1312 Treating Substance Use Disorder with Dr. Glen Hanson : Dentistry Uncensored with Howard Farran
It's just a huge honor for me today to be podcast interviewing Dr Glenn R Hansen DDS PhD he received his DDS from Ucla in seventy three and his PhD in Pharmacology from the University of Utah Taua Seventy eight and completed a fellowship a neuropharmacology in one thousand nine hundred eighty at the national institutes of Health and I ate Bethesda Maryland he practiced dentistry dentistry full and part-time over ten year period. He is a tenured full professor of pharmacology and Vice Dean in the school of Dentistry. He was the acting director of the the National Institute of Drug Abuse at the National Institute of Health and recognizes the leading expert on the neurobiology of the psychostimulants stimulants. UPPERS I. Dr Hanson has given several hundred presentations around the world on his research and program development related to drug abuse and the public health implications his also also testified multiple times for the United States Congress and the State of Utah legislator on issues of Drug Abuse Policy and Medicaid dental strategies and is frequently interviewed interviewed by local and International. Press about this topic's he's a member of the State of Utah Legislative Advisory Committee on drugs of abuse. He's the author of over over two hundred forty period. Viewed Scientific Papers Thirteen editions of a textbook entitled Drugs and society and has been awarded over thirty five million dollars dollars and NIH National Ceuta Health grants to conduct research related to drug abuse and his treatment. Dr Hanson has recently been involved in studying the effects of including comprehensive dental care as part of the treatment for substance use disorder. And it was a really interesting article that caught my eye Where where was it where the Was all over social media Just this May twenty-first Twenty nineteen dental care helps drug abuse patients recover. The study showed the drug abuse patients who consulted dental professionals for major oral health problems stating treatment almost two times longer and then they quote yours truly. This is a powerful synergy between oral healthcare and substance use disorder said Glenn Enhancing The studies I author and professor at the University of Utah Dr Hanson. Thank you so much for coming on the show today. This is such a controversial subject has seems to be so emotional and I can tell by the word you use now you have a PhD like you call it You don't I'm calling substance abuse. You call it. What do you call it? Substance use disorder substance use disorder. So it seems like I just want to start stirred this an old perspective. It seems like when I got out of school in eighty seven The media said the doctors are the bad guy. 'cause there's grandma suffering offering from cancer. She had surgery. They won't give her any pain pills and we were the bad guys so we started giving them the pain pills and then the pendulum swung all the the other side. And now they're like well you naughty little boy look what you did to grandma she's She's a heroin addict. And how do you. How do you gauge between you need this opioid for pain? But I don't want this to ruin your life and you become addicted to it. Well I tickets one. You have to train the provider the one who writes the prescription the one who assesses the risks on the part of the patient and to start start off with they have to understand what substance use disorder really is most people know addiction but it's referred to now as as you gay issue is defined in the DSM five manual and the disk in five manual. These manuals are used for psychiatrist interest in mental health workers to diagnose mental health disorders in. There's about a hundred and fifty two hundred pages out this manual that talk just about drug abuse. And so in this last edition they decided not to refer to it as dependence or addiction but to call it substance shoes disorder. That's why you hear that new nomenclature in the last few years because of this assess switching term that came out of the DSM DSM five But that's what it's referring to basically is what most of us think up as far as addiction so providers need to know what the differences insist between drug dependence drug abuse and substances disorder or addiction. so forgive me if I use those two interchangeably. 'cause I WANNA make sure that you're listening. Audience is aware of addiction. We're talking about the provider. Divider need to know that. There's a difference between these three phenomena and the three were drug dependence drug abuse and and Drug and Substance Substance Use disorders or addiction entering. Now I I've been hearing more and more more that If you have a drug issue oh I'm not so I don't have the PhD of this. I might just call drug issues plays but if you have a drug dependence drug abuse substance use disorder that at least you know eighty percent of these people have an underlying mental diseased mental disorder. Do you agree with that or disagree with that. I I really disagree with it just because it. It is so distinct. According to the individual all substance use disorder does not look the same. It's kind of like a cancer. No sometimes we you say oh yeah. My friend has cancer well. Cancer isn't cancer isn't cancer isn't cancer because there's so many different forms and and works very differently in different people in substance use disorders. Same Way. It's a very individual phenomena and so risk looks different environment looks different. There are those who claim that even those who have very low risk for substance substance use disorder if you put them in the right environment high stress Very very threatening where there's lot of tension a lot of demands placed on you at a very low self image that you who are still vulnerable to substance use disorder so it's the environment and there is also the risks that natural genetic risks and it. It may be the disease. There are some diseases where like neurodegenerative diseases where damaged unto the brain. That could be. It could be done down because of an accident. A car accident the damage to piece of your brain or it could be a pathology like a Parkinson's disease canals timers disease. That makes you more susceptible to problems with drugs than when you were younger. So it's a time of life that could it also have an impact as to whether you're suffering issues with that shoe so there is nobody that is immune. I'm the right kind of circumstances the having these kinds of problems with these substances humans are extremely complex. Aren't they much her. I'm I'm convinced at age. Fifty seven that. I'm the only normal person on well. That sounds like a mental have I diagnose myself I'm history's always in the news. About opioids like this. Just recently opioids unnecessary for dental work. DOC says American dental association recently reported dentistry is responsible for prescribing. Twelve percent of all instant release opioids Dr Mo.. Oh Jam Sutton advanced cosmetic dentistry