Substance Abuse and Overdose

Abstainers

(1/3 of the population) have never used drugs or alcohol

Social users

(majority of the population) occasionally use drugs or drink, however they are able to have one drink and then stop. Does not lead to personal problems

Postsynaptic neurons

a neuron to the cell body (or dendrite) of which an electrical impulse is transmitted across a synaptic cleft by the release of a chemical neurotransmitter from the axon terminal of a presynaptic neuron.

Substance abuse

a pattern of self-administrated drug use that may lead to drug addiction

Physically dependent addicts

adaptation of the body's chemistry; undergo withdrawal signs

Cocaine

A CNS stimulant and local anesthetic with a potent vasoconstrictor Snorted, inhaled, smoked Because of its potent vasoconstrictor effects, cocaine is used medically as a local anesthetic agent for mucous membranes, such as in nasal surgical procedures. The free base form of the drug, commonly known as "crack" is preferred for smoking because this pure form is more rapidly acting and powerful than the cocaine salt. Within the sympathetic autonomic nervous system, cocaine prevents the reuptake of dopamine, norepinephrine, and serotonin, all excitatory neurotransmitters. Cocaine's mechanism of action is primarily as a dopamine reuptake inhibitor. As a result dopamine-containing neurons within the brain constantly release dopamine for postsynaptic receptor attachment. Its peak effect takes place in 10-30 minutes. The effects rarely last more than 1 hour. Increases sense of well-being Heightened awareness Anorexia Decreased desire to sleep, restlessness Elation, grandiosity Agitation Tachycardia Seizures Respiratory failure Psychotic states Euphoria Increased sexual desire and improved sexual function NO EPINEPHRINE: No local anesthetic with epinephrine, no retraction cords with epinephrine Cocaine potentiates the response of sympathomimetic amines UNM: no epinephrine 24 hours after use Risks: Myocardial infarction Stroke Cardia arrhythmias Death Caution when prescribing S+S: Dilated pupils Slow or no reaction of pupils to light Gingiva or alveolar bone necrosis above maxillary premolar Increased caries Carbs added to cocaine as filler Spontaneous gingival bleeding due to thrombocytopenia Frequent rubbing of nose Irritation around nose Excitement, hyperactivity Delusional sense of self confidence Unfocused Paranoia Hallucinations Use is followed by a moderate to severe post-cocaine depression Providing compulsion to use again Overdose can be life threatening

Fetal Alcohol Syndrome (FAS)

A pregnant woman with an active alcohol addiction is at risk for delivering a child with FAS. Intellectual and developmental disabilities, physical impairments, and infant failure to thrive can result. Education for mothers is critical. Characteristics: Abnormal facial characteristics Intellectual and developmental disabilities Learning disabilities Hearing, speech, and vision impairments Hyperactivity Memory and problem-solving deficits Poor motor coordination Major organ malformations Musculoskeletal system malformations Compromised immune system

Systemic Effects of Local Anesthetics

Affect both the Central Nervous System and the Cardiovascular System. Adverse reactions and toxicity are directly related to: Nature of the drug Concentration of the drug/dose Route Rate Vascularity Age Weight Health Route and rate of metabolism and excretion

Neurophysiology

All neurons are electrically excitable, maintaining voltage gradients across their resting membranes by sodium ion pumps. Changes in the voltage across the nerve membrane can alter the function of the voltage-dependent ion channels. If the voltage changes by a large enough amount, then an electrochemical pulse called an action potential is generated. This travels rapidly along the cell's axon, and activates synaptic connections with other cells. Between neurons lies the synaptic gap, which is the space between the terminal that is sending the message and the dendrite that is receiving the message. This jump between neurons is accomplished through biochemicals called neurotransmitters. Neurotransmitters transmit the message from one neuron to the receptors on another.

