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782: Synthetic Opioids in Dentistry – Tom Viola, R.Ph., C.C.P.

We think we know about drugs and the people who use them. But there is so much we get wrong — and it could be harming our patients! To help you prevent harm and improve your prescribing practices, Kirk Behrendt brings back Tom Viola, “Mr. Pharmacology” and founder of Pharmacology Declassified, to share critical information about synthetic opioids and how it can affect your patients and practice. To expand your knowledge on this complex topic, listen to Episode 782 of The Best Practices Show!

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Main Takeaways:

  • Patients are more medically complex than ever.
  • Be familiar with current, older, and mainstream drugs.
  • There will always be a new drug to be concerned about.
  • Some drugs that your patients take will go under the radar.
  • Use pharmacology to deduce the right questions to ask patients.
  • A complete medical history can prevent dangerous drug interactions.
  • Ask patients what they take, why they take it, and if they took it today.
  • Don't assume anything when it comes to medication and patients’ health.
  • Always document that you had the drug use conversation with your patient.

Quotes:

“Your patients have never been so medically complex. They are taking more medications these days, they are treating more disease states these days, and we are identifying more disease states these days. We are diagnosing disease states earlier in life. So, you've got people living longer who are treating diseases longer with more and more medications. As a dental professional these days, you've got to walk down two sides of a very narrow street. You have to be knowledgeable in every drug we use in dentistry — analgesics, anesthetics, anti-infectives — because any one of those can affect a patient's medical care and the drugs they use to treat their medical conditions. But at the same time, you’ve got to be an expert and walk down this side of the street, because here you know everything about every medication and every disease state a patient is treating with those medications because any one of those can affect dentistry. So, you've got to be an expert in the medical side of dentistry and the dental side of medicine. And that is a tall order.” (5:28—6:24) -Tom

“You don't know the demons that lurk behind the facade. Lots of folks have internal demons. I do — and I'm not ashamed to say it. They're out there, and they’ve plagued me for years. Everyone has demons, no matter what they are. Sometimes, the demon is substance use disorder. Not me, personally, but I've had family members who have dealt with it. So, you never know what demons a person is dealing with or trying to conquer. And as dental professionals, yeah, we talk all about medical histories. I'm sure you've heard me say it a thousand times, ‘Take the medical history! Take the medical history!’ But it's not just that. It's also looking behind the medical history, looking behind the facade that people put up and seeing, what else is brewing here? What else should I be aware of, and should I be accommodating for this patient? Because heck, if that person is dealing with anxiety, for example, find me a more stressful place in this world than a dental chair when you're a layperson and don't know what's going on in that dental office.” (7:58—8:58) -Tom

“The joke I tell everybody is, you walk into a medical office, and you walk in the back. What do you see? Doors. Little rooms and little doors, and everybody is safe behind their little door. You don't ever see anybody, but they're there. You can hear them. Then, you walk into a dental office, and it's like walking into a little shop of horrors. You see open operatories, all the humans on their backs just laying there. You hear high-speed instrumentation like drills and Cavitrons. You smell things like burning flesh, and you're like, ‘What kind of place is this?’ Then, you get in the operatory in your own chair, and everybody comes at you from behind. So, you're always like, ‘What's going to happen next?’ It's nerve-racking and tension-producing and anxiety ridden. So, we're going to take a person who may have issues with depression or anxiety — who may be using substances that may alter their response to a real-life situation — and putting them into one of the most stressful situations a patient can find themselves. That's why we have to be able to have that sixth sense to read beyond the medical history, to find out what's lurking back there that we may have to deal with.” (8:58—10:07) -Tom

“When you hear ketamine, especially some of us more seasoned clinicians in dentistry, we’ll remember ketamine is something we actually used in dentistry for a while as a dissociative hallucinogen to basically dissociate the patient from the procedure that we were doing. In some states, it’s still common practice to use ketamine. Ketamine is often used as a veterinary anesthetic. So, you get both ends of the spectrum. But ketamine is often used now to treat depression in a clinical setting when other forms of depression treatments aren't working. Ketamine is used for a wide variety of different illnesses and different psychosis. So, all we know for sure is that Matthew Perry had issues with substance use disorder in the past, and ketamine may have been a substitute for some of the other substances he was no longer using. Again, I don't know the man. I don't know him personally. I can't speak to any of those points, other than to say if that was the case, he led an exemplary life trying to tell people to not use substances, to push people to have the courage to walk away from substances. Yet, he himself was still a victim of substance use disorder. So, imagine, if he's out there, what other examples we might have of people who are fighting that brave fight every day.” (11:24—12:47) -Tom