talk to Fox News It's it's a tough call because we'll talk wisdom thi this. It seems like that's the procedure. The news talks about the most little billy came in his eighteen. He got his for wisdom. Teeth removed Dr routinely gave Vicadin. And now there's a problem So and then the as even saying that the dentist prescribed twelve percent of instant release opioids. Is that not to What what are your thoughts about? Dentists and opioids. Why would say that? The dental profession has sort of a unique niche in this big problem. I testified I'd been an expert witness. I've been involved in committees both at the national on the local level discussing this issue who are the providers who are the individuals that we need to really focus our attention on in providing education patients so that they're involved in the solution and they're not involved in causing the problem and when dentistry comes up almost without exception for those who know who really know what's going on here. They see them as a piece of the puzzle usually they are used by individuals who are best. Ud as a means of filling a void of getting access S.. Two drugs for a short period of time so like over the weekend or whatever reason they've run out of their opioid or they don't have access to their supply apply. Maybe they're out of town and so they go to a dentist on a Friday afternoon when he or she is just about to close may say oh. I've got this terrible root canal problem. It hurts so bad. Is there any way you can give me a just a small prescription. Get me over the weekend. I'll be here Monday. I'll the dentist wants to go home. Doesn't know the patient accepts them at their there were. Maybe they're dressed while they look like all they should be having an SUV. Problem writes the prescription. Gives them ten fifteen. If he's really agenda it gives a twenty so they get these using the carry them over until they can find the main source of their drug where they're getting hundreds op. Tablets are getting ten or fifteen so they used the dental professionals as it means to hold them over until they can get access says to the big numbers very rarely. Do you see dentists up. Prescribing hundreds of these opioids which are necessary in order to maintain an S. U. D. A. Person. They're rarely the ones that are doing that. They're they're they're contributing but usually they don't start started And also note ended and they just kinda contribute in the middle of their disorder. Ignorant as to what's going on around around Monday right there little prescription and SUV patient goes on his or her way When you say their source source I hear other people? This is You know there's many many different opinions and angles on this but a lot of people say that when when you you look at the opioid deaths I mean. And they're they're so high. I mean they're incredibly high. A lot of people say that that's a side effect of them being illegal that if they bought the opioid like say bike it in our heidrick own at Walgreens it wouldn't have been cut with cut now and that when it's illegal and they drive drive to underground illegal manufacturing opioids. The way they're made is a big part of the of the OPIOID death. Do you think mm-hmm how do you wrap your mind around the pros and cons of it being illegal so this they buy illegal drugs cut with you know other. There's things versus at least that they were legal. You would know. A high-quality laboratory made the OPIOID. So there certainly is a fraction of individuals who overdose and die because there's some fenton nail or something else that they used to cut the medication they are going to be illegals. You're not going to get these from the pharmacy. You're not going to get because the prescription but you're going to get it because you went to the street for whatever reason and it may ab that your prescriber usually a physician or a PA.. Your prescriber says enough is enough. I'm really concerned. You're getting too much judge so I'm GONNA cut back. I'm not going to provide you the stuff anymore and so they have to look elsewhere to satisfy the the addiction they go to the street and then they take something that has been nil in it so there are some deaths come from this. But they're the minority. The majority of people who over were dose on opioids usually have multiple drugs in their system. They have a prescription opioids in their system. Either Anoxia he co down maybe a morphine or they have a maturity or could be a hydro down. I mean there's a variety of drugs that they could be taken hit he could even be Methadone. It could be part of the treatment where they are using Methadone to help help them get off heroin and they're using it legally but they mixed with other stuff so these folks and I've been an expert witness on a a number of these locally nationally and in every case that I worked on there are at least three other drugs in the system. Usually there was alcohol in it. There was sixty percent of the time. There's a benzodiazepine in it. Like a valium drug and and then there is an over the counter or a common kind of drug in their either an antihistamine that they're using to try to get to slate sometimes they have they have congestion. And they're using the antihistamine or they have muscles that are jumpy and they're using a muscle relaxant Soma. So that's in there so there's three or four and then now we're seeing more and more as medical marijuana or recreational. Marijuana is becoming yeah look they have. THC In their system as well so they've got three or four CNS depressants and opioid is one of them and they're working together and they typically die in their sleep so they also have natural physiological CNS S. depression because of the sleep usually die about two or three in the morning. Somebody comes in the next morning and tries to wake them up and they can't wait come up because they have Sakaba Cobb overnight. So it's not just opioids opioids is a critical piece discussion. It's other things that are happening being in their life that they're trying to address other than just pain. Yeah I mean there's been some very high profiles every thing you were saying. Remind mind me of the Whitney Houston case the multiple things found in her bloodstream. Typical do so you think they Do you think the legalization and another very controversial Legalization of marijuana were seeing that role across the state. Do you think that will make some people leave the harder stuff like opioids and do something less toxic or less lethal lethem like marijuana or what is your view of this wave of marijuana legalization absolutely not. I don't believe that for second and I've worked in this field for forty years now and I testified before the drug czar before the administration when I was back at National Institute on Drug Abuse Abuse and at that time this was in two thousand one. Two thousand two. We're very concerned about marijuana. The drug czar had decided decided that they as they're as they're focused they were gonNA use a campaign to try to discourage marijuana use is so they