This interactive Ohio Dental Ebook contains 30 hours of continuing education. To complete click the Complete Your CE button at the top right of the screen.
OHIO Dental Continuing Education
Elite Learning
Need to complete the DEA’s new one-time Substance Use Disorder requirement? SEE INSIDE FRONT COVER FOR MORE DETAILS
Inside : Mandatory 2-hour Opioid prescribing education for acute, subacute and chronic pain
Continuing Education Package for Dentists and Dental Hygienists
Complete today at: ELITELEARNING.COM/BOOK
WHAT’S INSIDE
Chapter 1: Prescription Drug Abuse Among Dental Patients: Scope, Prevention, and Management Considerations (Mandatory) [5 CE Hours] The purpose of this course is to provide dental practitioners with an appreciation of the scope of the problem of prescription drug abuse and a realization that the misuse and abuse of these drugs likely take place among the patient populations they serve. By becoming familiar with the pharmacology of the most commonly abused drugs, the risk factors for developing addictive behaviors, and the manner in which these medications are commonly acquired, dental providers will be positioned to curb prescribing practices that contribute to this growing problem and will be better able to serve their patients and their communities as informed prevention advocates. THIS COURSE FULFILLS THE 2-HOUR REQUIREMENT FOR OPIOID PRESCRIBING EDUCATION FOR ACUTE, SUBACUTE AND CHRONIC PAIN Chapter 2: Allergic Reactions to Metals in the Mouth, 2nd Edition [1 CE Hour] This course reviews the importance of metals for human health, identifies common harmful metals and their role in disease, and discusses hypersensitivity reactions, with particular regard to metal allergies in medical and dental patients. Corrosion is also discussed relative to its role in the hypersensitivity reactions experienced by dental patients. Chapter 3: CDC and the Practice of Dental Hygiene This intermediate-level course is intended to address this training deficit by providing dental healthcare professionals with an overview of the nature and scope of chronic pain, as well as basic skills for effective assessment and adjunctive treatments of chronic orofacial pain conditions and related problems. To accomplish these goals, the course first examines the basic physiological principles that underlie pain, describes the distinction between acute and chronic pain, and explains the factors that contribute to acute pain becoming chronic. The prevalence and impact of chronic pain on physical functioning, health, and quality of life are examined. An introduction to the practical assessment of chronic pain provides readers with a description of selected assessment tools and interview procedures. Dental practitioners may be familiar with the diagnosis and treatment of pain in a specific context, for example, temporomandibular disorders. However, the emphasis of this course lies in assessing other causes of chronic orofacial pain and in discussing their corresponding pharmacological and biobehavioral treatment modalities. The course provides an overview of common medications used to treat chronic orofacial pain and discusses issues surrounding addiction and adherence to a prescribed medication regimen. The course also provides basic information on empirically supported psychosocial treatment strategies that can be useful when working with patients who are experiencing chronic pain. This course is designed for dental health professionals who wish to further their knowledge in orofacial pain conditions. After taking the course, the participant will be able to assess the patient with chronic orofacial pain, identify comorbid disorders, and recommend appropriate treatment or referral options. Chapter 5: Common Complications Associated with Oral Surgery [1 CE Hour] This course addresses common complications associated with oral surgical procedures and outlines evidence- based methods to prevent, minimize, or manage them. Patient education about what to expect postoperatively helps minimize emergency after-hours phone calls and the need for additional treatment. Proper techniques of postoperative pain and infection control may also facilitate the healing process and reduce both postoperative complications for patients and stress for practitioners.
1
24
31
[2 CE Hours] The purpose of this course is to familiarize the dental hygienist with the document Guidelines for Infection Control in Dental Health-Care Settings, 2003. The 2016 CDC document, Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care will be introduced and discussed, and new information relevant to the practice of dental hygiene published by CDC since 2003 will be presented. Chapter 4: Chronic Pain Management for the Dental Practitioner: A Psychosocial Perspective 46 [5 CE Hours]
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DENTAL CONTINUING EDUCATION
Chapter 6: Dental Ethics and the Digital Age, 2nd Edition
81
[3 CE Hours] This course will help dental professionals gain a better understanding of dental ethics, professionalism, and current ethical challenges, with a particular emphasis on the impact of the digital age. A section of this course will address the ways that the law and ethics intersect. Through a systematic, case-based approach, this course will provide dentists, dental hygienists, and dental assistants with the tools to recognize and navigate the complex ethical issues that may arise in practice. Chapter 7: Dental Radiation Health: Safety and Protection in the Digital Age, 2nd Edition
106
[3 CE Hours] This course reviews the biologic effects of radiation, the methods used in radiation measurement, and the potential sources of radiation exposure. This course discusses radiation safety and protection measures for both patients and dental healthcare workers. Chapter 8: Diabetes: Dental Management and Links to Periodontal Disease, Updated Edition 122 [1 CE Hour] The purpose of this course is to equip dental professionals with the ability to recognize the classifications and classic signs and symptoms of diabetes mellitus, to grasp the relationship between periodontal disease and diabetes, and to identify periodontal and other oral manifestations associated with diabetes, including attachment loss, alveolar bone loss, gingivitis, xerostomia, and oral candidiasis. Chapter 9: Medical Consequences of Acts of Terrorism and Disaster: A National Perspective, 2nd Edition 131 [3 CE Hours]
