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Chapter 25:Chapter 25:
Drug AbuseDrug Abuse
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
22Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Chapter 25 OutlineChapter 25 Outline Drug abuseDrug abuse
General considerationsGeneral considerations• DefinitionsDefinitions
• Psychologic dependencePsychologic dependence
• Physical dependencePhysical dependence
• ToleranceTolerance
• Addiction, habituation, and dependenceAddiction, habituation, and dependence
Central nervous system (CNS) depressantsCentral nervous system (CNS) depressants• Ethyl alcoholEthyl alcohol
• Nitrous oxideNitrous oxide
• Opioid analgesicsOpioid analgesics
• Sedative-hypnoticsSedative-hypnoticscont’d…cont’d…
33Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Chapter 25 OutlineChapter 25 Outline Drug abuseDrug abuse
CNS stimulantsCNS stimulants• CocaineCocaine
• AmphetaminesAmphetamines
• CaffeineCaffeine
• TobaccoTobacco
Psychedelics (hallucinogens)Psychedelics (hallucinogens)• Lysergic acid diethylamideLysergic acid diethylamide
• PhencyclidinePhencyclidine
• MarijuanaMarijuana
Identifying the drug abuserIdentifying the drug abuser The impaired dental health care workerThe impaired dental health care worker
44Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Drug AbuseDrug Abuse
Haveles (pp. 308-309)Haveles (pp. 308-309) Dental health care workers may become Dental health care workers may become
involved with drug abuse in a variety of waysinvolved with drug abuse in a variety of ways They should become familiar with the various They should become familiar with the various
types of drugs commonly abused and their types of drugs commonly abused and their patterns of abusepatterns of abuse
Alcohol and tobacco abuse causes more medical Alcohol and tobacco abuse causes more medical problems than all of the other drugs of abuse problems than all of the other drugs of abuse combinedcombined
cont’d…cont’d…
55Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Drug AbuseDrug Abuse
The idea of using drugs to produce profound The idea of using drugs to produce profound effects on mood, thought, and feeling is as effects on mood, thought, and feeling is as old as civilizationold as civilization The forms of drugs used today are much stronger The forms of drugs used today are much stronger
and have a much faster onset of actionand have a much faster onset of action This quick reinforcement produces abuse more This quick reinforcement produces abuse more
quickly quickly
cont’d…cont’d…
66Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Drug AbuseDrug Abuse
Agents used for their psychoactive properties Agents used for their psychoactive properties can be divided into those that have can be divided into those that have therapeutic value and those that have no therapeutic value and those that have no proven therapeutic valueproven therapeutic value Some agents may move from one category to Some agents may move from one category to
anotheranother Marijuana, previously considered to be worthless, Marijuana, previously considered to be worthless,
is now claimed to be useful in the treatment of is now claimed to be useful in the treatment of nausea associated with cancer chemotherapy and nausea associated with cancer chemotherapy and for glaucomafor glaucoma
77Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
General ConsiderationsGeneral Considerations
Haveles (pp. 309-310)Haveles (pp. 309-310) DefinitionsDefinitions Psychologic dependencePsychologic dependence Physical dependencePhysical dependence ToleranceTolerance Addiction, habituation, and dependenceAddiction, habituation, and dependence
cont’d…cont’d…
88Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
General ConsiderationsGeneral Considerations
Haveles (p. 309)Haveles (p. 309) Abuse of a drug is defined as the use of a drug Abuse of a drug is defined as the use of a drug
for nonmedical purposes, almost always for for nonmedical purposes, almost always for altering consciousnessaltering consciousness Both legitimate and illegitimate drugs may be abusedBoth legitimate and illegitimate drugs may be abused
Misuse of a drug means using the drug in the Misuse of a drug means using the drug in the wrong dose or for a longer period than wrong dose or for a longer period than prescribed prescribed
99Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
DefinitionsDefinitions
Haveles (p. 309)Haveles (p. 309) Abstinence syndromeAbstinence syndrome
A state of being free of drugs, which is the goal of any A state of being free of drugs, which is the goal of any treatment programtreatment program
AddictionAddiction This vague term should be replaced with dependenceThis vague term should be replaced with dependence The pattern of abuse that includes compulsive use The pattern of abuse that includes compulsive use
despite complications and frequent relapses after despite complications and frequent relapses after “quitting”“quitting”
cont’d…cont’d…
1010Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
DefinitionsDefinitions
DependenceDependence A combination of either physical or psychologic A combination of either physical or psychologic
manifestations occurring in a drug-dependent manifestations occurring in a drug-dependent person when the drug is removedperson when the drug is removed
Drug abuseDrug abuse Self-administration of a drug in a socially Self-administration of a drug in a socially
unacceptable manner, resulting in negative unacceptable manner, resulting in negative consequencesconsequences
cont’d…cont’d…
1111Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
DefinitionsDefinitions
Drug dependenceDrug dependence A state, which may be physical, psychologic, or A state, which may be physical, psychologic, or
both, that occurs as a consequence of the both, that occurs as a consequence of the interaction between a drug and a patientinteraction between a drug and a patient