asked me to come and explain to the drug czar and their organization The da about marijuana and what does that look like. And what are my concerns about the marijuana discussion and marijuana's the drug or is a group of drugs because marijuana is a plan has got a lot of stuff in it and it represents a category of drugs. We call the canals annoyed. So the active ingredient in marijuana's. THC that tried cannabinoid Loyd heard about CD which is connected. Die All but it's also kind of canaveral annoyed that's related to THC. So there's a Zam Lee of these drugs that are out there and people tend to think Oh. Marijuana is what we're talking about a really not talking about marijuana we're talking about got a category of drugs that have different properties but they have some similarities as well. So what does that mean in terms. The medical discussion. Is there a place for marijuana in trading disorders. I don't know if marijuana is the best style of what we WANNA use. But there will be connected noy drugs that will give selectivity and allow us to access excess body symptoms. It will be useful and are being useful in treating disease minor. League problem with marijuana. One is a plant. Why do you WANNA use a plant that has all kinds of hundreds of chemicals that we don't nothing about as a means to introduce introduced? THC which is drug you really after. This doesn't even make medical sense and then to think you're going to be able to control things such as Dose Close Control Self Administration when you've got a drug that is a very potent drug works with a lot of different systems. It has a really bad profile in people who have mental health problems. Everybody accepts view. Take marijuana and you've got underlying problems such as psychosis or schizophrenia or bipolar disorder or affect disorder. This drug can cause great harm to these people fifty to sixty percent of the users a recreationally and prescription fiction have underlying mental health disorders. So we're giving the drug to the very people that it's most likely to create side effects. Yeah so it's just it's it's peace stick of dynamite and we've lived diffused and now we're going to sit back and see what happens happens with it has used patterns exchange because people start using it more and more and more and more disliked tobacco. You know tobacco wasn't all that toxic when people people only smoked once or twice a day when they got up to two or three packs a day that we realize what a toxic substances. We'll see the same thing I have no doubt we'll see the same thing with marijuana as you start to get. People were smoking it as much as individuals smoke tobacco. They'll do the same kinds of stuff that'll damage so long it'll have problems. It could cause cancers it'll have mental problems at will alter your logical systems and then we're really really concerned about adolescent use. We know there's good literature out there that says adolescence to use this while they're developing have a very very high incidence of problems long-term if not permanent problems but ninety percent of the first time users of marijuana are adolescence it always has been that way even when it was illegal ninety percent of the first time users rattled lessons. Why do we think this will change with? We make it legal all are if we make medical and adolescence set off his can hurt me. This has been approved by physicians and the Medical Article Community. This is GonNa do me good and it's going to attract them to using this drug even more. I mean that's one thing we learned time and time again. I'm not joe with just with marijuana but with every drug tobacco is the same way. Alcohol is the same way that adolescence are more interested in these drugs than adults. Adults are and so whatever you do in terms of making access easier for these compounds better always asked the question. Why is this GonNa do to an already already big problem with a high adolescent use of these substances and are we ready to deal with this as for the next twenty thirty forty years? I'll be folks grow up after bringing their brains up under the influence of marijuana. But what do you think of a child future win safe from twelve to twenty two. They've I've been smoking marijuana daily. Well one thing we already know and these are hard studies to do because it's hard to get an I. R. B. and Institutional Review aboard to approve giving an adolescent marijuana three times a day while they grow up. I'm GonNa do this so governance. All you can do is retrospective studies and go back and see if I can find somebody out there who self reports that. They used at a certain rate over over the growth during their developmental period. So it's retrospect they self report but still we know we know that if they are exposed frequently they there will be very high instance of addiction. We know that it'll be very hard for them. I'm to get off of the marijuana decide tobacco or you used about early on or alcohol you use early on the brain changes. Its Neuro Chemistry because it sees substances. That are active and all the way those pathways form. So now it's used to seeing when there are adults they expected almost as though it's a natural substance they expected and you try to come and take it away. The brain does not like that because you disrupted dotted all meals. Stasis of the brain that had developed throughout its adolescent period and they'll have withdrawals they'll be really the high cravings and motivation to use it. It'll be very hard to get them off. Some people in Dentistry are reporting that the cannabis Abbas users need more anesthesia for surgery. Are you noticing that I could see why that could be the case Here again. We're in an area that has not been well studied. We think that the receptors. These are the targets for Things like THC or other substances related to the to the THC. We know that some of them are involved in pain modulation relation and so if you are a user. There's one thing we know about marijuana and that is it causes tolerance and all all the CNS depressant stugatz alcohol data Benzel dyes paints. Do it the opioids do it and marijuana does it. They all 'cause tolerance hollering so that the systems adjust if you use drugs over and over and over again which means if you want to maintain the effect you have to increase the dose so as tolerance occurs. You're dosing increases. You either have to take the substance more often or you've got to find a more potent substance out there which is already happening with marijuana. The percent of active ingredients in marijuana. One is two to three times higher than we've ever seen it in the past already cultivating hire more potent marijuana and some of this is because people are using it more and more and more and they want the fact in order to do that. You need a more potent Cepsa site going from Hydro Kodo own to a oxycodones to a Federal Neil. The Hydra Code doesn't work anymore doesn't control anymore. A bump up to the next potency and then you go to the next potency. While what do we do with marijuana