Terrorism has become a fact of daily life in the United States and most of the world. It is not always obvious when a disaster is a terrorist attack and not all emergencies or disasters are terrorist attacks. Understanding the basics of a disaster and/or terrorist attack, as well as the role a healthcare provider plays in dealing with the medical consequences, syndromic surveillance/reporting requirements, and treatment are vital to successful mitigation and response in a disaster or terrorist attack. Chapter 10: Obstructive Sleep Apnea: A Comprehensive Review for Dental Professionals, 3rd Edition [2 CE Hours] This course reviews OSA from a dental perspective. It addresses current findings on the links between overall health and OSA and cites common presenting symptoms likely to be encountered in the dental practice. This intermediate- level course discusses the latest evidence-based diagnostic approaches for OSA and outlines recommended treatment strategies, including continuous positive airway pressure (CPAP), OAs, and surgical intervention, to mitigate the health impact of this common condition. Several resources listed at the end of this course can provide [2 CE Hours] This course explores the variables affecting women’s oral health and discusses the issues and concerns that dental professionals face in providing care to females across their life span. Chapter 12: Working With Fearful and Anxious Dental Patients [2 CE Hours] The purpose of this intermediate-level course is to familiarize the dentist and every member of the dental team with nonpharmacological techniques and strategies for guiding and supporting fearful dental patients. dental professionals with further opportunities for education and training in this area. Chapter 11: Oral Health Issues for the Female Patient, 3rd Edition
156
170
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©2023: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional services advice. Colibri Healthcare, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials. ii DENTAL CONTINUING EDUCATION
FREQUENTLY ASKED QUESTIONS
What are the requirements for license renewal? License Expires
CE Hours Required
Mandatory Subjects
Dentists - 30 Dental Hygienists - 20 (All hours are allowed through home-study)
Minimum of two (2) hours pertaining to the prescribing of opioids for acute, subacute, and chronic pain
Licenses expire December 31 of odd-numbered years
How much will it cost?
Dental Hygienist 20-Hour Package
Dentist 30-Hour Package
Course Code
Course Title
Price
Chapter 1: Prescription Drug Abuse Among Dental Patients: Scope, Prevention, and Management Considerations (Mandatory) Chapter 2: Allergic Reactions to Metals in the Mouth, 2nd Edition
5
5
DOH05PD $49.95
1 2
1 2
DOH01AR $9.95 DOH02CD $19.95
Chapter 3: CDC and the Practice of Dental Hygiene
Chapter 4: Chronic Pain Management for the Dental Practitioner: A Psychosocial Perspective Chapter 5: Common Complications Associated with Oral Surgery Chapter 6: Dental Ethics and the Digital Age, 2nd Edition Chapter 7: Dental Radiation Health: Safety and Protection in the Digital Age, 2nd Edition Chapter 8: Diabetes: Dental Management and Links to Periodontal Disease, Updated Edition Chapter 9: Medical Consequences of Acts of Terrorism and Disaster: A National Perspective, 2nd Edition Chapter 10: Obstructive Sleep Apnea: A Comprehensive Review for Dental Professionals, 3rd Edition
5
DOH05CP $49.95
1 3
DOH01CC $9.95 DOH03DE $29.95
3
3
3
DOH03DR $29.95
1
DOH01DB $9.95
3
DOH03AT $29.95
2
2
DOH02AP $19.95
Chapter 11: Oral Health Issues for the Female Patient, 3rd Edition Chapter 12: Working With Fearful and Anxious Dental Patients Dental 30-Hour CE Package - Best Value - Save $119.40 Dental Hygienist 20-Hour CE Package - Best Value - Save $179.60
2 2
2 2
DOH02OH $19.95 DOH02WW $19.95 DOH3023 $180.00
30
20 DHOH2023 $120.00
How do I complete this course and receive my certificate of completion? See the following page for step by step instructions to complete and receive your certificate. Are you an Ohio State Dental Board-approved provider?
Colibri Healthcare, LLC is designated as a Nationally Approved PACE Program Provider for FAGD/MAGD credit. Approval does not imply acceptance by any regulatory authority or AGD endorsement. Current approval period is 1/1/2022 to 12/31/2025; Provider ID# 217536. Colibri Healthcare, LLC is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Are my hours reported to the Ohio State Dental Board? No, the board performs random audits at which time proof of continuing education must be provided. What information do I need to provide for course completion and certificate issuance? Please provide your license number on the test sheet to receive course credit. Your state may require additional information such as date of birth and/or last 4 of Social Security number; please provide these, if applicable. Is my information secure? Yes! We use SSL encryption, and we never share your information with third-parties. We are also rated A+ by the National Better Business Bureau. What if I still have questions? What are your business hours? No problem, we have several options for you to choose from! Online at EliteLearning.com/Dental you will see our robust FAQ section that answers many of your questions, simply click FAQs at the top of the page, e-mail us at office@elitelearning.com, or call us toll free at 1-866-344-0972 Monday - Friday 9:00 am - 6:00 pm, EST. Important information for licensees: Always check your state’s board website to determine the number of hours required for renewal, mandatory topics (as these are subject to change), and the amount that may be completed through home-study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file. Licensing board contact information:
Ohio State Dental Board | 77 South High Street, 17th Floor | Columbus, OH 43215 Phone: 614-466-2580 | Fax: 614-752-8995 | Website: https://dental.ohio.gov/
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DENTAL CONTINUING EDUCATION
Please read these instructions before proceeding. Read and study the enclosed courses and answer the final examination questions. To receive credit for your courses, you must provide your customer information and complete the evaluation. Follow the instructions below to receive credit and your certificate of completion. How to complete continuing education
Fastest way to receive your certificate of completion
Online • Go to EliteLearning.com/Book . Locate the book code found on the back of your book: » Dentists - your book code is: DOH3023 » Dental Hygienists - your book code is: DHOH2023 Enter your code in the example box then click GO .