Medications for Alcoholism Treatment

Blocks the metabolism of alcohol Disulfiram (Antabuse) Citrated calcium carbamide Antagonizes opiate receptors Naltrexone Serotonin antagonism Ondansetron

Statistics

National survey on drug use and health: 2015 Report 27.1 million people aged 12 or older used illicit drugs in the past 30 days. 52 million people aged 12 or older are cigarette smokers. 138.3 million Americans aged 12 or older reported current use of alcohol, including 66.7 million who reported binge alcohol use in the past month. 20.8 million people aged 12 or older have a substance use disorder. In a dental practice setting of 2000 patients, approximately 175 abuse at least one drug or substance. For at least 170 of these patients, the substance is alcohol.

Opioids

CNS depressant Opioids are synthetic substances that act on opioid receptors to produce morphine-like effects that mimic the effects of the natural poppy plant. Opioids are most often used medically to relieve pain. Decrease pain perceptions Causes a modest level of sedation Euphoria The mechanism of action of opioid drugs involves the binding of the exogenous agent with specific opioid receptors in the CNS and spinal cord. Opiates produced from this natural source are morphine and codeine. Propoxyphene Diphenoxylate Fentanyl Buprenorphine Methadone Hydrocodone Hydromorphone Heroin Oxycodone Meperidine Prescribed drug May seem less "harmful" since it is given by a doctor In households Children/teens have access to them Healthcare providers have access to them Filling Rx for personal use The discovery of endogenous opioid-like agents helped to determine the presence of opioid receptors (mu, kappa, delta) within the body. S+S: Constricted pupils Non-reactive to light Analgesia (feeling no pain) Sedation Euphoria (feeling high) Respiratory depression (shallow or slow breathing) Small pupils Nausea, vomiting Itching or flushed skin Caution when prescribing medications Patient may not feel oro-facial pain even when pathology is present

Amphetamines

CNS stimulants. "Uppers" "Speed" "Pellets" Increase synaptic dopamine by releasing dopamine stores, which in turn give the user the dopamine high. Hyper-alertness Euphoria Physical endurance More intense than cocaine Half life is longer (longer lasting than cocaine) 8-24 hours Sometimes used clinically for weight loss, ADHD, narcolepsy, and treatment-resistant depression. Dependence developed after ONE USE. Amphetamine agents stimulate the CNS by activating a sympathetic autonomic nervous system response. Fight or flight. They prevent the neuronal reuptake of the excitatory neurotransmitters norepinephrine and dopamine within the SANS. Prevention of the reuptake of the neurotransmitters results in the endogenous chemicals constantly being released by presynaptic neurons originating in the CNS. These chemicals are then readily available to be transmitted through postsynaptic neurons to the target organ or tissue to exert their excitatory effects, instead of being "taken back up" and stored by neurons in an inactive state for future use. Dexedrine Ritalin Adderall Phentermine Methamphetamine

CBD oil

Cannabidiol hemp oil, or CBD hemp oil CBD hemp oil is made from high-CBD, low-THC hemp, unlike medical marijuana products, which are usually made from plants with high concentrations of psychoactive tetrahydrocannabinol (THC). Because hemp contains only trace amounts of THC, these hemp oil products are non-psychoactive. CBD interacts with the body through the endogenous cannabinoid system (ECS) or endocannabinoid system. First discovered in the late 1980's, the endocannabinoid system regulates the body's homeostasis, or general state of balance, impacting such functions as mood, sleep, appetite, hormone regulation, and pain and immune response. Potential benefits: Natural pain relief Anti-inflammatory properties Quitting smoking Drug withdrawals Epilepsy and other mental health disorders Helps fight cancer Anxiety disorders Type 1 diabetes Acne Alzheimer's disease

Parotid Gland Enlargement

Chronic Bilateral Diffuse Non-inflammatory Non-neoplastic Painless swelling of the parotid Likely due to malnutrition Discuss

Benzodiazepines

Now used in place of barbiturates for their sedative-hypnotic effects, including reduction of anxiety, anticonvulsant, and muscle relaxant properties. The mechanism of action of benzodiazepine agents is the same as that for barbiturate agents. Valium Versed Xanax Klonopin Ativan Halcion

