Underreported drug use among dental patients

There remains a substantial unmet need regarding treatment for people who engage in risky drug use behaviors in the United States. In 2019, 20.4 million people in the United States 12 years or older had a substance use disorder (SUD), but only 2.1 million received any form of treatment.¹ Moreover, the number of drug-related overdose deaths has been increasing in the United States, with more than 100,000 deaths reported during the 12-month period ending in April 2021, corresponding to a 30% increase from the previous 12-month period.² Owing to the marked divergency between diagnoses and treatment, patient visits to health care providers—including dental care professionals—increasingly are being regarded as additional opportunities for drug use screening. ^3,4

Increased recognition of the significance of identifying patient drug use has been an important first step by the dental care profession, as evidenced by a section on screening for SUDs in a guide published by the American Dental Association.⁵ The question that naturally follows, however, is whether patients’ drug use histories are captured accurately and consistently at dental visits. Screening by dental care professionals can represent an important—and sometimes sole—step in curbing problematic drug use. Our commentary discusses how the prevalence of reported drug use among a large sample of dental patients at a university center compares with estimates from a nationally representative sample of people in the United States.

DATA SOURCES AND DRUGS OF INTEREST

Data were obtained from 2 sources, limited to people aged 12 through 34 years in 2019. First, data were extracted from the electronic health records of patients treated at the general dental clinics at New York University (NYU) College of Dentistry (N = 32,921). Second, data from the National Survey on Drug Use and Health (NSDUH) were acquired. NSDUH is a nationally representative sample of noninstitutionalized people 12 years and older in the United States, representative of all 50 states plus the District of Columbia (N = 56,136).¹ We examined lifetime use of alcohol and tobacco and both lifetime and current use of cannabis, cocaine, opioids (nonmedical, recreational use), 3,4-methylenedioxymethamphetamine (Ecstasy), methamphetamine, ketamine, and heroin. We focused on national estimates because city- and state-level estimates do not match our year, age group, or all drugs of interest; however, as is shown in the eTable, available online at the end of this commentary, available estimates between the local level and the national level are comparable.

During visits at NYU College of Dentistry, patients were asked to report on their recreational drug use on the basis of the following question: “Do you or did you ever use any recreational drug?” Those who responded affirmatively (yes vs no) were asked to “describe the drug and frequency of use” in an open-ended manner. This assessment was conducted by providers chairside, and responses were inputted into the patient’s chart in a text box field. Participants also were asked specifically about lifetime use of alcohol and tobacco.

Regarding NSDUH data, participants answered a survey administered by an interviewer via computer-assisted interviewing and audio computer–assisted self-interviewing. They were asked whether they had used each drug in their lifetimes, and those reporting use were asked whether they had used in the past 30 days. Prescription opioid misuse was defined as “using in any way a doctor did not direct you to use,” including use without a prescription, more often, in greater amounts, or longer than directed to use them, or use in any other way not directed to use. Analysis of these deidentified data were exempt from review from the NYU institutional review board.

IS PATIENT DRUG USE UNDERESTIMATED WHEN REPORTED AT DENTAL VISITS AND DOES IT MATTER?

We calculated the prevalence of self-reported use in the dental sample and compared prevalence for each drug using z tests (Table). Estimated prevalence of lifetime and current use of each drug in the US population were significantly higher than prevalence of reported use at dental visits (P < .001). In other words, findings showed that prevalence of drug use was notably lower when obtained from dental electronic health records compared with estimates derived from a nationally representative sample, which may suggest significant underassessing at dental appointments. This discrepancy remained true across all drugs considered and held for both current use and lifetime use.

Table.

Comparisons between self-reported lifetime and current use of various drugs among people aged 12 through 34 years.

