Addiction

Secrets and Lies: Alcohol and Drug Addiction In Dentistry

Ms. Kittelson will present "Secrets and Lies: Alcohol and Drug Addiction in Dentistry" at the ADA Annual Session in San Francisco on Sunday, October 25, 1 pm - 3:30 pm, in the Franciscan Ballroom 1 at the ANA Hotel.

Dentists, like other health professionals, are at risk for the development of substance abuse disorders. Recent advances contribute to a deeper understanding of the disease nature of these disorders; signs and symptoms as evidenced in dental practice are discussed, along with support resources.

The abuse of mood-altering substances and development of addiction have been called an occupational hazard for health professionals.1 Contributing factors cited often include high stress levels, unrealistic and perfectionistic expectations of oneself, grandiose feelings of invulnerability and knowledge about and access to drugs. A useful working definition of addiction is that used by the American Society of Addiction Medicine: "a disease process characterized by the continued use of a specific psychoactive substance despite physical, psychological or social harm."2 Addiction brings with it a multitude of problems in potentially all the major life arenas. For health professionals, issues of professional competence, public safety and trust, professional licensure, reputation, and credentialling are critical. Dentists run the additional risks of impairment in practice management, jeopardizing livelihood for themselves, their staff, and their families.

Denial and secrecy are hallmarks of addiction. Professionals in general are sophisticated in avoiding exposure of their addictions, and are aided in this by social status and attribution. Robert Holman Coombs, in his recent book, Drug-Impaired Professionals, refers to "pedestal professionals" to make the point that dentists (and other high-accountability professionals) are likely to be seen (and to see themselves) as set apart from the general population.3

The reality is that dentists are human beings first, and dentists second. Addiction is a human disease, and some of the people who have it are dentists.

Research conducted over the last several decades is bearing fruit in new knowledge about the genetics and neurophysiology of addiction. Family, twin, and adoption studies consistently show that relatives of alcoholics have significantly higher rates of addiction than do relatives of nonalcoholics; for children of alcoholics, this rate is three to four times greater than for children of nonalcoholics.4 In an alcohol challenge study, for example, otherwise similar college-age men were grouped by family history of alcoholism (i.e., positive or negative family histories). Given the same dosage of alcohol and subjected to the same physiological indicators, the group with a positive family history showed a lower intensity of reaction to alcohol than did those with no family history of alcoholism.5 Using laboratory rodents, researchers from Indiana University have been able to breed successive generations of alcohol-preferring and alcohol-nonpreferring animals. Those animals preferring alcohol over water would consume progressively more alcohol over the generations, to a physiological threshold, while the nonpreferrers continue to consume low levels of alcohol in later generations.6 This lends support to the concept of a biological process not subject to peer pressure, social learning, dysfunctional families of origin, cultural norms, liquor company ads or other of the factors often thought to influence alcohol and other drug use among humans.

The genetic studies speak to one aspect of vulnerability to the disease of addiction; research in neurotransmitters and brain structure speaks to another. Numerous studies show that similar substances are abused by animals and humans, that animals will voluntarily self-administer to the point of sacrificing food, water, and sex and that these particular substances (opiates, alcohol, amphetamines and benzodiazepines) acutely enhance brain reward mechanisms.7 The same behaviors can be observed in human drug addicts. Science tells us "the addicted brain is distinctly different from the nonaddicted brain, as manifested by changes in brain metabolic activity, receptor availability, gene expression, and responsiveness to environmental cues."8 Alan Leshner, Ph.D., director of the National Institute on Drug Abuse, puts this succinctly when he says, "addiction is a brain disease."8 That healthcare professionals, including dentists, would risk sacrificing years of academic dedication, the rigors of exacting specialized training, violation of professional ethical codes and practice acts, endangerment of their patients and threats to their own financial security, is evidence in itself of the power of this brain disease.

