Substance-use screening and interventions in dental practices

RESEARCH

Substance-use screening and interventions in dental practices Survey of practice-based research network dentists regarding current practices, policies and barriers Jennifer McNeely, MD, MS; Shana Wright, MPA; Abigail G. Matthews, PhD; John Rotrosen, MD; Donna Shelley, MD, MPH; Matthew P. Buchholz, MS; Frederick A. Curro, DMD, PhD

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 Background. Dental visits represent an opportunity to identify and assist patients with unhealthy substance use, but little is known about how dentists are addressing patients’ use A RT IC LE of tobacco, alcohol and illicit drugs. The authors surveyed dentists to learn about the role their practices might play in providing substance-use screening and interventions. Methods. The authors distributed a 41-item Web-based survey to all 210 dentists active in the Practitioners Engaged in Applied Research and Learning Network, a practice-based research network. The questionnaire assessed dental practices’ policies and current practices, attitudes and perceived barriers to providing services for tobacco, alcohol and illicit drug use. Results. One hundred forty-three dentists completed the survey (68 percent response rate). Although screening was common, fewer dentists reported that they were providing follow-up counseling or referrals for substance use. Insufficient knowledge or training was the most frequently cited barrier to intervention. Many dentists reported they would offer assistance for use of tobacco (67 percent) or alcohol or illicit drugs (52 percent) if reimbursed; respondents who treated publicly insured patients were more likely to reply that they would offer this assistance. Conclusions. Dentists recognize the importance of screening for substance use, but they lack the clinical training and practice-based systems focused on substance use that could facilitate intervention. Practical Implications. The results of this study indicate that dentists may be willing to address substance use among patients, including use of alcohol and illicit drugs in addition to tobacco, if barriers are reduced through changes in reimbursement, education and systems-level support. Key Words. Substance use; tobacco-use cessation; tobaccouse interventions; dental practice; dental clinics; Practitioners Engaged in Applied Research and Learning. JADA 2013;144(6):627-638.

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Dr. McNeely is an assistant professor, Department of Population Health and Department of Medicine, Division of General Internal Medicine, New York University School of Medicine, 227 E. 30th St., Room 623, New York, N.Y. 10016, e-mail [email protected]. Address reprint requests to Dr. McNeely. Ms. Wright is an assistant research scientist, Department of Psychiatry and Department of Population Health, New York University School of Medicine, New York City. Dr. Matthews is a biostatistician, The EMMES Corp., Rockville, Md. Dr. Rotrosen is a professor, Department of Psychiatry, New York University School of Medicine, and associate chief of staff for mental health research, Veterans Affairs New York Harbor Healthcare System, New York City. Dr. Shelley is director, Research Development, and an associate professor, Department of Population Health, Division of Comparative Effectiveness and Decision Science, New York University School of Medicine, New York City. Mr. Buchholz is a senior clinical research associate, PEARL Network, New York University College of Dentistry, New York City. Dr. Curro is director of clinical operations, PEARL Network, and director of regulatory affairs, Bluestone Center for Clinical Research, New York University College of Dentistry, New York City.

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isuse of tobacco, alcohol and illicit drugs leads to more death and disability than any other preventable health condition, yet a remarkably small percentage of users are offered treatment within health care settings.1-4 Patients’ visits to health care providers increasingly are viewed as opportunities to provide screening and interventions for patients with unhealthy substance use. There is strong evidence that even brief interventions in primary medical care settings can produce significant and sustained reductions in tobacco use and alcohol consumption.5-7 The U.S. Preventive Services

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RESEARCH

Task Force (USPSTF)8 recommends that health care providers screen all adults for tobacco use and provide cessation interventions for current users. The Public Health Service’s guideline, “Treating Tobacco Use and Dependence: 2008 Update,9” advises multiple interventions at each point of contact with the health care system. The USPSTF also recommends that primary care providers screen patients for and counsel them about risky alcohol use and misuse,10 and a growing body of research findings supports this approach for users of illicit drugs as well.11 Dentists represent a largely untapped resource for identifying harmful substance use and for increasing access to treatment. Clinicians in dental practices see a broad proportion of the population and have regular contact with people who do not otherwise visit medical care providers. In 2008, an estimated 42 percent of adults in the United States visited a dentist,12 23 percent of whom saw no other health care provider during the year.13 In addition to their public health benefits, substance-use interventions are clinically relevant for dentists, owing to the substantial effects of use of tobacco, alcohol and illicit drugs on oral health. Tobacco use and alcohol consumption are the primary risk factors for oral and pharyngeal cancer in the United States.14 Tobacco use also is associated with early tooth loss, periodontal disease, gingivitis and caries.15-18 Direct consequences of alcohol and illicit drug use on oral health include early and severe periodontitis and dental caries.19-22 Screening and interventions conducted in dental settings can be effective in helping patients stop using tobacco, and they are highly cost-effective.6,23-25 As an endorsement of the role of dentistry in tobacco-use–cessation efforts, Healthy People 202026 includes as a key objective improving the rates of screening and cessation counseling in dental care settings. The results of surveys of dentists conducted over the past 15 years indicate that screening for tobacco use has increased from about onethird of dentists reporting that they conducted routine tobacco-use screening in the earlier surveys27,28 to a majority (59 percent) reporting that they did so in a more recent (2009) survey of Florida dentists.29 Yet, although tobacco-use screening is being performed more routinely in dental practices, rates of tobacco-use–cessation assistance remain relatively low. Dentists have cited multiple barriers to providing tobaccouse–cessation assistance, including limited time and knowledge, a lack of reimbursement and a concern that patients will not be receptive to ad-

