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 xiPreface xiiiAcknowledgments xv1 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 102 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 26Appendix 2.A: Common Opioid Analgesics and their Brand Names 27References 29Resources and Further Readings 303 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 464 Special Pain Management Considerations: (1) Chronic Methadone, Buprenorphine, and Naltrexone Therapy; (2) Chronic Opioids for Nonmalignant 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 585 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 826 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 1187 Tobacco Cessation: Behavioral and Pharmacological Considerations 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 1408 Detection and Deterrence of Substance Use Disorders and 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 1589 Interviewing and Counseling Patients with Known or Suspected Substance 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 16710 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 17611 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 187Summary 189References 189Resources and Further Readings 19012 Due Diligence and Safe Prescribing 191Michael O’Neil, PharmDIntroduction 191Definitions 191Case Scenarios 192Summary 205References 206Continuing Education Examination 207Index 213