The ADA Practical Guide to Substance Use Disorders and Safe Prescribing E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: ADA Practical Guide
• Sprache: Englisch

Seitenzahl: 490

Veröffentlichungsjahr: 2015

Beschreibung

Dentists have been inundated by patients with an array of complicated medical conditions and pain/sedation management issues. This is in addition to a variety of legal regulations dentists must follow regarding the storage and recordkeeping of controlled substances. Avoid unknowingly putting your practice at risk by becoming victim to a scam or violating a recordkeeping requirement with The ADA Practical Guide to Substance Use Disorders and Safe Prescribing. This Practical Guide is ideal for dentists and staff as they navigate: * Detecting and deterring substance use disorders (SUD) and drug diversion in the dental office (drug-seeking patients) * Prescribing complexities * Treating patients with SUD and complex analgesic and sedation (pain/sedation management) needs and the best use of sedation anxiety medication * Interviewing and counselling options for SUD * Federal drug regulations Commonly used illicit, prescription, and over-the-counter drugs, as well as alcohol and tobacco, are also covered. Special features include: * Clinical tools proven to aid in the identification, interviewing, intervention, referral and treatment of SUD * Basic elements of SUD, acute pain/sedation management, and drug diversion * Summary of evidence-based literature that supports what, when and how to prescribe controlled substances to patients with SUD * Discussion of key federal controlled substance regulations that frequently impact dental practitioners * Checklists to help prevent drug diversion in dental practices * Chapter on impaired dental professionals * Case studies that examine safe prescribing and due diligence

Leseprobe

Andrew Taylor O'Neil (September 2, 1991–September 9, 2014)

This book is dedicated to Andrew – high-school valedictorian, Eagle Scout with highest honors, naturalist, intellectual, humorist, friend and teacher to all, brother, and most importantly an amazing, caring, giving, and loving son. No parent could ever be more proud of a son than I am of you. You are forever in the hearts of all that ever met you.

Dad

The ADA Practical Guide to Substance Use Disorders and Safe Prescribing

Edited by

Michael O'Neil, PharmD

Professor and Vice-Chair, Department of Pharmacy Practice Drug Diversion, Substance Abuse, Pain Management Consultant South College School of Pharmacy Knoxville, TN, USA

Copyright © 2015 by American Dental Association. All rights reserved

Published by John Wiley & Sons, Inc., Hoboken, New Jersey Published simultaneously in Canada

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Library of Congress Cataloging-in-Publication Data

The ADA practical guide to substance use disorders and safe prescribing / edited by Michael O'Neil.       p. ; cm.    Practical guide to substance use disorders and safe prescribing    American Dental Association practical guide to substance use disorders and safe prescribing    Includes bibliographical references and index.    Summary: “This is in addition to a variety of legal regulations dentists must follow regarding the storage and record keeping of controlled substances”—Provided by publisher.    ISBN 978-1-118-88601-4 (paperback)    I. O'Neil, Michael (Pharmacist), editor.   II. American Dental Association, issuing body.   III. Title: Practical guide to substance use disorders and safe prescribing.   IV. Title: American Dental Association practical guide to substance use disorders and safe prescribing.    [DNLM: 1. Dental Care–United States.   2. Substance-Related Disorders–United States.   3. Dental Offices–organization & administration–United States.   4. Dentist-Patient Relations–United States. 5. Drug Prescriptions–standards–United States.   6. Drug and Narcotic Control–United States. WM 270]    RK701    617.6061–dc23

2015006921

Cover images (clockwise from top middle): © iStockphoto/JurgaR; © iStockphoto/mphillips007; © iStockphoto/KarenMower; © iStockphoto/Bunyos; © Stephen Wagner, used with permission

Contents

Contributors

Preface

Acknowledgments

1 Substance Use Disorders, Drug Diversion, and Pain Management: The Scope of the Problem

Introduction

Definitions

Substance Use Disorder, Drug Misuse, Drug Diversion, and Pain Management in the Dental Community

Understanding the Cultures of Substance Use Disorder, Drug Misuse, and Drug Diversion

Summary

References

2 Understanding the Disease of Substance Use Disorders

Introduction

Definitions

Epidemiology: Drug/Alcohol

Pathophysiology/Brain Pathways

Signs, Symptoms, Behavior

Treatment Methods

Summary

Appendix 2.A: Common Opioid Analgesics and their Brand Names

References

Resources and Further Readings

3 Principles of Pain Management in Dentistry

Introduction

Definitions

Neurophysiology and Neuroanatomy of Acute Inflammatory Pain

Orally Administered Analgesic Agents

Medication-Assisted Therapies for Treating Drug-Dependent Patients

Adjunctive Drugs Used to Limit Pain in Dentistry

Guidelines for Analgesic Therapy

Summary

References

Resources and Further Readings

4 Special Pain Management Considerations: (1) Chronic Methadone, Buprenorphine, and Naltrexone Therapy; (2) Chronic Opioids for Nonmalignant Pain

Introduction

Definitions

Interviewing the Patient: Establishing Goals of Treatment

Pharmacological Treatment of Opioid Addiction

Treating Acute Dental Pain

Acute Pain in Patients Receiving Opioid Maintenance Therapy

The Active Opioid Addict

Acute Pain Management in Patients Receiving Naltrexone Therapy

Acute Pain Management in Patients Receiving Opioids for Chronic Pain

Summary

References

5 Sedation and Anxiolysis

Introduction

Definitions

Spectrum of Anesthesia and Sedation

Preoperative Evaluation

Physical Status Classification

Sedation

Medications Available for Sedation of Patients with Substance Use Disorder

The Concept of Balanced Anesthesia

Monitoring and Documentation

Summary

Disclaimer

References

Resources and Further Readings

6 Common Substances and Medications of Abuse

Introduction

Definitions

Signs and Symptoms of Substance Use Disorder

Common Substances of Abuse

Prescription Medications

Over-the-Counter Medications

Summary

References

Resources and Further Readings

7 Tobacco Cessation: Behavioral and Pharmacological Considerations

Introduction

Definitions

Forms of Tobacco

Oral Effects of Tobacco Use

Dental Practitioner Management of Tobacco Use

Spit Tobacco Interventions

Oral Substitutes

Social Support/Disapproval

Medication Management for Smoking Cessation

The Role of Nicotine

Pharmacotherapy Options

Summary

References

Resources and Further Readings

8 Detection and Deterrence of Substance Use Disorders and Drug Diversion in Dental Practice

Introduction

Definitions

Screening Patients for Substance Use Disorder

Schemes and Scams to Obtain Prescription Drugs

Dental Practitioner- and Office Personnel-Related Prescription Drug Diversion

Prescription Drug Monitoring Programs

Disposal of Controlled Substances

Universal Precautions in Prescribing Controlled Substances

Summary

References

Resources and Further Readings

9 Interviewing and Counseling Patients with Known or Suspected Substance Use Disorders: Dealing with Drug-seeking Patients

Introduction

Definitions

Preinterview Considerations

Patient Interview Considerations

Interviewing and Counseling Techniques

What Questions Should Be Asked?

