Chapter 2: A Dental Professional’s Field Guide to Substance Abuse

7 CE Hours

By: Staff Writer Learning objectives ŠŠ List the most common oral symptoms of illegal drug use. ŠŠ Describe the characteristics associated with meth mouth, including ŠŠ Explain the mechanism and role of neurotransmitters, such as why meth mouth is a misleading term. dopamine, in addiction. ŠŠ Describe the implications of chronic IV drug use on the oral cavity. ŠŠ Distinguish between drinking habits of social alcohol users vs. ŠŠ List the most common sources for nonmedical opioid alcohol-dependent drinkers. prescription drugs. ŠŠ Compare and contrast substance abuse, physical dependence, ŠŠ Describe the physiological effects that most commonly cause and addiction. fatalities with excessive opioid use. ŠŠ Explain how a poor diet and xerostomia, in combination, ŠŠ Define nonmedical use of prescription drugs, according to the U.S. contribute to decay. National Survey on Drug Use and Health. ŠŠ Compare and contrast the hazards of smoking methods such as ŠŠ List strategies for minimizing prescription drug diversion through cigarettes, cigars, and hookahs. responsible prescribing practices. ŠŠ List the most common oral cancerous and precancerous conditions ŠŠ List common characteristics and strategies of drug-seeking behavior. associated with cigarette smoking. ŠŠ Explain the potential drug interactions and contraindications of ŠŠ List the segments of the U.S. population most likely to use anesthesia and sedation for the following types of drug abuse: smokeless tobacco. alcohol, cocaine, methamphetamine, and opioids. ŠŠ List contraindications for patients who are excessive alcohol users ŠŠ Discuss strategies for pain control in opioid addicts or former addicts. and reformed alcoholics. ŠŠ Explain the rationale for drug screening and intervention in the ŠŠ List the oral conditions more common in marijuana smokers. dental office. ŠŠ Describe the oral indications of stimulant abuse. ŠŠ List the bodies of law and legal requirements governing ŠŠ List the potential adverse drug interactions for patients who communication among health care providers regarding use cocaine. substance abuse. ŠŠ Contrast patterns of drug use between designer-drug users and ŠŠ Explain the significance of the5 A’s and SBIRT in substance abuse traditional drug users. intervention.

Introduction Most medical professionals are aware that excessive drug use the oral cavity, the management and clinical implications for these endangers the health of millions of people in the United States. Some patients, and the most effective strategies for intervention and referral. of these abused substances (e.g., tobacco and alcohol) are legal; some This course will teach dental professionals and staff members to (e.g., opioids, codeine, or the anti-anxiety medication, Xanax) are recognize common characteristics of drug abuse to: controlled substances, legally prohibited without a prescription; and ●● Identify patients who are excessive substance users, to protect others (e.g., cocaine or heroin) are generally prohibited for public them from potential drug-related risks during dental treatment (i.e., use. Many of these drugs have highly addictive qualities that greatly contraindications, drug interactions, etc.). increase the risk of their abuse, as well as the potential for many ●● Ensure prescription drugs are not diverted to unintended users. serious diseases and drug-related deaths. The course is divided into five sections: But, not as well known, is that many of the symptoms and effects of ●● Section I: Nature of Substance Abuse and Addiction. substance abuse are exhibited in poor oral health, either as a direct effect ●● Section II: Commonly Abused Legal Substances. of consumption or exposure to the substance, or indirectly, through ●● Section III: Commonly Abused Illegal Substances. multiple compromised body systems. A recent study published in the ●● Section IV: Prescription Drug Abuse. Journal of Substance Abuse Treatment, found a strong association ●● Section V: General Intervention Strategies. between substance abuse and poor oral health, showing increased rates of disease and decay among users of marijuana, heroin, methamphetamine, The specific legal and illegal substances discussed in this prescription pain medication, alcohol, and tobacco, in comparison to course (tobacco, alcohol, marijuana, cocaine, MDMA/ecstasy, nonusers. Those using opioids (pharmaceutical narcotics or heroin) methamphetamine, heroin, and prescription opioids) were selected showed the most extreme and rapid rates of deterioration [1]. for their prevalence and potential for abuse, but there are many more addictive substances that result in poor oral health [2]. Professional dental associations and organizations encourage dentists, hygienists, dental clinicians, and dental office personnel to familiarize Some are customary among specific subcultures or minorities, such themselves with characteristics of drug abuse through professional as khat chewing (common in Yemen), which causes receding gums continuing education. They should learn physical symptoms and with mucosal white lesions; betel nut (Southeast Asia), which stains effects of the most commonly abused drugs on the body—particularly the teeth and gingiva red and is associated with oral cancer; or steroids (athletes use to promote strength and endurance), which cause gingival enlargement. Depending on the population served, a clinician may Dental.EliteCME.com Page 45 encounter a greater incidence of some types of substance abuse among his or her patients than exists among the general population [3][4][5].

Section I: Nature of Substance Abuse and Addiction

Overview According to the U.S. National Survey on Drug Use and Health, about embarrassment or judgment by those seeing the forms, concerns 22 million people aged 12 and older could be classified as substance related to insurance coverage, or general privacy issues [7][8]. abusers or substance-dependent. The majority are dependent on Effective management of patients who abuse drugs or alcohol requires alcohol (about 15 million); with an additional 4 million dependent a keen understanding and awareness of [9]: on one or more illegal drug(s) (or drugs obtained illegally), but not ●● Characteristic symptoms and effects of commonly abused drugs. alcohol; and an additional 3 million dependent on alcohol, as well as at ●● Clinical implications of drug use. least one illegal substance [6]. ●● Effective screening instruments to identify drug abusers. Given the prevalence of substance abuse, it is likely that most dental ●● Potential drug interactions and side effects complicating professionals regularly meet patients who are chemically dependent. procedures or treatment. Dentists who unknowingly treat a patient who is a substance user ●● Potential complications related to a general state of compromised or abuser may be exposing the patient to a higher degree of risk health, weakened immune system, and poor healing ability. and increased potential for adverse effects, even with routine dental ●● Management strategies to address patients who miss appointments, procedures or treatment. exhibit drug-seeking behaviors, or come to an appointment under Identifying substance abusers can be difficult, particularly if you rely the influence of drugs or alcohol. on self-reported medical histories, which are notoriously inaccurate. ●● Dangers of prescribing certain pain medications to opioid abusers, One recent study found almost half of all survey respondents were products with alcohol to alcoholics, or use of any medication or not completely truthful on medical forms due to fear of possible procedure contraindicated in drug users, those in recovery for substance abuse and addiction, and reformed users. ●● The nature of addiction and effective intervention strategies.

Types of drug use and users There are many types of drugs and users. A drug’s potential for Social users rarely show the escalating degree of emotional or physical dependency or addiction differs according to drug type, potency, need for the drug that characterizes a potential substance abuser [10]. frequency of ingestion, methods of production (differences in A primary distinguishing feature of the social user is that he or she is cultivation or processing), and consumption (smoking, injecting), as unlikely to take the types of risks associated with substance abuse, and well as genetic, psychological, and environmental variables associated resists the repetitive behavior that progresses to chronic use. However, with the individual using the substance. Not all users are addicts, nor some long-term social users may escalate to dependency at some point are all addicts obviously dependent on a substance. in their lives. Individuals with a propensity for dependence escalate Alcohol and drug use serves many functions. Early use of many more readily to habitual and/or increasingly risky use. As consumption illegal and legal addictive substances begins in a social environment. of the substance becomes increasingly important, the dependent Young people may try a prohibited substance to achieve a desired individual is willing to assume higher thresholds of risk to continue pharmacological effect, to satisfy a curiosity, take a risk, or because a using the substance. Users go to great lengths to hide their degree of friend or family member shares in the activity. substance use, even as it threatens to destroy jobs and relationships. Many continue to use alcohol and drugs socially. Although casual, Some individuals take a drug for purely recreational purposes, while occasional use characterizes this type of user, the frequency and others use drugs to relieve their physical or emotional pain. The latter amount of drug use may vary widely. Some social usually consume type of substance use is known as self-medication. For those with alcohol or drugs in association with a specific event (a celebration), chronic pain, the initial source is often a valid prescription. Once the time in life (college), or group of friends. Even if the individual uses prescription runs out, the individual will attempt to find other doctors a specific substance on a regular basis, the pattern of use may not be to prescribe the same medication or a similar medication, friends and problematic or potentially abusive. relatives with prescriptions, or turn to black market sources.

Abuse, dependence, and addiction Substance abuse is a disease characterized by maladaptive patterns of drug more of the substance or more potency to achieve the same effects) and consumption that result in damaging consequences for the individual, who withdrawal symptoms, once use of the drug is discontinued. continues to use the substance in the same manner, although it continues While physical dependence and addiction are often used to result in negative repercussions. Substance abuse is characterized interchangeably, they have distinct meanings. Physical dependence is by heavy use, but does not necessarily imply dependence. Physical (or a necessary characteristic of addiction, but addiction also includes a physiological) dependence is indicated by drug tolerance (requiring psychological dependence on the drug. Table 1 contrasts the elements of addiction and dependence [11].

Table 1. Elements of addiction and dependence Addiction Dependence Physical dependence Yes Yes Psychological dependence Yes No Withdrawal symptoms Yes Yes Drug-seeking behavior Yes No

Page 46 Dental.EliteCME.com Physical dependence Physical dependence is an individual’s escalating need for the drug and coworkers, or friends for years before they are found out. Keeping withdrawal effects that appear if he or she stops using the substance. dependence a secret becomes increasingly difficult as it grows. Common characteristics of increasing dependency include failure to Symptoms of withdrawal are a defining feature of physical dependence. fulfill work obligations, inability to change one’s habits, and assuming They typically begin when the user’s blood levels of the substance go increased personal risk due to poor judgment or physical dysfunction. below a certain threshold, with symptoms relieved when the drug levels These behavioral patterns demonstrate the increasing necessity of increase. Users may switch to a similar substance if a preferred drug is getting and using the substance. The individual’s focus and priorities not available, or tolerance increases to a level where the substance no change as these new needs eclipse obligations and responsibilities longer provides a sufficient effect. A substance abuser may use alcohol at work and home. It may be a very long time before dependence one decade and prescription medication the next. Moving from one is discernable to the general public or health care professionals. addictive substance to another over time is referred to as transference [12]. Substance abusers may hide their use from family members,

Addiction Addiction is defined as a progressive illness characterized by long-term uncontrollable cravings for the substance that persist even in the changes to the brain’s structure and function that occur due to repeated face of negative or harmful consequences to the user or others. The use of a substance that can persist long after use is discontinued. The individual may put friends or family members at physical risk (i.e., amount of drug required to cause this change varies by individual. babysitting, driving drunk), or at risk of legal prosecution. Like other Addicts report that the psychological component of addiction can be as chronic diseases, addicts may alternate between relapse and reinitiating powerful as the physical need in its potential to cause relapse [13]. drug use. In some cases, symptoms of withdrawal can be life- If left untreated, addiction can result in disease, disability, or threatening. It is generally accepted that addicts are unable to return to early death. The symptoms of addiction include compulsive or social or occasional use of the abused substance.

How addictive substances produce their effects Drugs are chemicals that alter the way nerve cells in the brain send, occur without the use of drugs. With repeated use, the brain adjusts to receive, and process information. Some drugs, such as marijuana and these surges in dopamine and other neurotransmitters by producing heroin, activate neurons because their chemical structure is similar to less dopamine, or reducing the number of receptors that can receive that of a natural neurotransmitter. This parallel structure allows drugs signals. The drug abuser’s natural reward system diminishes, and the to lock into receptors, activating nerve cells, but acting in a different individual is unable to enjoy things that previously brought him or her manner with different effects than the neurotransmitter they mimic. pleasure. The drug becomes the only way to raise the user’s levels of Amphetamine drugs or cocaine cause nerve cells to release abnormally dopamine, with more of the drug necessary to create the same high, [14]. large amounts of natural neurotransmitters, such as dopamine, or prevent indicating increasing physical dependence their normal recycling. Dopamine is a neurotransmitter responsible for The same mechanisms involved in the development of tolerance can regulating movement, emotion, cognition, motivation, and feelings of eventually lead to profound changes in neurons and brain circuits, with the pleasure (located in the pleasure center of the brain) that are elemental potential to severely compromise the long-term health of the brain. This to the brain’s reward system. The flood of dopamine produces a high or rewiring of the brain triggers irresistible cravings for the drug. If the drug euphoric sensation, reinforcing the drug-taking behavior. This leads to is not available, the individual is likely to exhibit drug-seeking behavior repeated use, paving the way for potential abuse and addiction. and attempt to obtain the drug through any means necessary. Because the need for the drug is positively reinforced by the effects of its consumption Commonly abused drugs may release anywhere from two to 10 times (the high), drug taking becomes a learned reflex. These changes in the the amount of dopamine that would typically be released by the brain brain are associated with an overwhelming need for the drug, which, even under normal circumstances, with a much longer duration than would after years of abstinence, is strong enough to cause relapse.

Section II: Commonly Abused Legal Substances

Tobacco According to the 2010 National Survey on Drug Use and Health, about Even though the health risks associated with tobacco use are well one-third of all individuals in the United States aged 12 years and older documented and publicized, the price has risen precipitously, and it (almost 70 million people) have used at least one form of tobacco. is prohibited in most public and many private spaces, smoking has Cigarette smokers form the largest portion of tobacco smokers (about proven to be a habit with staying power and a persistent following. 58 million people), followed by about 13 million who smoke cigars, 9 Studies suggest the majority of nicotine addicts would like to quit, and million who use smokeless tobacco, and 2 million who smoke pipes [15]. have attempted it at least once [16.1]. Discontinuing tobacco use can be While smoking tobacco (i.e., cigarettes, cigars, hookahs, or pipes) and extremely difficult not only because the user may experience severe smokeless tobacco (i.e., snuff or plug) come from the same processed or potentially dangerous withdrawal systems (nicotine replacement green tobacco leaf, each tobacco product is subject to a different therapies and other commonly prescribed medications are not always curing, aging, and fermentation process. There are more than 4,000 successful in quelling cravings), but also because it requires the different chemical compounds in tobacco, but the concentration of tobacco user to commit to significant, permanent changes in his or her each may vary significantly according to the way it is processed and behavior, priorities, and environment, or risk relapse. other ingredients or flavorings added to the product[16] . The ingredient in tobacco associated with dependence is nicotine. Those who have never felt the grip of nicotine addiction may be perplexed by the behavior of friends who refuse to quit such an obviously dangerous and self-destructive habit.