Characterized by a compulsion to take the drug to Characterized by a compulsion to take the drug to obtain its effects or to prevent the abstinence obtain its effects or to prevent the abstinence syndromesyndrome
EnablingEnabling The behavior of family or friends that associate The behavior of family or friends that associate
with the addict that results in continued drug abusewith the addict that results in continued drug abuse
cont’d…cont’d…
1212Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
DefinitionsDefinitions
HabituationHabituation Physiologic tolerance to or psychologic dependence Physiologic tolerance to or psychologic dependence
on a drug, short of addictionon a drug, short of addiction Physical/physiologic dependencePhysical/physiologic dependence
The state in which the drug is necessary for continued The state in which the drug is necessary for continued functioning of certain body processesfunctioning of certain body processes
Psychologic dependencePsychologic dependence The state in which, after withdrawal of the drug, The state in which, after withdrawal of the drug,
manifestations of emotional abnormalities and drug-manifestations of emotional abnormalities and drug-seeking behavior occurseeking behavior occur
cont’d…cont’d…
1313Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
DefinitionsDefinitions
ToleranceTolerance With repeated dosing, the dose of a drug must be With repeated dosing, the dose of a drug must be
increased to produce the same effect, orincreased to produce the same effect, or The same dose of a drug produces less effect with The same dose of a drug produces less effect with
consecutive dosingconsecutive dosing WithdrawalWithdrawal
The constellation of symptoms that occurs when a The constellation of symptoms that occurs when a physically dependent person stops taking the drugphysically dependent person stops taking the drug
1414Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Psychologic DependencePsychologic Dependence
Haveles (p. 309)Haveles (p. 309) A state of mind in which a person believes A state of mind in which a person believes
that he or she is unable to maintain optimal that he or she is unable to maintain optimal performance without having taken the drugperformance without having taken the drug Although some highly abused drugs have only Although some highly abused drugs have only
psychologic dependence, the “need” to use these psychologic dependence, the “need” to use these drugs can be as strong or stronger than drugs with drugs can be as strong or stronger than drugs with a physical dependencea physical dependence
1515Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Physical DependencePhysical Dependence
Haveles (p. 309)Haveles (p. 309) The altered physiologic state that results from The altered physiologic state that results from
constantly increasing drug concentrationsconstantly increasing drug concentrations The presence of physical dependence is established The presence of physical dependence is established
by the withdrawal or abstinence syndromeby the withdrawal or abstinence syndrome Withdrawal symptoms are often the opposite of Withdrawal symptoms are often the opposite of
the symptoms of use of the drugthe symptoms of use of the drug
1616Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
ToleranceTolerance
Haveles (p. 309)Haveles (p. 309) Characterized by the need to increase the Characterized by the need to increase the
dose continually to achieve the desired effect dose continually to achieve the desired effect or the giving of the same dose, which or the giving of the same dose, which produces a diminishing effectproduces a diminishing effect Central tolerance is a definite decrease in the Central tolerance is a definite decrease in the
response of brain tissue to constantly increasing response of brain tissue to constantly increasing amounts of the drugamounts of the drug
1717Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Addiction, Habituation, and Addiction, Habituation, and DependenceDependence
Haveles (pp. 309-310)Haveles (pp. 309-310) The desire to continue using the drug is The desire to continue using the drug is
present in both addiction and habituation, but present in both addiction and habituation, but dependence is also present in addictiondependence is also present in addiction Habituation and dependence are really only Habituation and dependence are really only
degrees of misuse or abuse of drugsdegrees of misuse or abuse of drugs Experts recommend that these terms be replaced Experts recommend that these terms be replaced
by dependence, a state of psychologic or physical by dependence, a state of psychologic or physical desire to use a drugdesire to use a drug
cont’d…cont’d…
1818Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Addiction, Habituation, and Addiction, Habituation, and DependenceDependence
Haveles (pp. 309-310)Haveles (pp. 309-310) Drugs that produce tolerance and physical Drugs that produce tolerance and physical
dependence are grouped according to their dependence are grouped according to their ability to be substituted for one anotherability to be substituted for one another The phenomenon of substitution to suppress The phenomenon of substitution to suppress
withdrawal between different drugs is called cross-withdrawal between different drugs is called cross-tolerance or cross-dependence tolerance or cross-dependence
cont’d…cont’d…
1919Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Addiction, Habituation, and Addiction, Habituation, and DependenceDependence
Approximately 80% of incarcerated Approximately 80% of incarcerated individuals are there because of drug abuse individuals are there because of drug abuse problemsproblems Problems and treatment are less related to the Problems and treatment are less related to the