dressing tobacco use in the dental setting.27,30-32 Understanding these barriers is important to develop interventions that can be implemented widely and sustained as part of regular clinical practice. Much less is known about dentists’ clinical practices regarding their patients’ use of alcohol and illicit drugs. No investigators, to our knowledge, have conducted studies in which they assessed the types of screening practices that dentists may have in place to identify unhealthy alcohol and drug use or whether they are offering services (such as counseling, referral to drug treatment programs) to high-risk patients. This issue is particularly salient in light of the rising rates of prescription opioid abuse33 and the role of general dentists and oral surgeons as frequent prescribers of these medications for treatment of postprocedural pain.34,35 To learn more about dentists’ practice patterns, experiences and attitudes regarding substance-use screening and interventions, we undertook a survey of primary care dentists. Our goal was to assess the potential for dental practices to play a greater role in screening patients and providing assistance to those with unhealthy substance use, as well as to determine potential barriers to integration of these services in the dental setting. To our knowledge, this study represents the first attempt to characterize U.S. dental practitioners’ attitudes toward screening and interventions for alcohol and illicit drug use alongside those for tobacco use, and it contributes to the growing body of knowledge regarding preventive dental interventions.13,36-40 Methods

Study design and population. We administered the survey to dentists who were members of the Practitioners Engaged in Applied Research and Learning (PEARL) network. The PEARL Network was one of three dental practice-based research networks (PBRNs) established in 2005 with a seven-year grant from the National Institute of Dental and Craniofacial Research, National Institutes of Health. PEARL Network members are practicing dentists who have expressed an interest in conducting research in their own clinical pracABBREVIATION KEY. AOD: Alcohol and other drugs. HIV: Human immunodeficiency virus. NA: Not applicable. PBRN: Practice-based research network. PEARL: Practitioners Engaged in Applied Research and Learning. USPSTF: U.S. Preventive Services Task Force.

628 JADA 144(6) http://jada.ada.org June 2013 Copyright © 2013 American Dental Association. All Rights Reserved.

RESEARCH

tices. PEARL recruits dentists from a variety of settings, including private and group practices, corporate models of dentistry and community health centers. We chose PEARL dentists for this study because of an expressed interest within the PBRN in studying tobacco-use–cessation interventions in dental settings. All 210 dentists active in the PEARL Network as of May 2010 were eligible to participate. We collected responses over an eight-week period during the summer of 2010. All PEARL Network dentists received an e-mail notifying them of the study and directing them to a secure website to participate in the Web-based survey. PEARL research staff members made follow-up telephone calls and sent up to six e-mails to dentists who did not complete the survey after the initial notification. We asked participants to read a statement of consent before beginning the study, and we used a click-to-consent process. Dentists received compensation of $100 for completing the survey. The institutional review board at the New York University School of Medicine, New York City, approved the study. Variables and measures. Survey. A 41item survey was the primary means of data collection. Four of us (J.M., J.R., D.S., F.A.C.) developed the survey, with input from the PEARL data coordinating center (The EMMES Corp., Rockville, Md.) and PEARL staff members. We pilot tested the survey questionnaire with members of the PEARL executive committee, which includes dental practitioner-investigators. Two of us (J.M., F.A.C.) conducted a telephone focus group composed of participants in the pilot test group to discuss the survey; on the basis of their review, we made changes to the preamble and phrasing of survey questions. The survey assessed respondents’ characteristics and attitudes, as well as aspects of their clinical practice sites, including policies and procedures pertaining to addressing substance use. All information collected was based on respondents’ self-reports. For practice characteristics, the survey asked dentists to base their responses on the clinic in which they worked the majority of the time. Survey data collected about the respondents’ and practices’ characteristics included practice type and practice setting, staffing levels and insurance accepted, provider demographics, provider type and years since graduation from dental school. Survey items asked participants for responses specific to tobacco, alcohol or illicit drug use. We asked dentists about attitudes toward and practices regarding screening, counseling and

