Substance use disorder assessment strategies are increasingly being employed by dentistry, while adequate evaluation requires reaching out to other cotreating providers and collaborating on patient care. The field of dentistry has a range of barriers often not experienced in other professions, including limitations on e-record communication and clinical practice setting often isolated from the patient’s general medical care. Barriers can be overcome if the dentist facilitates communication.
Key points
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Substance use disorder assessment strategies are increasingly being employed by dentistry, while adequate evaluation requires reaching out to other cotreating providers and collaborating on patient care.
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The field of dentistry has a range of barriers often not experienced in other professions, including limitations on e-record communication and clinical practice setting often isolated from the patient’s general medical care.
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Barriers can be overcome if the dentist facilitates communication.
The problem of controlled substance risk assessment and management is well known. Dentists have been increasingly identified as health care practitioners who can be on the front line to identify individuals at risk, effectively managing their dental care and providing appropriate triage to other health care colleagues who can deliver additional evaluation and management of their potential substance use disorders. In a systematic review, Badri and colleagues identified collaboration between health care professionals and dentistry to be a major barrier to adherence for pediatric patients, a population where the importance of working across disciplines would appear most obvious. Although there is some debate for expanding dentistry’s scope of practice, few argue that increased collaboration between dentistry and other health care professions benefits the patient and the profession.
Notwithstanding a national push to promote interprofessional education and multidisciplinary clinical care, dentistry continues to lag behind other health care professions in addressing this issue. As management of patients with complex medical conditions has required more robust medical knowledge, other disciplines have moved forward with interprofessional collaboration by establishing teams to evaluate and care for patients, integrate e-medical records, and work to.
Part of the problem may stem from current dental school training. In a review encouraging interprofessional collaborative practice, Cole and colleagues explain that “interprofessional education occurs when two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes.” Although dental schools adhere to this definition, they tend to provide interprofessional education by offering lectures that cross dental disciplines, providing parallel educational efforts with medical schools, or adding a series of didactic lectures taught by basic scientists or mental health professionals. Few health professions schools promote care in which the dentist functions as an active member of the health care team, a concept that is critical in assessing patients with substance use risk. A recent American Dental Education Association publication asserts that a broader perspective should be considered, noting that “dentistry will and should become more closely integrated with medicine and the health care system on all levels: research, education, and patient care.” Similarly, in a response to the Miller and colleagues commentary on the question as to whether dentistry has a role in health care, Keith and Kulich suggest that this effort needs to be at the predoctoral training level on substance use risk, involving “collaboration on complex cases where each discipline can provide critical input within their expertise. For example, we are now fortunate to have joint programs in Massachusetts where dental, medical, pharmacy and nursing students review complex cases and receive education on opioid overdose reversal with naloxone as part of this training.” As part of this effort, Patterson and associates integrated dental (n = 74), medical (n = 205), and pharmacy (n = 300) students for a series of half-day programs. Faculty from each discipline developed an integrated teaching case using an acute orofacial pain patient presenting to the emergency department, concurrently on assisted suboxone treatment for opioid use disorder. Students worked collaboratively to address effective pain management for the simulated patient, develop risk mitigation strategies, and interpret the results from the state Prescription Drug Monitoring Program (PDMP). Issues of opioid adverse effects and risk for overdose were addressed, with pharmacists in training demonstrating how to administer various formulations of naloxone. Although more than half of medical and pharmacy students had exposure to naloxone administration prior to the training, fewer than 10% of dentists in training had similar exposure. Results showed that 70% of dental students now felt that they would take necessary action to intervene with an opioid overdose, and the majority identified the correct interval for second-dose administration.
