Screening tools In addition to the health history, a number of screening tools are available that specifically target drug abuse and intervention. Although most of these screening tools were developed for general physician practices, they are easily adaptable to the dental office for providers interested in incorporating approaches designed to screen for potential abuse. Screening, brief intervention, and referral to treatment One of the available tools, S creening, Brief Intervention, and Referral to Treatment (SBIRT), was originally designed as a screening tool to assess alcohol abuse in all patients presenting to an office, clinic, or emergency room for care and was found to be promising in screening for other behavioral health problems such as drug abuse. This assessment is brief (5 to 10 minutes), universal, and supported by strong evidence. Depending on the score, patients can be reinforced for healthy behavior, referred for brief intervention, or referred for more intensive intervention appropriate to the risk for abuse (SAMHSA, 2017). NIDA-modified alcohol, smoking, and substance involvement screening test The NIDA-Modified Alcohol, Smoking, and Substance Involvement Screening Test (NM ASSIST) consists of a short series of screening questions and a score that guides the identification of the level of intervention indicated (NIDA, n.d.d). A one-question version, the NIDA Drug Use Screening Tool Ethical considerations The principle of beneficence in the ADA Principles of Ethics and Code of Professional Conduct states that the “most important aspect of this obligation is the competent and timely delivery of dental care within the bounds of clinical circumstances presented by the patient, with due consideration being given to the needs, desires and values of the patient” (ADA, 2018b). When there is reasonable cause for suspicion of drug abuse, caution
Quick Screen , asks: “In the past year, how many times have you used alcohol, tobacco products, and prescription medication for nonmedical reasons, or illegal drugs?” If a positive answer is received, proceeding with NM ASSIST is recommended (NIDA, n.d.c). Other screening tools The Drug Abuse Screening Test (DAST-10) is a shortened version of the original 28-question DAST tool specific to screening for drug abuse (SAMHSA, n.d.b). The CAGE Substance Abuse Screening Tool , named for the four areas of questions asked (Cut down, Annoyed, Guilty, and Eye-opener) was developed in 1982 for alcohol screening and later modified as the CAGE- AID , or CAGE-Adapted to Include Drugs tool (Ewing, 1984; Johns Hopkins Medicine, n.d.). A number of other tools are also available that are targeted to screen specifically for opioid abuse in the in patients with chronic pain prior to prescribing long-term therapy. With any of the available screening tools, thoughtful planning to identify who will conduct the screening and what will be done with positive results will make the process run more smoothly. Being aware of community resources that can assist in the referral process is also essential to follow-up for patients requiring additional treatment. in prescribing drugs with high abuse potential is appropriate (Wentworth, 2008). Table 6 contains information provided by the ADA to guide dentists when treating the suspected or known drug user. It is also important to be familiar with state and federal regulatory laws for prescribing controlled substances as well as with laws regarding privacy when contemplating discussing concerns with a member of the patient’s family.
Table 6: ADA Statement on Provision of Dental Treatment for Patients with Substance Use Disorders 1. Dentists are urged to be aware of each patient’s substance use history and to take this into consideration when planning treatment and prescribing medications. 2. Dentists are encouraged to be knowledgeable about substance use disorders – both active and in remission – in order to safely prescribe controlled substances and other medications to patients with these disorders. 3. Dentists should draw upon their professional judgment in advising patients who are heavy drinkers to cut back, or the users of illegal drugs to stop. 4. Dentists may want to be familiar with their community’s treatment resources for patients with substance use disorders and be able to make referrals when indicated. 5. Dentists are encouraged to seek consultation with the patient’s physician, when the patient has a history of alcoholism or other substance use disorder. 6. Dentists are urged to be current in their knowledge of pharmacology, including content related to drugs of abuse;recognition of contraindications to the delivery of epinephrine-containing local anesthetics; safe prescribing practices for patients with substance use disorders – both active and in remission; and management of patient emergencies that may result from unforeseen drug interactions. 7. Dentists are obliged to protect patient confidentiality of substance abuse treatment information, in accordance with applicable state and federal law. Note . American Dental Association. Adopted October 2005. Retrieved from American Dental Association. (2018). Substance use disorders . https:// www.ada.org/en/advocacy/current-policies/substance-use-disorders. Used with permission.
Alternative prescribing practices and their efficacy Although the risk of abuse of the prescription drugs discussed in this module needs to be considered when prescribing therapy for dental pain, it must be balanced against the need to appropriately treat patients who present to the dental office with pain. There are instances in which opioid pain relievers are indicated, and judicious use of these drugs plays a legitimate role in the practice of dental medicine. However, when the patient who presents is suspected of having an abuse problem or in situations in which pain can be adequately treated with nonopioid medications, alternative therapies are available to the healthcare provider.
Nonopioid analgesics The pain relief potential of the nonopioid analgesics, which include the nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen (APAP), is perceived by some to be inferior to “stronger” drugs such as the opioids. Yet research has shown that the nonopioid pain relievers can provide similar, if not superior, pain relief (Becker, 2010; Krebs et al., 2018; Mehlisch et al., 2010; State of Washington, 2017). The anti-inflammatory properties of the NSAIDs, in addition to their analgesic effect, make them particularly ideal for treating dental pain. There are contraindications to using either of these drugs in certain patients, reinforcing the need to obtain a comprehensive health
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