Dental.EliteCME.com Page 47 Smoking tobacco The 1964 U.S. Surgeon General’s Report on Smoking and Health was one reconstituted tobacco may treat the tobacco with humectants, adhesives, or of the first public documents linking smoking to increased risk of cardiac other potentially hazardous additives [18]. [16.2] and vascular disease . Recent research shows a relationship between Biomarkers such as nicotine, carbon monoxide, hydrogen cyanide, tobacco use and health risks such as increased periodontal disease and benzene, and PAH (polynuclear aromatic hydrocarbons) are many types of cancer, (mouth, pharynx, esophagus, lung, pancreas, and compounds found in body fluids and the exhaled breath of smokers bladder), among other dangerous conditions and disorders [17]. that can be used to assess a smoker’s degree of exposure to the toxic Tobacco smoke, like all smoke, is the result of incomplete combustion and carcinogenic compounds in tobacco smoke. For example, tobacco of the material burned. While most tobacco is equivalent in toxic and smoke contains at least 10 carcinogenic forms of PAH; by measuring carcinogenic compounds (though at varying levels), there are considerable this biomarker in the smoker’s exhaled breath, one can determine the differences in the health risks of each product. For example, cigars and amount exhaled, and the amount remaining in the smoker’s respiratory cigarettes use different qualities of tobacco, are different sizes, and contain tract, which may be as high as 90% in a long-term smoker [19]. other materials smoked with the tobacco, such as the cigar wrapper or According to the International Agency for Research on Cancer (1987), cigarette rolling paper. Tobacco products, with the exception of most some of the most dangerous ingredients found in processed tobaccos standard sized cigars, are flavored with many additives that contain toxic are arsenic, beryllium, chromium, nickel, and cadmium, all of which ingredients inhaled in the smoke. Smokers who use filtered cigarettes are known to be carcinogenic [20]. Other toxic substances include trace or cigars may encounter more flavoring ingredients, as well as the amounts of mercury, lead, and assorted metals, as well as pesticides possibility of industrial plasticizers used to apply filter tips. Products using used in tobacco cultivation, and radioactive elements, such as lead 210 and polonium 210, which are byproducts of phosphate fertilizers [21]. Cigarettes The cigarette is a carefully crafted nicotine delivery system containing Each draw of a cigarette yields 1 mg to 2 mg of nicotine, depending more than 4,000 other chemicals. Once inhaled, nicotine is absorbed on the strength of the draw, with about 10 inhalations per cigarette. through the mucous membrane in the oral cavity and alveolar surface A pack-a-day smoker receives a dosage of about 200 mg of nicotine of the lung. Within 10 seconds of inhalation, nicotine reaches the per day. The vast majority of smokers (about 85% to 90%) use more brain, causing the release of dopamine. Physical effects include the than five cigarettes per day, and exhibit clear symptoms of nicotine release of adrenaline, with a corresponding increase in the smoker’s dependence. In most cases, one a smoker begins the habit, daily respiration and heart rate. Psychological effects associated with consumption increases over a period of years, then levels out [24]. smoking cigarettes include feelings of pleasure, well-being, and a Each year, millions of smokers vow to quit smoking, but more that 85% sense of peace or control. Many cigarette smokers tout its ability to are likely to relapse within 1 week. Most smokers feel the symptoms of energize and relax at the same time. nicotine withdrawal within a few hours of quitting. Cravings to smoke These highly desirable effects dissipate quickly, requiring the individual and symptoms of irritability, depression, anxiety, lack of ability to to repeat the process to reach the dosage of nicotine that allows him concentrate, and insomnia peak after a few days. Most smokers who quit or her to induce or maintain feelings of well-being. If the individual is experience severe withdrawal symptoms for no more than a few weeks, nicotine-dependent, he or she will experience symptoms of withdrawal but some may find symptoms lingering much longer[25] . upon discontinuing use. Nicotine is extremely addictive. Between 35% An important part of smoking cessation is avoiding common triggers and 50% of all people who try a cigarette develop an escalating pattern that make cravings worse and encourage relapse. For some, this might [22]. The level of nicotine dependence among adults is typically of use be the sight of a cigarette, having a cocktail, or socializing at a party. higher in those who had their first smoking experience at a younger age; Behavioral therapies can be useful in identifying these triggers and in general, the younger the person when he or she first smoked, the more addressing them with strategies that strengthen the individual’s resolve likely he or she is to be dependent on nicotine [23]. not to smoke. Nicotine replacement therapies and medications may facilitate smoking cessation in some people. Cigars While the specific origins of the cigar are unknown, they have likely The cigar wrapper, on its own, has the same concentration of been a part of Central American cultures for thousands of years. The hazardous compounds as a typical cigarette, and creates more carbon word cigar is thought to be related to the Mayan word for smoking. monoxide per gram of tobacco burned [28]. In the United States, pipes were the only method of smoking tobacco Cigars vary markedly in size, but most are quite a bit larger than until the late 1700s, when cigars brought from Cuba ignited a demand cigarettes. A traditional cigar contains about 5 g to 15 g of tobacco, for the product. Domestic tobacco production grew in importance and while the majority of cigarettes contain less than one gram. The larger [26]. Cigar sales were relatively popularity throughout the next century size of cigars means more tobacco and longer smoking times, resulting stable for years, expect for a decline in 1913, the year manufactured in extended periods of exposure to substances such as carbon monoxide, cigarettes were introduced; and an increase in 1964, the year that the hydrocarbons, ammonia, and cadmium, as well as tar and nicotine [29]. U.S. Surgeon General’s report on the dangers of cigarette smoking was released. Cigars continue to have a loyal following, however, with cigar Cigars contain varying amounts of nicotine—ranging from the amount smokers comprising a relatively stable 5% of the U.S. population [27]. in one cigarette to one pack of cigarettes—with the nicotine amount directly correlated with the amount of tobacco in the cigar. Nicotine The majority of cigars are made from a single type of wrapped can be absorbed through the lips from both cigars and cigarettes, but air-cured, fermented tobacco. Cigars almost always have higher levels from cigars are absorbed more readily due to the higher (more concentrations of toxins and carcinogens than cigarettes because they alkaline) pH of cigar smoke. Because cigar smokers absorb more tend to be larger, but also because the cigar fermentation process nicotine across the oral mucosa than cigarette smokers, they are able results in smoke that is higher in cancer-causing nitrosomes than to get a sizable dose of nicotine without inhaling the smoke (to get a cigarette smoke, as well as nitrogen oxides and ammonia. similar dosage of nicotine, a cigarette smoker would have to inhale far more smoke, far more deeply into the lungs).

Page 48 Dental.EliteCME.com In fact, nicotine is ingested the entire time an individual’s lips are in number of inhalations, it is actually associated with many of the same contact with the cigar tip, even if the cigar is not lit [30]. risks as cigarette smoking, as well as a few of its own. In general, for cigar and cigarette smokers, the risks of smoke-related diseases are While some believe cigar smoking is associated with a lower risk of [31] disease than cigarette smoking because of differences in the depth and proportional to their exposure to tobacco smoke . Nicotine delivery It is not known how many cigar smokers exhibit symptoms of that cigar smoking may have a lower potential for nicotine dependence. While cigar smokers absorb high levels of nicotine into the addiction than cigarette smoking. Heavy, frequent cigar smoking body by inhalation through the lungs as well as absorption through the significantly increases the potential for addiction. oral mucosa, studies suggest the degree of dependency and addiction is ●● Patterns of use among cigar smokers (infrequent or inconsistent less in cigar smokers than cigarette smokers for these reasons [32]: use, far less average tobacco smoked per day, and lower rates of ●● Delivery systems that distribute nicotine slowly, in low doses, such inhalation) are quite different from those of cigarette smokers, as the nicotine patch, gum, or smokeless tobacco, are associated typically producing less psychological and physical symptoms with fewer, less severe, and a shorter duration of withdrawal of dependence. symptoms. Cigar smoking typically distributes nicotine more ●● Cigar smokers, unlike chronic cigarette smokers, are unlikely to begin slowly than cigarette smoking. smoking until young adulthood. In combination, these factors add up ●● Lower rates of inhalation in cigar smokers and slower (not less) to far less hazardous smoking habits and less risk of addiction. absorption of nicotine through the lining of the mouth suggest

Inhalation and risk of disease Cigar and cigarette smoke share many characteristics, which suggests tissue, which absorbs the smoke’s toxic elements, particularly carbon comparable patterns of disease, but this is not the case. Cigarette and monoxide. Surveys show the majority of cigarette smokers inhale smoke cigar smoking are associated with distinct diseases and degrees of risk into the lungs, while the majority of cigar smokers do not [33.1]. due to differences in patterns of use between the two products. Cigar Tobacco-related cancer accounts for about one-third of all cancer smokers are more likely to be nondaily users of tobacco, and inhale deaths, with smokers showing cancer rates two times as high as those less deeply than cigarette smokers. There are also differences between of nonsmokers. Lung cancer is the main cause of cancer deaths, with [33]. the two products in the composition of smoke nine out of 10 cases of lung cancer associated with cigarette smoking. While the lower pH of cigar smoke makes nicotine absorb more easily Cigarette smokers also show higher mortality rates for coronary heart across the oral mucosa, the lungs more readily absorb the higher (more disease and chronic obstructive pulmonary disease (COPD). Mortality acidic) pH of cigarette smoke. Cigarette smokers must inhale more rates for cigar smoking are primarily associated with cancers of the frequently and deeply to ingest comparable quantities of nicotine as is larynx, oral cavity, and esophagus. Very heavy cigar smokers, or those absorbed through the oral mucosa of cigar smokers. Inhalation increases who inhale deeply, show higher risks for lung and heart disease, with the cigarette smoker’s exposure to tobacco smoke through lung an increased risk for aortic aneurysm [34]. Symptoms and effects Smoking tobacco has been linked to cancers of the mouth, pharynx, Tobacco smoking is one of the most common risk factors for oral larynx, esophagus, lung, stomach, pancreas, cervix, kidney, and cancers, with tobacco smokers showing a rate of oral and pharyngeal bladder. Heavy tobacco smokers exhibit clear indications of the cancers up to 10 times higher than nonsmokers. All cigar and cigarette product’s use, with adverse effects on the oral cavity due to the oral smokers expose their lips, mouth, tongue, throat, and larynx to many tissue’s direct exposure to smoke, and the systemic effects of nicotine, hazardous chemicals in smoke inhalation, resulting in increased among other chemicals [35]. incidence of precancerous and cancerous conditions [37][38]. Exposure to tobacco smoke exacerbates inflammation, dry mouth Smoking is associated with leukoplakia, a precancerous lesion occurring (xerostomia), and vasoconstriction, reducing salivary flow in the mouth in the soft tissue of the mouth that appears as a white patch or piece of and blood supply to the oral tissues. Vasoconstriction and xerostomia plaque, and cannot be removed by scraping. Because leukoplakia is rarely (dry mouth) contribute to the oral conditions most prevalent in heavy painful or irritating, the patient may be unaware of the condition unless smokers, including candidiasis (a fungal infection commonly known he or she seeks professional dental care. Without treatment or smoking as a “yeast” infection or “thrush”), smoker’s keratosis (a potentially cessation, the number of lesions and risk of cancer can increase. cancerous white discoloration, usually caused by heat and seen on the Squamous cell carcinoma is the most common oral cancer linked roof of the mouth), nicotine stomatis (a lesion that typically progresses to cigarette smoking. While it can be found anywhere in the mouth, from keratosis) , and oral cancers. These conditions pose an increased it is most commonly seen on the lateral borders of the tongue, the risk of bone loss and damage to the tooth and gums. Smokers have ventral surface of the tongue, or the floor of the mouth. If detected a much higher incidence of periodontal disease and severe forms of early enough, the prognosis is favorable, but half of those who detect gingivitis than nonsmokers, including acute necrotizing gingivitis and squamous cell carcinoma 2 or more years after its onset will die from necrotizing ulcerative gingivitis (NUG), severe bacterial infections, also the cancer or related complications. known as “trench mouth,” which cause inflamed, swollen, and bleeding gums, and more often require root canal [36]. Statistics show highly elevated rates of tongue cancer for all tobacco smokers, strongly correlated with the total amount of tobacco smoked Tobacco residue trapped on the tongue causes discolored papillae and per day and depth of inhalation. enamel (yellowish to dark brown or black). Food and bacteria stuck to the surface of the tongue inhibit the shedding of dead cells, increasing The risk of esophageal cancer is similar among cigar and cigarette the chance of halitosis. While smokers are prone to xerostomia, smokers, and much greater than among the rate of nonsmokers, but cigar the act of smoking triggers a temporary burst of saliva associated smokers show higher rates of mortality. This is due to a greater build-up with increased calculus production. The excessive stain and calculi of tobacco residue coating the inside of the cigar smokers’ mouth in contribute to increased rates of gum disease. comparison to cigarette smokers. The coating combines with saliva and is swallowed. This carcinogenic mixture travels down the esophagus, increasing tissue exposure and the risk for oral and esophageal cancers. Dental.EliteCME.com Page 49 Management and clinical implications Smokers exhibit a far higher incidence of severe periodontal diseases Because tobacco use is one of the most significant causative and compared with nonsmokers, largely due to the direct effects of smoke contributing factors for oral cancers and periodontal diseases, careful exposure. While periodontal disease is normally indicated by bleeding oral examinations for early symptoms of disease are essential. of the oral tissues upon probing, vasoconstriction in heavy smokers Routine care should include a meticulous oral evaluation and careful inhibits blood flow, so it is important to recognize other indications of documentation, with preventative oral cancer screenings for cancerous periodontal disease, as this inhibited blood flow can be misleading[39] . and precancerous conditions. Early detection techniques and products Recuperation may be delayed in patients who smoke because the include visible light fluorescent wands, toluidine blue staining, vital [41]. reduced blood supply available to the oral tissues causes wounds to staining, DNA-evaluation, and saliva-based oral cancer diagnosis heal more slowly, especially those directly exposed to smoke. Dry The American Dental Association (ADA) advises dentists to follow its sockets are four times more prevalent among smokers after oral standards of care by including a caries evaluation as standard dental surgery than nonsmokers. They are likely to occur when a patient hygiene protocol for patients who are substance abusers. If amenable, returns to smoking too quickly after surgery, interrupting the process patients should be encouraged to describe their smoking habits, oral of blood coagulation (clotting) required for bleeding to stop and hygiene practices, eating habits, or other practices or behavior (such wounds to heal. These are significant factors in postsurgical care, as alcohol consumption) that might increase risk of disease or adverse with smokers treated for periodontal disease experiencing far less effects from dental procedures or treatments[42]. successful treatment results than nonsmokers [40].

