JOURNAL TRANSCRIPT

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Contact Information

Street Smarts for Patient Charts

[email protected] thomasviola.com facebook.com/TomViolaRPh facebook.com/dentalpharmacology facebook.com/dentallocalanesthesia linkedin.com/in/thomasviola @thomas_viola

What Your Patients Don't Know …And Don’t Want YOU to Know… About Their Substance Abuse

Thomas A. Viola, R.Ph., C.C.P. © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

© 2014 Thomas A. Viola, R.Ph., C.C.P. All Rights Reserved

Program Learning Objectives

Program Learning Objectives  Identify characteristics, oral manifestations and pathologies indicative of substance dependence

Upon successful completion of this program, participants should be able to:

 Identify the most common substances of abuse and dependence and discuss – Street names – Forms and routes of administration – Common adverse effects/oral manifestations – Dental treatment considerations

 Explain the definitions of substance use, abuse and dependence  Discuss substance dependence as a treatable disease  Explain the biochemical nature of substance dependence  Discuss the impact of substance dependence on dental care and patient health

 Discuss techniques in addressing substance dependency . diversion in the dental office  Prevent drug . . . . .

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© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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Substance Use, Abuse and Dependence

Part I Substance Use, Abuse, and Dependence

While it is important for us to recognize substance abuse, it is equally important for us to identify the varying levels of that abuse.  Substance Use – Occasional use of substance for non-medical reasons • No tolerance or withdrawal develops  Substance Abuse – Persistent use of substance • Use continues despite the development of social and financial issues stemming from the use © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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Substance Use, Abuse and Dependence  Substance Dependence (Addiction) – Frequent, persistent use of substance • Tolerance develops – Need for increasing doses to produce the same level of desired effect

Part II Substance Dependence as a Disease

• Withdrawal symptoms develop – Upon abrupt discontinuance of the substance – Substance is now taken to avoid withdrawal symptoms • Relapse occurs – Even after prolonged periods of abstinence 7

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

Substance Dependence as a Disease

Substance Dependence as a Disease

Substance dependence is a progressive disease with genetic and psychosocial factors influencing its development and manifestation.

 Risk factors associated with substance dependence – Positive family history (genetic predisposition) – Current dependence on “gateway” substances

 It is considered a brain disease because substance use, abuse and dependence actually changes brain structure and function – Degeneration of dopamine/serotoninneurons  The disease progresses slowly – Experimental use to social use to abuse to dependence 9

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

 Personality traits associated with substance dependence – Narcissism – Obsessive-compulsive behavior – Controlling or manipulative tendencies – Negative coping abilities • Excessive aggression, anger, depression © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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The Nature of Substance Dependence

Part III The Biochemical “Nature” of Substance Use, Abuse and Dependence

The neurotransmitter dopamine is associated with areas of the brain that interpret feelings of satisfaction and pleasure.  Feelings of pleasure provide positive reinforcement to the performance of certain activities

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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The Nature of Substance Dependence

The Nature of Substance Dependence

Anticipation of pleasurable feelings as a reward results in behavior consistent with proactively and repeatedly performing these same activities

All substances of abuse overstimulate and overwhelm the brain with dopamine  Substance use satisfies feelings of “cravings”

 The biochemical “reward” of satisfaction we feel after eating ensures that we continue to seek food we like (and thus don’t starve)

 These feelings result from the desire to seek more of this ultimate pleasurable activity

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© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

The Nature of Substance Dependence

The Nature of Substance Dependence

As substance use becomes more frequent, the brain becomes desensitized to the effects of excessive dopamine

Desensitization to dopamine in the brain continues even after periods of substance abuse end  Substance abusers feel “down” and “numb” when not using the substance

 Increased doses are required to produce the same pleasurable feelings (tolerance)

 Unable to feel any pleasure in life, substance abusers need to use the substance to “feel normal” (dependence)

 Substance abuse leads to behavior which favors acquiring more of the substance versus other life activities 15

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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The Impact of Substance Dependence

Part IV The Impact of Substance Dependence on Dental Care and Patient Health

Substance dependence puts patients at increased risk for disease, infection and adverse reactions to medical and dental treatment.  Increased risk of communicable disease from instrument sharing and high-risk sexual behavior – HIV/AIDS – Hepatitis B and C  Increased risk of bacterial endocarditis from septic intravascular injections © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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The Impact of Substance Dependence

The Impact of Substance Dependence

 Increased risk of cardiovascular, respiratory, hepatic and renal disease

Complications arising from substance abuse are possible in virtually all age groups.