referring patients for use of these substances. The survey included specific questions about evidence-based tobacco-use–cessation practices, as well as about potential barriers to implementation of screening and interventions for tobacco, alcohol and illicit drug use in dental practices. We defined illicit or street drugs in the survey as “narcotics, illegal drugs, nonmedical use of prescription drugs.” A survey item that asked respondents to rate the importance of screening patients for tobacco use, alcohol use, illicit drug use, human immunodeficiency virus (HIV) and hypertension used a broad definition of screening to include “having patients fill out a medical/dental history or survey form, asking them in person . . . or [conducting] a diagnostic test.” Survey questions about the respondent’s clinical practice defined screening more specifically; one question asked, “Does the patient dental/medical history form include questions about [tobacco use, alcohol use, illicit or street drug use]?”, and another asked if providers “routinely ask patients verbally about [tobacco use, alcohol use, illicit or street drug use].” Another item asked if “providers in your practice routinely counsel and/ or provide referrals to patients with [tobacco use, alcohol use, illicit or street drug use].” The survey included a set of questions about barriers to addressing substance use: these barriers included a lack of time, a belief that dental practices are not effective in helping patients quit, a lack of knowledge/training in providing interventions, a belief that the dental practice is not an appropriate setting, resistance by staff members, and having nowhere to refer patients with substance-use problems. Respondents’ profiles. We gathered the following information about respondents’ and practices’ characteristics from the PEARL Network’s membership profiles of survey respondents: dental degree, ownership status and geographical region. Statistical analysis. Descriptive analyses consisted of frequencies and distributions of practices’ and respondents’ characteristics. We used univariate logistic regression to independently examine associations of respondents’ characteristics and practices’ characteristics with perceived barriers regarding willingness to offer either tobacco-use–cessation assistance or alcohol- or illicit drug–use assistance. We based respondents’ readiness to offer assistance on responses to the following survey item: “If thirdparty reimbursement were available, I would offer counseling and assistance to patients who use [tobacco, alcohol, illicit drugs].” The answer JADA 144(6)  http://jada.ada.org  June 2013 629

Copyright © 2013 American Dental Association. All Rights Reserved.

RESEARCH TABLE 1

Dentists’ and dental practices’ characteristics (N = 143). No. (%) *

Characteristic Dentists Age, in years Median Range Interquartile range Sex Male Female Race/ethnicity† White Asian African American Hispanic Other Degree Doctor of Dental Surgery Doctor of Dental Medicine Years since graduation Median Range Interquartile range Provider type Generalist Specialist Ownership status Owner Co-owner/partner Neither Dental Practices Practice type General Pediatric Periodontics Other Practice setting Suburban Urban Rural Other Practice region Northeast South Midwest West Active patients, no. < 1,000 1,000-1,999 ≥ 2,000 Full-time dentists, no. None 1 2-3 ≥4 Missing data Full-time hygienists, no. None 1 2-3 >3 Missing data

53 30-70 11

100 (70) 43 (30)



99 15 12 12 5

(69) (10) (8) (8) (3)



80 (56) 63 (44) 26 2-43 11



130 (91) 13 (9)



92 (64) 28 (20) 23 (16)



126 8 5 4

(88) (6) (3) (3)



86 43 12 2

(60) (30) (8) (1)



100 25 12 6

(70) (17) (8) (4)



31 (22) 62 (43) 50 (35)



3 (2) 82 (57) 35 (24) 14 (10) 9 (6)



38 43 28 13 21

(27) (30) (20) (9) (15)

* Unless otherwise specified. † Dentists reporting Hispanic ethnicity were classified as Hispanic, regardless of race.

choices were “yes,” “no” or “neutral/don’t know.” We dichotomized responses, with “yes” considered positive and any other response considered negative. We considered “neutral/don’t know” to be a negative response because it implies that the respondent was not currently ready to offer substance-use counseling and assistance. Responses to items assessing respondents’ willingness to offer assistance to patients who use alcohol or illicit drugs indicated that our sample of dentists regarded intervention for these two substance classes similarly. The univariate analyses indicated that the same characteristics associated with readiness to offer assistance to patients who use alcohol also were associated with readiness to offer assistance to patients who use illicit drugs. We observed a high correlation (f = 0.89) between respondents’ readiness to offer assistance for alcohol use and for illicit drug use. Given the high degree of overlap in responses to questions regarding these two substance classes, we inferred that respondents did not make a distinction between alcohol and illicit drug use. On the basis of this observation, as well as a recognition that alcohol and illicit drug problems demand similar clinical interventions,41,42 we later combined alcohol and illicit drugs into a single variable—alcohol and other drugs (AODs)—for analytic purposes. We ranked the willingness-to-offer-assistance variable for patients who used AODs as “yes” if the dentist’s response was positive for willingness to address either alcohol or other drug use and “no” for all other responses. For questions about perceived barriers to addressing unhealthy substance use, we assessed dentists’ responses by using a five-point scale ranging from 5 (strongly agree) to 1 (strongly disagree). In the descriptive analyses, we dichotomized these responses into “agree” versus “disagree,” with neutral responses included in the “disagree” category. We then examined the intercorrelation between the six barriers for each substance class (tobacco, alcohol, illicit drugs) using Cronbach a. The results suggested that, with the exception of the survey item about referral sources, the barrier items could be combined into a single score. When we excluded the barrier item pertaining to lack of referral sources, Cronbach a was 0.71 for the tobacco-use barriers, 0.72 for the alcohol-use barriers and 0.72 for the illicit drug–use barriers. In a second step, we calculated barrier scores to indicate the strength of perceived barriers to addressing tobacco or AOD use across the queried domains (that is, time, effectiveness, knowledge and training, staff member resis-