Screening Tools

Documentation

Summary

References

Resources and Further Readings

10 Office Management of Controlled Substances

Introduction

Federal Statutes and Regulations

Definitions

Common Violations by Dental Practitioners

Surviving a Drug Enforcement Administration Inspection

Practice Due Diligence Program

Management of Noncontrolled Substances in the Office

Summary

Resources and Further Readings

11 Addiction and Impairment in the Dental Professional

Introduction

Definitions

The Complexity of Addiction

The Neurobiology of Addiction

The Stigma of Addiction

Epidemiology of Addiction in Dentistry

Risk Factors for Substance Use Disorder

Substances of Choice

Identifying Addiction

“The Conspiracy of Silence”

Intervention

Evaluation/Assessment

Treatment

Family and Staff

Relapse

Monitoring

Peer Assistance or Dental Well-being Committee Programs

Summary

References

Resources and Further Readings

12 Due Diligence and Safe Prescribing

Introduction

Definitions

Case Scenarios

Summary

References

The ADA Practical Guide to Substance Use Disorders and Safe Prescribing

Continuing Education Examination

Index

EULA

List of Tables

Chapter 2

Table 2.1

Table 2.2

Table 2.3

Table 2.4

Chapter 3

Table 3.1

Table 3.2

Table 3.3

Table 3.4

Table 3.5

Table 3.6

Chapter 5

Table 5.1

Table 5.2

Table 5.3

Table 5.4

Chapter 6

Table 6.1

Table 6.2

Table 6.3

Table 6.4

Table 6.5

Table 6.6

Table 6.7

Table 6.8

Table 6.9

Table 6.10

Table 6.11

Table 6.12

Table 6.13

Table 6.14

Table 6.15

Chapter 7

Table 7.1

Table 7.2

Table 7.3

Chapter 9

Table 9.1

Chapter 11

Table 11.1

Chapter 12

Table 12.1

Guide

Cover

Table of Contents

Preface

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Contributors

Carlos M. AquinoDEA Compliance Consultant Milford, MA, USA Retired Police Department Officer Retired Drug Enforcement Agent, DEA

James H. Berry, DOAddiction Psychiatrist Medical Director – Chestnut Ridge Center Inpatient Services Assistant Professor – Department of Behavioral Medicine and Psychiatry West Virginia University Morgantown, WV, USA

Matthew Cooke, DDS, MD, MPHAssistant Professor Departments of Dental Anesthesiology & Pediatric Dentistry University of Pittsburgh School of Dental Medicine Pittsburgh, PA, USA and Departments of Oral & Maxillofacial Surgery & Pediatric Dentistry Virginia Commonwealth University School of Dentistry Richmond, VA, USA

Amanda Eades, PharmDAssistant Professor/Clinical Pharmacist University of Illinois at Chicago Chicago, IL, USA

Elliot V. Hersh, DMD, MS, PhDProfessor Pharmacology Director – Division of Pharmacology and Therapeutics University of Pennsylvania School of Dental Medicine Philadelphia, PA, USA

William T. Kane, DDS, MBA, FAGD, FACDGeneral Dentistry Dexter, MI, USA

William J. MaloneyClinical Associate Professor Department of Cariology and Comprehensive Care New York University College of Dentistry New York, NY, USA

Sarah T. Melton, PharmD, BCPP, BCACP, CGP, FASCPAssociate Professor of Pharmacy Practice Gatton College of Pharmacy at ETSU Johnson City, TN, USA

Paul A. Moore, DMD, PhD, MPHProfessor – Pharmacology and Dental Public Health University of Pittsburgh School of Dental Medicine Pittsburgh, PA, USA

Michael O'Neil, PharmDProfessor and Vice-Chair Department of Pharmacy Practice South College School of Pharmacy Knoxville, TN, USA

Ralph A. OrrDirector Virginia's Prescription Monitoring Program Henrico, VA, USA

George F. Raymond, DDSClinical Instructor Department of Cariology and Comprehensive Care New York University College of Dentistry New York, NY, USA

Carl Rollynn Sullivan, MDProfessor and Vice-Chairman Director, Addictions Programs WVU School of Medicine Department of Behavioral Medicine & Psychiatry Morgantown, WV, USA

Frank Vitale, MANational Director Pharmacy Partnership for Tobacco Cessation Pittsburgh, PA, USA

Preface

Health-care practitioners have become inundated by an array of patients with multiple medical conditions that are further complicated by pain/sedation management issues, substance use disorders (SUDs), and worries of drug diversion. Pain management, whether for acute or chronic pain, has become a primary concern for dental practitioners. Practitioners often feel pressured by patient survey results and patients to “overprescribe” controlled substances. With the rise in opioid addiction there has been a significant increase in medication-assisted treatment, including use of methadone and buprenorphine products. These agents have proven efficacy in both the treatment of opioid addiction and pain. However, evidence-based studies evaluating treatment of patients with concurrent opioid addiction and acute or chronic pain are lacking. Opioid or alcohol addiction treatment medications, such as naltrexone, have complicated opioid analgesia in many patients.

The plethora of substances being abused in society today includes household products such as paints and “cleaners” to combinations of heroin, cocaine, and other medicinal agents. Public health risks of medication misuse and substance abuse have reached epidemic proportions. When patients present to the dental practitioner with a history of SUD or recent substance abuse, routine procedures are no longer routine. Dental practitioners treating patients under the influence of substances may put both the patients and themselves at unnecessary risk of complications. Use of routine local anesthetics, such as lidocaine with epinephrine, now has the potential to put the methamphetamine addict in a life-compromising situation. Data supporting definitive management of patients with acute pain and SUD are limited. Recognizing patients with SUD, intervening, and directing them to appropriate treatment require time and expertise.