 Increased risk of adverse reaction to local anesthetics and epinephrine

 Babies exposed to legal and illegal drugs in utero are at risk for premature and underweight birth.

 Increased risk of additive adverse effects from pre-operative sedatives and opioid analgesics

 Early-life environmental drug exposure in young children can slow intellectual development and affect behavior later in life.

 Increased risk of unexpected and/or inappropriate behavior in response to medical and dental treatment © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

 Adolescents abuse “gateway” drugs, such as alcohol and marijuana, often before the age of 13. 19

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The Impact of Substance Dependence  Young adults abuse substances to enhance athletic and cognitive performance and endurance in an effort to “keep-up” with others. Part V

 Middle-aged patients abuse substances to cope with depression and stress, get sleep and lose weight.

Identifying Substance Dependence in Your Patient

 Older patients who began abusing substances in the 1960’s -1970’s are vulnerable to systemic diseases and mental illness brought on by literally decades of substance abuse. © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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Identifying Substance Dependence

Identifying Substance Dependence  Indicative Physical Characteristics – Poor personal hygiene

Despite the best efforts of dental professionals to carefully document medical histories, there will always be patients who successfully conceal their use of illicit drugs.

– Unhealthy general appearance – Unexplained weight loss or weight gain

 Some physical and behavioral characteristics are indicative (but not conclusive) of substance dependence

– Symptoms of nutritional deficiencies – Persistent low grade fever

 Certain oral manifestations and oral pathologies related to substance abuse © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

– Poor physical coordination 23

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Identifying Substance Dependence

Identifying Substance Dependence

 Indicative Physical Characteristics – Abnormal pupil size

 Indicative Behavioral Characteristics – Wearing climate-inappropriate clothing

– Red, “bloodshot” eyes

– Wearing dark sunglasses indoors

– Excessive rhinorrhea

– Using vasoconstrictor eye drops (such as Visine) excessively and for long periods

– Tremor of the head, jaw and extremities – Excessive sweating

– Changes in personality and abnormal mood swings

– Irregular pulse

– Hyperactivity and talkativeness 25

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

Identifying Substance Dependence

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

Identifying Substance Dependence

 Oral Manifestations of Substance Abuse – Poor or inadequate oral hygiene

 Oral Pathologies Common with Substance Abuse – Angular cheilitis

– Excessive plaque and gingival inflammation

– Oral candidiasis

– Excessive caries and tooth decay

– Acute necrotizing ulcerative gingivitis (ANUG)

– Bruxism

– Xerostomia

– Halitosis

– Leukoplakia

– Labial burns and stomatitis

– Advanced periodontal disease 27

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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Dependency and Controlled Substances

Part VI Dependency and “Controlled Substances”

The Controlled Substances Act of 1970 empowered the DEA to regulate the manufacture and distribution of substances with abuse potential.  Termed “controlled substances”, these substances can only be prescribed and dispensed when there is a currently accepted medical use.  Substances are placed in assigned “schedules” based on abuse potential and accepted uses. © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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Dependency and Controlled Substances  Schedule I

Dependency and Controlled Substances  Schedule III

– High potential for abuse – Not considered safe for use – No accepted medical indication in the U.S. • Heroin, LSD, marijuana

– Some potential for abuse – Moderate to low risk of physical dependence – High risk of psychological dependence – Accepted medical indication with some restrictions • Codeine, hydrocodone, anabolic steroids

 Schedule IV

 Schedule II

– Low potential for abuse – Low risk of physical and psychological dependence – Accepted medical indication with some restrictions • Diazepam (Valium), alprazolam (Xanax)

– High potential for abuse – High potential for physical and psychological dependence – Accepted medical indication with strong restrictions • Morphine, oxycodone, cocaine © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

Dependency and Controlled Substances  Schedule V – Low potential for abuse – Limited risk of physical and psychological dependence when used inappropriately – Accepted medical indication with few restrictions (available OTC in some states) • Robitussin with codeine, Lyrica