630 JADA 144(6) http://jada.ada.org June 2013 Copyright © 2013 American Dental Association. All Rights Reserved.

RESEARCH

Results

TABLE 2

Type of health insurance accepted by dental practices (N = 143). Insurance Type

No. (%) of practices accepting insurance

Percentage of patients covered by insurance* Median

Range

Interquartile Range

Private

141 (99)

60

2-100

35

Medicaid

43 (30)

20

1-95

25

Medicare

30 (21)

13

11-75

21

Other

17 (12)

15

1-100

18

* Percentage reported for practices having at least one patient with this insurance type.

100

RESPONDENTS (PERCENTAGE)

tance and appropriateness in dental practice settings). The scores represent a sum of ranked answers to the questions about barrier items (possible range, 5 through 25). A higher barrier score indicates a stronger perception of barriers to addressing use of these substances. We examined independently the association between respondents’ perceived lack of referral sources and willingness to address tobacco, alcohol or illicit drug use. We developed two multivariate models to examine predictors of respondents’ willingness to offer assistance to users of tobacco or AODs. In model A, the dependent variable was willingness to provide tobaccouse–cessation assistance; in model B, the dependent variable was willingness to provide assistance for AOD use. We used a stepwise model-building approach to develop each multivariate model, with an entry P value of .10; we assessed statistical significance at the .05 level. We used statistical software (PASW Statistics Version 18, IBM SPSS, Armonk, N.Y.) for all final analyses.

90

93%

80 70

76%

78% 73%

60

63%

Tobacco

50

Alcohol

44%

40

Illicit Drugs

30

33% 29%

20

25%

10 0

Included on Dental/Medical History Form

Ask Orally

Counsel/Refer

SCREENING AND ASSISTANCE

Figure 1. Percentage of dentists who reported that their dental practices provide screening of, and assistance to, patients who use tobacco, alcohol or illicit drugs (N = 143).

Designate a staff person to be responsible for tobacco-use–cessation activities Train providers to provide interventions

10%

17%

Of the 210 eligible dentists, Prescribe or provide tobacco 17% pharmacotherapy 143 participated in the survey (68 percent response Use prompts in patients’ records to remind staff 29% to ask or advise patients about tobacco use rate). Table 1 shows characteristics of respondents Refer patients to community programs 40% and their primary dental or state quitlines practices. We compared the Offer pamphlets or self-help materials 49% member profiles of survey to patients respondents with those of the entire PEARL Network and found no substantial Figure 2. Percentage of dental practices engaged in specific evidence-based tobacco-use– differences between the cessation interventions (N = 143). two groups with regard to age, sex, race/ethnicity or practice setting. Most participants were in The majority of practices had one full-time general practice settings, including four pubdentist and were located in the northeastern lic health and two dental medicine clinics. United States. Sources of payment primarily JADA 144(6)  http://jada.ada.org  June 2013 631 Copyright © 2013 American Dental Association. All Rights Reserved.