All dental office staff must now look for drug diversion behaviors on a daily basis. Unknowingly, dental practitioners may become victims of various scams and schemes. Recognition, prevention, deterrence, detection, and reporting of potential criminal behaviors interrupt the daily work flow for many dental practices. Prescription drug fraud and “Dr Shopping” are only two of the many diversion activities dental practitioners must address. A significant rise in prescription fraud has created an environment of fear and frustrations for prescribers, patients, law enforcement agencies, and local communities.

Dental practitioners must be fully prepared to manage a variety of patients with complex analgesic/sedation needs and SUD and, at the same time, protect themselves and their staff from drug diversion activities.

The purpose of this book is multifactorial:

Review basic elements of SUD, acute pain/sedation management, and drug diversion.

Provide clinical tools proven to aid in the identification, interviewing, intervention, referral, and treatment of SUD.

Summarize evidence-based literature that supports what, when, and how to prescribe controlled substances to patients with SUD (e.g., analgesia, sedation).

Discuss key federal controlled-substance regulations that frequently impact dental practitioners.

Provide checklists that will help prevent drug diversion in dental practices.

In completing this challenge, dental practitioners will be better prepared to care for patients, protect the community, and safeguard their own practices.

Michael O'Neil

Acknowledgments

I am forever indebted to the chapter authors of this book. Their work, patience, and commitment to excellence are nothing less than exceptional. Managing patients in an environment of increasing frequency of substance use disorders, drug diversion, and pain is often an overwhelming endeavor. The expertise offered by the chapters is practical and evidence based and will guide dental practitioners in their day-to-day practices. I wish to acknowledge the American Dental Association (ADA) staff editors of this book for their excellent and timely work. These include Amy Lund, Senior Editor, Kathryn Pulkrabek, Manager/Editor Professional Products, Alison Siwek, Manager, Dentist Health and Wellness, and Carolyn Tatar, Senior Manager of Product Development and Management. I wish to thank Carolyn Tatar for her direction in this project.

I would also like to thank the Wiley publishing team of Rick Blanchette, Nancy Turner, and Jennifer Seward for their due diligence and commitments to making this book a success.

I am indebted to Alison Siwek for her insights and perspectives regarding the many concerns of dental practitioners working with the ADA. The authors and I would like to thank the ADA leadership for their recognition of the need to create this book to educate their members.

Michael O'Neil

1Substance Use Disorders, Drug Diversion, and Pain Management: The Scope of the Problem

Michael O'Neil, PHARMD

Introduction

The practice of dentistry has become increasingly complicated by multiple factors, including increasing numbers of patients with substance use disorder (SUD), patients receiving chronic pain medications, and prescription drug-related crime (see Box 1.1). In January 2012, the Centers for Disease Control (CDC) announced that the USA is experiencing an epidemic of prescription drug-related overdoses with the majority of these involving prescription opioids.1 Findings from the 2011 National Health and Aging Trends Study reported bothersome pain afflicts half of the community-dwelling US older adult population and is associated with significant reduction in physical function, particularly in those with multisite pain.2 National Survey on Drug Use and Health (NSDUH) 2012 data indicate that 6.8 million people aged 12 or older are current nonmedical users of psychotherapeutic drugs and that 4.9 million of these were users of pain relievers.3 The NSDUH 2012 data also indicate that the rate of current illicit drug (e.g., cocaine, marijuana, inhalants) use among persons aged 12 or older was 9.2%. In 2012, the NSDUH survey revealed an estimated 22.2 million persons aged 12 or older were classified as having an SUD in the past year (8.5% of the population aged 12 or older). Other results from this survey are include 2.8 million people were classified as having an SUD of both alcohol and illicit drugs, 4.5 million had an SUD associated with illicit drugs but not alcohol, and 14.9 million an SUD associated with alcohol but not illicit drugs. Overall, 17.7 million had an SUD associated with alcohol and 7.3 million had an SUD associated with illicit drugs.3

Box 1.1 Factors Complicating the Practice of General Dentistry

Chronic pain management.

Misuse of prescription medication.

SUD associated with prescription medications.

SUD associated with illicit substances.

SUD associated with alcohol.

Psychiatric disorders (diagnosed and undiagnosed).

Opioid maintenance treatment programs (methadone, buprenorphine).

Aging population.

Polypharmacy (use of multiple medications to treat the same condition).

Patient criminal activity.

The extent of the overlap of pain management, SUD, prescription drug misuse, and drug diversion in the same patient has not been well defined. However, patients commonly present with more than one of these clinical and ethical challenges at any given office visit or hospital admission. Individual motivations and behaviors leading to the abuse, misuse, and diversion of prescription drugs, illicit drugs, and alcohol vary significantly. This chapter will provide an overview of SUD, prescription drug misuse, drug diversion, pain management, and cultural considerations in patients involved in these activities. Key terminology used throughout this book is also defined.

Definitions

Acute Pain

Acute pain comes on quickly, can be moderate to severe in intensity, and generally lasts a short period of time (e.g., from days up to 3 months). Acute pain is considered a beneficial process, warning of potential harm to the body from injury or medical conditions. Acute pain is most commonly nociceptive, modulated by mediators such as prostaglandins, substance P, and histamines, or neuropathic, characterized by alterations in the transmission pathways of nerves.

Addiction

Addiction is a primary chronic disease of brain reward, motivation, memory, judgment, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations that frequently result in destructive and life-threatening behaviors.4 Addiction is influenced by multiple factors, including, but not limited to, genetics, environment, sociology, physiology, and individual behaviors.

Addiction is characterized by the inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems in behavior and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.4

Chronic Pain

Chronic pain generally refers to intractable pain that exists for 3 months or more and does not resolve in response to treatment. Some conditions may become chronic in as little as 1 month. Chronic pain may be continuous or reoccurring, persisting for months or even a lifetime. While the exact duration and characteristics of acute and chronic pain may overlap considerably depending on a patient's medical condition, dental practitioners should recognize that specific timelines for the diagnosis of acute versus chronic pain may be integrated into federal and state legislation and into state board regulations to promote safe pain management practices and safe medication prescribing guidelines.

