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FLORIDA Dentist Continuing Education
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8-hour course to satisfy the DEA’s new substance use disorder training requirement. SEE INSIDE FRONT COVER FOR MORE DETAILS
This book includes mandatory topics required for license renewal.
30-hour Continuing Education Package $180.00 ELITELEARNING.COM/BOOK Complete this book online with book code: DFL3024
WHAT’S INSIDE
Chapter 1: Prescribing Controlled Substances Safely: A DEA Requirement (Mandatory) [8 CE Hours] Nurse Practitioners (NPs), Physician Assistants (PAs), Pharmacists, and Dentists care for patients with disorders in many healthcare settings. Individuals may seek care for an acute illness or worsening of a chronic condition. Often, pain is the leading reason for seeking medical care. Appropriate prescribing practices are critical for all medications, but controlled substances require special attention. The Drug Enforcement Agency (DEA), the Food and Drug Administration (FDA), and the U.S. Department of Health and Human Services (HHS) all have a role in controlled medication schedules. Prescribers must understand federal and state requirements for all controlled substances. This course will provide a general review of federal and state-controlled substance regulations and the prescribing practices for controlled substances. Additionally, substance use disorders are complex phenomena affecting many lives. This course also reviews common substance use disorders, including alcohol, anxiolytics, stimulants, hallucinogens, and tobacco/vaping. However, the focus is on clinical safety considerations when prescribing non-cancer-related opioid medications for acute/chronic pain in adults. THIS COURSE FULFILLS THE REQUIREMENT FOR PRESCRIBING CONTROLLED SUBSTANCES Chapter 2: Family Violence: Implications for Dental Patients and Practice in Florida (Mandatory) [2 CE Hours] Members of the dental team must become more aware of the problem of family violence to help prevent abuse and neglect. Clinical protocols can easily be modified to include identification and intervention for cases of suspected abuse and neglect. By applying the knowledge of symptomatology obtained in this basic-level course and providing appropriate intervention, every member of the dental team can help stem the epidemic of family violence. THIS COURSE FULFILLS THE REQUIREMENT FOR DOMESTIC VIOLENCE Chapter 3: Protecting Patient Safety in the Dental Office: Preventing Medical/Dental Errors (Mandatory) [4 CE Hours] This course discusses the current state of medical/dental errors and patient safety. Along with highlighting the different types and causes of medical/dental errors, strategies to prevent or control medical/dental errors are presented, and
1
39
55
methods of identifying, analyzing, and reporting medical/dental errors are discussed. THIS COURSE FULFILLS THE REQUIREMENT FOR PREVENTION OF MEDICAL ERRORS Chapter 4: Allergic Reactions to Metals in the Mouth, 2nd Edition
74
[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 5: 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 6: Dental Radiation Health: Safety and Protection in the Digital Age, 2nd Edition 106 [3 CE Hours] Radiation safety remains a top concern for the general public, and the dental professional needs to stay up to date on the latest research and current thinking on radiation safety and protection. This basic-level 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. Perhaps most important, this course prepares all dental professionals – including dentists, dental hygienists, and dental assistants – to accurately respond to patient questions and concerns about radiation safety in dentistry.
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DENTAL CONTINUING EDUCATION
Book Code: DFL3024
Chapter 7: Erosion-Related Tooth Wear
122
[1 CE Hour] Early recognition of tooth wear is essential to successful prevention and management of disease progression. The primary dental care team is in the ideal position to provide this care to patients with dental erosion and other forms of tooth wear. This intermediate-level course provides dentists, dental hygienists, and dental assistants with an overview of the etiology of tooth wear and explains the pathogenic processes involved in tooth erosion. It describes the necessary protocol for assessing erosion in patients and making a diagnosis. Preventive measures and treatment approaches are included. Chapter 8: Medication-Related Damage to Soft and Hard Dental Structures 130 [2 CE Hours] The purpose of this course is to prepare dentists, dental hygienists, and dental assistants to identify these medication- related adverse effects and treat or assist in treating them. This course begins by presenting conditions involving damage to the hard dental structures caused by fluoride, anticonvulsants, chemotherapeutics, and medications such as bisphosphonates that are associated with osteonecrosis of the jaw. Tooth discoloration is also discussed. Damage to oral soft tissues is then reviewed. Color changes to the oral mucosa, including mucosal pigmentation and black hairy tongue, are described. Drug-related gingival enlargement and other mucosal disorders, oral allergic reactions, drug-related white lesions, and conditions of the salivary glands are examined. Chapter 9: Obstructive Sleep Apnea: A Comprehensive Review for Dental Professionals, 3rd Edition 143 [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 dental professionals with further opportunities for education and training in this area. Chapter 10: Oral Health Issues for the Female Patient, 3rd Edition 157 [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 11: Three Drug Classes: Antibiotics, Analgesics, and Local Anesthetics Mod I: Antibiotics, 3rd Edition 169 [2 CE Hours] After completing this course, the participant will be able to discuss the differences among antibiotics typically prescribed for orofacial infections. In the case of special patient populations such as orthopedic, cardiac, and immunosuppressed individuals, the selection and timing of appropriate prophylactic antibiotics will be made clear. The principles learned will also be directly applicable to the appropriate selection of antimicrobial therapy for the pregnant or breastfeeding patient and will aid in recognizing those patients with a significant allergic history and how to best and safely treat them. This intermediate-level course is specifically designed for all members of the dental healthcare team: dentists, dental hygienists, and dental assistants.
