Good afternoon, everyone, and welcome to today's webinar. I am Felicia Bloom, manager in the Practice Institute at the American Dental Association. On behalf of the ADA and our collaboration with the Providers Clinical Support System, PCSS, I'm very pleased to bring you today's webinar, Integrating Controlled Substance Risk Assessment and Management into Dental Practice. These are our learning objectives for today. Before we begin our presentation, I would like to make you aware of two resources offered through PCSS that may be of interest to you. First, their mentor program is designed to offer mentoring assistance to those in need of more one-on-one interactions with their colleagues to address clinical questions. You have the option of requesting a mentor from their mentor directory, and they will be happy to pair you with one. To find out more information, please visit their website using the web link noted on the slide. Second, PCSS offers a discussion forum, which is comprised of their PCSS mentors and other experts in the field who help provide prompt responses to clinical cases questions. They also have a mentor on call each month. This person is available to address any submitted questions through the discussion forum. You can create a new login account by clicking the image on the slide to access the registration page. This slide simply notes the consortium of lead partner organizations that are part of the PCSS project. Finally, please reference this slide for their contact information, website, Twitter, and Facebook handles, and to find out more information about their resources and educational offerings. Our esteemed speaker today is Ronald Kulich, PhD. Dr. Kulich is professor, Tufts University School of Dental Medicine in the Department of Diagnostic Sciences. Additionally, he is a lecturer in the Department of Anesthesia, Critical Care and Pain Medicine, Department of Psychiatry, Massachusetts General Hospital. Thank you everyone for joining us today. Without further delay, I'd like to turn the program over to Dr. Ronald Kulich. I'm delighted to speak on this topic. I'm gonna put some of this in historical context in terms of how we essentially got into this work some six or seven years ago. We were approached by the dean of our medical school and asked to sign off on a plan addressing curriculum content, essentially in a medical school with respect to the opioid crisis and opioid risk stratification. And I met with the dean, our dean at that time, Dr. Hugh Thomas, and we thought, well, this doesn't really make a whole lot of sense because the approach to risk mitigation and dealing with opiates for dentistry is actually quite a bit different than medicine. So we embarked on a collaborative effort in Massachusetts with actually our governor Baker and a number of others to set up a curriculum across schools here that targeted essentially curriculum specifically focused on dentistry. From this evolved the Controlled Substance Risk Initiative and some of my team that I've been part of and a number of manuscripts, as well as a series of modules that I'll be talking about and some outcome research that you could look into further if you'd like after this talk. So some of this data from my colleagues, and there are many, particularly David Keith, Michael Shatman, Steve Scrivani for some of this stuff, and a number of other folks are greatly appreciated. Particularly appreciated, we have some considerable funding from the Covaries Community Healthcare Foundation and the Rise Massachusetts Foundation to develop some of our training work and our research. And we're also now on an effort to go across the country and reach underserved areas in terms of opioid and general controlled substance risk mitigation. Let me start off by something I often put more toward the end of the talk, because I think whether we're talking about dental students, practicing dentists, oral surgeons, seniors in a field, it's really nice if you could have a cheat sheet in terms of what to do for assessment for a complicated patient that you may not necessarily see all the time. And this is our controlled substance clinical management checklist that ideally our students and some of our collaborating dentists more or less keep in their pocket. And essentially goes through the steps of a comprehensive risk assessment. There's some things that are probably more critical for some patients than others. One doesn't have to cover everything in these four panels in all cases, but I'm gonna go through them very briefly. And in the context of a couple of complicated patients, I'll talk to them about, toward them a little later in our talk. Certainly we, the patient, we need to assess their current level of substance use, the ideal is to get some history on a patient, look at their medical history as a history of personal substance abuse in the past, substance use disorder presentation, family history of substance use disorder and the like, and observe. Often dentists and primary care physicians and others are focused on specific things they're doing, but often observing the patient is lost in some circumstances. A nice example for the bottom one in terms of analyzing a relevant physical exam and looking at the patient's mental status. I remember one of my fellows several years back after we all met with the patient in an exam room, he came up to me and he said, did you see this young woman? She was 17 year old, did you see her arms? And we're all looking at each other, people have been a field for years. And I said, well, we didn't exactly look. And he pointed out to us that she had fresh marks from a suicide attempt, as well as track marks from likely substance use disorder. And again, the idea of observation and documentation is important. Looking a little bit closer for these complicated patients, I'll talk a lot about the Prescription Drug Monitoring Program. Dentists are sort of notoriously poor at using it. NIDA quick screen is a very, very quick strategy for doing a rapid assessment of a patient with risk. I'll mention that. And again, I'm probably gonna go over and over again about the idea of the whole concept of interprofessional care and communication