drugs themselves than to the “inner person” of the drugs themselves than to the “inner person” of the patient involved in this type of behavior and his or patient involved in this type of behavior and his or her genetic predispositionher genetic predisposition
cont’d…cont’d…
2020Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Addiction, Habituation, and Addiction, Habituation, and DependenceDependence
Haveles (p. 310)Haveles (p. 310) Abusable drugs are divided intoAbusable drugs are divided into
CNS depressantsCNS depressants CNS stimulantsCNS stimulants HallucinogensHallucinogens
Some drugs may fall in more than one groupSome drugs may fall in more than one group
2121Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Central Nervous System Central Nervous System DepressantsDepressants
Haveles (pp. 310-316)Haveles (pp. 310-316) Include alcohol, opioids, barbiturates, Include alcohol, opioids, barbiturates,
benzodiazepines, volatile solvents, and benzodiazepines, volatile solvents, and nitrous oxidenitrous oxide
2222Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Ethyl AlcoholEthyl Alcohol
Haveles (pp. 310-313)Haveles (pp. 310-313) The most often abused drugThe most often abused drug
Alcoholism is the number one public health problem Alcoholism is the number one public health problem in the United States in the United States
The incidence of alcoholism in the United States is The incidence of alcoholism in the United States is about 10%about 10%
2323Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Pharmacokinetics of Ethyl Pharmacokinetics of Ethyl AlcoholAlcohol
Haveles (p. 310) (Fig. 25-1)Haveles (p. 310) (Fig. 25-1) Ethyl alcohol is rapidly and completely absorbed Ethyl alcohol is rapidly and completely absorbed
from the gastrointestinal tractfrom the gastrointestinal tract Peak levels while fasting occur in less than 40 minutesPeak levels while fasting occur in less than 40 minutes Food delays absorption and reduces the peak levels Food delays absorption and reduces the peak levels
Metabolism follows zero-order kinetics; thus a Metabolism follows zero-order kinetics; thus a constant amount is metabolized per unit of time, constant amount is metabolized per unit of time, regardless of the amount ingestedregardless of the amount ingested
2424Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Acute Intoxication of Ethyl Acute Intoxication of Ethyl AlcoholAlcohol
Haveles (p. 310)Haveles (p. 310) Impairment of judgment, emotional lability, and Impairment of judgment, emotional lability, and
nystagmus occur with mild intoxicationnystagmus occur with mild intoxication Dilated pupils, slurred speech, ataxia, and a Dilated pupils, slurred speech, ataxia, and a
staggering gait are noted with moderate intoxicationstaggering gait are noted with moderate intoxication Seizures, coma, and death can occur if intoxication Seizures, coma, and death can occur if intoxication
is severeis severe Treatment includes fluids and electrolytes, Treatment includes fluids and electrolytes,
thiamine (vitamin Bthiamine (vitamin B66), sodium bicarbonate, and ), sodium bicarbonate, and
magnesiummagnesium
2525Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Withdrawal from Ethyl AlcoholWithdrawal from Ethyl Alcohol
Haveles (pp. 310-311)Haveles (pp. 310-311) Stage 1 usually begins 6 to 8 hours after Stage 1 usually begins 6 to 8 hours after
drinking has stopped and includes withdrawal, drinking has stopped and includes withdrawal, psychomotor agitation, and autonomic nervous psychomotor agitation, and autonomic nervous system hyperactivitysystem hyperactivity
Stage 2 withdrawal includes hallucinations, Stage 2 withdrawal includes hallucinations, paranoid behavior, and amnesiaparanoid behavior, and amnesia
Stage 3 includes disorientation, delusions, and Stage 3 includes disorientation, delusions, and grand mal seizuresgrand mal seizures
cont’d…cont’d…
2626Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Withdrawal from Ethyl AlcoholWithdrawal from Ethyl Alcohol
A cross-tolerant benzodiazepine may be used A cross-tolerant benzodiazepine may be used to prevent withdrawal symptomsto prevent withdrawal symptoms Withdrawal is termed delirium tremens (DTs) Withdrawal is termed delirium tremens (DTs)
because the patient will often experience shaky because the patient will often experience shaky movementsmovements
2727Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Chronic Effects of Ethyl AlcoholChronic Effects of Ethyl Alcohol
Haveles (p. 311)Haveles (p. 311) Chronic medical effects include deficiency of Chronic medical effects include deficiency of
proteins, minerals, and water-soluble vitaminsproteins, minerals, and water-soluble vitamins Fetal alcohol syndrome can occur if a pregnant Fetal alcohol syndrome can occur if a pregnant
woman is using ethanol chronicallywoman is using ethanol chronically More severe cases include cardiac abnormalities and More severe cases include cardiac abnormalities and
mental retardationmental retardation Chronic alcohol use increases the risk of cancer Chronic alcohol use increases the risk of cancer
of the mouth, pharynx, larynx, esophagus, and of the mouth, pharynx, larynx, esophagus, and liverliver
2828Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
AlcoholismAlcoholism
Haveles (pp. 311-312) (Box 25-1)Haveles (pp. 311-312) (Box 25-1) A disease in which the alcoholic continues to A disease in which the alcoholic continues to
drink despite the knowledge that drinking is drink despite the knowledge that drinking is producing a variety of problemsproducing a variety of problems A genetic link for alcoholism existsA genetic link for alcoholism exists ““Red flags” include drinking at an inappropriately Red flags” include drinking at an inappropriately
early time, shaking when not drinking, blackouts early time, shaking when not drinking, blackouts when drinking, and being told that you drink too when drinking, and being told that you drink too muchmuch
2929Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Treatment of AlcoholismTreatment of Alcoholism