RESEARCH

patients to community programs or state quit90 lines. Seventeen percent of practices prescribed or 80 provided tobacco pharmacotherapy. Respondents 70 named dentists and hy60 gienists most frequently as Tobacco the staff members primar50 Alcohol ily responsible for provid40 ing counseling to patients Illicit Drugs who used tobacco. 30 Barriers to addressing tobacco, alcohol 20 and illicit drug use. We 10 asked dentists to identify their level of agreement 0 Lack of No Referral Lack of Staff Dental Dental with six specific potential Knowledge/ Resources Time Resistance Practices Practices barriers to addressing Training Not Effective Not in Helping Appropriate tobacco, alcohol and ilPatients Setting to Quit Address licit drug use among their Substance Use patients (Figure 3). RePERCEIVED BARRIERS spondents ranked barriers to addressing tobacco use Figure 3. Dentists’ perceived barriers to addressing patients’ tobacco, alcohol and illicit drug lower than they ranked use in dental practices (N = 143). barriers to addressing alcohol and illicit drug use. Lack of knowledge/ were private insurance or no insurance/selftraining was the most frequently cited barrier pay; a minority of dental practices had at to addressing tobacco (53 percent), alcohol (81 least one patient who was covered by Medipercent) and illicit drug use (84 percent). The care or Medicaid (Table 2). second most commonly cited barrier to addressScreening and assistance. The majority of ing use of tobacco and alcohol was a lack of participants responded that it was “somewhat referral resources. For illicit drugs, the second important” or “very important” for dental pracmost commonly cited barrier was a belief that tices to screen patients for tobacco (99 percent), clinical practice staff would be resistant to adalcohol (92 percent) and illicit drug use (93 dressing substance use. With regard to whether percent). Participants also responded that they dentists thought that dental practices are an considered it “somewhat important” or “very appropriate setting to address substance-use important” to screen for hypertension (99 perproblems, the survey results showed a statisticent) and HIV (91 percent). Many respondents cally significant difference (P < .001) between reported that their dental practices conducted responses for tobacco use and those for alcohol screening for substance use (Figure 1). Dental or illicit drug use. Three percent of respondents practices screened patients primarily through felt the dental practice was an inappropriate the written dental and medical history form, but setting to address tobacco use, whereas 18 and dental care providers also reported conducting 23 percent of respondents, respectively, thought in-person screening, more often for tobacco use it was an inappropriate setting to address alcothan for AOD use. A majority of respondents hol and illicit drug use. reported that dental care providers in their Willingness to offer tobacco-, alcoholpractice “routinely” counseled patients, provided and illicit drug–use assistance. The surreferrals to patients who used tobacco, or both, vey asked dentists whether they would offer but they reported providing these services less counseling and assistance to patients who use frequently to AOD users. tobacco, alcohol or illicit drugs if third-party Evidence-based practices for tobaccoreimbursement were available. A majority of use cessation. The survey asked specific quesdentists indicated a willingness to provide tions about evidence-based practices for tobaccoassistance to users of tobacco (67 percent) and use–cessation assistance (Figure 2). The most to users of alcohol or illicit drugs (52 percent). frequently reported activities were providing Sixty-seven participants (47 percent) indicated pamphlets and self-help materials and referring DENTISTS WHO AGREE OR STRONGLY AGREE (PERCENTAGE)

100

632 JADA 144(6) http://jada.ada.org June 2013 Copyright © 2013 American Dental Association. All Rights Reserved.

RESEARCH

that they would provide assistance for all three substances. Among those who were not willing to offer assistance, the majority responded “neutral/don’t know” rather than “no.” Table 3 presents the univariate associations between respondents’ and dental practices’ characteristics associated with willingness to offer assistance to patients for tobacco or AOD use. Among practice characteristics, having at least 5 percent of patients with Medicaid or Medicare coverage was positively associated with a willingness to provide tobacco-use– cessation assistance. Eighty-two percent of dentists from practices that met this criterion for Medicaid coverage responded that they would offer tobacco-use–cessation assistance, compared with 62 percent of those from practices in which less than 5 percent of patients were covered by Medicaid. The difference between these groups was statistically significant (P = .023). Similarly, dentists from practices in which at least 5 percent of patients were enrolled in Medicaid were significantly (P = .006) more likely to have reported that they were willing to offer assistance for AOD use. A higher percentage of nonwhite respondents than white respondents were willing to provide assistance to patients for AOD use. However, race was significantly associated with having at least 5 percent of patients enrolled in Medicaid (39 percent of nonwhite participants versus 22 percent of white participants; P = .04). We found that the mean barrier score for tobacco use was lower among dentists who responded that they were ready to offer assistance to tobacco users than it was among those who were not ready (mean score, 11.5 versus 13.3; maximum possible score, 25), and that the tobacco-use barrier score was significantly associated with readiness to offer assistance to both tobacco users (P = .005) and AOD users (P = .039). The mean AOD barrier score was lower among those who responded that they were ready to offer assistance to AOD users than it was among those who were not ready (mean score, 13.7 versus 17.2). The AOD barrier score was significantly associated with readiness to provide assistance to patients for AOD use (P < .001) but not for tobacco use (P = .056). The barrier score for “lack of referral sources” was not significantly associated with readiness to offer assistance to patients who used tobacco or AODs. In addition, we found no significant association between race and the barrier score for tobacco or AOD use. Table 4 (page 636) presents two multivariate models that examine respondents’ and practices’

characteristics that may predict willingness to offer substance-use counseling or referrals. Model A examines predictors of willingness to offer tobacco-use–cessation assistance, and model B examines willingness to offer AOD-use assistance. After controlling for having at least 5 percent of patients covered by Medicaid, we found the adjusted odds of willingness to offer tobacco-use–cessation assistance (model A) were significantly lower for dentists who perceived high barriers to offering such assistance. Willingness to offer tobacco-use–cessation services was not affected significantly by perceived barriers to offering AOD services in the multivariate model. Similarly, in model B, high perceived barriers to providing AOD services significantly decreased the adjusted odds of being willing to offer assistance to patients who used these substances. Controlling for perceived barriers to addressing tobacco or AOD use, we found that practices in which at least 5 percent of patients were enrolled in Medicaid had significantly higher adjusted odds of being willing to offer assistance to AOD users (OR = 3.06, P = .020). Discussion