DRUG	LIFETIME USE		CURRENT USE
	NSDUH,* Weighted % (95% CI)†	NYUCD,‡ %§	NSDUH Weighted % (95% CI)	NYUCD, %¶
Alcohol	70.2 (69.3 to 71.1)	31.7	47.0 (45.9 to 48.0)	–
Tobacco	48.8 (47.9 to 49.7)	14.7	21.4 (20.8 to 22.1)	–
Cannabis	45.8 (44.8 to 46.8)	7.2	17.5 (17.0 to 18.0)	3.6
Cocaine	11.5 (11.0 to 12.1)	0.3	1.2 (1.1 to 1.4)	0.1
Prescription Opioids #	10.8 (10.3 to 11.3)	0.3	1.2 (1.1 to 1.4)	0.0
3,4-methylenedioxymethamphetamine (Ecstasy)	10.6 (10.1 to 11.1)	0.1	0.6 (0.4 to 0.8)	0.0
Methamphetamine	3.7 (3.4 to 4.1)	0.1	0.5 (0.4 to 0.6)	0.0
Ketamine	1.9 (1.7 to 2.1)	0.0	0.2 (0.1 to 0.3)	0.0
Heroin	1.8 (1.6 to 2.0)	0.3	0.2 (0.1 to 0.3)	0.0

^*NSDUH: National Survey on Drug Use and Health.

^†Total no. of patients from NSDUH data, 56,136.

^‡NYUCD: New York University College of Dentistry

^§Total no. of patients from NYUCD data, 32,921.

^¶The results of all comparisons between NSDUH and NYUCD via z test were significant (P < .001).

^#Prescription opioids refers to misuse or nonmedical or recreational use.

Inaccurate drug use measurements—or lack of such measurements—are problematic for several reasons. First, this represents a missed health care system opportunity for the identification of potentially harmful drug use. This point is underscored when considering the fact that dental appointments represent the sole interaction with the primary care health system for an estimated 27 million people in the United States in any given year.⁶ Second, this represents a missed opportunity for the advancement of oral health care research as it pertains to drug use. For example, although studies have reported that cannabis use is associated with poorer periodontal health, ⁷ there still remains a paucity of research investigating potential effects of other drugs on oral health measures. A limiting factor to such research may be the lack of data that encompass both drug-use findings and measures of oral health. In this way, then, there is a veritable public health need for dental care professionals to incorporate questions on drug use consistently as a standard part of the review of patient medical history.

CALL TO ACTION

There are likely several reasons underlying the discrepancy in drug use prevalence between the dental records and the US population. For instance, it has been speculated that patients are more prone to underreport drug use when in a health care setting, perhaps owing to a fear of being stigmatized.⁸ It is also probable that some dentists opt not to probe patients about their drug use, which would suggest that dentists’ attitudes are also a barrier to screening. Indeed, a study of a nationally representative sample of US dentists found that approximately two-thirds did not agree that screening for drug use was compatible with their profession and one-quarter did not ask their patients about substance misuse,³ perhaps owing to fear of effects on patient acceptance.⁹

Understanding the reasons for underreporting is important for developing strategies that can be adopted practically in clinical practice. Our first recommendation for dentists is to incorporate at least 1 drug use question into the standard medical history questionnaire or interview form. To address the fear that patients may not be receptive to such queries, drug use questions can be prefaced by briefly explaining that the use of drugs can affect patients’ oral health and the treatments they may be recommended. Providers should not exude hesitancy when querying drug use; maintaining an air of professionalism and a safe space can foster patient honesty. Open-ended questions about drug use also tend to lead to underreporting of use, so asking about use of specific drugs is ideal.¹⁰

To be clear, we are not imploring that the dental care profession at large expand its scope of practice to include diagnosing SUD or recommending specific drug use interventions. Rather, we believe it to be best practice if dentists were to document patients’ reported drug use history consistently alongside their medical or social history and recommend further counseling or intervention with primary care providers if a drug use problem is identified. In the long run, this approach also may yield valuable data that can underpin future studies investigating the dental management of patients who use various drugs.

CONCLUSION

Compared with data from the US population, the prevalence of use of alcohol, tobacco, cannabis, cocaine, opioids (nonmedical and recreational use), 3,4-methylenedioxymethamphetamine, methamphetamine, ketamine, and heroin were markedly lower when obtained from dental records. Dentists should show more diligence toward probing drug use during review of medical history.