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When Your Patient Has an Addiction Dr. William Kane

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The focus of this article will be on indentifying the dental patient with a substance use disorder (SUD) or an addictive disease, as these terms are basically the same. Additionally, it will cover how an addictive disease affects all aspects of a patients’ life.

IDENTIFICATION AND UNDERSTANDING ADDICTIVE DISEASES
When our patients seek our skill and care for their oral health needs, they bring a variety of interesting needs with them. These needs can be emotional, psychological, financial and physical issues that must be addressed prior to and along the way in the dentist/patient relationship. By the fourth year of dental school, we have discovered this.

At a patients’ initial appointment, they fill out a health history, giving us an insight into their current and past medical and dental health. Certain diseases, conditions and patient behavior give us information regarding the patients’ systemic health and will assist us in making the appropriate diagnosis and dental treatment plan.

When examining a patients’ social history, dental professionals should routinely ask about the use, frequency and quantity of alcohol, tobacco and other drugs, as well as any history of addiction, alcoholism or substance abuse. However, a West Virginia survey of dental professionals states that 36 percent of respondents acknowledged not doing so.1

The prevalence of substance abuse is so high that every health care provider in the U.S. sees patients either at risk themselves or experiencing negative effects of substance use by a friend, family member or co-worker.2 Addiction is an “equal opportunity” disease that can be present in patients from all walks of life.

In broad terms, substance use can be described as use, misuse, abuse, addiction. Use is of course the proper application of say an opioid for post-operative pain following a dental procedure. Misuse would be taking the same opioid for “non medical” use. The next term abuse is when one has too many drinks on their birthday, or takes more pain medication than actually prescribed to obtain a more profound or euphoric effect. Finally, addiction is when the individual will continue using the substance despite adverse consequences.

A short and to-the-point definition of addiction is as follows: “Addiction is a medical disorder with a complex etiology, multiple manifestations and a varied clinical course.”3 A recent definition states: “Addiction coops the brain’s neuronal circuits necessary for insight, motivation and social behaviors. This functional overlap results in addicted individuals making poor choices despite awareness of the negative consequences; it explains why previously rewarding life situations and the threat of judicial punishment cannot stop curtailing addictions.”4 Patients with an addiction have “mental mismanagement” where poor decisions are the norm, not the exception. As the disease progresses, all areas of the patients’ life continue on a downward fashion.

Addictive diseases are chronic and progressive and can be fatal if not adequately treated. Dental professionals may have difficulty identifying a patient whose disease state is in the early to middle stages. Also, one may have difficulty addressing an addictive disease in the later stages with patients since they are almost always in denial that they indeed are suffering from an addiction.

Unfortunately dental professionals have not been trained to conduct screening and intervention techniques when patients present with addictive diseases. This is certainly an area that could be addressed more aggressively by organized dentistry and dental education. In a busy general or specialty practice, this type of screening is hard to implement.

Certain factors should be considered when looking at a patient’s health and social history. Certain medical and dental professionals may have a greater suspicion their patient may have other substance use disorders if they are heavy smokers or smokeless tobacco users. This is certainly a point to consider! Substance use disorders and addictions can negatively affect certain organ systems such as the hemopoetic, the cardiovascular and the digestive systems. A patient reporting a past history of hypertension, recent pneumonias and pancreatitis often have an alcohol abuse or dependence. The patient presenting with complex health histories will often require a medical consult which can reveal more information than perhaps the patient has reported. Additionally, patients tend to underreport certain conditions for a variety of reasons. If a patient lists allergies to several commonly prescribed narcotic pain medications this should cause some reason for concern.

Frequently, patients with addictions seek episodic emergency care. This may bring someone new to your practice seeking relief from a painful dental condition. One can also observe established patients interest in their oral health deteriorate over time along with the progression of the disease. These patients may be more apt to respond to a dental professional’s brief screening or intervention since a relationship has been established.

A new emergency patient in addition to the painful condition concerning them may have heightened fears and anxieties concerning dental treatment. Very often the front office can pick up on this and alert the clinical team and ultimately the dentist. When the patient is examined, health and social history reviewed, radiographs interpreted and a diagnosis made, often the treating dentist will have a fairly good idea of what is going on.

This is where the “red flags” may start to appear. Certain patients with addictions will complain of extreme dental pain and extreme anxiety to secure narcotic prescriptions. Some of these patients are master manipulators and can get what they want rather easily. When they are successful, they will continue to have these or other pain issues and also refer their “network” of friends and family. Others whose disease has progressed are far less skilled in manipulation. It takes a seasoned dental professional to resist the skillful manipulation of these “dentist shopper” patients.

