1. Chapter 25: Drug Abuse
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.

2. Chapter 25 Outline Drug abuse General considerations
Definitions
Psychologic dependence
Physical dependence
Tolerance
Addiction, habituation, and dependence
Central nervous system (CNS) depressants
Ethyl alcohol
Nitrous oxide
Opioid analgesics
Sedative-hypnotics
cont’d…

3. Chapter 25 Outline Drug abuse CNS stimulants
Cocaine
Amphetamines
Caffeine
Tobacco
Psychedelics (hallucinogens)
Lysergic acid diethylamide
Phencyclidine
Marijuana
Identifying the drug abuser
The impaired dental health care worker

4. Drug Abuse
Haveles (pp )
Dental health care workers may become involved with drug abuse in a variety of ways
They should become familiar with the various types of drugs commonly abused and their patterns of abuse
Alcohol and tobacco abuse causes more medical problems than all of the other drugs of abuse combined
cont’d…

5. Drug Abuse
The idea of using drugs to produce profound effects on mood, thought, and feeling is as old as civilization
The forms of drugs used today are much stronger and have a much faster onset of action
This quick reinforcement produces abuse more quickly
cont’d…

6. Drug Abuse
Agents used for their psychoactive properties can be divided into those that have therapeutic value and those that have no proven therapeutic value
Some agents may move from one category to another
Marijuana, previously considered to be worthless, is now claimed to be useful in the treatment of nausea associated with cancer chemotherapy and for glaucoma

7. General Considerations
Haveles (pp )
Definitions
Psychologic dependence
Physical dependence
Tolerance
Addiction, habituation, and dependence
cont’d…

8. General Considerations
Haveles (p. 309)
Abuse of a drug is defined as the use of a drug for nonmedical purposes, almost always for altering consciousness
Both legitimate and illegitimate drugs may be abused
Misuse of a drug means using the drug in the wrong dose or for a longer period than prescribed

9. Definitions Abstinence syndrome Addiction Haveles (p. 309)
A state of being free of drugs, which is the goal of any treatment program
Addiction
This vague term should be replaced with dependence
The pattern of abuse that includes compulsive use despite complications and frequent relapses after “quitting”
cont’d…

10. Definitions Dependence Drug abuse
A combination of either physical or psychologic manifestations occurring in a drug-dependent person when the drug is removed
Drug abuse
Self-administration of a drug in a socially unacceptable manner, resulting in negative consequences
cont’d…

11. Definitions Drug dependence Enabling
A state, which may be physical, psychologic, or both, that occurs as a consequence of the interaction between a drug and a patient
Characterized by a compulsion to take the drug to obtain its effects or to prevent the abstinence syndrome
Enabling
The behavior of family or friends that associate with the addict that results in continued drug abuse
cont’d…

12. Definitions Habituation Physical/physiologic dependence
Physiologic tolerance to or psychologic dependence on a drug, short of addiction
Physical/physiologic dependence
The state in which the drug is necessary for continued functioning of certain body processes
Psychologic dependence
The state in which, after withdrawal of the drug, manifestations of emotional abnormalities and drug-seeking behavior occur
cont’d…

13. Definitions Tolerance Withdrawal
With repeated dosing, the dose of a drug must be increased to produce the same effect, or
The same dose of a drug produces less effect with consecutive dosing
Withdrawal
The constellation of symptoms that occurs when a physically dependent person stops taking the drug

14. Psychologic Dependence
Haveles (p. 309)
A state of mind in which a person believes that he or she is unable to maintain optimal performance without having taken the drug
Although some highly abused drugs have only psychologic dependence, the “need” to use these drugs can be as strong or stronger than drugs with a physical dependence

15. Physical Dependence
Haveles (p. 309)
The altered physiologic state that results from constantly increasing drug concentrations
The presence of physical dependence is established by the withdrawal or abstinence syndrome
Withdrawal symptoms are often the opposite of the symptoms of use of the drug

16. Tolerance
Haveles (p. 309)
Characterized by the need to increase the dose continually to achieve the desired effect or the giving of the same dose, which produces a diminishing effect
Central tolerance is a definite decrease in the response of brain tissue to constantly increasing amounts of the drug