Haveles (p. 312)Haveles (p. 312) Alcoholics anonymousAlcoholics anonymous
A self-help organization made up of recovering A self-help organization made up of recovering alcoholicsalcoholics
Members give support to alcoholics who are Members give support to alcoholics who are attempting recoveryattempting recovery
Outpatient psychiatric treatment can help provide Outpatient psychiatric treatment can help provide some insight for alcoholicssome insight for alcoholics
cont’d…cont’d…
3030Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Treatment of AlcoholismTreatment of Alcoholism
Haveles (p. 312)Haveles (p. 312) Drug treatmentDrug treatment
Alcoholics who are motivated and socially stable Alcoholics who are motivated and socially stable can be given disulfiram can be given disulfiram • A buildup of acetaldehyde occurs because disulfiram A buildup of acetaldehyde occurs because disulfiram
inhibits the metabolism of aldehyde dehydrogenaseinhibits the metabolism of aldehyde dehydrogenase
• Acetaldehyde produces significant side effects if alcohol Acetaldehyde produces significant side effects if alcohol is ingestedis ingested
• These effects include vasodilation, flushing, tachycardia, These effects include vasodilation, flushing, tachycardia, dyspnea, throbbing headache, vomiting, and thirstdyspnea, throbbing headache, vomiting, and thirst
cont’d…cont’d…
3131Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Treatment of AlcoholismTreatment of Alcoholism
Naltrexone was originally used to prevent Naltrexone was originally used to prevent relapse in the opioid-dependent patientrelapse in the opioid-dependent patient Its new use is to reduce alcohol cravingIts new use is to reduce alcohol craving
More detailed knowledge of the receptors More detailed knowledge of the receptors affected by alcohol may increase the chance affected by alcohol may increase the chance of developing other agents to manage this of developing other agents to manage this diseasedisease
3232Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Dental Treatment of the Alcoholic Dental Treatment of the Alcoholic PatientPatient
Haveles (pp. 312-313) (Fig. 25-3)Haveles (pp. 312-313) (Fig. 25-3) Dental treatment of the alcoholic patient Dental treatment of the alcoholic patient
includes some modificationsincludes some modifications Most alcoholic patients have poor oral hygieneMost alcoholic patients have poor oral hygiene Check for sweet musty breath and painless bilateral Check for sweet musty breath and painless bilateral
hypertrophy of parotid glandshypertrophy of parotid glands Cirrhosis of the liver can occur when alcoholics Cirrhosis of the liver can occur when alcoholics
continue to abuse alcohol continue to abuse alcohol
cont’d…cont’d…
3333Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Dental Treatment of the Alcoholic Dental Treatment of the Alcoholic PatientPatient
The liver is able to store less vitamin K, and The liver is able to store less vitamin K, and conversion of vitamin K to the coagulation factors conversion of vitamin K to the coagulation factors is reduced because of hepatic failureis reduced because of hepatic failure The outcome of these effects is a deficiency in The outcome of these effects is a deficiency in
coagulation factors II, VII, IX, and X, with resulting coagulation factors II, VII, IX, and X, with resulting bleeding tendenciesbleeding tendencies
The patient’s international normalized ratio (INR) The patient’s international normalized ratio (INR) can be elevatedcan be elevated
Thrombocytopenia secondary to portal Thrombocytopenia secondary to portal hypertension and bone marrow depression hypertension and bone marrow depression magnifies the hemostatic deficiencymagnifies the hemostatic deficiency
Spontaneous bleeding can occur due to the Spontaneous bleeding can occur due to the presence of esophageal varices presence of esophageal varices
cont’d…cont’d…
3434Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Dental Treatment of the Alcoholic Dental Treatment of the Alcoholic PatientPatient
Haveles (p. 313) (Box 25-2; Table 25-2)Haveles (p. 313) (Box 25-2; Table 25-2) Oral complications include glossitis, loss of Oral complications include glossitis, loss of
tongue papillae, angular/labial cheilosis, and tongue papillae, angular/labial cheilosis, and Candida Candida infectioninfection
The dental health care worker should check The dental health care worker should check any oral lesions carefully because alcohol any oral lesions carefully because alcohol and tobacco use and abuse predispose a and tobacco use and abuse predispose a patient to oral squamous cell carcinomapatient to oral squamous cell carcinoma
Dose reductions may be necessary because Dose reductions may be necessary because of diminished liver functionof diminished liver function
3535Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Nitrous OxideNitrous Oxide
Haveles (p. 314)Haveles (p. 314) Nitrous oxide is an incomplete general Nitrous oxide is an incomplete general
anesthetic readily available in many dental anesthetic readily available in many dental officesoffices It is abused primarily by dentists, dental It is abused primarily by dentists, dental
hygienists, and dental assistantshygienists, and dental assistants
3636Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Abuse Pattern of Nitrous OxideAbuse Pattern of Nitrous Oxide
Haveles (p. 314) (Fig. 25-4)Haveles (p. 314) (Fig. 25-4) Abuse can result in psychologic but not Abuse can result in psychologic but not
physical dependencephysical dependence Inhalation of 50% to 75% produces a “high” for Inhalation of 50% to 75% produces a “high” for
30 seconds followed by a sense of euphoria and 30 seconds followed by a sense of euphoria and detachment for 2 to 3 minutesdetachment for 2 to 3 minutes
Tingling or warmth around the face, auditory Tingling or warmth around the face, auditory illusions, slurred speech, and a stumbling gait illusions, slurred speech, and a stumbling gait can occurcan occur
