Diversion And Addiction among dental professionals

Every September marks the celebration of National Recovery Month. This observance means a lot to me.

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There Is Help Available: The First Step Is Admitting The Problem

By NOEL BRANDON KELSCH, RDHAP

Every September marks the celebration of National Recovery Month. This observance means a lot to me. It means possibilities, futures, recovery, and mostly, HOPE. This month promotes the societal benefits of treatment for substance use and mental disorders, celebrates people in recovery, lauds the contribution of treatment and service providers, and promotes the message that recovery in all its forms is possible. Recovery month spreads the positive message that behavioral health is essential to overall health, prevention works, treatment is effective, and people can recover.1

Drug addiction is a very complex brain disease. It is not just a matter of choice. It is characterized by compulsive and sometimes uncontrollable drug cravings, seeking, and use that persists even in the face of extremely negative consequences.2

In fact, the very act of drug seeking becomes compulsive. The brain is altered during prolonged drug use, and this directly affects behavior, sometimes permanently. The problem is drug addiction can be chronic, with relapses possible even after long periods of abstinence.

There are a number of risk factors associated with drug abuse. The Mayo Clinic Drug Recovery Program lists some of the risk factors for addiction:

  • Family history of addiction — Drug addiction is more common in some families and likely involves the effects of many genes. If you have a blood relative, such as a parent or sibling, with alcohol or drug problems, you’re at greater risk of developing a drug addiction. Current research suggests that genetic factors play a major role (40% to 60%) in a person’s risk of developing an addiction.3 Having that predisposition increases the risk factors, but does not mean addiction is inevitable. 4
  • Being male — Men are twice as likely to have problems with drugs.
  • Having another psychological problem or disease — If you have a psychological problem such as depression, attention-deficit/hyperactivity disorder, or post-traumatic stress disorder, you’re more likely to become dependent on drugs. The thinking here is that you may be self-medicating for the disorder you’re dealing with.
  • Peer pressure — Particularly for young people, peer pressure is a strong factor in using and abusing drugs.
  • Lack of family involvement — A lack of attachment with parents may increase the risk of addiction, as can a lack of parental supervision.
  • Anxiety, depression, and loneliness — Using drugs can become a way of coping with these painful psychological feelings.

The First Steps Start With Acceptance

The person experiencing addiction must accept that he or she has a problem. Each of us needs to look at how we view people that have the disease of addiction. If I told you my son had cancer, I’m sure you’d want to support my child and me. If I shared that my son was addicted to meth, would you feel that same compassion toward my son? Social acceptance is key to treating the disease. When diseases are not discussed, and people with diseases are not supported in the community, it is challenging to reenter the community. Your view, acceptance, and treatment of people that are experiencing drug addiction will contribute to recovery in your community.

Health-care professionals pose a risk to themselves and to members of the public who may seek treatment when the professionals are experiencing the impact of addiction. It is essential that practitioners are made aware of the support available to them, and that problems are diagnosed and treated quickly and efficiently.5 As you read these words you may be thinking of your behavior or the behavior of those you work with.

As health-care professionals, we are all at risk and have a responsibility to report anyone that may be putting others at risk. We all need to be aware of the programs that are available, encourage our boards to develop support programs for addiction for clinicians if they do not have one. Ethically, we need to report anyone who is practicing in a compromised manner, including ourselves. Accepting this disease and openly talking about can and will change lives.

Looking At Ourselves

How can I tell if I might be addicted to alcohol or other drugs?

The CAGE Questions were developed to help everyone be able to see if they are addicted to alcohol or other drugs. This system was developed by Dr. John Ewinging of the University of North Carolina at Chapel Hill.6 This is now used international and has been adapted to look at all types of addiction. This can also be utilized in evaluating another person’s addiction. Science has proven that one of the most important factors in recovery is that the client must be a central participant in treating this disease. They must recognize the need for change and recovery. These questions can be the first step in that process.

C — Have you ever tried to CUT down on the amount you use or quit using alcohol or other drugs? A positive response indicated the person has lost control and is attempting to show that they have control. Though people with addiction can quit for a period of time, if the drug or similar drug is reintroduced they will start the behavior again.

A — Have you ever been ANNOYED by others comments about your substance use? In most situations people will only make comments about someone addiction it they witness a problem from it.

G — Have you ever felt GUILTY about something you said or did while under the influence of alcohol or other drugs? This guilt can be anything from domestic violence to job related events.

