Oral Health Group
Feature

Dental Management of Patients with a History of Substance Abuse with Special Consideration for Addicted Pregnant Women and Addicted Dental Care Providers


March 1, 2013
by Fahmida Hussain, BDS, DMD, MBE, FAGD, Robert W. Frare, DMD and Karen L. Py Berrios, DMD

The problem of substance abuse has emerged as a major issue in society and has become an area of major focus for healthcare professionals. According to the 2007 drug survey interview, the rate of current (past-month) illicit drug use among people aged 12 or older was 19.9 million, representing about 8.0% of the U.S. population.1. “With high rates of abuse of various types of substances among a diverse population, there is an urgent need for the investigation of the best practices for treating pain and improving pain-free care. It is also imperative to develop proper diagnosis and management protocols to reduce future abuse.” Substance abuse is often described as “self-administration of various drugs that deviate from medically or socially accepted use, which, if prolonged, can lead to the development of physical and psychological dependence.”2 “This disease process, often referred to as chemical dependency, is characterized by periodic or continuous impaired control over drug(s) acquisition, and distortions of mental capacity, most notably denial.”3

Various other definitions of substance abuse have also been proposed by professional organizations in the past. Those include:

• “Non-medical use of a drug,” [Drug Enforcement Administration (DEA)],

• “Non-medical use of a substance” [National Institute on Drug Abuse (NIDA)],

• “Non-medical use of a substance for psychic effect, dependence, or suicide attempt or gesture” [Substance Abuse and Mental Health Services Administration (SAMSHA)],

• “Any harmful use, irrespective of whether the behavior constitutes a ‘disorder’ in the DSM-IV diagnostic nomenclature [Institute of Medicine (IOM)],

• “A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by one or more of the following occurring within a 12-month period: recurrent substance use resulting in a failure to fulfill major obligation at work, school, or home; recurrent substance use in situations in which it is physically hazardous; recurrent substance-related legal problems; or continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.” [Diagnostic and Statistical Manual of Mental Disorders (fourth edition; DSM-IV, 1994) by the American Psychiatric Association].

THEORIES OF DRUG ADDICTION
There have been numerous theories proposed to describe the essential nature of drug addiction. It is important to realize that drug addiction is neither a weakness in character nor a moral issue.

Genetic and Biochemical Theories
Although substances of abuse are chemically divergent molecules with very different initial activities, the resultant addictions share many important features. Most addictive drugs directly or indirectly activate the brain’s reward system by markedly increasing the release of dopamine. Dopamine is a neurotransmitter regulating emotion, cognition, movement, motivation and pleasure. Overstimulation of the brain reward pathway with dopamine produces intense euphoric effects sought by most drug abusers. This pleasurable sensation is very reinforcing. The brain reward pathway is associated with several substances of abuse, including nicotine. There can be associated changes in behavior that reflect changes in neuron physiology and biochemistry.

Exaggerated response to lower levels of stimuli can lead to dependence in susceptible individuals. This has been shown to be true with the hypersensitivity of nicotinic acetylcholine receptors to nicotine. These individuals can develop tolerance and sensitization due to chronic exposure to nicotine. Usually, this kind of susceptibility plays a role in the transition from substance use to dependence and also from chronic use to addiction.4

The cholinergic muscarinic 2 receptor has been associated with the function of memory and cognition, but has also been shown to be related to alcohol dependence and major depressive syndrome. Researchers have identified specific alleles, genotypes, haplotypes, and diplotypes associated with risk for either dependence or affective disorders. Moreover, substance abuse has been documented within multiple generations of some families, indicating genetic predisposition.4 Figure 1 is the diagrammatic representation of the limbic circuitry with tentative localization of functions involved in drug addiction.5

Psychiatric co-morbid conditions
It has been suggested that some substance abusers typically exhibit pre-existing co-morbid traits such as novelty-seeking and antisocial behavior. Many of them choose the drug to self-medicate coinciding with the symptoms of the co-morbid psychiatric disorders.4

Exposure-related Theories
Researchers have suggested that exposure to a class of drugs that have the potential for abuse can sensitize the reward pathways in the brain to promote substance abuse. Such exposure alters the chemistry of the addicted brain, changing the relative levels of the neurotransmitters, such as γ-aminobutyric acid, dopamine and serotonin. “For example, Anesthesiologists can be affected due to occupational exposure and may continue to use the agents to alleviate the withdrawal symptoms they feel when away from the exposure.” Additionally, low doses of opiates that can induce sensitization are present and measurable in the exhaled breath of patients receiving them. However, some believe that the trace levels are not enough to cause chemical changes.4

