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An intervention to improve the oral health of drug users

Introduction

As my target group I have chosen heroin addicts using methadone as part of their rehabilitation because research shows that this particular group has a high caries rate and poor oral health. (P.G Robinson et al, 2005) Heroin is a stronger opiate and analgesic than methadone and may be why clients present with dental problems once starting rehabilitation as dental problems may be masked by the analgesic effects of heroin. This also may be why some link methadone with dental problems and may think that this is one of the main causes. Both heroin and methadone are opiates and opiates cause xerostomia which increases the risk of tooth decay and periodontal disease. The acidic pH of both types methadone increases the risks of dental erosion. (Nathwani and Gallagher, 2008)

The clinic I attended was a drugs misuse service in Ashton under Lyne. The clinic contained leaflets on various topics such as smoking, hepatitis, HIV but none in relation to opiates such as heroin and methadone with oral health. The clinic offers advice, councelling, assessments, prescription of medication, needle exchange scheme, screening, brief interventions and referral via GP, practice nurse or self referrals.

I wish to promote oral health to the staff at a drugs misuse service in Ashton Under-Lyne and hopefully incorporate oral health advice into the sessions they hold with the clients on a daily basis, through education leaflets and a flip chart to help with the promotion of oral health. This will hopefully develop knowledge for the clients, encourage them to be motivated and highlight the risks to the oral cavity.

Literature Review

This review aims to show why there is a need for an intervention in my selected target group, recovering heroin addicts using methadone as part of their rehabilitation programme. I have gathered information to show risks to the oral health, general health and barriers that may be encountered.

Demography

I chose to carry out my intervention at a drug misuse clinic in Ashton Under-Lyne.

AshtonunderLyne is in the Greater Manchester area of the North West of England, U.K. It is part of the historical County of Lancashire and is now the administrative centre of the Metropolitan Borough of Tameside. (Ashton-under-Lyne.com, 1998-2009).

The population of tameside is 213045. (Census, 2001)

(Bridgeman and Gratrix 2004) states that “Oral health in Tameside and Glossop is amongst the poorest (ranked 13th from bottom in figures for decay levels in five year old children from 42 PCTs in the former North West Region 2002). There is a wealth of dental epidemiological data in Tameside and Glossop children, but information regarding adults is confined to national not local surveys. Adult dental surveys are carried out every ten years. A higher proportion of adults in Tameside have lost all their natural teeth compared to national figures.”

(Office for National statistics, 2009) states that “In England and Wales in 2008, the total number of drug misuse deaths rose to 1,738, the highest level recorded since 2001. There were 897 deaths involving heroin or morphine in 2008, an 8 per cent rise compared to 2007, and the highest number since 2001.”

Research Indicating a Need for Intervention

Introduction

In a study by (P.G Robinson et al, 2005) explores oral health attitudes and behaviours of drug users. Many of the participants attributed their dental disease to methadone use, it is commonly prescribedfor short term detoxification and long-term maintenance of opiate-dependent patients. The aim is to encourage users to switch from injecting to oral administration. Some users hold the medication in the mouth, although with this study it was not the case with these participants. There is no longitudinal data to show how much methadone contributes to dental caries alone and is possible that it is a small part of a larger process.

In a journal by (Nathwani.N and Gallagher.J, 2008) states that “Methadone, used in the rehabilitation of drug-users, is available as a sugar-free preparation; however the sugar-based version is most often used. Dentists are most likely to encounter patients on methadone as a dental emergency and they need to be aware that methadone users are at greater risk of decay and erosion from methadone sugar syrup, as well as perhaps their lifestyle. For dental practitioners, addressing the oral health needs of methadone users can contribute to their general well-being. Methadone, a long-acting synthetic opiate, has been used in healthcare since the 1960s as a narcotic pain reliever. Detoxification, which involves the reduction of methadone over a few weeks or few months, should be accompanied by social and psychological support and regular reviews. Dentists in particular, need to be aware that opioids may have masked dental pain and so this cohort of patients will now require urgent treatment. However, research suggests that dentists, doctors and pharmacists have shown reluctance to provide healthcare for drug misusers

Cases in which the progression of dental caries has been exacerbated by drug therapy have been reported in the literature; it has been suggested that this can be due to the direct effect of sugar-based medications or, indirectly, by inducing xerostomia.

