● A patient history of drug abuse or addiction therapy unknown to the dentist, which might affect the prescribing of pain medications. ● Questions about quantities of medication being prescribed. In some instances, writing prescriptions for smaller quantities with a refill would allow the pharmacist to counsel the patient and help determine whether a return trip to the dental practitioner might be needed. ● Questions regarding possible alterations of prescriptions (e.g., potential changes in quantities and number of refills). ● Data derived from the prescription drug monitoring programs of a state or close neighboring states that indicate a history of doctor shopping. This type of interprofessional communication can improve patient outcomes when collaborative practice agreements are in place between pharmacists and dental providers. Most critically, these interactions can serve to reassure the dentist that opioid prescriptions are being used as intended. Health history The first dentist-patient encounter at each dental visit typically involves obtaining or reviewing the patient’s health history. This analysis provides an ideal opportunity to begin screening for potential drug misuse, abuse, or diversion. Yet healthcare professionals are often reluctant to probe for this information or are unaware that this initial screening can effectively take place at this first encounter. In 2005, a survey of physicians by the National Center on Addiction and Substance Abuse (CASA) at Columbia University found that only about half (53.8%) asked about prescription drug abuse when taking the health history (CASA, 2005). This may have been due, in part, to inadequate preparation of healthcare providers during training. The same CASA study found that fewer than half of the physicians surveyed received training on identifying prescription drug abuse and addiction; even fewer (19.1% to 39.2%) stated that they received training in identifying prescription drug diversion at some point in their medical school or residency programs (CASA, 2005). For dentists, the ADA and the American Dental Education Association (ADEA) have called for enhanced education regarding drug abuse and prevention during professional training (ADA, 2018a,c; ADEA, 2018). Both providers and patients may be uncomfortable discussing the topic of drug use and abuse. Providing an opening question on a standard health history form ensures that all patients are being asked about drug use, both illicit and prescribed, and prevents patients from feeling they are being “singled out” (Ilgen, 2012). Providing a safe, private environment in which to broach and discuss the topic can also make the patient more comfortable. Familiarizing the patient with office policy that ensures the confidentiality of all personal health information can also provide reassurance to the patient. It is important to solicit information about past and current prescription drug use, along with a history of other drug use, including alcohol and illicit drugs. Adolescents and young adults who abuse prescription drugs are more likely to report using other drugs as well (NIDA, 2018i; SAMHSA, 2019). It is important to follow up with patients who report a history of prior drug use to ascertain where they are in the recovery process because this can affect the selection of pain medication to be prescribed. In these instances, consultation with patients’ physicians is necessary to safely prescribe controlled substances to these patients (ADA, 2018c). A family history of substance abuse should also be solicited because individuals with a positive family history are at an increased risk for abuse (Mayo Clinic, 2017). Some behaviors and responses that may occur during the dental visit have been identified as potential warning signs of a possible abuse or diversion problem, particularly regarding medication for pain, a common complaint in the dental office. These patient behaviors include:
● Coming to the office at the end of the day or claiming to be going out of town (especially patients new to the practice). ● Providing convincing descriptions of pain but an ambiguous health history. ● Arriving with a radiograph supporting their claims of pain, but refusing to have a new radiograph taken. ● Being unwilling to provide the name of a primary care provider. ● Claiming to have “lost” their medication or prescription. ● Requesting a specific drug by name or claiming that certain medications “don’t work.” ● Putting undue pressure on the dentist to prescribe opioid medications (DEA, 1999; Girgis, 2017). Tables 4 and 5 provide a list of these and other characteristics and behaviors that are common to the drug-seeking patient. Table 4: Common Characteristics of the Drug Abuser • Unusual behavior in the waiting room. • Assertive personality, often demanding immediate action. • Unusual appearance – extremes of either slovenliness or being overdressed. • May show unusual knowledge of controlled substances and/ or gives medical history with textbook symptoms OR gives evasive or vague answers to questions regarding medical history. • Reluctant or unwilling to provide reference information. Usually has no regular doctor and often no health insurance. • Will often request a specific controlled drug and is reluctant to try a different drug. • Generally has no interest in diagnosis – fails to keep appointments for further diagnostic tests or refuses to see another practitioner for consultation. • May exaggerate medical problems and/or simulate symptoms. • May exhibit mood disturbances, suicidal thoughts, lack of impulse control, thought disorders, and/or sexual dysfunction. • Cutaneous signs of drug abuse: skin tracks and related scars on the neck, axilla, forearm, wrist, foot, and ankle. Such marks are usually multiple, hyperpigmented, and linear. New lesions may be inflamed. Shows signs of “pop” scars from subcutaneous injections. Note. Adapted from “Don’t Be Scammed by a Drug Abuser,” by the U.S. Department of Justice, Drug Enforcement Administration, Office of Diversion Control, 1999. Retrieved from https://www.deadiversion. usdoj.gov/pubs/brochures/drugabuser.htm Table 5: Tactics Often Used by the Drug-Seeking Patient ● Must be seen right away. ● Wants an appointment toward the end of office hours. ● Calls or comes in after regular hours. ● States that he or she is traveling through town or visiting friends or relatives (not a permanent resident). ● Feigns physical problems, such as abdominal or back pain, kidney stone, or migraine headache in an effort to obtain narcotic drugs. ● Feigns psychological problems, such as anxiety, insomnia, fatigue, or depression in an effort to obtain stimulants or depressants. ● States that specific non-narcotic analgesics do not work or that he or she is allergic to them. ● Claims to be a patient of a practitioner who is currently unavailable or will not give the name of a primary or reference physician. ● States that a prescription has been lost or stolen and needs replacing. ● Deceives the practitioner, such as by requesting refills more often than originally prescribed. ● Pressures the practitioner by eliciting sympathy or guilt or by direct threats. ● Utilizes a child or an elderly person when seeking methylphenidate or pain medication. Note. Adapted from “Don’t Be Scammed by a Drug Abuser,” by the U.S. Department of Justice, Drug Enforcement Administration, Office of Diversion Control, 1999. Retrieved from https://www.deadiversion. usdoj.gov/pubs/brochures/drugabuser.htm
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