E — Have you ever needed an EYE-OPENER? This means that the person needs to use something the next morning to stop withdrawal from occurring.7

As people take this test it can help them realize that they need help. There are many resources available for help and a vast array of programs. There are more than 11,000 rehabilitation facilities in the United States. Each program focuses on different aspects of addiction: everything from behavior therapy to counseling and medications. It is important to match the needs of the client and to the type of program.Science-based studies support the concept that each person must be the central participant in his or her own recovery, and that personally recognizing the need for change and transformation is necessary.

The Substance Abuse and Mental Health Administration has a great list1 (www.recoverymonth.gov) of the options available for treatment. These include:

Inpatient or residential treatment programs — These treatment programs are located in a hospital or residential setting where people temporarily or permanently live to participate in rehabilitation and recovery. They include hospital-based rehabilitation units, which are located in a medical/hospital setting or a specialized chemical dependency facility. These programs include medical detoxification and are best suited for people who need intensive monitoring or have developed chronic or acute medical or psychiatric problems along with their addiction.

Inpatient programs and therapeutic communities — Short- or long-term inpatient treatment programs house individuals at a treatment facility while they undergo intensive therapy. This type of treatment is often followed by extended participation in support groups (e.g., ongoing group therapy or individual counseling and 12-step programs).

Outpatient treatment programs — In these programs, individuals don’t live at the treatment facility, but return for treatment services through scheduled visits offered in health or hospital clinics, counselors’ offices, local health department offices, community mental health centers, or inpatient programs that also offer outpatient clinics. They may include individual counseling. These are private one-on-one sessions that help people address issues of motivation and build skills to resist substance use through behavioral therapy to modify attitudes and behaviors and improve relationship and life skills.

Medication-assisted treatment (MAT) — These clinically driven treatment programs use medications combined with counseling and behavioral therapies to provide a whole-patient approach to the treatment of substance use disorders. For example, buprenorphine, methadone, and naltrexone are FDA-approved medications used in treating alcohol and opioid dependences.

Family counseling — These counseling sessions are led by a professional and usually take place in a private practice or clinic to provide a neutral forum. This approach educates family members about substance use disorders, helps them become aware of their loved one’s need for support, and improves family communication.

Group therapy — This type of therapy has trained leaders that offer healing to foster recovery from substance use disorders. This approach reduces isolation, enables members to witness the recovery of others, provides positive peer support, helps members cope with their condition, offers useful information to those new to recovery, and instills hope.

Recovery support services — Recovery support services are nonclinical options that provide help through all stages of recovery. Recovery community groups are nonprofit organizations that provide support services to people in recovery, which include job training and employment services, housing assistance, parent/family education, and life skills development.

Other Recovery Support Services

Peer-to-peer support programs — These are led by leaders in the recovery community who are often in recovery themselves. Such programs can expand the capacity of formal treatment systems by initiating recovery and intervening early if relapse does occur.

Mutual support groups — These groups offer an open environment for members with similar problems to share experiences, and can help participants sustain recovery by building new friendships with people who don’t use alcohol or drugs. They include well-known programs such as Alcoholics Anonymous and Narcotics Anonymous (accessed at http://www.aa.org and http://www.na.org), and other non-12-step programs such as SMART Recovery.

Faith-based support groups — Many people rely on their spirituality during difficult times, and these support programs are available at many places of worship and are usually low cost or free of charge.

Online support — Online support provides individuals the opportunity to receive treatment sessions and attend meetings virtually from any location at any time. Online support includes e-therapy services. These offer participants electronic counsel through text- and non-text-based communication methods (e.g., email, Internet chats, text, telephone, and video conferencing).

Recovery chat rooms — Online venues such as chat rooms offer a free-form structure for people to share their stories with fellow members of the recovery community.

Blogs and social networking sites — One way to connect with others in treatment and recovery is through blogs and social networking sites such as Facebook and Twitter.

Substance Abuse and Mental Health Services Administration’s Treatment Facility Locator was developed to help you find a program. It is available at Findtreatment.samhsa.gov. It has a searchable directory that allows you to enter an address into the quick search feature, and a list of nearby substance abuse treatment facilities will be displayed.

Dental Board And Hygiene Board Programs

Each state has a dental practice act that includes stipulations about this disease.

The California Dental Board has one of the most successful diversion programs available to health-care professionals. Check with your state for their program details. In many states, because this is a disease, people are able to receive disability while in the program.

I interviewed Lori Reis of the California Dental Board about the program.