Signs and Symptoms: Anesthetic Overdose on the CNS

Observable: Excitatory-nervousness-talkativeness Slurred speech/stutter Involuntary twitching/shivering Light-headedness/dizziness Tremor in facial muscles Confusion/apprehension Sweating Vomiting Elevated respiration/heart rate/blood pressure Convulsions (Tonic-Clonic) Respiratory depression Depressed heart blood pressure/heartrate CNS depression, coma, death Subjectively Felt: Disorientation Nervousness Flushed skin color Apprehension Twitching tremors Shivering Dizziness Light-headedness Visual disturbances Auditory disturbances Headache Tinnitus Metallic taste

Dependence vs. abuse

Dependence (3 or more) Tolerance Substance taken longer or in larger amounts Time spent acquiring drug Withdrawal Activities reduced Continued use despite knowledge of negative implications Abuse (1 in last 12 months) Never met criteria for dependence Failure in a major role/obligation Taken in situations that are physically hazardous Legal issues Continued use despite knowledge of negative implications

How Drugs Enter the Body

Direct contact with skin or mucous membranes Orally, by swallowing Snorted through the nose Sublingual placement Against oral mucosa Injected Directly into the bloodstream (intravenously) Into a muscle mass (muscling) Underneath the skin (skin popping) All injection methods place the user at risk for hepatitis, septicemia, abscesses, and human immunodeficiency virus infection.

Patient education

Discuss risks of substance abuse "When will you know it is time to quit?" Let them know what you can do Positive reinforcement and encourage ANY improvement Be sympathetic

Neurotransmitters

Dopamine (pleasure) Endorphin (rush) Enkephalin/Encephalin (pain-killer) Serotonin (deficiency=depression) Substance P (transmission of pain) Epinephrine (adrenaline) Acetylcholine (muscle/nerve impulses)

Stages of Behavior Change

Helping patients change a particular behavior. Listening to a patient and asking NONJUDGMENTAL questions about the patient's readiness to make an attempt at quitting. If a patient admits to substance abuse but states that they are not ready to stop: Provide information about the benefits of stopping. "When will you know it is time to quit?" Collaboration, not persuasion: positive interprofessional atmosphere that is conducive to change but not coercive. Eliciting information, not imparting information: the tone is not one of imparting information, but rather drawing out of motivation for change. The patient will do most of the talking, it is our job to listen carefully. Emphasizing the patient's autonomy, not the authority of the expert. The responsibility for change is left with the patient.

Treatment Planning Considerations

Emergency treatment: Vital signs: Slow or irregular breathing (<8 breaths/minute) Rapid pulse Vomiting Unresponsive Behavioral treatment: The most effective treatments for substance abuse occur when the abuser is motivated to seek medical intervention, behavioral changes, and social reinforcement, although treatment does not need to be voluntary to be effective. Pharmacologic treatment Drug therapy Intraoral and extraoral screenings

Distribution of Local Anesthetics

Higher blood levels of the drug increase the chance of the patient developing an overdose. The vasoconstrictor will reduce rapid systemic absorption, which reduces systemic toxicity and increases the duration. If the anesthetic is inadvertently injected intravascularly, it will be absorbed into the bloodstream rapidly, significantly increasing the possibility of an overdose. After being injected into the bloodstream, high vascular organs have higher concentrations of the anesthetic. Easily cross the blood-brain barrier: nerves are predominately susceptible to local anesthetics.

Liver functions

Filters blood Detoxifies chemicals Metabolizes drugs Creates proteins for blood clotting Works with pancreas and intestines to digest, absorb, and process food Metabolism: With the help of vitamin K, the liver produces proteins that are important in blood clotting. It is also one of the organs that break down old or damaged blood cells. The liver plays a central role in all metabolic processes in the body. The liver is an essential metabolic organ, and its function is controlled by insulin and other hormones. Drugs can be metabolized by oxidation, reduction, hydrolysis, hydration, conjugation, condensation, or isomerization. Whatever the process may be, the goal is to make the drug easier to excrete. Individual drug metabolism rates are influenced by genetic factors and/or coexisting disorders. Particularly chronic liver disorders and advanced heart failure. As well as drug interactions. Especially those involving induction or inhibition of metabolism.