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Enter book code
Example: ANCCFL2422
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• If you already have an account created, sign in to your account with your username and password. If you do not have an account already created, you will need to create one now. • Follow the online instructions to complete your final exam. Complete the purchase process to receive course credit and your certificate of completion. Please remember to complete the online survey.
Dental Hygienist Hours
Dentist Hours
Course Name
Course Code DOH3023 DHOH2023
Dentist 30-Hour CE Package
30
Dental Hygienist 20-Hour CE Package
20
Prescription Drug Abuse Among Dental Patients: Scope, Prevention, and Management Considerations (Mandatory)
5
5
DOH05PD
Allergic Reactions to Metals in the Mouth, 2nd Edition
1
1
DOH01AR
CDC and the Practice of Dental Hygiene
2
2
DOH02CD
Chronic Pain Management for the Dental Practitioner: A Psychosocial Perspective
5
DOH05CP
Common Complications Associated with Oral Surgery
1
DOH01CC
Dental Ethics and the Digital Age, 2nd Edition
3
3
DOH03DE
Dental Radiation Health: Safety and Protection in the Digital Age, 2nd Edition
3
3
DOH03DR
Diabetes: Dental Management and Links to Periodontal Disease, Updated Edition Medical Consequences of Acts of Terrorism and Disaster: A National Perspective, 2nd Edition Obstructive Sleep Apnea: A Comprehensive Review for Dental Professionals, 3rd Edition
1
DOH01DB
3
DOH03AT
2
2
DOH02AP
Oral Health Issues for the Female Patient, 3rd Edition
2
2
DOH02OH
Working With Fearful and Anxious Dental Patients
2
2
DOH02WW
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DENTAL CONTINUING EDUCATION
Chapter 1: Prescription Drug Abuse Among Dental Patients: Scope, Prevention, and Management Considerations (Mandatory) 5 CE Hours
Release Date : December 31, 2020
Expiration Date : December 31, 2023
Faculty Authors: Marnie Oakley, DMD, is the associate dean of clinical affairs at the University of Pittsburgh School of Dental Medicine, from which she received her DMD in 1992. Dr. Oakley served in both active duty and reserve roles as a dental officer in the United States Navy. As an experienced educator, she has taught numerous courses related to clinical dentistry, including Oral Diagnosis and Treatment Planning, Clinical Restorative Dentistry, and the Clinical Responsibility course series. In addition to being a published author and presenter on the subject of prescription drug abuse, Dr. Oakley was responsible for the development and implementation of the University of Pittsburgh School of Dental Medicine Comprehensive Care Program. Dr. Oakley also served as Chair of the American Dental Education Association (ADEA) Annual Session Planning Committee for two consecutive years, for which she received a Presidential Citation. She served in officer positions in several ADEA committees and groups. Dr. Oakley maintains membership in numerous professional organizations including the American Dental Association (ADA), Pennsylvania Dental Association (PDA), Western Pennsylvania Dental Association (WPDA), Omicron Kappa Upsilon, and the Academy of General Dentistry. Author: Jean O’Donnell, DMD, MSN , is the associate dean for academic affairs at the University of Pittsburgh School of Dental Medicine, from which she received her DMD in 1990. She is also the academic integrity officer for the school and chair of the first-professional curriculum committee. Within the same institution, she is an associate professor in the department of Restorative Dentistry and Comprehensive Care. Dr. O’Donnell holds a bachelor’s degree in nursing from Pennsylvania State University and a master’s degree in nursing from the University of Pittsburgh. She is a graduate of the American Dental Education Association (ADEA) Leadership Institute and currently serves as one of the university’s liaisons to the ADEA Commission on Change and Innovation in Dental Education. She is also the dental school’s Women’s Liaison Officer with the ADEA. She is a How to receive credit ● Read the entire course online or in print. ● Depending on your state requirements you will be asked to complete: ● A mandatory test (a passing score of 75 percent is required). Test questions link content to learning objectives as a Colibri Healthcare, LLC implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity. Disclaimer The information provided in this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative Disclosures Resolution of conflict of interest
member of Omicron Kappa Upsilon. Prescription drug abuse and tobacco cessation are among Dr. O’Donnell’s special interests. Author: Michael A. Zemaitis, PhD, holds a bachelor’s degree in pharmacy and a PhD in pharmacology. He is a professor in the Department of Pharmaceutical Sciences in the University of Pittsburgh School of Pharmacy, and he teaches in the professional and graduate programs in the School of Pharmacy and the School of Dental Medicine. Dr. Zemaitis’s current area of research interest is biochemical pharmacology, with a special interest in drug and metabolite analysis in biological fluids. He has worked as a consultant for state and federal government entities and is a charter member of the Pennsylvania Drug Utilization Review Board. Peer Reviewer: Wayne McElhiney, DPh, DDS, is a 1966 graduate of the University of Tennessee College of Pharmacy and a 1974 graduate of the University of Tennessee College of Dentistry. He maintained a private practice for 25 years and is currently director of the Wellness Committee of the Tennessee Dental Association. Dr. McElhiney is a member of NAADAC, the Association of Addiction Professionals, and he serves on the Advisory Council of the University of Utah School on Alcoholism and Other Drug Dependencies. In 2012-2013, he served as a consultant for the American Dental Association Counsel on Dental Practice. He serves as a consultant for the Drug Formulating and Pain Regimen for Alive Hospice in Nashville, Tennessee. Dr. McElhiney is a noted lecturer and published author and is currently involved in teaching the disease concept of addiction at the University of Tennessee College of Dentistry, the University of Tennessee College of Dental Hygiene, and Tennessee State University College of Dental Hygiene. The authors and peer reviewer have disclosed that they have no significant financial or other conflicts of interest pertaining to this course. Planner: Karen Hallisey, DMD AGD Subject Code - 134 method to enhance individualized learning and material retention. ● Provide required personal information and payment information. ● Complete the mandatory Course Evaluation. ● Print your Certificate of Completion. Sponsorship/commercial support and non-endorsement It is the policy of Colibri Healthcare, LLC not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.