Part VII Selected Substances of Abuse and Dependence

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CNS Stimulants  Cocaine . – Produces sense of exhilaration • Blocks dopamine reuptake in the midbrain • Also blocks norepinephrine and serotonin reuptake

CNS Stimulants

– Leaves are still used in Coca-Cola as a flavoring agent…but the cocaine has been removed

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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CNS Stimulants  Cocaine – Street names • Coke, blow, bump, crack, snow, flake

CNS Stimulants  Cocaine – Hydrochloride decomposes if smoked directly. • Converted back to relatively pure base state (freebasing) for smoking. • Uses heated volatile chemicals (explosive)

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– Dosage forms and routes of administration • Cocaine hydrochloride (street cocaine) –Inhaled (snorted) –Topically applied –Injected • Crack cocaine and free-base cocaine –Smoked © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

– Crack is converted to base using baking soda and water • Eliminates the dangers of explosion and fire encountered in conventional freebasing 37

CNS Stimulants

 Methamphetamine – Street names • Speed, meth, crystal, ice, crank – Dosage forms/routes of administration • Methamphetamine powder –Swallowed, snorted, injected • Crystallized methamphetamine –Smoked • Legal methamphetamine??? –Desoxyn tablets • Treatment of ADHD

– Long-term exposure causes cell death in the area of the brain that governs behavior control and personality. • Altered inhibition and judgment • Leads to engaging in unsafe behaviors

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CNS Stimulants

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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CNS Stimulants

 Methamphetamine – Often “cooked” (made) in clandestine labs

 MDMA (Methylenedioxymethamphetamine) – A hallucinogen with effects similar to methamphetamine • Blocks reuptake of serotonin • Increases release of serotonin • Stimulates 5HT2 receptors • Stimulates Alpha-2 receptors

– Easily manufactured from pseudoephedrine – The extra methyl group alters the effects, duration and potency. • Allows for better fat solubility and thus better penetration into the brain.

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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CNS Stimulants

 Methamphetamine – Causes an excess release of dopamine and a subsequent reduction in dopamine receptors

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

 Also causes some release of dopamine – Causes degeneration of dopamine and serotonin neurons 41

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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CNS Stimulants

CNS Stimulants

 MDMA (Methylenedioxymethamphetamine) – Street names • Ecstasy, XTC, Molly –Increases libido • Love Pill, Hug Drug –Increases social bonding

 MDMA (Methylenedioxymethamphetamine) – Exerts paradoxical effects of relaxation and stimulation – Exerts adverse effect on immune system, particularly with heavy use.

– Dosage forms/routes of administration • Available in oral dosage forms (swallowed)

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

CNS Stimulants

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CNS Stimulants

 Prescription Drugs for ADHD – Types • Ritalin/Concerta (methylphenidate) –Poor Man’s Cocaine, Coke Jr., Skippies • Adderall (dextroamphetamine) –Brain Food, Altoids

 “Bath Salts” (…not really) – Powerful stimulants similar to methamphetamine • Do not generate positive urine test results!

– Available on the internet, smoke shops, head shops…and your local convenience store!

– Licit Use • Treatment of ADHD – Illicit Use • Increased alertness and physical endurance • Swallowed whole or dissolved and injected © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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CNS Stimulants

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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Common Adverse Effects

 “Bath Salts” – Street names • Cloud 9 • Ivory Wave • Vanilla Sky • Blizzard

 Physical Effects – Pallor – Increased body temperature – Runny nose – Dilated pupils

– Dosage forms and routes of administration • Marketed as plant food caps (swallowed) • Marketed as herbal incense (smoked) © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

– Anorexia and weight loss – Increased blood pressure and pulse 47

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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Common Adverse Effects

Common Oral Manifestations  Xerostomia – Increased tooth decay and carious lesions

 CNS Effects – Insomnia

 Periodontal disease – Results from neglect of good oral hygiene – Exacerbated by vasoconstriction, xerostomia

– Psychosis • Irritability • Anxiety • Paranoia

 Bruxism – May result in TMJ pain, incisal wearing – Crown fractures yield retained, exposed roots

– “Tweaking” • Users have numerous scabs from picking at imaginary insects crawling under their skin © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

 Signs of malnutrition – Angular cheilitis, candidiasis, glossdynia 49

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

Specific Oral Manifestations

Dental Treatment Considerations

 Methamphetamine – “Meth mouth” • Brittle decalcified tooth enamel with extensive black gingival decay –Corrosive substances used in manufacture are vaporized upon smoking and dissolve tooth enamel and dentin • Sulfuric acid, red phosphorus, lye

Due to the effects of stimulant abuse and dependence on cardiovascular function, drugs used commonly in dentistry may have serious, unexpected adverse effects.