©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 Book Code: DFL3024 DENTAL CONTINUING EDUCATION
FREQUENTLY ASKED QUESTIONS
What are the requirements for license renewal? License Expires CE Hours Required
Mandatory Subjects
2 hours - Prescribing Controlled Substances 2 hours - Prevention of Medical Errors 2 hours - Domestic Violence (every 3rd biennial renewal period in addition to an original 30 hours) 4 hours - First biennium renewal, licensees are only required to complete 2 hours on Prescribing Controlled Substances and 2 hours of HIV/AIDS
30 (All allowed through online courses)
Licenses expire February 28 of the even year
How much will it cost?
COURSE TITLE
HOURS PRICE COURSE CODE
Chapter 1:
Prescribing Controlled Substances Safely: A DEA Requirement (Mandatory) Family Violence: Implications for Dental Patients and Practice in Florida (Mandatory) Protecting Patient Safety in the Dental Office: Preventing Medical/Dental Errors (Mandatory)
8
$79.95
DFL08DR
Chapter 2:
2
$19.95
DFL02FV
Chapter 3:
4
$39.95
DFL04PS
Chapter 4: Chapter 5: Chapter 6: Chapter 7: Chapter 8:
Allergic Reactions to Metals in the Mouth, 2nd Edition Dental Ethics and the Digital Age, 2nd Edition
1 3
$9.95
DFL01AR DFL03DE DFL03DR DFL01TW DFL02DS
$29.95 $29.95
Dental Radiation Health: Safety and Protection in the Digital Age, 2nd Edition 3
Erosion-Related Tooth Wear
1 2
$9.95
Medication-Related Damage to Soft and Hard Dental Structures
$19.95
Obstructive Sleep Apnea: A Comprehensive Review for Dental Professionals, 3rd Edition 2
Chapter 9:
$19.95
DFL02AP
Chapter 10: Oral Health Issues for the Female Patient, 3rd Edition
2
$19.95
DFL02OH
Three Drug Classes: Antibiotics, Analgesics, and Local Anesthetics Mod I: Antibiotics, 3rd Edition
Chapter 11:
2
$19.95
DFL02AB
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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 a Florida 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. Colibri Healthcare, LLC is an approved provider of continuing education by the Florida Board of Dentistry (Provider #50-4007). Are my credit hours reported to the Florida board? Yes. We will report your hours electronically to CE Broker within 1 business day. 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 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: Department of Health Board of Dentistry 4052 Bald Cypress Way, Bin C-04 Tallahassee, FL 32399-3258
Phone (850) 488-0595 Fax (850) 921-5389 Website: https://floridasdentistry.gov/
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DENTAL CONTINUING EDUCATION
Book Code: DFL3024
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(s) of completion. How to complete continuing education
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Online IF YOU’RE COMPLETING ALL COURSES IN THIS BOOK: • Go to EliteLearning.com/Book and enter code DFL3024 in the book code box, then click GO .
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• If you already have an account created, sign in with your username and password. If you don’t have an account, 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. IF YOU’RE ONLY COMPLETING CERTAIN COURSES IN THIS BOOK: • Go to EliteLearning.com/Book and enter the code that corresponds to the course below, then click GO . • Each course will need to be completed individually.