17. Addiction, Habituation, and Dependence
Haveles (pp )
The desire to continue using the drug is present in both addiction and habituation, but dependence is also present in addiction
Habituation and dependence are really only degrees of misuse or abuse of drugs
Experts recommend that these terms be replaced by dependence, a state of psychologic or physical desire to use a drug
cont’d…

18. Addiction, Habituation, and Dependence
Haveles (pp )
Drugs that produce tolerance and physical dependence are grouped according to their ability to be substituted for one another
The phenomenon of substitution to suppress withdrawal between different drugs is called cross-tolerance or cross-dependence
cont’d…

19. Addiction, Habituation, and Dependence
Approximately 80% of incarcerated individuals are there because of drug abuse problems
Problems and treatment are less related to the drugs themselves than to the “inner person” of the patient involved in this type of behavior and his or her genetic predisposition
cont’d…

20. Addiction, Habituation, and Dependence
Haveles (p. 310)
Abusable drugs are divided into
CNS depressants
CNS stimulants
Hallucinogens
Some drugs may fall in more than one group

21. Central Nervous System Depressants
Haveles (pp )
Include alcohol, opioids, barbiturates, benzodiazepines, volatile solvents, and nitrous oxide

22. Ethyl Alcohol The most often abused drug Haveles (pp. 310-313)
Alcoholism is the number one public health problem in the United States
The incidence of alcoholism in the United States is about 10%

23. Pharmacokinetics of Ethyl Alcohol
Haveles (p. 310) (Fig. 25-1)
Ethyl alcohol is rapidly and completely absorbed from the gastrointestinal tract
Peak levels while fasting occur in less than 40 minutes
Food delays absorption and reduces the peak levels
Metabolism follows zero-order kinetics; thus a constant amount is metabolized per unit of time, regardless of the amount ingested

24. Acute Intoxication of Ethyl Alcohol
Haveles (p. 310)
Impairment of judgment, emotional lability, and nystagmus occur with mild intoxication
Dilated pupils, slurred speech, ataxia, and a staggering gait are noted with moderate intoxication
Seizures, coma, and death can occur if intoxication is severe
Treatment includes fluids and electrolytes, thiamine (vitamin B6), sodium bicarbonate, and magnesium

25. Withdrawal from Ethyl Alcohol
Haveles (pp )
Stage 1 usually begins 6 to 8 hours after drinking has stopped and includes withdrawal, psychomotor agitation, and autonomic nervous system hyperactivity
Stage 2 withdrawal includes hallucinations, paranoid behavior, and amnesia
Stage 3 includes disorientation, delusions, and grand mal seizures
cont’d…

26. Withdrawal from Ethyl Alcohol
A cross-tolerant benzodiazepine may be used to prevent withdrawal symptoms
Withdrawal is termed delirium tremens (DTs) because the patient will often experience shaky movements

27. Chronic Effects of Ethyl Alcohol
Haveles (p. 311)
Chronic medical effects include deficiency of proteins, minerals, and water-soluble vitamins
Fetal alcohol syndrome can occur if a pregnant woman is using ethanol chronically
More severe cases include cardiac abnormalities and mental retardation
Chronic alcohol use increases the risk of cancer of the mouth, pharynx, larynx, esophagus, and liver

28. Alcoholism
Haveles (pp ) (Box 25-1)
A disease in which the alcoholic continues to drink despite the knowledge that drinking is producing a variety of problems
A genetic link for alcoholism exists
“Red flags” include drinking at an inappropriately early time, shaking when not drinking, blackouts when drinking, and being told that you drink too much

29. Treatment of Alcoholism
Haveles (p. 312)
Alcoholics anonymous
A self-help organization made up of recovering alcoholics
Members give support to alcoholics who are attempting recovery
Outpatient psychiatric treatment can help provide some insight for alcoholics
cont’d…

30. Treatment of Alcoholism
Haveles (p. 312)
Drug treatment
Alcoholics who are motivated and socially stable can be given disulfiram
A buildup of acetaldehyde occurs because disulfiram inhibits the metabolism of aldehyde dehydrogenase
Acetaldehyde produces significant side effects if alcohol is ingested
These effects include vasodilation, flushing, tachycardia, dyspnea, throbbing headache, vomiting, and thirst
cont’d…

