Thank you so much for your thoughtful responses to the SUD questions! I was SO impressed with your thorough and insightful comments. Some of you had questions for Dustin – he is still working through those, and I will send them out when I get them back.
I thought I’d post some of the responses that really jumped out at me. There were many, many excellent responses – way too many to post here – so these are just a few. Questions 2, 4, 5, and 6 are more fact-based, so I just picked one good answer for those. Questions 1, 3, and 7 were more open-ended, so I posted several responses for those.
Question 1: In your own words (it doesn’t need to be perfect or even scientific), how would you define substance use disorder?
Substance use disorder usually starts innocently enough with a curiosity and desire to have an experience like nothing else. The first high is amazing beyond words, but over time, this response starts to diminish as the brain turns off the reward centers. While trying to experience that euphoric experience one last time, the brain starts to rewire itself and the drug becomes a necessity; a substance that the brain desperately needs to function properly.
Substance use disorder is a disorder like any other. It really is out of the control of the person who is affected. It is being addicted to a substance, knowing it is wrong and not being able to do anything about it because it actually changes your brain.
Substance use disorder and its definition can be specific to each individual, but overall I would define it as: a disorder due to the constant seeking of an unsustainable feeling of euphoria that can’t be obtained elsewhere.
SUD is a rearrangement of the neural pathways in the brain that stems from an initial experience of euphoria. It stems from a number of risk factors predisposing the brain to an experience that it cannot find in any other day-to-day activities.
A dysregulation process that occurs in the brain related to abuse of a substances that creates an intense, unnatural and unsustainable feeling of euphoria. It starts to interfere with behaviors and thinking processes both while using and while not using.
When a person finds him or herself addicted to a using a drug or other substance – not necessarily because continued use of the substance makes them feel good but simply because constant use of the substance has changed the hardwiring in the brain to need the substance for normal function.
I would define substance use disorder as the need to use some sort of mood altering chemical. I think of it like if you can’t get up in the morning without it, or you can’t go to work without it, that’s substance abuse.
Question 2: A common misperception is that kids is that kids use drugs to cope with problems (Dustin mentioned hearing people say “What’s so bad in these kids’ lives that they need to turn to drugs to cope?”). What’s the real reason most kids start using?
It’s a natural curiosity to experience the excitement, pleasure, and euphoria associated with the high. What can increase one’s curiosity is if use of the substance is also considered to be cool.
Question 3: There are lots of different recovery programs for alcohol abuse, but Alcoholics Anonymous is the most successful. What are some of the concepts behind the 12 steps of AA?
Powerlessness: identifying the loss of control or the inability to predict what is going to happen when someone starts using Spirituality: trying to identify a higher power greater than yourself, which can be anything (not just God) Self-awareness: getting to know yourself Self-acknowledgement and steps to repair ones life, starting by making amends for things that may have happened when you were using.
Alcoholics Anonymous is program that helps those with substance abuse disorders, specifically the use of alcohol. The 12 steps focus on things like acknowledging powerlessness, self awareness and steps to repair ones life. What I love most about Alcoholics Anonymous is the emphasis on identifying a higher power. I believe this is essential in finding peace, hope and encouragement during tough times. Another concept that is great is the mentorship that young people with SUDs can get advice from others that have been dealing with SUDs for a long time.
• Acknowledge powerlessness – Admit that you need help and that the drugs/alcohol are taking over your life. • Acknowledge and identify a higher power – The higher power does not have to be a God ( you do not need to be religious). • Self awareness – Looking at yourself and taking stock in yourself. • Self acknowledgement – Understanding the problems with what you are doing and acknowledging that you have a problem. • Steps to repair one’s life – Making changes in your life to better yourself and work to tackle the problem.
Acknowledge the powerlessness, I believe this is recognizing that within yourself you to help to gain the power within in you to battle the problem. Identify a higher power (i really like this one), is recognizing that an all mighty creator is watching over you and cares about you. Self awareness, is recognizing who you are as a person, not letting something or someone define who you are. Self acknowledgment, is recognizing the things you are over come and realizing your progression in life. Steps to repair one’s life, is providing structure and a plan to address the problem. Addressing a problem without a plan is like setting sail into the ocean without a map. You may arrive at your destination, you may take the longest rout to your destination, or you may not get to your destination.
Admitting that you are powerless over alcohol, turning from the substance, and make a moral inventory of yourself.
Acceptance of what you can’t change and the idea that there’s a greater force in the world than yourself.
Question 4: What’s the most significant factor that predicts the development of substance use disorder? Why?
The age of first use. This is due to the way that our brain develops. When we are younger, our brain is still developing and the less developed the brain, the more intense the first euphoric experience is going to be. This will make the individual want to use more often.
Question 5: What are some symptoms of mild substance use order?
The key word is RECURRENT! – Recurrent use; failure to meet obligations – Recurrent use in hazardous situations, i.e. DUI, unsafe sex, risk at the hands of others – Recurrent use in spite of persistent social or personal problems caused by use.