–Rampant dental caries • Persistent xerostomia • Exacerbated by cravings for sweets © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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 However, while its use may seem warranted, epinephrine may exacerbate the reduced oxygenation of the brain which results from druginduced tachycardia and may result in convulsions

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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CNS Depressants  Benzodiazepines – Types • Xanax (alprazolam) –Footballs, Totem Poles • Klonopin (clonazepam) –Super Valium, K-Pin

CNS Depressants

– Licit Use • Relieve anxiety, produce sleep, prevent seizures – llicit Use • Manage withdrawal symptoms • Produce sedation after abuse of stimulants © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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CNS Depressants

CNS Depressants

 Rohypnol – A benzodiazepine • Not approved for use in the U.S.

 Rohypnol – Street names • Roofies, Roche

– Approximately ten times more potent than Valium • Abused for euphoria-producing effects – Used as a predatory drug • High doses can cause loss of muscle control, partial amnesia, loss of consciousness

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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CNS Depressants

CNS Depressants

 GHB (gamma-hydroxybutyrate) – CNS depressant originally developed as an anesthetic • Also used by athletes as a synthetic steroid and growth stimulant

 GHB (gamma-hydroxybutyrate) – Street names • Liquid ecstasy • “GBH” (“grievous bodily harm”)

– Causes amnesia and susceptibility to suggestion • Used as a date rape drug

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

– Dosage Forms/routes of administration • Oral Tablets (swallowed) • Oral Tablets, crushed and ground up (snorted)

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CNS Depressants

– Dosage forms/routes of administration • Salty-tasting, colorless liquid (swallowed) • Powder (swallowed) • Capsule (swallowed)

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

CNS Depressants  Clonidine – Vitamin C, Rehab, Boost

 Psychotherapeutic Agents – Types • Seroquel (quetiapine) –Baby Heroin, Suzie-Q, Q-Ball – Licit Use • Treatment of schizophrenia and bipolar disorder

– Licit Use • Treatment of hypertension (Catapres) • Treatment of ADHD (Kapvay) • Treatment of alcohol withdrawal

– llicit Use • Treat anxiety resulting from stimulant abuse • Combined with stimulants to prolong euphoria • Swallowed whole or “cheeked”

– llicit Use • Produce sedation after abuse of stimulants • Used for “boosting” effects of sedatives • Relieve alcohol/opioid withdrawal symptoms • Used for self-imposed drug rehabilitation

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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Common Adverse Effects

Common Dental Considerations

 Physical Effects – Impaired motor coordination – Withdrawal symptoms from physical dependence • GI upset • Excessive sweating • Weakness

 Reduced salivary flow – Xerostomia – Increased tooth decay and carious lesions – Possible candidiasis  Periodontal disease – Exacerbated by xerostomia

 CNS Effects – Impaired memory and anterograde amnesia – Altered perception – Reduced mental acuity – Tolerance to sedative effects is common 61

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

Dental Treatment Considerations

Dental Treatment Considerations

Due to the effects of sedative/hypnotic abuse and dependence on the CNS, drugs used commonly in dentistry may have serious, unexpected adverse effects.

Due to drug-induced alteration of liver metabolism, drugs used commonly in dentistry may have serious, unexpected adverse effects.

 Analgesics containing opioids may cause additive CNS, respiratory depression with sedative/hypnotic abuse  Benzodiazepines used in conscious-sedation techniques may have additive effects with selfadministered sedative/hypnotics of abuse 63

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

 Anti-infectives may inhibit liver metabolism and increase serum levels and therefore adverse effects associated with sedative/hypnotic abuse – Erythromycin, Biaxin (clarithromycin) – Diflucan (fluconazole), Mycelex (miconazole)

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© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

Illicit Opioids  Heroin – Synthesized from morphine • Derived from the poppy plant

Opioids

– Available on the street at low purity levels • Usually “cut” with sugar, starch, powdered milk, or quinine – Yet, the typical user today consumes more heroin than a typical user did a decade ago • Higher purity available at the street level

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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Illicit Opioids

Illicit Opioids  Heroin – Dosage forms/routes of administration • IV injection (mainlining) • IM injection (muscle-popping) • SC injection (skin-popping)

 Heroin – Street names • Smack • Brown sugar • Speedball –When combined with cocaine

–Drug is liquefied by heat then injected • Powder - usually white to dark brown due to impurities or additives • Black Tar - tar-like consistency resulting from crude processing

• Cheese –When combined with crushed tablets of OTC cold medication containing Tylenol .