with others. There are other pieces of this control substance checklist that are also important. One can assess the patient's level of risk, the likelihood that the patient is gonna follow up. I'm gonna point out that the average patient that comes to a dental practice, 50% of patients don't exactly follow your instructions. So in the best of circumstances, whether they're medical or dental patients, 50% adherence is about what you'd see. If you add substance use disorder to the picture, your patient may not be adherent. And these are things to look at. And our checklist, we hope to go through all of these things, speaking to other providers, reassessment. And again, we won't all address this today. We have some manuscripts on neonatal abstinence syndrome and naloxone and so on and so forth. So there's much more to be said than we can do in an hour. I'll give a brief overview of all of what you folks probably know. We saw the opioid crisis in the 1990s. Really, that was the onset with the rise in prescription opioid overdose deaths. Prescriptions were being written to an extreme extent by all providers. That essentially within 10 to 20 years shifted pretty dramatically to more use of heroin and synthetic opiates, and not to go through all the time changes over the last 20 years. But essentially, we've now moved in a direction where overdoses are often due to multiple substances, multiple control substances, as well as other drugs that are illicit. Now we see things shifting. So the thought that patients are gonna necessarily have overdoses from prescriptions written by dentists has changed, or other physicians. I think that's changed over the last, certainly four or five years. A little few comments on where this all came from. We do know that the opioid crisis started with the efforts at unscrupulous marketing and a part of some pharmaceutical industries. There were kickback schemes. People were getting compensated to prescribe more medications. Some of this does still go on. And even including promotion of off-label use by some of the pharmaceutical industry, I point out that this is not just opiates. So one thing to take away from this talk is we talk about risks associated with opiates and opioid risk stratification. We should look at the whole spectrum of control substances and the risks associated with controlled substance misuse or substance use disorder. So it's not just opiates. Good example is gabapentin, which now is on a prescription drug monitoring program is considered a clear drug of abuse, often got promoted off-label. Examples of pill mills. I saw a patient about a year ago, came into our office on the dose equivalent of 500 oxycodone per day, prescribed by a physician in New York and she carried a letter with her indicating that this was appropriate dosing. So we see some of these efforts still going on, although they've largely abated. There were some egregious examples of pill mills, even in Florida, where on the same street, the pain clinic was operating. It would essentially a pill mill and shortly down the street owned by the same operators was a tapering program for substance use disorder and tapering of opiates. So it's complicated and the history is a little dark in terms of what's happened over the years. We often see particularly more persistent pain patients, unrealistic expectations regarding complete relief of pain. And again, these are all things that contributed. But the most important thing I wanna talk about is the provider's failure to adequately identify and monitor misuse and overuse, not just opiates, but all controlled and at-risk substances. Mayo has done much of this work on PCPs, but the work has also been done in dentistry as well. This has been going on for many years. Much has been said. This is an early comment from Chiodo in 2000. Dentists have an ethical obligation to move beyond simply refusing prescriptions for patients of suspected to be chemically dependent. They should sensitively discuss the issue with these patients and be prepared to offer a referral for an intervention. This often doesn't occur in practices. We encourage you to do it. We're working on efforts to find champions, particularly in underserved areas where we assume that not all dentists are going to be experts at substance use assessment and management. But the idea of clearly identifying champions can go a long way, particularly in the areas that are largely underserved by these services. So moving forward, we did a paper with Dinesco and the group in 2011, and it talks a little bit about where things were at. At that point, all prescribers have a responsibility to minimize the potential for drug misuse and diversion while maintaining legitimate access to opiates for patients in need of such analgesic treatments. That was an interesting first statement. And I will say when we did this in 2011, this effort was partially funded by the pharmaceutical industry. And my guess is that's how the last part of that statement came in there. And we absolutely do know that providers in many cases do need to prescribe opiates, but now we're aware that nonsteroidals and other medications actually can have even better analgesic effect. So Dinesco talked about prescribing providers needing to communicate with general dentists, and this is clearly all true. Cross-communication with PCPs, some states now require that clinicians, including dentists, address leftover medications. And I might add that oral surgery of a group has the most leftover of opiates of any subgroup conducting surgery in comparison to orthopedic surgeons and other types of surgeons. Certainly we need to conduct a screening for substance use disorder. And Dinesco starts to talk about the SBIRT. Now, you folks can go online and get SBIRT training, which is a fairly efficient training to assess the high-risk patient. I'd recommend just looking more closely at the NIDA quick screen, because you could put it on your phone and it can be used pretty efficiently. Even Dinesco talked about dentists doing urine drug testing. That's really not gonna happen in most dental practices. I think the Dinesco meeting kind of had unrealistic expectations. So in brief, by the time