Drug Diversion

Drug diversion may be defined as the intentional transfer of a substance, or possession of a substance, or alteration of legitimate medication orders outside the boundaries designated by the Food and Drug Administration, federal Drug Enforcement Administration (DEA), or state regulatory board. Drug diversion may involve prescription or over-the counter (OTC) medications or illicit substances. These illegal activities are usually motivated by financial incentives, SUD behaviors, or other activities, such as sharing medications with the intent to help. Examples include a patient selling or giving their prescription medication to someone else, altering the original information on a prescription without the prescriber's consent, or theft of medications.

Drug Misuse

Drug misuse may be defined as taking a prescribed or OTC medication for nonprescribed purposes, in excessive doses, shorter intervals than prescribed or recommended, or for reasons other than the original intent of the prescription. Examples include doubling the dosage, shortening dosing intervals, or treating disorders for which the medication was not prescribed.

Opiates and Opioids

Opiates refer to natural substances derived from the poppy plant. Opioids function in a similar manner to opiates but are either synthetic or partially synthetic derivatives of opiates. For the purpose of this text, the term opioid will be used interchangeably for opiate.

Prescriber–Patient Mismatch

Prescriber–patient mismatch is defined as the inconsistency in treatment goals or expectations of treatment between the prescriber and the patient. Examples include analgesia, sedation, or anxiolysis.

Substance Abuse

Substance Abuse is a maladaptive pattern of chemical use (e.g. alcohol, medications, marijuana, cocaine, solvents, etc.) leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

Recurrent chemical use resulting in a failure to fulfill major role obligations at work, school, or home

Recurrent chemical use in situations in which it is physically hazardous

Recurrent chemically-related legal problems

Continued chemical use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by the effects of the chemical

The substance abuse culture consists of individuals whose sole intent is to alter in any number of ways their mood, psychological sense of well-being, physical sense of well-being, or their personal connection with the world around them.5

Substance Dependence

Substance dependence may be defined as persistent use of alcohol, other drugs, or chemicals despite having problems related to use of the substance. It is a maladaptive pattern of chemical use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring within a 12-month period:

Tolerance, as defined by either of the following:

– a need for significantly increased amounts of the substance to achieve intoxication or desired effect;

– significantly diminished effect with continued use of the same amount of the substance.

Withdrawal, as manifested by either of the following:

– the characteristic withdrawal symptom for the substance (see Chapter 2);

– the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.

The substance is often taken in larger amounts or over a longer period than was intended.

There is a persistent desire or unsuccessful efforts to cut down or control substance use.

A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.

Important social, occupational, or recreational activities are given up or reduced because of substance use.

The substance 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 substance.

5

Substance Use Disorders

In May 2013, The American Psychiatric Association redefined terminology previously used in the Diagnostic and Statistical Manual of Mental Disorders Text Revision (DSM-IV TR) guidelines regarding diagnostic classifications of Substance Dependence and Substance Abuse Disorders. SUD in DSM-5 combines the DSM-IV-TR categories of substance abuse, substance dependence and addiction disorders into a single disorder measured on a continuum from mild to severe. Nearly all SUDs are diagnosed based on the same overarching criteria which have not only been combined, but strengthened. (For example, in DSM-IV TR, a diagnosis of substance abuse previously required only one symptom, in DSM-5 a diagnosis of mild SUD requires two to three symptoms from a list of 11 [see Box 1.2]. SUD may be best described as a continuum of substance abuse and the disease of addiction.6

Box 1.2 SUD Symptoms List

Taking the substance in larger amounts or for longer than you meant to take it.

Wanting to cut down or stop using the substance but not managing to be successful.

Spending a lot of time getting, using, or recovering from use of the substance.

Cravings and urges to use the substance.

Not managing to do what you should at work, home, or school because of substance use.

Continuing to use the substance, even when it causes problems in relationships.

Giving up important social, occupational, or recreational activities because of substance use.

Using substances again and again, even when it puts you in danger.

Substance dependence.

Developing tolerance.

Developing withdrawal symptoms.

Substance Use Disorder, Drug Misuse, Drug Diversion, and Pain Management in the Dental Community

The terms psychological or psychiatric dependency and addiction are often used interchangeably with SUD, the term used in this book. Although the terms chemical, medication, drug, substance, chemical substance, or illicit substances are often used interchangeably, in this book the term substance is used when generally referring to products that are being abused or misused. Differences are only likely to occur based on federal and state classifications or medically accepted use.

Substance Use Disorder

Dental practitioners likely observe many patients at various stages of the substance abuse–disease of addiction continuum known as SUD. Specific patient behaviors may range from subtle exaggerations of pain severity with the intent to acquire more medications, to patients presenting in an exaggerated euphoric or dissociative state. Although the impact of opioid abuse and misuse on health care has been evaluated,7 the financial and workload burden of these behaviors has not been well characterized in the practice of dentistry. However, in a comprehensive statewide survey of dentists by O'Neil, 75% of dentists surveyed suspected 1–20% of their patients had a drug addiction or drug abuse disorder and 94% of dental practitioners altered their prescribing practices of opioid analgesics if the patient acknowledged an SUD.8 These survey results suggest SUD likely impacts patient management and the prescribing practices of dentists.

Medication Misuse

Prescription drug misuse has been identified as a significant health-care problem. Individuals self-medicating with prescription drugs outside of the boundaries of the original intent of the prescription appears to be a significant contributing factor in the development of SUD. Recent survey data from the SAMSHA in 2012 indicated 6.8 million Americans aged 12 or older (or 2.6%) had used psychotherapeutic prescription drugs without a prescription or in a manner or for a purpose it was not prescribed in the past month.3 Individuals may misuse drugs by self-prescribing unused or expired drugs. The impact of self-medicating with prescription drugs by patients for dental procedures or dental pain has not been well described in the USA. Excessive opioid prescribing by dental practitioners has been suggested in the dental literature, and these surveys have reported a wide dosing range of opioid analgesics for identical or similar dental procedures.9,10 Multiple factors may influence excessive prescribing (see Box 1.3). Dental practitioners should be aware of prescription medication misuse and abuse behaviors (see Box 1.4). These behaviors are discussed in more detail in Chapter 8. Ultimately, the most effective pharmacological agent, with minimal side effects or adverse effects, should be prescribed with the lowest dose possible for the minimal amount of time to achieve a reasonable effect such as analgesia, anxiolysis, or sedation. The impact of SUD on dental health and the dental community will be discussed in Chapter 6.