to diagnostic and treatment options of a specific patient’s medical condition.
©2023: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is not meant to provide medical, legal, or professional advice. Colibri Healthcare, LLC recommends that you consult a medical, legal, or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation nor circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The models are intended to be representative and not actual customers.
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INTRODUCTION
Learning objectives After completing this course, the learner will be able to: Describe the history and scope of prescription drug abuse and the role of the dental professional. Define the terminology used in discussing prescription drug abuse. Course overview National concern is growing regarding the rise in prescription drug abuse in the United States. Addressing the abuse of drugs in general has been a long-standing battle for healthcare providers and law enforcement agencies, but the increased nonmedical use of therapeutic agents is particularly disturbing. Abuse of prescription drugs has increased so dramatically that in 2017 the United States Department of Health and Human Services (HHS) declared a public health emergency (HHS, 2019b). Prescription drugs carry an aura of acceptability because they are legal and prescribed by professionals, yet the repercussions of using them for other than their intended purpose are often neither recognized by the user nor discussed by the prescriber. Prescription drug abuse, like other forms of drug abuse, spares no one; it crosses boundaries of gender, age, race, and socioeconomic status. The abuse of prescription drugs is both an individual and a public health concern, costing individuals and the nation in terms of lost productivity and resulting healthcare costs, in addition to the devastating effects on families and significant others. Dental providers frequently prescribe medications for their patients, especially for the control of pain. Although initially prescribed to help alleviate pain, their pleasurable side effects cause these drugs to be among those that carry the highest risk of abuse. Pain is often an unavoidable sequela to invasive dental procedures and untreated or long-standing oral disease. Balancing the desire to alleviate pain against the suspicion that the patient may be a drug seeker is just one of the issues that confront dental providers. The patient’s past medical, dental, and social history; current history; chief complaint; and history of prescription drug use all contribute to the impression received by the dental provider. How the dental provider manages this information is critical to the result of the visit and subsequent outcome for the patient. Diversion of prescription drugs is another part of the growing abuse problem. Diversion refers to the illegal use of legal drugs; it is seen most frequently with those drugs used to relieve pain (Coalition Against Insurance Fraud [CAIF], 2007). Diversion of drugs can occur when drugs are stolen or prescriptions are forged, as in the submission of fraudulent prescription claims to insurance companies, which is a significant portion of the problem (CAIF, 2007; U.S. Drug Enforcement Administration [DEA], n.d.b). Diversion also occurs when healthcare providers sell prescriptions to known abusers, or when pharmacists falsify records and sell the drugs involved (DEA, n.d.b). These forms of diversion all involve blatant criminal activity, but diversion can also occur when medications are shared with others for nonmedical use – actions that are also illegal. In fact, the primary source of prescription drugs for nonmedical users is through family and friends (Lipari & Hughes, 2017). “Doctor shopping,” the practice of going to multiple healthcare providers to obtain prescription drugs for nonmedical use, is also considered to be
Explain the pharmacology, physiology, and regulatory control of the prescription drugs that are most commonly abused and the extent and impact of their nonmedical use. Describe the populations most at risk for abusing prescription drugs and their access to these drugs. Discuss the tactics and resources available to manage and prevent prescription drug abuse in the dental practice. a form of diversion (National Institute on Drug Abuse [NIDA], 2018c). Over-the-counter (OTC) medications, although not the focus of this course, are also part of the problem of prescription drug abuse. These readily available medications, particularly cough and cold preparations, are often among the first drugs abused by adolescents. It is estimated that 1 in 11 teens have abused cough medicine or other OTC products (Stanford Children’s Health, 2019). As dental providers explore their patients’ histories of prescription drug use, they should also consider OTC preparation use and abuse (NIDA, n.d.e). Although prescription drugs have been identified as essential tools to treat a myriad of illnesses as well as manage various levels of pain, it has been their recent “misuse” and its relation to the opioid overdose epidemic that has caught the attention of the nation (Blanco et al., 2007; Office of National Drug Control Policy [ONDCP], n.d.c). People across all demographics can appreciate