3737Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Adverse Reactions of Nitrous Adverse Reactions of Nitrous OxideOxide
Haveles (p. 314)Haveles (p. 314) GeneralGeneral
Adverse reactions include dizziness, headache, Adverse reactions include dizziness, headache, tachycardia, syncope, and hypotensiontachycardia, syncope, and hypotension
Nitrous oxide impairs the ability to drive or operate Nitrous oxide impairs the ability to drive or operate heavy machineryheavy machinery
Can produce chronic mental dysfunction and Can produce chronic mental dysfunction and infertility with chronic useinfertility with chronic use
cont’d…cont’d…
3838Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Adverse Reactions of Nitrous Adverse Reactions of Nitrous OxideOxide
Haveles (p. 314)Haveles (p. 314) MyeloneuropathyMyeloneuropathy
Chronic use or abuse of nitrous oxide can lead to Chronic use or abuse of nitrous oxide can lead to myelopathy, resulting in a combination of myelopathy, resulting in a combination of symptoms pathognomonic for nitrous oxide abusesymptoms pathognomonic for nitrous oxide abuse• Initial symptoms include loss of finger dexterity and Initial symptoms include loss of finger dexterity and
numbness or paresthesia of the extremitiesnumbness or paresthesia of the extremities
• Later, Lhermitte sign, clumsiness, and weakness can be Later, Lhermitte sign, clumsiness, and weakness can be demonstrateddemonstrated
Neurologic deficiencies include extensor plantar reflex and Neurologic deficiencies include extensor plantar reflex and polyneuropathypolyneuropathy
The neurologic deficiency is similar to that of spinal cord The neurologic deficiency is similar to that of spinal cord degeneration in pernicious anemiadegeneration in pernicious anemia
3939Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Opioid AnalgesicsOpioid Analgesics
Haveles (pp. 314-315)Haveles (pp. 314-315) Heroin, methadone, morphine, Heroin, methadone, morphine,
hydromorphone, meperidine, oxycodone, and hydromorphone, meperidine, oxycodone, and oxycodone sustained release are currently oxycodone sustained release are currently the most popular abused opioidsthe most popular abused opioids In addition to being analgesics, opioids produce a In addition to being analgesics, opioids produce a
state described as complete satiation of all drives state described as complete satiation of all drives in some peoplein some people
The driving motivation to obtain the drug The driving motivation to obtain the drug becomes more and more negative with the becomes more and more negative with the development of physical dependencedevelopment of physical dependence
4040Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Pattern of AbusePattern of Abuse
Haveles (p. 314)Haveles (p. 314) Heroin is the most commonly administered Heroin is the most commonly administered
parenteral opioidparenteral opioid The signs and symptoms of an acute overdose are The signs and symptoms of an acute overdose are
fixed, pinpoint pupils, depressed respiration, fixed, pinpoint pupils, depressed respiration, hypotension and shock, slow or absent reflexes, and hypotension and shock, slow or absent reflexes, and drowsiness or comadrowsiness or coma
Tolerance develops to most of the pharmacologic Tolerance develops to most of the pharmacologic effects but does not develop to miosis or effects but does not develop to miosis or constipationconstipation
cont’d…cont’d…
4141Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Pattern of AbusePattern of Abuse
The symptoms and time course of the The symptoms and time course of the withdrawal syndrome are determined by the withdrawal syndrome are determined by the specific drug abused and the dose of the drugspecific drug abused and the dose of the drug The first signs of withdrawal from heroin are The first signs of withdrawal from heroin are
yawning, lacrimation, rhinorrhea, and diaphoresis, yawning, lacrimation, rhinorrhea, and diaphoresis, followed by a restless sleepfollowed by a restless sleep
Anorexia, tremors, irritability, weakness, and Anorexia, tremors, irritability, weakness, and excessive gastrointestinal activity occur with excessive gastrointestinal activity occur with further abstinencefurther abstinence
4242Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Management of Acute Overdose Management of Acute Overdose and Withdrawaland Withdrawal
Haveles (pp. 314-315)Haveles (pp. 314-315) Naloxone should be administered Naloxone should be administered
immediately if the triad of narcotic overdose immediately if the triad of narcotic overdose (respiratory depression, pinpoint pupils, and (respiratory depression, pinpoint pupils, and coma) is presentcoma) is present Patients in withdrawal can be made comfortable Patients in withdrawal can be made comfortable
with methadone, a long-acting opioid that can with methadone, a long-acting opioid that can replace heroin and then be gradually withdrawnreplace heroin and then be gradually withdrawn
4343Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Dental ImplicationsDental Implications
Haveles (p. 315)Haveles (p. 315) Pain controlPain control
Because an opioid abuser develops tolerance to Because an opioid abuser develops tolerance to the analgesic effects of any opioid, treating the analgesic effects of any opioid, treating patients with opioids is ineffective and can cause a patients with opioids is ineffective and can cause a recovering addict to begin using opioids againrecovering addict to begin using opioids again
Best to alleviate the cause of the pain and then Best to alleviate the cause of the pain and then prescribe nonsteroidal antiinflammatory drugsprescribe nonsteroidal antiinflammatory drugs
cont’d…cont’d…
4444Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Dental ImplicationsDental Implications
