In the online assignment on SUD, there was space to ask Dustin Chapman questions – and many of you wrote in with really interesting questions. Here are Dustin’s responses, which are very thoughtful and reflect his years of experience in the field. I strongly suggest reading through these, because there is a lot of information here that will be useful when you get out in practice.
Q. Is there something a dentist can say to help patients to open up? Also, what are some things we can say or do to keep them open to the thought of getting help?
A. I think if you used a screening tool completed by the patient prior to seeing you, that would be a way of starting the conversation. I would suggest even having a casual conversation about why the screening is being done, and the emphasis on early identification and intervention being a focus of healthcare today. Sometimes this may help someone to open up – if not about themselves, then about a family member or friend.
Q. Not everyone is open to getting help outside of their immediate milieu. It would be nice to have something to say to them if they refuse help.
A. I would support the individual in knowing that services are available and you would be happy to help them find a resource if they wanted it in the future. If that time arrives, the patient may contact you for suggestions since you showed interest in them and their well-being. Be prepared for this by having a list of current resources available. I also would suggest they have an assessment which is a way to determine if they have an issue. They would not be under any obligation to follow through with any recommendations made by the assessor.
Q. I just want to know how to go about approaching a patient about an SUD. I was watching Grey’s anatomy the other day and Alex was trying to give a teenager in the ER some pamphlets on alcoholism/addiction. The show highlighted how awkward it is even for a doctor to provide resources to a patient about a touchy subject. How do I help patients with SUD’s without sounding so “high and mighty”??
A. I always try to be relaxed and comfortable and to be as non-threatening as possible. Since you are talking about a touchy subject with someone who is likely a stranger, I think it is important to not be aggressive or detached. If you can present yourself as being concerned for their welfare and at the same time non-threatening, it can be effective – if not immediately, then in the future.
Q. How do you talk to a patient who you think is using a substance but you aren’t 100% sure? If patients are using an illegal substance are we obligated to tell anyone? If there are signs of physical abuse (perpetrator or victim), who do we tell?
A. I would approach the person with my observations and why I was bring up the issue. You can’t make someone admit something they do not want to. However, if you’re in a prescribing situation and your instincts are telling you something isn’t right, then listen to those instincts. In terms of reporting obligations, I am unaware of any requirements. However, if you find someone is using multiple physicians to acquire opiates then this should be reported to authorities as this is a crime. You may want to check state reporting requirements to parents if the patient is a minor.
Q. Why is it more acceptable to use drugs in schools now than it was before?
A. I don’t know if it’s so much that it’s more acceptable as that that schools tend to focus more on mental health issues, and some school counselors view drug use as self-medication of an underlying problem. The focus then becomes identification of this underlying problem – treating that problem and assuming the substance use will go away. It most likely will not go away. Since marijuana is the most common drug used in schools and the public perception is that marijuana isn’t that bad, there may be more of a turning a blind eye to the subject. School budgets are an issue – counselors are often the first cuts when budget crises arise. Sometimes too, schools will minimize drug use in their schools because they want to maintain a clean image.
Q. What are your thoughts on the legalization of marijuana? Will more availability cause more problems down the road or does education and regulation control some problems.
A. I am opposed to legalization. The argument that marijuana is less harmful than alcohol is irrelevant. Both drugs have their own consequences. Ask yourself “would we be better off as a society if alcohol had never been discovered?” Then ask “Does society need another mind-altering drug that has harmful affects?” Globally, how would marijuana affect the US’ standing in a world economy? Would China and India welcome the legalization of marijuana in the US because they know it would affect our productivity? This is ultimately a lengthy discussion so these are just a couple of different arguments not usually heard.
Q. What are the current opioid prescription trends among dentists and oral surgeons? I’ve seen a few articles in ADA newsletters but I’m just curious to know what dentists are doing to curb the problem.
A. I do not know current trends but opiate addiction has become a nation-wide epidemic. Many of today’s heroin addicts started out with prescription opiates (either prescribed or pilfered). The ease with which opiates are prescribed today is alarming. Not too many decades ago opiates were rarely prescribed except for temporary pain relief following surgery or injury, for chronic pain, or for end-of-life pain. Since the 1980s with the advent of new opiates, prescription of these drugs has skyrocketed, leading to the situation we have today. I think all doctors and dentists need training and education on alternatives to opiates. Prior to the widespread prescribing of opiates, a lot of alternatives were given for chronic pain. Many of these were effective in reducing pain to moderate and tolerable levels but they required patience, commitment and some effort on the part of the patient. Taking a pill seems so much easier to a lot of people.