we got to 2016, these are the dental education core competencies. We know now that rational prescribing does not mean not writing opiates. So opiates are appropriate in many cases. They can be best practices, but non-opiate formulations are preferable for patients. And there's much data to suggest that those can be actually quite efficacious. We need to consider interventional and non-pharmacologic strategies, and also assess the patient's expectations in terms of their pain care. And finally, I think this is the most important for the purpose of this talk. We need to look at assessing acute and chronic pain, but also, and this is what I'll go on and on about, we need to do a little bit better job about assessing control substance risk factors. And this is what much of our work has been tied into. Now, having said that, just look at what we've had over the last, maybe 10, 12 years. Opiate prescribing generally has dropped across the board with healthcare providers, but particularly with dentists. Relative dental opiate prescribing decreased from 15% to 6.4% by 2012. There was further drops. Nonetheless, dentists still ranked second to PCPs as the top prescribers. But again, dentists write opiates for acute pain conditions. And if you look at primary care docs, we're really comparing apples and oranges here because primary care docs in many cases are writing opiates for more chronic conditions, and that really complicates things and increases the risks for patients. So dentists may get a reasonable pass on some of this. If you look at the continued dropping of rates, I think a lot of these dropped due to the CDC guidelines coming out in 2016. It's a good read if you're interested in looking at control substance pathways for managing a complicated patient, and I would encourage the CDC guideline, although it has been a bit controversial in some areas. We know that a lot of this drop also occurred in writing due to press reports, the CE programs that you've all participated in over the last four or five years. Even the board and professional organizations have come up with recommendations, not that we're anti-opiate, but suggested more reasonable rational prescribing practices. And I'll leave this section of my talk with a summary from a brilliant researcher, Dr. McCauley, and she's written much in this area. Continued vigilance among dental prescribers is warranted when considering opiates for pain management, particularly among adolescents and young adults given the potential risks conferred for the future opiate use and abuse. Consistent with the ADA recommendations, dental prescribers should standardly consider non-opiate alternatives as the first-line management options. And if prescribing opiate, should utilize prescription drug monitoring programs and provide thorough patient counseling regarding pain management expectations and employ opioid risk mitigation strategies, secure storage, et cetera. So this is 2021. You can have access to this paper as well as the video. This was developed from work through funding through our nonprofit group. So the thing I wanna bring home for everybody is we're not just talking about opiates. We really need to look broader as opposed to this being just a quote-unquote opioid epidemic. Well, certainly it has been. Substance use disorders and substance misuse remain at epidemic levels. I'm not gonna spend the entire talk showing you graphs. That is currently available out there. We do know that overdoses are commonly the consequences of not just opiates, but multiple substances. Over-focus on opiates may in fact distract from focusing on other issues. So while we're obsessing whether a patient may or may not be on five milligrams of oxycodone, if they're concurrently significantly abusing alcohol or on other substances, that significantly complicates the issue. If you take a patient on opiates and you add in a benzodiazepine, the likelihood of death by overdose goes up eightfold. So again, polysubstance issues are the greatest barrier I think that we face or the greatest problem and we shouldn't be looking at all substances. So in terms of assessment of the patient with the controlled substance risk, this is some data largely from Macaulay but others that we adapted. US dentists, three out of four report they ask their patients about substance misuse. Well, that may seem pretty good. The trouble is those questions tend to be a single question or two buried in the written history that the patient fills out and not often addressed. If you, excuse me, if you look at more data on this, two thirds of dentists disagree that such screening is compatible with their professional role. There is an incentive not to do these assessments and I'll talk a little bit later about the barriers here, but it becomes a real problem for the simple reason that dentists are not incentivized to do these assessments and there's often not a comfort with them and the stigma still exists. This is from another study in 2019, dentists who did not believe substance use disorder was a problem in their practice, 86.2%. I think it's fairly naive because there's even in any given day, you're gonna face a number of patients that come through your door that do have a substance, an active substance use disorder. Dentists significantly underestimate the prevalence, bias and stigma cause reduced access to care across the board, inhibit referrals, healthcare providers often lack the understanding that these substance use disorders are also reoccurring. So it's really no different than medical issues such as uncontrolled diabetes, which may have ups and downs of significance and secondary medical comorbidities over a period of time. Really the same thing with substance use disorders. It's not a one assessment and then you're done. It needs to be an ongoing picture because relapses are actually quite common. So one of the things that surprised us when we were doing our research is we gathered 20 national experts and in oral facial pain and addiction, physicians, dentists, a fairly large group of folks who spent an enormous amount of time with us. And we knew before going into this that the data showed five to 6% of dentists request medical