Chapter 23: Substance Use Disorders Learning Objectives

Substance Use Disorders

Chapter 23

Learning Objectives
  • Define substance use disorder.
  • Identify central nervous system depressants commonly abused, including:
      - Patterns of abuse
      - Treatment methods
      - Adverse reactions
      - Management of overdose and withdrawal
      - Dental treatment implications
  • Identify central nervous system stimulants commonly abused.
  • Describe the abuse patterns, withdrawal, and treatment for tobacco use and summarize the role of the dental hygienist in tobacco cessation.
  • Discuss psychedelic hallucinogens and recognize symptoms from their use.
  • Discuss how dental hygienists can identify patients or colleagues abusing drugs.
What Does Addiction Look Like?
  • Substance abuse is prevalent in both legal and illegal drugs.
  • "Potential" patients may call dental offices complaining of pain and seeking prescriptions.
  • Employees in dental offices may also abuse drugs.
  • Substance abuse disorder has become an epidemic, especially among adolescents.
Fun Facts
  • Alcohol and tobacco account for more health problems than all other drugs combined.
  • Psychoactive substances have been used to affect mood and consciousness since the beginning of civilization.
  • Indigenous tribes in Colombia have a long history of chewing coca leaves.
  • Risk factors for higher potential for drug abuse include:
      - High potency
      - Rapid onset of action
      - Low cost
      - Easy distribution
  • Example: Crack cocaine highlights these risk factors.
Psychoactive Properties
  • These substances can change behavior or induce psychosis-like reactions.
  • There are two key categories based on therapeutic value:   - Therapeutic Value: Includes substances with medical applications such as opioids, sedatives, and certain psychedelics.   - No Therapeutic Value: Includes illicit drugs, such as cocaine and amphetamines.
Definitions
  • Abuse: Use of a substance for nonmedical purposes, typically to alter consciousness.
  • Misusing: Incorrect use of a drug, either in inappropriate dosages or durations.
  • Addiction: A chronic, relapsing brain disorder characterized by compulsive drug-seeking behavior despite adverse consequences.
  • Substance Use Disorders: Occur when recurrent substance use results in significant impairment, such as health problems or failure in responsibilities.
  • Enabling: The behavior of friends or family that perpetuates a loved one's substance use.
  • Relapse: The return to substance use after attempting to quit.
  • Tolerance: Need for increased dosage to achieve the same effect or diminished effect with the same dosage over time.
  • Withdrawal: A collection of symptoms, as defined in the DSM-5, that occur when a dependent individual stops using a substance.
Psychological and Physical Dependence
  • Psychological Dependence:   - A mental state believing that optimal performance cannot be achieved without the substance.   - Severity varies.   - Typically seen with drugs like benzodiazepines, opioids, and amphetamines.
  • Physical Dependence:   - An altered physiological state due to increased drug concentration.   - Established by withdrawal or abstinence syndrome.   - Symptoms may include diarrhea, lacrimation, and piloerection related to opioid withdrawal.
Addiction vs. Habituation
  • Both addiction and habituation involve a desire to continue using the drug.
  • Addiction includes dependence, while habituation can occur without significant physical or psychological consequences.
  • Drugs producing tolerance and dependence can often substitute one another (e.g., heroin and morphine).
Huffing
  • The process involves inhaling substances from a bag (e.g., paint).
  • Substance misuse can result in irreversible damage to the liver and brain.
  • Other methods may include sniffing glue or inhaling propellants.
CNS Depressants – Ethyl Alcohol
  • Alcohol abuse is the #1 public health problem in the U.S. with various health implications.
  • Alcohol has sedative properties and follows zero-order kinetics: a constant amount is metabolized irrespective of the amount consumed.
  • Food intake can delay absorption and reduce peak blood alcohol concentrations occurring within 40 minutes (on an empty stomach).
  • Alcohol is primarily absorbed in the gastrointestinal tract with excretion via lungs and urine.
Stages of Alcohol Intoxication
  • Mild Intoxication: Impaired judgment, emotional lability, nystagmus.
  • Moderate Intoxication: Dilated pupils, slurred speech, ataxia, staggering gait.
  • Severe Intoxication: Potential for seizures, coma, or death.
  • Treatment Options:
      - Fluids and electrolytes, vitamin B6 (thiamine), sodium bicarbonate, and magnesium.
  • An increased alcohol intake correlates with increased withdrawal severity.
Long-Term Effects of Alcohol Abuse
  • Cirrhosis of the Liver: Impaired vitamin K storage leading to diminished clotting ability and potential for elevated INR levels.
Alcohol Treatment Options
  • Alcoholics Anonymous (AA): Shows the most success among treatment options.
  • Inpatient Detoxification: Generally not required; outpatient psychiatric care can provide insight.
  • Drug Treatments:
      - Antabuse (disulfiram): Creates side effects if alcohol is consumed.   - ReVia (naltrexone): Reduces cravings for alcohol.   - Campral (acamprosate): Restores normal brain activity during withdrawal without causing sickness from alcohol consumption.