31. Treatment of Alcoholism
Naltrexone was originally used to prevent relapse in the opioid-dependent patient
Its new use is to reduce alcohol craving
More detailed knowledge of the receptors affected by alcohol may increase the chance of developing other agents to manage this disease

32. Dental Treatment of the Alcoholic Patient
Haveles (pp ) (Fig. 25-3)
Dental treatment of the alcoholic patient includes some modifications
Most alcoholic patients have poor oral hygiene
Check for sweet musty breath and painless bilateral hypertrophy of parotid glands
Cirrhosis of the liver can occur when alcoholics continue to abuse alcohol
cont’d…

33. Dental Treatment of the Alcoholic Patient
The liver is able to store less vitamin K, and conversion of vitamin K to the coagulation factors is reduced because of hepatic failure
The outcome of these effects is a deficiency in coagulation factors II, VII, IX, and X, with resulting bleeding tendencies
The patient’s international normalized ratio (INR) can be elevated
Thrombocytopenia secondary to portal hypertension and bone marrow depression magnifies the hemostatic deficiency
Spontaneous bleeding can occur due to the presence of esophageal varices
cont’d…

34. Dental Treatment of the Alcoholic Patient
Haveles (p. 313) (Box 25-2; Table 25-2)
Oral complications include glossitis, loss of tongue papillae, angular/labial cheilosis, and Candida infection
The dental health care worker should check any oral lesions carefully because alcohol and tobacco use and abuse predispose a patient to oral squamous cell carcinoma
Dose reductions may be necessary because of diminished liver function

35. Nitrous Oxide
Haveles (p. 314)
Nitrous oxide is an incomplete general anesthetic readily available in many dental offices
It is abused primarily by dentists, dental hygienists, and dental assistants

36. Abuse Pattern of Nitrous Oxide
Haveles (p. 314) (Fig. 25-4)
Abuse can result in psychologic but not physical dependence
Inhalation of 50% to 75% produces a “high” for 30 seconds followed by a sense of euphoria and detachment for 2 to 3 minutes
Tingling or warmth around the face, auditory illusions, slurred speech, and a stumbling gait can occur

37. Adverse Reactions of Nitrous Oxide
Haveles (p. 314)
General
Adverse reactions include dizziness, headache, tachycardia, syncope, and hypotension
Nitrous oxide impairs the ability to drive or operate heavy machinery
Can produce chronic mental dysfunction and infertility with chronic use
cont’d…

38. Adverse Reactions of Nitrous Oxide
Haveles (p. 314)
Myeloneuropathy
Chronic use or abuse of nitrous oxide can lead to myelopathy, resulting in a combination of symptoms pathognomonic for nitrous oxide abuse
Initial symptoms include loss of finger dexterity and numbness or paresthesia of the extremities
Later, Lhermitte sign, clumsiness, and weakness can be demonstrated
Neurologic deficiencies include extensor plantar reflex and polyneuropathy
The neurologic deficiency is similar to that of spinal cord degeneration in pernicious anemia

39. Opioid Analgesics
Haveles (pp )
Heroin, methadone, morphine, hydromorphone, meperidine, oxycodone, and oxycodone sustained release are currently the most popular abused opioids
In addition to being analgesics, opioids produce a state described as complete satiation of all drives in some people
The driving motivation to obtain the drug becomes more and more negative with the development of physical dependence

40. Pattern of Abuse
Haveles (p. 314)
Heroin is the most commonly administered parenteral opioid
The signs and symptoms of an acute overdose are fixed, pinpoint pupils, depressed respiration, hypotension and shock, slow or absent reflexes, and drowsiness or coma
Tolerance develops to most of the pharmacologic effects but does not develop to miosis or constipation
cont’d…

41. Pattern of Abuse
The symptoms and time course of the withdrawal syndrome are determined by the specific drug abused and the dose of the drug
The first signs of withdrawal from heroin are yawning, lacrimation, rhinorrhea, and diaphoresis, followed by a restless sleep
Anorexia, tremors, irritability, weakness, and excessive gastrointestinal activity occur with further abstinence

42. Management of Acute Overdose and Withdrawal
Haveles (pp )
Naloxone should be administered immediately if the triad of narcotic overdose (respiratory depression, pinpoint pupils, and coma) is present
Patients in withdrawal can be made comfortable with methadone, a long-acting opioid that can replace heroin and then be gradually withdrawn