Box 1.3 Potential Influential Factors of Excessive Prescribing

Limited guidelines for appropriate drug and dosage selection for specific disease states or dental procedures.

Subjectivity of individual patient

or dentist's

perception of pain severity.

Patient assertiveness or aggressiveness toward prescriber.

Complicated patient pathology.

Lack of knowledge of pharmacologic principles and treatment options.

Prescriber–patient mismatch.

Provider availability.

Patient or prescriber convenience.

Box 1.4 Common Prescription Drug Misuse and Abuse Behaviors in Dental Patients

Requesting refills or running out of medications early.

Repeated frequent or unnecessary office visits.

Obvious powder or tablet fragments in nostrils.

Impaired patients at initiation of office visit.

Request from members of the family (spouse, parent) or patient's friends (boyfriend, girlfriend) for more medications.

Family members or patient friends demanding to be present when asking for medications (excluding young children).

Patients reporting multiple allergies to

only

less potent opioids and nonsteroidal anti-inflammatory drugs (NSAIDs).

Clinical Consideration

Prescribing of any medication requires comprehensive patient histories, examinations, screening prior to prescribing or dispensing medications, and patient education regarding medication misuse.

Alcoholism

Alcohol-related SUD is the most common of all SUDs in society today. In 2012, the NSDUH found that slightly more than half (52.1%) of Americans aged 12 or older reported being current drinkers of alcohol.3 This information translates to an estimated 135.5 million current drinkers in 2012.3 Other results in this same survey indicated nearly one-quarter (23.0%) of persons aged 12 or older were binge alcohol users in the 30 days prior to the survey. This translates to about 59.7 million people. Heavy drinking was reported by 6.5% of the population aged 12 or older, or 17.0 million people.3 The cost of excessive alcohol consumption in the USA in 2006 reached $223.5 billion according to the CDC in a 2006 study.11 The CDC defines excessive alcohol consumption, or heavy drinking, as consuming an average of more than one alcoholic beverage per day for women, and an average of more than two alcoholic beverages per day for men, and any drinking by pregnant women or underage youth.11 The exact costs of alcohol abuse and addiction to the dental health-care system have not been well elucidated. Because many dental patients are seen routinely for preventive as well as treatment services, dental practitioners may have the greatest opportunity to recognize potential alcohol SUD behaviors. This recognition at a minimum should result in a recommendation or referral to a local substance treatment center, substance abuse counselor, or primary-care physician for evaluation. See Box 1.5 for common signs and symptoms of potential alcohol-associated SUD. Chapter 2 will discuss the diseases of alcoholism and other SUDs.

Box 1.5 Common Signs and Symptoms of Potential Alcohol-Associated SUD

Alcohol odor on breath or clothes during normal day hours.

Slurred speech.

Oversedation

before

office procedures start.

Clumsiness, imbalance while walking.

Unexplainable loud and argumentative behavior.

Reduced effects of anesthetics during procedures.

Drug Diversion

Drug diversion presents in various forms, from simple self-prescribing and using someone's leftover prescription medications, to criminal activity to acquire more medications to sell or abuse. The penalties and punishments for these behaviors vary significantly.

Box 1.6 lists the most common types of drug diversion. For the purpose of this textbook, information provided will focus on common prescription drug diversion methods related to dental practices. An important concept for all health-care practitioners to understand is that an individual demonstrating specific drug diversion behavior frequently may not have an SUD. Various drug diversion behaviors are commonly motivated by other factors, such as financial incentives or sex.

Box 1.6 Common Types of Drug Diversion

Counterfeit medications/misbranding.

Robbery/burglary.

Trafficking/transport of illegal medications.

Prescription forgeries (written or verbal)

Sharing prescription medications.

Internet scams avoiding state, federal, and national drug control regulations.

Fraudulent or “fake” patient schemes, injuries, or complaints.

Selling prescriptions or prescription medications.

Personnel/office staff theft of medications from offices, hospitals, stock supplies.

Doctor/dentist/pharmacy shopping with intent to deceive.

Knowingly overprescribing medications by prescribers.

Health-care fraud.

Extortion/coercion.

Self-prescribing leftover medications/misuse.

Dental practitioners are likely to be victims of fraudulent patient schemes, written or phoned-in prescription forgeries or “dentist/pharmacy shoppers with the intent to deceive the dental practitioner or pharmacy.” The actual impact of drug diversion behavior on the dental community is not well defined. However, a statewide survey by O'Neil revealed that nearly 60% of dentists surveyed suspected they were victims of prescription drug diversion or fraud by their patients by methods such as theft of prescription pads, fake phoned-in prescriptions, altered refill or pill quantity on prescriptions, or false “stolen prescription” reports.8 When taking this information into consideration, time spent addressing these aberrant patient behaviors by dental practitioners and their office staff likely would have a significant impact on dental practitioner and office staff time. Chapter 8 will discuss in greater detail the various patient drug diversion schemes and scams as well as intervention and prevention strategies. Chapter 11 will discuss dental practitioner behaviors frequently involved in SUD.

Pain Management in Dentistry

Effective prevention and minimization of pain is a primary focus of all dental practitioners. Prescriptions for analgesics lead the list of prescribed medications by dental practitioners. Most prescribing is for acute pain, although occasionally analgesics or muscle relaxants may be prescribed for more chronic pain conditions, such as trigeminal neuralgia or temporomandibular joint disorders. Acute pain management in dentistry may be influenced by underlying chronic, nondental-related pain, diseases, or injuries. Although the reported incidence of chronic pain in the USA varies, most pain specialists would agree that at least 100 million Americans suffer annually with chronic pain.12 As life expectancies continue to increase in the USA, dental practitioners should expect an increase in patients on chronic analgesics for chronic pain now requiring medications for acute pain management. Similarly, the opioid-addicted population continues to rise, and many of these patients are maintaining a successful addiction recovery through opioid-based treatment programs with methadone or buprenorphine. Chapter 4 will discuss dental treatment considerations for acute pain in patients receiving opioid therapy for chronic pain and opioid-based addiction treatment.