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All 30 hours in this book
DFL3024 DFL08DR
Prescribing Controlled Substances Safely: A DEA Requirement (Mandatory)
Family Violence: Implications for Dental Patients and Practice in Florida (Mandatory)
DFL02FV
Protecting Patient Safety in the Dental Office: Preventing Medical/Dental Errors (Mandatory)
DFL04PS
Allergic Reactions to Metals in the Mouth, 2nd Edition
DFL01AR
Dental Ethics and the Digital Age, 2nd Edition
DFL03DE
Dental Radiation Health: Safety and Protection in the Digital Age, 2nd Edition
DFL03DR
Erosion-Related Tooth Wear
DFL01TW
Medication-Related Damage to Soft and Hard Dental Structures
DFL02DS
Obstructive Sleep Apnea: A Comprehensive Review for Dental Professionals, 3rd Edition
DFL02AP
Oral Health Issues for the Female Patient, 3rd Edition DFL02OH Three Drug Classes: Antibiotics, Analgesics, and Local Anesthetics Mod I: Antibiotics, 3rd Edition DFL02AB
iv
Book Code: DFL3024
DENTAL CONTINUING EDUCATION
Chapter 1: Prescribing Controlled Substances Safely: A DEA Requirement 8 CE Hours Release Date : May 1, 2023 Expiration Date : May 1, 2026 Authors
Humberto Reinoso, Ph.D., FNP-BC, ENP-BC , serves as Assistant Professor and Nurse Practitioner Coordinator at Georgia Baptist College of Nursing of Mercer University. Dr. Reinoso’s clinical responsibilities have progressively evolved as his role in healthcare changed during the past 16 years of clinical practice. Initially, as a registered nurse (RN), he focused on providing the best care possible for patients at the bedside of a busy emergency department (ED) in a teaching hospital in south Florida. As an emergency nurse practitioner (NP), he focused on coordinating and improving patient care in the ED through prescribed interventions and advanced care. Having expanded his role and practice as a dual-certified advanced practice provider, he was granted a greater understanding of how nursing and medicine intertwine. As an experienced Family Nurse Practitioner (FNP) and Emergency Nurse Practitioner (ENP), he oversees a full range of nursing care for emergency department patients. Dr. Reinoso received his Ph.D. from Barry University in Miami, Florida. He incorporates current guidelines and real-world scenarios as innovative pedagogical content delivery methods. His passion for nursing education has evolved as healthcare demands on the practitioner, patient, and community have become more complex. Preparing nurses to sharpen their skills and perform at the level of advanced practice providers has become his passion. His pedagogical approach focuses on bridging clinical practice with theoretical/didactic content. As 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 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
an Assistant Professor and the Nurse Practitioner Coordinator at Georgia Baptist College of Nursing of Mercer University, he can combine his passion for clinical practice and the education of future advanced practice professionals. Humberto Reinoso has no significant financial or other conflicts of interest pertaining to this course. Robyn B. Caldwell, DNP, MSN, FNP-BC, PMHNP, earned a Doctor of Nursing Practice (DNP) from Samford University in nursing administration with an emphasis on nursing education in 2013, A post-master’s certificate as a psychiatric nurse practitioner (PMHNP) from Wilkes University in 2022, a postmaster’s certificate as a family nurse practitioner from Delta State University in 2003, a master’s degree in nursing administration (MSN) in 1996, and a Bachelor of Science in Nursing (BSN) degree in 1990 from the University of Tennessee. Dr. Caldwell has worked in various healthcare settings throughout her 32-year career, including adult and pediatric emergency nursing, nursing administration, and nursing education (LPN to DNP) in community college and university settings. She has published and presented on topics relevant to nursing education and patient outcomes at local, state, and national venues. Dr. Caldwell currently works in a rural urgent care setting. Robyn B. Caldwell has no significant financial or other conflicts of interest pertaining to this course. AGD Subject Code - 134 objectives as a 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. Learning objectives After completing this course, the learner will be able to: Differentiate among substance use disorders and associated concepts, including diversion. Examine the roles of the DEA, FDA, and HHS in scheduling- controlled substances and enforcing controlled substance laws and regulations. ○ Controlled substance act. Differentiate the DEA Controlled Substance Schedules and prescribing regulations. ○ DEA Controlled Substance Schedules. ○ Schedules of a controlled substance (I, II, III, IV, V). Examine medical marijuana legislation. Describe essential considerations when prescribing controlled substances, including regulatory exceptions and clinical concerns.
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Book Code: DFL3024
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○ Nurse practitioners prescribing controlled substances: requirements. ○ Integrative Therapies. Controlled substance prescribing practices. ○ Prescription drug monitoring programs (PDMPs). ○ Electronic prescribing of controlled substances (EPCS). ○ Facsimile and oral prescriptions for Schedule II controlled substances. Course overview Nurse Practitioners (NPs), Physician Assistants (PAs), Pharmacists, and Dentists care for patients with disorders in many healthcare settings. Individuals may seek care for an acute illness or worsening of a chronic condition. Often, pain is the leading reason for seeking medical care. Appropriate prescribing practices are critical for all medications, but controlled substances require special attention. The Drug Enforcement Agency (DEA), the Food and Drug Administration (FDA), and the U.S. Department of Health and Human Services (HHS) all have a role in controlled medication schedules. Prescribers must Implicit bias in healthcare Implicit bias significantly affects how healthcare professionals perceive and make treatment decisions, ultimately resulting in disparities in health outcomes. These biases, often unconscious and unintentional, can shape behavior and produce differences in medical care along various lines, including race, ethnicity, gender identity, sexual orientation, age, and socioeconomic status. Healthcare disparities stemming from implicit bias can manifest in several ways. For example, a healthcare provider might unconsciously give less attention to a patient or make assumptions about their medical needs based on race, gender, or age. The unconscious assumptions can lead to delayed or inadequate care, misdiagnoses, or inappropriate treatments, all of which can adversely impact health outcomes. Addressing Substance use disorders are a significant public health problem with a wide range of negative effects on individuals' mental, physical, and social well-being. Mental health problems co- occurring with substance use disorders include depressive, anxiety, and psychotic disorders, as well as organic brain syndromes (American Psychiatric Association [APA], 2013). Substance use disorders share many of the same features but differ in pharmacology and associated behaviors that account for the unique effects of each substance (Boland & Verduin, 2022).