Treatment Planning Considerations

Mentally sound to make treatment decisions Relapse likely: extensive restorative tx now? May need shorter appointments to decrease anxiety Consult with PCP Pain management Adjuncts Fluoride Night guard Shorter/more frequent recalls Alcohol-free rinses

Long Term Use of Alcohol

Increased risk of: Oral cancer Breast cancer Malnutrition Hepatitis and liver damage Dementia Fetal Alcohol Syndrome

Local Anesthesia

Local anesthetic drugs act mainly by inhibiting sodium influx through sodium-specific ion channels in the neuronal cell membrane. Voltage-gated sodium channels All nerve fibers are sensitive to local anesthetics, but generally, those with a smaller diameter tend to be more sensitive than larger fibers. Block conduction occurs via small myelinated axons, nonmyelinated axons, then large myelinated axons. There are 2 major routes of delivery Topical and submucosal Topical anesthetic agents are prepared in higher concentrations than injectable anesthetics to facilitate diffusion of the drug through the mucous membranes. Due to this, there is a risk for toxicity if large amounts of topical anesthetics are applied to limited areas. In contrast, submucosal injections of local anesthetics are more effective than topical routes of administration because the local anesthetic solution is injected and placed in close proximity to the nerve trunk of the area to be anesthetized. This allows the solution to more effectively reach the nerve.

Cardiovascular Effects of an Overdose

Low to moderate overdose Elevated blood pressure and heart rate Moderate to high blood levels Cardiovascular depression (decreased blood pressure) Decreased excitability (decreased heart rate) Cardiac arrest Symptoms of an overdose: Headache Lethargy Increased slurring of speech Increased disorientation Possible loss of consciousness

Diseases Affecting Metabolism

Lysosomal storage disorders: -Hurler syndrome -Niemann-Pick disease -Tay-Sachs disease -Guacher disease -Fabry disease -Krabbe disease Galactosemia Maple syrup urine disease Phenylketonuria (PKU) Glycogen storage diseases Mitochondiral disorders Friedreich ataxia Peroxisomal disorders -Zellweger syndrome -Adrenoleukodystrophy Metal metabolism disorders Wilson disease Hemochromatosis Organic acidemias Urea cycle disorders

Pharmacokinetics of Local Anesthetic Drugs

Pharmacokinetics is the study of the action of drugs within the body. These actions include mechanisms of: Drug absorption Distribution Metabolism Excretion Onset of action Duration of effect Biotransformation Effects and routes of excretion of the metabolites of the drug

Alcohol

Reduces anxiety, causes intoxication, and sensory alterations. Alcoholism: a primary chronic disease with genetic, psychosocial and environmental factors, often progressive and fatal. Characterized by impaired control over drinking, preoccupation with alcohol, use of alcohol despite future consequences, and distortions of thinking (most notably denial). Standard drink: approximately ½ fluid oz. of alcohol: 12 oz beer 5 oz wine 1 ½ oz 80 proof distilled spirits Binge drinking: 5 or more drinks on same occasion at least once in the last 30 days. ¼ of the population. Heavy drinking: binge drinking 5 times in the last 30 days. 7% of the population. Enters blood stream within 5 minutes, remains 1-4 hours. Liver breaks down alcohol approximately 1 drink/hour.

Meth

Potent synthetic psychostimulant form of amphetamine Highly addictive "Speed" "Crank" "Ice" "Crystal" More intense withdrawal symptoms than cocaine Cessation results in severe depression, suicidal thoughts, and hyper-insomnia Methamphetamine has recently become the leading drug of abuse: it is easy to produce, it is inexpensive, and it provides extended states of euphoria. S+S: Dilated pupils Slow or no reaction of pupil to light Xerostomia Increased caries: "Meth Mouth" Extreme tooth wear due to bruxism Trismus Increased physical activity Increased blood pressure and breathing rate Elevated body temperature Heavy sweating Loss of appetite Sleeplessness Paranoia or irritability NO EPINEPHRINE: No local anesthetic with epinephrine, no retraction cords with epinephrine Methamphetamine potentiates the response of sympathomimetic amines UNM: No epinephrine 24 hours after use Risks: Myocardial infarction Stroke Cardiac arrhythmias Death Caution when prescribing medications Increased bleeding and poor coagulation May need labs prior to invasive surgeries or NSPT