Although the actual medications used to manage dental-associated pain are generally limited to two major classes of medications, (NSAIDs and opioid analgesics, actual prescribing patterns may vary considerably between practitioners prescribing for the same indication. Multiple factors certainly influence the quantity of medications and duration of pain medication therapy. See Box 1.7 for a list of some common considerations that may influence analgesic prescribing. Unless otherwise contraindicated, NSAIDs remain the first-line drug therapy of choice for most dental pain, including prophylaxis, dental-procedure-induced pain, infection, or structural damage.13 However, many dental practitioners remain reluctant to prescribe them as first-line agents. Variability in analgesic prescribing in dentistry will likely be reduced as national and state regulatory boards continue to promote “best practices” for pain management and as evidence-based studies are published in the dental literature. Chapter 3 will further discuss acute pain management considerations in dental practice.

Box 1.7 Common Considerations That May Influence Analgesic Prescribing

Complexity of dental pathology.

Perceived physical forces required for extractions and procedures.

Duration of procedures.

Combined pathologies, such as injury and infection.

Patient pain sensitivity.

Patient allergies and medication tolerance.

Drug–drug interactions.

Drug–disease interactions.

Underlying diseases.

Patient analgesic preferences.

Prescriber analgesic preferences.

Understanding the Cultures of Substance Use Disorder, Drug Misuse, and Drug Diversion

Individuals' motivations leading to the abuse, misuse, and diversion of drugs vary significantly. Although most health-care practitioners, licensing boards, and law enforcement agencies focus their efforts on controlled substances under DEA regulation, it is important to recognize that a significant amount of prescription and OTC drug misuse, abuse, and diversion occurs with drugs such as muscle relaxants, anticonvulsants, antipsychotics, and antibiotics not regulated by the DEA. Understanding the cultures associated with these behaviors is a key step to help facilitate education, treatment, and prosecution of these individuals. The cultures of SUD, drug misuse, and drug diversion can be divided into four categories. Each culture has its own characteristics. These categories include the sharing culture, the income-driven culture, the substance abuse culture, and the addiction culture. Categories may be identified based on the intent of the individual. Each category can be further divided to identify subpopulations.14

The Sharing Culture

The sharing culture may be defined as the giving, lending, or borrowing of prescription medication to anyone other than whom the prescription was intended. The intent of the sharing culture is to help treat illness, symptoms of an illness, or a perceived psychiatric or physical problem that may or may not have been appropriately diagnosed by a health-care practitioner. The sharing culture is characterized by the patient's perception that prescription medications are safe simply because the medical or dental practitioner prescribed them and a pharmacist or prescriber dispensed them. There is little recognition that the sharing of prescriptions is illegal and a type of drug diversion. Sources of these medications include leftover prescriptions, expired medications, or discontinued medications. Subcategories include adult-to-adult sharing or adult-to-child/adolescent sharing.14

The Income-driven Culture

The income-driven culture consists of patients, prescribers, and pharmacists. Medication theft, prescription forgeries, dentist/doctor/pharmacy shopping, and illegal Internet acquisition of medications are all methods individuals use to obtain prescription medications. The income-driven culture is motivated by financial gain and items or services that may be traded, such as other drugs or sex. However, at the community level, prescription drug sales may be a major source of income that an individual uses to pay utility bills or to buy food. Other characteristics include individuals who may never abuse any of the drugs they sell nor have they been diagnosed with legitimate medical or dental problems.14

The Substance Abuse Culture

The substance abuse culture consists of individuals whose sole intent is to alter in any number of ways their mood, psychological sense of well-being, physical sense of well-being, or their personal connection with the world around them. This culture can be further categorized into two subgroups: experimenters and mood modifiers. Experimenters try substances to evaluate whether or not they “like” or “dislike” the way a substance makes them feel. If the experience is perceived as positive and then leads to a more routine use of the substance, the individual may be categorized as a mood modifier. Mood modifiers may use these substances to enhance social, academic, or work performances. Prolonged abuse or misuse of substances by mood modifiers frequently leads to the disease of addiction.14

The Addiction Culture

The addiction culture consists of individuals who meet the diagnostic criteria for this disorder. Addiction behaviors may include substance seeking, compulsion to use, loss of control, craving, and continued use in spite of known negative consequences. This culture may be further divided into active addicts, who are abusing medication and not in recovery, and addicts who are in recovery. These categories may be further divided based on selective substance use behaviors.14

Combinations of Cultures

In reality, it is not unusual for dental practitioners to have patients in more than one culture. For example, active addicts may share their medications with friends or family to minimize withdrawal symptoms between “highs.” An individual may also sell part of their own prescription in order to obtain food for their family while maintaining their own drug habit with the remaining drug. The complexity of these cultures makes identification, prevention, treatment, and prosecution difficult. Dental practitioners and their office staff are likely to interface with all types of professionals involved in dealing with these various behaviors.14 Box 1.8 contains a list of resources that dental practitioners and office staff can interface with when necessary to optimize patient outcomes or simply report aberrant behaviors.

Box 1.8 Office Ready-Access List for Dental Practitioners

Law enforcement/regulatory agencies

Local police department.

State drug task force.

DEA.

State Board of Pharmacy.

State dental board.

Specialists

Addiction specialist for methadone/buprenorphine.

Pain specialist.

Community pharmacist.

Substance abuse counselor.

Local addiction treatment centers.

Drug information center/poison center.

Local hospital or emergency room.

Summary

In summary, dental practitioners are at the center of a very complex, demanding profession that requires, at a minimum, significant skills in dental and surgical procedures, knowledge of medical diagnoses, recognition of concurrent medical and psychiatric disorders, advanced communication and interview skills, and advanced knowledge in pharmacology, pharmacotherapy, pain management, drug diversion, and SUD. Dental practice is further complicated by the multitude of social issues and personalities of patients who visit the dental practitioner's office daily and cause difficulties in the dental practice. Safe prescribing of medications and recognition of SUD must be accomplished by dental practitioners staying up to date and knowledgeable about federal and state regulations. The following chapters will serve as a clinician's guide to help dental practitioners understand and successfully practice fundamental concepts involving SUD, pain and sedation management, and drug diversion prevention. These chapters will emphasize outpatient management of dental patients.

References

CDC Grand Rounds: prescription drug overdoses—a U.S. epidemic. Morb Mort Wkly Rep 2012;61(01):10–13.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm

. Accessed January 5, 2015.