A recent study by the National Institute on Alcohol Abuse and Alcoholism9 identified lifetime prevalence of alcohol dependence in the general population at 13.3 percent and 12-month prevalence at 4.4 percent. It is generally thought that prevalence of addiction among healthcare professionals is similar to that of the general population, though there are some differences related to drugs of choice.10 These differences reflect familiarity with particular drugs and access to them; not surprisingly, the most commonly abused drugs among dentists are alcohol, hydrocodone, and nitrous oxide.11

The University of Kentucky College of Dentistry and the University of Kentucky Center for Prevention Research, in collaboration with the American Dental Association, the American Association of Dental Schools, the University of South Florida, and the American Medical Association, have recently completed a national survey of dentists and dental students to estimate the prevalence of past and current drug use, abuse and dependence within the dental profession. This is the first study of its kind and sophistication to attempt to quantify this problem for dentistry. Data analysis was still underway at the time this paper was written.

The Council on Dental Practice of the American Dental Association, through its Dentist Well-Being Program, sponsored a stress assessment survey project at annual sessions from 1995-1997. The CAGE12 screening questions for alcohol abuse/dependence were incorporated into the questionnaire; five percent of the dentists who participated had a positive score, and it is reasonable to think this bears a relationship to the current prevalence of substance-related problems among participants.

The criteria identified in DSM-IV, the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) published by the American Psychiatric Association, are the standard for diagnosis of substance dependence.13 Those criteria, along with some of the symptoms that may be seen in the dental office, are inserted in Table 1.

Drawing on years of clinical experience with addicted dentists, Dr. Jerry Gropper and staff from Talbott-Marsh Recovery Campus have identified a personality profile common to that group.14 In their experience, these dentists were dissatisfied with their career choice; they struggled with fear of causing pain, low professional esteem, obsessive-compulsive and perfectionistic behavior, a high need to be in control while simultaneously feeling very out of control and an avoidant style in interpersonal relationships (especially in the face of any perceived or actual rejection). Others have written about stresses and hazards within dentistry that may support the development of an addictive disorder.15,16,17 These include the isolation of solo practice and perceived demands by patients for perfection, availability and empathy.

Beyond the discussion of genetics, neurophysiology, disease prevalence and signs and symptoms, is the impact of this devastating disease on individual dentists' lives, practices and families. There are stories of dentists sneaking into the office after hours to use nitrous oxide, wanting to stop and not being able to, knowing the risks yet feeling invulnerable, some of them using until their fingers go numb with peripheral neuropathy, some of them being found by staff the next day, dead in the chair. There are stories of DEA agents descending on dental offices, closing practices and putting dentists in jail. There have been conversations between two dentists--"I need to tell you I've been getting some of your patients into my practice, and they tell me it's because you have alcohol on your breath." There are dentists telling lies to spouses, children and staff about why they're not on top of things and where the money is going, why they didn't make it to the office or the soccer game. There are patients who have been hurt with poorly handled instruments and improperly executed procedures. There are children who have been terrorized in the dental chair. There are long, sad stories of family devastation, broken hearts, broken dreams and financial ruin.

A full discussion of intervention, treatment strategies, monitoring and regulatory issues is beyond the scope of this paper. Addictive disease, not unlike other disorders, "is a chronic, relapsing disorder".8,18 It is a treatable disorder, fortunately, and treatment outcomes with professionals, including dentists, are particularly good.19 Resources for assistance include dentist well-being programs and peer support networks sponsored by constituent and/or component dental societies, specialized treatment programs, alternative to discipline agreements with licensing boards and the Dentist Well-Being Program sponsored by the Council on Dental Practice of the American Dental Association.

Coming to terms with addictive disease is a difficult process for many. With a cultural legacy of stigma, defining addiction to alcohol and/or other drugs as a failure of will and moral character, it is challenging to take on a new paradigm.8 Dentists, as human beings first and scientifically-trained professionals second, have an obligation to pay attention to the science. Out of this comes the possibility of treating themselves and their fellows with compassion and accountability, saving practices and lives from ruin.

Table 1

CRITERIA FOR SUBSTANCE DEPENDENCE

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:14

Tolerance, as defined by either of the following:

* A need for markedly increased amounts of the substance to achieve intoxication or desired effect.14

* Ordering patterns for stock medications may change; there may be increased utilization of nitrous oxide.

* Staff may be asked to phone in prescriptions ( sometimes in other names) for the dentist's own use.

* Markedly diminished effect with continued use of the same amount of the substance.14

Withdrawal, as manifested by either of the following:

* The characteristic withdrawal syndrome for the substance.14

* Office staff may notice morning lethargy, irritability, slight tremor.

* Office hours may be changed to accommodate drinking or drug use schedules to avoid acute withdrawal symptoms.