The dentist’s role in cessation and intervention Tobacco is a significant risk factor for oral disease. Dental care providers most smokers) can take advantage of tobacco cessation treatment have the opportunity to inform patients about the risks associated with developed specifically for this group[46][47] . tobacco use and refer them to tobacco cessation resources. Although The American Dental Hygienists’ Association (ADHA) established clinicians often ask their patients about their tobacco use as a matter guidelines for a smoking cessation program within the dental office of course, most do not attempt to discuss the possibility of smoking called the Ask.Advise.Refer campaign. A one-page information sheet cessation. In one study, one-third of all teenagers reported their is available at http://doh.sd.gov/prevention/assets/AARposter.pdf). physician counseled them about the dangers of tobacco, but only one- Members of the dental team can refer their patients to telephone- [43]. fifth reported their dentist provided a similar message based tobacco cessation services, accessed through a toll-free number. Research suggests that the limited extent to which dentist are This service provides callers with educational materials, referral implementing recommended guidelines for smoking intervention to treatment programs, and individual counseling by phone [48]. represents a significant missed opportunity to change smoking Detailed information about Ask.Advise.Refer. can be found at http:// behavior, particularly among adolescents. Surveys show the majority smokingcessationleadership.ucsf.edu/Downloads/catolgue/cot10209.pdf of smokers have a desire to quit, and would accept assistance from Other steps that facilitate smoking cessation among patients are: a physician. Dentists should be encouraged to know that a number ●● Availability of nicotine replacement products (e.g., patch, gum, of studies show patients offered cessation services (such as referrals lozenge, inhaler, spray) or prescription medication (e.g., bupropion) to substance abuse treatment professionals) feel increased levels of proven effective in relieving nicotine withdrawal symptoms [49]. satisfaction with their health care provider; and a physician or dentist’s ●● Resources for referrals to counseling services, support groups, and recommendation that a patient stop smoking was associated with [50] [44][45] medical assistance, if necessary . increased attempts by the patient to quit . ●● No lecturing or judgment; patients look to dental professionals to help Dentists have a professional responsibility to address tobacco them stop smoking, but are unlikely to pursue this objective if the dependence with their patients, educate patients about tobacco dental environment feels critical or unreceptive. Training in use of the cessation, and provide support. Failure to do so is a missed opportunity 5 A’s (see Section V for more detail) can educate office personnel and to prevent potential harm to the patient’s oral and general health. Even clinicians about supportive and effective interventions [51]. patients who see a physician or dentist only once a year (typical for Most smokers experience a number of failed attempts before finally quitting the habit [52]. Hookahs Traditional pipe smoking produces much more tar and nicotine per gram many of the same health risks posed by cigarette smoking, including of tobacco than cigarette smoking. Water pipes (also known as bongs) nicotine dependence, periodontal disease, high blood pressure, heart block some of these particles because the user draws smoke through disease, asthma, COPD, and many types of cancer. Among the harmful water in a chamber, which cools and filters it before it inhalation. ingredients that water does not filter out are nicotine, tar, heavy Hookahs are a particular type of water pipe, in which smoke is inhaled metals, carbon monoxide, and a host of other toxins and carcinogenic by mouth through a tube or hose. Hookahs may be communal, with compounds associated with oral cancer, among many other diseases. a number of people sharing one water pipe, and each person drawing Some establishments use charcoal or wood to light the hookah. The smoke through a hose that may or may not be shared with others. smoke produced when these materials combust contains carbon Hookah smoking originated in Persia (now Iran) and India more monoxide and PAH, which have carcinogenic properties, among other than 500 years ago. In the past 20 years, hookahs have become more hazardous compounds [54]. common in the United States, with hookah bars and cafes growing in A study published in the Journal of Periodontology reported that hookah [53]. popularity, especially for young people aged 18 to 25 years smoke might be even more addictive and detrimental to dental health Some users think hookahs are a cleaner, safer, or less addictive than smoking cigarettes. Their research provided strong evidence that alternative to other tobacco smoking methods because the tobacco hookah smokers expose themselves to greater volumes of tobacco is typically fruit-flavored and the smoke is filtered by water. These smoke than cigarette smokers, due to the depth of inhalation and social assumptions are contradicted by a recent World Health Organization context or physical environment of hookah smoking [55]. (WHO) study that found an association between hookah smoking and

Page 50 Dental.EliteCME.com Hookah smokers take long, deep breaths and smoking sessions Additionally, smokers in hookah bars have little control over are relaxed, and may last hours as hookah bars are commonly the the cleanliness of the water pipes. Smokers are at higher risk for evening’s destination. Often, the smoker is sharing a hookah with contracting and spreading communicable diseases through saliva. friends. While smoking a cigarette takes a matter of 10 minutes or Like other smoking methods, hookah smoking is associated with bad so, a session of hookah smoking is likely to last an hour or more, breath and discoloration (yellowing) of the teeth; and like any other significantly increasing the length and amount of exposure to smoke. nicotine delivery system, smoking tobacco with a hookah can lead to According to the WHO study, hookah smokers may inhale the dependence and addiction. equivalent of 100 or more cigarettes’ worth of smoke in a sitting [56]. Smokeless tobacco Smokeless tobacco (also called chewing tobacco or snuff, among other This successful marketing strategy made smokeless tobacco one of terms) is tobacco leaves that are typically sweetened, ground, and/or the fastest growing bad habits in North America. Contributing to its formed into various shapes and textures. In the mid-1980s, during a popularity was the perception that it was safer than smoking cigarettes. precipitous rise in use, it was estimated about 5% of individuals in the In the late-1980s, health professionals, legislators, and parents pressured United States were smokeless tobacco users [57]. The surge in popularity tobacco companies to stop advertising chewing tobacco using athletes, was attributed to aggressive advertising campaigns that recast the image and to produce a public awareness campaign acquainting the general of smokeless tobacco using professional athletes to promote the product. public with the potential dangers of smokeless tobacco [58].

Prevalence and patterns of use Studies using statistics from 2009 to 2011, estimated between 3% are far more likely to be members of the working class (blue-collar) and 3.5% of all individuals in the United States used smokeless than office workers (white-collar)[60] . tobacco, including about 7% of all high school students and 3% of Adults between 18 and 25 years of age show the highest rate of smokeless all middle school students. In most ages, males are more likely to tobacco use among the general public, at slightly more than 5%. Military use than females; however, statistics from middle school students in personnel show the highest incidence of smokeless tobacco use, with one 2009 reported a slightly higher percentage of girls than boys using study estimating more than 12% were current smokeless tobacco users [61]. smokeless tobacco (1% of boys, and 1.5% of girls). Native American men and women, living in Canada and Alaska, show particularly high Studies show these demographic patterns of use are no accident. The rates of smokeless tobacco use [59]. five largest tobacco manufacturers spend vast amounts of money developing smokeless tobacco marketing campaigns targeted to Smokeless tobacco users are predominantly Caucasian males living in specific populations, those considered most susceptible to their the Southern United States. They are between the ages of 10 and 30 message [62]. Not surprisingly, there is significant crossover between years of age and had their first experience with smokeless tobacco at smokeless and smoking tobacco, with more than 40% of smokeless an average age of 19 years. More than 10% started in the 6th grade, tobacco users also smoking cigarette [63]. and more than 25% started in the 8th grade. Smokeless tobacco users

Types of smokeless tobacco The two main types of smokeless tobacco are chewing tobacco and these ground or loose strips of cured tobacco leaves are sweetened and snuff, each of which is sold in many forms. Depending on the product, usually packaged in a pouch. Two other forms of chewing tobacco are tobacco may be pulled from the pouch by hand (in a pinch), as well much less common: (a) a plug is made from compressed cured tobacco as cut or bitten off from a larger piece. The material is placed in the leaves that are combined with sweet syrup and wrapped in a tobacco cheek, and the ball or wad of tobacco is positioned between the teeth leaf and (b) a twist or roll is made of cured flavored tobacco leaves and gum where it is alternatively held, or chewed, over some length twisted or braided together. Together, plug and twist chewing tobaccos of time. Almost immediately after placement in the mouth, nicotine is are favored by about 1% of the smokeless tobacco market. absorbed into the bloodstream through the oral mucosa. Dry snuff is a fire-cured tobacco, processed into a powder, taken in a Most smokeless tobacco users suck or chew on the tobacco, then spit pinch, orally or inhaled through the nose. Its use has been declining for out the saliva containing the tobacco juice, although a small portion is years, and now totals about 1% of the smokeless tobacco market. Most swallowed. Those who hold the tobacco in their mouths for longer periods users are older adults. and swallow more tobacco mixed with saliva increase their exposure to The tobacco industry has introduced a variety of new and innovative the estimated 28 carcinogens (plus nicotine) in smokeless tobacco [64] . smokeless tobacco products in recent years. These items use Snuff comes in both moist and dry forms, but the most popular compressed, processed tobacco leaves to make a dissolvable powder smokeless tobacco by far is moist snuff, comprising about 75% of that can be consumed orally without the need to spit out tobacco residue. the smokeless tobacco market, and a special appeal to young people Products take the form of lozenges, tablets, tabs, strips, and sticks [65]. Moist snuff is made from cured and fermented tobacco leaves [].Tobacco lozenges (not the same as nicotine lozenges, used for smoking processed into fine particles. A pinch (also called a dip or rub) is cessation purposes), look and dissolve in the mouth like hard candy [66]. placed between the cheek or lower lip and gum, commonly in the Snus are a form of smokeless tobacco packaged in a small pouch, which gingival groove (sulcus) and mandibular labial mucosa. Products are is placed into the area between the upper lip and gum. The user keeps attractively packaged in convenient ready-to-use packets resembling the product in place for less than one hour, than discards it. While data tea bags (called sachets). The tobacco remains in the packet, which on these new products are very limited, a recent study estimated that is placed in the mouth. While most forms of snuff used in the United 6% of adults aged 18 years and older in the United States have tried States are oral products, some types of dry snuff are inhaled through dissolvable tobacco products, and more than 5% have tried snus [67]. the nose, but the practice is more common in European countries. The second most popular type of smokeless tobacco, with 22% of the market share, is chewing tobacco. Also known as chew or chaw,

Dental.EliteCME.com Page 51 Symptoms and effects Smokeless tobacco is associated with a number of cancers and Dental caries, especially near the placement site, are common among precancerous conditions of the mouth, including [68]: smokeless tobacco users, in part because the product is sweetened, ●● Pathologic changes of the oral mucosa, indicating an increased risk then held in the mouth against the teeth for an extended period. for cancer of the oral cavity. Decreased saliva flow means the sweetened tobacco residue stays in ●● Leukoplakia, a precancerous lesion of the soft tissue in the mouth the mouth for a longer period of time, rather than washing relatively that consists of a white patch or plaque that cannot be scraped off, rapidly down the esophagus. Studies suggest that smokeless tobacco and can lead to aggressive oral cancers if left unchecked. encourages bacteria growth, including Streptococcus, which is often ●● Verrucous carcinoma, an aggressive form of squamous cell associated with tooth decay [70]. carcinoma that is preceded by severe leukoplakia. In most Quitting smokeless tobacco may result in nicotine withdrawal cases, stopping the habit before the onset of cancer results in the symptoms that include cravings, anger/irritability, anxiety, depression, disappearance of lesions and a return to normal mucosa. or weight gain. Most of these effects are short-term, but can be longer ●● An increased risk of developing complications at the location in or more severe for those who have used heavily for many years. Like the mouth where the patient repeatedly places the tobacco product. cigarettes smokers, those who use smokeless tobacco most frequently Smokeless tobacco is associated with recession of the gums, gum disease, show the most severe patterns of withdrawal. In general, smokeless and tooth decay. Periodontal disease and gingival recession are caused by tobacco withdrawal symptoms are less severe than those experienced irritation of the gum adjacent to the placement site, which usually shows by cigarette smokers, because most smokeless tobacco formulations a higher degree of recession. In most patients, gingival inflammation is deliver nicotine relatively slowly or in low daily doses. indicated by bleeding of the oral tissues upon probing, but heavy nicotine use causes chronic vasoconstriction that inhibits this effect [69].

Management and clinical implications Dental professionals are in a key position to identify smokeless tobacco to the patient, with attention to degree of damage at the location where use, explain its negative health and cosmetic effects, and discuss a tobacco is repeatedly placed against the gum [70]. plan of action for quitting. Young people are likely to have little sense Dental professionals should work with the patient and his or her of the destructive and unattractive results of long-term use. Images of primary care physician, if the patient consents and expresses interest, smokeless-tobacco-related oral cancers, or invasive surgeries required to to develop a plan for nicotine replacement therapy in the form of address them, quickly communicate the potential severity of health risks patches, gum, or lozenges. Many prescription medicines approved for associated with smokeless tobacco. The dental professional should relay nicotine addiction and smoking cessation treatment are likely to help any observable signs of precancerous changes in tissue to the patient. those who use chewing tobacco. Clinicians should take the time to point out the visible indications of use

Identification and intervention Smokeless tobacco users exhibit characteristic oral symptoms that ●● Limit contact with smokeless tobacco users, particularly soon after indicate excessive use, but early signs are not obvious. Questions quitting. Ask those around you to avoid using and avoid going about smokeless tobacco use should be included on the medical history places where others will be using. form, along with questions about smoking tobacco, alcohol, and other ●● Avoid handling smokeless tobacco, having it near you, or in an common addictive substances. accessible location. Avoid activities or people that you associate with using smokeless tobacco, at least temporarily. In recent years, strategies to reduce the rate of smokeless tobacco use in ●● Focus on the negative and positive aspects of not using tobacco, the United States focused primarily on preventing the practice, rather than including financial, health-related, and cosmetic effects. identifying and treating it. But, since many users start at a very young age, ●● Seek counseling. Attend support group meetings and seek a that strategy has been rethought. Smokeless tobacco users suffer relatively referral to a specialist trained in nicotine cessation treatment for few and mild withdrawal systems compared with other types of tobacco smokeless tobacco use. users, suggesting smokeless tobacco users may be particularly good ●● Some find a nonnicotine replacement (usually an herbal blend) candidates for intervention and/or cessation treatment [72]. for smokeless tobacco an effective addition to other therapies, as Both smoking and chewing tobacco are delivery systems for nicotine, it fills in a behavioral gap of habitual actions associated with the creating dependence in the same manner. Although most tobacco practice of chewing tobacco. Using nontobacco dips, or chewing treatment programs were developed for smokers, all address nicotine nonnicotine gum can provide support or comfort even without dependence and addiction, and most can be adapted for patients who nicotine delivery. If gum or another substance is chewed or placed are smokeless tobacco users [73]. in the mouth as a substitute for smokeless tobacco, it should be There are many resources to support patients quitting smokeless sugarless and have ingredients that increase saliva flow. tobacco. A good starting place is the American Cancer Society, which recommends the following strategies for those trying to stop [74]: Alcohol Alcohol is an addictive substance formed by a chemical reaction high financial, emotional, and physical price for their habit, alienating produced when starches and sugars (usually in grains) are combined family and friends, risking loss of employment, and endangering with yeast, and left to ferment. There are many types of alcohol, such themselves and/or others with injudicious behavior. as methyl alcohol (rubbing alcohol) and butanol, but ethyl alcohol Alcohol metabolizes very quickly upon consumption and is rapidly (also called ethanol) is the only form they can be consumed without absorbed into the bloodstream through the stomach and small risk of poisoning (although sufficient amounts of ethanol can be fatal). intestine. Upon reaching the brain, alcohol alters the action of specific Although alcohol is a legal drug, addiction to it can be as severe and neuroreceptor sites, including those for serotonin, GABA (Gamma- dangerous as dependence on many illegal substances. Abusers pay a Aminobutyric acid), and glutamine. The action of alcohol on these

Page 52 Dental.EliteCME.com and other neurotransmitters in the brain’s pleasure center produces the CNS impairment caused by alcohol are slurred speech, blurred vision, characteristic feelings of intoxication associated with alcohol [75]. and poor equilibrium, all familiar signs of drunkenness. Alcohol depresses normal function of the central nervous system (CNS), Alcohol also produces significant effects on the frontal cortex, or outer which controls a number of critical body functions, including regulation layer of the brain. This part of the brain controls conscious thought of motor skills required for speech, muscle coordination, and use of the and judgment. Alcohol use decreases inhibition and increases poor sense organs. The CNS is responsible for assessing information received decision-making, so those under the influence are more likely to through the senses and responding appropriately. Common symptoms of behave differently than if they were sober.