1. If a person comes to the board for diversion, will they lose their license?

A licensee will rarely lose his or her license behind the diversion program. In instances where licensees have repeated acts of noncompliance, or are deemed a public risk while in the program, there is a possibility that they will lose their license.

2. During diversion can they practice?

Upon intake into the program each licensee must undergo a clinical assessment and is required to cease practice for 30 days. During this time, they will be randomly drug tested and must provide 30 consecutive days of negative drug testing before being considered to return to work. The Diversion Evaluation Committee (DEC) will then determine whether he or she may safely resume the practice of dentistry.

3. Is the diversion program free?

No, there are substantial fees involved.

4. Does participation in this program go into public records?

Only if an accusation is filed with the attorney general’s office, and as a result the licentiate is placed on probation with a requirement to enter a diversion program, then yes, it is public information and will be placed on the board’s website for public viewing.

5. What is the goal of this program?

As outlined in Business & Professions Code, section 1695, it is the intent of the Legislature that the Board of Dental Examiners of California seek ways and means to identify and rehabilitate licentiates whose competency may be impaired due to abuse of dangerous drugs or alcohol, so that licentiates may be treated and returned to the practice of dentistry in a manner that will not endanger the public health and safety.

6. If someone is arrested and required to do diversion, can they still use the program offered by the DCA for their license?

Yes.

7. How long does a diversion program take?

It varies, but participation is normally between three and five years.

8. What happens to the records after someone completes a program?

Records are destroyed in compliance with B&P Codes 156.1(a) and 1698 after the DEC, in its discretion, has determined a program participant has been rehabilitated. Records of successful completions are destroyed immediately. All other records are destroyed after three years.

Some Solutions For Help

Affordable Care Act of 2010 expands health care to approximately 32 million Americans who were not previously insured. This federal law includes many new provisions aimed at improving coverage for and access to substance abuse and addiction prevention, treatment, and recovery support services.8

Employer health plans with more than 50 employees enrolled that choose to include coverage for substance use and mental health services must provide those benefits in the same way as all other medical and surgical services covered by their plans. Therefore, for plans that choose to offer coverage, copayments, deductibles, and annual and lifetime caps on substance use and mental disorder treatment benefits must be equal to benefits for other medical conditions. This will make a major impact on the lives and health of thousands.

September’s celebration of National Recovery Month means a lot to me. It means HOPE. If you need help, I hope that you will go for help. If you know someone who needs help, my dream is that you will prepare yourself to share the available resources. If you do not know about the disease of addiction and how much community support means, I hope you will discover the celebration of life by going to www.recoverymonth.gov. The decisions you make may save the life of someone experiencing addiction, or like my sister, the victim of someone with addiction. RDH

Some Websites To Visit

• World Health Organization, Brief Intervention for Substance Use http://www.who.int/substance_abuse/activities/en/Draft_Brief_Intervention_for_Substance_Use.pdf Manual for Use in Primary Care downloadable manual gives you the tools for intervention in medical settings.

• National Institute on Drug Abuse: Screening for Drug Use in General Medical Settings manual gives forms, information, and resources for intervention

• Resource Guide http://www.drugabuse.gov/sites/default/files/resourceguide.pdf

References

1. http://www.recoverymonth.gov Accessed Feb 2012

2 Drugabuse.gov accessed Feb 2012

3 Drug Abuse and Addiction. The National Institute on Drug Abuse website: http://drugabuse.gov/scienceofaddiction/sciofaddiction.pdf, p. 8. Accessed Feb 2012

4 Family History of Alcoholism: Are You at Risk? National Institutes on Alcohol Abuse and Alcoholism website: http://pubs.niaaa.nih.gov/publications/FamilyHistory/ Family%20History.pdf, p. 2

5. Brooks SK, Chalder T, Gerada C. Doctors vulnerable to psychological distress and addictions: Treatment from the Practitioner Health Programme. Journal of Mental Health, April 2011; 20(2): 157–164.
6. Ewing JA ‘Detecting Alcoholism: The CAGE Questionaire’, Journal of the American Medical Association 252: 1905-1907.
7. www.addictionsandrecovery.org/addiction-self-test.htm accessed Feb 2012.
8. Focus on Health Reform: Summary of New Health Care Reform Law. The Kaiser Family Foundation website: http://www.kff.org/healthreform/upload/8061.pdf access Feb, 2012


For My Sister

I dedicate this article to my sister Linda Brandon, and her daughter, Jennifer Brandon-Seline. As I write this article, my family is living through the 10th anniversary of the impact of addiction on our family. My beautiful sister Linda was taken from us as a direct result of the addiction of a health-care professional. She died when a young EMT who chose to drink and drive hit her head-on as she crossed the street in a crosswalk. Her amazing daughter has shown the world through her artwork and writing what a difference attitude and determination can make. Linda and Jennifer, you are my heroes. Your lives have taught me to forgive.