43. Dental Implications Pain control Haveles (p. 315)
Because an opioid abuser develops tolerance to the analgesic effects of any opioid, treating patients with opioids is ineffective and can cause a recovering addict to begin using opioids again
Best to alleviate the cause of the pain and then prescribe nonsteroidal antiinflammatory drugs
cont’d…

44. Dental Implications Prescriptions for opioids
Haveles (p. 315)
Prescriptions for opioids
Abusers often come to the dental office requesting an opioid for severe pain
Increased incidence of disease
Certain diseases that can be transmitted by the use of needles for injections have a higher incidence in opioid abusers
Chronic pain
Patients who have pain for a much longer time than normal deserve a workup for chronic pain

45. Opioid Street Drugs
Haveles (p. 315)
Opioids available on the street change with time and are different in different parts of the country
The dental health care worker should be aware that most drug abusers misuse more than one substance and that street drugs are often adulterated

46. Sedative-Hypnotics
Haveles (pp )
Sedative-hypnotics include barbiturates, alcohol, meprobamate, methaqualone, chloral hydrate, benzodiazepines, and nitrous oxide
Initial symptoms resemble the well-known symptoms of alcohol intoxication
Drowsiness and sleep occur with increasing doses, respiration is depressed, cardiac output is decreased, and gastrointestinal activity and urine output is diminished

47. Pattern of Abuse of Sedative-Hypnotics
Haveles (pp )
CNS depressant drugs are generally taken orally
Respiratory and cardiovascular depression occur with an acute overdose, leading to coma and hypotension
The pupils may be unchanged or small, and lateral nystagmus is seen
Confusion, slurred speech, and ataxia are always present
cont’d…

48. Pattern of Abuse of Sedative-Hypnotics
Haveles (pp )
The first signs of withdrawal are insomnia, weakness, tremulousness, restlessness, and perspiration
Delirium and convulsions may culminate in cardiovascular collapse and loss of the temperature-regulating mechanism
Another troubling abuse of sedative-hypnotics involves administering them to other people to control them

49. Management of Acute Overdose and Withdrawal of Sedative-Hypnotics
Haveles (p. 316)
The most important consideration with an acute overdose of a CNS depressant is support of the cardiovascular and respiratory systems
Withdrawal from CNS depressants can be life threatening, and the patient should be hospitalized
A long-acting benzodiazepine is usually substituted for the abused drug and then gradually withdrawn over a period

50. Central Nervous System Stimulants
Haveles (pp )
Cocaine
Amphetamines
Caffeine
Tobacco

51. Cocaine
Haveles (p. 316)
Cocaine is a CNS stimulant with local anesthetic properties when applied topically
Cocaine induces intense euphoria, a sense of total self-confidence, and anorexia
Paranoia and extreme excitability cause some cocaine users to perform violent acts while under its influence
Psychologic dependence becomes intense, but neither tolerance nor withdrawal has been shown

52. Amphetamines Pattern of abuse Haveles (p. 316)
Sympathomimetic CNS stimulants are abused for their ability to produce a euphoric mood, a sense of increased energy and alertness, and a feeling of omnipotence and self-confidence
With prolonged use, tolerance to the euphorigenic effect develops, and toxic symptoms appear
Signs and symptoms of an acute overdose include dilated pupils, elevated blood pressure, rapid pulse, and cardiac arrhythmias
cont’d…

53. Amphetamines Management of acute overdose and withdrawal
Haveles (p. 316)
Management of acute overdose and withdrawal
Treatment of an overdose of a CNS stimulant is symptomatic
The most serious sociologic problem with stimulant abuse is the induction of mental abnormalities
Experimental evidence suggests that amphetamine psychoses can be induced in previously unaffected volunteer subjects

54. Caffeine Caffeine stimulates the CNS Haveles (p. 317) (Table 25-3)
Toxicity can occur with as little as 300 mg of caffeine contained in two or three cups of coffee
A withdrawal syndrome can be identified that begins around 24 hours after the last cup of coffee
Symptoms consists of headache, lethargy, irritability, and anxiety