Oral Health Effects of Opiates

In a study by (P.G Robinson et al, 2005) explores oral health attitudes and behaviours of drug users. It suggests that high caries rates are seen in heroin users, perhaps caused by a combination of high sugar content in methadone, used to manage withdrawal symptoms from the drug and xerostomia caused by opiates. Oral cleanliness may also be reduced in opiate users. Oral health can be of low priority for them. The participants in this study also reported high levels of disease and described behaviours that threatened oral health. The cariogenic diets, xerostomia, decreased oral hygiene with concomitant reduced exposure to fluoride and lack of health consideration during periods of drug use are likely to have contributed to the development of caries. The participants in this study described effects on their taste sensation and made food unpalatable. Drugs especially opiates, affected their taste sensation, making ordinary meals taste like 'cardboard', so they could not appreciate food. They need quick and easy snacks to be eaten on the go. High consumption of sugars could be a necessity rather than a craving and would be a major aetiological factor for the high levels of dental caries seen in drug users. (P.G Robinson et al, 2005)

Participants eating habits and body weight improved in this study once they had got into treatment or rehabilitation programmes or maintained a drug free lifestyle. (P.G Robinson et al, 2005)

Misuse of opiates is associated with a high caries rate and periodontal disease, and greater than seen in the general population. Malnutrition may also be associated with angular chelitis, candidiasis and glossodynia. (BMS, burning mouth syndrome) Although there is little evidence on the impact of oral methadone on the health of drug users, all opiates reduce salivation, having an effect on the neutralizing acids in the mouth. (J.Sheridan et al 2001)

Risks to the oral health of methadone (both sugar-based and sugar free)

Based on its content, and the literature, there are three ways that methadone mixture can potentially contribute to decay and erosion:

Prolonged contact with sugar-based methadone has been associated with tooth decay and dental caries, especially towards the front of the mouth. There are several cases of advanced tooth destruction from widespread severe carious lesions where methadone syrup has been used intra-orally in a drug rehabilitation programme, but little formal research. However, it is unlikely that the sugar in the methadone is the sole cause of dental caries in these individuals. There is evidence that poor dental health is endemic among opiate users and that methadone may therefore be exacerbating pre-existing problems rather than causing new ones. Both varieties of methadone have been noted to have an acidic pH, between 3.5 and 5. Methadone can therefore cause detrimental effect on teeth in terms of being an extrinsic source of acid, in addition to a lifestyle involving reflux and vomiting. Health policy advice on brushing after ingestion of methadone is likely to increase the risk of erosion, and therefore should be challenged. Drugs such as opioids are one such cause of xerostomia and hence may contribute to the caries risk.

(Nathwani.N and Gallagher.J, 2008)

Methadone and Dental Erosion

Dental erosion is the loss of dental hard tissue through either chemical etching and dissolution by acids of non-bacterial origin or chelation. (B.T. Amaechi and S.M. Higham 2005) It is important important that dental erosion should be identified in those who are at risk. (B.T. Amaechi and S.M. Higham 2005)

There are a number of ways in which preventative measures can be used in relation to dental erosion such as drinking acidic drinks through a straw has been reported to reduce the contact of the acidic drink with the teeth and enhance the rate of clearance of the agent from the oral cavity. Acidic drinks should not be ‘swished' around the mouth and swallowed quickly. Dairy products such as milk have been shown to reharden softened tooth surface and may be useful after consuming food, drinks or medication that is acidic. Fluoride varnish applied professionally can increase the resistance of the dental tissues and therefore resistance to an erosive attack. It should be stressed that brushing the teeth immediately after an acidic challenge is hazardous to the dental tissues and should be substituted for an agent, such as fluoride mouthwash or a neutralizing agent such as milk. It should also be stressed that consuming acidic foods or drinks before bedtime should be avoided. People who are at a high risk of dental erosion should use a toothbrush with a soft filament and the use low abrasive toothpaste. Also fluoride has been shown to increase abrasion resistance and decrease the development of erosions in enamel and dentine. The use of a fluoride mouth wash can be used immediately after an acidic challenge as an alternative to brushing due to the risk of further erosion.

