How to spot an addict, Issue 3

You’ve noticed one of your patients has lost a lot of weight and seems to have trouble focusing during appointments-assuming she shows up. Or maybe another dentist in the practice spends a lot of time in his office with the door closed, only to come out acting much differently than when he went in.

You’ve noticed one of your patients has lost a lot of weight and seems to have trouble focusing during appointments-assuming she shows up. Or maybe another dentist in the practice spends a lot of time in his office with the door closed, only to come out acting much differently than when he went in.

Paranoid. Confrontational. Unreasonable. Moody. Whether these words come to mind when you think about a patient or someone you work with, chances are they describe someone who is struggling with addiction. Either way, it’s important for you and your staff to recognize addiction and have a plan in place to address any problems, whether it’s a patient causing a scene in the waiting room, a recovering alcoholic who should avoid certain medications or a hygienist who can’t seem to make it to work on time.

The high patient

Although it’s not common for a patient to come to the office high, it does happen. Dilated pupils, an inability to focus and nervousness are all signs that you might be dealing with someone on Meth or other drugs, said Audrey Ticknor, RDH, MA, who presents seminars part-time for MAPP-SD (Methamphetamine Awareness and Prevention Project of South Dakota). If you suspect something isn’t right, Ticknor recommends asking the patient directly if he or she is under the influence.

“You are providing treatment to them and if you are doing a procedure that requires local anesthetic and they’re already high, that could cause a medical emergency,” Ticknor said. “You need to get the information out of them.”

Remember you can’t make a diagnosis, said Dr. Harold Crossley, who is an expert on street drugs and chemical dependency as well as the clinical pharmacology of dental drugs. Maybe the patient you think is an alcoholic had a few shots of whiskey before coming to the office to relieve some anxiety, or maybe the marijuana you think you smell is something else. Making accusations will only leave you open to lawsuits.

Be prepared

What if the patient you suspect is using drugs or alcohol brought children to the appointment? What if you fear the patient may cause a traffic accident if he or she drives home? These are all serious situations, and Ticknor recommends offering the patient bus fare, asking the patient if there is someone you can call to come pick them up and, as a last resort, to call the police.

When you’re in this kind of situation, you don’t want to have to think too much about what to do or to debate a course of action with other staff members. You need to have a plan in place, a plan that everyone on staff is familiar with and is ready to implement if the need arises. Sit down with your staff as a group and talk about different situations that might come up and how the team will handle those situations.

As part of establishing a protocol, talk to the local police about who you should contact and what you should do if something happens in the office, said Dr. Mark Storer, a Chicago dentist who lectures on addiction. Ask them what the chain of command is. And make sure you have a contingency for all sorts of different situations, from a domestic dispute in the waiting room to a confrontational patient who refuses to calm down.

“The big thing is putting out the fire before it gets worse,” Dr. Storer said. “The one thing you don’t want to do is get involved with any physical contact with a patient whatsoever. And you don’t want your employees to get involved, either.”

It also doesn’t hurt to have resources on hand that you can offer patients, Ticknor said. Ultimately it’s up to them to seek treatment, but it doesn’t hurt to provide them with information about clinics and treatment centers in the area.

“You can’t do much beyond talking to patients and referring them to services,” Ticknor said. “It’s just like smoking. You talk to the patient and say ‘Here are the health risks. You’re putting your life in danger. Here are the oral cancer risks, here are the costs that might be associated with your continued use. Now that you have all the information, I hope you make right decision.’”

The recovering addict

Every office’s patient questionnaire should include questions about drug and alcohol addiction, Dr. Crossley said. It’s important to know if you’re working on a patient with a history of addiction because it does affect treatment. If the patient is recovering from drug or alcohol addiction, you need to be careful with prescribing pain medications and using mouth rinse that lists alcohol as one of its ingredients.

“They’re not going to hide it because they’re worried about relapse,” Dr. Crossley said. “And my opinion is if the patient denies having a history of chemical dependency and you use narcotics to control pain and that patient relapses, that’s his or her responsibility.”

It’s also a good idea to encourage their sobriety, Ticknor said. Ask them when their anniversary is and tell them how great it is to see them looking healthy.

“It always helps to know somebody cares or somebody notices, because it’s not easy,” Ticknor said. “Recovery is probably harder than actually going for the treatment because it’s something you have to continue to do everyday. It’s a struggle. It has to be constantly on their mind. Do I make it through the day or is this the day I fall off the wagon?’”

This type of encouragement is especially important in the early stages of recovery, Dr. Crossley said. Working on patients who are still in rehab can be challenging, but it can also be gratifying.

“Patients in the early stages of recovery have low self esteem and feel like they’ve ruined their life,” Dr. Crossley said. “They go to the dentists and have their teeth cleaned. They don’t ache any more so there’s no excuse to take a narcotic. You fix up their front teeth so they can smile again. They start to build their self esteem and they feel good. It’s really gratifying to see that.”

What if it’s a colleague

Dentists have access to drugs through prescriptions and samples. They have stressful lives filled with social, financial and professional pressures. They often think because they know so much about pharmaceuticals and what different drugs do, they can handle using something to take the edge off, Dr. Storer said, but that typically isn’t the case.

When a dentist is abusing drugs, staff members usually notice first. Patients are complaining about the dentist’s behavior. Maybe he’s rude or showing up late for scheduled appointments. His handwriting might change. The inventory of controlled substances might go up, or someone might notice that he’s writing a lot more prescriptions for family and friends. His office behavior has changed, and everyone on staff knows something is wrong.

Even though you might want to confront him, Dr. Storer said that isn’t a good idea. If one of the hygienists on staff is the one to start the conversation, she may lose her job. If your practice is in a small town, rumors of a drug problem would bring scandal to the practice.

Instead, Dr. Storer recommends contacting your state’s concerned dentist program or another agency that handles addiction. You can tell the volunteers what’s happening at your practice and they’ll investigate. It’s an anonymous call that may save the person you’re concerned about.

“It shows the dentist there is a way out,” Dr. Storer said. “He doesn’t necessarily have to lose everything, and it’s better to do it voluntarily than to be forced to do it by a professional regulatory system. The idea is for these programs to intervene and get the doctor into recovery so he can practice again.”

When it’s an employee

These programs only investigate people who need a license to practice, so that means the program only works for dentists and hygienists. If you suspect another member of your staff has a problem, the best thing you can do is sit down for a one-on-one conversation (maybe include a witness) and encourage him or her to seek treatment. Remember you can’t necessarily fire an employee who has a substance abuse problem.

To help avoid this type of situation, Dr. Storer also suggests you put together a policy for the office that mandates everyone has to take a toxicology test. Include random drug tests and the right to ask an employee to take a drug test if you suspect there’s a problem with drug abuse. Make sure everyone on staff is aware of the policy.

Don’t forget they’re people, too

Whether it’s a patient, a colleague or a staff member who is affected by addiction, it’s important for you to know something about this disease and how to handle certain situations. It’s probably not something you’ll deal with everyday, Dr. Crossley said, but when it does come up, you and your staff need to be prepared.

“Preparation and knowledge are really helpful. And compassion, too,” Dr. Storer said. “My perception of drug abuse has changed in the 28 years I’ve been a dentist. Most people who use aren’t on the street. They’re using it as a coping mechanism to perform on a daily basis because for some reason or another they can’t take life on life’s terms. They need help.”