records. Now it's sort of interesting because dental records tend to be isolated from medical records. So there's a lot of information that you're not going to have, but because of the barriers, very few dentists look for medical records where much of this data about the patient risk can be ascertained. And we got pushed back from even our own expert group in terms of at least a few of the experts arguing, maybe this is not on the front end of my interest to look at medical records. So I think there are a lot of barriers and I think some we could overcome, some are more challenging. But simply familiarity with the common drugs of misuse are important. I've had complaints from dentist colleagues where they open up the prescription drug monitoring program and they're actually quite unfamiliar with a number of the meds that may be listed on the patient's profile. To respond appropriately, dentists need to understand the terminology of prescription drug abuse, but be able to identify and describe the drugs most often misused or abused, be able to identify individuals who may be at risk for prescription drug abuse and be prepared to manage patients at risk in a dental setting. So this is ideal. People have been talking about it since 2011. We're kind of getting gradually a little better at it. And I could show you some data to suggest that we've had some successes, but I still think we have failures. So these are examples of the drugs on the right. And all of these drugs on the right also have implications in terms of dentistry. I mentioned gabapentin, for example, under anticonvulsants. It's often not thought of as a drug abuse, but it certainly can be. And the company involved in its production has had some challenges in terms of their aggressive marketing of that drug. All the rest are common to you. Barbiturates, benzodiazepines often get forgotten. So again, we think of overdoses and risk. It's usually a combination of drugs. So looking at the right-hand column is as important as looking at the left-hand column in that slide. Now, I'm not gonna belabor this. Everyone in this column knows the oral manifestations much better than I do, but they're large. And these are things that you'll see in your practice that may in fact be predictors of an ongoing substance use disorder. I wanna focus a little bit more on a prescription drug monitoring programs. These are right now national in virtually all states. They require participation by physicians and dentists. Pharmacies can always have access. In some states, law enforcement has access to healthcare licensing boards, but healthcare providers are the main source of access to these programs. They have had a mixed impact in terms of dentistry. And I'm gonna point out that prescription drug monitoring programs are not just for opiates. In fact, there's other drugs that you may see on this list that are actually much more important than the opiates that may or may not pop up. Washington study, only 11% of dentists were registered with the PDMP. This was back in 2018, not that long ago, and actually consulted it. I'll talk a little bit about our data, which was a little scary. And I think we're doing a better job right now to mitigate some of our scary data. 2019, almost half of dentists reported having never consulted the PDMP, some McCauley's work. 2020, about half of dentists were PMP registered, less than physicians, PAs, NPs, and so on and so forth. So dentistry has not been fairly good at this, and it's a resource, not necessarily to identify patients and then throw them out of your office because they happen to, they may have a substance use disorder, but as a vehicle to have a conversation with the patient. So let me tell you a little bit about the work that we've just started to do here. We looked at close to 3,500 medical, I'm sorry, excuse me, 3,500 dental records for documentation with regard to use of the PDMP, looking at all sorts of terms. Out of 3,500 records, we only found 24 records for adjusting documentation. Now that's a little scary. Unfortunately, our system has changed the focus such that clinicians now have easy access to this, which was a great move. However, this is, again, sort of a frightening number in terms of the number of folks that are actually documenting PDMP. Many more may have checked it, but documenting in a record is critical and perhaps having an important conversation with the patient. And to be honest with you, those 24 hits out of 3,500, I wanna talk, I ideally wanna talk to those folks because from my perspective, those are our future champions. Those are the folks who really wanna zero in and focus on these patients of high risk and they could be great resources. Another scary stat that we found is in oral facial pain programs, and these programs address patients that have really high risk and often are, not always, but often are on opiates. They tend to be patients who are decidedly more complicated than general dental patients. But there were oral facial pain programs that had zero participation in the PDMP while others had 100. Maybe this is changing, we'll see. So we're, again, in dentistry, not doing quite as good job as we can do. So let me give you a nice example of a patient who, one of our dental students, and we were actually quite proud of him and one of the faculty members brought this in for a case presentation. And it was a complicated patient who arrived to one of the dental training practices, patient commenting that I wanna get my teeth fixed at a reasonable cost, 58 year old male. He was working, occasional smoker. He said one drink per week. Later on, he says he drinks socially, which is not always consistent for one drink per week. I always enjoy it when I see in a medical or dental record, quote, drink socially. That could mean socially a quart of vodka twice a day. So again, one of the things we focus on with our students is to specify, and things like deny the quick screen can help that. This person denied recreational drugs at all, no regular use of controlled substances. He required extensive dental work. So we needed a plan from a dental standpoint. And the students really judiciously went back and looked at the prior