Duration of Anesthesia

Protein binding: longer acting local anesthetics such as bupivacaine are more firmly bound to the receptor sites than shorter-acting local anesthetics such as lidocaine. Increased protein binding allows the cations to bind/cling more firmly so duration is increased. Vascularity of the injection site: vascularity increases absorption of the anesthetic, allowing the drug to leave the injected area faster, decreasing potency as well as duration. Presence or absence of a vasoconstrictor drug: added vasoconstrictors to a local anesthetic decrease the vasodilatory properties of local anesthetics by constricting the surrounding blood vessels at the site of administration, increasing the duration of the anesthetic. The rate of systemic absorption of local anesthetics is dependent upon the total dose and concentration of the drug administered, the route of administration, the vascularity of the tissues at the administration site, and the presence or absence of a vasoconstrictor in the anesthetic solution.

Signs of Alcohol Abuse

Red puffy eyes Infections from immunosuppression Spider angiomas Parotid gland enlargement Whole body: blackout, dizziness, shakiness, craving, or sweating. Behavioral: aggression, agitation, compulsive behavior, self-destructive behavior, or lack of restraint. Mood: anxiety, euphoria, general discontent, guilt, or loneliness. Gastrointestinal: nausea or vomiting. Psychological: delirium or fear. Also common: physical substance dependence, problems with coordination, slurred speech, or tremor.

Barbiturates

Sedative-hypnotic agents (CNS depression) Treatment of insomnia Alleviate anxiety Produce sedation Pentothal for general anesthesia Phenobarbital for anticonvulsant properties Enhance the effects of an inhibitory neurotransmitter within the CNS (gamma-aminobutyric acid, or GABA) GABA agonists: encourages GABA to bind to its receptor sites to enhance inhibitory effects. Result is sedation or hypnosis. Butalbital is a barbiturate that is sometimes combined with caffeine and an analgesic, such as acetaminophen or aspirin for treatment of headaches.

Marijuana

Smoked or ingested A preparation of the cannabis plant intended for use as a psychoactive drug or medication Creates a feeling of euphoria, relaxation, slows reaction time, increases heart rate and appetite, impairs learning and memory, can increase or decrease anxiety. Deposits more tar in lungs than cigarettes No studies suggest it is correlated with cancers In fact, some studies show Delta-9-tetrahydrocannabinol (THC) has antitumor/anti-carcinogenic effects Referred to as the "gateway" drug Legal in some states Medicinal purposes

Liver Disease

Symptoms may include: Loss of appetite, nausea, vomiting, abdominal pain, fever, and jaundice. Up to 35% of heavy drinkers develop alcoholic hepatitis and of these, 55% already have cirrhosis. Symptoms include: Yellow skin and eyes as well as increasing belly size due to fluid accumulation. Treatment involves: Hydration, nutritional care, and stopping alcohol use. Steroid drugs can help reduce liver inflammation.

Stimulants

force the release of large amounts of neurotransmitters (epinephrine and dopamine) which creates, stimulates, and exaggerates the messages being sent to the CNS.

Extraoral

The general appearance of patients can alert the dental hygienist to the possibility of substance abuse. Do they look substantially older than their stated age, have a disheveled appearance, have poor oral hygiene, insist on wearing sunglasses, and wear long sleeves even in hot weather (cover needle marks)? Is alcohol or another odor detected on their breath? Do they appear to be lethargic or intoxicated? Do they experience tremors? Look at their eyes for signs of substance abuse. Needle marks on the forearms, bruises, increased pigmentation over the veins as a result of multiple injections (which may be observed during a blood pressure reading) may indicate illicit drug use. The subcutaneous "popping" of heroin can cause skin abscesses. Crack abusers will often have burns or scars on the thumb of the dominant hand from the repeated use of a disposable lighter. Multiple healed and healing burns or abrasions may be the result of physical trauma experienced while the patient was under the influence of alcohol or drugs. Snorting or inhaling substances can burn nasal passages, cause nosebleeds, and significantly damage nasal structures. Oftentimes these patients continually sniff their noses and use handkerchiefs or tissues. Watch their behavior and speech for signs of confusion, disorientation, lethargy, lack of concentration, or memory impairment. Extreme depression or agitation may indicate a drug overdose.

