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Substance abuse in dentists
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Drug and Alcohol Use by Dental Healthcare
Professionals and Students
George A. Kenna, Ph.D., B.S.Pharm., R.Ph.
Assistant Professor of Psychiatry Center for Alcohol and Addiction Studies
Brown University, Providence RI
Clinical and Investigational Pharmacist
Miriam Hospital, Providence, RI American Academy of Oral Medicine 4/12/14
Learning Objectives:
Discuss the prevalence of alcohol and other drug use by dentists
compared to other healthcare professionals and to the general population
Consider if suicide rates are higher in the dental profession
Know the basics for identifying substance use disorders (SUDs) in
yourselves and colleagues
Recognize the basics for treatment and support
Understand the importance for dentists and dental students to be involved
in ongoing education of SUDs
American Academy of Oral Medicine 4/12/14
• While not citing any prevalence studies of substance use by dentists, Hedge (1985) estimated that as many as 15% to 18% of dentists could be addicted to drugs and alcohol.
• “Chemical dependency has received much attention as a
national problem, and current evidence suggests that it
may be more widespread among dentists than among the
overall population of the United States.” (Clarke, Chiodo,
& Cowan, 1988. )
• “The health professions may attract those vulnerable to drug abuse because of their emotional impairment due to alcoholic and emotionally abusive parents.” (Coombs, Drug Impaired Professionals, 1996)
Speculative Comments:
American Academy of Oral Medicine 4/12/14
• Several studies of dental students (Bowermaster, 1989; Sammon et al; 1991; Sandoval et al., 1988; 1990) suggested that many dentists come from dysfunctional families or families with a history of alcoholism or chemical dependency. e.g. Sammon et al. (1991) reported that 35-39% of students at two dental schools had an alcoholic parent or grandparent.
• Chiodo and Tolle (1997) drawing on non-representative disciplinary action data, deduced that dentists were at higher risk for substance use and abuse than the general population, and questionably concluded the literature had consistently reported disproportionately higher rates of chemical dependency in HCPs.
Speculative Comments:
American Academy of Oral Medicine 4/12/14
• Used qualitative or treatment samples
• Poor use of measures
• Assessed only one healthcare profession
• Used professional organizations to recruit
• No consideration of Type II error
Problems with many previous studies included:
―Prevalence of Alcohol and Other Drug Use and Abuse
in Healthcare Professionals
• The major aim of this study was to investigate the prevalence
of substance use in the major groups of HCPs using
methodologically sound criteria.
American Academy of Oral Medicine 4/12/14
Method
• Used validated measures
• Stratified by zip-codes
• Randomly chose Dentists, Nurses, Pharmacists, Physicians
licensed in Rhode Island, but living in RI, MA or CT only.
• 6 contacts over 8 weeks: Social-exchange theory (Dillman,
2001)
• 7 page self-report survey
• N = 479/697
• Response rate 68.7%
– MDs = 63.4% to RNs = 73.3%.
American Academy of Oral Medicine 4/12/14
Dentists
Registered
Nurses
Pharmacists
Physicians
Number of
Licensees*
755 18,927 1,917 4,174
Gender Men
80.3
Women
19.7
Men
10.7
Women
89.3
Men
51.6
Women
48.4
Men
74.3
Women
25.7
Demographics Supplied by the Rhode Island Department of Health
Note. The Department of Health figures differ from those used for the study as they include all
licensees regardless of state of residency.
(Kenna Dissertation, 2003) American Academy of Oral Medicine 4/12/14
American Academy of Oral Medicine 4/12/14 (Kenna & Wood, Journal of the American Pharmaceutical Association, 2004).