Our survey findings indicate that dentists in the PEARL PBRN approve of screening for substance use, and most reported that they conducted screening in their practices. As PBRN members, these practitioners already had expressed a strong interest in research, and they may be more likely to adopt newer practices such as screening and interventions for substance use. However, even among this group, reported rates of follow-up counseling and referrals for patients with positive screening results were much lower than rates of screening, particularly with respect to AOD use. Our findings suggest that more support is needed (for example, clinical decision support or training staff members and assigning them to specific roles) to implement clinical interventions that go beyond screening to offer assistance to patients who use tobacco or AODs. Tobacco-use screening and intervention. Survey respondents reported that they screened patients and offered cessation assistance more often for tobacco use than for AOD use, and dentists perceived fewer barriers to providing tobacco-use–related services. These providers reported higher rates of screening for tobacco use and of conducting interventions than those reported in previous surveys of dentists.27,28,31 Although some of this discrepancy may be attributable to the characteristics of PBRN JADA 144(6)  http://jada.ada.org  June 2013 633

Copyright © 2013 American Dental Association. All Rights Reserved.

RESEARCH TABLE 3

Dentists’ and dental practices’ characteristics associated with willingness to offer patients tobacco-use or AOD*-use assistance. P value‡ for tobacco

P value‡ for AODs

Would offer assistance to AOD users, No. (%) †

Would not offer assistance to AOD users, No. (%) †

.505



75 (52)



68 (48)

.400

.736



53 (53) 22 (51)



47 (47) 21 (49)

.840



46 (46) 29 (66)



53 (54) 15 (34)

24 (30)



45 (56)



35 (44)

23 (37)



30 (48)



33 (52)



69 (53) 6 (46)



61 (47) 7 (54)



44 (48) 31 (61)



48 (52) 20 (39)

CHARACTERISTIC

No. of respondents (N = 143)

Would offer assistance to tobacco users, No. (%) †

Would not offer assistance to tobacco users, No. (%) †

Age, in years

143



96 (67)



47 (33)

Sex Male Female

100 43



68 (68) 28 (65)



32 (32) 15 (35)

Race/ethnicity White Nonwhite

99 44



63 (64) 33 (75)



36 (36) 11 (25)

80



56 (70)



63



40 (63)



130 13



89 (68) 7 (54)



1 (32) 6 (46)

92 51



60 (65) 36 (71)



32 (35) 15 (29)

Dentists

Degree Doctor of Dental Surgery Doctor of Dental Medicine Provider type Generalist Specialist Ownership status Solo owner Co-owner or nonowner Barrier score for tobacco ¶ Mean Standard deviation Range Barrier score for AODs ¶ Mean Standard deviation Range

.033 §

.184

.745

.707

.291

.634

.513

.139

.005 § 12.1 3.6 5-24

11.5 2.9 6-18

13.3 4.5 5-24

.039 § 11.5 3.0 6-18

12.8 4.0 5-24 < .001 §

.056 15.4 4.0 6-25

14.9 4.2 6-25

16.3 3.4 10-25

13.7 3.5 6-22

17.2 3.8 10-25

* AOD: Alcohol and other drugs. † Unless otherwise specified. ‡ P values are based on univariate logistic regression in which the dependent variable is willingness to provide counseling and other assistance to patients who use tobacco or to patients who use AODs. § P ≤ .05. ¶ The barrier score is the sum of individual responses to barriers faced in addressing tobacco or AOD use. Participants provided responses on a five-point Likert scale (1 = strongly disagree, 5 = strongly agree).

dentists, it also likely reflects regional variations and temporally changing patterns of dental practice. Our results are comparable to those of a 2003-2004 national survey of health care providers, in which investigators found that 90 percent of dentists “ever ask if a patient smokes” and 71 percent advised smokers to quit.4 Our results also are similar to those of a 2009 survey of Florida dentists, in which 59 percent reported performing routine tobacco-use screening and 46 percent offered advice to patients.29 However, although a majority of respond-­ ents in our study reported that their practices offered some counseling and referrals to tobacco users, the results of our analysis showed that

the adoption of effective evidence-based approaches to tobacco-use–cessation assistance, including provision of pharmacotherapy, was low. This is consistent with findings from previous studies of tobacco-use–cessation efforts in dentistry.28,30,31,43 Respondents indicated that they perceived numerous barriers to integrating tobacco- and AOD-use services into dental practice, and these barriers were associated with willingness to offer assistance to substance users. Of the specific perceived barriers, “lack of knowledge/ training” was the most frequently cited barrier to addressing all substance use. In their survey of Florida dentists, Succar and colleagues29 also

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RESEARCH TABLE 3 (continued)

CHARACTERISTIC

No. of respondents (N = 143)

Would offer assistance to tobacco users, No. (%) †

Would not offer assistance to tobacco users, No. (%) †

P value‡ for tobacco

Would offer assistance to AOD users, No. (%) †

Would not offer assistance to AOD users, No. (%) †



67 (53) 8 (47)



59 (47) 9 (53)



24 (56) 43 (50) 8 (57)



19 (44) 43 (50) 6 (43)



52 (52) 23 (53)



48 (48) 20 (47)