Intraoral

The placement of drugs directly in the vestibule, or sublingually, may cause localized tissue necrosis. Gingival lesions may be caused by cocaine placement. Alcohol and drug abusers often crave sweets so consequentially large, dark areas of buccal cervical caries from ingesting large quantities of carbs may be present. Other oral manifestations associated with substance abuse include oral candidiasis as a result of immunosuppression and glossodynia (pain in the tongue). Cocaine users tend to have severe bruxism causing flat cuspal planes on the premolars and molars. Tissue healing can be affected.

Neurotransmitters

The three main components of a neuron (nerve cell) include: Dendrites (input zone): receive signals from other neurons. Cell body (soma): nourishes the neuron and keeps it alive. Axons (summation zone): carry the messages. Afferent nerves: carry toward Efferent nerves: carry away

Oral Manifestations of Alcohol Abuse

Xerostomia Poor oral hygiene BOP Coated tongue Glossitis (nutritional deficiency) Attrition Erosion Broken teeth Buccal cervical caries

Addiction

a chronic, cyclic disease usually accompanied by a social stigma. Compulsive use despite the adverse medical/social consequences

Presynaptic neurons

a neuron from the axon terminal of which an electrical impulse is transmitted across a synaptic cleft to the cell body (or one or more dendrites) of a postsynaptic neuron by the release of a chemical neurotransmitter.

Clinical Considerations for Patients with Alcoholism

Thorough completion of health history Drug interactions = life-threatening Increased bleeding Increase healing time May need to alter dosage of anesthesia and sedatives Caution when administering anesthesia or prescribing medications Consult with physician for necessary modifications Alcohol-free rinses

Red Flags for Suspicion of Substance Abuse

Unreliable; frequently misses appointments Careless in appearance and hygiene Lapses in memory, concentration, or both Alcohol on breath Speech is slurred; appears intoxicated Needle marks on arm Rapid mood swings (within minutes) Frequently requests written excuses from work Frequently requests specific medication for pain High tolerance to sedatives and analgesics Pupils are abnormally dilated or constricted Calls the dental office, complains of severe pain, and requests that a prescription for pain medication be given without making an appointment with the dentist Claiming to have lost a prescription or have had a prescription stolen Exaggerated symptoms Frequent visits to other doctors and the emergency room Does not seem interested in the actual diagnosis Unwilling or unable to provide medical records or contact information

Endorphin and encephalin

have opiate-like effects creating a sense of well-being.

Psychological dependence vs Physiological dependence

belief that the drug is needed to maintain a state of well being biological alteration in the user's brain from consistent drug use

Psychedelic drugs

confuse neurotransmitters by exaggerating or distorting messages. Creates visual and auditory images in the brain.

Tolerance

constantly needing to increase doses to reach desired effects

Binge drinking

consuming 5 or more standard drinks on the same occasion at least once within a 30-day time frame

Psychoactive drugs

disrupt the endogenous reward systems in the brain. Can be a desirable effect (to decrease pain sensation: Morphine) Substances primarily disrupt dopamine circuits Motivation, drive, conditioned learning, inhibitory controls

Illicit drugs

marijuana/hashish, cocaine, heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics used non-medically

Drug abuse

self administration of a drug in a manner that differs from its accepted medical use

Withdrawal

symptoms a person will experience after stopping a drug they developed a physiological dependence to Nausea, vomiting, sweating, diarrhea, tachycardia, anxiety, convulsions, severe cramps, hypertension, severe headache

Psychologically dependent addicts

used to cope with life, can never return to social use, exhibit tolerance, compulsive use, preoccupation, denial, loss of control, and they use it despite the consequences