* Nausea/vomiting or diarrhea from opiate withdrawal may disrupt patient care.

* Fatigue and impaired concentration may result from stimulant abuse.

The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms:14

* A dentist may consume enough alcohol in the morning to manage withdrawal symptoms of tremor, irritability or craving; the odor of alcohol may be noticeable to patients or staff because of close proximity during exams or procedures.

* Prescription medications (such as benzodiazepines) may be taken from office stock and
used to alleviate withdrawal.

The substance is often taken in larger amounts or over a longer period than was intended:14

* Loss of control may be evident in intoxication at dental meetings or office functions (like a holiday party).

* References to intoxication may be made by the dentist, spouse or other close associates.

There is a persistent desire or unsuccessful efforts to cut down or control substance use:14

* Watch for promises, usually broken, to family, staff or peers to stop drinking/using.

* Rules about drinking/using are often established and rigidly followed; should an office or patient emergency interfere with the 'cocktail hour' a dentist may react inappropriately.

A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects:14

* Dentists abusing nitrous oxide may spend additional time in the office during weekends or off-hours, in order to use more.

* There may be increased use of 'sick time' to recover from using/drinking binges.

* A dentist may become unreliable with the schedule, coming in late, taking long lunches or unscheduled breaks.

Important social, occupational, or recreational activities are given up or reduced because of substance use:14

* Office hours may be cut back.

* A dentist may withdraw from professional activities (dental society activities, study clubs, continuing education), often placing blame on others for the withdrawal (e.g., not wanting to be involved in politics, others don't have anything to offer, etc.)

* Practice management tasks and income production may suffer; it is not unusual for serious financial problems to develop.

The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption).14


Table 2

AVAILABLE RESOURCES

Confidential assistance with chemical dependency is available to dentists, their families and dental team members through the well-being committees of component societies of the California Dental Association.

California Dental Association
Subcommittee of the Council on Membership Services
Hot Line: 800/807-3268 Northern California or: 800/969-1393 Southern California\
Bay Area Well-Being Committee Chairman
(800) 807-3268

Southern California Well-Being Committee Chairman
San Diego - (619) 275-7180
Southern California - (213) 969-1393

CALIFORNIA DENTAL ASSOCIATION
CALIFORNIA REGIONAL WELL-BEING COMMITTEE CHAIRMAN

Northern California Regional Committee
George Koerber, DDS, Chairman
3150 Birdsall Avenue
Oakland, CA 94619
(510) 261-6980

Southern California Regional Committee
Bruce Walker, DDS, Chairman
8540 South Sepulveda Blvd. Suite 1212
Los Angeles, CA 90045
(213) 969-1393


California Dental Association
Northern California Component Well-Being Committee Chairmen

Well-Being Committee Chairman
Alameda County Dental Society
c/o Executive Director
1345 Grand Avenue, Suite 102
Piedmont, CA 94610
(510) 261-6980

Domenic J. Cavallaro, DDS
Well-Being Committee Chairman
Berkeley Dental Society
3000 Colby Street, Suite 302
Berkeley, CA 94705
(510) 843-4450

W. Thomas Pelton, DDS
Well-Being Committee Chairman
Butte-Sierra Dental Society
415 Alturas Street, Suite 2
Yuba City, CA 95991
(916) 673-0233
(916) 673-0237(fax)

Thomas J. Becker, DDS
Well-Being Committee Chairman
Central Coast Dental Society
120 N. Miller Street, No. D
Santa Maria, CA 93454
(805) 925-6939
(805) 348-1643(fax)

George F. Koerber, DDS
Well-Being Committee Chairman
Contra Costa Dental Society
1160 Arnold Drive
Martinez, CA 94553
(510) 372-7100

Well-Being Committee Chairman
Fresno-Madera Dental Society
c/o Executive Director
371 East Bullard, Suite 120
Fresno, CA 93710
(209) 439-5280

Well-Being Committee Chairman
Humboldt-Del Norte Dental Society
c/o Executive Director
Post Office Box 6368
Eureka, CA 95502
(707) 443-7476

Thomas E. Jarvis, DDS
Well-Being Committee Chairman
Marin County Dental Society
920 Northgate Drive, No. 1
San Rafael, CA 94903
(415) 479-1840