P value‡ for AODs

Dental Practices Practice type General Other

126 17



87 (69) 9 (53)



39 (31) 8 (47)

Setting Urban Suburban Rural/other

43 86 14



35 (81) 52 (60) 9 (64)



8 (19) 34 (40) 5 (36)

Region Northeast Other

100 43



69 (69) 27 (63)



31 (31) 16 (37)

Active patients, No. < 1,000 1,000-1,999 ≥ 2,000 Full-time dentists, No. 0-1 >1 Full-time hygienists, No. 0-1 >1 Patients covered by Medicaid, % <5 ≥5 Patients covered by Medicare, % <5 ≥5

.190

.636

.055

.825

.469

.870

.953 31 62 50



20 (65) 43 (69) 33 (66)



11 (35) 19 (31) 17 (34)

.815

16 (52) 32 (52) 27 (54)



15 (48) 30 (48) 23 (46)

.863 85 49



56 (66) 33 (67)



29 (34) 16 (33)

.830

45 (53) 25 (51)



40 (47) 24 (49)

.963 81 41



53 (65) 27 (66)



28 (35) 14 (34)

.567

41 (51) 23 (56)



40 (49) 18 (44) .006 §

.023§ 104 39



64 (62) 32 (82)



40 (38) 7 (18)



47 (45) 28 (72)



57 (55) 11 (28)

.022 § 118 25



74 (63) 22 (88)



44 (37) 3 (12)

identified a lack of knowledge and training as one of the most common barriers to addressing tobacco-use cessation. Researchers conducting studies of tobacco-use activities among dentists have reported barriers, such as a lack of referral resources, time pressures and staff resistance, that we identified in our dentist population.27,43 Our study is unique in that we also examined barriers to providing assistance to users of AODs. Perhaps not surprisingly, given the relative lack of focus on interventions for AOD use compared with tobacco-use–cessation interventions in dental practices, dentists perceived fewer barriers to addressing tobacco use than they did to addressing AOD use. Notably, dentists in practices with patients enrolled in Medicaid were more willing than other dentists to offer services for AOD use if reimbursement were provided. It is possible

.091

58 (49) 17 (68)



60 (51) 8 (32)

that practices accepting patients with public insurance have a more explicit public health mission or a service delivery system that is more accommodating of behavioral interventions. Our sample did not include enough of these providers for us to identify specific characteristics of dentists or practices that could explain their greater willingness to provide substance-use interventions. Study limitations. Our study had important limitations. We drew the survey sample exclusively from practitioners in the PEARL Network, and we cannot assume that it represents a more general population of dentists. One might expect dentists participating in a PBRN to have more favorable views toward incorporating new approaches to care, such as screening and providing interventions for tobacco and other substance use, into their clinical practices. JADA 144(6)  http://jada.ada.org  June 2013 635

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RESEARCH

sion. In particular, the survey asked Multivariate models of dentist- and practice-level whether providers in the practice characteristics and adjusted odds of willingness to “routinely” enoffer tobacco-use or alcohol and other drug (AOD)—use gaged in screening assistance. (defined as asking Variable Model A: Model B: patients orally) or Would offer tobacco-use Would offer AOD-use providing assist† * assistance assistance ance (defined as ‡ § OR (95% CI ) P Value OR (95% CI) P Value counseling, referNA # NA 3.06 (1.19-7.87) .020 ≥ 5% of Patients rals or both), but ¶ Covered by Medicaid it did not explicTobacco Barriers Score 0.89 (0.79-0.99) .039 NA NA itly define the fre< .001 AOD Barriers Score NA NA 0.76 (0.67-0.87) quency implied by * The dependent variable is willingness to offer tobacco-use assistance (“yes” versus “no/neutral” response to “routinely” or the survey item: “If third-party reimbursement were available, I would offer counseling and assistance to patients specific approaches who use tobacco.”). Hosmer-Lemeshow goodness-of-fit test; P = .40. † The dependent variable is willlingness to offer alcohol and other drug—use assistance (“yes” versus “no/ (such as adminisneutral” response to one of these survey items: “If third-party reimbursement were available, I would offer tering screening counseling and assistance to patients who use alcohol” or “If third-party reimbursement were available, I would offer counseling and assistance to patients who use illicit drugs”). Hosmer-Lemeshow goodness-of-fit questionnaires or test; P = .42. using evidence‡ OR: Odds ratio. based counseling § CI: Confidence interval. ¶ The reference category is less than 5 percent of patients covered by Medicaid. approaches) to # NA: Not applicable. The variable did not remain in the multivariate model after variable selection. conducting these activities. ReliThis could have biased our sample toward reance on dentists’ self-reports may have inflated porting higher rates of support for screening estimates of substance-use–related practices owand intervention than might be found in a gening to a social desirability bias. We also do not eral sample of dentists. The results of a 2009 know how accurately respondents characterized study from another dental PBRN showed that, the activities of their dental practices, including overall, their members’ characteristics were those of other dentists and staff members. Howsimilar to those of U.S. dentists at large, alever, most dentists in our study worked in small, though that analysis did not specifically address single-provider practices. Finally, we asked spesubstance-use activities and attitudes.44 cifically about willingness to provide substanceOur sample was relatively homogeneous in use assistance if reimbursement were available terms of both respondents’ and practices’ charfor these clinical services. We did not explore acteristics. These results largely represent the how responses might differ at varying levels of behaviors and attitudes of experienced general reimbursement, although this could be a relevant dentists in fairly small suburban and urban area for future research. dental offices. Although this does represent Conclusions the predominant practice model in dentistry,45 The results of this study show that dentists a greater diversity of practice types, including in the PEARL Network recognized the imporlarger or public clinics, may have given us more tance of screening for substance use, but they insight into practice characteristics associated did not consistently follow up screening results with a willingness to address substance use. with effective interventions, and they perceived Having more geographical variation and represignificant barriers to doing so. The most fresentation of rural practitioners also would have quently cited barrier was a lack of knowledge/ provided a more comprehensive picture of dentraining about substance-use assistance, and we tal activities to address substance use. Although could expect educational interventions (such as our response rate compares favorably with focused training in office-based brief counseling) those of similar surveys,4,28,29,46 it is possible that to have a favorable impact in this area. But dendentists who elected to participate differed in tists also endorsed systems-level barriers (lack their attitudes and practice patterns, and they of time and referral resources) that may require may have been more supportive of the types of more complex and practice-specific solutions. substance-use services that were the focus of The most important barrier may be the lack of our survey. reimbursement for substance-use screening and Some terms used in our survey lacked preci-