ORAL MANIFESTATION OF SUBSTANCE ABUSE
Many of the abused substances have devastating consequences on oral health. Cocaine can result in movement disorder and manifest itself as transient chorea. Additionally, buccolingual dyskinesia, which is commonly known as ‘crack dancing’ or boca torcida (twisted mouth), can also be present. In the case of heroin abuse, increased numbers of decayed, missing, and filled teeth can be detected in the mouth. This can result from chronic malnutrition, poor oral hygiene due to impaired motor function and neuropathology secondary to infection, vasculitis, septic emboli, thromboembolism, prolonged heroin-induced respiratory depression, hypotension, positional vascular compression, acute Parkinsonism, and spongiform leukoencephalopathy. Marijuana abuse can lead to acidic erosion of enamel due to cannabinoid hyperemesis, in which frequent episodes of vomiting occurs. Additionally, these patients develop dental caries, inflammation and hyperplasia of gingival, uvulitis, leukoplakia, oral papillomas, and tongue carcinoma. The underlying pathology includes poor oral hygiene due to short-term and long-term debilitating psychological effects, xerostomia, alveolar bone loss, and carcinogens in marijuana. Increased incidence of HIV has also been reported. “Indirectly, marijuana use has been linked to HIV because the abusers adopt more risky and unprotected sexual practice.”On the other hand, the major psychoactive component in marijuana (the cannabinoids), including Δ9-tetrahydrocannabinol (THC) induce immunosuppression and increase HIV replication in severe combined immunodeficient mice implanted with human peripheral blood lymphocytes (huPBL-SCID mice), indicating a direct link between marijuana abuse and HIV infection.6 Several mechanisms have been described in chronic abuse of methamphetamine which leads to “Meth mouth” (Fig. 2), and characterized by large carious lesions in buccal smooth surface areas and fractured teeth.6,7 “Xerostomia occurs due to the stimulation of the a2 receptors, mild dysphoria, and prolonged sleep which leads to poor oral hygiene. Drug-induced craving for high-calorie carbonated beverages results in increased dental caries, bruxism, clenching and fracture of the comprom
ised dentition due to increased motor activity.” Lastly, vasoconstriction leads to periodontal breakdown.6 It is important to note that a significant level of osteoporosis has also been reported in a high percentage of methamphetamine abusers.8 Therefore, it is possible that such structural weakness can occur in the dentition as well.

CUTANEOUS MANIFESTATIONS OF SUBSTANCE ABUSE
In addition to a thorough history taking that follows all of the HIPAA (Health Insurance Portability and Accountability Act) Guidelines, it is necessary to look for any cutaneous manifestations in this group of individuals. Often patients may present with infection and cellulites of the area where the drug has been injected. Usually, the pathogens get introduced into the area due to unsterile supplies, licking of the needles, and use of saliva to moisten the skin and dilute the drug. Ulceration or necrosis of tissue can result from vasoconstriction, sclerosed veins and chronic venous insufficiency. Examples include delayed leg ulcers and nasal necrosis seen in cocaine abuse. Subcutaneous and intramuscular route of drug abuse can be favored by the abusers to hide track marks. This practice is often referred to as “skin popping” and can subsequently form sclerosed veins. The localized infections resulting from substance abuse often heal with characteristic irreversible scarring, called ‘pop scars.’ These can be well-circumscribed irregular round or oval area 0.5-3 cm in diameter, and can be hypopigmented or hyperpigmented, atrophic or hypertrophic scars or keloids.6 Excoriated papules and gangrene of extremities have also been reported with cocaine abuse.9,10 Impaired lymphatic drainage can also ensue and lead to puffy hand syndrome, a term, which is self-explanatory.6 These conditions have been illustrated in Figures 3a-c. We observed both pop scars and puffy hand syndrome in our 61-year-old completely edentulous female patient. Her well-circumscribed lesions measured between 3-18 mm in diameter. Each lesion was characterized by a central area of elevated scarring with depressed peripheries. The lesions were surrounded by hyperpigmented smooth skin. However, she did not report any itching, burning, or pain sensation in or around the lesions. She admitted to both cocaine and methamphetamine abuse and skin popping behavior.6 Substance abuse is often marked with significant behavioral clues. Patients often think that they have been infested with “Crank bugs.” This delusional parasitosis causes the individual to pick their own skin. As a result, sharply circumscribed chronic ulcerations that do not heal are hard to diagnose with cultures or biopsies. The patients may often present inorganic types of ‘fibers’ as evidence of infestation. This condition has been referred to as “Morgellons Disease.” Some of these individuals also demonstrate cutting of own wrists, arms and other body parts that constitute deliberate carving behavior.6