Aside from the cross-disciplinary knowledge acquired by the dental student, programs such as this can promote a level of comfort around the delivery of collaborative care. Medical fields such as oncology and pediatrics already are familiar with cointerviewing patients. This approach may reduce patient burden as identical sensitive questions many not need to be repeated, and patient comfort may be enhanced with increased cross-communication and consistent patient messaging. Similarly, Tufts Orofacial Pain Center, a university-based clinic, conducts assessments in this manner for its most complex patients, many of whom present with substance use risk. For complex patients who present with polypharmacy, they concurrently interview the patient with the dentist, neurologist, and pain psychologist. In the absence of a fully integrated dental practice within a comprehensive health care setting, these efforts are unlikely to be implemented within general dentistry practices. Nonetheless, data from other medical fields provide support for cost-effectiveness, reduced discharge rates, and enhanced patient adherence. ,
Communication and collaborating with cotreating clinicians
Integrating health care disciplines into the patient’s overall care has received understandable resistance, even for very complex patients. Because the general dentist is not typically integrated into the medical decision-making teams, identifying responsible medical and addiction psychiatry sources can be an even greater challenge, which is especially alarming when the patient may be at-risk for overdose.
As early as the 1990s, the field of pain medicine came under scrutiny for abuses of interdisciplinary treatment, where there often was a failure to adequately screen patients who might require such intensive care. At the time, a medical director of a large health maintenance organization opined that some interdisciplinary pain centers “never saw a discipline they didn’t like.” As a result of billing abuses and resistance from insurance carriers, many interdisciplinary pain centers went out of business. In response, the American Pain Society commissioned a managed care committee to address the issue and efforts were made to accommodate concerns of third party payors. A similar process is currently underway with respect to interdisciplinary addiction medicine facilities where examples of fraud are now surfacing. For example, interdisciplinary addiction programs now offer equine therapy, with many of these integrated services being marketed in the absence of supporting research. Even in the best scenario where the dentist identifies an at-risk patient abusing a substance, where does one responsibly go to refer and collaborate?
Some dentists have already identified and established relationships with local mental health and substance abuse treatment providers, usually pre-empting the need for finding other resources. Ideally, many at-risk patients will also arrive at the dental practice with their cotreating clinician already in place, most likely a primary care physician (PCP) or substance use disorder specialist. Substance use clinicians can have backgrounds in internal medicine with specialty board certification in addiction medicine. Similarly, some psychiatrists can have added board certification in addiction psychiatry. Many patients are treated by doctoral level clinical psychologists specializing in addiction disorders, as well as social workers and licensed chemical dependency counselors. Emergency evaluation and inpatient treatment services should be readily accessible as resources for anyone undergoing formal substance abuse treatment. Although many of these services are valuable adjuncts to effective substance use disorder care, group support services such as Alcoholics Anonymous are not considered treatment providers. Support group programs should not be considered an adequate or exclusive referral option for care. Unfortunately, as responsible community or state-based services become increasingly identified, dental practices are typically not on regional state notification lists. For example, information about naloxone distribution is more commonly provided to medical providers, and many states offer distribution without prescriptions at various sites. The dentist will need to be proactive in identifying relevant local resources and urge state dental societies to better inform their members about substance use disorder care. Recently Massachusetts PDMP has added a list of resources that is imbedded in each patient’s database.
Utilizing government- and nonprofit-based rapid access referral services can be an effective option. Details on formal outpatient and inpatient local facilities can be accessed on the Substance Abuse and Mental Health Services Administration Web site. The National SAMHSA Helpline is free, confidential, and available around the clock as a referral and information resource. Dentists can reach out to this resource for referral purposes, as well as individuals and families with mental and/or substance use disorders. Structured controlled substance risk screeners such as the NIDA Quick Screen also link dentists to specific resources for patients.