Another “red flag” may pop up when the patient presents with a mouth with multiple pathologies present and the patient blames this condition on several outside factors. These may include, “The dentist I had in the Army, or previous dentist have done all these horrible things to me.” These stories can be very “interesting,” but the bottom line is the patient takes no personal responsibility for the condition of their mouth.

The reality is, patients with addictions can and do have real painful dental emergency conditions that really do require treatment. This is really a “slippery slope” for the dental professional – what are the choices? Generally dentists would want to eliminate the painful condition yet not participate in enabling the addiction to continue.

Here are some things to consider:
  • Am I comfortable with treating this patient? If the answer is yes, proceed with caution, if your gut-level feeling tells you no, refer the patient.

  • Although not the focus of this article, should you decide to treat this patient, offer immediate relief of pain, profound local anesthetic and perhaps an extraction, an I and D, or open up the tooth initiating endodontic therapy. If the patient accepts and you can do this, at least the acute painful condition can be eliminated. However if they reject this treatment and attempt to steer you towards prescribing a powerful narcotic this can be the game changer!

  • Since the patient may be exhibiting various degrees of “mental mismanagement,” adequate informed consent documents should be in place as well as written post operative instructions.

  • Become familiar with substance abuse treatment facilities in your community. A great source of information could be patients in recovery that you are successfully treating.
TREATING A DENTAL PATIENT IN ACTIVE ADDICTION
Most general dentists and dental specialists have patients present with painful conditions that require rather urgent treatment. Sometimes these patients are easy to treat and other times those presenting with complex medical issues may not be so easily treated. Patients presenting in our practices with addictive diseases fall into the later, and are far more difficult to manage and treat.

Patients with addictions can present with unpredictable and maladaptive behaviors. They could have even possibly created their own iatrogenic dental pathology. This group of patients will have dependability problems such as keeping appointments and following treatment recommendations. Generally, they will also have exaggerated fears and anxieties regarding dental treatment.

The ultimate goal of treating a patient in acute pain whether they have an addictive disease or not is to treat and eliminate the painful condition. The goal for some patients in active addictive disease would be to utilize the dentist to continue to support their addiction through liberal prescribing practices. We must be diligent not to allow perpetuation of their addiction.

In general terms, our goal when treating patients in active addiction is to stabilize the oral health. Attempting to proceed with extensive dental treatment in these patients prior to adequate treatment of the addiction will be frustrating. This would be similar to attempting to proceed with extensive periodontal and restorative dentistry on a patient with untreated hypertension and diabetes and expecting a good outcome.

Dentists are often the first healthcare providers to identify suspicious indicators such as hypertension, advanced periodontitis or other symptoms such as possible addictive diseases. We routinely inform our patients of our findings and make appropriate referral to their primary health care provider for evaluation of these conditions.

How to handle a patient you feel has an addiction can be challenging, and depends on where the patient is in the disease spectrum. This is where dentists struggle to adequately address the addictive disease to the patient. There are no easy answers here. A good source of information would be patients in your practice who are in recovery or perhaps a dental colleague in recovery.

If you decide you will treat a patient with an active addiction, you should realize they will be more difficult and take longer to treat. Again, there are no simple answers or check lists for treating these patients. The first priority of course is an accurate diagnosis of the dental pathology. Also there may be several areas of the patients’ mouth that may need attention. After informing the patient of your findings, next is your decision on the treatment to present to the patient.

Since these patients may be under the influence of their drug of choice or requiring more of the drug, informed consent is a challenge. Adequate written informed consent and written postoperative instructions are a must. One could place in the post-operative instructions that “lost or stolen” analgesic prescriptions will not be replaced, and that no refills will be called in.

It is often advisable to have a physician consult if time would permit. If you suspect the patient has used IV drugs, antibiotic prophylaxis is indicated. It is not a good idea or appropriate to treat a patient that is intoxicated, unless of course there is dental trauma involved. It is a general rule of thumb not to treat a patient who has used cocaine or methamphetamine within the last 24 hours; this of course is unrealistic to expect a patient to do this. Adequate pre-operative screening including adequate vital signs should allow you to make the decision to treat immediately or defer or refer the proposed treatment.

Perhaps the best treatment plan if time would allow is to attempt to immediately eliminate the painful condition. This treatment could consist of an extraction, opening the tooth for endodontic therapy or even an emergency I and D and area of acute swelling. This would not work in the case of extreme swelling involving trismus.

If the patient accepts this treatment and you proceed, thorough written post-operative instructions should be presented. This would include the number of days postoperatively you feel they may have some discomfort, the amount of pain medicine we will prescribe and that you must see them in the office if the pain persists after two to three days.