DENTAL MANAGEMENT OF DRUG ABUSERS
The management of drug abuse in patients can often become a daunting task. A study report published in 2002 identified four possible causes of mutual mistrust in the medical care of drug users. Firstly, the physicians are skeptical about the medical necessity of opiates to treat pain in the drug abusers. The abusers fear a deceiving practice on their part because the assessment of pain is mostly dependent on the documentation of the self-reporting. Secondly, there is no standard approach available to verify the actual need with precision. Thirdly, physicians felt uncomfortable in addressing the issues that they suspected were based on deception on the abusers’ part and are more uncertain in terms of assessment and intervention. Lastly, the drug abusers also feel mistreated. They perceive physician inconsistency and avoidance as signs of biased attitude. They viewed delayed care as intentional mistreatment. Unfortunately, the dental setting can prove to be the same if the dental care providers are not knowledgeable about the recommended protocols.11

Our edentulous patient was referred to the oral surgeon for the removal of the bilateral maxillary exostoses that she presented with since those would prevent the fabrication of a maxillary complete denture. Subsequently, a set of maxillary and mandibular complete dentures were fabricated to address her esthetic and functional needs. Patients like her, who need simple or extensive dental procedures, also require adequate pre- and/or post-operative pain management.

As a routine, patients associate the quality of dental care with the degree of effective pain management. Many dental situations call for prescribing over-the-counter non-narcotic analgesics. Non-steroidal Anti-inflammatory Drugs (NSAIDs) such as aspirin, ibuprofen, and naproxen are excellent because of the dual anti-inflammatory and analgesic effects. However, these increase bleeding tendency. Acetaminophen can be used for less intense pain. COX-2 inhibitors such as rofecoxib and celecoxib have been used for effective treatment of TMJ problems but are not without risks. Corticosteroids can be used in urgent cases to reduce inflammation and swelling, thereby preventing nerve damage, but have the potential to cause adrenal crisis and elevation of blood glucose level.6

It has been advised that prescribing acetaminophen for postoperative pain should be limited to less than 2.5 g daily in dental patients with a history of drug and alcohol abuse with compromised hepatic function. The recent reduction of the recommended daily maximum dose of Acetaminophen for healthy individuals by its maker might also indicate the need for a revision of this regimen.6

However, the degree of severity of a condition may necessitate the selection of a stronger and effective opioid analgesic. Therefore, certain formulations like fentanyl can be delivered transdermally to ensure gradual onset, minimize the need for frequent self-administration, and reduce abuse potential. Oxycontin offers a sustained-delivery mechanism through dual delivery mechanism, which is characterized by an enhanced immediate release phase followed by sustained delivery to prolong the duration of action. A combination of an opioid pain reliever and an opioid antagonist such as naloxone, naltrexone, or nalmefene could also reduce abuse potential. However, ‘experienced’ drug users can still find ways to manipulate the abuse potential. Combining analgesics with different modes of action such as an opioid and acetaminophen could provide greater analgesic efficacy than therapy utilizing a single agent. Combining ibuprofen and acetaminophen can be as effective for some moderate to severe pain control. Interestingly, health care professionals can also suffer from “opiophobia” and remain reluctant to prescribe, administer, dispense, or stock opioid drugs. Dental care providers must be knowledgeable about the pharmacological effects, duration of action, and half-life of the opioids in order to prescribe the correct medication for effective pain management. Various behavioral management techniques such as Contingency management can also be utilized with delivery of vouchers contingent upon naltrexone compliance, drug-free urine specimens. Involving a significant other has been also shown to increase compliance and utilization of available pharmacotherapies.6