TABLE 4

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RESEARCH

for tobacco- or AOD-use interventions in dental practice. If barriers were reduced through changes in reimbursement, education and systems-level support, our findings indicate that more dentists may be willing to address substance use among their patients. In medicine more generally, the shift toward patient-centered medical homes has resulted in an evolving focus on addressing behavioral health conditions, including substance use, as part of primary care.47-49 Given this changing focus and the potential for dentistry to have a broad impact on public health, dentists’ role as partners in identifying and addressing substance use among patients may deserve further exploration. n Disclosure. None of the authors reported any disclosures. This research was supported by grants 5U10DA013046 and U10 DA13035 from the National Institutes of Health (NIH)/National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN), Bethesda, Md., and by grant U01 DE016755 from the National Institute of Dental and Craniofacial Research, NIH. Dr. McNeely received support from NIH/NIDA grant K23DA030395 and from grant KL2RR029891 from the NIH/New York University Clinical and Translational Science Institute, New York City. The authors thank Damon Collie and Don Vena, The EMMES Corp., Rockville, Md., and George E. Bigelow, National Institute on Drug Abuse/Clinical Trials Network Publications Committee. The authors thank Nora Volkow, MD, director of National Institute on Drug Abuse, National Institutes of Health, and colleagues at the Clinical Trials Network for support and encouragement in exploring acceptability and sustainability of innovation in approaches to tobacco-use cessation. 1. Horgan CM. Substance Abuse: The Nation’s Number One Health Problem—Key Indicators for Policy Update. Princeton, N.J.: Robert Wood Johnson Foundation; 2001:45-73. 2. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000 (published correction appears in JAMA 2005;293[3]:293-294). JAMA 2004;291(10):1238-1245. 3. Office of Applied Studies, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, and RTI International. Results from the 2008 National Survey on Drug Use and Health: National Findings. Rockville, Md.: U.S. Department of Health and Human Services (DHHS), Substance Abuse and Mental Health Services Administration, Office of Applied Studies; 2009. National Survey on Drug Use and Health (NSDUH) Series H-36, DHHS publication SMA 09-4434. http://oas.samhsa.gov/ nsduh/2k8nsduh/2k8Results.cfm#1.1. Accessed April 30, 2013. 4. Tong E, Strouse R, Hall J, Kovac M, Schroeder SA. National survey of U.S. health professionals’ smoking prevalence, cessation practices, and beliefs (published online ahead of print May 27, 2010). Nicotine Tob Res 2010;12(7):724-733. doi:10.1093/ntr/ntq071. 5. Solberg L, Maciosek M, Edwards N, Khanchandani H, Goodman M. Repeated tobacco-use screening and intervention in clinical practice: health impact and cost effectiveness. Am J Prev Med 2006;31(1):62-71. 6. Fiore MC, Jaen CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update—U.S. Public Health Service Clinical Practice Guideline executive summary. Respir Care 2008;53(9): 1217-1222. 7. Whitlock EP, Polen MR, Green CA, Orleans T, Klein J; U.S. Preventive Services Task Force. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2004;140(7):557-568. 8. U.S. Preventive Services Task Force. Counseling and Interventions to Prevent Tobacco Use and Tobacco-Caused Disease in Adults

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638 JADA 144(6) http://jada.ada.org June 2013 Copyright © 2013 American Dental Association. All Rights Reserved.