General Health Effects of Opiate

In a study by (P.G Robinson et al, 2005) it discusses medical problems of drug misuse that are relevant to dentistry such as abscesses at injection sites, viral hepatitis, HIV, endocarditis and anesthesia complications. (P.G Robinson et al, 2005)

Neglect of personal care is an often observed behaviours amongst opioid users, irrespective of economic status. Users tend to seek treatment only when the disease is advanced and the symptoms become severe. Late-presenting patients may be anxious and demanding, making their management more challenging.

Opioid users are highly susceptible to a variety of infections such as HIV, viral hepatitis and infective endocarditis all of which have significance in the dental setting. (A. Titsas and MM Ferguson2002)

Barriers Involved

In a study by (P.G Robinson et al, 2005) it discusses the barriers to care which include fear of dentists, needle phobia, acceptability of dental services, the ability to self medicate and organizational factors in their lifestyles. Also in this study the recovering drug users recalled that their over-riding concern had been to avoid withdrawal symptoms. This was the main priority. (P.G Robinson et al, 2005)

Data shows that drug users self-report difficulty accessing dental treatment and are less likely to have visited the dentist in the last 12 months. They report higher levels of self-assessed oral health problems, with less use of services than non-drug users. (J.Sheridan et al 2001)

Pre-existing dental problems of opiate users may be more severe because of late presentation as a result of being poor attendees. Also, patients present to dental practices with management problems associated with drug interactions, pain control and behavioural difficulties.(Nathwani.N and Gallagher.J, 2008)

Factors Involved

In a study by (P.G Robinson et al, 2005) it discusses the factors involved in the aetiology of dental disease in drug users. In this study drug use is one of the many factors involved in the aetiology of dental disease. A combination of low saliva secretion, increased consumption of sugars, unemployment and social exclusion are important considerations. These factors are in addition to the medical complications of drug use. The symptoms of caries have been masked by the pharmacological effects of heroin and methadone and on occasions where symptoms were severe, participants have self medicated. Dental problems may have become more noticeable during methadone use because it is less sedative and does not have the same analgesic effect as heroin. Withdrawal symptoms may also exacerbate any existing dental problems.(P.G Robinson et al, 2005)

There is anecdotal evidence that drug users crave sugar and high consumption has been noted. However it can be interpreted as a number of factors acting together, such as nausea, vomiting and appetite suppression will affect the intake and retention of food by chronic drug users. (P.G Robinson et al, 2005)

Illicit drug use is associated with a low expendable income and poor nutrition is common, especially the intake of foods high in calories and sugars. Lack of expendable income is also likely to place dental treatment far from the list of priorities and a chaotic lifestyle makes regular dental treatment difficult to provide. (J.Sheridan et al 2001)

Heroin is also a powerful analgesic, so toothache may only start to be felt when the user is stabilized on methadone. Methadone users are known to practice retaining the syrup in the mouth for some time, prolonging the attack on the teeth. This may be done to prolong the absorption time, or with a view to regurgitating it for later sale or injection. Injection is possible with sugar-free methadone. For this reason, many practitioners may not want to prescribe it. (Nathwani.N and Gallagher.J, 2008)

Methadone and Drug Addiction

Drug use is now widespread and most dentists in the UK will provide services for patients with a drug problem at some stage. Qualitative research suggests that dental care can contribute to their general rehabilitation.

