Patients admit, but they omit. They don’t always tell you every drug they take, which creates a challenge for treating them safely. One way to protect them is by staying educated, and Kirk Behrendt brings back Tom Viola, “Mr. Pharmacology”, to share critical information about popular street drugs and how they can affect patients while they’re in your chair. By learning more about the drugs people take, you can potentially save more lives! To learn what dental school never taught you about drugs, listen to Episode 548 of The Best Practices Show!
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Links Mentioned in This Episode:
Chicago Midwinter Meeting schedule: https://www.cds.org
Hinman Dental Meeting schedule: https://hinman.org/Education-Events/Courses
Greater New York Dental Meeting schedule: https://www.gnydm.com
Star of the North Meeting schedule: https://star.mndental.org
People today have greater access to drugs.
Educate yourself on common and popular substances.
Patients don’t always tell you every drug and medication they take.
Use verbal skills when asking patients about substance use or abuse.
Know how to detect substance use in your patients and how to get them help.
“Pharmacology is like the Rosetta Stone. If you know a patient’s medications, you know everything about them. All you need to have is a list of medications and a working knowledge of pharmacology, and you’ve got everything you need to fill in that medical history with everything that’s important for today and for the future, as far as treating that patient. So, it’s building treatment plans, it’s building the rapport, but it’s treating the patient as safely as possible.” (2:42—3:07)
“Twenty-five years ago, when I first got started in dental pharmacology, when I first designed that form that people would fill out for their medical history, I left spaces for people to write in the names of their medications. I left five spaces, and most people filled in three. So, can you imagine — 25 years ago, people took three medications. Now, if they have cardiovascular disease, that’s three drugs just by itself. Then, you add on GI, respiratory, diabetes, the list goes on and on. It’s not uncommon now for patients, on average, from what I’m seeing just working with my students, eight to ten meds — eight to ten medications! Plus, the over-the-counter drugs, the dietary supplements. It’s an incredible, long list of things. And with every new drug comes new complexity for dentistry, which is why we do what we do.” (4:57—5:43)
“Patients either give you the wrong information or don’t want to tell you everything about them. And there are numerous reasons why. Sometimes it’s also, ‘I’ll tell you, but I won’t tell you the extent to which.’ So, for example, alcohol is a good one. Tobacco, another good one. Marijuana, another good one. ‘Do you use marijuana?’ ‘Occasionally.’ But what is your definition of occasional? And lately, it’s this topic of street drugs. What really is not a street drug anymore — I would say there are substances of abuse that are in the fringes. They’re not mainstream drugs, but they’re becoming more mainstream, and more and more people are being exposed to them. So, do you, as a dental professional, know everything you need to know about that substance to be able to treatment plan around it? Were you taught about it in school? Where would you get an education on a “street drug” or a substance of abuse if you’ve never even heard of it before?” (6:43—7:36)
“If I had to say to an average dental professional, ‘Give me an example of a street drug,’ I think some people would say heroin. Some people might say cocaine or methamphetamine. But when you think about it, those drugs have been around for 20 to 30 years. And at the same time, the heroin that I saw people doing on the streets of New York City when I lived there so many years ago, that heroin is nothing like the heroin that’s available today. That potency back then may have been somewhere around 8% to 10%. Now, the potency of heroin that’s available on the street is upwards of 80% to 90%.” (7:59—8:33)
“Beyond what we call mainstream street drugs or substance abuse are the more exotic ones. The one that’s affecting a lot of communities right now is a drug called xylazine, which is known on the street as “tranq” because it’s a tranquilizer. But it’s mixed with so many other drugs, heroin and fentanyl, especially. And the problem is, it’s so popular, it’s so attractive that it gets mixed into the “drug supply”. Even though you didn’t ask for it, you get it anyway.” (8:43—9:17)