American Academy of Oral Medicine 4/12/14
(Kenna & Wood, Journal of the American Pharmaceutical Association, 2004)
American Academy of Oral Medicine 4/12/14 (Kenna & Wood, Journal of the American Pharmaceutical Association, 2004)
American Academy of Oral Medicine 4/12/14
(Kenna & Wood, Journal of the American Pharmaceutical Association, 2004). American Academy of Oral Medicine 4/12/14
American Academy of Oral Medicine 4/12/14 Kenna & Wood, Drug and Alcohol Dependence, 2004
Alcohol Use and Misuse During the Past Month
Dentists
(n = 81)
Nurses
(n = 70)
Pharmacists
(n = 87)
Physicians
(n = 69)
NHSDA
2002
Quantity by Frequency Index
Mean drinks/ month (SD)
26.7 *
(21.9)
20.5
(18.8)
18.4
(15.9)
17.9
(20.3)
Mean drinking days/month 12.6*
(8.4)
10.7
(7.9)
9.3
(6.7)
10.0
(7.8)
Mean drinks/drinking day 2.1
(1.1)
1.9
(.86)
2.0
(1.0)
1.7
(.88)
Heavy episodic alcohol use (%) 15.9 * 8.5 12.0 7.7 18.1
Heavy alcohol use (%) 0.9 0.8 0 1.9 5.7
Consider self a heavy drinker (%) 0.9 0 0 1.9
Consider self a problem drinker (%) 0.9 0 0 0
Kenna & Wood, Drug and Alcohol Dependence, 2004
*P<.05; **P<.01; ***P<.001
American Academy of Oral Medicine 4/12/14
Kenna, G.A. & Wood, M.D. Journal of the American Dental Association. July 2005; 136: 1023-1032.
American Academy of Oral Medicine 4/12/14
0.8
American Academy of Oral Medicine 4/12/14
American Academy of Oral Medicine 4/12/14
Kenna, G.A. & Wood, M.D. Journal of the American Dental Association. July 2005; 136: 1023-1032.
American Academy of Oral Medicine 4/12/14
Kenna, G.A. & Wood, M.D. Journal of Substance Use, 2005; 10 (4): 225-238.
American Academy of Oral Medicine 4/12/14
0
10
20
30
40
50
60
70
Den t ist s Nur ses Phar macist s Physician s
One or more f amily members
*P<.05; **P<.01; ***P<.001
***
Family History of Alcohol Problems
American Academy of Oral Medicine 4/12/14 Kenna, G.A. & Wood, M.D. Journal of Substance Use, 2005; 10 (4): 225-238.
0
5
10
15
2 0
2 5
3 0
Den t ist s Nur ses Phar macist s Physician s
One or more f amily members
Percen
tage
*P<.05; **P<.01; ***P<.001
**
Family History of Drug Problems
American Academy of Oral Medicine 4/12/14 Kenna, G.A. & Wood, M.D. Journal of Substance Use, 2005; 10 (4): 225-238.
Summary of Results • General Results
• The prevalence of illicit drug use by HCPs only slightly exceeds that of the general population
• Based on self-report those HCPS who report illicit drug use appear more poly-drug experienced (data not shown)
• Dentists consumed significantly more alcohol than all but nurses
– More reported past month use of marijuana however the
prevalence of drug use by Dentists does not exceed that of other
HCPs
– Received significantly more offers to drink alcohol in social
situations than other HCPs (data not shown)
– Lowest proportion of family history of alcohol and drug use of
HCPs surveyed
American Academy of Oral Medicine 4/12/14
Learning Objectives:
American Academy of Oral Medicine 4/12/14
Discuss the prevalence of alcohol and other drug use by dentists
compared to other healthcare professionals and to the general
population
Consider if suicide rates are higher in the dental profession
Know the basics for identifying substance use disorders (SUDs) in
yourselves and colleagues
Recognize the basics for treatment and support
Understand the importance for dentists and dental students to be
involved in ongoing education of SUDs
CAUSES OF STRESS IN DENTISTRY
•Confinement and Physical problems often sitting in one position
•Isolation
•Economic pressures
•Time pressures
•Compromise treatment frustration
•Patient anxiety
•Lack of exercise
•Alcohol use increases stress, anxiety and sleep problems
•Dentist's personality • compulsive attention to details;
• extreme conscientiousness;
• careful control of emotions;
• unrealistic expectations of himself or herself and others (i.e. employees and
patients);
• a marked dependence on individual performance and prestige. Lang R DDS (2007) http://www.oralhealthgroup.com/news/stress-in-dentistry--it-could-kill-you/1000214585/?&er=NA
American Academy of Oral Medicine 4/12/14 Roberts et al., High-risk occupations for suicide. Psych Medicine 2013 Jun;43(6):1231-40.
American Academy of Oral Medicine 4/12/14 Roberts et al., High-risk occupations for suicide. Psych Medicine 2013 Jun;43(6):1231-40.