Question 6: How is the brain different in severe (as opposed to mild/moderate) substance use disorder?
Severe substance use disorder is when the brain is unable to achieve or maintain homeostasis naturally and relies on the drug to achieve normalcy. This is when the body is dependent on the substance and craves the substance. Instead using to achieve this unnatural euphoria, they are now using to try and feel normal and avoid withdrawal symptoms. Mr. Chapman mentioned that all strong emotions, whether they are bad or good, can be considered a stress and can trigger substance use. For example, if someone with substance use disorder were to win a million dollars, this positive stress could very easy trigger substance use as a means of ‘celebration’.
Question 7: You’re nearing graduation (yay!) and you and two classmates have the opportunity to be in on the development of a new dental clinic in an underserved area of Minneapolis. There’s a nice big grant, so funding isn’t a constraint. You want to make sure you adequately address the issue of substance use disorder in your patients. What kinds of things would you build into your clinic?
I would like to have a substance abuse counselor on staff that would have his/her own office space within the building. Upon meeting new patients, I would have them fill out a medical history form that would include questions relating to/alluding to a possible substance use disorder. If I was at all concerned about the patient, I would have the counselor join me in the room and introduce them. I would have pamphlets about substance use disorder and mental illness in the waiting room for anyone to look at. I would also have a list of contacts for anyone who wishes to seek additional help. All of my staff will have attended trainings on substance use disorders and will also have received naloxone training. I would use a prescription monitoring program to help reduce the number of opiate prescriptions.
I would want to implement questions pertaining to alcohol and drug use in medical history. I would have open conversations with patients about their use history and if they desire help have team ready to set up an appointment with drug counselors like Dustin. Even building into my clinic a drug counseling area so the patient doesn’t have to leave the building and can be seen same day. This would be interprofessional working and holistic medicine. Treating not only the patients oral health but mental health.
One thing that stuck out to me in the lecture was his explanation of making a patient schedule an appointment for help while in your office instead of just giving them information and hoping that they reach out on their own. Over-prescribing of opiates is obviously a huge issue in dentistry. I am planning on pursuing oral surgery and unless something better comes along, I plan on adopting the philosophy of the UMN oral surgery department. The decreased number of opiate prescriptions and number of pill per prescription at this point are staggering. The department is currently working on a patient satisfaction research project to determine if this has influenced patient outcomes. They have had very few complaints about their current prescribing protocols and it will be interesting to see the patient perspective. No doubt in my mind that Prescription Drug Monitoring Programs are a must in order to continue progress. It is such an easy thing for prescribers to participate in and I do not see any reason to not apply and use it.
Being age is the number one risk factor for developing SUD an after school program would be of high priority. Creating a space children are able to achieve natural highs will be the greatest priority. Another point touched on in the lecture was integrative care – having a dental office tied to other forms of practice is probably something soon to be reality. There is a lot of talk about integrating dentistry in schools. During this time a five minute speech on drug use may prove to be useful.
We could have a mental health/addiction office included in the clinic. Screenings could be a part of the dental visit and then if needed, the patient could stop by at the addiction office right there. From here the person could be set up with a team that could help them get what they need: Follow up calls/appointments, rehab, SBIRT-type tools, available groups/therapy, or any other resources the person many need. Wouldn’t this be great?! Does this grant actually exist?
I would make sure to minimize the prescription of opioids but make sure no one feels too embarrassed to express any issues they have hadn’t with substance abuse. I always worry that coming from a practitioner the question of history of drug use or substance abuse can come off accusatory or judgmental and could cause some people to lie instead of opening up. So I am sure there are some training programs that teach people how to effectively talk about substance abuse and make sure patients know it’s a safe space and there won’t be any judgement.
According to McNeely et al. (JADA 144(6)), dentists are more than willing to incorporate SUD screening and intervention into their practice, however, the biggest barrier is poor reimbursement to the provider for these services. Therefore, I’d use the grant money to make up that difference and incorporate a screening and intervention program at the clinic.
I think that it would be very useful to tackle the problem of substance use disorder from many angles. First of all, it would be helpful to strongly limit the number of narcotics being prescribed to patients. If it is possible to have the patient on a less addictive medication then put them on that. Next, I think it would be helpful to council patients that are on narcotics about the dangers and signs of substance usage disorder. If a patient is prescribed with a long term narcotic, they should have to check in weekly or bi-weekly in order to allow the dentist to check for signs of substance usage disorder in the patient before the prescription is renewed. Lastly, I think it would be important to partner with a cessation program similar to Alcoholics Anonymous for patients that appear to be developing a substance usage disorder.
First, I would try and hire Dustin as a consultant or any other mental health/substance use professionals as part of my team. Then I’d have a medication return window for expired or unneeded medications so that they aren’t flushed or sold to others, specifically opiates. I’d make sure all of my staff is trained to administer Naloxone and have some in stock. Also, I’d like to add SBIRT and try to integrate the clinic with other health facilities so that we’re able to keep better track/take better care of our at-risk patients.