Local anesthetics with vasoconstrictors can increase cardiovascular risks such as lethal cardiac arrhythmias and cerebral hemorrhage in substance abusers. Cocaine abusers experience convulsions with the use of Lidocaine. Intrapocket application of gingival retraction cord and Oraqix, a combination of lidocaine/prilocaine gel can also increase the risks due to the absorption of significant amount of vasoconstrictors. On some occasions, peripheral nerve stimulator can be as effective as 2% lidocaine with 1:100,000 epinephrine and can further reduce cardiovascular risks. Nonetheless, it is advisable to consult with a patient&rs
quo;s physician or abuse specialist to outline a treatment plan that allows for conscious sedation for major dental procedures.6

The course of action for dental management also depends on the extent of the renal insufficiency. The presence of an arteriovenous shunt in a hemodialysis patient warrants antibiotic prophylaxis. NSAIDs can prove to be nephrotoxic. Therefore, those should be avoided in patients with renal insufficiency, but can be used if the patient is already in an end-stage renal disease with no residual renal function. Similar protocol has been proposed with the use of narcotics in substance abusers with renal insufficiency. Regardless, narcotics with prolonged duration of action should be avoided. However, active metabolites of meperidine can accumulate in renal patients to cause seizures and should be avoided. In patients with renal insufficiency, no specific adjustments for the dosage are required with the use of local anesthetics, but the amount of vasoconstrictor should be minimized because of hypertension secondary to renal disease.6

There are evidence-based studies that confirm the occurrence of hepatitis C in substance abusers. Many drug abusers can also be alcoholics with hepatic impairment. The resulting compromise in the hepatic function requires extra caution with the use of amide-type anesthetics like lidocaine and prilocaine, both of which are metabolized in the liver. Moreover, esters are biotransformed by plasma cholinesterase (also known as pseudocholinesterase). This is an enzyme that is also synthesized by the liver. Therefore, the use of the ester type of anesthetic does not provide additional benefits in patients with hepatic failure. Hepatic insufficiency does not affect the duration of action of local anesthetics. Therefore, these patients require the standard amount of local anesthetic for each treated site. It is still advisable to treat only one quadrant at a time to minimize the total dose.6

Use of long-acting local anesthetics in oral surgery and endodontic procedures should be considered for this group of patients to reduce the overall amount of anesthetics. Long-acting anesthetics like 0.5% bupivacaine with 1:200,000 epinephrine could delay the onset, and reduce the intensity of postoperative pain, though bupivacaine has also been shown to cause severe toxicity, including cardiovascular arrest. Levobupivacaine and ropivacaine have been deemed to be safer alternatives for long-acting anesthetics.6

Drug abusers can present for dental care at any stage of abuse. Comprehensive oral hygiene regimen must include dental prophylaxis and oral hygiene instruction consistently every three to six months for partially edentulous patients. Regular neutral fluoride is recommended instead of the acidulated ones to prevent further damage to the already compromised dentition. The patients need to be educated about the harmful effects of drug abuse on oral and overall health. Sialogogues such as pilocarpine hydrochloride and cevimeline hydrochloride, sugarless gum or oral moisturizers can be prescribed to address the problems with xerostomia. Saliva substitutes may not be as effective.6

Mouth rinses containing alcohol should be avoided in patients with drug abuse who also have fungal infections. This may also be true for severe xerostomia. Topical application of hydrocortisone and iodoquinol or nystatin and triamcinolone cream can be recommended. Severe fungal infection can be treated with fluconazole instead of ketoconazole, which can be hepatotoxic.12

PREGNANT WOMEN AND HEALTH CARE PROVIDERS AS ABUSERS
The fact that pregnant women and health care providers who are also substance abusers can seek dental care is often overlooked. Substance use by pregnant women is a leading preventable cause of mental, physical, and psychological problems in infants and children. In 2002 and 2003, 4.3 percent of pregnant women aged 15 to 44 used illicit drugs during the past month, 4.1 percent reported binge alcohol use, and 18.0 percent reported smoking cigarettes. It has also been noted that pregnant women aged 15 to 25 were more likely to use illicit drugs and smoke cigarettes during the past month than pregnant women aged 26 to 44.13 Nearly 16 percent of pregnant women aged 15 to 17 used alcohol in the past month, and they consumed an average of 24 drinks in the past month (i.e., they drank on an average of 6 days during the past month and had an average of about four drinks on the days that they drank).14 Combined data from 2004 to 2006 indicate that an annual average of 6.3 million women aged 18 to 49 (9.4 percent) needed treatment for a substance use problem. Research suggests that most people who have a substance use problem do not receive treatment. In 2006, 7.4 million women aged 18 or older needed treatment for a substance abuse disorder involving alcohol or illicit drugs, but only 822,000 (11.2 percent) received treatment. This report focuses on substance use treatment among women of childrearing age (18 to 49), for whom substance use may pose particular risks to vulnerable offspring.15

