g. alcohol, medi-cations, marijuana, cocaine, solvents, etc.)leading to clinically significant impair-ment or distress, as manifested by one (or

more) of the following, occurring within a12-month period:

� Recurrent chemical use resulting in a fail-ure to fulfill major role obligations at work,school, or home

� Recurrent chemical use in situations in whichit is physically hazardous

� Recurrent chemically-related legal problems� Continued chemical use despite having per-

sistent or recurrent social or interpersonalproblems caused by or exacerbated by theeffects of the chemical

The substance abuse culture consists ofindividuals whose sole intent is to alter inany number of ways their mood, psycho-logical sense of well-being, physical senseof well-being, or their personal connectionwith the world around them.5

Substance DependenceSubstance dependence may be defined as per-sistent use of alcohol, other drugs, or chemi-cals despite having problems related to use ofthe substance. It is a maladaptive pattern ofchemical use, leading to clinically significantimpairment or distress, as manifested by three(or more) of the following, occurring within a12-month period:

� Tolerance, as defined by either of the follow-ing:– a need for significantly increased amounts

of the substance to achieve intoxication ordesired effect;

– significantly diminished effect with con-tinued use of the same amount of thesubstance.

� Withdrawal, as manifested by either of thefollowing:– the characteristic withdrawal symptom

for the substance (see Chapter 2);

4 The ADA Practical Guide to Substance Use Disorders and Safe Prescribing

– the same (or a closely related) substanceis taken to relieve or avoid withdrawalsymptoms.

� The substance is often taken in largeramounts or over a longer period than wasintended.

� There is a persistent desire or unsuccessfulefforts to cut down or control substance use.

� A great deal of time is spent in activities nec-essary to obtain the substance, use the sub-stance, or recover from its effects.

� Important social, occupational, or recre-ational activities are given up or reducedbecause of substance use.

� The substance use is continued despiteknowledge of having a persistent or recur-rent physical or psychological problem thatis likely to have been caused or exacerbatedby the substance.5

Substance Use DisordersIn May 2013, The American Psychi-atric Association redefined terminologypreviously used in the Diagnostic andStatistical Manual of Mental DisordersText Revision (DSM-IV TR) guidelinesregarding diagnostic classifications ofSubstance Dependence and SubstanceAbuse Disorders. SUD in DSM-5 com-bines the DSM-IV-TR categories of sub-stance abuse, substance dependence andaddiction disorders into a single disordermeasured on a continuum from mild tosevere. Nearly all SUDs are diagnosedbased on the same overarching criteriawhich have not only been combined, butstrengthened. (For example, in DSM-IVTR, a diagnosis of substance abuse pre-viously required only one symptom, inDSM-5 a diagnosis of mild SUD requirestwo to three symptoms from a list of 11[see Box 1.2]. SUD may be best describedas a continuum of substance abuse andthe disease of addiction.6

Box 1.2 SUD Symptoms List� Taking the substance in larger amounts or for

longer than you meant to take it.� Wanting to cut down or stop using the

substance but not managing to be successful.� Spending a lot of time getting, using, or

recovering from use of the substance.� Cravings and urges to use the substance.� Not managing to do what you should at work,

home, or school because of substance use.� Continuing to use the substance, even when it

causes problems in relationships.� Giving up important social, occupational, or

recreational activities because of substanceuse.

� Using substances again and again, evenwhen it puts you in danger.

� Substance dependence.� Developing tolerance.� Developing withdrawal symptoms.

Substance Use Disorder, DrugMisuse, Drug Diversion, andPain Management in theDental Community

The terms psychological or psychiatric depen-dency and addiction are often used inter-changeably with SUD, the term used in thisbook. Although the terms chemical, medica-tion, drug, substance, chemical substance, orillicit substances are often used interchange-ably, in this book the term substance is usedwhen generally referring to products that arebeing abused or misused. Differences are onlylikely to occur based on federal and state clas-sifications or medically accepted use.

Substance Use DisorderDental practitioners likely observe manypatients at various stages of the substance abuse–disease of addiction continuum known as SUD.Specific patient behaviors may range from

Substance Use Disorders, Drug Diversion, and Pain Management: The Scope of the Problem 5

subtle exaggerations of pain severity with theintent to acquire more medications, to patientspresenting in an exaggerated euphoric or dis-sociative state. Although the impact of opioidabuse and misuse on health care has beenevaluated,7 the financial and workload burdenof these behaviors has not been well character-ized in the practice of dentistry. However, ina comprehensive statewide survey of dentistsby O’Neil, 75% of dentists surveyed suspected1–20% of their patients had a drug addiction ordrug abuse disorder and 94% of dental prac-titioners altered their prescribing practices ofopioid analgesics if the patient acknowledgedan SUD.8 These survey results suggest SUDlikely impacts patient management and theprescribing practices of dentists.