Patel KV, Guralnik JM, Dansie EJ, Turk DC. Prevalence and impact of pain among older adults in the United States: findings from the 2011 National Health and Aging Trends Study. Pain 2013;154(12):2649–57.

Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings. NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. 2013. Substance Abuse and Mental Health Services Administration, Rockville, MD.

http://media.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/NationalFindings/NSDUHresults2012.pdf

. Accessed January 5, 2015.

American Society of Addiction Medicine. The definition of addiction. 2011.

http://www.asam.org/advocacy/find-a-policy-statement/view-policy-statement/public-policy-statements/2011/12/15/the-definition-of-addiction

. Accessed January 5, 2015.

Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision, DSM-IV-TR. 2000. American Psychiatric Association,

The Diagnostic and Statistical Manual of Mental Disorders, 5th ed., DSM-5. 2013. American Psychiatric Association.

Manchikanti L, Boswell MV, Hirsch JA. Lessons learned in the abuse of pain-relief medication: a focus on health care costs: impact on healthcare costs. Expert Rev Neurother 2013;13(5):527–43.

http://www.medscape.org/viewarticle/803051_6

. Accessed January 5, 2015.

O'Neil M. Dentists' experiences with drug diversion and substance use disorders. Accepted for poster presentation, ADEA Annual Conference, March 2015.

Mutlu I, Abubaker AO, Laskin DM. Narcotic prescribing habits and other methods of pain control by oral and maxillofacial surgeons after impacted third molar removal. J Oral Maxillofac Surg 2013;71(9):1500–3. doi: 10.1016/j.joms.2013.04.031.

O'Neil M. A statewide survey of opioid prescribing practices in dentistry: clinical implications. JADA 2015; under review.

CDC. Excessive drinking costs U.S. $223.5 billion. 2014.

http://www.cdc.gov/features/alcoholconsumption/

. Accessed January 5, 2015.

American Academy of Pain Medicine. AAPM facts and figures on pain.

http://www.painmed.org/patientcenter/facts_on_pain.aspx

. Accessed January 5, 2015.

Hersh EV, Kane WT, O'Neil MG, Kenna GA, Katz NP, Golubic S, Moore PA. Prescribing recommendations for the treatment of acute pain in dentistry. Compend Contin Educ Dent 2011;32(3):22, 24–30.

O'Neil M, Hannah KL. Understanding the cultures of prescription drug abuse, misuse, addiction, and diversion. W V Med J 2010;106(4 Spec No):64–70.

2Understanding the Disease of Substance Use Disorders

James H. Berry, DO and Carl Rollynn Sullivan, MD

Introduction

Substance use disorder (SUD) includes some of humanity's most common and destructive disease states. The range of physical, emotional, social, familial, legal, financial, and spiritual problems associated with SUD is vast and frequently uncompromising to patients and families. Unfortunately, identification and treatment of these patients is often complicated by their own denial, rationalization, or minimization of their condition. This has traditionally been compounded by a society where alcoholic or addicted patients were often morally stigmatized as “bad” or “weak” people rather than having a disease and in need of medical help. But this attitude is changing as scientific discovery has significantly enhanced our understanding of the neurophysiology of addiction. In the last 40 years, we have been able to identify the meso-limbic reward pathway as the primary site of dysfunction and have begun to understand the primary role of “craving” as the mediator to ongoing drug or substance usage. Researchers have mapped the receptors for all the major classes of addicting drugs and have developed medication treatments to specifically target those areas of dysfunction. Equally important has been the development of evidence-based psychotherapies to assist in the goal of psychosocial recovery of the individual and family suffering with an SUD. In this chapter we will present a concise overview of our current understanding of SUD.

Definitions

Addiction

Addiction is a primary chronic disease of brain reward, motivation, memory, judgment, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations that frequently result in destructive and life-threatening behaviors. Addiction is influenced by multiple factors, including, but not limited to, genetics, environment, sociology, physiology, and individual behaviors.

Addiction is characterized by inability to consistently abstain, impairment in behavior control, craving, diminished recognition of significant problems in behavior and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.1

Ambivalence

One of the most important concepts to understand regarding a person suffering from SUD is ambivalence. Ambivalence is the coexistence of both positive and negative feelings and thoughts towards an action. This often results in no action being taken. Working through this ambivalence is a normal part of life as individuals negotiate many of the choices made as human beings. In SUD, however, this process results in significant internal conflict that keeps people engaged in many behaviors that they often know are not healthy.

Cross-addiction

Cross-addiction occurs when a person gives up one substance and becomes addicted to another. This can occur immediately after the initial substance is discontinued or in the future. Because all reinforcing substances activate the reward pathway in the brain as discussed later, a person predisposed to addiction is at risk regardless of the substance. This is an important concept for the dental practitioner to understand as one must be very cautious in prescribing a controlled substance to a recovering alcoholic, for example.

Medication-assisted Therapy

Taking into account that SUD is a disease, several evidence-based medications have been developed to treat this disease. This chapter will highlight many of these pharmacotherapies. Medication-assisted therapy is a term most commonly used in reference to medications used in the treatment of opioid-use disorders.

Medical Model

Much stigma has been attached to addiction throughout history. People suffering from addiction have been considered morally or spiritually weak and that the problem is primarily a social problem. The medical model of addiction recognizes that SUD is a health problem with features that parallel other chronic disease states. There are genetic predispositions, environmental factors, and organ (brain) susceptibilities that factor into the development and course of this disease. Furthermore, treatment outcomes are similar to other chronic diseases, such as type 2 diabetes mellitus, hypertension, and asthma.2

Psychological Therapy or Psychotherapy

Psychotherapy is the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviors, cognitions, emotions, and/or other personal characteristics in directions that the participants deem desirable.3

Tolerance

Tolerance may be defined by either a need for markedly increased amounts of the substance to achieve intoxication or desired effect or a markedly diminished effect with continued use of the same amount of the chemical.1

Transtheoretical Model of Change

Understanding behavior change is a process that occurs in specific stages with specific implications for each stage and is helpful in approaching the addicted patient. DiClemente and Prochaska developed the transtheoretical model of change (Figure 2.1), which identifies five stages of change.4 As illustrated in the figure, a person moves from the initial stages of not recognizing a problem exists or being unwilling to make a change, to understanding there is a problem and identifying that change needs to occur, to preparing to make a change and taking action, and finally sustaining the change. The treatment implications are clear. It will not be beneficial to approach an individual who is in the precontemplation stage as if they were in the action stage. To do so would invite considerable resistance from the patient, further frustration for the clinician, and potentially damage the therapeutic alliance.