“People ask me this all the time, ‘Why is fentanyl so popular?’ Every time I hear anybody talking about drugs, it’s fentanyl, fentanyl, fentanyl. The answer is micrograms. That’s the best way I can describe it. Fentanyl is so super potent that you only need micrograms of the drug. Now, that’s less than a milligram, a microgram of this drug, to get some feeling. So, number one, that means, what? It’s easy to conceal because you only need a very little bit. It’s easy to transport because, again, you only need a little bit. So, it’s not like you’ve got this big package of hashish or this big package of cannabis you’re trying to carry around. You can carry this in a tiny, tiny, little bag in your pocket without anybody really noticing. So, a small amount of drug yields a big return. Fentanyl will always reign supreme because it has this super potency. A little goes a very long way.” (9:54—10:57)
“I get this all the time, and it’s a very good question, ‘Hey, Tom. I work in a pretty nice neighborhood. I don’t have people that are strung out on drugs lying on the street or in shelters around me. Most of my clientele are middle class or upper middle class. They’re not going to be the type to use fentanyl and xylazine.’ And that’s the problem. The problem is, people who are not in the mode of staying under the influence of a drug all the time will use smaller doses and will use enough so that they can still function, but still use at the same time. So, you don’t get to the point where you’re under the influence of this combination of two drugs for days at a time, but maybe for several hours.” (14:02—15:52)
“At some point, I need to see a dentist. Right? At some point, I need to see my hygienist. And you may not suspect that this person is using fentanyl with this drug, xylazine, in it. You might think this person doesn’t do any drugs at all because they don’t mention it on their medical history. They don’t “look” like someone that uses fentanyl with xylazine mixed in it. But what if they need anesthesia? What if they need sedation, conscious sedation? Now, even though they haven’t mentioned it on their medical history, and never mentioned it to you — it doesn’t even come up in conversation — that becomes life-threatening because the drugs that we use for sedation, some of the drugs that we use, anxiolytics, even nitrous oxide, can increase the potency of these drugs, fentanyl and xylazine, dramatically.” (15:59—16:45)
“You might say, ‘Who would be nuts enough to use fentanyl and xylazine before they go to see the dentist?’ And that’s when I always say, what’s one of the most stressful places a patient can find themselves? In your dental chair. So, in that case, why wouldn’t they use the fentanyl and xylazine in advance of the dental appointment to escape what they consider to be the pain that they’re going to experience in the chair? So, that’s where the medical mystery and medical emergency comes from.” (16:46—17:13)
“I decided the easiest way to do it was to be flat-out honest and ask point-blank. In the nicest voice and with the biggest smile on my face, I say, ‘Have you had, or do you currently have, an issue with a substance abuse disorder? Do you have an issue with substances? Can you say that you rely on a substance on a somewhat regular basis to get through your busy, trying days?’ And just let it hang in the air. It’s awkward and it’s uncomfortable for the first five seconds. But then, when the patient realizes you mean them no harm and that you’re not going to be calling the police and that you just honestly need to know that information, that’s when it comes out.” (18:30—19:13)
“You and I might talk about a glass of wine, ‘How many glasses did you have?’ I might admit to three, but I probably had six. It might just be that with using fentanyl and xylazine. Again, there’s no cookie-cutter approach to this. Every patient is going to be different. Some patients might take offense. But always try to keep it as light as possible, and keep it coming from the perspective of, ‘Look, we deal with thousands of patients. We’re not here to judge. We’re just here to get all the information we can to keep this appointment safe for you. So, we’re not judging. We just need to know.’ And that’s what I say over and over again. And when you say it like that, and when you let it hang there, and you don’t say anything else, after you ask that question, ‘Do you currently have, or have you had an issue with substances or a substance abuse disorder?’ stop talking. Let them talk. And they might say no. So, maybe you qualify a little bit and say, ‘What I mean is, do you use substances like a lot of people use, like cannabis? Have you tried fentanyl?’ ‘Maybe two or three times.’ If you get a no each time, then fine. Then, I think you could say you’ve probably exhausted every effort. But I think when you ask a few times, and you keep it light, and you keep the smile on your face and come from that perspective of, ‘Look, just trying to get the information here. Not just you, it’s thousands of patients,’ those people who really do use it were more than likely to admit to some part of using it.” (19:17—20:43)