the pleasurable side effects of these drugs and can be at risk for addictive behaviors. Additionally, life- threatening complications can occur when an individual other than the intended recipient takes these medications, or when the intended recipient takes them in a manner outside of their prescribed purpose. From 1999 to 2017, almost 218,000 people died in the United States from overdoses related to prescription opioids. Overdose deaths involving prescription opioids were five times higher in 2017 than in 1999 (Centers for Disease Control and Prevention [CDC], 2018d). In March of 2007, in response to these trends, and in recognition of this problem as a serious healthcare issue facing our nation, NIDA, a component of the National Institutes of Health, initiated its first large-scale national study related to prescription drug abuse (NIDA, 2007). Focused education and collaborative efforts are required to properly position healthcare professionals to help manage and prevent continued abuse of prescription drugs (Riggs, 2008). The information provided in this course is applicable to all dental team members, regardless of their practice setting or scope of practice. The information is of interest to dental team members in private practice, academic institutions, military service positions, hospitals, and community health centers. The purpose of this basic-level course is to provide dental practitioners with an appreciation of the scope of the problem of prescription drug abuse and a realization that the misuse and abuse of these drugs likely take place among the patient populations they serve. By becoming familiar with the pharmacology of the most commonly abused drugs, the risk factors for developing addictive behaviors, and the manner in which these medications are commonly acquired, dental providers will be positioned to curb prescribing practices that contribute to this growing problem and will be better able to serve their patients and their communities as informed prevention advocates.
THE ROLE OF PRESCRIPTION DRUGS
(CNS) depressants, and stimulants – play an important role in mitigating the devastating manifestations of the diseases they treat and are used responsibly by most people (Mayo Clinic, 2018b; National Institute on Drug Abuse [NIDA], 2011b, 2018i). Opioids are prescribed to relieve pain that ranges from mild to severe and, when taken as prescribed, can be very effective.
Prescription drugs have undoubtedly contributed to both the life expectancy and quality of life of countless individuals in the United States. However, use of prescription drugs is not without hazards. Some carry a significant risk for abuse and a potential for addiction. The three most commonly abused prescription drug categories – opioids, central nervous system
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Central nervous system depressants, such as sedatives and tranquilizers, are used for treating anxiety and sleep disorders. Due to their high abuse potential, stimulants are currently employed for only a few conditions, including for narcolepsy The potential for misuse and abuse of prescription drugs The prescription drug abuse problem has become an epidemic in the United States (McHugh, Nielsen, & Weiss, 2015), and in 2017 the United States Department of Health and Human Services declared it a public health emergency (HHS, 2019b). A number of possible reasons for the rise in prescription drug abuse in this country have been postulated. The volume of prescriptions written for the drugs in the most-abused categories increased substantially since the 1990s; between 1992 and 2002, as the U.S. population rose by 13%, prescriptions for controlled drugs rose 154% (Coalition Against Insurance Fraud, 2007). The overall opioid prescribing rate in the United States peaked and leveled off from 2010 to 2012 and has been declining since 2012, but the amount of opioids in morphine milligram equivalents (MME) prescribed per person is still around three times higher than it was in 1999 (CDC, 2018d). In spite of awareness of the problem, Medicare paid for more such prescriptions in 2012 than it had in 2011 (Ornstein & Jones, 2014). Pain relievers, the most abused category of drugs, have become both stronger and more effective, increasing their medical utility, but also their allure and street value. Adding to the problem of prescription drug abuse is our nation’s culture of believing that a “pill” will cure all and that these pills’ legal prescription status makes them somehow more acceptable or less harmful. Insufficient training of healthcare professionals and inadequate initiatives in educating the public are also factors that may contribute to the growing abuse problem. The perception that prescription drugs are safe is also promoted when drugs are advertised or labeled misleadingly. For example, the manufacturer originally labeled OxyContin as “less addictive, less subject to abuse, and less likely to cause withdrawal symptoms” than other pain medications – claims that were unsupported by the findings of the U.S. Food and Drug Administration (FDA), but resulted in the drug becoming popular with narcotic users. In 2007, the drug’s manufacturer pleaded guilty to felony misbranding (Chasan, 2007). About the time that OxyContin was first marketed, pain was gaining wider History of prescription drug abuse The use and abuse of drugs is not new. Narcotics and related drugs are known to have been used from as early as 3400 BC for relaxation, stimulation, or euphoria (History.com, 2019a). Addiction problems in the United States were recognized as early as 1875, when San Francisco outlawed opium dens (History. com, 2019a). It was not until the twentieth century, however, that national drug laws were enacted, with the Pure Food and Drug Act of 1906 (U.S. House of Representatives, n.d.) and the Harrison Narcotics Tax Act of 1914 (History.com, 2019a). These laws required labeling of medications containing opium and certain other drugs and forbade the sale of such drugs except by designated professionals; in 1920, a