New Regulations Causing Patients to Show up Already Medicated

A DOCS Education Gold member writes:
In my practice, I sedate the patient and my husband/partner does the procedure. I have seen four cases in the past month where the patient pre-medicated themselves with Valium (or something else) for their appointment. Two took the advice of a friend, and two were pre-medicated by their physician. I am wondering how other dental offices go about handling this; these patients are not given education beforehand - and all but one drove themselves to and from the office. We are in Virginia, a state where the dentist is required to have a special permit to give N2O and a Valium. Also a state where whoever gives a person alcohol is liable for any car accidents - thus my increased concern about liability and these patients driving and sedating themselves. Not to mention that we are using meds on them and who really knows what they have taken. I have considered requiring the person to be offered a taxi home, though I would prefer this not to be going on at all. The regulations appear to have created a new problem that is much harder to control. What do the rest of you suggest? How do you control this if they are getting it from medical doctors and doing it beforehand without your knowledge?

Dr. Jerome Wellbrock, DOCS Education faculty, responds:
I would personally refuse to treat these patients. You are putting both yourself and husband at a legal risk. You are also letting a patient put themselves at risk of either harm with additional sedation or in operating a car, etc. You need to have a serious discussion with the patient about taking meds on their own and I would also consider a conversation with the physicians who are prescribing and emphasize the risk that they are also putting themselves in if the patient has any negative outcome. I highly recommend to never let a sedated patient enter a cab, Uber, etc... These are patients that still have some level of sedative meds in their system, and the potential for trouble is uncomfortable to me.

John Bitting, DOCS Regulatory Counsel, adds:
I agree with Dr. Wellbrock's recommendation, and would only add one caveat. Be sure your informed consent contains a provision whereby you (dentist) reserve the right to immediately terminate this doctor-patient relationship if the patient self-medicates before any appointment, not just a sedation appointment. If you decide to proceed with the appointment anyway, you must treat it like a sedation appointment and monitor the patient.

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