“My cousin, who passed away from opioid use disorder, said this to me prior to his death. He said, ‘You know, Tom, this disease is the one disease that people blame you for. If you have cardiovascular disease, nobody blames you and says, did you have one too many cheeseburgers in your life? Or if you have diabetes, nobody says, did you have one too many donuts in your life? But when you have substance use disorder it's, why don't you get over it already? What's taking you so long? Snap out of it. Get sober already.’ It's a disease. And sometimes, even despite our best efforts, we're not successful in treating it.” (12:52—13:27) -Tom

“We have to be aware that there are those folks out there who might be using these substances leading what appears to be normal lives. And yet, if we now start using the drugs that we're used to using in dentistry — like opioids to treat pain and some sedatives for conscious sedation and minimal oral sedation — we could be putting their lives at risk because we simply don't know that they're using these drugs recreationally.” (16:11—16:35) -Tom

“I have to realize there's always something new, that I don't think I really know everything, because as soon as I think I know everything about substance use disorder, there's yet another drug to be concerned with.” (17:08—17:18) -Tom

“If you're asking, ‘Why do I need to know [about drugs like nitazine, phenibut, and gabapentin], Tom?’ The answer is because they're going to go under the radar for most people. If you're thinking, ‘Well, yeah. But if people are using these drugs, they're going to probably show up on a urine test.’ No, they're not. As a matter of fact, gabapentin is never going to raise a red flag on a urine test. If I'm taking gabapentin for chronic pain, yeah, it'll show up in my urine. Guess what? I'm taking it in higher doses than anybody knows to get that opioid-like effect. Therefore, I can fly under the radar for a long time. Now, why that matters is, no one is going to mention this in a medical history. If they do, I'd be surprised. You're going to use sedatives for conscious sedation. You're going to use things like propofol, and you're going to use benzodiazepines. You may prescribe an opioid to treat someone's pain. ‘How do I get this information, Tom, if nobody wants to tell me?’ The answer is, you've got to be creative in the way you ask questions.” (18:56—19:56) -Tom

“What does the question look like? This is my take. You can use any word you like. My take is, ‘Look, I really don't want to know if you're using any substances. To be honest, it's none of my business. Therefore, I really shouldn't know. However, everything you do, every drug you take, every substance you use can impact anything I'm going to use to treat you today, and that may cause you harm. I don't want to cause you harm. So, I guess, in a way, I am asking about any other substances you use because I need to know to keep you safe. Just tell me everything. It doesn't have to go anywhere. I'm not the police. I'm not the DEA — it's going to stay here. But between you and me, I need to know.’ And then, stop talking. It’s the hardest thing to do because it's going to bring up an awkward, uneasy silence. Dead air, as I like to call it. It's okay. Give them the space to say what it is they have to say in a safe environment, knowing full well — you've reassured them that it's not going anywhere. That's when you're going to get it, if you're going to get it at all. Now, if they don't tell you, they don't tell you. But what's important here is that you made the effort. And please, from the litigious side of things, make sure you document that you had that conversation. It’s so important.” (20:22—21:39) -Tom

“[When you document], it could be something as simple as, ‘Patient denied the use of other substances,’ or, ‘Patient denied the use of other opioids or other substances, of a potential substance use disorder.’ However you want to word it, it doesn't matter. The point is you do have to document it. You may not want to document a lot. I get it, because you've already promised the patient it wouldn't go anywhere. But remember, you don't operate on an island. Dentistry is a lot like operating on an island, and I get it. You work in your own practice, you do your own thing, and sometimes being able to conference with other people in the profession is limited. That's why you go to meetings. But the point is, you don't work on an island in your office. Meaning, you're not the only practitioner. If you're a solo practitioner, great. But there are people in that office — there's your hygienist, your assistant — who need to know this information too. If you work with another colleague, they're going to need to know it too. So, make sure you document enough to get the point across without straying from whatever you promised this person. Again, your files are yours. But I want to make sure that you honor that, that it's going to stay between the two of you — but you have to document. If you don't document it, it never happened. Trust me, I've been through enough of these proceedings. Three years from now, some smart aleck attorney is going to ask you, ‘Oh. So, tell me about that day. What do you remember about that patient on that day and their clinical suitability for a procedure that day? What did you feel as far as their suitability for treatment?’ You're going to have to try to convince everyone in that courtroom that you remember that patient, from that day, three years ago, after you've seen a thousand patients since. It's just not going to happen. But if you document it, it's indisputable.” (21:59—23:47) -Tom