Regardless of the drug(s) ingested or the clinical symptoms, it is very hard to predict the anesthetic implications in the drug abusers. It is also true for both regional and general anesthesia administered to the parturient. Alcohol and other substances taken by pregnant women can harm the mother and the unborn baby. Occasionally, emergency situations may arise where the dentists will have to perform major surgical procedures on the expecting mothers who also have a known or concealed substance abuse history. Accidents and other trauma cases may require emergency maxillofacial surgical procedures on a pregnant patient who can also be an active substance abuser. In those cases, administering regional or even general anesthesia may become imperative. Unfortunately, the administration of local, regional or general anesthesia can have major health consequences.

Healthcare professionals too can become addicted to the drugs that they frequently handle during their job responsibilities. Various mechanisms can play a role as have been described under the possible theories of drug addiction. Alcoholism and other forms of substance abuse can affect between 10 to 15 percent of dentists and need assistance from their peers to overcome the problem.16 There are many telltale signs that can be observed in a healthcare professional who abuses drugs. Those are summarized below:17,18

• Most striking sign can be withdrawal from family, friends and leisure activities. Instead more time can be spent at work, where drugs can be easily available.

• Often these practitioners will volunteer for extra calls or shifts and show up for work during off hours.

• Mood swings can include episodes of depression, euphoria, anger, irritability, hostility and can mimic split personality.

• They can also refuse to take lunch or coffee breaks to stay behind or take frequent restroom breaks in order to find an isolated environment to procure or administer the drug.

• When on call, these providers can be hard to reach on pager, or cannot function. They fail to respond to emergencies when on night call.

• These providers can sign out way more than normal amount of narcotics for any given case so that the excess amount can be utilized for self-administration.

• For the same reason there can be unexplained increase in the amount of “ampoule breakage” or “waste.”

• Weight loss and pale skin due to failure to maintain a healthy lifestyle.

• They can also dress up in a manner such as clothes with long sleeves, so that they can hide physical evidence of drug abuse.

The situation usually gets a little tricky when a health care professional becomes addicted to restricted substances. It becomes problematic to confront one of the colleagues based on suspicion. Legal implications cannot be discounted either. On one hand, it is ethically responsible to address the p
roblem. On the other hand, it can be a challenge to report a colleague or a superior. Nonetheless, the intervention has to be initiated sooner than later. On many occasions, the abuser can be in denial or simply employing deception. Then it becomes the obligation of the peers to intervene. There are a few guidelines that can be followed while intervention is offered to an addicted healthcare professional. Those have been listed below:4,17-19

• Colleagues need to talk to the impaired dentist and advise him to seek help. Such discussion has to be done in a private setting. However, it is advisable to have other trusted individuals in the room as witness.

• Reporting a colleague or superior can produce rifts between the parties. Therefore, the Chief Executive of the company or practice can be notified to handle the situation, if it is an inconvenience to confront a friend, colleague, or a senior dentist.

• The Americans with Disabilities Act, enacted in 1992, offers some protection to the addicted health care provider. However, that applies more to the individuals who are addicted to alcohol and does not protect the individuals addicted to other substances of abuse.

• A trained interventionist must be made available during the sessions at all time.

• Intervention must always be done in a larger group. The addicted individual will not feel singled out. At the same time, the treatment outcome may turn out to be favorable if the group includes supportive individuals such as the spouse, family members, friends and colleagues.

• Special attention has to be paid to the gender of the addicted provider. An intervention group consisting of all male members may not be welcome by a female individual.