Dental Treatment of the Alcoholic Patient
  • Oral Complications: May include glossitis, loss of tongue papillae, angular/labial cheilosis, candida infections, poor healing, and difficulty clotting.
  • Treatment Considerations:
      - Alcoholics may look typical; modifications in treatment may be needed based on disease severity.   - Dentists and hygienists should conduct breath analyses, palpations of parotid glands, and monitor for poor oral hygiene.
Alcohol - Dental Considerations
  • Due to possible liver failure, patients may be unable to metabolize drugs, leading to increased bleeding risks.
  • Alcohol and tobacco significantly increase risks for oral squamous cell carcinoma.
  • Avoid aspirin and NSAIDs in these patients due to risks of gastrointestinal bleeding.
  • When treating a patient with GI bleeding, acetaminophen may be the safest analgesic at low doses, limited to 4g/24 hours.
CNS Depressants – Nitrous Oxide (N2O)
  • Commonly abused among dental professionals; available in tanks and as whipping cream propellant.
  • Abuse Effects: Psychological dependence; short-lived euphoric highs with risks of dizziness, slurred speech.
  • Adverse Reactions: Include dizziness, headache, tachycardia, hypotension, hallucinations; potential long-term effects may include chronic mental dysfunction, B12 deficiency, and fatal hypoxia from lack of oxygen.
CNS Depressants – Opioid Analgesics
  • Common abused opioids include:
      - Heroin
      - Methadone (Dolophine)
      - Morphine
      - Dilaudid (hydromorphone)
      - Demerol (meperidine)
      - Fentanyl
      - Oxycodone (Percodan, Oxycontin)
Reasons for Opioid Misuse
  • Opioid use may lead to feelings of complete satisfaction, mood elevation, and reducing fear and anxiety.
  • Known side effects include appetite suppression and diminished reflexes.
Management of Opioid Overdose and Withdrawal
  • Overdose Management:
      - Narcan (naloxone): Administer if respiratory depression and pinpoint pupils are observed.   - Methadone: Eases withdrawal symptoms and allows gradual reduction.   - Benzodiazepines or phenothiazines may be prescribed to reduce withdrawal tension.   - Maintenance Strategy: Gradual transition from methadone to long-acting opioid antagonists like naltrexone.
Dental Implications - Opioid Abusers
  • Pain management might require NSAID prescriptions due to high tolerances to opioids.
  • Be aware of the increased incidence of diseases transmitted through needles among opioid abusers, including Hepatitis B and HIV/AIDS.
  • Chronic pain may present both as dental-related issues (TMJ disorders) and can extend beyond typical dental treatment timelines.
CNS Depressants – Sedative-Hypnotics
  • Include drugs such as:   - Barbiturates
      - Alcohol
      - Miltown (meprobamate)
      - Benzodiazepines (e.g., Librium, Valium)
      - Nitrous Oxide
      - Chloral hydrate (knock-out drops)
      - Rohypnol (Roofies)
  • These are generally taken orally and commonly in combination with other drugs.
CNS Stimulants
  • Include several substances such as:   - Cocaine
      - Amphetamines (e.g., Desoxyn, Dexedrine, Ritalin)
      - Caffeine
      - Tobacco
Cocaine
  • Typically administered via sniffing, injecting, or smoking (crack form).
  • Cocaine elevates heart rate and blood pressure and may result in severe cardiac complications.
  • Life-threatening interactions occur with vasoconstrictors, possibly leading to arrhythmias.
Amphetamines
  • Include substances like methamphetamine and methylphenidate that lead to longer effects than cocaine.
  • Associated with increased energy, alertness, euphoria, mydriasis, and elevated vitals.
Crystal Meth and Bath Salts
  • Crystal Meth: A crystalized form of methamphetamine leading to severe oral health issues (xerostomia, bruxism, "meth mouth" with extensive decay).
  • Bath Salts: Synthetic derivatives causing severe adverse effects similar to cocaine.
Caffeine
  • The world’s most commonly used stimulant found in coffee, tea, and energy drinks.
  • Toxicity can manifest with withdrawal symptoms including headache, lethargy, and anxiety at doses as low as 300 mg.
Tobacco - Nicotine
  • Approximately 26% of Americans over 12 smoke; nicotine leads to higher BP, pulse rates, and is linked with various oral health challenges.
  • Smokeless Tobacco: Includes forms like chewing tobacco and snuff, leading to oral mucosal changes including gingivitis and precancerous lesions.
Electronic Cigarettes
  • Devices delivering nicotine in aerosol form; marketed as safer alternatives to cigarette smoking but still involve health risks.
Management and Withdrawal - Nicotine
  • Various cessation methods such as nicotine gum (Nicorette), nasal sprays, patches, and prescription medications (Zyban, Chantix) may assist in quitting.
  • Precautions: Some methods have significant risks, including neuropsychiatric events from Chantix.
Psychedelics (Hallucinogens)
  • Used to induce altered states of perception with no established medical use.
  • Examples include LSD, PCP, DMT, MDMA (Ecstasy), and peyote, which heighten sensory inputs.
Marijuana
  • The most widely used drug after alcohol and tobacco in the U.S.; primarily contains THC as the psychoactive component.
  • Medical marijuana has applications in various conditions (glaucoma, nausea, appetite stimulation).
  • Synthetic alternatives: Recently gained popularity as legal alternatives marketed as “safe”.