○ Schedules III-V controlled substance prescribing considerations. ○ FDA warning for codeine- and hydrocodone-containing cough and cold products. ○ Special considerations for nurse practitioners prescribing controlled substances.
understand federal and state requirements for all controlled substances. This course will provide a general review of federal and state-controlled substance regulations and the prescribing practices for controlled substances. Additionally, substance use disorders are complex phenomena affecting many lives. This course also reviews common substance use disorders, including alcohol, anxiolytics, stimulants, hallucinogens, and tobacco/ vaping. However, the focus is on clinical safety considerations when prescribing non-cancer-related opioid medications for acute/chronic pain in adults. implicit bias in healthcare is crucial for achieving equity in medical treatment. Strategies to combat these biases involve education and awareness programs for healthcare professionals. These programs help individuals recognize and acknowledge their biases, fostering a more empathetic and unbiased approach to patient care. Additionally, implementing policies and procedures prioritizing equitable treatment for all patients can play a pivotal role in reducing healthcare disparities. Ultimately, confronting implicit bias in healthcare is essential to creating a more just and equitable healthcare system where everyone receives fair and equal treatment regardless of their background or characteristics.
INTRODUCTION
Alcohol, opioids, central nervous stimulants, cannabinoids, and tobacco describe the phenomenon associated with substance disorders. The hallmark of substance use disorders includes cognitive, behavioral, and physiological symptoms of intoxication, withdrawal, and dependence (APA, 2013). Diagnosis is based on pathological patterns of substance use. All substances activate the same brain reward pathway via dopaminergic neurotransmission (Paxos & Teter, 2019).
NEUROBIOLOGY OF SUBSTANCE USE DISORDERS
Substance use disorders (SUDs) are complicated physiologic and psychologic disorders with multiple intersecting factors, such as drug use behaviors and poor judgment influenced by the pharmacodynamics and pharmacokinetic actions of the drug (Boland & Verduin, 2022). The central element of drug dependence is drug-using behavior. Drug use initiates a cascade of rewarding or aversive physical, psychological, and social consequences that determine the likelihood of subsequent use (Boland & Verduin, 2022). The development and persistence of SUDs are primarily based on key components within the basal ganglia, amygdala (extended), and prefrontal cortex (U.S. Department of Health and Human Services [HHS], 2016). The basal ganglia and its subnetworks are responsible for reward, pleasure, and the formation of habitual substance use (HHS, 2016). The amygdala is responsible for uneasy feelings, anxiety, and withdrawal irritability. The prefrontal cortex is involved in executive function and exerts control over the individual’s cognitive inability to reject substance use based on neurocircuitry, namely impulsivity and compulsivity (Stahl, 2020). These endophenotypes are found trans-diagnostically present across many psychopathologies.
Impulsivity causes the individual to act without forethought and with lack of reflection on previous behavior. Compulsivity is characterized by inappropriate actions which persist regardless of the situation (Stahl, 2020). Over time, impulsive substance use becomes compulsive addiction as this dysregulation becomes a dependent conditioned response. The impulses in the ventral loop of reward and motivation migrate dorsally because of neuroplasticity and engage in a habit system, creating the conditioned response of addiction (Stahl, 2020). Impulsive drug use produces a high , which, if experienced too often, cause the migration to compulsive use (addiction) to reduce the unpleasant effects of withdrawal. The mesolimbic pathway is hypothesized to be the final common pathway of reward and reinforcement in the brain, where all addictive drugs increase dopamine, especially with habitual use (Stahl, 2020; Wise & Jordan, 2021). Arising in the ventral tegmental area (VTA), it projects into the nucleus accumbens (NA) and prefrontal cortex (PFC). The psychology of substance use disorders reflects psychodynamic theories dating back 100 years (Boland & Verduin, 2022). Disturbed ego functions, self-medication, and alexithymia (inability to describe feelings) are common among substance users. Aside from pharmacologic effects, positive reinforcement is gained from paraphernalia and associated
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Book Code: DFL3024
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behaviors with drug use (Boland & Verduin, 2022). Conditioned responses (similar to Pavlovian phenomena), such as cravings and withdrawal, promote relapsing behaviors (Boland & Verduin, Implicit bias and stigma in substance use disorders The language used by clinicians, such as addicts , can stigmatize individuals with substance use disorders reflecting misconceptions that these behaviors are choices rather than compulsions (NIDA, 2022). Negative biases can dehumanize individuals and affect the therapeutic alliance, and, ultimately, the course of recovery (NIDA, 2022). Clinicians who stereotype drug use as a criminal activity marginalize disadvantaged groups
2022). Individuals aged 18-24 years have a high prevalence rate for every substance disorder.
and negatively influence treatment plans, which may increase drug use (NIDA, 2022.) Stigma and implicit biases impact fear of disclosing substance use, decreased quality of care, or reduced access to care (NIDA, 2022). To this end, the word addiction has been eliminated from the DSM-5® (Diagnostic and Statistical Manual of Mental Disorders , 5th ed.) in favor of the more neutral term substance use disorder (APA, 2013). Healthcare Considerations: Every member of our community may help to lessen stigma and prejudice against those who suffer from drug use disorders by: ● Understanding substance use disorders are chronic, treatable medical conditions. ● Changing stigmatizing language with more empowering, preferred language that does not equate people with their condition or have negative connotations. ● Addressing systemic racism, sexism, and other forms of discrimination leads to multiple layers of stigma for many people with addiction. (NIDA, 2022) Risk factors for substance use disorders Adult risk factors for substance use disorders include the following:
• Ability to afford drugs. • Avoidant coping style. • Bereavement. • Caucasian ethnicity, • Chronic pain.