• All evidence has to be brought to the discussion. Otherwise, the encounter may turn out to be of an accusatory nature rather than one that is aimed at helping the individual. Usually, employers can perform random drug screenings to run an effective monitoring program. Due process is paramount in obtaining specimen and conducting the tests. The cost of initial drug screening is usually borne by the employer or hospital or department or the practice. However, a recovering addict is often required to bear the cost for future tests. In 2008, the cost for one urine test with a fentanyl assay in a New York laboratory was $32.50; but the cost increased dramatically to $290 for a propofol assay and crossed $1000 for analysis of each hair sample.

a) Specimen collection has to be truly random and unpredictable,

b) Micturation must be witnessed,

c) Each urine specimen should be split; half tested and half frozen. The first half of the specimen is tested with radioimmunoassay (RIA) which only rules out drug use.

d) Any positive result must be confirmed with gas chromatographic-mass spectrometry (GC/MS). Hair analysis can also be done with this technique.

e) Other specific requests must be made based on the need. For example, specific requests have to be made for the assay of phenylpiperidines or fentanyl analog use, reentry on naltrexone, use of propofol.

• Do not let the individual leave alone or drive, as he or she can be impaired or can get suicidal.

• Arrangements need to be made for direct transfer to an outpatient facility prior to the intervention.

• The addict is not to be allowed to dictate the treatment. This may include the exact nature of the treatment or the time for initiation of the process. An impaired person is not capable of making a sound judgment.

• If all attempts fail to convince the addict to seek help, the person handling the session should threaten to call the police as a last resort.

• The dentist’s impairment or abuse history should not be revealed to the patient at any point. As an individual the impaired dentist also has the right to privacy. Disclosing such delicate information can be considered a violation of privacy and defamation.

• It is not unusual for an addicted dentist to seek help, overcome the condition and resume normal duties. However, in many instances, a dentist’s career can be jeopardized forever because of the rumors that surface because of the failure in following proper protocols. That can become a huge legal liability for the persons involved in the mismanagement.

• It is also mandatory to report the colleague to the ‘professional assistance or chemical dependency committee of the appropriate dental society.’ This is because your duty does not end until you have made sure that the individual has sought professional help. However, individual state laws and the availability of the ‘dental society-sponsored programs’ must be explored before taking that action. If such programs do not exist, then at the least, you can notify his / her physician.

It may be advisable to refer the individual to a specialist in occasions where following all of these guidelines may not be possible. An individual who becomes suicidal or may be too aggressive and may cause harm to others should not be managed on premises.

RECENT RESEARCH INITIATIVES AND TRACKING SYSTEM
Many approaches have been introduced in recent years in an effort to combat the current trend of increasing substance abuse. More research initiatives and tracking systems have been in place on top of educating the health care professionals. For example, human psychopharmacology is being used as an essential tool to monitor the individuals that have a history of drug abuse. SPECT (single photon emission computed tomography) and PET (position emission tomography) have been used for better understanding of the pharmacokinetics and pharmacodynamics of abused drugs. These technologies have been used to study drug mechanisms, drug interactions (e.g., cocaine and alcohol), their acute effects, such as euphoria and craving of drugs on active drug abusers.20

Complex genetic and environmental factors make certain individuals vulnerable to drug and alcohol addiction. The identification of these “addiction genes” is a difficult task because of the variance in the genetic component. In order to make the research endeavor more effective, affordable and widely available, the researchers have recently turned to the invertebrate models systems, namely Drosophila melanogaster and Caenorhabditis elegnas. Researchers hope to identify the mechanisms by which abused substances such as ethanol, cocaine, and nicotine modulate behavior. The research on these flies and worms with sophisticated genetics yet simple anatomy can provide useful insight applicable in the clinical setting because of the remarkable similarity to mammals.21

The Food and Drug Administration (FDA) has set up its own tracking systems to monitor the sales of substances from Manufacturers to Channels of Distribution. Usually the outlets monitored within the retail market include the settings such as chain drug stores, independent drug stores, mass merchandisers, food stores, and mail service. Tracked outlets within the non-retail market include clinics, non-federal hospitals, federal facilities, HMOs, long-term care facilities, home health care, and other miscellaneous settings. The various drug use databases operated by FDA include:22

• IMS Health, IMS National Sales Perspectives™ that measures the volume of drug products, both prescription and over-the-counter, and selected diagnostic products moving from manufacturers into various outlets within the retail and non-retail markets. Volume is expressed among other things in terms of sales dollars, extended units, and share of market.