Heroin addicts using methadone as part of their rehabilitation have already taken the step into improving their health. Introducing oral health care into their rehabilitation can contribute to their general rehabilitation. (Meechan and Seymour 2002)

Health Risks Associated with Heroin

Heroin is and opioid analgesic and IV abuse may lead to cardiac valve damage and may make a patient susceptible to endocarditis. Cross infection with HIV and hepatitis is also a risk. Pigmented lesions of the tongue have been reported in heroin addicts who inhale. The drug also depresses respiration and can cause postural hypotension. (Meechan and Seymour 2002)

Oral Health Risks Associated with Heroin

Can cause xerostomia leading to an increased risk of caries, candidal infections and poor denture retention. (Meechan and Seymour 2002)

Health Risks Associated with Methadone

A drug of dependence and thus can cause withdrawal symptoms if the medication is stopped abruptly. Such cessation of methadone may account for unusual behaviour changes and poor compliance of dental treatment. The drug also depresses respiration and causes postural hypotension. Patients on methadone substitution therapy must be regularly screened for increased susceptibility to dental caries. (Meechan and Seymour 2002)

Effects on the oral and dental structures include:-

Xerostomia leading to an increased risk of caries, candidal infections and poor denture retention. (Meechan and Seymour 2002)

Administration of methadone used as a substitution therapy in opioid dependence:-

In the form of a thick syrup with a high sugar content. This is to prevent the drug from being injected and to allow the dosage to be titrated to each individuals need with ease.

Sugar free preparations are available but do not have the advantages of the syrup. There is a significant risk of methadone induced caries and the patients undergoing this treatment should be aware of the risk and afforded the appropriate anti-caries treatment. (Meechan and Seymour 2002)

Health Promotion

The World Health Organization defines health promotion as the planned and managed process of encouraging and assisting improvement in the health of a population as distinct from the provision of healthcare services.

Health Promotion Includes

Increasing individual knowledge about the functions of the body and ways of preventing illness.

Raising competence in using the healthcare system.

Raising awareness about the political and environmental factors that influence health.

(Ireland 2006)

Oral Health Education

Generally understood to mean giving patients personally relevant information about their dental health, based on scientific evidence. Skills required to perform oral health education involve communicating, motivating, teaching and training individuals and small groups. (Ireland 2006)

Oral Health Promotion

Oral health promotion involves oral health education, but looks at the wider picture and encompasses involvement in planning and evaluating strategies, identifying and networking with significant agencies and individuals and working with groups to maximise their effectiveness. Also includes political lobbying, influencing people with power and negotiating compromises and agreements. Effective communication skills are essential tools in delivering oral health education and oral health promotion.(Ireland 2006)

The Ottawa Charter

The world health organisation defined the Ottawa Charter in 1986. This identified five key themes for health promotion.

Developing personal and social skills can be achieved through health education. Health education can be defined as opportunities created for learning specifically aimed at producing a health related goal.

Basic educational objective include:-

Health professionals at various levels of healthcare positively contributing to the pursuit of health. Shifting resources away from dominant treatment and curative services towards those that promote health and prevent disease. (Daly, 2002)

Planning Stage

I plan to use the Ewles and Simnett (2003) planning model to plan the oral health promotion project. I have chosen this model in particular because it is easy and simple to follow and highlights the aims and objectives clearly. Also highlights if the intervention was successful or not.

Aims

Objectives

Identify Clients and Their Characteristics

The target group I have chosen are recovering heroin addicts using methadone as part of their rehabilitation at a drug misuse service in Ashton Under-Lyne. Research shows that this particular group has a high caries rate, poor oral health and their oral health priorities can be low. The clients have already took a step to improve their health by attending the clinic and feel that incorporating oral health into the sessions with the staff will benefit the clients. The clinic provides the following:-

The clinic already encourages the use of sugar free methadone and prescribes this as much as possible instead of the sugar based methadone.