Prevalence and patterns of use Studies of alcohol consumption use the following measurements to ●● Binge drinking is consuming five or more drinks within 2 hours quantify alcohol consumption: a typical drink contains 0.6 oz pure alcohol. for men, and four or more within 4 hours for women. Recent Therefore, one drink = 12 oz of beer, OR 5 oz of wine, OR 1.5 oz (a shot) survey data showed about 23% of persons aged 12 or older in 2012 of 80-proof distilled liquor, such as gin or vodka. While studies vary in the (almost 60 million) reported binge alcohol use in the past month, way they categorize consumption patterns, the following classifications with about half (30 million) reporting binge drinking on a regular [76] are useful in discussing alcohol consumption : basis. A 2006 Centers for Disease Control (CDC) study concluded ●● Problem drinking is primarily identified by the individual that a relatively small number of binge drinkers are responsible for repeatedly acting in an uncharacteristic way under the influence a great majority of the financial, emotional, and physical costs to of alcohol (in a way that he or she would not act if sober). The [77] National Institutes of Health (NIH) report 15% of people living in society caused by alcohol abuse . the United States are problem drinkers. Of this group, 5% to 10% These types of consumption patterns are considered high-risk drinking of men and 3% to 5% of women qualify as alcoholics. behaviors. The National Institute on Alcohol Abuse and Alcoholism ●● Heavy drinking is consuming five or more drinks on the same (NIAAA) estimates about 30% of the U.S. population engage in risky occasion, for 5 or more days of the past 30 days. According to drinking behaviors. one report, 6.5% of the U.S. population aged 12 or older (about 17 million people) drank heavily in the past month.

Distinguishing alcohol abuse, dependence, and addiction (alcoholism) It is estimated about 10% of women and 20% of men in the United Although dependence and addiction are sometimes used interchangeably, States abuse alcohol. Abuse is characterized by a maladaptive pattern there are important differences between them. Physical dependence of alcohol consumption that continues although it produces adverse is indicated by the need to consume increasing amounts of alcohol to consequences for the user. Consumption often begins in the teen years, achieve the same level of effects (tolerance) and by withdrawal symptoms with drinking patterns established by young adulthood. Alcohol abuse if use discontinues. Physical dependence is a necessary component of is characterized by heavy use, but alcohol abusers are not necessarily addiction, but is not itself addiction. Alcohol addiction (alcoholism) is a physically dependent or addicted to alcohol. An alcohol abuser does chronic, progressive disease affecting more than 14 million people in the not necessarily have an increased tolerance for the substance, nor does United States. Addiction differs from physical dependence because it has abstinence from alcohol necessarily cause withdrawal symptoms [78]. a psychological, as well as physical, component [78].

Physical symptoms and effects Excessive alcohol consumption weakens the immune system is more destructive the longer it remains on the teeth. An individual and adversely affects every organ of the body. It contributes to who regular drinks, vomits, and falls asleep or passes out will exhibit malnutrition, neurological disorders, and liver disease, and increases extensive damage from the prolonged exposure to acids and sugars. the risk of cardiovascular disease and cancer. Alcohol-induced Chronic regurgitation of alcohol is associated with severe erosion of irritation of the gastrointestinal (GI) tract causes lesions, hemorrhage, the palatal surface of upper incisors, and lesions in the esophageal and ulceration of the digestive system. Alcohol is associated mucosa at the gastroesophageal junction [8][83][84]. with increased risk for complications in dental and other medical Alcoholics tend to have more inflammation of the gingiva and a procedures due to adverse interactions between alcohol and many higher incidence of dental carries and missing teeth than nonalcoholic [79]. pharmaceutical substances used in treatment individuals. Excessive consumption is associated with significantly Common features of excessive alcohol consumption include [80]: increased rates of chronic inflammatory periodontal disease (CIPD), ●● A coated tongue and significant deposits of plaque and calculi. and deep gingival pocketing, indicative of bone loss. Research suggests ●● Enlarged parotid salivary glands, which is a symptom of potential that alcohol causes inflammation and periodontal disease by increasing liver disease [81]. inflammatory cytokines in the gingival crevice, and weakening neutrophils ●● Xerostomia, which exacerbates the already unhealthy oral that would usually reduce the increased levels of bacteria [85][86]. environment and increases the risk of complications, such as Alcohol abuse is a risk factor for oral cancers, with alcoholics more opportunistic infections or dry sockets after extractions. than 10 times more likely to develop oral squamous cell carcinoma ●● More severe dental erosion than in nonusers due to decreased than the general population. Research suggests that acetaldehyde, salivary secretions. produced when the body metabolizes alcohol, makes mucosal surfaces ●● Symptoms of alcohol-induced bruxism, which causes grinding more vulnerable to carcinogens by attaching to proteins in the oral during REM sleep that is particularly abrasive in combination with cavity that triggers an inflammatory response associated with cancer reduced salivary flow. cell growth. The most common oral cancer sites are on the lips, tongue Severely damaged and decayed enamel and extreme tooth erosion (top and underside), gingiva, and palate [87][88]. may be the result of the patient regurgitating highly acidic vomit on a regular basis, a trait of binge drinkers. Excessive alcohol consumption and vomiting creates an acidic oral environment that

Dental.EliteCME.com Page 53 Management and clinical implications All office and clinic personnel should be able to recognize the signs of injectable/topical anesthetics), or an accidental injury (the patient trips inebriation in patients. Excessive alcohol consumption may be obvious in the bathroom and hits his head on the sink). It is not unheard of for by the smell of alcohol on the breath or a product used to mask it, such a dental office to keep a breath analyzer (Breathalyzer) onsite to test a as mouthwash Alcoholics exhibit hypertrophy of the parotid glands, patient’s alcohol level to ensure treatment is not contraindicated. impaired motor function exhibited in slurred speech or inability to sign Office personnel should be familiar with policies relating to drug and in, poor balance, or inappropriate behavior. Because alcohol can cause alcohol use, as well as the best way to address an intoxicated patient dizziness or light-headedness, as well as disturbed balance, it is a risk without alienating or embarrassing him or her. Testing the patient’s factor for increased falls and fall-related injuries [89]. blood alcohol levels or breath analysis provides conclusive evidence A patient who comes to the appointment in an inebriated state must without having to interrogate the individual, but may be considered be rescheduled and accompanied to his or her home by a responsible far more intrusive. Both may cause the patient to react defensively. person. While this may create awkwardness or potentially offend the Encourage the patient to reschedule, but require him or her to sign patient, it is necessary. Not only is the dental team ethically responsible an agreement that he or she will not consume alcohol for a specified to act in the best interests of the patient, the dental office would be period before and after the next appointment. liable if adverse consequences resulted from treatment (administering

Medical management Many alcoholics suffer from serious tooth decay and gum disorders. excessive amounts of alcohol metabolize amide drugs in such a way Research suggests the increased prevalence and rapid progression that the substance is likely to bypass the injection site, rapidly enter the of dental disease among alcoholics is due not only to the direct bloodstream, and circulate throughout the body. The alcoholic’s blood physical effects of alcohol, but lifestyle choices that increase the risk levels will rise more rapidly and reach dangerous levels more quickly and severity of diseases affecting the oral cavity. Alcohol abusers than a nonusing patient, and fall much more slowly. demonstrate inconsistency in oral hygiene habits, brushing and flossing Attention to repeated dosage is extremely important, as alcoholics are less effectively and consistently than the general population. far more susceptible to overdose reactions than other patients. The patient requires a dose of local anesthesia that produces adequate pain All these factors can contribute to extreme decay, particularly if the relief, but reduces the alcoholic’s greater susceptibility to dangerously patient delays treatment, which is common. high blood levels and potential overdose that are associated with While excessive alcohol consumption weakens the immune system standard administration practices [93][94]: and adversely affects virtually every organ and body system, a primary 1. When administering an initial dose of amide local anesthetic or concern in the clinical treatment of an alcohol abuser are the very benzodiazepine, a normal dose is usually indicated. Monitor the serious complications associated with drug interactions involving patient to ensure no ill effects. alcohol and pharmaceutical substances used in dentistry [90]. 2. Administration of subsequent doses requires monitoring patient blood levels and reducing the dosage amount or extending the The Food and Drug Administration (FDA) recently identified length of the intervals between doses to prevent excessive levels of 50 commonly prescribed drugs with ingredients that interact or the drug from building up in the blood. react with alcohol including analgesics, antibiotics, and sedatives. 3. Use of a vasoconstrictor may assist in providing the desired Reformed alcoholics may be highly susceptible to relapse if exposed effects at the local site without running the risk of excessive to even a small amount of alcohol. Many over-the-counter (OTC) systemic absorption. and prescription drugs, as well as personal hygiene items (such as mouthwash) contain alcohol. Because alcohol (found in antacids, Excessive alcohol use damages the liver and bone marrow, resulting analgesics, antidiarrheals, and tranquilizers) poses such a significant in bleeding disorders and the possibility of spontaneous or excessive risk for individuals in recovery, extreme caution is necessary in bleeding during a dental procedure. If this occurs, stop treatment [92] prescribing medication or recommending oral hygiene products . and apply digital pressure immediately. Liver damage decreases Central nervous system (CNS) depressants, such as sedatives and the body’s ability to store or convert adequate levels of vitamin benzodiazepines (anti-anxiety drugs such as Xanax), should not be K, needed for blood coagulation. This deficiency creates the prescribed to patients who present symptoms of alcohol abuse. The potential for clotting disorders (thrombocytopenia) and associated combined effects of alcohol (a depressant) and narcotics (any drug with risks. Medical evaluation and blood coagulation tests should be sedating effects), or other types of prescription drugs, greatly increase administered, and the findings carefully reviewed before moving the patient’s risk of adverse consequences, such as respiratory failure. forward with further treatment. Acidic drugs, such as aspirin and The use of local anesthetics (particularly amides) and benzodiazepines, nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided as well as other drugs metabolized in the liver, do not act the same in due to increased risk of bleeding in the stomach. Acetaminophens alcohol abusers as they do in other patients. Individuals who consume should be limited to a daily maximum of 4 g (4000 mg) [95].

Routine examination protocol Given the increased risks of disease and contraindications ●● Identify concurrent abuse of tobacco products that worsens associated with alcohol abuse, great caution is required with dental disease and increases the risk of oral cancer. This patients suspected of excessive alcohol consumption, even in additional risk to oral health should be explained to patients who routine procedures or examinations. As a matter of course, patients use both products. If amenable, the dentist can introduce tobacco dependent on alcohol require: or alcohol cessation information. ●● Oral cancer screenings to locate premalignant or malignant lesions ●● Frequent neurological assessment. performed at each dental exam, due to the significantly increased risk ●● Vital signs, including pulse rate and blood pressure, monitored of oral cancer and rapid progression associated with alcohol abuse [96]. throughout the appointment. An irregular pulse or hypertension ●● All patients should be educated about the association between may be indications of alcohol addiction [97]. alcohol abuse and oral cancers, and shown how to self-monitor for ●● Patients should be tested to determine their blood counts, liver potential signs of cancer in the oral cavity. function, and blood clotting ability, before the development of

Page 54 Dental.EliteCME.com a treatment plan, as results may dictate what interventions can to cough if the airways become even partially blocked during proceed without risk to the patient. treatment. Should the patient begin choking, vomit or blood may ●● Special attention to keeping the patient’s airways clear. Alcohol present a serious risk of suffocation [98]. abuse may inhibit the gag reflex, reducing the patient’s ability Identification and intervention Alcoholism is often hidden, undetected, and untreated. The dental Dental personnel should do their best to provide an easy and convenient practitioner is in an ideal position to identify patients who abuse alcohol, way to introduce the patient to resources. If the patient considers it not only for the purpose of ensuring their safety, but as an opportunity to acceptable, dental personnel can discretely send appropriate brochures provide a brief intervention or referral, if the patient is agreeable [99][100]. or referral information home with the patient along with a toothbrush, Usually, patients will not admit they have an alcohol problem, and are floss, or toothpaste sample in a take-home bag. unlikely to provide accurate or reliable information about their past If the patient is amenable, discuss the possibility of working with his or or current drug use on the medical form or in discussion with dental her primary care physician to develop an appropriate treatment program. personnel. The dental office should be stocked with information Discuss the potential benefits of prescription medications that help reduce materials from organizations such as Alcoholics Anonymous (AA) or alcohol cravings [101]. Do not force the patient to take informational Rational Recovery (RR), which provide a range of proven services materials, listen to advice, or receive referrals against his or her will. and support in the form of counseling, support groups, and referrals to medical and nonmedical specialists. Marijuana Marijuana is a species of the Cannabis Sativa plant that contains the Public opinion and the scientific community are divided on the psychoactive chemical tetrahydrocannabinol (THC), found primarily question of marijuana addiction. Some consider marijuana a in the leaves and flowering tops of the plant. Not all strains of cannabis nonaddictive substance; others claim users become emotionally or are grown or used for their THC content. physically dependent on the drug after repeated use. Most agree that Hemp, for example is a variety of cannabis with less than 1% of the effects and level of dependence, if any, are highly variable. THC and a long history of industrial use. Its fiber has been used The U.S. federal government currently prohibits the possession, for thousands of years to make rope, and its seeds and oil are a use, and sale of cannabis containing THC. However, in recent years, nutritional food source. more states are choosing to sanction marijuana for medical and/or [105][106]. With state and national laws at odds, the future Unlike hemp, marijuana is grown primarily for its THC content, which recreational use of marijuana legalization is uncertain. ranges anywhere from 3% to 22% [102]. Marijuana consumption produces feelings of relaxation and joy, and Marijuana has been used medicinally for thousands of years. In the stimulates the appetite. When ingested through smoking or eating, United States, medical marijuana is increasingly used to relieve THC, along with dozens of lesser known psychoactive substances symptoms of autoimmune diseases such as multiple sclerosis and (cannabinoids), rapidly enter the bloodstream and travel to the brain, conditions such as anxiety and depression. Currently, the primary [107]: locking into cannabinoid receptors, and triggering the release of applications of medical marijuana are ●● Controlling nausea and preventing vomiting (chemotherapy). dopamine, which produces the characteristic effects (the high) associated ●● Improving appetite (wasting disease). with the drug. Other common effects of THC use are short-term ●● Managing chronic pain (rheumatoid arthritis). memory lapses, xerostomia, impaired motor skills, and vasodilation ●● Bronchial dilatation/anti-asthmatic (asthma). of the eye vessels (bloodshot eyes). Less common side effects include ●● Reducing intraocular pressure (glaucoma). propensity to paranoia, anxiety, or self-consciousness [103][104].