Mary: Her Story

Author’s note: The following story was told to me by a very brave woman who changed her life. Her name and location have been changed to protect her identity. I would like to thank her for sharing her story and helping to change lives.

I still remember the feeling of being high for the first time. I was dizzy, giddy, and all the feelings of being “less than” left me. I was overweight and never felt comfortable inside my own body. But I was boy-crazy. With that first drink I was suddenly transformed. I became an at-ease cool kid who found her place in the crowd. Looking back, I now realize that for the first time in my life I was not depressed for a moment in time. I was invincible, unbeatable, and there was nothing that could hurt me. But eventually it did.

I slowly learned to refine the art of lying. First about little things, such as where I was, who I was with, school. There were no real consequences to my lying and drinking that outweighed how fantastic I felt when I was high.

As I attended parties and got high with my friends, everyone around me was taking it to the next level. Pot, cocaine, and mescaline were always available, and I thought, what could it hurt? My dad owned a bar, drank, and made a good living. My friends did drugs and they were still working.

I went to school high many times wearing sunglasses and thinking no one would know. Life was better when I was high. I wanted to see what it was all about. Just experiment, I thought. What could it hurt? At 20 I was using “just like everyone else.” I was able to “control” my use and mainly stuck to the weekends. I was moving forward and life was great. I loved getting high and it was working for me.

I used off and on and could not wait for the weekend when it was time to “party.” I could control when I used. I wondered, “What is all this bull about? I use; I’m not addicted; I’m functional, invincible. I’m a weekend drinker; I spend weekends getting high.” I got a business degree while doing this. I was working, and I was successful.

At age 23 I entered hygiene school. I wanted to make MONEY! During school I got high and it never stopped me. I used the drugs to help me with studying and to help me relax after those crazy and intense weeks. I got married and could not figure out why it wasn’t working. I drank a lot and worked on the art of lying, while cheating and developing a list of excuses for my behavior. My marriage ended in divorce.

When I was about 30 I decided to move across the country. I packed up my life and baggage and headed to California. My addiction followed me. There I discovered cocaine. I met a man who was very well-to-do, and his life included cocaine. From the first line, I loved cocaine. I was absolutely invincible, and this miracle drug solved the world’s problems, even at 4 a.m. I loved my life and I loved being high.

We had everything. The houses, the cars, and our dealer was even willing to deliver the drug to our doorstep! At first my boyfriend supplied all my needs, but then I made $50 an hour and could pay for my own! Every day was like Christmas — the excitement of knowing “it” was on its way. I felt free when I used. I could dance and embrace the glory of being high. I did my job and did it well (or so I thought) and came home to my world of bliss.

It took a while for using to impact work. At first I did not work on Mondays. I needed that day to get over what I did over the weekend. I usually slept the entire day. Then I extended that to Fridays … I had every excuse in the universe for being late and not showing up to work. I kept up and no one ever said a word.

Then I got pregnant at age 34. I had to try to stop. My boyfriend continued to use. It was his lifestyle, and he had the money and resources to do it. I had to put the brakes on it but I just could not stop. I justified everything. Just a little red wine, one little line; it won’t hurt. I was right once again, and I had a perfect baby. What was all the fuss about?

When the baby was born, I was like a tiger that had been caged. One week after delivery I was dying for a drink and a line of cocaine. I married my boyfriend, and we soon had our second child. I still thought that everyone else had a problem, not me! I was just being crucified when people questioned my behavior. I was functional! It was okay now if I got high. I had no responsibility! I wasn’t hurting anyone.

I did not have to work. I was a millionaire’s wife. The children had everything. A nanny was there to meet their every need. I deserved to be high as much as I wanted, and I could certainly afford it. I was not impacting ANYONE, or so I thought. I was the exception to the rule. I was not addicted. I was able to do what I wanted with no consequences.

But then consequences came, and they came hard and fast. Cocaine was once bliss, and then suddenly it wasn’t. I lived in denial. My husband went to rehab, yet I just blamed the cop, my family, the weather. I ended up with 30 days in jail. I did not see it as a problem at all. The problem did not come until thoughts of suicide came tumbling into my life. They were as extreme as the bliss that I got from my first cocaine high.

