The ADA Practical Guide to Substance Use Disorders and Safe Prescribing

Dentists have been inundated by patients with an array of complicated medical conditions and pain/sedation management issues. This is in addition to a variety of legal regulations dentists must follow regarding the storage and recordkeeping of controlled substances. Avoid unknowingly putting your practice at risk by becoming victim to a scam or violating a recordkeeping requirement with The ADA Practical Guide to Substance Use Disorders and Safe Prescribing.

This Practical Guide is ideal for dentists and staff as they navigate: 

Detecting and deterring substance use disorders (SUD) and drug diversion in the dental office (drug–seeking patients) Prescribing complexities Treating patients with SUD and complex analgesic and sedation (pain/sedation management) needs and the best use of sedation anxiety medication Interviewing and counselling options for SUD Federal drug regulations

Commonly used illicit, prescription, and over–the–counter drugs, as well as alcohol and tobacco, are also covered. 

Special features include: 

Clinical tools proven to aid in the identification, interviewing, intervention, referral and treatment of SUD Basic elements of SUD, acute pain/sedation management, and drug diversion Summary of evidence–based literature that supports what, when and how to prescribe controlled substances to patients with SUD Discussion of key federal controlled substance regulations that frequently impact dental practitioners Checklists to help prevent drug diversion in dental practices Chapter on impaired dental professionals Case studies that examine safe prescribing and due diligence

Contributors xxx

Preface xxx

Acknowledgements xxx

1. Substance Use Disorders, Drug Diversion and Pain Management– The Scope of the Problem
Michael O Neil

1. Introduction

2. Definitions

3. Overview: SUD, Drug Misuse, Drug diversion and Pain Management

a. SUD

b. Medication Misuse

c. Alcoholism

d. Drug Diversion

e. Pain Management in Dentistry

4. Understanding the Cultures of SUD, Drug Misuse and Drug Diversion

a. Sharing Culture

b. Income Driven Culture

c. Substance Abuse Culture

d. Addiction Culture

e. Combination of Cultures

5. Summary

2. Understanding the Disease of Substance Use Disorder
Carl Rollynn Sullivan and James Berry

1. Introduction

2. Definitions

3. Epidemiology: Drug / Alcohol

4. Pathophysiology

5. Signs /Symptoms/ Behavior

a. alcohol

b. benzodiazepines

c. opioids

d. stimulants

e. cannabis

f. nicotine

g. hallucinogens, designer drugs, inhalants

6. Treatment methods

a. Behavior modification and counseling

1. Motivational Interviewing

2. CBT

3. Contingency Management

4. AA / 12 steps

b. Pharmacological management

(Agents, pharmacology, pharmacokinetics, dosing, adverse effects, contraindications, drug selection, goals, duration of treatment, monitoring, outcome documentation)

7. Summary

3. Principles of Pain Management in Dentistry
Paul Moore and Elliot Hersh

1. Introduction

2. Definitions

3. Neurophysiology and Neuroanatomy of Acute Inflammatory Pain

4. Agents, pharmacology, pharmacokinetics, dosing, adverse effects, contraindications, Drug selection, duration of treatment, monitoring, documentation

a. nonopioid

b. opioid

5. Medication Assisted Therapies for Drug Dependence

6. Adjunctive Drugs

7. Preemptive Analgesics

8. Corticosteroids

9. Guidelines to Analgesic Therapy

10. Summary

5. Special populations (renal insufficiency, coagulopathies, etc.)

6. Safe prescribing considerations

7. Summary

4. Special Pain Management Considerations

Michael O Neil

1. Introduction

2. Definitions

3. Interviewing the Patient: Establishing Goals of Treatment

4. Pharmacological Treatment of Opioid Addiction / Acute Pain

a. methadone

b. buprenorphine

c. naltrexone

5. Acute pain management patients with chronic nonmalignant pain

6. Summary

5. Sedation and Anxiolysis
Matthew Cooke

1. Introduction

2. Definitions

3. Spectrum of Anesthesia and Sedation

4. Preoperative evaluation

5. Physical Status Classification

6. Sedation

7. Medications in Patients with SUD

a. nitrous oxide

b. benzodiazepines

c. opioids

d. ketamine

e. propofol

f. alpha–agonist

g. local anesthetics

8. Balance Anesthesia

9. Monitoring and documentation

10. Moderate conscious sedation

11. Deep sedation

12. Emergencies

13. Special considerations

14. Summary

6. Common Substances and Medications of Abuse
George Raymond and William Maloney

1. Introduction

2. Definitions

3. Signs and symptoms

4. (drugs/chemicals, pharmacology, effects, routes, dental characteristics/patho, disease specific complications)

a. Illicit drugs

1. Stimulants Methamphetamine, Cocaine

2. Hallucinogens

3. Opioids

4. Inhalants

5. CNS depressants

6. Marijuana

5. Prescription Drugs

1. Opioids

2. Stimulants

3. CNS depressants

4. Antipsychotics

5. Muscle relaxants

6. Anticonvulsants

7. Other Agents

6. OTCs

7. Summary

7. Nicotine and tobacco Cessation
Frank Vitale and Amanda Eades

1. Introduction

2. Definitions

3. Epidemiology –cigarettes, cigars, pipes, water pipes, chewing tobacco, dip/snuff

4. Oral effects of tobacco

5. Dental practitioner Management of Tobacco USE

a. Brief intervention

b. Low intensity

c. Moderate intensity

d. Spit tobacco interventions

6. Medication Management

a. Role of nicotine

b. NRT

c. Individual Agents

d. Non FDA approved treatments

7. Summary

8. Detection and Deterrence of Substance Use Disorder and Drug Diversion in Dental Practice
Sarah Melton and Ralph Orr

1. Introduction

2. Definitions

3. Screening patients and referrals for treatment/intervention

a. SBIRT

b. CAGE

c. NMASSIST

4. Schemes and scams

a. In office behaviors

b. Behavior prevention

c. Out of office behaviors

d. Dental practitioner Diversion

5. PDMP

a. Brief History of PDMPs

b. PDMP as a tool / general principles

c. Interpreting PDMP reports

d. Case

6. Drug disposal

7. Universal Safe prescribing practices

9. Summary

9. Dentist Interviewing and Counseling of Patients with Substance Use Disorders and Dealing with Drug Seeking Patients
George Raymond and William Maloney

1. Introduction

2. Definitions

3. Pre–interview considerations

4. Questions to ask

5. Interviewing / counseling

6. Screening tools

7. Documentation

8. Summary

10. Office Management of Controlled Substances and Record Keeping
Carlos Aquino

1. Introduction

2. Definitions

3. Federal and State Regulations

4. Common violations by dentist

a. Scope of practice

b. Record keeping

c. Storage

d. Record keeping

5. Record Keeping

a. Purchasing / storage /security

b. Drug disposal

6. Documentation

7. Surviving a Dental Board Inspection or DEA Audit

8. Due Diligence

9. Non–Controlled Substance Management

10. Summary

11. The Impaired Dental Health Professional and Office Staff
William Kane

1. Introduction

2. Definitions

3. Epidemiology of Substance Use Disorder in healthcare

4. Neurobiology

5. Stigma of Addiction

6. Risk Factors

7. Substances of Choice

8. Identification of the Impaired Professional

9. Interventions

10. Treatment

11. Well–being Committees

12. Summary

12. Due Diligence and Safe Prescribing
Michael O Neil

1. Introduction

2. Definitions

3. Case Scenarios A–J

4. Summary

Continuing Education Questions, xxx

Index xxx

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.