• Poor health status. • Significant drug burden/polypharmacy. • Unexpected or forced retirement. • Social isolation (living alone or with nonspousal others). • History of alcohol problems. • Previous or concurrent substance use disorder. • Previous or concurrent psychiatric illness. (Kuerbis, 2020)
• Chronic physical illness/comorbidity. • Physical disabilities or reduced mobility. • Transitions in care/living situations.
Evaluating Substance Use Disorder (Abbreviated)
Instrument
Purpose
Interpretation
Addiction Severity Index
• Assessment tool. • The clinician administers the semi- structured interview. • Screening tool. • Clinician/self-administered. • Evaluates the quantity and frequency of drinking. • Screening tool. • Clinician/self-administered. • Identifies the presence of problematic drinking. • Assessment tool. • Clinician administered. • *Gold standard for alcohol withdrawal assessment. • Assessment tool. • Clinician administered. • Used to follow the course of opiate withdrawal and effectiveness of medication regimen-no standard cutoff. • Comprehensive, integrated public health approach to early intervention and treatment for persons with or at risk for substance use disorders.
• 200 items, normed national data.
Alcohol Use Disorders Identification Test (AUDIT) Alcohol Use Disorder Identification Test- Consumption (AUDIT-C)
• 10 items.
Cage Questionnaire
4 items: • positive score ≥ 2.
Clinic Institute Withdrawal Assessment-Alcohol Revised (CIWA-Ar)*
10 items: • <10, mild withdrawal. • 10-18, moderate withdrawal. • >18 severe withdrawal.
Clinical Opiate Withdrawal Scale (COWS)
• 5-12 mild withdrawal. • 13-24 moderate withdrawal. • 25-36 moderately severe withdrawal. • >36 severe withdrawal. • Universal screening. • 5-10 minutes. • Scored low to severe risk. • Achieved at moderate risk; brief intervention implemented. • For use in alcohol, tobacco with growing evidence of illicit drug use.
Screening, brief intervention, and referral to treatment (SBIRT)
Note . Paxos & Teter, 2019; SAMSHA, 2022.
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SUBSTANCE USE INTOXICATION
Substance intoxication is associated with and without substance use disorders. The most common changes with intoxication include disturbances in wakefulness, attention, thinking, judgment, psychomotor, and interpersonal behaviors (APA, 2013). Specific routes of administration produce rapid absorption into the bloodstream, escalating intoxication effects Diagnosing substance use disorders Substance use disorders occur from mild to severe, based on symptomology and fluctuation of the disease process (APA, 2013). Individuals demonstrate a problematic pattern of substance use that leads to significant impairment as manifested by two or more criteria over 12 months for substance use disorder: ● Substance taken in more significant amounts over a more extended period than was intended. ● Persistent desire or unsuccessful efforts to cut down or control the use of the substance. ● A great deal of time spent in activities to obtain the substance. ● Craving or strong desire to use the substance. ● Recurrent substance use failing to fulfill significant role obligations at work, school, or home. ● Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance. ● Important social, occupational, or recreational activities are given up or reduced because of substance use. ● Recurrent substance use in situations in which it is physically hazardous. Alcohol addiction is a chronic relapsing disorder associated with compulsive drinking (NIAAA, 2021). Alcohol use is a common disorder defined by a cluster of behavioral and physical symptoms and can include withdrawal, tolerance, and craving (APA, 2013). Approximately 69.5% of ages 18 and older reported drinking alcohol in the past year, with 59.4% in the last month (NIAAA, 2022). Alcohol is a potent drug that causes physiological changes in almost every body system. The severity of the disorder is based on the number of diagnostic criteria in a given individual, along with changes in the severity of alcohol use across time, reflected by reductions in the frequency of alcohol consumed (APA, 2013). Alcohol use disorder has a variable course characterized by remissions and relapses (APA, 2013). Alcohol use disorder is associated with increased risks of accidents, violence, and suicide (APA, 2013). Severe alcohol use is associated with comorbid conditions such as depression or other disinhibitions of feelings which contributes to suicide attempts as well as completed suicides (APA, 2013). Other disorders associated with alcohol use disorders include psychosis, bipolar disorders, anxiety disorders, sleep disorders, and neurocognitive disorders (Levin et al., 2013). Addiction cycle in alcohol use disorder Alcohol consumption is linked to health and social consequences interfering in personal relationships, heart and liver disease, cancer, motor vehicle collisions, and violence (NIAAA, 2021). The powerful effects on the brain account for euphoria and pleasurable feelings, increasing the motivation to use substances despite the risk of harm (HHS, 2016). The addiction cycle is based on three concepts: (1) binge/intoxication, (2) withdrawal/ negative effects, and (3) preoccupation/anticipation (NIAAA, 2021). Individuals may experience all stages during the day, over weeks or months: ● Binge/intoxication stage is when an individual experiences a rewarding experience, including euphoria, anxiety reduction, and easing of social interactions. Repeat activation of the basal ganglia reinforces the likelihood of repeated consumption through motivation and routine behaviors. The repeated activation of the basal ganglia changes the way an
