Download Chapter 25

Chapter 25:
Drug Abuse
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
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…
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2
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
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3
Drug Abuse


Haveles (pp. 308-309)
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…
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4
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…
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5
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
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6
General Considerations






Haveles (pp. 309-310)
Definitions
Psychologic dependence
Physical dependence
Tolerance
Addiction, habituation, and dependence
cont’d…
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7
General Considerations


Abuse of a drug is defined as the use of a drug
for nonmedical purposes, almost always for
altering consciousness


Haveles (p. 309)
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
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8
Definitions


Abstinence syndrome


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…
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9
Definitions

Dependence


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…
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10
Definitions

Drug dependence



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…
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11
Definitions

Habituation


Physical/physiologic dependence


Physiologic tolerance to or psychologic dependence
on a drug, short of addiction
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 drugseeking behavior occur
cont’d…
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12
Definitions

Tolerance



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
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13
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
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14
Physical Dependence


The altered physiologic state that results from
constantly increasing drug concentrations


Haveles (p. 309)
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
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15
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
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16
Addiction, Habituation, and
Dependence


Haveles (pp. 309-310)
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…
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17
Addiction, Habituation, and
Dependence


Haveles (pp. 309-310)
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 crosstolerance or cross-dependence
cont’d…
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18
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…
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19
Addiction, Habituation, and
Dependence


Abusable drugs are divided into




Haveles (p. 310)
CNS depressants
CNS stimulants
Hallucinogens
Some drugs may fall in more than one group
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20
Central Nervous System
Depressants


Haveles (pp. 310-316)
Include alcohol, opioids, barbiturates,
benzodiazepines, volatile solvents, and
nitrous oxide
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21
Ethyl Alcohol


Haveles (pp. 310-313)
The most often abused drug


Alcoholism is the number one public health problem
in the United States
The incidence of alcoholism in the United States is
about 10%
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22
Pharmacokinetics of Ethyl
Alcohol


Ethyl alcohol is rapidly and completely absorbed
from the gastrointestinal tract



Haveles (p. 310) (Fig. 25-1)
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
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23
Acute Intoxication of Ethyl
Alcohol


Impairment of judgment, emotional lability, and
nystagmus occur with mild intoxication



Haveles (p. 310)
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
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24
Withdrawal from Ethyl Alcohol




Haveles (pp. 310-311)
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…
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25
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
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26
Chronic Effects of Ethyl Alcohol


Chronic medical effects include deficiency of
proteins, minerals, and water-soluble vitamins



Haveles (p. 311)
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
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27
Alcoholism


Haveles (pp. 311-312) (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
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28
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…
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29
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…
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30
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
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31
Dental Treatment of the Alcoholic
Patient


Haveles (pp. 312-313) (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…
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32
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…
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33
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
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34
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
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35
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
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36
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…
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37
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
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38
Opioid Analgesics


Heroin, methadone, morphine,
hydromorphone, meperidine, oxycodone, and
oxycodone sustained release are currently
the most popular abused opioids


Haveles (pp. 314-315)
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
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39
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…
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40
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
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41
Management of Acute Overdose
and Withdrawal


Haveles (pp. 314-315)
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
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42
Dental Implications


Haveles (p. 315)
Pain control


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…
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43
Dental Implications


Prescriptions for opioids


Abusers often come to the dental office requesting
an opioid for severe pain
Increased incidence of disease


Haveles (p. 315)
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
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44
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
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45
Sedative-Hypnotics


Haveles (pp. 315-316)
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
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46
Pattern of Abuse of SedativeHypnotics


Haveles (pp. 315-316)
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…
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47
Pattern of Abuse of SedativeHypnotics


The first signs of withdrawal are insomnia,
weakness, tremulousness, restlessness, and
perspiration


Haveles (pp. 315-316)
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
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48
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
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49
Central Nervous System
Stimulants





Haveles (pp. 316-318)
Cocaine
Amphetamines
Caffeine
Tobacco
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50
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
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51
Amphetamines


Haveles (p. 316)
Pattern of abuse



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…
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52
Amphetamines


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
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53
Caffeine


Haveles (p. 317) (Table 25-3)
Caffeine stimulates the CNS


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
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54
Tobacco


Haveles (pp. 317-318)
Nicotine



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…
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55
Tobacco


Haveles (p. 317)
Pattern of Abuse

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…
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56
Tobacco


Haveles (p. 317)
Smokeless tobacco


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…
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57
Tobacco


Haveles (p. 317) (Table 25-4)
Management and withdrawal

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…
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58
Tobacco


Haveles (p. 317)
Bupropion

Another approach to treating tobacco cessation
involves the use of bupropion, an antidepressant,
to reduce craving
cont’d…
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59
Tobacco


Haveles (p. 318)
Varenicline



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…
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60
Tobacco


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
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61
Psychedelics
(Hallucinogens)




Haveles (p. 318)
Lysergic acid diethylamide (LSD)
Phencyclidine (PCP)
Marijuana
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62
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
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
63
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
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64
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
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
65
Marijuana


The effects of marijuana include an increase in
pulse rate, reddening of the conjunctivae, and
behavioral changes



Haveles (p. 318)
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
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
66
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
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
67
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”

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68