Haveles (p. 315)Haveles (p. 315) Prescriptions for opioidsPrescriptions for opioids
Abusers often come to the dental office requesting Abusers often come to the dental office requesting an opioid for severe painan opioid for severe pain
Increased incidence of diseaseIncreased incidence of disease Certain diseases that can be transmitted by the Certain diseases that can be transmitted by the
use of needles for injections have a higher use of needles for injections have a higher incidence in opioid abusers incidence in opioid abusers
Chronic painChronic pain Patients who have pain for a much longer time Patients who have pain for a much longer time
than normal deserve a workup for chronic painthan normal deserve a workup for chronic pain
4545Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Opioid Street DrugsOpioid Street Drugs
Haveles (p. 315)Haveles (p. 315) Opioids available on the street change with Opioids available on the street change with
time and are different in different parts of the time and are different in different parts of the countrycountry The dental health care worker should be aware The dental health care worker should be aware
that most drug abusers misuse more than one that most drug abusers misuse more than one substance and that street drugs are often substance and that street drugs are often adulteratedadulterated
4646Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Sedative-HypnoticsSedative-Hypnotics
Haveles (pp. 315-316)Haveles (pp. 315-316) Sedative-hypnotics include barbiturates, Sedative-hypnotics include barbiturates,
alcohol, meprobamate, methaqualone, chloral alcohol, meprobamate, methaqualone, chloral hydrate, benzodiazepines, and nitrous oxidehydrate, benzodiazepines, and nitrous oxide Initial symptoms resemble the well-known Initial symptoms resemble the well-known
symptoms of alcohol intoxicationsymptoms of alcohol intoxication Drowsiness and sleep occur with increasing Drowsiness and sleep occur with increasing
doses, respiration is depressed, cardiac output is doses, respiration is depressed, cardiac output is decreased, and gastrointestinal activity and urine decreased, and gastrointestinal activity and urine output is diminishedoutput is diminished
4747Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Pattern of Abuse of Sedative-Pattern of Abuse of Sedative-HypnoticsHypnotics
Haveles (pp. 315-316)Haveles (pp. 315-316) CNS depressant drugs are generally taken CNS depressant drugs are generally taken
orallyorally Respiratory and cardiovascular depression occur Respiratory and cardiovascular depression occur
with an acute overdose, leading to coma and with an acute overdose, leading to coma and hypotensionhypotension
The pupils may be unchanged or small, and lateral The pupils may be unchanged or small, and lateral nystagmus is seennystagmus is seen
Confusion, slurred speech, and ataxia are always Confusion, slurred speech, and ataxia are always presentpresent
cont’d…cont’d…
4848Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Pattern of Abuse of Sedative-Pattern of Abuse of Sedative-HypnoticsHypnotics
Haveles (pp. 315-316)Haveles (pp. 315-316) The first signs of withdrawal are insomnia, The first signs of withdrawal are insomnia,
weakness, tremulousness, restlessness, and weakness, tremulousness, restlessness, and perspirationperspiration Delirium and convulsions may culminate in Delirium and convulsions may culminate in
cardiovascular collapse and loss of the cardiovascular collapse and loss of the temperature-regulating mechanismtemperature-regulating mechanism
Another troubling abuse of sedative-hypnotics Another troubling abuse of sedative-hypnotics involves administering them to other people involves administering them to other people to control them to control them
4949Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Management of Acute Overdose and Management of Acute Overdose and Withdrawal of Sedative-HypnoticsWithdrawal of Sedative-Hypnotics
Haveles (p. 316)Haveles (p. 316) The most important consideration with an The most important consideration with an
acute overdose of a CNS depressant is acute overdose of a CNS depressant is support of the cardiovascular and respiratory support of the cardiovascular and respiratory systemssystems Withdrawal from CNS depressants can be life Withdrawal from CNS depressants can be life
threatening, and the patient should be hospitalizedthreatening, and the patient should be hospitalized A long-acting benzodiazepine is usually A long-acting benzodiazepine is usually
substituted for the abused drug and then gradually substituted for the abused drug and then gradually withdrawn over a periodwithdrawn over a period
5050Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Central Nervous System Central Nervous System StimulantsStimulants
Haveles (pp. 316-318)Haveles (pp. 316-318) CocaineCocaine AmphetaminesAmphetamines CaffeineCaffeine TobaccoTobacco
5151Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
CocaineCocaine
Haveles (p. 316)Haveles (p. 316) Cocaine is a CNS stimulant with local Cocaine is a CNS stimulant with local
anesthetic properties when applied topicallyanesthetic properties when applied topically Cocaine induces intense euphoria, a sense of total Cocaine induces intense euphoria, a sense of total
self-confidence, and anorexiaself-confidence, and anorexia Paranoia and extreme excitability cause some Paranoia and extreme excitability cause some
cocaine users to perform violent acts while under its cocaine users to perform violent acts while under its influenceinfluence
Psychologic dependence becomes intense, but Psychologic dependence becomes intense, but neither tolerance nor withdrawal has been shownneither tolerance nor withdrawal has been shown
5252Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
AmphetaminesAmphetamines Haveles (p. 316)Haveles (p. 316)
Pattern of abusePattern of abuse Sympathomimetic CNS stimulants are abused for Sympathomimetic CNS stimulants are abused for