• IMS Vector One® National (VONA) measures retail dispensing of prescriptions or the frequency with which drugs move out of an estimated 59,000 retail pharmacies throughout the US into the hands of consumers via formal prescriptions. Information on the physician specialty, the patients’ age and gender, and estimates for the numbers of patients
that are continuing or new to the therapy are available. This database integrates prescription activity from a sample received from payers, switches, and other software systems that may arbitrage prescriptions at various points in the sales cycle.

• IMS Vector One® Total Patient Tracker (TPT). It is a national-level projected audit designed to estimate the total number of unique patients across all drugs and therapeutic classes in the retail outpatient setting over time. Vector One® (both VONA and TPT combined) receives over 1.4 billion prescription claims per year, representing over 120 million unique patients.

• Source Healthcare Analytics’ ProMetis Lx® is a longitudinal patient data source which captures adjudicated prescription claims across the United States across all payment types, including commercial plans, Medicare Part D, cash, assistance programs, and Medicaid. The database is linked to approximately 4.8 billion prescription claims linked to over 190 million unique prescription patients with the duration of therapy, the treating physician or facility and definitive diagnosis linked to each. The overall sample represents nearly 30,000 pharmacies, 1,000 hospitals, 800 outpatient facilities, and 80,000 physician practices.

• Encuity Research, LLC, Physician Drug & Diagnosis Audit (PDDA) with Pain Panel is a monthly survey designed to provide descriptive information on the patterns and treatment of diseases encountered in office-based physician practices in the US. The survey consists of data collected from over 3,200 office-based physicians representing 30 specialties across the US that report on all patient activity during one typical workday per month. The term “drug uses” is referred to a drug in association with a diagnosis during an office-based patient visit. This term may be duplicated by the number of diagnosis for which the drug is mentioned.

Unfortunately, in the past, evidence-based structured review indicated that chronic opioid analgesic therapy (COAT) exposure leads to abuse / addiction in a small percentage of chronic pain patients (CPPs), but a larger percentage will demonstrate aberrant drug-related behaviors (ADRBs) and illicit drug use. These percentages appear to be much less if CPPs are preselected for the absence of a current or past history of alcohol / illicit drug use or abuse / addiction.23

When the FDA database information is utilized, it can be observed that approximately 64,000 kilograms of combination hydrocodone-containing products were sold during the year 2011 accounting for a 28% increase from 50,000 kilograms sold during year 200722 (Fig. 4).

On top of the measures to detect and track substance abuse history, the American Dental Association (ADA) has a proposed guideline on the provision of dental treatment for patients with substance use disorders. It advises dentists to take into consideration a patient’s abuse history for thorough treatment planning. All dental providers need up-to-date knowledge about substance abuse disorders, must use professional judgment while making recommendations to the alcohol and substance abusers, and seek professional consultation, as needed. It is up to the practitioner to get familiar with the resources available to effectively render care and handle emergencies for this group of patients. All dentists are advised to take special precaution while prescribing medications and administering anesthetics with epinephrine for substance users that are both active and in remission. Lastly, all interactions and handling of information must be done with absolute protection of patient privacy, with particular attention paid to the federal and respective state laws.24

CONCLUSION
Despite increased awareness about the disease of addiction the number of patients with a history of substance abuse has been consistently increasing. All dental care providers can expect to see a steady number of substance abusing patients throughout the year. Dental patients usually consider effective pain management as a measure of quality care. Substance abusing patients are no exception. However, extra caution has to be taken to minimize drug interactions, and adverse effects while achieving this goal. Widespread education is needed to prepare our community to handle the demands. Awareness among the care providers has to be continual to ensure a sound foundation of knowledge on the topic.OH

Dr. Hussain is an adjunct clinical assistant professor, Department of Dental Public Health Sciences, Temple University Kornberg School of Dentistry, Philadelphia, PA, where Drs. Frare and Py Berrios are adjunct clinical instructors. Dr. Hussain is also a practicing general dentist and the dental coordinator, Quality Community Health Care, Inc., Philadelphia, where Drs. Frare and Py Berrios are practicing dentists. Additionally, Drs. Frare and Py Berrios maintain private practices in Voorhees, NJ and Philadelphia, respectively. Corresponding author: Fahmida Hussain, Email: fhussain@qchc.org

Oral Health welcomes this original article. References available upon request. See the article at: oralhealthgroup.com