and likelihood of patterns of use. Intoxication often begins in the teens and is the first substance-related experience. Withdrawal is usually, but not always, associated with substance use disorders but can occur at any age. Short-acting substances have a higher potential for withdrawal than longer-acting substances. The substance's half-life parallels withdrawal (APA, 2013). ● Continued substance use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by substance. ● Tolerance: ○ A need for markedly increased amounts of the substance to achieve intoxication or desired effect. ○ A markedly diminished effect with continued use of the same amount of the substance. ● Withdrawal: ○ The characteristic substance withdrawal syndrome. ○ The substance is taken to relieve or avoid the withdrawal symptoms. (Levin et al., 2014) Individuals who demonstrate a chronic loss of control or compulsive use of substances and a wide range of adverse risks (mental, physical, and social well-being) meet the criteria for substance-related disorders (Boland & Verduin, 2022). Standardized screening is important to determine the stage of substance use, consequences, and functional impairment (Paxos & Teter, 2019).
ALCOHOL USE DISORDER
individual responds to stimuli, which triggers powerful urges to consume the substance over time (NIAAA, 2021). ● Negative affect/withdrawal stage occurs when an individual stops drinking and withdrawal symptoms occur. These symptoms can be physical (sleep disturbances, pain, and ill feelings) or emotional (dysphoria, irritability, anxiety, and emotional pain). Negative feelings associated with alcohol withdrawal come from two sources. Diminished activation in the reward system makes it difficult to experience the euphoria associated with everyday living. Increased activation of brain stress contributes to anxiety, irritability, and unease (NIAAA, 2021). The individual consumes alcohol to escape the lows of chronic alcohol use. ● Pre-occupation/anticipation stage occurs when an individual seeks alcohol after abstinence. This stage can be triggered by various factors such as stress, social situations, or environmental associated with previous substance use. These triggers can create a psychological and physiological response in the brain, leading to a strong urge to use alcohol. The prefrontal cortex, responsible for executive function, is compromised in alcohol use disorder (NIAAA, 2021). Alcohol intoxication Alcohol intoxication usually develops over minutes to hours and lasts about several hours (APA, 2013). The first episode of alcohol intoxication likely occurs in the mid-teens, but alcohol use disorder is not identified in the late teens or early 20s. The essential feature of alcohol intoxication is the presence of behavioral or psychological changes, including inappropriate sexual or aggressive behavior, mood lability, impaired judgment, and levels of incoordination that may interfere with the performance of usual activities (APA, 2013). The degree of intoxication increases with the blood alcohol concentration, especially when combined with other sedation producing substances (APA, 2013).
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Book Code: DFL3024
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Delirium Although confusion and changes in the level of consciousness are not criteria for alcohol withdrawal, delirium may occur. Individuals with delirium are dangerous to themselves and others (Boland & Verduin, 2022). Delirium tremens occurs on the third day after reduction or cessation of alcohol and has a mortality of 20% if left untreated. Individuals demonstrate confusion, disorientation, hallucinations, delusions along with autonomic hyperactivity, anxiety, and fluctuating levels of psychomotor activity (Boland & Verduin, 2022). Alcohol induced disorders Wernicke encephalopathy (alcoholic encephalopathy) is characterized by ataxic gait, vestibular dysfunction, confusion, horizontal nystagmus, lateral orbital palsy, and gaze palsy (Boland & Verduin, 2022). The condition is reversible but may progress to Korsakoff syndrome (Boland & Verduin, 2022). Korsakoff syndrome is a chronic amnestic syndrome that follows Wernicke encephalopathy (Boland & Verduin, 2022). The main feature is anterograde amnesia, with possible confabulation (Boland & Verduin, 2022). Thiamine deficiency is the pathophysiologic between these two syndromes (Wernicke- Korsakoff syndrome) (Boland & Verduin, 2022). Thiamine is involved in the conduction of axon potential and synaptic transmission (Boland & Verduin, 2022). Antidipsotropic medications ● Acamprosate is the most effective medication for maintaining abstinence in alcohol use disorder (France, 2022). Acamprosate is thought to target GABA and N-methyl-D-aspartate glutamatergic receptor activity, thereby decreasing cravings and relapse (France, 2022). The individual must be alcohol-free at initiation and is contraindicated in severe renal disease. Side effects include diarrhea and nausea. Dosing is weight based, and titration is not required (Mariani, 2014). ● Disulfiram is a second-line treatment to treat individuals who are dependent on alcohol but are motivated to discontinue use (Stokes & Abdijadid, 2022). Alcohol consumption increases serum acetaldehyde causing diaphoresis, palpitations, facial flushing, nausea, vertigo, hypotension, and tachycardia. These symptoms are known as disulfiram- alcohol reaction and discourage alcohol intake (Stokes & Abdijadid, 2022). Side effects include headache, skin rash, drowsiness, and metallic aftertaste; adverse reactions include hepatitis and peripheral neuropathy. ● Naltrexone is a first-line treatment for alcohol and opioid dependence by blocking the µu receptor (Singh & Saadabadi, 2022). Additionally, naltrexone also modifies the hypothalamic-pituitary-adrenal axis to suppress alcohol consumption (Singh & Saadabadi, 2022). Absorption is almost complete after administration but has an extensive first pass effect. Nausea and abdominal pain are common. Caution is needed in hepatic and renal impairment. Healthcare Considerations: Delirium tremons should be considered a medical emergency and can be fatal if not managed. The best-validated tool to assess the severity of alcohol withdrawal is the Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar). The main treatment objectives for alcohol withdrawal are controlling agitation, lowering seizure risk, and reducing morbidity and mortality. Benzodiazepines are the first-line treatment for all alcohol withdrawals. Barbiturates are used for those patients who are refractory to benzodiazepines. Propofol in conjunction with benzodiazepines could be used in patients refractory to barbiturates; however, this would require mechanical ventilation (Hoffman & Weinhouse, 2023).