Well-Being Committee Chairman
Mid-Peninsula Dental Society
c/o Executive Director
125 Willow Avenue, Suite 207
Menlo Park, CA 94025
(415) 328-2242

Well-Being Committee Chairman
Monterey Bay Dental Society
c/o Executive Director
2100 Garden Road, No. B-10
Monterey, CA 93940-5316
(408) 658-0168

Well-Being Committee Chairman
Napa-Solano Dental Society
c/o Executive Director
164 East H Street
Benicia, CA 94510
(707) 745-1994

Curtis E. Vixie, DDS
Well-Being Committee Chairman
Northern California Dental Society
3020 Johnstonville Road
Susanville, CA 96130
(916) 257-2395

Clifford C. Snider, DDS
Well-Being Committee Chairman
Redwood Empire Dental Society
114 North Main Street
Cloverdale, CA 95425
(707) 894-3986
(707) 894-3988(fax)

David McIntire, DDS
Well-Being Committee Co-Chairman
Sacramento District Dental Society
4350 Marconi Avenue, No. 200
Sacramento, CA 95821-4310
(916) 483-4379

Stephen Ott, DDS
Well-Being Committee Co-Chairman
Sacramento District Dental Society
2821 Eastern Avenue, Suite 3
Sacramento, CA 95821
(916) 481-6700

Bruce T. Hiura, DDS
Well-Being Committee Chairman
San Francisco Dental Society
2305 Van Ness Avenue, No. E
San Francisco, CA 94109
(415) 776-2010

Mark A. Grecco, DDS
Well-Being Committee Co-Chairman
San Joaquin Dental Society
1507 West Yosemite Avenue
Manteca, DA 95337
(209) 823-9341
(209) 823-7836(fax)

Richard H. Dobson, DDS
Well Being Committee Co-Chairman
San Joaquin Dental Society
705 Dogwood Drive
Murphys, CA 95247
(209) 728-8356


Donald J. Coluzzi, DDS
Well-Being Committee Chairman
San Mateo County Dental Society
1690 Woodside Road, Suite 218
Redwood City, CA 94061
(415) 365-1400

John S. Pavel, DDS
Well-Being Committee Chairman
Santa Clara County Dental Society
259 Meridian Avenue, No. 14
San Jose, CA 95126
(408) 297-2300

Alan Lieberman, DDS
Well-Being Committee Chairman
Southern Alameda County Dental Society
3805 Beacon Avenue, Suite C
Fremont, CA 94538
(510) 796-8333

Robert A. Di Giorno, DDS
Well-Being Committee Chairman
Stanislaus Dental Society
680 South Avenue, Suite 9
Gustine, CA 95322
(209) 854-2777

Well-Being Committee Chairman
Yosemite Dental Society
c/o Executive Director
2448 M Street
Merced, CA 95340
(209) 383-0811

California Dental Association
Southern California Component Well-Being Committee Chairman

Richard Carpenter, DDS
Well-Being Committee Chairman
Harbor Dental Society
6226 East Spring Street, Suite 200
Long Beach, CA 90815
(562) 421-3336
(562) 429-4529(fax)

Well-Being Committee Chairman
Kern County Dental Society
c/o Executive Director
1701 Westwind Drive, No. 109
Bakersfield, CA 93301
(805) 327-2666

Steven Goldy, DDS
Well-Being Committee Chairman
Los Angeles Dental Society
416 North Bedford Drive, No. 409
Beverly Hills, CA 90210
(310) 550-1511
(310) 550-0781 (fax)

William Russell, DDS
Well-Being Committee Chairman
Orange County Dental Society
744 La Habra Blvd.
La Habra, CA 90631
(562) 691-0738
(562) 690-6360 (fax)

James Shelton, DDS
Well-Being Committee Chairman
San Diego County Dental Society
10201 Mission Gorge Road, Suite B
Santee, CA 92071
(619) 448-8998
(619) 448-8261 (fax)

Well-Being Committee Chairman
San Fernando Valley Dental Society
c/o Executive Director
21201 Victory Blvd., Suite 230
Canoga Park, CA 91303-2830
(818) 884-7395

Robert Shimasaki, DDS
Well-Being Committee Chairman
San Gabriel Valley Dental Society
277 South Euclid Avenue
Pasadena, CA 91101
(818) 793-4185