Prevalence and patterns of use Although federal law currently prohibits marijuana, it is one of the Marijuana is most commonly smoked, but is also consumed in foods and most commonly used illegal drugs in the country. According to the beverages. Most patients find the pain-relieving effects of marijuana are most conservative estimates, more than half of the U.S. population stronger when marijuana is smoked, likely because smoking is a much have used marijuana at some point, and the numbers are growing as more efficient way to absorb THC. Marijuana is commonly smoked in more states regulate its legal sale and use. a hand-rolled cigarette, called a joint, or placed in the bowl of a pipe. Dosage is highly variable due to lack of standardization in the size of a The three most common forms are [108]: ●● Marijuana, the dried leaves and buds of the plant, also known by joint or bowl, but is estimated to measure an average of 0.5 g to 1 g of many other names (pot, weed, dope, etc.). Marijuana is the most marijuana leaves. Smokers who combine tobacco and marijuana in a common and least concentrated form of THC (from 0.5% to 1%). cigarette (called a blunt) will use somewhat less. ●● Hashish (or hash), the resin produced by compressing marijuana When marijuana is smoked, THC passes rapidly from the lungs into the flowers. It contains anywhere from 2% to 20% THC. It is formed bloodstream, then throughout the body, linking with receptors in the into small brown or black lumps or bricks. brain. Eating, rather than smoking marijuana, subjects THC to first-pass ●● Hash oil, a thick liquid extracted from hashish that is the most metabolism by the liver, which results in a 25% lower concentration concentrated form of THC (at 15% to 50%) and is heated to of THC in the bloodstream than smoking the same amount. Unlike produce smoke, which is inhaled. smoking, where the effects of THC are felt almost immediately, the THC is increasingly available in products such as candy and soft initial effects of ingested marijuana may not be felt for up to 2 hours, [109]. drinks and is also available as a prescription pharmaceutical. A and are felt longer than those of smoked marijuana pill form of THC is sometimes preferred for medical applications Other tools used to smoke or consume marijuana include water pipes and because it provides a standardized dose, unlike the amount of THC in vaporizers. Water pipes, or bongs, are very much like hookahs, drawing marijuana, which varies widely, with dosage largely dependent on the smoke through a volume of water, which cools and partially filters it. Like amount and method of consumption. hookahs, bongs may appear deceptively safe, and are commonly assumed to be a less risky way to smoke marijuana. However, this is inaccurate Dental.EliteCME.com Page 55 because although water filters some tar and hazardous particles from wide range of breathing difficulties resulting from chronic or frequent marijuana smoke by water, it is still a health risk. use, including asthma, bronchitis, or COPD [110]. Filtered marijuana smoke contains carcinogens, acts as a bronchial Vaporizers are instruments that apply enough heat to marijuana to produce irritant, and contributes to a diverse range of diseases, just like filtered an inhalable vapor containing THC, but not a sufficiently high temperature cigarettes. Additionally, because the cooled smoke is easier and more that the marijuana burns and produces smoke rather than vapor. Medical comfortable to inhale, it facilitates deeper inhalation and a longer time professionals may recommend using a vaporizer with medical marijuana, holding the smoke in the lungs to maximize THC absorption. These especially if the user’s respiratory health is compromised, because vapor is habits increase exposure to other potentially dangerous components not associated with the health risks of smoke inhalation. in smoke. Those who use bongs to smoke marijuana can experience a

Physical symptoms and effects Marijuana affects multiple body systems, but the majority of its ●● Marijuana smokers show increased rates of caries due to a negative effects are evident in respiratory dysfunction and pulmonary combination of physical effects, such as xerostomia, and disease, usually associated with long-term or heavy use. Chronic behavioral variables, such as neglect of oral health and poor diet. marijuana smokers have symptoms of bronchitis and emphysema, Studies comparing the oral health care habits of marijuana smokers including coughing, wheezing, and mucus production [111]. and nonsmokers suggest that lifestyle choices (inconsistent brushing, infrequent visits to the dentist, and consumption of many Marijuana smoke has many of the same dangerous components as more sugary beverages and foods among smokers), contribute tobacco smoke (carbon monoxide, bronchial irritants, and tar). With significantly to decay and the formation of caries[115] . the exception of nicotine, the primary carcinogens found in tobacco ●● Periodontal disease is likely more prominent among marijuana (hydrocarbons, benzopyrene, and nitrosamines) are found at much smokers than nonsmokers for many of the reasons it is more higher levels in marijuana smoke than equal amounts of tobacco prevalent among tobacco smokers. Data on the specific effects of smoke. A single inhalation from a joint contains three times the tar of tobacco smoke, in part due to the lack of a filtering mechanism. marijuana are limited by the fact that many marijuana smokers Additionally, the deeper inhalation of marijuana smoke leaves more also smoke tobacco, making it difficult to disentangle one set of [116] tar in the respiratory tract. It is estimated that smoking a single joint risk factors from another . is equivalent to five to seven cigarettes in exposure to hazardous ●● Smoking marijuana is associated with oral premalignant lesions, substances and potential for respiratory disease [112]. including leukoplakia and erythroplakia, which result, in part, from exposure of the oral tissues to high temperatures for extended The following oral symptoms and conditions are more common among [113] periods. This increases the likelihood of cellular disruption, causing marijuana smokers than nonsmokers : changes in the composition and appearance of oral tissues [117]. ●● Candida (yeast) is estimated to be more prevalent in marijuana ●● Cannabis stomatitis is a condition found in individuals who users than tobacco users, possibly due to the presence of certain hydrocarbons in marijuana that nourish specific strains of fungi [114]. chew, as well as smoke, marijuana. It is characterized by ●● Chronic users are more prone to oral infections than nonusers, chronic inflammation of the oral epithelium, leukoplakia of the and may have compromised immune response due to marijuana’s buccal mucosa, and hyperkeratosis (a thickening of the tissues). immunosuppressive effects. Continued use increases the patient’s risk for neoplasia. Oral ●● Chronic use is likely to cause some degree of xerostomia, as cancers associated with marijuana typically appear on the tongue well as irritation and swelling of the tissues, dry throat, and or anterior floor of the mouth. redness of the uvula.

Management and clinical implications The dental team should be aware of the following treatment concerns ●● Patients experiencing dental treatment while under the influence of related to patients who use marijuana: marijuana may feel anxiety, discomfort, paranoia, or depression. ●● THC increases the heart rate and causes vasodilation, posing a In unknowingly treating marijuana smokers, dentists may increase their potential risk for blocked arteries (cardiac ischemia), atrial fibrillation patient’s risk for adverse effects or complications. Identifying patients (abnormal heartbeat), or angina (chest pain) due to oxygen-deficient who smoke marijuana is useful as it reduces the potential for unpleasant blood. These patients may need more oxygen than nonusers. surprises. Dental professionals should encourage discussion of marijuana ●● Epinephrine (used in a number of types of local anesthesia), should use by including questions regarding patterns of consumption on the not be administered if there is a possibility of recent marijuana use, medical history form, just as tobacco use is listed. With the increasingly as this can increase the potential for a dangerously increased heart legal status of marijuana, dentists are likely to see more of the conditions rate (tachycardia) or extended duration. identified here, and patients are likely to feel more at ease discussing them. ●● Patients using marijuana are at greater risk for low blood pressure when reclined in the dental chair [118]. ●● A combination of stress and the parasympathetic effects of marijuana may increase the patient’s potential for fainting.

Page 56 Dental.EliteCME.com Section III: Commonly Used Illegal Drugs The National Survey on Drug Use and Health (NSDUH) studies the Illegal drug use among individuals 12 years of age and older. use of prohibited substances in the United States, focusing specifically on the use of marijuana/hashish, cocaine/crack, heroin, hallucinogens, and inhalants. According to data collected in 2010, 22.6 million (almost 9%) of those in the United States aged 12 or older used an illegal substance during the month prior to the survey. The estimated numbers of substance users in each category are presented in the bar chart [119].

Source: 2010 National Survey on Drug Use and Health (NSDUH)

Stimulants Many abused substances are stimulants, which are known for Many stimulant users are polydrug users (more than one drug), as increasing physiological activity, producing an alert and energetic well as polystimulant users. Most stimulants produce a number of “high,” and feelings of well-being. Stimulants may be legal (caffeine) identifying oral effects. In a study of polystimulant use, participants or illegal (MDMA), or legal with a prescription (Ritalin). Other reported the following symptoms and effects: common illegal stimulants are methamphetamine (meth) and cocaine. ●● The most frequent short-term oral health effect of stimulant use was xerosotomia, with 95% reporting frequent dry mouth [122]. Most stimulants have the potential to damage the oral environment ●● 75% reported a need to chew something after ingesting stimulants, due to the physical byproducts of nervous system stimulation and the with about half of all users noticing a tendency to grind and clench behavioral habits of the individual using the substance. teeth, and nearly 40% of all users reporting a habit of biting their Stimulants are associated with bruxism, which can result in cracked cheeks, tongue, or lips after taking the drug. enamel or loosened teeth caused by the user’s stimulant-induced ●● More than half (56%) felt pain or tenderness in the jaw muscle or grinding or clenching. Patients may find some relief with orthodontic jaw joint after using stimulants; 30% felt clicking or popping when interventions such as a biteplate or retainer, to prevent further damage. opening and closing their mouths, with many unable to open their Over time, bruxism can lead to root and gum damage, creating a need mouths completely. for root canal or implants. Grinding is also associated with headaches, ●● About 37% of respondents complained of tooth sensitivity. neck pain, and earaches [120]. ●● Stimulant users showed a distinct pattern of tooth wear, exhibiting Like many other drugs, a common side effect of stimulant use is increased posterior erosion and significant occlusal wear of the xerostomia. While this factor contributes to increased rates of decay, lower first molar. stimulant users are also more likely than nonusers to drink alcohol and ●● More than one-third of participants reported feelings of numbness energy drinks, and choose soda and other sugary beverages to alleviate in their mouths after using stimulants. symptoms of dry mouth or thirst, which further increase the risk for severe tooth decay [121].

Cocaine Cocaine is a powerful and extremely addictive stimulant extracted only by prescription. The continued demand for cocaine and its legal from the leaf of the coca bush, a plant native to parts of South prohibition gave birth to a black market that has thrived ever since. America. Many cultures living in areas with coca bushes have a Two main forms of cocaine are prevalent in the United States: water- practice of chewing the leaves to produce a mild stimulating effect; soluble hydrochloride salt (cocaine hcl) , which takes the form of a white much like caffeine is used in the United States. This form of coca powder or crystals; and water-insoluble cocaine base, more commonly consumption has been a tradition for thousands of years, and is rarely known as crack. Both forms of cocaine begin as the same product and associated with addiction. share a very similar chemical composition. Crack is made from a volume Until 1914, cocaine was a legal commodity in this country, found of partially processed cocaine base removed in an early stage of cocaine in myriad OTC products such as soft drinks and health tonics, and production. It is processed with ammonia, or sodium bicarbonate and considered a necessity in any first-aid kit or medical clinic. Once water, and then heated to extract the hydrochloride, producing a smokable the clearly addictive properties of purified cocaine became apparent, substance. Cocaine hcl is typically consumed through nasal inhalation, products containing cocaine (most famously, Coca Cola) were required permeation of the oral tissues from rubbing it on the gums, or injection. to remove the substance. Cocaine became a controlled substance, sold Water-soluble cocaine base is generally smoked [123].

Dental.EliteCME.com Page 57 Cocaine’s highly addictive properties are related to its ability to Some of the health risks of cocaine use are not necessarily related to increase levels of the neurotransmitter dopamine in the brain. the properties of the coca leaf. Cocaine production is a lengthy process Normally, once dopamine releases, it returns to the same cell, bringing in which the product is likely to move great distances and change a stop to the movement between neurons. Cocaine prevents dopamine hands many times. At each step, there is an opportunity to increase from returning to its original cell, causing excessive amounts of profits by reducing the purity of the product. Many harsh chemicals dopamine to accumulate in the synapse between neurons, which are used to process cocaine, and the drug is often combined, or cut, creates cocaine’s euphoric high. Some of cocaine’s desirable effects with other substances, with little regard to the dangers they pose to are increased energy, alertness, and sociability; elation or euphoria; users. Vendors who sell directly to the user have been known to use and decreased fatigue, need for sleep, and appetite. substances such as cornstarch, talcum powder, or sugar, as well as cheap pharmaceuticals, including anesthetics and amphetamines.

Prevalence and patterns of use Reports from the NSDUH (2008) assess the number of cocaine users in poses a high risk of physical dependence, with a greater propensity for the country at 1.9 million, with more than 350,000 currently using crack. escalation of use, both in frequency and amount consumed. Psychological Overall, men report higher rates of current cocaine use than women. symptoms associated with cocaine binging include irritability, irrational Those reporting the highest rates of cocaine were young men between thinking, restlessness, paranoia, and anxiety [126]. [124] the ages of 18 and 25, totaling about 1.5% of the population . Like other addictive substances, repeated use of cocaine can alter brain Average cocaine doses are estimated to be 20 mg to 100 mg intranasally, function in the short- and long-term. Chronic use is associated with 10 mg to 50 mg intravenously (IV), and 50 mg to 200 mg smoked [125]. increased risk of psychological and physical dependence, and severe Binging, a common pattern of cocaine abuse in which the user consumes health risks. Cocaine users may use other drugs concurrently—users large amounts of cocaine in segments of time ranging from hours to days, may inject a combination of cocaine and heroin, known as a speedball. is likely to result in far larger doses than these averages. This type of use

Physical symptoms and effects Cocaine users are most likely to seek medical help for cardiovascular Cocaine may cause symptoms of digestive distress, such as abdominal symptoms, commonly chest pain [127]. Cocaine increases the heart rate pain and nausea, because it reduces gastric motility, (the rate at and blood pressure, which increases the amount of oxygen needed by which food digests). Users experience a lack of appetite, with some the heart. At the same time, cocaine induces vasoconstriction, which exhibiting signs of malnourishment. Cocaine-induced vasoconstriction decreases the heart’s already suppressed blood and oxygen flow. These and ischemia are causal factors for GI infarction and perforation; factors are associated with increased risk for cardiac arrhythmia, heart colitis; and ulcers of the stomach, pyloric canal, and duodenum [133]. attack, and congestive heart failure in patients with no evidence of heart Common oral health implications of cocaine use include: disease; and increased risk of stroke and seizures in people with no ●● Increased risk of dental caries, resulting from a combination of [128]. Other risks include platelet obvious risk factors for these conditions xerostomia, poor personal oral care, and infrequent or inconsistent aggregation, leading to increased vasoconstriction, vasospasming, blood professional dental care [134]. clot formation (thrombosis), and sudden death. The risk of seizure is ●● Heavy occlusal wear and a cervical abrasion caused by excessive [129][130]. highest within the first 90 minutes after cocaine ingestion clenching and grinding with associated temporomandibular joint Smoked cocaine produces respiratory symptoms similar to other (TMJ) complaints. Gold restorations may show signs of erosion smoked substances, including shortness of breath or wheezing, asthma, from cocaine’s caustic effects. a cough producing mucus, and chest pain. Inhalation of cocaine ●● Dry mouth (and possibly bruxism) contributes to increased levels of microparticles damages the lungs, affecting the pulmonary vascular gingival and periodontal disease. Oral candida infections, angular bed, alveoli, and capillaries, and producing potentially fatal conditions, cheilitis, halitosis, burning mouth, and erosive lichen planus, are more including pulmonary edema or hemorrhage, and scarring of the lung common and progress more rapidly in cocaine users than nonusers. tissue (interstitial disease) [131]. All are conditions exacerbated by dry mouth and poor nutrition [135]. Intranasal cocaine ingestion (snorting) results in a variety of relatively ●● Rubbing cocaine on the gums or inside cheek is associated with mild symptoms including nasal irritation and runny nose, chronic ulcers and oral lesions, and contributes to tooth erosion. Lesions [136]. inflammation of the mucus lining (rhinitis) and sinusitis, loss of sense typically heal normally once use stops ●● Chronic cocaine use by any route of consumption is associated of smell, and nosebleeds. More severe symptoms include difficulty with an increased risk of infection, most commonly viral hepatitis swallowing or oropharyngeal ulcers, while very serious cases of and HIV [137][138]. cocaine abuse involve perforation of the nasal septum and palate. Cocaine-induced vasoconstriction can lead to ischemic necrosis, where the bone dies due to lack of a blood supply [132].