Smoking cessation supported by dentistry
Dentists have been on the forefront of care with nicotine abuse, with the effects of vaping now being addressed by national and regional dental societies. The American Dental Association (2019) clearly notes that “because of the oral health implications of tobacco use, dental practices may provide a uniquely effective setting for tobacco use recognition, prevention, and cessation; dental professionals can help smokers quit by consistently identifying patients who smoke, advising them to quit, and offering them information about cessation treatment.” Although dentists may be qualified to counsel the patient, make the referral, and prescribe smoking cessation medications, few follow this approach, despite data showing its cost efficiency. Agaku and colleagues found that 31% of dentists advised patients to quit smoking, in contrast to 65% of physicians. Only 24.5% of dentists went beyond the simple advice to quit. Further complicating the situation for patients who are concurrently using regularly prescribed opioids, comorbid use of tobacco or cannabis significantly increased the likelihood of the patient being nonadherent or showing some drug aberrancy. , Even in cases where the dentist choses to defer prescribing appropriate smoking cessation products, collaborating with the PCP remains a mainstay of good care. Smoking, vaping, and/or excessive cannabis use all can negatively impact the oral cavity. Additionally, use of these substances can also predict the presence of other comorbid substance use disorders and should be considered a risk factor suggesting that a more comprehensive controlled substance risk assessment be conducted. The dentist can then confer and collaborate with appropriate providers who have expertise in substance use disorder treatment.
Attitudes toward substance use
The stigma associated with substance use disorder is common across all health care provider groups, including dentistry. Dentists also significantly underestimate the prevalence of substance abuse disorders within their patient populations, and the problem is not exclusive to the United States. Priyadarshini and colleagues found that 86.2% of dentists did not believe that substance use disorder was a problem in their practices. Training has been shown to alter these beliefs. Although attitudes can be changed when the dentist institutes standardized controlled substance risk screening in the practice and collaborates with colleagues who regularly evaluate and treat individuals with substance use disorders.
Stigma associated with substance abuse disorder can lead to denial, reduced access to and poor quality of care, and nonadherence. Failure to understand substance use disorders and related mental disorders often underpins the problem. Although easier to implement in dental schools, coevaluations can dramatically change the clinician’s attitude toward addiction and mental illness. Continuing education programs are attempting to address this issue with patient simulations, an effort that better promotes understanding and empathy. Dentists and most health care providers also lack an understanding that substance use disorders, by their nature, are reoccurring illnesses, and relapses are common. As with other addictive disorders such as smoking, few remain abstinent after the first attempt. That being said, treatment has been shown to be effective. Patients most benefit when support is made available through the family, employer, and health care providers. An example of this more enlightened approach closer to home is the issue of dental colleagues who may suffer from substance use disorder. Five percent to 10% of dentists experience a drug or alcohol problem during their careers. Once addiction takes over, they become too ashamed to seek help for fear of public exposure and reprisal by the licensing board. Most states support dentists through a confidential diversion program, creating an incentive to seek help. As a result, dentists get the help they need, and patients get the protection they deserve. Dentists who complete a diversion program recover at a rate of 80% to 90% – 3 times that of the general public. Massachusetts is currently developing a similar program. An Act Establishing a Dentist Diversion Program (H.238) is now being considered.
Disclosure to the patient
In the complex situation where substance use risk is present, a frank discussion with the patient is always prudent. When a patient presents with high risk of controlled substance misuse, and dental care is planned, a supportive explanation about the need to communicate with other prescribing clinicians is necessary. Normalizing the conversation is the first step, indicating that the patient’s safety is ensured and arriving at the best plan for providing effective pain relief if a procedure is planned. Although it is always ideal to seek consent from the patient, there are no HIPAA (Health Insurance Portability and Accountability Act) barriers for communication between providers, even where substance misuse or abuse is discussed. Reviewing PDMP results with the patient also is advisable, especially in cases where the results are consistent with the patient’s self-report. Finally, documenting the patient’s response to the plan is necessary, and exact quotes from the patient should be placed in the record. This process is an integral part of the verbal informed consent, and a positive step toward collaborating with the patient on his or her care. There are cases where the patient may adamantly decline to have the dentist contact the cotreating physician or other dental providers, as in the case of William M ( Box 1 ). Although discussion of the patient’s rationale for restricted communication can be helpful, this is typically a flag for other risk factors of possible substance abuse or diversion. Although the patient may require dental care, the dentist is typically not obligated to undertake treatment with such unreasonable restrictions in place.