Blood Alcohol Concentrations (BAC) with Impairment 20-30 mg/dL Slowed motor impairment with decreased thinking ability. 30-80 mg/dL Increased motor and cognitive problems. 80-200 mg/dL Incoordination and judgment errors with deterioration in cognition. 200-300 mg/dL Nystagmus, slurred speech, and blackouts. >300 mg/dL Impaired vital signs and possible death. If an individual lacks significant impairment at 150 mg/dL pharmacodynamic tolerance may be present (Boland & Verduin, 2022). Repeated alcohol intoxication can predispose individuals to depressed immune function leading to repeated infections and some cancers (APA, 2013). Blackouts Blackouts are identified as anterograde amnesia (the inability to form new memories while under the influence of alcohol) occurring with alcohol intoxication. During blackouts, individuals’ remote memory remains intact but short-term memory is deficient. Likely, the hippocampus and temporal lobe structures are affected. Intellectual faculties remain intact, and the individual can perform complicated tasks. It's important to note that blackouts are not the same as passing out, which occurs when a person loses consciousness due to alcohol intoxication. Alcohol withdrawal The decision to stop drinking is usually in response to a crisis followed by weeks of abstinence and then controlled nonproblematic drinking (APA, 2013). However, consumption escalates rapidly, and severe problems likely occur (APA, 2013). Individuals will often continue consumption to decrease the unpleasant side effects of withdrawal. A repetitive and intense use pattern develops, and individuals spend time consuming alcohol (APA, 2013). Alcohol withdrawal can be severe, including seizures and autonomic hyperactivity (diaphoresis, tachycardia). The classic sign of alcohol withdrawal is tremulousness (Boland & Verduin, 2022). Other withdrawal symptoms include nausea; vomiting; insomnia; transient visual, tactile, and auditory hallucination or illusions; psychomotor agitation; anxiety; and seizure (APA, 2013). The estimated progression of alcohol withdrawal symptoms is presented here:
Time to Presentation
Progression
Symptoms
Mild
Tremulousness.
6-8 hours.
Moderate
Perceptual disturbances. 8-12 hours.
Severe
Seizures.
12-24 hours.
Life Threatening Delirium tremens.
Within 72 hours.
Note . Boland & Verduin, 2022. Withdrawal seizures
Alcohol withdrawal produces generalized tonic-clonic seizures, but status epilepticus is rare (Boland & Verduin, 2022). Long- term alcohol use can produce hypoglycemia, hyponatremia, and hypomagnesemia, which also produces seizures (Boland & Verduin, 2022).
