chapter 25: drug abuse copyright © 2011, 2007 mosby, inc., an affiliate of elsevier. all rights...

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…


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



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…



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




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


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



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


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”




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




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




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




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


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


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


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


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




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




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




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


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


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%


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


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


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



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


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


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


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




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




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


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




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




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


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


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


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



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


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


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



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


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


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



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


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


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


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



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


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


Central Nervous System Central Nervous System StimulantsStimulants

Haveles (pp. 316-318)Haveles (pp. 316-318) CocaineCocaine AmphetaminesAmphetamines CaffeineCaffeine TobaccoTobacco


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


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



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


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


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



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



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



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



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



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



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


PsychedelicsPsychedelics(Hallucinogens)(Hallucinogens)

Haveles (p. 318) Haveles (p. 318) Lysergic acid diethylamide (LSD)Lysergic acid diethylamide (LSD) Phencyclidine (PCP)Phencyclidine (PCP) MarijuanaMarijuana


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


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


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


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


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


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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