ER dental records for the patient and found that he had been given eight oxycodone, five milligrams, and he booked the follow-up. So this was not an example where he was going from practice to practice to practice with problematic dental issues and in hitting each dentist for small amounts of opiates. That wasn't the case. He apparently just visited one practice, although we didn't quite know yet. So we wanted a little bit of information. And obviously the most priority is assessing the acute dental needs of the patient. Then easily enough, checking the prescription drug monitoring program, even if you're not gonna write opiates or control substances, is still, in a complicated patient, a very good idea to do. Gives you a better perspective on the patient's care. Place a call at a PCP, which the students did dutifully and acquired medical records. And then when you get the results of this, have some conversation with the patient about the overall dental treatment plan, as well as his risk factors. So here's what popped up on the patient's prescription drug monitoring program. A surprise to the students. Yes, the patient did get one script for oxycodone from the ER, but then he got a second script for a small amount of oxycodone. But he's been regularly using a benzodiazepine for an extended amount of time as well. This is something that I think is relevant if we're gonna care for a patient who may be undergoing dental procedures or perhaps more long-term dental care for a patient. And again, it requires a conversation in terms of why was the PDMP inconsistent with his self-report? This may not be a high-risk patient, but a patient that we can help by doing a better scrupulous assessment and pulling in some more information. Now, let me give you an example of a much higher risk patient that you folks, I'm sure at one point or another, have seen in your practice. Oh, if I could have worked in the past, I took it from my back, but I only have a couple left. My primary care doc writes that. I'm eating Tylenol and Motrin by the handfuls. You know, you just can't throw me out of the office without nothing for the weekend, doc. I mean, I got good insurance. You're gonna get paid. Have a little compassion. You know, I just need something to take the edge off for the weekend. You know, I have a lot of pain and my teeth are really bad. You know, I just can't get anybody to help me. I'm desperate. I've tried everything. Most of the other meds I take have nothing to do with my teeth. You know, they're from my back and my neck and my feet. This is a state-run database. What right do they have to look up that information? I'll sue them. You know, I'll sue you. You've got no right to do that. That's preposterous and unfair. You know, I just want to get rid of my pain. So, complicated fellow who is not unlike patients who may show up in a practice, not the ideal situation, but it does happen. And this patient is clearly in distress and he may present with a fairly complicated history. Perhaps a much higher risk patient than we saw last time. So my argument is with a patient such as this, let's take a step back, a step back. And I would encourage you, look at our little cheat sheet here and look at the comprehensive risk assessment and the risk checklist. And we should do a couple things to provide a little bit more comprehensive assessment for a patient such as this. He may need dental care fairly quickly in terms of his management, but that doesn't mean we can't still add to the assessment. One step would be to include the NIDA quick screen. I'll mention that in a second. Certainly we looked at the prescription drug monitoring program, maybe place a call to his primary care doc, which the students did do. Should we actually treat this patient or might he be better managed in terms of his even acute dental care in another setting, perhaps in a more interdisciplinary setting, perhaps a champion who has a more familiarity with patients who have challenging comorbid substance use disorders. This is an example of the NIDA quick screen. You could pull this up on your phone. The links are here. You'll have access to these. It's actually quite good. Ask the patients only four simple little questions. We are adding cannabis to it. As you go through the quick screen, it actually gives you discussion comments to entertain with the patient. And ultimately you could snake through the evaluation and it's fairly quick. This can be done anywhere from two minutes to 10 minutes. And at the end of 10 minutes, you actually have treatment recommendation through your smartphone that you can discuss with the patient as well as referral sources. So I've been sort of bullish on a NIDA quick screen. There are others that are out there. We are working towards standardizing it in dental practices, but in general, most of these instruments have not been standardized in dental practices, but I think it's a good fit. The gentleman we just saw on a videotape is an actor, but a good one. And this was his, in the case when we used in one of our modules, this was a example of his NIDA quick screen. We learned some more about him. This was an actual patient, not the person on the screen, but it was an actual patient who wanted Dr. Keese and learning more about him. We found that he was doing six beers on a weekend, may not be a huge amount, but cocaine once or twice a year, half a pack of cigarettes a day. And when you add all the complicating picture in, the patient may be certainly a moderate to high risk. So going back to our checklist, looking at comprehensive risk assessment, we need to explain to the patient why we're asking these sensitive questions, obviously assess pain, current substance misuse or risk of substance use disorder, asking medical psychosocial risk factors. And you can go through these on your own, but again, all patients, we're not gonna go through each panel, but the argument is we do parts of this that may be relevant to the patient. Certainly in this case that we look up the prescription drug monitoring program and have a conversation with his provider. Disposition and follow-up. Remember a patient of this sort is not going to be a one visit and that's