Supreme Court decision also made it illegal for physicians to knowingly prescribe narcotics to “cater to the appetite or satisfy the craving of one addicted to the use of the drug” (Schaffer Library of Drug Policy, n.d.). Drug abuse was recognized as a problem that often started at an early age and therefore required early intervention for prevention. Efforts by public school systems to introduce and require drug abuse education occurred as early as the 1930s, but were thwarted by fears that education would encourage experimentation; as a result, these efforts soon died out. At the same time that efforts by public schools began, other attempts to control drug abuse were being made by the federal government; however, by the 1950s, the use of marijuana, as well as amphetamines and tranquilizers, was increasing. In 1970, Congress enacted the Uniform Controlled Substances Act (CSA), which attempted to rank addictive drugs according
and attention-deficit/hyperactivity disorder (ADHD; Mayo Clinic, 2018b; NIDA, 2018h). Because the abuse and addiction potential for these drugs is high, the benefits from prescribing them must outweigh the associated risks for the patient. acceptance as a genuine medical condition, and the medical community increasingly recognized that patients, and chronic pain sufferers in particular, should not suffer needlessly when effective narcotic pain medications were available. Reflective of this thinking was the phrase coined by the American Pain Society and adopted in 2000 by the Veterans Health Administration: “Pain is the fifth vital sign.” The unintended result of this shift in thinking regarding pain management was a surge in the number of prescriptions for opioid pain relievers and the proliferation of “pill mills” – clinics, pharmacies, and doctors’ offices where narcotics are prescribed in large quantities or for nonmedical use under the pretense of legitimate pain relief (Coalition Against Insurance Fraud, 2007; Ling, Mooney, & Hillhouse, 2011). Researchers following this campaign to assist chronic pain sufferers found that their pain management was no more effective than before (Mularski et al., 2006). All of the three most abused categories of drugs – opioids, stimulants, and CNS depressants – have a high potential for abuse and addiction, but their pharmacological effects vary. Opioids, for example, reduce the intensity of pain, but can also produce a euphoric effect in some individuals who might then seek to increase the intensity of the experience through repeated or enhanced use of the drug. Stimulants, which increase attention, alertness, and energy, are more widely prescribed than ever despite the limited conditions they are used to treat. These effects, their broad availability, and the perception that they are safe because they are legal, have resulted in an upsurge in their use by diverse populations, including high school and college students, athletes, performers, and older adults (NIDA, 2018h). Around 6 million Americans (approximately 2% of the U.S. population aged 12 and older) misused prescription stimulants in 2016 (CDC, 2018d). Central nervous system depressants can be abused for their relaxing effects or to counter or enhance the use of other drugs (NIDA for Teens, 2019a). to their abuse potential (Cornell University Law School, Legal Information Institute, n.d.). The result was the classification of drugs into the five schedules that we use today, with Schedule I being drugs with no accepted medical use, such as heroin and LSD, and Schedule V being controlled substances with a low potential for abuse, such as the antitussives, antidiarrheal, and analgesic preparations. In between, and ranked by abuse potential, Schedule II drugs include pain relievers such as oxycodone and stimulants such as amphetamines, Schedule III drugs include anabolic steroids and the anesthetic ketamine, and Schedule IV consists of some of the CNS depressants such as diazepam and alprazolam (U.S. Drug Enforcement Agency [DEA], n.d.a). (See Table 1.) The Uniform Controlled Substances Act will be further discussed in a later section. In 1973, the Drug Enforcement Administration (DEA) was created to oversee enforcement of all controlled substance laws in the country. One year later, the National Institute on Drug Abuse (NIDA) was established as a federal agency for “research, treatment, prevention, training, services, and data collection on the nature and extent of drug abuse” (National Institutes of Health [NIH], 2018b). Fear that education would result in increased experimentation was finally countered by President Nixon’s “War on Drugs” in 1971, which included a call to increase awareness through education (History.com, 2019b). In 1988, the Anti-Drug Abuse Act was enacted to send a clear message of zero tolerance to the public, now including the user as well as the seller in the criminal and civil penalties that could
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government continues to focus on drug abuse in general, but has become increasingly aware of the problem of prescription drug abuse in particular. In addition, nongovernmental organizations such as the National Coalition Against Prescription Drug Abuse (NCAPDA), founded in 2010, work to further raise awareness of this growing national problem (NCAPDA, n.d.).
be imposed (U.S. Department of Justice, n.d.). It also provided for the establishment of the Office of National Drug Control Policy, which works to reduce drug use and its consequences by leading and coordinating the development, implementation, and assessment of U.S. drug policy (Executive Office of the President, Office of National Drug Control Strategy [ONDCS], n.d.a). Today, The scope of the problem In 2017, an estimated 6% of U.S. adults older than age 26 had used prescription drugs for nonmedical purposes for the first time within the past year. Also in 2017, statistics showed that as
many as 14% of young adults aged 18 to 25 were currently using prescription psychotherapeutic drugs for reasons other than those intended (NIDA, n.d.f).