“A lot of people won’t tell their medical doctor, their physician’s assistant, their nurse practitioner, about these strange sores on their arm that have developed as a result of this drug, xylazine. That’s the thing about xylazine. If you inject fentanyl that’s mixed with xylazine, you will get these sores on your arm that don’t heal very well — as a matter of fact, sometimes, become gangrenous and sometimes lead to amputation. So, ‘I don’t know what’s going on, but I’ve got these sores on my arm. They don’t look really good.’ I may not tell that to anybody, but I might tell you, the dentist or the hygienist, because you’re approachable. You’re easy to talk to. ‘Hey, you bothered enough to ask me, so here it is.’ Are you ready for that answer? What do you do then? So, that’s why you listen to podcasts like this, you come to courses like mine so you can say, ‘Okay, here’s what you’ve got to do.’” (20:47—21:38)
“The first thing you’ve got to do [if you have a patient with xylazine sores] is get them to see a medical doctor. And again, it’s no stigma. Ge them to see a medical doctor. Get that wound addressed because it could get bad quickly. We don’t want anybody getting amputations for a reason of, ‘Well, we only took a look at it.’ Get them medical help and let them know that they’re not the only ones. That way, you’ve taken a situation that could be potentially deadly for that patient and literally save their life. And you’ve heard me say that before. Dentists, hygienists, and assistants, save people’s lives every day because you save them from themselves. They don’t make very well-informed or well-thought-out decisions because they’re not experts. That’s where we come in.” (21:38—22:22)
“Stimulants [are important to know about]. I can’t say it enough. I know a lot of people really hang their hat on energy drinks and stuff like that. But I will tell you that ADHD medication still, ADD medication, still ranks up there as a stimulant that a lot of people use because, quite frankly, their insurance company pays for it. So, I don’t have to go out and buy methamphetamine, although it’s cheap enough now. I don’t have to go out there and buy cocaine. I can buy Adderall or Vyvanse. By prescription, my doc writes me the script. I go to the pharmacy, and I get them filled. It costs me virtually nothing, whatever my copay is. I come back to my room, if I’m a student in school, I come back to my house, and maybe four out of the seven days that week, I take my Concerta, my Vyvanse, or whatever, the way I’m supposed to, every day. But for the other three days, I crush the tablets up and I snort them. Now, nobody’s going to know this, number one, because it came out of the same bottle. And if anybody were to do a drug test on me, what would they find? I’ve already admitted I take Concerta. So, why would you look for anything else? But I’m not using it the way I’m supposed to. I’m using it in a way that I wasn’t supposed to. And yet, it flies under the radar, and nobody knows about it. So, stimulants scare me because of the access. And it’s the same thing with cannabis.” (22:35—24:01)
“Children have never had greater access to cannabis and stimulants than they have today. In my day, it was alcohol. My mom and dad would lock up the cabinet with the alcohol in it. But now, most homes have, perhaps somebody uses cannabis, even if it’s for medical reasons. Or maybe they have a child that uses medications like ADHD medications. The access is there. So, if you don’t know to think about it or ask about it, it won’t even show up on your radar. So, that’s why you ask the question as generically as possible, ‘Do you have any issue with substances? Do you have a substance abuse disorder?’” (24:06—24:45)
“What if [when you ask about substance use, a patient says], ‘I don’t know. Oh, you know, once in a while, I take . . .’ Go on the NIH.gov website. It’s right on the front page. Download the questionnaire. Hand it to the patient and say, ‘Fill this out.’ And just from their scores alone on that page, you could pretty much tell if they may have an issue with substance use. And that will help you make some more informed decisions about what to do with sedation, with the analgesics. If I’m using fentanyl and xylazine, and then I’ve had enough done that I need an opioid for my pain control, wow, that’s a lethal combination, adding an opioid to the fentanyl and xylazine I’m already using. Unwittingly, the dentist may have created that cocktail because he or she prescribed it without knowing the patient was on these other two drugs.” (24:45—25:31)