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© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

Illicit Opioids

Illicit Opioids

 Heroin – Dosage forms/routes of administration • “Dirty Hit” –Bottom of a soda can is used to dissolve heroin –May result in a fairly quick or delayed reaction –May result in abscess, cellulitis, septicemia, endocarditis, tetanus, flesh-eating disease

 Heroin – Dosage forms/routes of administration • Inhaled (snorted/smoked) - Red Rum –Low-purity heroin must be injected –High-purity heroin can be snorted or smoked • Eliminates syringe-borne disease • Eliminates evidence of IV use • “Chasing the dragon” - heated on aluminum foil from the bottom and allowed to run while user inhales smoke .

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© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

Illicit Opioids

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Licit Opioids

 Krokodil – Mixture of desomorphine, gasoline, oil, alcohol or paint thinner – Injected directly intravenously

 Prescription Opioid Analgesics – Types • Oxycodone (Oxycontin) • Oxycodone w/APAP (Percocet) –Hillbilly Heroin • Hydrocodone w/APAP (Vicodin, Lortab) –Vikes

– Causes dark, scaly patches of dead and decaying skin

• Duragesic patches (fentanyl) –Boiled (Texas Tea)

– Often results in brain damage and death

• Ultram (tramadol) –T-Ball

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Licit Opioids

Licit Opioids

 Prescription Opioid Analgesics – Licit Use • Prescribed for moderate to severe pain

 Opioid analgesics used in dentistry – Codeine • Combination with APAP (Tylenol with codeine) – Hydrocodone • Combination with APAP (Vicodin, Lortab) • Combination with ibuprofen (Vicoprofen)

– Illicit Use • Abused for CNS depressant effects • Combined with stimulants to reduce anxiety and prolong euphoria • Often used to “cope” with situations or “enhance” pleasant events • Readily available in medicine cabinets © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

– Oxycodone • Combination with APAP (Percocet, Endocet) • Combination with ASA (Percodan) • Combination with ibuprofen (Combunox) 73

Licit Opioids

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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Licit Opioids  Prescription Cough Syrups – Licit Use • Prescribed for relief of non-productive cough

 Prescription Cough Syrups – Types • Hycodan (hydrocodone/homatropine) • Tussionex (hydrocodone/chlorpheniramine)

– Illicit Use • Abused for depressant, sedative effects • Readily available in medicine cabinets • Available over the counter in some states

• Promethazine with codeine –Mixed with soda, candy (Purple Lean) • Promethazine with dextromethorphan –Mixed with soda, candy (Yellow Lean)

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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Licit Opioids

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Common Adverse Effects

 Drugs Used to Treat Opioid Addiction – Types • Suboxone (buprenorphine/naloxone) –Sub, Bupe

 Physical Effects – Impaired motor coordination – Pupil constriction – Nausea, vomiting, constipation – Withdrawal symptoms from physical dependence • Muscle aches, sweating, tremors, chills • Uncontrolled yawning, watery eyes and nose

– Licit Use • Part of treatment plan for opioid addiction • Blocks effects of opioid – Illicit Use • Hoarded by recipients and taken in high doses for abuse © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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 CNS Effects – Initial euphoria, then depression, dysphoria – Drowsiness and dizziness, impaired memory – Respiratory depression – Tachyphylaxis causes rapid dependence © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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Common Dental Considerations

Dental Treatment Considerations

 Xerostomia – Increased tooth decay and carious lesions

Due to respiratory depressive effects of opioids, drugs used commonly in dentistry may have serious, unexpected adverse effects

 Periodontal disease – Results from neglect of good oral hygiene – Exacerbated by xerostomia