Management and clinical implications Undisclosed cocaine use increases the potential for adverse outcomes an increased incidence of convulsions in cocaine users [142]. Chronic in even the most routine dental care. Chronic cocaine users have a cocaine use does not appear to increase risks associated with greater propensity to excessive hemorrhage after tooth extraction, general anesthesia, as long as the patient is experiencing normal and a higher risk of orofacial complications such as perforation of cardiovascular function at the time of surgery [143]. [139][140] the nasal septum and palate . Use of cocaine within the 24 hours before dental treatment can The administration of a local anesthetic with vasoconstrictors put the patient at greater risk of cardiovascular complications, (such as those containing epinephrine/ adrenaline) or the use of especially with the use of local anesthetics or adrenaline- epinephrine-impregnated retraction cords, is contraindicated for impregnated retraction cords. Dental offices may require patients to cocaine users, as the drug interaction puts the patient at risk of affirm in writing that they will not use cocaine (or other drugs) for an acute rise in blood pressure that can lead to cardiac arrest [141]. a specified period before and after dental treatment. Patients must Lidocaine use is also contraindicated, as it has been associated with understand that the potential consequences of drug interactions in Page 58 Dental.EliteCME.com dental care can be very dangerous, even fatal. This conversation on the day of the procedure, the patient shows signs of cocaine use, should occur at the time the patient schedules the appointment. If, dental treatment should be postponed.

Identification and intervention Observable physiological effects of very recent cocaine use include Symptoms include musculoskeletal pain, tremors, chills, involuntary increased heart rate, dilated pupils, perspiration, and nausea. movements, such as spasms or tics, depression, anxiety, fatigue, poor Infrequent or moderate cocaine use may be difficult to detect. concentration, lack of enjoyment, severe cocaine craving, hunger, Behavioral and psychological effects of chronic use may be exhibited increased need for sleep, and more lucid dreams. Most users who in erratic demeanor and moods, with effects as diverse as inappropriate quit experience symptoms for 1 or 2 weeks and require no medical grandiosity, panic attacks, paranoia, or delusional thinking. Users intervention to resolve their symptoms. Heavy users experience these may appear agitated or restless, exhibit tremors, spasms or tics, and in symptoms longer, with very severe symptoms, crashing, occurring extreme cases, symptoms of paranoia or hallucinations. Patients may soon after quitting. Crashing frequently involves severe depression and complain of recent insomnia, weight loss, or lack of appetite [144]. suicidal thoughts. It is associated with a greater likelihood of congestive Cocaine users who quit typically experience mild withdrawal symptoms heart failure because it increases the risk of coronary vasospasms, a [146]. that are primarily psychological and rarely pose physical risks [145]. common symptom of stimulant withdrawal Ecstasy (MDMA) MDMA (3-4 methylenedioxymethamphetamine) is a synthetically effects are caused by the MDMA-induced increased activity of three produced drug (referred to as a designer drug) with psychoactive neurotransmitters: serotonin, dopamine, and norepinephrine, which properties, similar in chemical structure to methamphetamine and influence mood and regulate functions such as appetite and sleep. mescaline. Commonly known as ecstasy, MDMA was developed in This amplified neurotransmitter activity increases levels of oxytocin the early 1900s, possibly for use as an appetite suppressant. Its use and vasopressin, hormones identified with feelings of love, trust, was negligible until the 1970s, when it was used in psychotherapy, sexual interest, and sociability. These produce ecstasy’s characteristic although the drug was not formally approved for therapeutic feelings of emotional warmth and empathy toward others, and possible applications. MDMA was largely unknown to the public until the aphrodisiacal qualities [149]. 1980s, when it burst onto the club scene as a party drug that produced MDMA is taken orally, usually as a capsule or tablet. The term, molly feelings of ecstasy, encouraged sociability and friendliness, and (slang for molecular), refers to the pure crystalline powder form of [147]. provided the energy and stamina needed for a night of dancing MDMA, usually sold in capsules. Ecstasy’s effects vary in duration, Ecstasy is one of a number of designer drugs popular among young and depend on the dose and purity of the drug. The effects last an users. These drugs often have stimulant and psychedelics properties and average of 3 to 6 hours, although it is not uncommon for users to take are frequently used recreationally, in a social environment. Designer a second dose of the drug as the effects of the first dose begin to fade. drug abusers show patterns of use very different from those who MDMA is frequently used in combination with other drugs, but rarely abuse traditional drugs, such as heroin or cocaine. In 1985, the Drug with alcohol, as alcohol is believed to diminish its effects. Enforcement Administration (DEA) labeled MDMA a Schedule I Studies of polystimulant abusers show ecstasy abusers are likely to substance; a drug with high abuse potential and no recognized medicinal use other amphetamine-based drugs (polystimulant use), particularly use. Recreational use spiked in the 1990s and continues to rise [148]. methamphetamine (speed), as well as ketamine hydrochloride (ketamine Ecstasy’s popularity is linked to its ability to produce an enhanced or Special K), and barbiturates, but were unlikely to have used heroin [150]. sense of pleasure, well-being, self-confidence, and peace. These

Physical symptoms and effects MDMA has many of the same physical effects as other stimulants MDMA affects oral health in a number of respects. Primary symptoms like cocaine and amphetamines, including increased heart rate and of MDMA consumption include the need to chew, and a strong blood pressure. It poses particular risks for people with circulatory tendency toward bruxism, with severe grinding and clenching soon or coronary disease. MDMA users may experience symptoms such after ingestion. Severe tooth grinders significantly weaken teeth, even as muscle tension, involuntary clenching of the teeth, nausea, blurred exposing the underlying dentine. Occlusal teeth bear the brunt of vision, chills, or sweating. A variety of adverse effects occur after the abrasion and wear showing the greatest degree of severity and number drugs initial euphoria wears off. Symptoms such as sleep disruption, of affected teeth. Those who use the drug with any frequency may drug cravings, depression, or confusion can last as long as a few weeks experience symptoms of TMJ with tenderness, pain, or tension in the depending on amount and frequency of use [151]. jaw muscle or joints during periods of nonuse [154]. MDMA is inconsistently metabolized by the body, creating the MDMA causes dry mouth, with users reporting much greater possibility that dangerous levels will build up in the blood. High consumption of carbonated soft drinks than nonusers. In one study, doses can interfere with the body’s ability to regulate temperature. In MDMA users consumed a mean value of three cans of soda during a rare cases, this can cause hyperthermia, and increase the risk of liver, single MDMA episode. Users taking the drug in the evening are likely kidney, or heart failure [152]. to experience its effects until the following morning [155]. Ecstasy is often contaminated with other substances. Common Ecstasy shares many characteristics of amphetamines and cocaine, additives include ephedrine, dextromethorphan (a cough suppressant), including potential for dependency or addiction. In a recent study, ketamine (a dissociative anesthetics in the same category as nitrous survey respondents who regularly used MDMA reported symptoms of oxide/laughing gas), caffeine, cocaine, methamphetamine, or synthetic dependence, including continued use despite knowledge of physical or cathinones (bath salts). Using these drugs alone or in combination psychological harm, tolerance (or diminished response), and withdrawal. poses serious risks for the user [153]. This is not surprising considering the neurotransmitters activated by MDMA are the same as those targeted by other highly addictive drugs [156].

Dental.EliteCME.com Page 59 Methamphetamine Methamphetamine (meth) is a powerful and highly addictive stimulant treat weight loss, fatigue, and nasal decongestion, among many other that affects the function of neurotransmitters in the brain, altering the uses. Although methamphetamine has a similar chemical composition levels of serotonin, dopamine, and norepinephrine. Meth is a long- to its parent drug, and produces many of the same effects—such acting drug, with users feeling its effects for up to 14 hours. During as feelings of well-being or euphoria, an increased propensity for this time, the individual is energetic, alert, and inclined to physical conversation and physical activity, and a lack of appetite—there are activity, but functionally impaired with limited ability to understand significant, potentially dangerous differences between them[158] . the repercussions of his or her actions. Chronic meth users have little Comparable doses of amphetamine and methamphetamine metabolize or no appetite and may become malnourished or underweight. Crystal in such a way that much greater amounts of meth permeate the brain, methylamphetamine (crystal meth) is a smokable form of meth that with effects estimated to be two times as powerful as amphetamine, [157]. has a very similar chemical structure and produces similar effects and long-lasting consequences far more detrimental to CNS function. Methamphetamine was derived from amphetamine (also known as Both amphetamine and methamphetamine are widely abused substances speed), a drug commonly sold without a prescription in the 1950s to regulated since 1970 under the Controlled Substances Act [159].

Prevalence and patterns of use In the 1980s, the availability, popularity, and prevalence of meth ●● Meth is a relatively good bargain for the user compared to similar surged to new heights, for the following reasons [160]: drugs. It produces an intense sustained high for a period of time ●● Meth was relatively easy to make. Unlike other processed drugs few substances can match for the same money. such as cocaine and heroin, the only necessary ingredient, ●● Meth is considered one of the most highly addictive, commonly ephedrine (or, if not available, pseudoephedrine, a closely related abused drugs. drug) could be found in many OTC cold medications. The other Between 2002 and 2004, the percentage of meth users who were chemicals needed for processing (lye, muriatic and sulfuric acids) dependent on the drug increased more than 30% (from 27.5% could be purchased at a grocery store. to 59.3%). In 2007, the NSDUH reported that about 5% of the U.S. population over 12 years of age (13 million) had used methamphetamine at least once [161].

Physical symptoms and effects Dependence on meth comes with severe costs to a user’s social, ●● Vasoconstriction contributes to the increased risk of periodontal financial, psychological, and physical well-being[162] . The disease by inhibiting the blood supply needed to maintain good mechanism by which meth produces a high progressively depletes oral health. When blood vessels constrict repeatedly due to meth neurotransmitter function, resulting in symptoms of depression and abuse, they can be irreversibly weakened to a point where they [163] physical consequences, including : are unable to deliver sufficient quantities of blood to keep the oral ●● Cardiac dysfunction, including irregular heartbeat or high blood tissues alive (oral necrosis) [168]. pressure, with chronic use associated with hallucinations or a ●● Many users grind or clench their teeth while experiencing the drug’s greater propensity to violence [164]. ●● Long-term meth users may be malnourished or underweight due to effects. Among meth users, signs of bruxism and TMJ are more lack of appetite or concern about the need to eat [165]. common among females than males. Vasoconstriction combined with [169] ●● Meth causes many of the same negative oral effects of other illegal bruxism makes the tooth enamel more fragile and prone to break . drugs, including xerostomia, bruxism, periodontal disease, and ●● Oral ulcerations and infections are common among meth users, oral ulceration. It reduces salivary gland function, causing greater regardless of mode of ingestion. Smoked and snorted meth abrasion and irritation of the tongue and lining of the mouth. exposes the oral cavity to caustic ingredients that irritate and Raw areas can more easily lead to lesions of the oral mucosa and burn oral tissues, leading to ulcers and infection, which are complications such as secondary infections [166]. exacerbated by xerostomia [170]. ●● One-third of meth users reported frequent dryness or cotton mouth, ●● If the drug is snorted, the corrosive chemicals are drawn down with some requiring liquids during meals to facilitate swallowing the nasal passage to the back of the throat, coating the teeth and food. Meth users consume excessive amounts of soft drinks and causing extreme damage to the enamel [171]. other beverages high in sugar, carbohydrates, and calories, due to Recent research provides strong evidence that IV drug use causes the meth-induced sugar cravings and a desire to prolong the high with most severe damage of any route of meth ingestion. IV meth users the stimulating effects of sugar and caffeine [167]. were significantly more likely to be missing teeth than those smoking or inhaling meth, who had much lower rates of dental disease.