American Academy of Oral Medicine 4/12/14
Are suicide rates higher in the dental
profession?
• No strong evidence to support this notion – Alexander (2001) and Sancho & Ruiz (2010) found little
valid evidence that dentists are at greater risk for suicide
than the general population.
– Looking at Roberts et al (2013) data, perhaps just
coincidental
• More data is needed
Sancho FM, Ruiz CN. Risk of suicide amongst dentists: myth or reality? Int Dent J. 2010 Dec;60(6):411-8.
Alexander, Stress-related suicide by dentists and other health care workers Fact or folklore? JADA
2001 132, 786-794 .
American Academy of Oral Medicine 4/12/14
Learning Objectives:
American Academy of Oral Medicine 4/12/14
Discuss the prevalence of alcohol and other drug use by dentists
compared to other healthcare professionals and to the general
population
Consider if suicide rates are higher in the dental profession
Know the basics for identifying substance use disorders (SUDs) in
yourselves and colleagues
Recognize the basics for treatment and support
Understand the importance for dentists and dental students to be
involved in ongoing education of SUDs
What is a Substance Use Disorder?
American Academy of Oral Medicine 4/12/14
American Academy of Oral Medicine 4/12/14
American Academy of Oral Medicine 4/12/14
Statement on Substance Abuse Among Dentists
(Trans.2005:32)
Resolved, that the following ADA Statement on Substance Abuse among Dentists be adopted.
Statement on Substance Abuse among Dentists
1.Dentists who use alcohol are urged to do so responsibly. Dentists are also urged to use
prescription medications only as prescribed by an appropriate, licensed healthcare professional
and to avoid the use of illegal substances.
2.Colleagues, dental team members, and the dentists’ family members, are urged to seek assistance
and intervention when they believe a dentist is impaired.
3.Early intervention is strongly encouraged.
4.Dentists with addictive illness are urged to seek adequate treatment and participate in long term
monitoring protocol s to maximize their likelihood of sustained recovery.
5. Impaired dentists who continue to practice, despite reasonable offers of assistance, may be
reported to appropriate bodies as required by law and/or ethical obligations.
6. Dentists in full remission from addictive illness should not be discriminated against in the areas
of professional licensure, clinical privileges, or inclusion in dental benefit network and provider
panels solely due to the diagnosis and recovery from that illness.
7.The ADA encourages additional research in the area of dentist impairment and the factors of
successful recovery.
American Dental Association Current Policies Adopted 1954-2012 Copyright
2013, American Dental Association, 211 East Chicago Avenue, Chicago, Illinois 6061
Teaching Dentists and Dental Students about
Substance Use/Dependence
American Academy of Oral Medicine 4/12/14
Statement on Substance Use among Dental Students (Trans.2005 :329)
1. The ADA supports educational programs for dental students that address professional
impairment associated with substance abuse.
2.Dental students who use alcohol should strive to do so responsibly. Dental students are
also urged to use prescription medications only when prescribed by an appropriate,
licensed healthcare professional and to avoid the use of illegal substances.
3. Dental school administration and faculty are encouraged to promptly intervene once
aware of inappropriate substance use by a student.
4. Dental schools are strongly encouraged to support a student’s referral to an addiction
treatment program, if appropriate, and indicated by a thorough evaluation, prior to
making disciplinary decisions.
5.Dental schools are encouraged to support only the responsible use of alcohol on their
premises or at their functions or by faculty when with students in social settings.
American Dental Association Current Policies Adopted 1954-2012 Copyright 2013,
American Dental Association, 211 East Chicago Avenue, Chicago, Illinois 6061
American Academy of Oral Medicine 4/12/14
The Story of Lance Smith
Graduated Posthumously Class of 2001
American Academy of Oral Medicine 4/12/14
The odor of alcohol on the breath or strong odor of mouthwash or mints to mask the
alcohol.
Hand tremor that occurs (when in alcohol withdrawal)
Excessive perspiration
Absent from work without notice, frequent absenteeism or late for work (? Alcohol
abuse)
Unexplained disappearance during work for long periods of time
Sleeping or dozing off while on duty
Frequent bathroom breaks
Deterioration in personal appearance
Reports of illness, minor accidents, and emergencies
Confusion, memory loss and difficulty concentrating
Increase in sloppy recordkeeping.