 Nitrous oxide – oxygen sedation may exacerbate respiratory depression associated with opioid abuse and dependence

 Signs of malnutrition – Angular cheilitis, candidiasis, glossdynia

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

 Opioid analgesics prescribed for the relief of dental pain may have additive effects with selfadministered opioids of abuse 79

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Dental Treatment Considerations Due to availability of combination opioid and non-opioid products, analgesics prescribed for the relief of dental pain may have serious, unexpected adverse effects

Hallucinogens  Analgesics frequently used in dentistry are products which combine opioid analgesics and non-opioid analgesics in fixed proportions – May result in unintentional overdose of nonopioid ingredients when combined with selfadministered opioids of abuse and OTC products © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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Hallucinogens

Hallucinogens

 Marijuana (cannabis) – Street names • Pot, weed, grass, hemp

 Synthetic marijuana – Street names • K2 • Spice • Herbal Incense

– Dosage forms and routes of administration • Leaves (mixed in foods, smoked as “joints”) • Butane hash oil “BHO” (dabbed on hot surface and smoke is inhaled)

– Dosage forms and routes of administration • Dried leaves (smoked “joints” or “blunts”)

– Active ingredient is tetrahydrocannabinol (THC) • Marinol (dronabinol): synthetic THC –Chemotherapy induced nausea –Appetite stimulation in AIDS patients .

– Active ingredient • Leaves are sprayed with psychoactive compounds or synthetic cannabinoids © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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Hallucinogens

Hallucinogens  Ketamine – A dissociative hallucinogen • Distorted perceptions of sound, sight • Feeling of detachment from environment • Amnesia, out of body experiences

 Phenylethylamines (2C’s) – Hallucinogens with stimulant side effects – Street names • 2C-I (“Smiles”) • 2C-B (“Nexus”) – Dosage forms and routes of administration • Liquid, powder • Tabs on blotting paper –Produced in home labs with varying potency

– Licit Use • Veterinary anesthetic which maintains gag reflex and little respiratory depression. – Illicit Use • Date rape drug © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

Hallucinogens

Hallucinogens

 Ketamine – Street names • Cat Valium, Special K, Vitamin K –Most legally produced ketamine is sold for veterinary use

 Dextromethorphan (“DM” or “DXM”) – Dextro isomer of opioid agonist levorphanol – Licit Use • Prescribed for relief of non-productive cough – Illicit Use • Abused for dissociative hallucinogenic effects –Doses up to 10 times therapeutic dose –“Poor Man’s PCP” • Readily available in medicine cabinets/OTC

– Dosage forms and routes of administration • Powder (inhaled) • Liquid (injected, smoked with tobacco) © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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Hallucinogens

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Hallucinogens

 Dextromethorphan (“DM” or “DXM”) – Types • OTC cough and cold products –Coricidin HBP (Skittles, Triple C’s)

 LSD (lysergic acid diethylamide) – A hallucinogen with effects similar to MDMA • Blocks reuptake of serotonin • Increases release of serotonin • Stimulates 5HT2 receptors • Stimulates Alpha-2 receptors

• OTC cough syrups –Robitussin DM (Roboshake) –Delsym (Agent Orange)

–Long-lasting hallucinogenic effect

• Prescription cough syrups –Promethazine DM (Purple Haze)

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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–Spontaneous recurrence of hallucinatory effects (flashbacks) possible. 89

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Hallucinogens

Hallucinogens

 LSD (lysergic acid diethylamide) – Street names • Acid

 PCP – Street names • Angel dust, whack, embalming fluid, rocket fuel

– Dosage forms and routes of administration • White crystalline powder mixed with sugar –“Acid” (swallowed)

– Dosage forms and routes of administration • Powder (inhaled) • Tablets and capsules (swallowed) • Liquid (applied to leafy material and smoked)

• LSD-impreganted blotting paper –“Microdots” (swallowed) • LSD-laced squares of gelatin –“Window panes” (smoked)

– Produces psychoses similar to schizophrenia and violent, aggressive behavior

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Hallucinogens

 Antihistamines (continued) – Licit Use • Used to decrease allergic reactions • Used to promote sleep • Used to treat motion sickness, vertigo –Dramamine, Bonine

– Antiemetics • Dramamine (dimenhydrinate)