their ability to produce a euphoric mood, a sense of their ability to produce a euphoric mood, a sense of increased energy and alertness, and a feeling of increased energy and alertness, and a feeling of omnipotence and self-confidenceomnipotence and self-confidence
With prolonged use, tolerance to the euphorigenic With prolonged use, tolerance to the euphorigenic effect develops, and toxic symptoms appeareffect develops, and toxic symptoms appear
Signs and symptoms of an acute overdose include Signs and symptoms of an acute overdose include dilated pupils, elevated blood pressure, rapid pulse, dilated pupils, elevated blood pressure, rapid pulse, and cardiac arrhythmiasand cardiac arrhythmias
cont’d…cont’d…
5353Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
AmphetaminesAmphetamines
Haveles (p. 316)Haveles (p. 316) Management of acute overdose and Management of acute overdose and
withdrawalwithdrawal Treatment of an overdose of a CNS stimulant is Treatment of an overdose of a CNS stimulant is
symptomaticsymptomatic• The most serious sociologic problem with stimulant The most serious sociologic problem with stimulant
abuse is the induction of mental abnormalitiesabuse is the induction of mental abnormalities
• Experimental evidence suggests that amphetamine Experimental evidence suggests that amphetamine psychoses can be induced in previously unaffected psychoses can be induced in previously unaffected volunteer subjectsvolunteer subjects
5454Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
CaffeineCaffeine
Haveles (p. 317) (Table 25-3)Haveles (p. 317) (Table 25-3) Caffeine stimulates the CNSCaffeine stimulates the CNS
Toxicity can occur with as little as 300 mg of Toxicity can occur with as little as 300 mg of caffeine contained in two or three cups of coffeecaffeine contained in two or three cups of coffee
A withdrawal syndrome can be identified that A withdrawal syndrome can be identified that begins around 24 hours after the last cup of coffeebegins around 24 hours after the last cup of coffee• Symptoms consists of headache, lethargy, irritability, and Symptoms consists of headache, lethargy, irritability, and
anxiety anxiety
5555Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
TobaccoTobacco
Haveles (pp. 317-318)Haveles (pp. 317-318) NicotineNicotine
The CNS active component of tobacco is nicotineThe CNS active component of tobacco is nicotine A large number of components of the gaseous A large number of components of the gaseous
phase of tobacco smoke contributes to its phase of tobacco smoke contributes to its undesirable effectsundesirable effects
These components include carbon monoxide, These components include carbon monoxide, nitrogen oxides, volatile nitrosamines, hydrogen nitrogen oxides, volatile nitrosamines, hydrogen cyanide, volatile hydrocarbons, and many other cyanide, volatile hydrocarbons, and many other substancessubstances
cont’d…cont’d…
5656Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
TobaccoTobacco
Haveles (p. 317)Haveles (p. 317) Pattern of AbusePattern of Abuse
Approximately 25% of the adult American Approximately 25% of the adult American population smokespopulation smokes• Children commonly begin smoking between 11 and 14 Children commonly begin smoking between 11 and 14
years of ageyears of age
Chronic use of tobacco is causally related to many Chronic use of tobacco is causally related to many serious diseases, including coronary artery serious diseases, including coronary artery disease and oral and lung cancersdisease and oral and lung cancers
cont’d…cont’d…
5757Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
TobaccoTobacco
Haveles (p. 317)Haveles (p. 317) Smokeless tobaccoSmokeless tobacco
More than one quarter of high school boys use More than one quarter of high school boys use chewing tobacco in some communitieschewing tobacco in some communities
Oral mucosal changes include chronic gingivitis, Oral mucosal changes include chronic gingivitis, leukoplakia, and precancerous lesionsleukoplakia, and precancerous lesions
cont’d…cont’d…
5858Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
TobaccoTobacco
Haveles (p. 317) (Table 25-4)Haveles (p. 317) (Table 25-4) Management and withdrawalManagement and withdrawal
The withdrawal syndrome that occurs after The withdrawal syndrome that occurs after cessation of chronic tobacco smoking varies greatly cessation of chronic tobacco smoking varies greatly from person to personfrom person to person• The most consistent symptoms are anxiety, irritability, The most consistent symptoms are anxiety, irritability,
difficulty in concentrating, and cravings for cigarettesdifficulty in concentrating, and cravings for cigarettes
The syndrome of withdrawal from tobacco can be The syndrome of withdrawal from tobacco can be suppressed to some extent by administration of suppressed to some extent by administration of nicotine chewing gum or nicotine patchesnicotine chewing gum or nicotine patches
cont’d…cont’d…
5959Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
TobaccoTobacco
Haveles (p. 317)Haveles (p. 317) BupropionBupropion
Another approach to treating tobacco cessation Another approach to treating tobacco cessation involves the use of bupropion, an antidepressant, involves the use of bupropion, an antidepressant, to reduce cravingto reduce craving
cont’d…cont’d…
6060Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
TobaccoTobacco
Haveles (p. 318)Haveles (p. 318) VareniclineVarenicline
Varenicline is a nicotine-receptor blocker that binds Varenicline is a nicotine-receptor blocker that binds to the nicotine receptor and prevents the nicotine to the nicotine receptor and prevents the nicotine from tobacco from reaching its receptor sitefrom tobacco from reaching its receptor site
By binding to the receptor, varenicline limits the By binding to the receptor, varenicline limits the amount of dopamine that is released in the brainamount of dopamine that is released in the brain