we do as we spoke more and we cultivate it so that the ingredient active ingredient is higher higher percentage which also means. It's more likely to cause side effects. which is again what? We're having a problem with our opioids because we're much more concerned about having feted Neil Berry high potency. Easy to kill people with Fenton Hill. Then we are with hydro Kodo doesn't mean we're not concerned about hydro 'cause we certainly are but anytime fed nil comes into the the discussion. We all get really excited. Because we know it only takes micrograms to kill people what fence nail. It takes hundreds of milligrams to kill people people with High Dakota well. We're seeing the same phenomenon. I'm not saying we've got a fed nil cannabinoid out there although also not saying the someday we may not find ones but we do see that. We're getting higher potencies of the products. We don't have really good control over the cultivation Asian of these products so coming back to your question about pain is if you're using it a lot it's going to mess up with a lot out of systems that have a Noida element to them and to the extent a pain has a cannabinoid element. You may be developing tolerance parts to that part of the pain pathway and so when you come and try to use traditional whether it's opioid or aspirin or Acetaminophen Ibuprofen. You find that you need more of it because it's developed a piece of its pain. Pathway has become come tolerant. It's not as sensitive as at want to us because it's been seeing this seeing the struggle over again to compensate by increasing the doses of these other drugs in order to control the path. That makes sense. Does your very profound. There's a big History I wonder what you what lessons we've learned from history Samuel Johnson used to say the The chains a habit are too weak to be affeldt until they are too strong to be broken and the opium wars and China. I mean those were from eighteen thirty nine to eighteen sixty so it would be the hard to say. This is a new problem. Yeah so wh- what so. It's not a new problem. Is it. Now it's not a new problem and yet we're not any smarter at addressing that we think we're fairly sophisticated we know the pharmacology. We note the molecular biology orgy. We know there's genetics. We know this. We know that we know the other and yet there are still people who are dying from overdoses. There are still hundreds of thousands or millions of people who get addicted. The addiction is a little different. I mean in those ancient days the Chinese days as or the other societies that could cultivate the marijuana poppies or the opium poppies they for the most part where he inner self administering or they had some herbal herbal stuff that would provide the raw material for them or today. We have doctors and dentists this and other prescribers who could give it to them. And hopefully they're better trained at recognizing someone who's got a substantial risk potential and so they're careful they manage and they watch closely in warned their patients and they tell them how to avoid avoid problems with it in a better way than they did anciently. But I'm not sure we're all that much better terms of outcomes. It doesn't seem like we're any better or at preventing severe diction preventing overdoses and terrible tragedies with these substances what what lessons do you think we should have learned from China. I mean we're coming up on twenty twenty so two hundred years ago China's one fifth of the world's population. And what do you think What what do you think the main takeaway lesson is from the opium wars the history of the opium wars to to the extent that I that I understand? It is that Britain who had lost a lot of its access to T- not at tax revenue was looking for substitute in. They came across opium from China. I mean T- came from China and so they had already engaged in in commercial transactions with China and they said well let's shift from T- let's go to another product let's work on the opium in the year producing and you don't really want to produce a you're trying to control it so give it to us and we'll distribute it for you. You make a lot of money on it and this one on for awhile and in Britain did make a lot of money and then China's said now we just can't do this anymore more. This is too destructive to our society. We want to stop this and Britain said no no. You can't stop at. This is making a lot of money. Wait for our nation and so that's where they went to war. Britain said. No you'd have to give us a provider This substance whether they had contracts axe or whatever and China's said no we don't want to be the opium source for the rest of the world and they ended up. Fighting Britain gets Hong Kong and a bunch of other things. But I think illustrates where society that is examining. Its problems carefully comes to to the conclusion. That enough is enough. We have got to put a stop to this. We can't let it take. Its natural course. We have to intervene and and tried to restrict its access because it's going to hurt our society I'd already has. It's GonNa hurt it even more and they are willing to go to war in order to change that halfway around. I think we should look at them and say China figured it out. They figured it have destructive was to their society. Maybe we need to look at ourselves and see if we haven't been the providers of some of these opioid products Through our pharmaceutical companies. And maybe we need to step back and take a more responsive position as far as providing the stop controlling and making sure that people understand and bombed rose bowl are protected from. It's out it's addictive consequences There's a lot of high profile trials over Companies manufacturing the opioids do you. You think those are well-deserved or do you think people are what are. What are your thoughts on those trials? I would say yes and no I actually actually a fairly familiar with some of them just because of a worry came from And My addiction background did my expertise and people talk to me and asks for opinions and that sort of stuff. I don't think that there are any innocence here but I don't think that there there is a company that is so guilty to we want to totally drum it out of business and bankrupt it. It seems like everybody should take some responsibility. It's not just the company's fault the company's trying to make a product and early on now they were probably merchandising some of these products particularly the sustained release once with not fully understanding understanding the potential of the addiction the consequences from what I know and what I've seen once. They started to realize as what was going on they tried to correct and they tried to create forms and products. That couldn't be abused lose to the same way. The original ones by putting substances in the sustained release products so that the addict wouldn't be tempted into Extract the Oxycontin out and injected. So I mean they were anxious to prevent addiction and I think they did things to try to prevent that addiction. A