55. Tobacco Nicotine Haveles (pp. 317-318)
The CNS active component of tobacco is nicotine
A large number of components of the gaseous phase of tobacco smoke contributes to its undesirable effects
These components include carbon monoxide, nitrogen oxides, volatile nitrosamines, hydrogen cyanide, volatile hydrocarbons, and many other substances
cont’d…

56. Tobacco Pattern of Abuse Haveles (p. 317)
Approximately 25% of the adult American population smokes
Children commonly begin smoking between 11 and 14 years of age
Chronic use of tobacco is causally related to many serious diseases, including coronary artery disease and oral and lung cancers
cont’d…

57. Tobacco Smokeless tobacco Haveles (p. 317)
More than one quarter of high school boys use chewing tobacco in some communities
Oral mucosal changes include chronic gingivitis, leukoplakia, and precancerous lesions
cont’d…

58. Tobacco Management and withdrawal Haveles (p. 317) (Table 25-4)
The withdrawal syndrome that occurs after cessation of chronic tobacco smoking varies greatly from person to person
The most consistent symptoms are anxiety, irritability, difficulty in concentrating, and cravings for cigarettes
The syndrome of withdrawal from tobacco can be suppressed to some extent by administration of nicotine chewing gum or nicotine patches
cont’d…

59. Tobacco Bupropion Haveles (p. 317)
Another approach to treating tobacco cessation involves the use of bupropion, an antidepressant, to reduce craving
cont’d…

60. Tobacco Varenicline Haveles (p. 318)
Varenicline is a nicotine-receptor blocker that binds to the nicotine receptor and prevents the nicotine from tobacco from reaching its receptor site
By binding to the receptor, varenicline limits the amount of dopamine that is released in the brain
The most common side effects include nausea, sleep problems, constipation, gas, vomiting, and changes in mood and behavior
cont’d…

61. Tobacco The dental health care worker’s role in tobacco cessation
Haveles (p. 318)
The dental health care worker’s role in tobacco cessation
Dental health care workers are in a special situation to be helpful in promoting tobacco cessation because of their role in encouraging patients to change habits
Smoking cessation is another habit change

62. Psychedelics (Hallucinogens)
Haveles (p. 318)
Lysergic acid diethylamide (LSD)
Phencyclidine (PCP)
Marijuana

63. Psychedelics
Haveles (p. 318)
Psychedelic agents are capable of inducing states of altered perception and generally do not have any medically acceptable therapeutic use
Psychedelics affect perception in such a way that all sensory input is perceived with heightened awareness
Psychedelic-induced dependence is psychologic, and tolerance develops within a short time

64. Lysergic Acid Diethylamide
Haveles (p. 318)
LSD is the most potent hallucinogen
An overdose of LSD produces symptoms that include widely dilated pupils, flushed face, elevated blood pressure, visual and temporal distortions, hallucinations, derealization, panic reactions, and paranoia
Flashbacks can occur years after ingesting LSD

65. Phencyclidine
Haveles (p. 318)
PCP, originally developed as an animal tranquilizer, was popular in the 1970s
PCP inhibits the reuptake of dopamine, serotonin, and norepinephrine
PCP is a powerful CNS stimulant with dissociative properties
Changes in body image and disorganized thought have led to bizarre behavior and psychosis

66. Marijuana
Haveles (p. 318)
The effects of marijuana include an increase in pulse rate, reddening of the conjunctivae, and behavioral changes
Euphoria and enhanced sensory perception occur with normal doses
This phase is followed by sedation and altered consciousness
Psychologic dependence is determined by the frequency of use
Physical dependence, tolerance, and withdrawal symptoms are rare

67. Identifying the Drug Abuser
Haveles (p. 318)
“Shoppers” interact with many health care workers in an attempt to obtain controlled substances for illegitimate uses
Many shoppers are excellent storytellers and actors with convincing histories and the presence of a pathologic dental condition
They may suggest certain drugs or give a history of allergy to analgesics they do not want

68. Impaired Dental Health Care Worker
Haveles (p. 318)
A professional who is abusing drugs is in denial, and confrontation by staff, relatives, and friends is often ineffective
The dentist’s practice deteriorates, and mood swings occur
Any dental health care worker who observes or suspects that another worker is abusing drugs should report the person to the appropriate “impaired professional committee”