Meth mouth Perhaps the most striking feature of meth abuse is the pattern of extreme severe damage, but the most destructive effects are typically associated decay and damage to tooth structure and surfaces, known as meth with the coronal tooth. Decay along the cervical third of the teeth mouth. First documented in 1992, meth mouth refers to the characteristic and labial surfaces can appear black or brown, due to stain or rot. In set of symptoms and physical manifestations of meth abuse seen in the some cases, the level of decay is so severe and so aggravated by other oral cavity. One part of this pattern is the excessive damage evident in symptoms of meth use (such as xerostomia) that teeth may need to be the number of teeth severely decayed, discolored, broken, missing, or extracted, as treatment or restoration is not possible [173]. showing remnants of tooth or roots left behind. In a recent study of meth The extreme pattern of decay seen in meth mouth is a function of a [172]. abusers, almost 23% reported broken or loose teeth number of factors working in combination [174][175]: Because deterioration is so extreme and rapid, even young or short- ●● Methamphetamine is a highly caustic substance produced from a term users may show severe signs of damage. Meth users and former host of hazardous chemicals, such as anhydrous ammonia (found users are more likely to wear (or need) dentures or prosthetics. The in fertilizers), red phosphorus (found on matchboxes), and the pattern of decay is distinct: lingual and buccal surfaces show signs of element lithium-ion (found in batteries). Homemade meth labs

Page 60 Dental.EliteCME.com have been known to add highly corrosive ingredients including drinks and junk food exposes the teeth to high levels of harsh paint thinner, acetone, and battery acid. Other materials commonly acids, which eat away at the tooth if they are not removed by found in meth are muriatic and sulfuric acid, chemicals commonly salivary flow or oral hygiene practices. added to swimming pool water, and the pharmaceutical drug, ●● Excessive grinding of weakened teeth increases the risk of decay, lithium, used to treat bipolar disease [176]. erosion, and fractures. ●● While these substances are poisonous or corrosive in themselves, For many years, there was a consensus in the treatment community the damaged oral environment of a meth abuser increases the that the extreme damage seen in meth mouth was caused by the direct potential for extreme decay and damage. Meth users’ extreme effects of exposure to meth smoke, or meth itself, on the oral cavity. xerostomia adversely affects oral health because there is less Recent research contradicts this assumption, providing strong evidence saliva to neutralize or wash down acids that remain after eating that IV drug use causes the most extreme damage of any route of meth and drinking. The more acidic environment breaks down the tooth ingestion, with IV meth users showing high rates of dental disease and enamel and attacks the gums, causing areas of weakness that are extreme symptoms of meth mouth very similar to those seen in chronic more susceptible to decay. IV users of other drugs, such as heroin [177]. ●● Other elements that contribute to the extreme pattern of decay and damage are behavioral, associated with poor hygiene, diet, lack of Analyzing the relationship between IV drug use and extreme decay is regular dental care, and delay in addressing medical issues until they complicated by the fact that noninjection users become injection users become emergencies. Meth users often have poor oral hygiene habits, as their level of dependence escalates. IV administration is an extremely brushing and flossing their teeth less frequently than nonusers. efficient delivery system, providing the user nearly 100% bioavailability ●● When under the influence of meth, users crave sugary foods and of the drug less than 1 minute after IV administration [178]. beverages, partly due to symptoms of dry mouth. Consuming soft

Management and clinical implications Meth users have a reputation for delay in addressing medical needs, If deep sedation is required, meth users must abstain for several days even if they are in pain for a long time. Research suggests users prior to the appointment [181]. primarily receive dental care in emergency rooms, when the situation Before confirming the appointment, the patient must affirm that he or has become critical, although the issue may have been long-standing. she understands the implications of meth use within the critical period In one study, meth users waited an average of 1.5 years for swollen before the appointment, and provide written assurance, if necessary, or bleeding gums, to 6.5 years for TMJ complaints, before seeking that he or she will abstain for the requisite period. The patient should professional dental care. The same study provided a free dental acknowledge awareness of the increased risk of specific adverse appointment to any participant in the study who wanted one, but no outcomes associated with using meth before or after the procedure. [179]. meth users took advantage of the offer On the day of the appointment, the dental team should pay special Meth users may be more difficult to schedule or contact, come to attention to patient demeanor and behavior for possible symptoms of appointments late, or miss them entirely, and are inconsistent in paying meth use, or use reliable screening techniques to avoid the possibility their bills. Given the dangerous combination of meth-induced oral of adverse drug interactions [182]. symptoms, poor oral hygiene, and lack of professional dental attention, Common behaviors in meth abuse that encourage decay are it is not surprising that a patient can progress from the early stages of consumption of low nutrition, high carbohydrate, high sugar foods periodontal disease to a state of severe damage in a relatively short time. and beverages (especially carbonated soft drinks), hard candies, or Dental management of meth users requires obtaining a thorough other sugary substances held in the mouth; infrequent or ineffective medical history and performing a careful oral examination. Meth users brushing; and bruxism. More than 90% of meth users smoke are unlikely to disclose their substance use, so dental professionals cigarettes. Suggested strategies for reducing harm include providing need to be aware of the physical symptoms and medical risks smoking cessation information, advising the patient to increase his presented by these patients [180]. or her frequency and effectiveness of oral hygiene practices (with If meth use is suspected, extreme care is required in choice and training, if necessary), regular dental check-ups, quitting or reducing administration of local anesthesia. Methamphetamine increases the soft drink consumption, and wearing a mouth guard to reduce tooth [183]. user’s risk for irregular heartbeat, heart attacks, and stroke. Anesthetic erosion and reduce TMJ pain with vasoconstrictors may be ineffective in relieving the patient’s pain, The most important factor in treating the oral effects of and are contraindicated, as are all vasoconstrictors. Injections must be methamphetamine is for the patient to stop using the drug. Therapeutic monitored carefully for adverse effects. If local anesthetic is used, it is treatment cannot combat the continued effects of abuse, which will critical that the patient avoid using meth within the previous 24 hours. eventually cause severe and irreparable damage.

Identification and intervention There is no stereotypical meth user—they come from all walks with meth use that have less obvious indicators, but may be equally of life and use the drug to meet a wide range of needs. Some look dangerous. Meth use may be indicated by TMJ dysfunction, for a recreational high or use it as a sexual aid; others for relief enlargement of the masseter muscle, the characteristic pattern of dental of depression or boredom. Hardworking students and business attrition associated with the drug, and an increased number of caries. professionals may use it to reduce the need to sleep, achieve more in A caries assessment is a recommended screening protocol to identify a day, meet a deadline, or work two jobs. Meth’s ability to keep the undisclosed meth use [184]. user alert and energetic, and reduce the need sleep are initially very Substance abuse research suggests that brief interventions by medical effective in helping users reach their goals. As use escalates, they professionals are surprisingly effective in preventing meth use, become more focused on obtaining and using the drug, with their decreasing the amount and frequency of drug use among users, and original priorities falling by the wayside. providing referrals that facilitate rehabilitation. Intervention may be as Meth users commonly present with multiple dental diseases and simple as mentioning the potential medical risks associated with meth conditions. By detecting early symptoms of use, dental professionals and providing an informational brochure. Most patients are disposed to can play a crucial role in reducing common comorbidities associated listen to dental professionals and consider their recommendations [185].

Dental.EliteCME.com Page 61 The following steps may encourage discussion and/or disclosure of symptoms of paranoia or a propensity to violence. If the meth use [186]: patient appears receptive, discuss the pattern of damage and ●● Warn every patient to avoid using meth, regardless of his or explain that they are characteristic of drug use. If there is any her characteristics. This is important because preconceived possibility of danger to the dental team or patient, adjust the assumptions about meth users can result in missed opportunities to timing and strategy accordingly. identify a patient who uses the drug. A recent study of meth abusers revealed an unexpected finding; ●● If meth is prevalent in the community, mention that fact and ask about 29% were concerned about the appearance of their teeth, with the patient what he or she knows about meth. If the patient appears IV meth users significantly more likely to report cosmetic concerns unaware of the drug or its consequences, provide this information related to oral health than those who smoked meth. This finding in an easily digestible form, such as an information sheet, challenged prevailing assumptions that meth users are largely unaware illustrated by photos of meth mouth. or unconcerned about aesthetic changes resulting from use. Knowing ●● Review clinical and radiograph findings for indications of that many users are not only conscious of, but concerned about, the potentially serious damage to the teeth or mouth that might be unattractive consequences of meth abuse suggests dental professionals related to meth use. Discuss this information with the patient. can appeal to an individual’s desire to appear more attractive and Direct, open-ended questions are most effective in encouraging healthy to motivate or stimulate a patient’s interest in treatment [187]. patients to disclose drug use. Dental clinicians can ask in a direct matter-of-fact way how the teeth came to be in their Understanding the symptoms of meth abuse that make the patient most current condition. emotionally or physically uncomfortable can suggest opportunities ●● Dental professionals should ensure their tone is one of caring for tailoring interventions that address the patient’s priorities and and concern, avoiding any words or actions that might be concerns, to increase the possibility of referral to substance abuse interpreted as judgmental. Long-term meth users may have counseling or treatment programs [188].

Heroin Heroin is a natural opioid derived from morphine, which is extracted effects on opioid receptors in the brain stem, the area that controls from the Asian opium poppy plant. Heroin usually appears as a white critical autonomic, or involuntary, body functions, such as breathing. or brown powder, or a black, sticky substance known as black tar Excessive amounts of heroin can suppress respiration, causing death [190]. heroin. Heroin is an illegal, highly addictive drug. It is both the most After an IV injection of heroin, users report feeling a rush of euphoria, abused and rapid-acting of the opioids. In 2011, 4.2 million Americans aged 12 or older (about 1.6%) reported using heroin at least once in accompanied by dry mouth and a warming or flush of the skin. their lives. It is estimated that about 23% of individuals who use heroin Following this initial high, the user may fall asleep, or remain in a become dependent on it [189]. drowsy wakeful state. Injection provides the greatest intensity and most rapid onset of euphoria (within 7 to 8 seconds). A heroin abuser Heroin can be injected, inhaled by snorting or sniffing, or smoked. All may administer injections multiple times per day. When heroin three routes of administration deliver the drug to the brain very rapidly, which contributes to its health risks and high rates of addiction. Upon is sniffed or smoked, peak effects are usually felt within 10 to 15 entering the brain, heroin is converted back into morphine, which minutes. Smoking and sniffing do not produce the strong initial rush binds to molecules on receptors in the brain and body that mediate the of an injection, but other effects are comparable. Regular heroin use perception of pain. Deaths from overdose are usually related to heroin’s results in tolerance and physical dependence, and produces changes in the brain similar to other highly addictive substances [191].

Physical symptoms and effects Chronic heroin users may develop collapsed veins, infection of the Heroin causes nausea in some, leading to acidic vomiting, which in heart lining and valves, abscesses, constipation and GI cramping, and chronic users produces the extreme degree of tooth erosion found in liver or kidney disease. Pulmonary complications, including various bulimia, or other conditions with frequent vomiting [195]. Chronic heroin types of pneumonia, may result from the generally compromised users exhibit the same oral symptoms referred to collectively as meth health of the user as well as respiratory complication directly related mouth. According to an article in the Journal of the American Dental to drug use. IV use is associated with an increased risk of infectious Association, the term is misleading, as it more directly characterizes diseases like hepatitis and HIV [192]. the consequences of chronic IV drug use. Intravenous heroin users In addition to the effects of the drug itself, street heroin often contains have the same pattern of extreme decay, with a high number of caries, toxic contaminants or additives that can clog blood vessels leading to missing and broken teeth, and increased risk of periodontal disease that the lungs, liver, kidneys, or brain, causing permanent damage to vital characterizes meth mouth. In surveys of IV heroin drug users, up to 70% organs. Although the heroin supply is less adulterated than it once described problems such as teeth snapping off and falling apart [196]. was when supply was more limited, most street heroin is mixed with Like excessive meth users, heroin addicts are also likely to have substances such as sugar, starch, powdered milk, or quinine, or far less periodontal disease and extreme tooth decay along the gum-line, with [193] benign ingredients such as strychnine and other poisons . negative oral conditions aggravated by xerostomia and bruxism. Heroin Users at all stages run the risk of heroin overdose due to the difficulty users are inclined to consume excessive amounts of sugary foods and of assessing the drug’s purity. Pure or uncut heroin can be as much beverages, due to strong cravings for sweets. The resulting build-up of of a danger as hazardous additives, particularly if the user typically acids and bacteria encourages the extremely rapid progression of disease consumes a more adulterated substance. Heroin overdoses result from and decay [197]. Heroin users are likely to delay treatment for very long all forms of ingestion. Users commonly experience slow and shallow periods, even when they are experiencing extremely painful conditions. breathing, convulsions, and, in some cases, coma, before death [194]. In some cases, the analgesic effects of the drug allow the user to postpone treatment far longer than would be possible without the substance [198].

Management and clinical implications Heroin, like other opioids, has the potential for dangerous information about this concern is presented below, in the section interaction with many drugs used in dentistry. More detailed discussing prescription opioid abuse.

Page 62 Dental.EliteCME.com Provide heroin users with information regarding risk factors in their of seeking dental attention regularly. Survey data show that virtually diet (excessive soft drink consumption), dental hygiene habits (the all heroin users also smoke cigarettes, so the dental team may want to need to brush their teeth before going to sleep), and the importance provide tobacco cessation information [199].

Identification and intervention Identification of heroin use follows the same protocol as meth last administration. They include achiness of the bones and muscles, screening. If necessary, a saliva test can be used to conclusively restlessness, perspiration, goose bumps, insomnia, agitation, GI determine if the patient has used heroin. distress, and kicking (resulting in the phrase, kicking the habit). Users experience extreme cravings for the drug, which greatly increase the Perhaps the biggest barrier to quitting heroin is the severe physical potential for relapse[200] dependence that results from chronic use. If a dependent user reduces . Former users may take synthetic opioids such or stops the drug cold turkey (without tapering use), he or she can as methadone and buprenorphine, both used in treatment for heroin experience severe withdrawal symptoms a few hours after the drug’s addiction. These drugs are also associated with certain medical risks, discussed in Section V.

Prescription opioids Opioids are pain relievers derived naturally from the opium poppy, because they directly affect pain receptors in the nervous system, or synthetically from sources that mimic its effects. They are the attaching to receptors in the brain, spinal cord, GI tract, and other source material for many narcotics (drugs that produce sedating organs. Once attached to receptors, opioids trigger a range of effects, effects) including codeine and morphine. All prescription opioids are including reduced pain, increased drowsiness and mental confusion, extremely effective at relieving pain, and have sedating effects due nausea, and constipation. The most significant effects in the context to their depression of CNS function. They are highly habit-forming of abuse are likely the euphoric high, associated with the drug and, if used over long periods, and more commonly abused than any other depending upon the amount of drug taken, shallow respiration, which prescription substances. Some of the most commonly prescribed can prove fatal [202]. opioids are codeine, hydrocodone (e.g., Vicodin), oxycodone (e.g., Those who abuse opioids may seek to intensify their experience by OxyContin, Percocet), and morphine (e.g., Kadian, Avinza) [201]. taking the drug in ways other than prescribed. For example, OxyContin While opioids (such as codeine or morphine) and nonopioids (such is an oral medication used to treat moderate to severe pain through a as acetaminophen or NSAIDs) are both classified as pain relievers, slow, steady release. People who abuse OxyContin may snort or inject opioids are narcotic analgesics, which are much stronger than the it, thereby increasing risk for serious medical complications, including nonnarcotic analgesics, acetaminophen, and NSAIDs. Opioids are overdose. Physical dependence is an almost certain consequence of able to provide a much greater degree of pain relief than nonopioids chronic opioid use [203].

Prevalence and patterns of use Opioid analgesics have many applications in dental care. They are 2 million people in the United States meet the criteria for prescription routinely prescribed for pain following oral surgery, among other opioid abuse or dependence [205]. Those who abuse the drug may change dental procedures, and may be used with anesthetics to provide more their method of ingestion to increase its effects, snorting or injecting it as effective pain management. The number of opioid prescriptions their dependence escalates, or switching to a stronger medication [206]. has risen sharply in recent years, primarily due to their increased Taken in ways other than prescribed, prescription opioids have effects use in chronic pain management. Between 1991 and 2010, opioid similar to heroin. A number of recent studies suggest that prescription prescriptions grew from about 75 million to 209 million. This greater opioids are a frequent precursor to heroin abuse. Almost half of IV heroin availability encouraged more widespread nonmedical use of opioids, users who participated in surveys about their drug use reported abusing [204]. with many doses diverted to those without prescriptions prescription opioids (typically by crushing, snorting, or injecting the It is estimated up to 23% of prescribed opioid doses are used drugs) before trying heroin. Many reported switching to heroin because it nonmedically, or about one of every 25 prescriptions written. Almost was cheaper and easier to obtain than prescription medication [207].