Identify Their Needs

As both heroin and methadone causes xerostomia and there is a definite link between this and dental caries, I will highlight this to the clients and staff and provide appropriate information on how the manage dry mouth, maintain good oral hygiene, how to access dental treatment in the Tameside area and whilst using methadone as part of their rehabilitation. The clinic itself does not have any information leaflets on oral health so I have provided them with an oral health guide leaflet with information regarding their oral health whilst on methadone and how to maintain it. (Appendix 1) Also I have provided a leaflet containing snack ideas to substitute for sugary foods and drinks and diet information. (Appendix 2) They provide the clients with a drink of water after dosing with methadone but this is mainly so that the client can be seen to have swallowed the drug to reduce the risk of reselling it on the streets or injecting it.

Goals for Intervention

Identify Resources

Intervention

I had contacted a drug misuse service in Ashton under Lyne via a written letter outlining the oral health promotion project and benefits for the clients attending the service. (Appendix 5) The team manager of the drugs misuse service contacted me via written letter and from there I contacted them to arrange a day to go in to the clinic to discuss the project further. (Appendix 6) I outlined the oral health risks to the clients using methadone as part of their rehabilitation and discussed what I could bring to service to benefit the clients. The following was discussed:-

This aims to improve the facilities of the clinic by providing them with leaflets and information they can provide to the clients and continue to use.

Once the discussed was ready for use, I contacted the team manager to arrange a date to attend. In the past the clinic provided appointments for the clients to see a dentist at the misuse service. The team manager explained that the clients used to fail appointments for this frequently so it was decided that I would carry the oral health sessions on a day where the clients were to attend the titration clinic and then brought straight through to myself. I attended to provide the oral health sessions but unfortunately that day I only managed to see a couple of clients. It was then decided to attend a second day and to advertise my services in the waiting room in advance. A poster was put up in the waiting room and on the second day I managed to provide the sessions to many more clients and presentation to the staff evaluated both by pre and post questionnaires and feedback.

This is the room in which the oral health sessions were carried out.

Flip chart and education aids used in discussions with the clients.

Contents of oral health pack with additional leaflets as required.

Additional leaflets provided by companies such as Colgate and Wrigleys.

I discussed the flip chart with a member of staff and provided the leaflets, presentation and guidance notes in a pack, on CD for them to continue to use. I obtained a letter from the team manager of attendance to the clinic. (Appendix 6)

As part of the project I liaised with the department of health regarding UK guidelines.

In a document produced by the department of health entitled Drug misuse and dependence: UK guidelines on clinical management 2007, it provides guidance on the treatment of drug misuse in the UK. The information in this document is based on current evidence and professional consensus on how to provide drug treatment for the majority of patients, in most instances. The document updates and replaces the 1999 clinical guidelines and has the same status across the UK as the 1999 clinical guidelines. I sent an e mail regarding this document to the department of health as it discusses on page 104 that methadone itself is acidic and preferably they are to brush there teeth after dosing with methadone. (Appendix 8) With reference to the literature review, dental erosion is a risk also if advised to brush your teeth after acidic foods or drinks so I sent the email to enquire about this information written in the document discussed. After contacting the department of health they replied confirming the correct advice is to not brush your teeth immediately after eating or drinking acidic foods or drinks and the departmental colleagues have agreed to liaise with the drug treatment policy section to ensure that they bring their guidance into line. (Appendix 9)

Evaluation

As part of the oral health sessions I devised a pre questionnaire (Appendix 10) and post questionnaire. (Appendix 11) A total of 15 clients completed the questionnaires in full and some of the results are as follows:-

Oral Health Session Evaluation

60% of the clients that took part were actually aware that methadone could cause dry mouth. I felt it was important for the clients to be aware that methadone could have these effects and the consequences that could result so that they could take preventative measures.

67% the clients were actually concerned over the effects that methadone could have on their teeth.