“Ask the questions. Amongst the team, everybody who walks in asks one or two questions. The three big questions have to be, when you're going over the medications, ‘What do you take?’ Don't say the word medication, like, ‘Oh, I want to know what medications you take,’ because they're only going to talk to you about medications, little bottles they get from the pharmacist, and there's way more that you need to know about. You need to know about over-the-counter drugs, dietary supplements, substances — you need to know everything. So, ‘What do you take,’ is as open-ended as you can get. Let them talk, and you keep writing or typing. ‘Why do you take it?’ It's important for two reasons. One, because it establishes buy-in. I want to take this person's temperature. Are they really taking prescription drugs the way they should, the way their doctor told them to, or are they taking it willy-nilly, whatever they feel like? That's going to tell me if they're going to do the same with the medications I'm going to prescribe them. But also, there are a lot of medications that are used for more than one thing. And you don't want to assume anything. So, if I'm on a blood pressure medication like amlodipine, Norvasc, well, somebody could be using that for blood pressure, certainly hypertension, but they can be using it for angina. They could be using it for arrhythmia. I have no idea why they're using it, and that matters. Those are different medical treatments, but those are also different treatment plans, as far as I'm concerned. And then, ‘Why do you take it?’ has to lead to, ‘Did you take it today? You're telling me you're taking amlodipine for hypertension. I just took your blood pressure, and it's elevated. Did you take it today?’ If your blood pressure is elevated and you're taking amlodipine, guess what? Amlodipine is not working, in my opinion. Everyone who sits in your chair who is taking medication for hypertension should have normal to slightly elevated blood pressure. If they don't, then they're not taking their medication, or not taking it correctly, or they're taking the wrong medication. So, those are the questions that inspire a lot of other questions. And again, it can get out of hand. It can go awry, and you could be spending a lot more time on medical histories than you want. But that's why you've got to use pharmacology to deduce the right questions to ask.” (25:33—27:38) -Tom

“The worst question you could ask is simply, ‘Any changes to your medical history?’ because the answer, for sure, is going to be, ‘No.’ I've seen it a million times. ‘No.’ ‘Let's move on.’ So, you don't get the information at all.” (28:06—28:20) -Tom

“There's always going to be a new drug. There's always going to be something new because the DEA is always looking to make substances illegal. So, that is an engine to generate more and more substances. But by the time the substance that we're talking about is hitting the mainstream, by the time there's genuine public awareness of that substance, most people have already moved on to the next substance.” (29:09—29:37) -Tom

“I know there are a few more synthetic opioids out there already that we don't even have names for yet here in the States. But I know they're already here. So, that's one thing. But the other part of this is, don't forget oldies but goodies. What's old is new again in substance use disorder.” (29:40—29:59) -Tom

“Mainstream use of kratom has become a thing because kratom is an opioid substitute. If I've been addicted to opioids and if I've had substance use disorder, opioid use disorder, I may not have access to that opioid anymore, but I can access kratom anywhere. A couple of news articles have come out about how widespread kratom use is even amongst people who are middle class, stay-at-home parents. Wow. Why is kratom so popular? Because it's a stimulant and an opioid, and I can use it for either or both, and it's something I can grow myself, and it's something that I can share with my neighbors and share with my friends. And just like that, as soon as I said the word, I bet we moved on to something else.” (30:56—31:48) -Tom

“Get [patients] to confide. Get them to work with you as a partner so that you're doing the best for them and for yourself. These are skills that take years to develop, so don't be too hard on yourselves if you're out there and saying, ‘I can never ask those kinds of questions! I need you to sit there next to me and tell me what questions to ask.’ No. You'll get there. You'll ask the questions yourself. You'll get good at this. It's like a muscle. You’ve got to exercise it to develop. But start today. Start practicing that today. Have a huddle with your team. Get them involved too and say, ‘Look, this is a real problem. We all know it is.’ And a lot of it is maybe I don't want to know. But you do want to know because, ultimately, it's all about keeping patients safe and keeping your team members safe and keeping yourself safe. You worked hard to get that license. Don't be willing to overlook things and put your license in jeopardy. It's important that you take care of patients and do everything you can to keep them safe, but you’ve got to keep yourself safe as well.” (34:00—34:59) -Tom

Snippets:

0:00 Introduction.

2:14 Tom’s background.

5:10 The importance of pharmacology to your practice.

7:25 Why this is an important topic.

10:08 The Matthew Perry situation, explained.

16:36 How to have the conversation with patients.

21:45 How to document the conversation.

23:48 Three questions you always need to ask.

28:56 Other things to know about synthetic opioids.

32:55 Final thoughts.

35:05 More about Tom and how to get in touch.

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. His 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. He instructs dental hygiene students and practice dental hygienists in pharmacology and local anesthesia in preparation for national board exams. As a published writer, he is well-known internationally for his contributions to several professional journals in the areas of pharmacology, pain management, and local anesthesia. In addition, he has served as a contributor, chapter author, and peer reviewer for several pharmacology textbooks. As a professional speaker, he 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.
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