it. The reality is he'll need to be managed over a period of time. And the communication with providers may not be once, it may be on multiple occasions. There are financial barriers to this. There are time barriers. There are barriers that are better addressed in medicine. Unfortunately, dentistry often does not get reimbursed for some of what we're talking about. Nonetheless, it's increasingly become a critical component of care. So a little bit about this other issue of cross communication and addressing substance use disorder risk factors when there are present. Again, always recommend that you wanna have a frank discussion about the patient, with the patient about what the risk factors are. We have a chapter in some of our papers on empathy and motivational interviewing techniques. There's been much, many seminars have run that, that have been run in that area that can help in many ways. As we've talked before, discuss patient expectations, look at the prescription drug monitoring program, but use it as a strategy to facilitate a conversation with the patient and their providers. And I always say, document whatever a patient says in the record. So the words that essentially came out of this patient's mouth, I would essentially word for word put those in the patient record to essentially illustrate how complicated a presentation you're facing. We have one of our modules on medical legal issues with managing this patient population. And that includes some excellent recommendations from an attorney who addresses board issues and malpractice issues for dentistry. So it's important to look at documentation. Interprofessional care. Again, we've done a lot on this, making the phone call to the patient or sending an email. Let me give you a good example of this. A lot of folks, they see a patient who comes in who may be on Suboxone or similar medication assisted treatment for substance use disorder. There's a, used to be a belief that you cannot write a short acting opiates for these patients. However, if you look to a Suboxone provider and expert in pain, you'll find that there are options for you to manage their dental care, even if they are on Suboxone and those options can be opiates. Again, a good conversation with experts should occur. Cross communication. There's often a fear about HIPAA. You're talking about sensitive subject matter. If you are co-treating with the patient psychiatrist or addiction specialist, you each can have a conversation that is not barred under HIPAA. And caution when the patient says, no, I don't want you to talk to my dentist. I want a free start. I don't want you to talk to my primary care doc. It may be that you can't treat a patient with those limitations. Share screening results, again, with the patient, with the providers. Again, the idea of establishing local relationships with mental health care and substance use experts is always a good idea. SAMHSA has a helpline that can help you do it. It's available nationally. It can provide resources for you for referring patients. And I've seen several patients within the last year referred by their clinician through this helpline. And they've really done well when the dentist shows that level of interest in their care. And be aware that not all medical collaborators give optimal care. We've had situations where the dentist dutifully calls the physician, the patient's on an industrial dose of opiates, perhaps significant risk for death by overdose. But the primary care doctor has little interest in changing or adding to his or her care. So don't always assume that the medical providers are doing their job. And there's cases where you may need to refer the patient for other resources. Don't forget about our colleagues, the dental hygienists and dental assistants. There's some states where they could come on as essentially assistants with the Prescription Drug Monitoring Program and provide tremendous help with the daily lookups of patients, reviewing PDMP profiles. So I cannot emphasize enough the potential role. There's absolutely no reason why our colleagues in dental hygiene can't do NIDA quick screens on patients. Often they know the patients better than the dentist. So I think there's a significant role for others in the office, and that can be particularly cost effective. Just a few more words here on other resources for the dentist, particularly naloxone. And in some states, particularly if you're doing surgical procedures, you're required to have naloxone in your office. Most of us argue that every dentist should have naloxone available in the office. It's the positive impact is great. There's a couple of links that I put out here. This one link from drugabuse.gov is outstanding, and it talks about the naloxone administration and offers some of the really great data on how naloxone has dramatically reduced the number of deaths by overdose. And in this case by Dr. Cohen, there's an interesting scenario where a complicated patient comes in with overdose. So if you want some more information, I encourage those. In terms of naloxone, we know it's an opioid reversal medication. It's completely safe. There are no risk factors. If librarians and transportation workers have naloxone in their drawers, I think it's reasonable to have dentists familiar with this as a life-saving treatment. It's most commonly intranasal in terms of what's out there now. And it's a critical component, but just a component of a substance use risk assessment. So it doesn't deprive one of other obligations to do a risk assessment if you have naloxone around. But I think it's an important component. It's fast-acting. It depends upon a person's metabolism and the type of opiate they have. But again, it's safe. There's monitoring required. Obviously, an individual may require more intensive care and may need transportation to the ER. But there are cases, too, I could think of, where overdoses did occur in dental offices, where this amounted to be an important life-saving move. It's specific for overdose, as you know, overdose only. But it can be administered essentially by anyone, family members and others. We're, Dr. Magnuson and our group are putting together a proposal, a program