Figure 2.1 Transtheoretical model of change.

Withdrawal

Withdrawal is an unpleasant physiologic phenomenon characterized by a wide range of signs and symptoms. Physiologic systems, such as the cardiovascular system or central nervous system (CNS) have adapted to function normally in the presence of substances not endogenous to the physiologic system. This usually occurs over a prolonged period of time. Abrupt discontinuation of the substance produces a hyperactive response by the same physiologic system. For example, long-term CNS depression by a substance will likely produce CNS stimulation upon withdrawal. Diazepam, a CNS depressant, will likely produce increased anxiety or agitation upon withdrawal in a patient who has physiologically adapted to being on the medication for a prolonged period of time.

Epidemiology: Drug/Alcohol

According to the 2012 National Survey on Drug Use and Health (NSDUH), an estimated 22.2 million persons aged 12 or older met criteria for an SUD in the past year (8.5% of the population aged 12 or older). Of these, 2.8 million met criteria for alcohol and illicit drugs, 4.5 million for illicit drugs but not alcohol, and 14.9 million alcohol but not illicit drugs. (Note: NSDUH used Diagnostic and Statistical Manual of Mental Disorders (DSM-)IV abuse/dependence criteria, not DSM-5 SUD criteria.5)

Age and Gender

Many studies have demonstrated that exposure to drugs and alcohol during adolescence increases the risk of developing problems with substances as an adult.6 According to the NSDUH, among adults, age at first use of marijuana was associated with illicit SUDs. Among those who first tried marijuana at age 14 or younger, 13.2% met criteria for an illicit drug use disorder, higher than the 2.2% of adults who had first used at age 18 or older. The first use of alcohol was also associated with an alcohol use disorder. Among those who first tried alcohol at age 14 or younger, 16.1% met criteria, which was higher than the 3.6% of adults who had first used alcohol at age 18 or older. Adults who had their first drink before age 21 were seven times more likely to have an alcohol use disorder than those who had their first drink at age 21 or older. This highlights the importance of screening youth for substance use and making treatment accessible, as well as providing education regarding the risks.

Rates of SUD were also associated with age. In 2012, the rate of SUD among adults aged 18–25 (18.9%) was higher than that among youths aged 12–17 (6.1%) and among adults aged 26 or older (7.0%). The rate of alcohol use disorders among youths aged 12–17 was 3.4%, 14.3% for adults aged 18–25, and 5.9% for those aged 26 or older.5 Furthermore, there is a growing body of evidence and concern for alcohol and substance use among the elderly population.7,8

Interestingly, the results from the NSDUH demonstrate a gender difference among adults compared with youth. Males have almost double the rate of an SUD for adults aged 18 or older, whereas the rate is equal for youth aged 12–17.5

Clinical Consideration

Early age abuse of substances such as alcohol or marijuana have a high association with SUD later in life when compared with individuals that began abusing these same substances as adults.

Treatment

The NSDUH also surveyed the rates of people obtaining substance use treatment. In 2012, 4 million received treatment for a problem related to the use of alcohol or illicit drugs. Of these, 1.2 million received treatment for the use of both alcohol and illicit drugs, 1 million received treatment for the use of illicit drugs but not alcohol, and 1.4 million received treatment for the use of alcohol but not illicit drugs. There were differences in where the individuals obtained treatment. The majority of people received treatment at a self-help group (2.1 million) or at a rehabilitation facility as an outpatient (1.5 million). An equal number (1 million) received inpatient treatment at a rehabilitation facility as those that got care as an outpatient at a mental health clinic. The numbers of persons who received treatment at other locations were 1 million at a rehabilitation facility as an inpatient, 1 million at a mental health center as an outpatient, 861 000 at a hospital as an inpatient, 735 000 at a private doctor's office, 597 000 at an emergency room, and 388 000 at a prison or jail.5

Pathophysiology/Brain Pathways

The mesolimbic reward pathway is known as the reward center of the brain for food, water, sex, social interactions, and other positive responses. This pathway connects the midbrain to the limbic system or emotion center of the brain to the prefrontal cortex (PFC), an area associated with higher cognitive and emotional control (Figure 2.2). The mesolimbic reward pathway has significant connectivity to the memory storage areas of the brain in the amygdala and hippocampus. Dopamine is the predominant neurotransmitter associated with this complex pathway. The nucleus accumbens (NAcc) is a small portion of the brain that regulates pleasure, motivation, and other survival behaviors. The NAcc is situated in the limbic system and plays a central role in this reward circuit. Virtually all substances of addiction act through specific receptor modulations along this pathway to either directly or indirectly exert their reinforcing effects by inducing dopamine bursts primarily in the NAcc. In the nonaddicted state there exists a balance between the cognitive decision-making and restraint of the PFC and the instinctual, libidinal, survival function of the limbic system's reward center. Repetitive substance usage induces alterations in this homeostasis that leads to changes in craving, motivation, reward perception, behavior control, salience attribution, and memory.10,11 These substance-induced brain alterations are the neurophysiologic hallmarks of SUD.

Figure 2.2 Brain pathways.9

Source: NIDA.

Signs, Symptoms, Behavior

The various substances of abuse have predictable signs and symptoms of withdrawal and intoxication. These often depend upon the category of medications in which the substance is placed. For example, cocaine and amphetamines are both stimulants and have similar effects on the human body. Frequently, the intoxicating effects of a substance will be the opposite of the withdrawal. Opioids are a case in point. During use, the pupils will constrict, and during withdrawal they will dilate. It is important to note that withdrawal, regardless of whether or not it is life threatening, can be very uncomfortable and often results in the dependent individual returning to use despite the horrible consequences.

Alcohol

Most Americans have used alcohol at some point in their lifetime and are familiar with the intoxication effects. For those who have not experienced these effects first hand, many have witnessed in others or seen examples of drunkenness portrayed in media. Signs/symptoms of intoxication are listed in Box 2.1.

Box 2.1 Signs and Symptoms of Alcohol Intoxication

Slurred speech

Incoordination/unsteady gate

Stupor/coma

Memory loss

Attention impairment