A year after our second baby was born, I went back to work, all while fighting with my husband, who was no longer sober. I thought this was all his fault. I thought if he would just stop buying and using, I would not do it anymore. This was never my responsibility. If someone had never offered me that first line, I would not be in this situation. I lived thinking that “they” put it up my nose and in my mouth. I was an innocent victim.

When he worked out his sobriety, my husband and I got divorced. He threatened to take the children because I was still using. I signed over money, thinking then that he could not take the kids. I got a tiny apartment and still had my hygiene license, so I got back to work. But I still could not stop using the drug.

I had no energy and I was on my own. I “dabbled” in cocaine. I knew I needed it if I was going to get the house clean or have the ability to go to work. I justified that I was just self-medicating. I always had enough with me to keep the little high going. I started working high more often. It gave me so much energy and made me so positive and gave me the ability to do anything!

Between patients I would go into the restroom and use the toilet tank to do a line of cocaine. I would meet my dealer during my lunch hour and return to work. It would soften those emotional feelings and allow me to just feel “normal” for a moment. I was never comfortable unless I was high. No one ever asked me at work if I was high, so I thought obviously I am not like the rest. I can work and be high and be just fine. But it was getting to the point that I was calling in with excuses more than I was coming in. I don’t know how many times one of my relatives died or one of my kids was sick, but I was a good liar.

I still cannot believe I was giving injections and working on patients while high, but at the time I could justify anything that I did. I started doing really crazy things and developed paranoia. I carried a gun in my purse.

There was nothing anyone could do for me to help me stop. I did not see a problem. Drugs were working for me. Depression came in waves. There were days it did not come because I was high all day. But when it came, it was as extreme as the glory of being high.

I started thinking of suicide on a daily basis. I would get really high all weekend and try to come down before Monday. Sundays became depression day, and on one of those Sundays I finally hit the wall. I sat in the closet and could not come out. Many things had happened in the past few days. I almost lost my son due to my lack of attention and he almost drowned. I was seeing a counselor and I never told the truth and that was coming to a head. An anonymous letter had arrived calling me out on my behavior. My kids were being dragged down by my addiction. The kids were gone on this Sunday and I just wanted to die. The withdrawal from the cocaine literally knocked me down on the ground and I could not get up. I was close to the point of death.

It is the closest I have ever been to death. I will never be the same. I went into rehab right after that. I wish I could tell you that the story ends there, that I went and was just fine after that. But drug addiction does not work that way. Recovery is a lifetime commitment.

I went to rehab but I did not really go there. I did stay clean and sober for six months. I had this cocky attitude, wondering why others relapsed. That would not happen to me! I hung out in bars and attended meetings, stood on both sides of the fence, yet wanted my old life and sobriety at the same time. I went to AA, heard their words, and thought once again, “They are addicts; I am just experiencing a rough spot.”

I bounced in and out of programs. I continued to lie to everyone, but most importantly, I lied to myself. I was out on disability for the first year from work. I pulled in new friends, and I was attending three meetings a day as required by my jail sentence. This was not keeping me sober. I was only doing what I wanted to do when I wanted to do it. So not surprisingly, the program did not work. The program really works. But my attitude did not work.

For me, recovery has been a very slow process. There has been no light bulb moment. It has been a step-by-step process of daily choices. Addiction can keep rearing its head over and over in many forms. I had to take care of the disease of addiction, not just my drug of choice — cocaine. I have to treat this disease every day of my life in every aspect of my life. It took over my priorities, my love for work and family, and it has impacted me in ways I never thought possible.

The road was long. I am back at work. I am clean and sober. I have my kids and a wonderful support system. I have to make the decision to be clean and sober every single day in everything that I do. It is up to each person to make the change. They have to first admit there is problem; then it is amazing how much help they will see, help that was always there for them to become whole and healthy.

That’s the end of my story, and I plan to stay sober.

NOEL BRANDON KELSCH, RDHAP, is a syndicated columnist, writer, speaker, and cartoonist. She serves on the editorial review committee for the Organization for Safety, Asepsis and Prevention newsletter and has received many national awards. Kelsch owns her dental hygiene practice that focuses on access to care for all and helps facilitate the Simi Valley Free Dental Clinic. She has devoted much of her 35 years in dentistry to educating people about the devastating effects of methamphetamines and drug use. She is a past president of the California Dental Hygienists’ Association.

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