Q. I would like to get Dr. Krafts’ and Mr. Chapman’s take on this video which I saw a few months ago and that left an impression with me. It is somewhat at odds with Mr. Chapman’s lecture.
A. Dr. Chapman: My reaction to the YouTube video was that I had some agreement. Drugs do interfere with and ultimately replace meaningful relationships with others. Treatment has always included goals of re-socializing with supportive family and friends as well as supportive organizations such as AA or NA. However, I disagree that social isolation causes drug addiction. I believe social isolation can lead to drug use, but the addiction is the dysregulation of the brain caused by the drug use. Many people end up with substance use disorder because their social group advocates substance use. The example of returning Viet Nam vets that were addicted to heroin who stopped using when they came home is not surprising. But remember, not all returning vets who were addicted stopped using. I do not know the numbers, but I had many Viet Nam veterans as patients in the late 70’s and early 80’s. I also believe if some of those who stopped returned to Viet Nam, even as tourists, they would be at a high risk for relapse.
A. Dr. Krafts: The main message of the video, to me, is that addiction is a result of a person’s “cage” – and if we can remove people’s cages of isolation, and replace them with healthy and loving relationships, that will eliminate addiction. Although the message seems to be supported by facts (e.g,. most of the heroin users in Vietnam quit using when they came home to their loving families), I think that it misinterprets the facts to the point of being dangerous.
I agree with the message in one sense: if children have a loving home environment, and they know their parents don’t want them to try alcohol or drugs, that goes a long way towards preventing substance abuse disorder later in life. That is supported by evidence (kids who know their parents would be really upset/hurt if they use drugs/alcohol are much less likely to try them).
However, the idea that changing one’s environment, or having more loving relationships, can prevent or stop addiction is not supported by evidence. The video misinterprets the Vietnam vet story. Yes, it may be true that most vets stopped using heroin when they returned to the states – but some didn’t stop. To assume that the vets who stopped using did so because they had loving families (and, by implication, that the vets who continued to use did not) is a big leap. And to further assume that their loving families kept most vets from using (and that isolation caused the rest of the vets to use) sounds like a nice theory – but it’s not supported by facts.
Changing one’s environment or having more loving relationships may make a problem drinker stop drinking – but it won’t do anything for an alcoholic. Alcoholism has been described as a physical “allergy” to alcohol (alcoholics respond very differently to alcohol than non-alcoholics) and a mental obsession to continue drinking (willpower won’t help), in a spiritual void. Having a more loving family or more friends does not remove the physical “allergy” (which might be better termed brain dysregulation). Once the alcoholic takes that first drink, the mental obsession begins, and at some point the alcoholic will not be able to stop drinking. Many alcoholics try changing their environment by moving to a different place and starting over – with no success.
My interpretation of the Vietnam vet story is that those vets who stopped using heroin (and, presumably, didn’t simply replace heroin with another drug like alcohol) were not addicts to begin with – and that those vets who did continue to use heroin were addicts. They may very well have had loving families – but that didn’t remove the physical “allergy” to the drug, or the mental obsession with using, or the spiritual void the addict was in. If someone is truly addicted to a substance (in the way the DSM-5 describes SUD), a change in environment may be temporarily distracting, but it will not remove the addiction. Alcoholics Anonymous has a higher success rate than any program – and none of its 12 steps involves changing one’s environment, developing better or more relationships, or fixing one’s problems.
The reason I think the video’s message is dangerous is that if we assume addicts use drugs to cope with their problems (including the problem of isolation), we may try to help addicts stop using by changing their circumstances, fixing their problems, or helping them develop more loving relationships – and that will not work. In fact, it may prevent the addict from getting the help he or she needs.
Q. I would like to know about the resources available in Illinois (where I hope to practice) so that I know where to direct patients in the future.
A. I am unaware of services in Illinois. At the time of your relocation to Illinois you may want to check with county social services to get an idea of services available. You can Google services but this would not be a reliable method in determining the quality of those services.