that offers more education for dentists in naloxone training. But there is much that's out there. But we have barriers, there's no question. The barriers are significant. We do know dentists nowadays are writing fewer opiates. If you actually look at some of the recent data, the stigmas in terms of substance use disorder is getting better. The attitudes are improving. Nonetheless, the data seems to show, Macaulay and others' work strongly shows that there's discomfort with risk assessment. We found it in some of our own research. A quote from an unnamed colleague is that when we approached about teaching students about medical legal issues, our number 10 module, the quote was, well, maybe this module is too complicated. Maybe it's better for graduate students. I think there's a fear sometimes that this content is not relevant. Even in dental school settings, we all work to sort of overcome that fear. Dental practices still often exist in isolation from co-treating health specialists. That's changing over time. It will continue to change. But that's a barrier in terms of access to care and your ability to reach out to somebody who's an addiction medicine specialist or PCP. It's not as easy as it is with other medical specialists. E-barriers are significant. And I can't emphasize how significant those are. A lot of dental E-record barriers do not have easy capacity to put in brief screeners for substance use risk. They often never cross-communicate the medical records like Epic and others. And sometimes they do, but often they don't. So the medical sort of E-record, dental records still are a barrier. And hopefully that's going to change over time with their structure and their ability to cross-communicate. If financial incentives, if you're a nurse practitioner, you could do a NIDA quick screen or a quick substance use assessment, and it may not seem like a lot, but the patient can get billed $15 or what have you. We've talked to some of the dental insurers. There may be room for changes in that. CE programs are another barrier. Even our state, many of our dentists have gone to medical CE programs. Ironically, one that was initially funded in terms of its development by Purdue Pharma. And these programs are good in many respects, but often targeted to primary care physicians and others, not dentists. So we still have a dearth of CE programs specifically for dentists. PDMP was discussed here in terms of use. And then we don't have limited resources, particularly in dental practices, although those you can develop, I reinforce the access to the SAMHSA website to help with those. So just a little bit of a shout out for some of our work that occurs through some nonprofit funding. So all of what I'm showing you is available without a fee because of some of that funding for the time, and we have a series of 10 really outstanding modules that I give you a little snippet of one of our actors. We go through a historic overview of dentistry, interviewing strategies, special screening resources in Houston NIDA, as well as other screeners. We also talk about acute dental pain, medical and psychiatric comorbidities, which is a significantly large topic because it predicts a poor outcome. Some of the content from the dental clinics book is available through this program as well. We look at managing the high-risk dental patient example that I just showed you in here, actually the patient who may overdose in your office. Michael Chapman reviews motivational interviewing strategies, which is his specialty specifically for dentistry. I spent a lot of time with the section we did with Dr. Hugh Thomas on interprofessional collaboration. That's a rough one because picking up the phone is not often that simple. It's complicated and time-wise there are challenges, but I think there is an increasing role for better interprofessional collaboration. We're doing some work with some others over at the Harvard Dental School, recently retired Dr. Donoff, who talks a lot about some better ways so we can approach this. High-risk populations are an issue. For example, Dr. McGee does a nice chapter on this, but we presented a paper on neonatal abstinence syndrome some six or seven years ago. One of the reviewers rejected it because he felt that neonatal abstinence syndrome has no relevance to dentistry. I would argue the number of patients that come through your office who are in childbearing years need to be addressed, particularly if they're on controlled substances. Finally, our chapter that I mentioned before, managing liability risks with Dr. Keith and a colleague who's from law. I mentioned that you have access to some of these articles from the clinic's book. I'll leave you with just this access to some of this information. It's really sort of hard to squeeze in what would be hours of clinical pearls and a lot of outcomes research into a short time. I hope this was helpful. My email is available here, easily accessible, and I really want to thank you. I know it's right now 10 minutes to an hour, and we'll have some questions, and I'll be delighted to discuss those further, any of these issues further. Thank you. Thank you so much, Dr. Kulich, for your presentation. So we're now in our Q&A session audience, and we've had a couple questions that come in, but if you haven't asked a question and you have one for Dr. Kulich, please type it in the Q&A on your screen. Would you mind providing the name of the SBIRT, I think, phone app that you mentioned, Dr. Kulich? Okay. The link for, so the NIDA quick screen is essentially a subpart of the SBIRT, S-B-I-R-T. And I can't give you the, the link is on this presentation. Will the presentation be posted? Yes, and it's been posted. It's been posted for everybody in the chat. Okay. So the link for the NIDA is on there, and it's been updated within the last year, and we have the updated link on there. If there's any barriers, you can send me an email, but I think, I think that will get you straight through it. The SBIRT is a more extensive training program that has NIDA and other things nested within it, and it's also very, very good. I just, I'm of the belief that the simplest things tend to get the best adherence. So that's