Table 1: Definition of Controlled Substance Schedules Drugs and other substances that are considered controlled substances under the Controlled Substances Act (CSA) are divided into five schedules. An updated and complete list of the schedules is published annually in Title 21 Code of Federal Regulations (C.F.R.) §§ 1308.11 through 1308.15 . Substances are placed in their respective schedules based on whether they have a currently accepted medical use in treatment in the United States, their relative abuse potential, and likelihood of causing dependence when abused. Some examples of the drugs in each schedule are listed here.
Schedule I Controlled Substances Schedule II Controlled Substances
● Substances in this schedule have no currently accepted medical use in the United States, a lack of accepted safety for use under medical supervision, and a high potential for abuse. ● Some examples of substances listed in Schedule I are heroin, lysergic acid diethylamide (LSD), peyote, methaqualone, and 3,4-methylenedioxymethamphetamine (“Ecstasy”). ● Substances in this schedule have a high potential for abuse that may lead to severe psychological or physical dependence. ● Examples of Schedule II narcotics include hydromorphone, methadone, meperidine, oxycodone, and fentanyl. Other Schedule II narcotics include morphine, opium, and codeine. ● Examples of Schedule II stimulants include amphetamine, methamphetamine, and methylphenidate. ● Other Schedule II substances include amobarbital, glutethimide, and pentobarbital. ● Substances in this schedule have less potential for abuse than substances in Schedules I or II, and abuse may lead to moderate or low physical dependence or high psychological dependence. ● Examples of Schedule III narcotics include combination products containing not more than 90 milligrams of codeine per dosage unit and buprenorphine. ● Examples of Schedule III non-narcotics include benzphetamine, phendimetrazine, ketamine, and anabolic steroids. ● Substances in this schedule have a low potential for abuse relative to substances in Schedule III. ● Examples of Schedule IV substances include alprazolam, carisoprodol, clonazepam, clorazepate, diazepam, lorazepam, midazolam, temazepam, and triazolam.
Schedule III Controlled Substances
Schedule IV Controlled Substances Schedule V Controlled Substances
● Substances in this schedule have a low potential for abuse relative to substances listed in Schedule IV and consist primarily of preparations containing limited quantities of certain narcotics. ● Examples of Schedule V substances include cough preparations containing not more than 200 milligrams of codeine per 100 milliliters or per 100 grams and ezogabine. Note. Adapted from “Controlled Substance Schedules,” by the U.S. Department of Justice, Drug Enforcement Administration, Office of Diversion Control, n.d.a.. Retrieved from https://www.deadiversion.usdoj.gov/schedules/
United States makes up only 4.6% of the world’s population but uses 80% of the global supply of opioid pain relievers (Institute of Addiction Medicine, n.d.). Drug overdose deaths from opiates rose from 8,048 in 1999 to 47,600 in 2017. Deaths from opioid overdoses alone now outnumber deaths due to heroin and cocaine combined, and have increased six-fold in the past 20 years (NIDA, 2019a). Populations at risk for prescription drug abuse cross all demographic sectors, although the drug of choice may differ. Colleges, for example, have seen abuse of prescription stimulants. Nonmedical use of Adderall increased between 2009 and 2013, but decreased from 2013 to 2017 (NIDA, 2018i). Certain populations may be more at risk than others, including youth, women, and older adults; people between the ages of 18 and 25 have the highest reported rate of abuse of prescription drugs (NIDA, 2018i). Early prescription drug use for nonmedical reasons, particularly prior to age 21, is a predictor of future abuse (McCabe et al., 2007; NIDA, 2018i). Older adults, particularly women, are more likely to abuse prescription pain relievers than any other substances (Hemsing, 2016). The number of pregnant women with opioid use disorder (OUD) at labor and delivery more than quadrupled from 1999 to 2014, according to an analysis by the CDC. The babies born to these
Emergency room visits involving prescription drug abuse have seen alarming increases. Approximately 1.2 million emergency room visits in 2011 were attributed to misuse of prescription drugs. Narcotic pain reliever-related emergency room visits involving nonmedical use increased 117% from 168,379 visits in 2005 to 366,181 visits in 2011 (Crane, 2015). These numbers do not include hospital visits and deaths resulting from the effects of driving while impaired by prescription drug abuse, a number that still remains largely unknown. Admission to treatment facilities for prescription drug abuse and addiction has also increased more than for most other drug admissions. According to the 2017 Treatment Episode Data Sets Annual Report on Admissions to and Discharges from Publicly-Funded Substance Use Treatment, the most frequently reported primary substances abused in 2017 were opiates (34%), alcohol (29%), marijuana/ hashish (13%), stimulants (12%), and cocaine (5%), accounting for 93% of all admissions of patients aged 12 years and older. Additionally, the proportion of admissions aged 12 years or older for primary use of opiates other than heroin increased from 5% in 2007 to 10% in 2011 and 2012, before declining to 7% in 2017 (HHS, 2017). The most frequently abused prescription drugs are those used for the control of pain, particularly opioids (NIDA, 2018b). The