lot of people are saying that. There's no need for an opioid industry ministry that they often quote that. If you alternate tylenol with aspirin every four hours that that was you know that that's even even better than an opioid other people say well. There's no clinical trials on that if someone said to you there's no need for opioids and dentistry a period into story. Implants wasn't he through canals. How would you answer that? Would you agree disagree. I would say that if used properly opera lead the OPIOIDS. It's a tool. I mean all of these things are tools in all of them have side effects. You know how many people we kill with aspirin every year because they lead out or they have ulcers paraded ulcers mean aspirin when it's not used properly can be very damaging being toxic drug. What about Acetaminophen? You know there are a lot of people who died from liver failure if they use too much acetaminophen and we had we. We didn't know this for a long time and now anybody that has underlying liver problems whether they have hepatitis. History or they're now call consumer Zimmer they probably should not be using a much acetaminophen because out bill liver toxicity so every one of these things has potential side effects. So you gotta do. You need to do a benefit risk assessment. Why need to look at the type of pain? That's going going to result. Is it inflammatory pain. If it's inflammatory then and non steroidal anti inflammatory drug is probably the better drug OPIOIDS can block that. But they don't do anything for the inflammation so you may get to force with the end sets and eye inflammation as well as some analgesic. How severe is the pain going to be? Where's the pain coming from is a pain that's associated with the tea or with with the bone or with the Jinja? These are our tissues that respond fairly well to the end sets. If if it's a pain that's coming from inside if it's coming from. Let's say the Sinus or it's coming from internal structures. They don't respond respond as well to end said opioid to probably be a better option regardless of which are the ones you choose in terms of. How severe is ZIP? The more severe I can get better analgesics with Moore paid you'll ever get with. IBM Pro Foot- ACETAMINOPHEN ASPIRIN or a combination. The Nation there are it's because I do. or it's because opioids work three different levels of the pain. Pathway the Anti inflammatories Tories work at one. Maybe two and those are peripheral opioids tend to be more centrally more in the spinal cord and even up into the brain and the higher level structures. So they do and they work in different places sometimes. The best thing is to combine them. I mean this is actually a nice synergistic combination if ya if you get a hydro co down combined with the Or Heidrick Combined with the C with an aspirin you can get the best of both worlds and you don't have to use high doses of either one so that combination is is actually something that was tied a lot when I went to school and I taught in medical school and we taught the physician to same thing. We teach our our dental students. Now that state thing so it's not like well throw Dow's all away 'cause they're Causing US problems today and will embrace these until they start causing us problems and then we'll throw those away and then we'll go back to the older you Kinda referred to that when you talked about the days when we said if people hurt we should be letting them hurt we need to give them opioids Control and then we started to get the abuse in the deaths and and the pendulum swung the other way. And resettle. We shouldn't be using opioids which just use all the end sets and it swings back and forth and back and forth and we just have to use our information we know what these things look like. We know what the side effects look like we. We know what causes the side effects it for just prescribing and sending our patients home and expecting them to figure all this out on their own. Then I don't care what a drug you give him props we've gotta be engaged. We have to be talking. We've got to know what their histories are and then decide which are the most those to procreate drugs or target the ejected and for the background of our patients so you graduated from dental school you went to Ucla. Hey you're sitting in a According to the news a new thirty six million dollar building you made the newspaper. University youtall celebrates breach new thirty six million dollars dental school building Tell us about the new dental school and how was it different than Ucla back in the day so UCLA. Ucla was great and although they don't football's not so good university. Utah's football's better. But anyway it is. It's a different time time. And this new school has given us the opportunity to look at the dentistry at its curriculum. And particularly its relevance to the other primary care providers and comprehensive when talk about comprehensive. Health incompetency care what role does oral health play in that whole discussion and so as dental final score the University of UTAH. We are part of the University of Utah Healthcare System so we were very closely with primary care providers we have several offsite clinics throughout the State of Utah and those clinics for the most part have dentistry and primary care working shoulder to shoulder and so the physician or the nurses bell see something. They'll notice that there's an rural health issue and they'll bring the patients across the hall to us In dentistry or to the hygienic. or we see something in our patients and we could just walk across the hall and take to the medical care providers we were very closely together. And and we're starting to fine nine that not only by working closely together. Do we serve the patient better but we also find that that we complement each other in terms of our medical slash schedule objectives. I don't think I don't think anybody would be surprised. He's looking in the mirror to to realize that the mouth is part of the rest of the body. Unfortunately we sometimes practice as though it is in practice in a silo and we say oh no no no no. We don't want to go anywhere further back in the math. Because that's really not our herb. You that somebody else's are or the Mac. So facial or primary care or pediatrician. Don't WanNa come into the mouth because they feel like. Oh that's totally off base for us. We should be going going there. We should be having these discussions amongst ourselves as to what we could contribute what they can contribute to us and vice versa. And this kind of gets to a study that we had recently we call it The floss steady F- losses enact credential for grant we we got from her sub health restore services administration to study what happens when you provide comprehensive dental care to patients who are being treated for substitutes disorder. So this is kind of the issue that I am referring to. We shouldn't be trading their conditions. There's all these are totally separate not associated with each other by rather you should be treating them as though they're