The most common side effects include nausea, The most common side effects include nausea, sleep problems, constipation, gas, vomiting, and sleep problems, constipation, gas, vomiting, and changes in mood and behaviorchanges in mood and behavior
cont’d…cont’d…
6161Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
TobaccoTobacco
Haveles (p. 318)Haveles (p. 318) The dental health care worker’s role in tobacco The dental health care worker’s role in tobacco
cessationcessation Dental health care workers are in a special situation Dental health care workers are in a special situation
to be helpful in promoting tobacco cessation to be helpful in promoting tobacco cessation because of their role in encouraging patients to because of their role in encouraging patients to change habits change habits • Smoking cessation is another habit changeSmoking cessation is another habit change
6262Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
PsychedelicsPsychedelics(Hallucinogens)(Hallucinogens)
Haveles (p. 318) Haveles (p. 318) Lysergic acid diethylamide (LSD)Lysergic acid diethylamide (LSD) Phencyclidine (PCP)Phencyclidine (PCP) MarijuanaMarijuana
6363Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
PsychedelicsPsychedelics
Haveles (p. 318)Haveles (p. 318) Psychedelic agents are capable of inducing Psychedelic agents are capable of inducing
states of altered perception and generally do states of altered perception and generally do not have any medically acceptable not have any medically acceptable therapeutic usetherapeutic use Psychedelics affect perception in such a way that Psychedelics affect perception in such a way that
all sensory input is perceived with heightened all sensory input is perceived with heightened awarenessawareness
Psychedelic-induced dependence is psychologic, Psychedelic-induced dependence is psychologic, and tolerance develops within a short timeand tolerance develops within a short time
6464Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Lysergic Acid DiethylamideLysergic Acid Diethylamide
Haveles (p. 318)Haveles (p. 318) LSD is the most potent hallucinogenLSD is the most potent hallucinogen
An overdose of LSD produces symptoms that An overdose of LSD produces symptoms that include widely dilated pupils, flushed face, include widely dilated pupils, flushed face, elevated blood pressure, visual and temporal elevated blood pressure, visual and temporal distortions, hallucinations, derealization, panic distortions, hallucinations, derealization, panic reactions, and paranoiareactions, and paranoia
Flashbacks can occur years after ingesting LSDFlashbacks can occur years after ingesting LSD
6565Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
PhencyclidinePhencyclidine
Haveles (p. 318)Haveles (p. 318) PCP, originally developed as an animal PCP, originally developed as an animal
tranquilizer, was popular in the 1970stranquilizer, was popular in the 1970s PCP inhibits the reuptake of dopamine, serotonin, PCP inhibits the reuptake of dopamine, serotonin,
and norepinephrineand norepinephrine PCP is a powerful CNS stimulant with dissociative PCP is a powerful CNS stimulant with dissociative
propertiesproperties Changes in body image and disorganized thought Changes in body image and disorganized thought
have led to bizarre behavior and psychosishave led to bizarre behavior and psychosis
6666Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
MarijuanaMarijuana Haveles (p. 318)Haveles (p. 318)
The effects of marijuana include an increase in pulse The effects of marijuana include an increase in pulse rate, reddening of the conjunctivae, and behavioral rate, reddening of the conjunctivae, and behavioral changeschanges Euphoria and enhanced sensory perception occur with Euphoria and enhanced sensory perception occur with
normal dosesnormal doses This phase is followed by sedation and altered This phase is followed by sedation and altered
consciousnessconsciousness Psychologic dependence is determined by the Psychologic dependence is determined by the
frequency of usefrequency of use Physical dependence, tolerance, and withdrawal symptoms Physical dependence, tolerance, and withdrawal symptoms
are rare are rare
6767Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Identifying the Drug AbuserIdentifying the Drug Abuser
Haveles (p. 318)Haveles (p. 318) ““Shoppers” interact with many health care Shoppers” interact with many health care
workers in an attempt to obtain controlled workers in an attempt to obtain controlled substances for illegitimate usessubstances for illegitimate uses Many shoppers are excellent storytellers and Many shoppers are excellent storytellers and
actors with convincing histories and the presence actors with convincing histories and the presence of a pathologic dental conditionof a pathologic dental condition
They may suggest certain drugs or give a history They may suggest certain drugs or give a history of allergy to analgesics they do not wantof allergy to analgesics they do not want
6868Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Impaired Dental Health Care Impaired Dental Health Care WorkerWorker
Haveles (p. 318)Haveles (p. 318) A professional who is abusing drugs is in A professional who is abusing drugs is in
denial, and confrontation by staff, relatives, denial, and confrontation by staff, relatives, and friends is often ineffectiveand friends is often ineffective The dentist’s practice deteriorates, and mood The dentist’s practice deteriorates, and mood
swings occurswings occur Any dental health care worker who observes or Any dental health care worker who observes or
suspects that another worker is abusing drugs suspects that another worker is abusing drugs should report the person to the appropriate should report the person to the appropriate “impaired professional committee”“impaired professional committee”
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