why I've just kind of championed NIDA at this particular point in time. Okay. Great. Thank you. Here's another question. How do we have access to the PDMP records of our patients? Well, depending upon the state you're calling from, I don't know that any state does not automatically give you access if you're registered and you're writing, not necessarily just controlled substances. If you're writing antibiotics, you have access in most states. You may not choose to write opiates, but you should have access in your state. So you don't need the patient's permission with the PDMP, although it's nice to have a conversation with the patient if there's unexpected things in the PDMP. So you should have ready access to it. Each state has a registration system. And I, by the way, I think it's, virtually every state mandates it and includes dentistry as well. So I don't know if I answered your question, but. Okay. Thank you. More information is requested, Dr. Coolidge, on the modules. Is this series of modules and chapter trainings available to anyone? Or is there a way to get access to it? Yeah. So the link is on the end. I just put in the updated link. I'm going to trust that would work. And, because I tried it. And there are 10 modules. We're no longer testing them for outcome. We finished the testing, but the modules are up and available right now with the companion chapters. There are 10. And this was due to funding initially by Calvary's. And the outreach part was funded by the Rice Foundation in Massachusetts. But everybody's, those are accessible to everybody. You just have to register. It's a pretty easy process to the CE system. And it's, you know, at this point, they're all open access, you know, don't get charged for anything. We don't sell you anything. It's pretty straightforward. Thank you. It's pretty straightforward. Yeah. Thank you. And. It's a nice resource. No, we appreciate your sharing that wonderful body of work. It's a great series of resources for everybody. Here's another question, Dr. Coolidge. When we find that a patient is high risk for medications and we need to follow with a dental procedure, what should we do? Yeah, I think due diligence in terms of assessing the risk factors. Okay. So if it looks like the PDMP, the patient is on other concurrent meds, a call to the patient's provider, okay, if they're on, for example, if they're on Suboxone or they're on methadone or so on and so forth, is a necessary step. Having for high risk patients, that doesn't mean you don't go ahead and do your procedure. But again, as this person knows who called, it may be that many of the procedures really don't require opiates anyway. In fact, NSAIDs and other agents may work better than opiates. So that's one part of the path. But that shouldn't be the only answer. The answer should also be if you find a patient who is at high risk, the idea of having a discussion with the patient and making a referral. So I give you some wonderful examples of dentists who referred for substance use assessment, substance use risk assessment. Sometimes patients, sometimes dentists say, well, I'll just send the patient back to their primary care doc. I think that's not good enough because you can't assume that the patient has a relationship with the primary care doc, nor can you assume that the primary care doc is going to be necessarily responsible in terms of the patient's care. So in the same way that the dentist has no problem referring a complicated patient to a rheumatologist or a specialty surgeon or somebody else in a subspecialty, I think referral for substance use risk assessment is perfectly appropriate and within the scope of practice for a dentist. Even though there's some discomfort involved in that. It's not discomfort just on the part of the dentist. I've had orthopedic surgeons tell me before they do major surgical procedure on a patient that I'm never going to send this patient directly to the substance use person. I'll just send them to the pain clinic and let them handle it. Well, six months later, they're getting a dozen injections, often repeatedly, and nobody's addressed the risk factors that popped up. So I think the dentist is in a good position and often sees the patient at a higher frequency than some of their other providers. Often has a better relationship. If not the dentist, the dental hygienist often has a better relationship than many others in their healthcare scope. So. Thank you. And in the interest of time, I'm going to ask one more question. What do we do if we find a patient is diverting medication? Who do we contact? Okay. Well, if they're diverting your medication, okay, then you're perfectly within your rights to notify law enforcement. And we published one paper with a fellow by the name of Tommy Shannon in law enforcement. David Keith and I and Lieutenant Shannon published this paper together and talked about how to navigate this. But that's, diverting is an illegal, dangerous practice. And if it appears that the diversion is occurring through another provider, we recommend that you also contact the other provider when this is the case. So this can have tremendous impact on the patient's health, obviously. The impact on those that they're being diverted to. And there are medical legal issues in terms of if they're diverting your medications. So the answer is not necessarily just to stop writing medications if they're your medications, although that's one thing that likely should be done. The answer is to address it with the patient and also provide resources because this may be a patient with significant psychiatric and substance use disorder comorbidities. So it's a long answer. But. No, it's very helpful. Thank you so much, Dr. Kulich. And to all of you attendees for joining us on this webinar today. For additional wellness resources, please visit the ADA.org slash wellness page and PCSSNOW.org. This concludes today's program. Have a great afternoon and thank.

Dr. Ronald Kulich

substance use disorder risks

comprehensive risk assessment

prescription drug monitoring programs

NIDA quick screen

interprofessional collaboration

naloxone

modules and chapters

barriers to substance use risk assessment