complementing each other and that you can get get better outcomes in both areas if you treat both things together and so as I think most dentists health or health providers know the people that have substance use disorder. Generally many of them have made your oral health problems which AGGRAVA- all the difficulties call the wrestling with as part of their issued deep problems. They're not employed they're unemployed. They have very poor self-confidence they went draw their they're isolated. They feel as though their total failure said there are in total despair. Many of them contemplate things such as suicide. Because they don't see any light at the end of this tunnel and there's no way that they can manage it or that can convert and so they just let their mouths Go untreated some of the drugs. They treat zero Estonia. They do damage to the mouse in. This worsened said that condition. They can't eat a Boston contition. They heard all the time because they've got infections. They got root canals. It needs to be done. They can't sleep at night. So malnourished malnourished terrible self image. They don't have any works socially out social outcasts and a lot of this is coming out of the mouth now and the things that have happened to the mouth and so we thought maybe if we could put these two areas together as part of therapy that you and get better outcomes in trading substance use disorder. So he did that Nazi. This grant grant gave us the wherewithal to do it so he took three hundred. Patients patients. had major SUV problems. They had made your oral health problems as well. Almost half of them were heroin so a really high. I proportional heroin about thirty percent were math. Methamphetamine twenty percent alcoholics about ten percent were marijuana than the rest of them or odds and ends of other kinds of drugs. Very few of them were single drug users. It's unusual unusual to find someone who has a major substance use disorder and they're only focusing on what drought most of them are poly substance abusers but. They had their they had their primary drug until we identified the primary drug so we brought a man took care and this was comprehensive dental and it wasn't just emergencies urgency's I mean we certainly took care of the emergency issues but we wanted to restore their mouths in the same way that any of us going into a dentist office would expect act so they got the full complement. The only thing we would or could it do for these patients was implants but we did everything else. We did restorative. We did we did. We did ended on exceeded all the oral surgery. we did chronic bridge. We did removable. We did did everything that they needed. So at the end of the day after the treatment they walked out of that office in the mouth was back where it should be. We had this great big Humira as they as they could. Walk out of. The clinic was into the waiting room loses big mirror and most of them would stop at the mirror. Once is it. Dental work was done. And just give this great big smile. They would look at the Pierre and see what had happened. the transfiguration that it occurred to them so we thought well this looks like this is really working well so we went to the SUV providers who are trot that were the managing them and providing care for their substance use disorder. Said what what does this look like. In terms of other aspects of issue. I mean they. They look like they're feeling better about themselves when they're coming out after we take care of the oral health piece so they went and they looked at their outcomes assessments assignments and this is when we found a dramatic affected terms of Treatment Outcomes. They stayed in treatment two to three times longer longer. The average treatment duration for major as substance use disorder like heroin abuse. Mental abuse was about three months Matz hundred days. If they're getting competency dental care. It approached the year so wound up dramatically. We found Out that employment went up dramatic rate when they left. They were two to three times more likely to be employed if they had comprehensive comprehensive dental care than they didn't have comprehensive dental care. They were three times more likely to get off their primary drug of abuse. So they you're much more likely to become abstinent and if they had had a history homelessness before they came into treatment if they got comprehensive yes he dental care literally homelessness disappear when they laughed. They left their SUV treatment. They finish the dental care. They had a home. They had a place to go. They did not go back on the streets or under the by ducts so homelessness disappear you. Where did you get the word word floss participants? What what did you say flustered for cutting a lifetime floss facilitating a lifetime of oral health? Sustainability leave for substance use disorder patients and families. That's it I never remember it. That's what I always call it floss but but if you tease those words out it that's kind of what is talking about it's talking about what does it mean. Will you take care of. Their oral health needs. What does it mean as far as their substance substance abuse problem in a long term way in our data suggests that it means a lot? It really helps ins. We're words words that study published in the journal American Dental Association. It's okay July issue about this year. Two Thousand and two thousand Nineteen Yup gotta got it. Yes comprehensive oral care trying to connect the floss term comprehensive oral care improve treatment outcomes a male and female patients with high severity and chronic substance use disorder. It is just such a complex issues in it it it totally is and when I talk to people about this I talked to dental groups and also talked to the Medicaid organizations across cross country. Me One of the outcomes of this because the effects were so dramatic we took them to the state legislates legislature and we. We said we think that if we could provide comprehensive dental care to Medicaid patients who have thought substance substance use disorder issues. They're treated and we couple competency dental care with that through the Medicaid program. We're we're GONNA see the same kinds of outcomes in our medicaid population and we got it through the legislature. Almost unanimously the Medicaid Office. I said yes. Let's do it. The Federal Medicaid Office when we sent a request to have it part of the Federal Medicaid Program. They called us and said we'd never heard of this before you explain this to us as to what you're talking about and we said sure that We invited them to come to the dental the school which show them they came a spend an afternoon with us and we had some gloss patients down in our clinic. We're taking care of that day. We took down down. Introducing the FLOSS patients introduce them to the dental students and they just heard why a positive experiences this was not only for the patients as you're totally changing their self image in their outlook but also to the dental student who had a chance to see they