Medication MisusePrescription drug misuse has been identifiedas a significant health-care problem. Individ-uals self-medicating with prescription drugsoutside of the boundaries of the original intentof the prescription appears to be a significantcontributing factor in the development of SUD.Recent survey data from the SAMSHA in 2012indicated 6.8 million Americans aged 12 orolder (or 2.6%) had used psychotherapeuticprescription drugs without a prescription orin a manner or for a purpose it was not pre-scribed in the past month.3 Individuals maymisuse drugs by self-prescribing unused orexpired drugs. The impact of self-medicatingwith prescription drugs by patients for den-tal procedures or dental pain has not beenwell described in the USA. Excessive opi-oid prescribing by dental practitioners hasbeen suggested in the dental literature, andthese surveys have reported a wide dosingrange of opioid analgesics for identical orsimilar dental procedures.9, 10 Multiple fac-tors may influence excessive prescribing (seeBox 1.3). Dental practitioners should be awareof prescription medication misuse and abusebehaviors (see Box 1.4). These behaviors are

Box 1.3 Potential Influential Factors ofExcessive Prescribing

� Limited guidelines for appropriate drug anddosage selection for specific disease states ordental procedures.

� Subjectivity of individual patient or dentist’sperception of pain severity.

� Patient assertiveness or aggressiveness towardprescriber.

� Complicated patient pathology.� Lack of knowledge of pharmacologic

principles and treatment options.� Prescriber–patient mismatch.� Provider availability.� Patient or prescriber convenience.

Box 1.4 Common Prescription DrugMisuse and Abuse Behaviors inDental Patients

� Requesting refills or running out of medicationsearly.

� Repeated frequent or unnecessary office visits.� Obvious powder or tablet fragments in nostrils.� Impaired patients at initiation of office visit.� Request from members of the family (spouse,

parent) or patient’s friends (boyfriend,girlfriend) for more medications.

� Family members or patient friends demandingto be present when asking for medications(excluding young children).

� Patients reporting multiple allergies to onlyless potent opioids and nonsteroidalanti-inflammatory drugs (NSAIDs).

discussed in more detail in Chapter 8. Ulti-mately, the most effective pharmacologicalagent, with minimal side effects or adverseeffects, should be prescribed with the lowestdose possible for the minimal amount of timeto achieve a reasonable effect such as analgesia,anxiolysis, or sedation. The impact of SUD ondental health and the dental community will bediscussed in Chapter 6.

6 The ADA Practical Guide to Substance Use Disorders and Safe Prescribing

Clinical Consideration

Prescribing of any medication requirescomprehensive patient histories, examinations,screening prior to prescribing or dispensingmedications, and patient education regardingmedication misuse.

AlcoholismAlcohol-related SUD is the most common ofall SUDs in society today. In 2012, the NSDUHfound that slightly more than half (52.1%) ofAmericans aged 12 or older reported beingcurrent drinkers of alcohol.3 This informationtranslates to an estimated 135.5 million currentdrinkers in 2012.3 Other results in this samesurvey indicated nearly one-quarter (23.0%) ofpersons aged 12 or older were binge alcoholusers in the 30 days prior to the survey. Thistranslates to about 59.7 million people. Heavydrinking was reported by 6.5% of the popula-tion aged 12 or older, or 17.0 million people.3

The cost of excessive alcohol consumptionin the USA in 2006 reached $223.5 billionaccording to the CDC in a 2006 study.11 TheCDC defines excessive alcohol consumption,or heavy drinking, as consuming an averageof more than one alcoholic beverage per dayfor women, and an average of more than twoalcoholic beverages per day for men, and anydrinking by pregnant women or underageyouth.11 The exact costs of alcohol abuse andaddiction to the dental health-care system havenot been well elucidated. Because many dentalpatients are seen routinely for preventive aswell as treatment services, dental practitionersmay have the greatest opportunity to recognizepotential alcohol SUD behaviors. This recogni-tion at a minimum should result in a recommen-dation or referral to a local substance treatmentcenter, substance abuse counselor, or primary-care physician for evaluation. See Box 1.5 forcommon signs and symptoms of potentialalcohol-associated SUD. Chapter 2 will discussthe diseases of alcoholism and other SUDs.

Box 1.5 Common Signs and Symptomsof Potential Alcohol-AssociatedSUD

� Alcohol odor on breath or clothes duringnormal day hours.

� Slurred speech.� Oversedation before office procedures start.� Clumsiness, imbalance while walking.� Unexplainable loud and argumentative

behavior.� Reduced effects of anesthetics during

procedures.

Drug DiversionDrug diversion presents in various forms, fromsimple self-prescribing and using someone’sleftover prescription medications, to criminalactivity to acquire more medications to sell orabuse. The penalties and punishments for thesebehaviors vary significantly.

Box 1.6 lists the most common types of drugdiversion. For the purpose of this textbook,

Box 1.6 Common Types of DrugDiversion

� Counterfeit medications/misbranding.� Robbery/burglary.� Trafficking/transport of illegal medications.� Prescription forgeries (written or verbal)� Sharing prescription medications.� Internet scams avoiding state, federal, and

national drug control regulations.� Fraudulent or “fake” patient schemes, injuries,

or complaints.� Selling prescriptions or prescription

medications.� Personnel/office staff theft of medications from

offices, hospitals, stock supplies.� Doctor/dentist/pharmacy shopping with intent

to deceive.� Knowingly overprescribing medications by

prescribers.� Health-care fraud.� Extortion/coercion.� Self-prescribing leftover medications/misuse.