I must admit that I love to play games. One of my favorite dinner table games is 20 questions. In this game, a player picks a secret object from one of 4 categories (person, place, thing or animal). The other players have to guess what the secret object is by asking no more than 20 questions. Whoever guesses correctly, then selects the next secret object for the game. Each question asked should build upon what is known about the secret object and elicit additional unknown information that will reveal the object’s identity.
At our dinner table, we start the game by asking, “Is it a person, place, thing or animal”? Then we ask more detailed questions, based upon the identified category, such as “How big is it?”, “Is it in our house right now?”, “Can I see this animal at the zoo?” or “What do I use this object for”? By the end of the game, most of the questions that were asked and answered started with the interrogative words Who, What, or Why?
In dentistry, we often play a similar game of trivia with our patients! It starts from the moment they sit in our dental chair and we begin to review our patients’ health history forms. We ask our patients questions, like “What medications are you taking?” or “When was the last time you saw your physician”, in response to their self-reported responses on our medical/dental forms. But when the question on the form is “Do you have a history of substance abuse?” the 20-question game abruptly and awkwardly comes to an end! We lose interest in continuing the “game” out of fear of offending or embarrassing our patients. We even rationalize the “end of the game” by telling ourselves it is none of our business and that addiction instead is our patient’s own personal business. However, by ending the 20-questions, we subscribe to the widely held belief that addiction is a behavioral or moral issue rather than the currently accepted definition of addiction as a disease with genetic, biologic and environmental risk factors. By ending the questioning, we also end the ability to elicit important information necessary to understand our patients’ oral conditions and create modified treatment plans to address the negative oral effects of substance abuse, including hyposalivation, bruxism, and increased caries, that derails treatment success.
Asking a patient, “what drug is being abused” allows you to recognize the physical, behavioral, and oral symptoms unique to that drug of choice. For example, a patient who reports using methamphetamine will exhibit hyperactivity, and have dilated pupils and elevated vital signs and present quite differently from a patient who reports using opioids. Asking “when was the drug last used” allows you to determine if that patient may be under the influence of a controlled substance. The answer to this question may force you to put down the dental drill, anesthetic syringe and prescription pad and re-schedule the patient to avoid a fatal drug-to-drug interaction. However, the most important question to ask patients is “why?”.
For the past 25 years, I have worked with patients who have significant substance-use disorders. During this time, I have never had a patient tell me that he/she started using drugs to become addicted, to destroy relationships with family and friends, or to end up in a jail cell. Instead, my patients have shared their why’s often with tears of sadness and regret. The “why” of a painful divorce or years of child abuse. The “why” of a neurochemical imbalance in the brain’s reward center that was only “fixed” with drugs that stimulate dopamine release. The “why” of feelings of emptiness, hopelessness, and despair that were remedied temporarily with a puff, drink, pill or needle.
Understanding the “what”, “when” and “why’s” of our patient’s substance use allows us to be caring and competent dental care professionals to our patients. It helps us to understand the challenges that our patients face with empathy and concern, identify patients to refer for recovery and sobriety support, and allows us to have open and honest conversations with patients to un-silence and destigmatize the disease of addiction. Asking questions is more than just a game! Asking questions can save our patient’s lives!