were developing a skill set. Back could turn a person's life completely around. I mean we literally early had stories about individuals who are going to commit suicide until they had an opportunity to have their oral health needs to dress and they did it and one lady. She is an administrative assistant for at the airport. The the mayor's Office of Salt Lake County. I I mean they got these high-profile jobs. They were trained people but they had gotten into drug problems and they distributed away from their skill skill sets and now now the restored the mouth you given them self confidence you given them a good quality of life. They feel like they have the energy not to address the drug abuse issues and they can put that life back together again so it's been a very powerful lesson to our students that this is a place where you can really make a difference in people's lives very interesting data you have there. The chart is a I step house. Self declared a self-declared malls methodology outcome It doesn't seem like this is a very easy research it all so total at the journey. You you've You're twelfth edition of drugs in society. I mean what a commitment I mean. When did the first edition come out? And Will there be a thirteenth addition. Can we make news on dentistry uncensored by announcing the thirteenth edition. Listen well there will be another edition or working on that now but I started working with the Johnson Bar is the publisher assured this is around. Nineteen ninety sewer almost into the thirtieth year of this And it turned out so so I I was in. I was in the field. I've been working in drug abuse. That neurobiology wasn't doing much with dentistry. Because we didn't have a dental school at the University of that time saw. Aw I was in the College of Pharmacy in the School of medicine than in those days. but I got a chance to do this and it works so well. It was so well received that we just doing the next edition to the next edition on the next edition and it sells about twenty thousand copies copies a year and it is used to buy two to three hundred universities across the country as their principal goal taxed in Drug Abuse Drug Abuse in society so it in a way it became a an exercise have really immersing myself in all aspects of drug abuse because as a scientist the only thing I did was I objected. Rats I extracted are took out their brains and I. It narrowed chemistry genetic analysis and looked at the effects of drug abuse. Working with this talk and then later going back to the National Institute on Drug Abuse I had a chance to really see how drug abuse in society interacted in its many many aspects respect the public health piece and that and really set me up for coming back into the dental school and saying you know I could bring these two things together. I can bring my background at drug abuse and dentistry and that's how we got to the paper that we just talked about. Who are we? SEGER is a connection for dentistry industry as we try to deal with these other chronic diseases such as substance use disorder. An hour trying to sort out. Why now what? What is happening here when you take care of persons oral health? The makes their ability to deal with diseases like as you d much more effective an outcomes to become more positive and we should as dentists oral health providers. We should be sitting at the table with the other. Health providers providers wellness providers talking about strategies talking about partnerships. Talking about putting our skill sets together in order to took provide better competency outcomes for patients. So how is this. How is this message? Being being delivered to the new dental students are. It's a new generation. We always hear how different the millennials are than the earlier generations. Like the boomers is this. How is this is pretty complicated message to teach them? It's not that complicated. Because we won we have a really good example in substance use disorder which is an in your face saying nobody questions that is a problem is not a problem because there's so many aspects affects of it where it is a problem and then we can take that as an example all been under served population that has made your oral health challenges and bring them into our dental clinic. which is sort of controlled we have our our the attending our students and then we have our didactic instruction where we can kind of fill in gaps? What they're not learning in clinic they can learn in the classroom astros vice versa and so they can see a comprehensive approach to introducing dam and their skill sets to what it is? They're going to ECOMMERCE wants to be calm when they walk out. This collect dentistry here at the university Utah with DDS degree and they put together a practice. What do I you WanNa look like do? I want to be working in in Hollywood and working on movie stars or my entire career which is kind of Miam- Bishen when I came out of. UCLA AH UCLA was right up there. I actually has a student worked out a lot of movie stars. Not The big ones. But I had a lot of movie stars. I've got. Hey this is my idea of a practice. But I didn't ever work on these patients. The underwritten underserved patients never get that exposure. Were giving that to our students. Now they walk out they say I've got a role to play out here. I mean they wanna make a living K.. Totally understand that but they I also have a skill set. That could turn people's lives around in a way that they never quite understood before so they see real life they see and you can't teach better lessons in real life so when you You guys are very cerebral. I mean you have a DSP ESPN the Dean Wyatt Rory Hume has a DSP HD win. You guys decided to start a dental school in two thousand thirteen Did did you guys feel. There is a need for a new dental school or that you wanted. Some unique selling proposition in a country was so many dental schools. What was the impetus to want to start a new school? I think you hit it right on the now right on the head. We felt that there was something different that we could do this one just because of the lake with the rest of the university. We were embraced by God. The Medical School Pharmacy Nursing and the other health professionals shawls because they fell. There was a role for dentistry to play and quite frankly their healthcare system that was being administered by the university we had very little dentistry. There we had we had a residency program general practice residency program. But that was it and they didn't have the experience of dental students. Interacting with medical students with pharmacy students in nursing students and as we went out and tried to create make these offsite clinics to care for some of these underserved populations. They were doing the same thing from the medical side and so we partnered her and we put clinics together as a partnership instead up. They didn't ours. We did our and we would invite them over for Christmas lunch. Ed Invite us over for Christmas We live together in the same building in the same clemmie and we worked together