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may also be more likely to abuse prescription drugs alone or in combination (NIDA, 2018b; Regier et al., 1990). The prescription drug abuse epidemic affects society as well as individuals. Economic costs in the form of lost productivity, healthcare expenses, and law enforcement costs, to name a few, amount to tens of billions of U.S. dollars annually (NIDA, 2017). Inadequate or insufficient treatment of individuals suffering from abuse or addiction exacerbates this drain on the country’s resources. can effectively prevent abuse through awareness of the scope of the problem and identification of patients who are at risk for abuse or addiction, or who are currently abusing prescription medications. Education of both patients and staff can raise awareness, and identification of at-risk patients can result from the collaborative efforts of dentists, staff, physicians, and pharmacists. A thorough history that includes specific questions regarding past use of prescription drugs (California Dental Association, 2015) can identify potential abuse, yet research has shown that these questions are not frequently asked during the health history interview (Brown University, 2011). The use of screening tools in the dental office and frank conversations with the patient’s network of healthcare providers when abuse is suspected or identified can curtail the problem of abuse. Having knowledge of the common characteristics and tactics of drug-seeking patients helps dental professionals identify these patients in their practice. Clarification of terminology regarding addiction and physical dependence is also important, particularly to avoid overdiagnosis of addiction when discussing issues of pain management. Addiction and physical dependence can occur together (NIDA, 2018d) or can be independent from each other. Addiction is compulsive drug use despite harmful consequences and is characterized by an inability to stop using a drug; failure to meet work, social, or family obligations; and sometimes (depending on the drug), tolerance and withdrawal (NIDA, 2018b). Therefore, a patient with chronic pain who is physically dependent on her medication in order to perform the necessary daily activities that allow her to get to work may not necessarily crave the medication or exhibit other signs of addiction; however, she may exhibit withdrawal symptoms if her medication regimen is significantly altered. Tolerance refers to the need to use a higher dose of a drug to achieve the same effects previously achieved by a lower dose (Volkow, 2010). Tolerance occurs as the drug is used over time and, depending on the drug, can result from different physiological mechanisms. Tolerance to a drug is not synonymous with addiction, although the drug being used may also have addictive potential (Volkow, 2010). A patient with chronic pain, for example, may require an increase in the dosage of medication over time in order to provide adequate pain relief without exhibiting signs of addiction. It is important to note, however, that tolerance can occur alongside addiction.
women may exhibit neonatal abstinence syndrome (NAS), and are more likely to have a developmental delay or speech or language impairment in early childhood compared with children born without NAS (CDC, 2018a,b). Patients with comorbidities (defined as two or more conditions that occur at the same time but for which there is not necessarily a cause-and-effect relationship), particularly psychiatric disorders, are significantly more likely to also abuse prescription drugs. Individuals who abuse other substances (for example, alcohol or illicit drugs) The role of the dental professional Dentists are mentioned less frequently than other healthcare providers in the literature or on websites addressing the prescription drug abuse problem, yet dental providers can contribute to both the scope and prevention of this growing epidemic. Although there are fewer indications for dentists to prescribe stimulants or CNS depressants, the use of prescription pain relievers such as opioids is quite common in dental practices. Opioids are frequently used for the relief of acute pain resulting from infection or following invasive treatment procedures such as the extraction of third molars. In addition, the dental office can be a target for patients seeking prescription drugs for nonmedical use, including patients who engage in “doctor shopping” as a source of drugs. The dental provider can take steps to avoid becoming an unwitting participant in the growth of the prescription drug abuse epidemic, including reviewing current prescribing practices and considering alternative medications for the control of pain. Working together, the dentist and office staff Definitions The terminology surrounding drug abuse requires some standardization to enable practitioners to communicate effectively with patients and colleagues. In this course, the term prescription drug s refers to those controlled substances that are prescribed and dispensed legally by dental providers. In contrast, the term illicit drugs refers to those drugs that are not legally permitted and includes references to street drugs. The terms prescription drug abuse and nonmedical use have the same meaning for the purposes of this discussion and are in keeping with accepted terminology in the literature. These terms are defined as “the intentional use of an approved medication either without a prescription, in a manner other than how it was prescribed, for purposes other than prescribed, or for the experience or feeling the medication can produce” (Volkow, 2010). This includes a teenager sharing his narcotic pain reliever prescribed following third molar extractions with his best friend, for example, or this same patient continuing to use his medication for its pleasurable effects long after the need for pain management has ceased. This is in contrast to the term misuse , which generally refers to the unintentional and incorrect use of a medication by patients who may use a drug for other than the prescribed purpose, take too little or too much, take it too often, or take it for too long. The term “misuse” is also sometimes employed to refer to the behavior of dentists or other healthcare providers who prescribe medications for the wrong indication, at too high a dose, or for too long (Volkow, 2010).
HISTORY OF UNITED STATES DRUG LAW
● Establish uniformity between federal and state law, and uniformity among states, in the control of scheduled drugs. ● Classify all currently available substances into appropriate schedules. ● Anticipate the classification of drugs not yet available, such as newer “designer drugs” that might be developed in the future (Braun, 1991).
Throughout this course, reference is made to scheduled or controlled drugs. Scheduled or controlled drugs are drugs whose use and distribution are tightly controlled because of their potential or risk of abuse. These drugs are classified into one of five schedules (see Table 1) based on whether they are otherwise useful in medical treatment. This drug scheduling system was first promulgated under the Uniform Controlled Substances Act of 1970, which was later superseded by the Uniform Controlled Substances Act of 1990. The 1990 Act attempted to:
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