– Illicit Use • Used in very high doses as hallucinogen • Used with opioids to increase euphoria • Used to reduce opioid withdrawal • Available OTC and in medicine cabinets

– Anti-vertigo Agents • Bonine (meclizine)

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Hallucinogens

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Hallucinogens

 Salvia divinorum – Diviner's Sage, Magic Mint, or Sally D

 Inhalants – Solvents • Paints, paint thinner • Magic markers, correction fluid • Nail polish remover – Gases • Butane, propane • Nitrous oxide (“whippets”) • Hair spray, air freshener – Nitrites • Butyl nitrite (“rush”, “bolt”) • Amyl nitrite (“poppers”, “snappers”)

– Licit Use (alleged) • Herbal carminative – Illicit Use • Powerful hallucinogen similar to LSD, PCP • Leaves are smoked, chewed • Does not generate positive urine test results • Available at gas stations/convenience stores © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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Hallucinogens

 Antihistamines – First-generation antihistamines • Benadryl (diphenhydramine)

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Common Adverse Effects

Specific Adverse Effects  Inhalants – Physical Effects • Liver and kidney damage • Blood oxygen depletion and suffocation • Peripheral neuropathies • Heart failure and death • Hearing loss • Loss of motor coordination

 Physical Effects – Impaired motor coordination – Dilated pupils and blurred vision – Increased body temperature/excessive sweating – Increased or decreased blood pressure, pulse – Increased appetite (marijuana)  CNS Effects – Sense of well-being, euphoria and relaxation – Increased awareness of sensory input – Illusions and hallucinations (flashbacks) – Psychoses (PCP) © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

– CNS Effects • Stimulation and loss of inhibition • Depression • Memory impairment 97

Common Dental Considerations

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Dental Treatment Considerations

 Xerostomia – Increased tooth decay and carious lesions

Due to the effects of stimulant abuse and dependence on cardiovascular function, drugs used commonly in dentistry may have serious, unexpected adverse effects.

 Periodontal disease – Results from neglect of good oral hygiene – Exacerbated by increased appetite for sweets

 Hallucinogens may either increase or decrease cardiovascular function and adverse effects associated with local and general anesthetics

 Rashes and residue around nose and mouth (inhalants)

 Epinephrine may exacerbate reduced oxygenation of the brain from drug-induced cardiovascular alterations and may result in convulsions © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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What’s New?  Albuterol – Enhances athletic performance, weight loss

What’s New? • • • •

Albuterol Neurontin Niacin Imodium

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 Neurontin (gabapentin) – Reduces alcohol or cocaine cravings – Promotes relaxation after stimulant binging

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What’s New?  Niacin – Taken in high doses to “flush” positive drug tests Part VII Preventing Drug Diversion in the Dental Office

 Imodium (OTC Methadone) – Reduces opioid withdrawal symptoms – May exacerbate constipation

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Preventing Drug Diversion

Preventing Drug Diversion  Recognizing drug-seeking behavior – Emergency calls or visits near the end of office hours, especially before weekends/holidays

Since dental offices are potential sources of these substances of abuse, the dental team must take precautions involving prescribing and access to prescriptions.

– Requesting specific drugs by name

 Preventing drug diversion in the dental office requires that the dental team: – Recognize drug-seeking behavior and prescribe opioid analgesics appropriately – Safeguard prescription pads and utilize strategies to prevent prescription alteration © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

– Repeated “loss” of prescriptions – Reluctance to provide prior medical records or information for other treating physician(s). – “Don’t bill my insurance, I’ll pay cash” 105

Preventing Drug Diversion

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Preventing Drug Diversion

 Safeguarding prescription pads – Store prescription pads in secure locations away from patient areas – Entrust access to blank prescription pads to as few employees as possible

 Preventing prescription alteration – Complete all required information on the prescription blank, including patient’s full name, address and date of birth – Date all prescriptions and use words and numbers to indicate quantity to be dispensed

– Order small quantities of prescription pads at one time to facilitate tracking

– Enter the exact number of refills authorized or the word “zero” if none are authorized (do not leave blank)

– Do not pre-sign blank prescriptions and do not use prescriptions with pre-printed DEA numbers © 2014 Thomas A. Viola, R.Ph. All Rights Reserved

© 2014 Thomas A. Viola, R.Ph. All Rights Reserved

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