and so this was an opportunity to change and the model that we think is actually going to be the future much of dentistry as we go down this it's Rhode They call it. They call it Bonding or blending. Where you bland different services in a way that makes sense for wellness but also make fiscal sales? If you talk to Medicaid Medicare talked talked to some of the insurance providers these days They are trying to find ways to to land together a a comprehensive care rather than say have a cancer patient. We know that we're GONNA be treating 'em they know. We know they have oral health problems. So oftentimes at cancercenter percenter will send them to a dentist Danis have your dentist take care of all. Listen and come back and we'll start the cancer treatment on you rather and then sitting down with a dentist and say okay. We're treating this. Cancer is your concerns. Tell us what you think in terms of the oral health piece. What do we need to keep in mind as we radiate or we do surgery hour we give chemotherapy? What sort of oral issue shade we be buying full up so the dentists dentist's is right there with them all the way through the treatment and patient? That's the winner at the end of the day. So if you if you go go to the insurance companies say we provide comprehensive care for this. This cancer patient ended includes all of these things that are important for for wellness. The Price Tag will be this. Whatever that price tag happens to be but it covers all of these and it makes the providers Blan- Glen I think We as the dentist. We know they're on chemotherapy. We know it's GONNA compromise therapeut- system we know that they're paying. The management is GONNA look different. We know they're nutrition's GONNA look different. So fat informs us that we can provide better dentistry for them and vice versa. The patients the winner. The United States has a rich history in dental education. I mean the for the world's first dental school was in Bainbridge the Ohio in eighteen twenty eight now to dental museum. The First Dental College in the world was Baltimore College of Dental Surgery in eighteen forty. So so now it's twenty twenty when we're supposed to be seeing more clearly now in twenty. Twenty and yet Medicaid Medicaid and Medicare her Dentistry is not even part of the human body. I mean I'm do you think the dental schools. It's time that maybe the DDS and DM degrees should go back to the MD degree and they should get on the same train track or is a from eighteen. Twenty eight two twenty twenty. It's almost two hundred years. Two Hundred Years of dentists being on one drag. United Sates has two hundred eleven thousand Americans we have an active license to practice dentistry and over a million have an MD degree. Do you think these two trains will ever get on the same track Iraq. I think I think they will I think that they are. I don't know that it's necessary to think of ourselves as the physicians of the mouth. I mean I have no particular argument against it but I think it's important. That are the dental students. Be trained trained how to do clinical dentistry. I'm a little nervous. If you feel there are those who feel that while we'll let the residency programs. I teach the clinical dentistry piece of this and their undergraduate. We will teach Sam the medicine physician piece of it. I don't think thank were there and I'm not sure that we need to go there. Do we need to give our students an excellent background in in basic science as is in a pathology disease as an Barma College. Yes I think we do because it's important as important to us understand the effects of pathology disease in pharmacology in the mouth as it is to an internal medicine doc or not just Or any other. They're professional or specialists but having said that. I don't know that we need to be training our dentists. How To catcher therapy therapy or need to be training them how to do surgery and removal gallbladder? I'm not sure that's necessary. I I think the dental skills we give clinical dental skills are sufficient and and worthy of being included in the big discussion. Chinook the overall health of the patient. I think that what we need to be doing is one closely and not be afraid of the part of comprehensive health discussions but I think we also need to show that win. We decide is dental. Ever wanted to be a part of Medicare that we can come to the table. Hopefully what the papers like what we've done and others will do and say you know what the literature says it says if we can provide comprehensive dental care to these Medicare patients and they have substance use disorder their response to treatment for the SUV is gonNA be dramatically improved. I personally believe that you'll see the same connection between comprehensive dental care and prediabetes comprehensive dental care and Alzheimer's Disease Comrades Dental Care and cardiovascular disease. I think if you you can give these patients that have these serious major chronic diseases good oral health so that they have good nutrition Russian so that they feel good about themselves so that they feel they have contributions to make still we call quality blythe you give them a good quality of life through their oral health that you'll have a dramatic impact on the rest of their health. And so we go to Medicare and we say hey. This is what we're bringing. We're going to save you money on all these other diseases because they're going to get better faster and you're going to slow down on the deterioration that caused by the disease so we're going to save you money. And even more importantly we're going to help preserve and lengthened the health health. Your patients can have be- we if we have the evidence we have that discussion. Guess what will be part of Medicare we are part artem Medicaid but that varies from state to state so each state makes determination in our state. The dental school the floss program. The other pieces went up to the Medicaid. And not only did we get our Medicaid program both of the state and the federal level. Not only did we get them to to extend coverage dental coverage to Medicaid patients but we also got them to expand Dan comprehensive dental care or patients that have disabilities so disabled patients. So these are people that have diabetes. They have Degenerative diseases they can't work because general and this year they have extended it to the elderly Medicaid so our elderly in the State State of Utah. Get comprehensive dental care as part of their Medicaid package. You look at those together. That's almost half of the Medicaid adult population in the State of Utah. Get the very best. Dental coverage through the Medicaid program. Other states can do the same thing Well I'll tell you what. I'm so glad you came on this show today. This was so informative. I've been wanting to get you on for so long This was just amazing. Dr Glenn Dr Hanson DDS Peachy Professor and Dean University of Utah School of Dentistry. Thank you so much for. We're coming on the show today. Thank you our pleasure. Have a great day take care.