The majority of clients didn't know the exact effects that methadone could have on their teeth. This could explain why 33% answered no to the previous question of are you concerned about the effects that methadone has on your teeth? If they are unaware that methadone can have an effect on the cavity then this may be why the remaining 33% answered that they was not concerned.

80% of the clients that completed the questionnaires were having problems with their teeth at the time the oral health session was held. 40% of the clients that had dental problems felt that this had started since they had been on methadone.

Pre and post questionnaires show that the clients rated their oral health as more of a priority after the oral health session. Other results from the questionnaires showed that their knowledge had increased in regards to their oral health after the oral health session and they felt that they had benefitted from the session and thought others would do.

The full results of the pre and post questionnaires can be found in (Appendix 12)

Presentation Evaluation

There were five members of staff from the drugs team that attended the presentation. I asked them to fill in a multiple choice pre questionnaire each, highlighting the key points in regards to oral health. After the presentation they filled out a post questionnaire which showed that their knowledge in regards to methadone and its effects on the oral cavity had increased. The post questionnaire also showed that the staff felt confident in giving oral health advice to the clients. (Appendix 13)

Discussion

I feel my intervention went well as I received a positive response from the staff and a positive response via e mail from the department of health regarding guideline changes.

The results of my questionnaires showed that 80% of the clients had problems with their teeth on the day of the oral health session. The percentage of clients that related this to methadone use was 40%. It suggested in research that I carried out that this particular group had high levels of dental caries and some related this to methadone use. (P.G Robinson et al, 2005) The results showed that most of the clients had dental problems at that particular time and some attributed this to the use of methadone. Research has also suggested that this particular group are poor attendees in regards to dental appointments (Nathwani.N and Gallagher.J, 2008) and are less likely to have visited the dentist in the last 12 months. (J.Sheridan et al 2001) The results for the questionnaires shows that 47% of the participants attended the dentist more than 12 months ago and 33% more than 3 years ago. This left only 20% that had attended the dentist in the last 12 months.

The clients that attended the oral health sessions with me seemed to enjoy it. The majority of the clients seemed interested and in response, asked questions regarding their oral health. I received a mixed response in regards to the pre and post questionnaires but mostly positive responses in regards to the post questionnaires. Some did not seem to mind filling out the forms but others felt that the pre questionnaire was lengthy so if I was to carry the project out again I would reduce the questionnaires to include just the vital information. Overall I received good feedback from the clients in regards to the oral health sessions overall and all felt like they had benefitted from the sessions and thought that others would. I went through the flip chart with a member of staff and received a good response and they thought that the information was relative to the clients. I also included the flip chart in the oral health sessions in which the clients were interested and thought the flip chart was informative. I provided all the information I used in the oral health sessions in a pack with guideline notes so the staff can carry on providing the clients with the relevant information after the intervention. If I was to carry out the project again I would leave the flip chart and leaflets with the staff to carry out in their own time to evaluate them.

Conclusion

The clients rated their oral health as more of a priority after the oral health sessions. Obviously the main priority for them is rehabilitation but feel that if these brief interventions are done more often it will encourage and motivate the clients to take more care of their oral health. The flip chart, leaflets, guidance notes and remaining oral health packs have been given to the staff to continue to use. They will be incorporating these into the regular titration clinics with the clients on a daily basis.

I feel my project has improved and broadened the facilities of the clinic by providing oral health advice to the clients on a daily bases in which this was not the case before the project. The presentation provided to the staff improved their knowledge and gave them more confidence in giving oral health advice to the clients. This will be presented again in the future using the guidance notes I provided. Also another positive outcome to the project is that the drug treatment policy section from the department of health will be reviewing UK guidelines in relation to methadone and oral health to bring these in to line with current evidence.

Acknowledgements

I would like to thank Mr Barry Gilman, team manager at Lees street drugs misuse service in Ashton Under Lyne for allowing this to be possible. Also I would like to thank all the staff there for taking part allowing the intervention to be continued with their help. I would also like to thank Mr Parsons for his supervision throughout the project.

References:

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