Jeffrey J. Petron, DDS
Well-Being Committee Co-Chairman
Santa Barbara-Ventura County Dental Society
10235 Telephone Road, Suite A
Ventura, CA 93004
(805) 647-7606

Frank E. Hull, DDS
Well-Being Committee Co-Chairman
Santa Barbara-Ventura County Dental Society
525 E. Micheltorena Street, Suite 302
Santa Barbara, CA 93103
(805) 965-9755

Martin Boyd, DDS
Well-Being Committee Co-Chairman
Tri-County Dental Society
4959 Arlington Avenue, Suite E
Riverside, CA 92504
(909) 689-0220
(909) 369-1817 (fax)

Dennis Tank, DDS
Well-Being Committee Co-Chairman
Tri-County Dental Society
720 East Latham Avenue, Suite 2
Hemet, CA 92543
(909) 929-4800
(909) 929-1591 (fax)

Larry Jones, DDS
Well-Being Committee Chairman
Tulare-Kings Dental Society
1040 North Cherry Street
Tulare, CA 93274
(209) 686-1773

Bruce Walker, DDS
Well-Being Committee Chairman
Western Los Angeles Dental Society
8540 South Sepulveda Blvd. Suite 1212
Los Angeles, CA 90045-3819
(310) 645-2886
(310) 645-0346 (fax)

Additional information is also available through the Dentist Well-Being Program of the Council on Dental Practice of the American Dental Association. The phone number is extension 2622 on the toll-free line, or 312-440-2622. The program is accessible via email at kittelsonl@ada.org. Some information is available on ADA Online as well. All calls and contacts are confidential.

References

1. Coombs, Robert Holman, Drug-Impaired Professionals. Harvard University Press, Section Title,1997.
2. Steindler, EM, Addiction terminology. Principles of Addiction Medicine. American Society of Addiction Medicine, Chapter 2, Section I, 1992.
3. Coombs, Robert Holman, Drug-Impaired Professionals. Harvard University Press, 4,1997.
4. Anthenelli, RM., and Schuckit, MA, Genetics, Substance Abuse, A Comprehensive Textbook, Second Edition. Williams and Wilkins, Chapter 4, 1992.
5. Anthenelli, RM, and Schuckit, MA, Genetic studies of alcoholism. Int J of the Addictions, 81-94, 1990.
6. Stewart, RB, and Li, T-K, The neurobiology of alcoholism in genetically selected rat models. Alcohol Health & Research World 21(2):169-176, 1997.
7. Gardner, EL, Brain reward mechanisms. Substance Abuse, A Comprehensive Textbook,Williams and Wilkins, Second Edition, Chapter 7, 1992.
8. Leshner, AI, Addiction is a brain disease, and it matters. Science 278:45-47, 1997.
9. Grant, BF, Prevalence and correlates of alcohol use and DSM-IV alcohol dependence in the United States: Results of the National Longitudinal Alcohol Epidemiologic Survey. J of Studies on Alcohol 58:464-473, 1997.
10. Centrella, M, Physicians and other health professionals. Principles of Addiction Medicine. American Society of Addiction Medicine, Chapter 7, Section VIII, 1994.
11. American Dental Association, Council on Dental Practice, annual reports from constituent well-being chairmen, 1997. (Unpublished.)
12. Ewing, JA, Detecting alcoholism: The CAGE questionnaire. J Am Med Assoc 252(14), 1905-1906, 1984.
13. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. American Psychiatric Association, page 181, 1994.
14. Gropper, JM, and Porter, TL, Addiction and progressive self-destructive behavior in dentistry. Clark's Clinical Dentistry, St. Louis, Mosby-Year Book, Volume 5. Chapter 38, 1997.
15. Willis, EF, Nitrous oxide: Dentistry's own special addiction. GDA Action 16(5), 12-13, 1996.
16. Grace, E, Dentistry, stress, and substance abuse. MSDA Journal 39(2), 77-79, 1996.
17. Bowermaster, DP, Intervention and the chemically dependent dentist. Dentistry Faces Addiction: How to be Part of the Solution Mosby-Year Book, 1992
18. Lewis, DC, A disease model of addiction. Principles of Addiction Medicine American Society of Addiction Medicine, Chapter 7, Section I, 1994