Now on to the actual clinical procedure. We all have our ways of treating emergency patients in our practices. Again, several of these patients will have exaggerated fears and anxieties as well as increased drug tolerances and cross-tolerances. These are the folks when the Nitrous Oxide is at 50% plus will tell you they are not feeling any different! So, lots of topical anesthetic, gentle administration of profound local anesthetic and even the use of a long-acting local anesthetic.

Perform the extraction as gently as possible, open the tooth, remove the pulp, medicate and take the tooth out of occlusion, or excise and drain in your normal fashion. Consider the use of a glucocortical steroid such as Decedron in addition to appropriate antibiotic and analgesic therapy.

Selecting the appropriate post-operative analgesic for patients with an active addictive disease is challenging. If the patients’ drug of choice is ethyl alcohol they may have certain degrees of liver impairment. Since several of the commonly used analgesics contain acetaminophen (Tylenol) in addition to codeine or hydrocodone these analgesics should be carefully considered. Additionally, patients with liver impairment can have delayed wound healing. These patients may be more prone to developing alveolar osteitis (dry sockets).

If the patients’ drug of choice is an opioid, they have increased tolerances to opioid analgesics. In fact, they may actually require a higher dose of the analgesic to achieve adequate pain relief. This is a “slippery slope” for most dentists and a great time for a physician consult. Generally we have a good idea how long our patients will require post-operative analgesics. Since most dental pathology is generally of the inflammatory nature, we should also strongly consider the use of non-steroidal anti-inflammatory (NASIDS) agents. Also, inform the patient you will not call in any refills of their analgesics without them first coming back to the office.

If the patients’ drug of choice is in the stimulant category of cocaine or methamphetamine, one should be careful with the use of epinephrine in local anesthetic. This could be a problem if the patient has used the drug recently and an inadvertent intravascular injection was to take place. This is where the increased time involved with caring for these patients is evident.

In states where medical marijuana is legal, certainly patients are presenting to dental offices in acute painful conditions. These patients may be under the influence of the medical marijuana and perhaps making adequate informed consent decisions could be difficult as with all patients in active addiction. Also, since the method of administration involves smoking or use of a nebulizer, this could cause perhaps an increase in alveolar osteitis (dry sockets) following extractions. Post-operative analgesics may also be difficult to prescribe due to tolerances and cross-tolerances since there are over 300 active chemicals in cannabis.

Since patients with addictive diseases exhibit “mental mismanagement” as well as various states of denial, they may not be ready to address their addictions. Dentists have an ethical obligation to treat patients in pain yet not enable an addiction to continue. This is very challenging. We should attempt to discuss our concerns with our patients in a non-threatening fashion. For example: “I’m concerned you could be getting in over your head with your drug (or alcohol) use. Here’s the name of a person at a treatment center. I suggest you go talk to them to see if they can help you.” It helps to have a name and a little of what the patient can expect. For example, “Someone there should be able to see you in the next 24 hours – they’ll help you find a place you can afford.”5

Unfortunately training in screening and brief interventions is not included in dental school curriculums for substance abuse and tobacco addictions. Some of this training needs to be more available. Patients with addictive diseases will present in our practices, these patients are “medically compromised” and must receive adequate oral health care. Often these patients complete adequate treatment for their addiction and live very productive personal and professional lives in recovery.

References
  1. Tufts Health Care Institute Program on Opioid Risk Management. Executive Summary. The Role of Dentists in Preventing Opioid Abuse. March 11-12, 2010. Available at: www.thci.org/opoid/mar10doc/executivesummary.pdf
  2. Madden, T.E.: CDA Journal, Vol 36: No. 2: Feb 2008 (119-121)
  3. Vaillant, G.E.: Principles of Addiction Medicine, 3rd edition, 2003, (p.3)
  4. Volcow, N.D., Baler, R.D., Goldstien,R.Z., Neuron 69, Feb 24, 2011 (p599)
  5. American Dental Association. Oral health topics: Drug use talking with your patients—dentists version. “wwwlada.org/2663aspx#talking”. Accessed April 29,2011.
Author's Bio
Dr. William T. Kane graduated from the University of Missouri – Kansas City School of Dentistry in 1980. He maintains a general practice in rural Dexter, Missouri. In addition to practicing dentistry, Dr. Kane’s interest and passion have been in the area of recovery and wellness. Since 1987, Dr. Kane has been the Chairman of the Dentist Well–Being Committee for the Missouri Dental Association. Additionally, Dr. Kane served as a member of the Dental Wellness Advisory Committee (DWAC) with the American Dental Association. Dr. Kane is very familiar with issues facing patients with addictive diseases and has published and presented on these topics. He also completed an MBA in 1992 from Southeast Missouri State University. In the fall of 2010, Dr. Kane received his Fellowship in the American College of Dentists.
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