“The other thing that scares me a little bit besides stimulants is the drugs that you don’t know the patient is using. So, there are drugs out there, for example, Suboxone. Suboxone is prescribed for patients who have an opioid addiction to prevent relapse. But Suboxone in high doses actually causes an opioid-like effect. So, there are people out there that are addicted to Suboxone. The drug that they were using to treat the addiction has become the drug of the addiction. ‘Well, then somebody will find out.’ Really? How will they find out? They’re going to do a urine test and, ‘Whoa, it says Suboxone.’ ‘Well, I’m supposed to be on Suboxone.’ It’s that kind of hidden substance abuse that really makes it valuable for a dental professional who’s listening right now to say, ‘Hmm. Let me ask that question. How bad could it be? If I’ve got to know, I’ve got to know. But at least let me ask so that I cover myself and I protect my patient from themselves.’” (25:33—26:30)
“A lot of people who attend my lectures say, ‘I love everything you said, Viola. But the problem is, if I did everything your way, I’d need 15 minutes just for the medical history. I basically have three to four minutes to get all the information down. I can’t do everything you said.’ And I agree with them and say, ‘Okay, here’s what you do. You just ask a few questions, but ask good ones, a minute each. And don’t rely on asking questions to get all your information. Get the names of the medications. Anyone in your office can do that for you. They can make sure the patient has listed all their medications. So, when you look at that list of medications, you know, when you attend enough of my lectures to figure out, ‘Okay. This drug does this. This drug does that.’ Even if you have to look it up, you’re going to get a better sense for that patient than you would have if you didn’t pay attention.” (27:40—28:24)
“I’ve gone to dentists myself who never took my blood pressure, never took my pulse, never looked at my medical history. Didn’t know anything about me and just got right to work. Even some hygienists. So, the point is, now is our chance to change things to become more patient-centric and realize that we’re not just in the business of treating the mouth, we’re in the business of treating the person to which that mouth is attached, and all that comes with it, including becoming more knowledgeable about everything they’re putting in their bodies.” (28:29—28:59)
1:58 Tom’s background.
3:57 Why pharmacology is important in dentistry.
5:44 Patients often give you the wrong information.
7:37 Street drugs, defined.
9:18 The dangers of fentanyl and xylazine.
13:46 Why this is important in your practice.
17:20 How to begin the conversation with patients.
22:22 What to be aware of about other street drugs.
26:31 Ask patients short but meaningful questions.
29:13 Last thoughts on street drugs.
31:21 More about Tom’s courses, webinars, and future courses.
Tom A. Viola, R.Ph., C.C.P. Bio:
With over 30 years of experience as a pharmacist, educator, speaker, and author, Tom Viola, R.Ph., C.C.P., has earned his reputation as the go-to specialist for delivering quality continuing education content through his informative, engaging presentations. Tom’s sellout programs provide an overview of the most prevalent oral and systemic diseases and the most frequently prescribed drugs used in their treatment. Special emphasis is given to dental considerations and strategies for effective patient care planning.
As a clinical educator, Tom is a member of the faculty of 12 dental professional degree programs and has received several awards for Outstanding Teacher of the Year. Tom instructs dental hygiene students and practice dental hygienists in pharmacology and local anesthesia in preparation for national board exams. As a published writer, Tom is well-known internationally for his contributions to several professional journals in the areas of pharmacology, pain management, and local anesthesia. In addition, Tom has served as a contributor, chapter author, and peer reviewer for several pharmacology textbooks. As a professional speaker, Tom has presented continuing education courses to dental professionals internationally since 2001. Meeting planners agree that Tom is their choice to educate audiences within this specialty.