ANXIOLYTICS OR SEDATIVE-HYPNOTIC RELATED DISORDERS
Sedative hypnotics are among the most commonly prescribed psychoactive drugs by clinicians in primary care (Ehrlich, 2022). These drugs are frequently taken orally to obtain a steady
intoxicated state. Individuals with sedative-hypnotic or anxiolytic use disorders are frequently treated in the outpatient setting, as the overall stability requires less monitoring. Sedative
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Book Code: DFL3024
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drugs decrease activity diminishes excitement, and calm the individual (Mihic & Mayfield, 2023). Sedatives are often used to alleviate unwanted side effects of other substances (APA, 2013). Hypnotic drugs produce drowsiness and facilitate the onset and maintenance of sleep that resembles electroencephalography where the individual is easily aroused (Mihic & Mayfield, 2023). The usual course of these disorders begins in the teens or 20s, with social patterns, moving into daily use with high tolerance levels (APA, 2013). A less frequent pattern begins with prescription use and reports of anxiety, insomnia, or other complaints (APA, 2013). Individuals demonstrating a problematic pattern of substance use that leads to significant impairment as manifested by two or more criteria over a 12-month period meet the criteria for sedative, hypnotic, or anxiolytic use disorder: 1. Sedatives, hypnotics, or anxiolytics often taken in larger amounts or over a longer period than was intended. 2. A persistent desire or unsuccessful efforts to cut down or control sedative, hypnotic, or anxiolytic use. 3. A great deal of time spent in activities necessary to obtain the sedative, hypnotic, or anxiolytic or to use, or recover from the sedative, hypnotic, or anxiolytic. 4. Craving or a strong desire or urge to use the sedative, hypnotic, or anxiolytic. 5. Recurrent sedative, hypnotic, or anxiolytic use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued sedative, hypnotic, or anxiolytic use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of sedative, hypnotic, or anxiolytic. 7. Important social, occupational, or recreational activities are given up or reduced because of sedative, hypnotic, or anxiolytic. 8. Recurrent sedative, hypnotic, and anxiolytic use in situations in which it is physically hazardous (driving, operating machinery). 9. Sedative, hypnotic, or anxiolytic use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the sedative, hypnotic, or anxiolytic. 10. Tolerance: a. A need for markedly increased amounts of the sedative, hypnotic, or anxiolytic to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of sedative, hypnotic or anxiolytic. 11. Withdrawal: a. Characteristic withdrawal syndrome. b. Sedatives, hypnotics, or anxiolytics are taken to relieve or avoid withdrawal symptoms. (APA, 2013) Benzodiazepines (BZDs) are one of the most widely prescribed drug classes in the United States, known for depressant effects on the central nervous system (Edinoff et al., 2021). BZDs are Federal Drug Administration (FDA) indicated for anxiety disorders, insomnia, acute status epilepticus, induction of amnesia, spastic disorders, and agitation (Edinoff et al., 2021). Non-FDA-approved indications include Tourette’s syndrome, delirium, delirium tremens, sleep disorders, and abnormal medication movements (Edinoff et al., 2021). Barbiturates were popular before the introduction of benzodiazepines. Pentobarbital and secobarbital have short half-lives and are lethal, producing coma and death. Barbiturates produce profound respiratory depression, especially when added to another substance. These drugs are not widely utilized. Individuals with sedative-hypnotic or anxiolytic disorders are frequently treated in the outpatient setting as the overall stability requires less monitoring.
FDA Approved Benzodiazepines
Generic
Trade
Indication
Alprazolam Xanax Anxiety, panic disorders, agoraphobia. Chlordiazepoxide Librium Alcohol withdrawal syndrome. Clonazepam Klonopin Panic disorder and agoraphobia; myoclonic and absence seizures. Quazepam Doral Chronic insomnia. Temazepam Restoril Onset and sleep maintenance in insomnia. Diazepam Valium Alcohol withdrawal management. Lorazepam Ativan Anxiety disorders.
Midazolam (in-patient) Triazolam
Versed Procedural sedation.
Halcion Sleep onset in insomnia.
Note . Bounds & Nelson, 2022. Non-benzodiazepines including zolpidem, zaleplon, and eszopiclone (Z-drugs) have clinical effects similar to BZDs but are more prone to misuse and dependence (Borland & Verduin, 2022). Anxiolytics or sedative-hypnotic drugs can be viewed on a continuum based on sedating properties of the class. Physical and psychological dependence does occur, and all these drugs have withdrawal symptoms. Alcohol with other drugs in this class has additive effects (Boland & Verduin, 2022). The essential features of this drug class are maladaptive behavioral or psychological changes. Memory impairment causes anterograde amnesia similar to blackouts (Boland & Verduin, 2022). Sedative, hypnotic, or anxiolytic intoxication Low doses of sedative, hypnotic, or anxiolytic drugs can lead to intoxication during or shortly after use. Clinically maladaptive behavior or psychological changes can lead to: ● Drowsiness or sedation. Healthcare Considerations: In an emergency setting, treatment for benzodiazepine and barbiturate intoxication is primarily supportive. In cases of severe benzodiazepine intoxication, particularly if the patient is becoming hypoxic, flumazenil may be administered (Jahan & Burgess, 2022). Sedative, hypnotic, and anxiolytic withdrawal The severity of withdrawal varies with dose and duration; however, it can occur with short-term, relatively low dose BZDs (Boland & Verduin, 2022). Withdrawal symptoms include: ● Autonomic hyperactivity (diaphoresis, tachycardia). ● Hand tremors. ● Insomnia. ● Nausea/vomiting. ● Transient visual, tactile, or auditory hallucinations. ● Psychomotor agitation. ● Anxiety. ● Grand mal seizures. Deprescribing benzodiazepines is an important clinical skill and the first goal of treatment in detoxification (Drugs.com, 2022). Certain individuals may not require long term BZDs. When deprescribing BZDs, consider duration of treatment, dose, ● Slurred speech. ● Incoordination. ● Unsteady gait. ● Nystagmus. ● Impaired cognition. ● Stupor or coma.
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Book Code: DFL3024
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