19.5 Recognizing and Managing Substance Use Disorders

Recognizing and Managing Substance Use Disorders

Why this matters on the INBDE: This is a named blueprint task, and it intersects directly with pharmacology (FK8, 11%) and behavioral science and jurisprudence (FK9, 11%). Dentists are prescribers of controlled substances and are often the first clinician to see the oral consequences of substance use.

Screening

Ask about substance use as a routine, non-judgmental part of the medical history, in the same tone as questions about medications. Specific, quantified questions elicit more accurate answers than yes-or-no questions.

• Alcohol: "How many days a week do you have a drink, and how many on those days?" The single screening question — "How many times in the past year have you had five or more drinks in a day (four for women)?" — performs well.
• Tobacco and nicotine: include vaping and smokeless products explicitly.
• Cannabis: frequency, route, and time since last use.
• Other substances: ask directly about stimulants, opioids, and sedatives, including non-prescribed use of prescription medication.
• Timing matters clinically: "When did you last use?" changes today's anesthetic plan.

SBIRT — Screening, Brief Intervention, and Referral to Treatment — is the standard framework, and dental settings are an evidence-supported place to deliver it.

Oral and Systemic Manifestations by Substance

Anesthetic and Analgesic Decisions

Vasoconstrictors. The 24-hour rule for cocaine and methamphetamine is one of the most frequently tested facts in this area. Both drugs block catecholamine reuptake or drive catecholamine release; adding exogenous epinephrine risks severe hypertension, dysrhythmia, myocardial infarction, and cerebrovascular accident. If treatment cannot wait, use plain local anesthetic, monitor vital signs, and avoid epinephrine-impregnated retraction cord.

Acute pain management in a patient with opioid use disorder:

1. Do not interrupt maintenance therapy. Buprenorphine and methadone are continued; stopping them destabilizes recovery and worsens pain control.
2. Use multimodal non-opioid analgesia — the combination of an NSAID with acetaminophen provides analgesia superior to opioid monotherapy for acute dental pain.
3. Use long-acting local anesthesia (bupivacaine) for the immediate postoperative period.
4. Coordinate with the treating provider before prescribing any opioid; if an opioid is genuinely required, expect that tolerance raises the effective dose and prescribe the smallest quantity with close follow-up.
5. Naloxone co-prescribing should be considered for patients at elevated overdose risk.

Alcohol use disorder: reduce the acetaminophen ceiling (commonly to 2 g per day), avoid or minimize NSAIDs where gastritis or varices are present, assess coagulation before surgery (PT/INR, platelets), and anticipate altered sedative response — chronic use induces tolerance, but decompensated liver disease produces the opposite.

Safe Opioid Prescribing

1. Non-opioid first. For acute dental pain, an NSAID alone or combined with acetaminophen is the recommended first-line therapy and is more effective than an opioid alone for most postoperative dental pain.
2. Definitive treatment beats any prescription. Removing the source of pain — extraction, pulpectomy, drainage — is the analgesic that works.
3. When an opioid is indicated, prescribe the lowest effective dose for the shortest duration, commonly no more than three days, and avoid extended-release formulations and codeine-containing products in children.
4. Codeine and tramadol are contraindicated in children under 12, and in patients under 18 after tonsillectomy or adenoidectomy, because ultra-rapid CYP2D6 metabolizers can experience fatal respiratory depression.
5. Check the prescription drug monitoring program (PDMP) before prescribing a controlled substance — required in most states.
6. Never combine an opioid prescription with benzodiazepines or other central nervous system depressants without a compelling reason and explicit counseling.
7. Counsel on storage and disposal, and document the indication, quantity, and counseling provided.

The Drug-Seeking Encounter

Patterns that should prompt caution: presenting after hours or on a weekend, reporting severe pain with no clinical or radiographic findings, requesting a specific drug by name, reporting allergies to every non-opioid alternative, refusing definitive treatment such as extraction or endodontics, and having no regular dentist.

The correct response is neither hostility nor accommodation:

1. Perform a complete examination and appropriate radiographs — genuine pathology is sometimes present.
2. Offer definitive treatment for anything found.
3. Check the PDMP.
4. Decline to prescribe an opioid when the clinical findings do not support it, and say so calmly and without accusation.
5. Offer help — treat the substance use disorder as a medical condition, and provide a referral pathway.
6. Document findings, the conversation, and the decision.

Referral and Language

Substance use disorder is a chronic, treatable medical condition, not a moral failing. Language shapes care: "a person with a substance use disorder" rather than "an addict," "a person in recovery" rather than "clean," and "positive or negative test result" rather than "dirty." Stigmatizing language measurably reduces the quality of care patients receive and reduces disclosure.

Referral pathways include the patient's primary care provider, addiction medicine specialists, opioid treatment programs, and national treatment-locator services. Offer the referral concretely — a name, a number, and, where possible, a warm handoff — rather than a general suggestion to seek help.