Work performance that alternates between periods of high and low productivity.
Unreliability in keeping appointments and meeting deadlines
Personality changes and mood swings
Behavioral signs and symptoms of AOD use
American Academy of Oral Medicine 4/12/14
• Probably the most difficult professional decision a
dentist can make is to confront a co-worker with an
AOD problem.
• Dentists should consider that many colleagues in
retrospect feel that an intervention probably saved their
lives.
• As with physicians, nurses and pharmacist, if dentists
cooperate with treatment it is generally expected that
most will be allowed to resume their profession.
Taking Care of Your Own:
American Academy of Oral Medicine 4/12/14
Learning Objectives:
American Academy of Oral Medicine 4/12/14
Discuss the prevalence of alcohol and other drug use by dentists
compared to other healthcare professionals and to the general
population
Consider if suicide rates higher in the dental profession
Know the basics for identifying substance use disorders (SUDs) in
yourselves and colleagues
Recognize the basics for treatment and support
Understand the importance for dentists and dental students to be
involved in ongoing education of SUDs
Recovery Assistance Programs
•If a dentist requests help from a counseling agency, they will not
be reported
-the information they provide is by law confidential.
•However first step is usually inpatient treatment
•Inpatient e.g. Hazelden (part of Betty Ford Foundation),
The Farley Center, Talbott Recovery Center etc;
•Followed by Outpatient counseling programs.
•Referral to 12 step programs e.g. AA, NA etc.
•Caduceus is a 12-step program just for healthcare
professionals
American Academy of Oral Medicine 4/12/14
American Academy of Oral Medicine 4/12/14
Treatment Success
•The goal of returning a recovering dentist to practice with
the proper aftercare and monitoring program is realistic and
almost always successful.
•No data for dentists but a 1988 survey examined pharmacist
assistance programs in all 50 states and the District of
Columbia.
•Just over 88% of pharmacists successfully completed
treatment and returned to practice.
McNees, G.E., & Godwin, H.N.. American Pharmacy, 1990; NS30 (5):33-37.
American Academy of Oral Medicine 4/12/14
Learning Objectives:
American Academy of Oral Medicine 4/12/14
Discuss the prevalence of alcohol and other drug use by dentists
compared to other healthcare professionals and to the general
population
Consider if suicide rates are higher in the dental profession
Know the basics for identifying substance use disorders (SUDs) in
yourselves and colleagues
Recognize the basics for treatment and support
Understand the importance for dentists and dental students to be
involved in ongoing education of SUDs
Dental School Curricula
Huggett et al
40
American Academy of Oral Medicine 4/12/14
For Practicing Dentists
CMEs e.g.: http://mediasite.video.ufl.edu/Mediasite/Play/20a
372f19a0e4855a2f8c7f0041e3b711d
American Dental Association Health and Wellness Resources etc http://www.ada.org/4503.aspx
American Academy of Oral Medicine 4/12/14
For over 20 years, the ADA has actively supported the Dentists
Section of the Utah School on Alcoholism and Other Drug
Dependencies in Salt Lake City.
-Annual weeklong program to bring together dentists and
dental students (as well as many other groups of healthcare
professionals and others) with various state coordinators, state
administrators, industry representatives and interested persons
from around the country to listen to updates on various aspects of
AOD intervention and treatment.
Dental Section
http://medicine.utah.edu/uas/Dental%20Introduction.htm
American Academy of Oral Medicine 4/12/14
Conclusions •Rates of AOD abuse or dependence among dentists may be no greater than in the
other healthcare professionals and is similar to the general population but the
consequences of any impairment can have adverse effects on the dentist, practice and
patients.
•Alcohol use seems to be greater among dentists than other healthcare professionals
and is the greatest (drug) threat to a dentists health.
•Family history of alcoholism/drug appears lowest of major healthcare professions
•Stress is a ubiquitous problem for dentists but probably not more so than many
other jobs in the healthcare professions.
•Suicide does not appear to be a greater problem in dentistry than in any other
healthcare professions, but more data is needed.
•The profession has an ethical obligation to ensure that its practitioners can
discharge their duties with skill and safety.
•Policies should promote early discovery of professionals who overuse AOD in order
to minimize the period of time that patients are at risk of being harmed.
•Treatment is almost always successful.
American Academy of Oral Medicine 4/12/14