Sources of misused prescription opioids Studies of prescription opioid abuse identified the following sources ●● Almost 10% of users bought the drug from a family member or for nonmedical drug use [208][209]: friend who had leftover drugs from an old prescription. ●● More than half (55.3%) were given the drug by a friend or relative ●● 5% of users took the drug from a friend or family member without without charge. Within this group, 80% of those providing a drug to their knowledge or permission. a nonprescription user obtained the drugs from one prescriber. Data ●● More than 17% used medication they kept from a previous suggest friends and relatives who share their prescription medication prescription for a valid medical complaint. Each of the user’s are primarily motivated by a desire to help the other individual medications were prescribed by one medical professional, as opposed relieve physical pain, rather than provide a recreational high. to multiple prescribers, a common strategy of drug-seeking behavior. ●● Almost 5% purchased the opioid from a dealer.

Physical symptoms and effects As discussed in previous sections, opioid abusers show the highest use can also increase risks due to the effects of opioid abuse on rates of oral decay and disease of all drug users, with the most extreme motivation and decision-making. damage associated with IV administration. Opioids are implicated in a ●● Opioids affect hormonal function (opioid endocrinopathy, or OE) wide range of negative physical effects [210][211]: in both men and women. Hormonal dysfunction can result from ●● Opioid use is linked to the increased incidence of infectious any route of administration. Men are likely to suffer symptoms diseases, including hepatitis and HIV, in those who inject the drug, of sexual dysfunction (such as erectile dysfunction and decreased through use of shared or unsterilized needles. Noninjection drug libido). Serum hormone levels typically return to normal when drug use stops, after withdrawal symptoms resolve.

Dental.EliteCME.com Page 63 ●● Hyperalgia, or increased pain sensitivity, is associated with long- as spinal opioid receptors do not appear to inhibit intestinal term, high-dose opioid use, and is characterized by more acute motility to the same degree as other sites. pain, despite the administration of higher opioid doses. ●● Large amounts of opioids cause liver and kidney damage. ●● Symptoms of GI distress include nausea and vomiting, but ●● CNS depression results in slowed respiration, sleepiness, dizziness, primarily consists of constipation. When taken as directed, slowed unclear thinking, and confusion. Abuse of opioids, alone, with gut motility is an almost guaranteed side effect of opioid ingestion. alcohol, or other drugs, can depress breathing to the point of fatality. Excessive use causes severe constipation, hemorrhoids and rectal The most serious medical complications of opioids are associated pain, bowel obstruction or rupture, among other serious and fatal with its sedating effects. Deaths from unintended prescription opioid effects. Spinal administration may reduce the risk of constipation, overdose are now more than four times what they were in 2000, greater than all the heroin and cocaine deaths combined [212].

Risk of dependency All opioids, like other addictive drugs that trigger the pleasure center Given the need for more of the substance to attain the same results, it of the brain to produce euphoric effects, also produce tolerance in is not surprising that opioid abusers may try to amplify drug effects by those using for an extended period. While prescribing opioids for taking it in ways other than prescribed. Abusers seeking more potency temporary acute pain is safe for most patients, long-term use is a for the same amount of money will snort or inject the drug, or switch high-risk activity that almost certainly leads to addiction. Opioid users to a similar, but less expensive or more available drug. Greater potency experience a very unpleasant crash, when they discontinue use—the or dosage causes increased risk of adverse medical effects, as well as most common symptoms are intense craving for the drug, anxiety, undesirable side effects including dysphoria (feelings of discomfort, depression, and diarrhea. Those who have a pattern of stopping and unhappiness, or restlessness); symptoms of GI distress, such as nausea starting (if a supply is not available, for example), may alternate and vomiting; and potential for severe respiratory distress [214]. between extreme emotional highs and lows [213].

Section IV: Prescription Drug Abuse

Nonmedical use of prescription drugs Prescription drug abuse is the intentional use of a medication that spasm, a twisted ankle on a Saturday). Nonmedical use also includes is not prescribed for the individual using it. The NSDUH considers those with a prescription who use the drug recreationally, for the high, all use of psychotherapeutic drugs without a personal prescription rather than its intended purpose. Psychotherapeutic drugs include nonmedical use, although some of these diverted prescription drugs prescription pain relievers, tranquilizers, stimulants, and sedatives [215]. may legitimately have been used to treat pain (a friend with a back

Prevalence and patterns of use In 2010, about 7 million people were users of psychotherapeutic drugs Survey results from 2011 showed 2.6 million people 12 years of age taken nonmedically (2.7% of the U.S. population). This class of drugs is and older used psychotherapeutics nonmedically for the first time broadly described as those targeting the CNS, including drugs used to treat within the preceding year (about 7,000 new users each day in 2010). psychiatric disorders. The medications most commonly abused are [216]: The average age at which pain relievers were first used nonmedically ●● Pain relievers: 5.1 million. was 20 years. Common reasons an individual might take a prescription ●● Tranquilizers: 2.2 million. drug without a valid prescription include self-medication for emotional ●● Stimulants: 1.1 million. or physical pain, anxiety, sleep disorders, or poor concentration. ●● Sedatives: 0.4 million. Prescription medication may be used to help an individual function Among adolescents, prescription and OTC medications account for more efficiently, postpone sleep so he or she can achieve more in a [218]. most of the commonly abused illegal drugs [217]: day, or stay alert for work or family obligations ●● Nearly one in 12 high school seniors reported nonmedical use of These abused substances complicate dental treatment in many ways. Vicodin; one in 20 reported abuse of OxyContin. Given the intensity of addiction, dentist must be aware that patients ●● When asked how prescription narcotics were obtained for who are substance abusers may be coming in looking for a source of nonmedical use, 70% of 12th graders said they received them from prescription drugs. The next section describes common characteristics a friend or relative. of drug-seeking behavior, and strategies to minimize nonmedical use.

Drug-seeking behavior Substance abuse affects every age group, socioeconomic status, and ●● Claim to be from out of town, or to have left a prescription out of town. ethnicity—there is no reliable profile for prescription drug abuse.All ●● Claim to be in pain or have a history of oral pain, with no observed dental personnel and staff should be aware that the office or clinic reason, and repeatedly request new prescriptions or refills. could be a target for a prescription drug abuser seeking a supply. ●● Request early refills of lost or stolen medications. Users may engage in doctor shopping, visiting multiple medical ●● Claim to be allergic or immune to the effects of all drugs except professionals to obtain as many prescriptions for controlled substances controlled substances. as possible. Dentists should become familiar with common strategies ●● Claim only one type of drug will work. of drug shopping, and think twice about patients who [219][220][221]: If you think a patient is drug or doctor shopping, ask yourself the ●● Appear to time emergency visits when the office is about to close, [222] or contact the dentist by phone after regular office hours or during following questions : weekends or holidays, claiming to be in severe pain and needing ●● How frequently does the patient contact the office or come in immediate relief (asking the doctor to phone in a prescription to for treatment? their local drugstore right away). ●● Does a new patient not want you to talk to his/her former doctor? ●● Have a history of broken appointments, or frequently reschedule ●● Is the patient paying in cash? appointments. ●● Does the patient have a known and valid current and former address?

Page 64 Dental.EliteCME.com ●● Is it often difficult to contact the patient? ●● Does the patient fill prescriptions at more than one or two pharmacies? ●● Has the office ever lost or misplaced prescription pads? ●● Is the patient participating in recommended non pharmaceutical ●● Does the patient ask for drugs by specific name, dosage, and/or therapies as well as the medication for his/her treatment? number? In a survey of dentists in West Virginia, 58% of respondents believed ●● Does the patient have more than one primary care physician? they were the victims of fraud or theft of prescriptions. Dentists ●● Does the patient request the most frequently abused opioids, such as reported patients using the following strategies to obtain drugs: 43% the immediate-release (IR) opioids hydrocodone and oxycodone? pretended to be in pain, 28% claimed their prescriptions were stolen, ●● Does the requested drug have high demand and resale value? 14% forged prescriptions, and 14% found a way to increase the ●● Does the patient have prescriptions from more than one or two number of pills in the prescription [223]. doctors?

Appropriate prescribing practices Overprescribing occurs when prescriptions are written in quantities It is important to note that the need for analgesics varies widely; greater than might be needed to treat the patient’s pain, or are stronger patients with similar health profiles undergoing similar procedures than required for the anticipated degree of pain [224]. In the United may have very different pain management needs. Although the States, IR forms of hydrocodone and oxycodone are the two most recommended dosage of an opioid analgesic, such as hydrocodone frequently abused opioids. Dentists are the second greatest source for with acetaminophen, is between 2 and 3 days for a procedure like these drugs, prescribing 12% of all IR opioids used. The only greater third-molar extraction, some patients legitimately need analgesics for source is family physicians, at a close 15% [225]. up to a week or more [230]. Given the high number of IR opioids prescribed by dentists and the While some flexibility in prescribed amounts is necessary, research has extent of misuse, dentists play a role in minimizing the potential for demonstrated that prolonged pain after surgery is frequently an indication nonmedical use by reducing the excess supply through appropriate of a problem, such as poor healing or infection. A visit to the dentist’s prescription practices. Dentists must apply patient-specific opioid office will facilitate a decision about how to proceed, as the practitioner prescribing practices to ensure adequate pain control, while limiting can assess if and why the patient’s healing is delayed. Dentists should opportunities for abuse and diversion [226]. generally prescribe no more than a few days of medication. Quantities [231]. Available data and peer-reviewed recommendations suggest that lasting a longer period than necessary pose a potential health risk clinicians prescribe no more than the number of doses needed based Dentists have a responsibility to identify patients with substance on ADA recommendations [227]. An ADA survey of 563 practicing abuse issues due to the increased risk of drug interaction or overdose. oral and maxillofacial surgeons in the United States, reported that A patient’s self-reported medical history is unlikely to provide many two-thirds of respondents prescribed between 10 and 20 doses of IR clues of suspected prescription drug abuse, but there should be a opioid analgesics after third-molar extraction. Forty-one percent of section that addresses the issue. Whether or not the patient is a drug respondents said they expected patients to have medication remaining abuser, it is important to know what pain relievers he or she used in the after resolution of their postoperative pain [228]. A 2008 study showed past; how effective they were; and what side effects, if any, occurred. that 72% of respondents who were prescribed an opioid had leftover Even if a patient is not truthful about drug use on the medical history, medication, and 71% of those with leftover medications kept them. it is a good starting point for a discussion about pain medication. Given these statistics, it is easy to see how such a vast number of prescription drugs have found their way into public use [229].

Guidelines for prescription pain control The dental professional should employ the following guidelines in including number and frequency of all prescription refills; and considering the use of controlled substances for pain control [232]: acknowledging the circumstances under which drug therapy may 1. Evaluation of the patient: An appropriate medical history and be discontinued (such as violation of the agreement). Informed dental examination must be conducted and documented in the dental consent must include a description of the planned treatment, and record, which should detail information regarding the nature and address the possible risk of triggering a relapse. intensity of the pain, current and past treatments for pain, underlying 4. Periodic review: At reasonable intervals based on the individual or coexisting diseases or conditions, the effect of the pain on circumstances of the patient, the practitioner should review the physical and psychological function, and history of substance abuse. course of treatment and any new information about the etiology of The dental records should document the presence of one or more the pain. Continuation or modification of therapy should depend recognized dental indications for the use of a controlled substance. on the practitioner’s evaluation of progress toward stated treatment 2. Treatment plan: The written treatment plan should state objectives (such as improvement in the patient’s pain intensity objectives that will be used to determine treatment success, and improved physical and/or psychosocial function, the ability to such as targeted pain relief and improved oral-facial, physical, work, need of health care resources, activities of daily living, and and psychosocial function, and should indicate if any further quality of social life). If treatment goals are not being achieved diagnostic evaluation or other treatments are planned. After despite medication adjustments, the practitioner should reevaluate treatment begins, the dental care practitioner should adjust drug the treatment to determine if it is still appropriate. therapy to the individual patient needs. Other treatment modalities 5. Consultation: The practitioner should be willing to refer the or a rehabilitation program may be necessary depending on the patient for additional evaluation and treatment as necessary to etiology of the pain and the extent to which the pain is associated achieve treatment goals. Special attention should be given to with physical and psychosocial impairment. patients at risk for misusing or diverting their medications for 3. Informed consent: The practitioner should discuss the risks and nonprescription use. Pain management in patients with a history benefits of the use of controlled substances with the patient or of substance abuse or with a comorbid psychiatric disorder may with the patients’ surrogate or guardian if he or she is incompetent require extra care, monitoring, documentation, and consultation or a minor. The patient should receive prescriptions from one with or referral to an expert in the management of such patients. dental care practitioner and one pharmacy, when possible. If the 6. Dental records: The dental clinician should keep accurate and patient has a history of substance abuse, or is currently using, complete records including: the practitioner may employ the use of a written agreement ○○ The medical history and dental examination. between the office and patient, outlining patient responsibilities, ○○ Diagnostic, radiographic, therapeutic, and laboratory results.

Dental.EliteCME.com Page 65 ○○ Evaluations and consultations. dental care practitioners must be licensed in the state and comply ○○ Treatments and treatment objectives. with applicable federal and state regulations. Dental professionals ○○ Discussion of risks and benefits. should refer to The Physician’s Manual of the U.S. DEA (and ○○ Medications (including date, type, dosage, and quantity any relevant documents that may be issued by their state dental prescribed). board) for specific rules governing controlled substances as well ○○ Instructions and agreements. as applicable state regulations. Dental care practitioners are ○○ Periodic reviews. encouraged to use the Automated Prescription System to monitor and report suspected diversions. Records should remain current, be maintained in a recognized 8. Anesthesia: When administering any type of sedation or general SOAP (Subjective, Objective, Assessment, Plan) format, be anesthesia to a patient, dental professionals should refer to accessible, and readily available for review. the ADA’s “Guidelines for the Use of Sedation and General 7. Compliance with controlled substance laws and regulations: Anesthesia by Dentists” and to their State Board of Dentistry’s To prescribe, dispense, or administer controlled substances, the Administrative Rules on sedation and general anesthesia.

Implementing strategies to reduce opioid overprescription Clinicians should be mindful of the inherent abuse potential of opioids, substances the patient is currently prescribed and what has been and comply fully with federal and state regulations regarding the prescribed in the past. Using this technology, local pharmacies and legitimate prescribing and administration of controlled substances by [233]: dental clinicians can identify the doctor prescribing a medication, the ●● Incorporating substance abuse screening into routine practice. pharmacy dispensing it, and a patient’s prescription history [236][237]. ●● Learning the signs and symptoms of substance abuse. Dentists can play a role in minimizing opioid abuse through patient ●● Incorporating standard safeguards for prescribing opioids. education in a number of subject areas [238]. A primary point of concern ●● Educating patients about proper disposal of unused opioids. is the need to convey the dangers of sharing prescription medications ●● Developing a referral network for the treatment of substance with family members or friends. Dental professionals should take the abuse disorders. time to discuss the implication of sharing medications and disposing of Generally, dentists should not prescribe drugs without first examining drugs improperly. the patient and documenting the patient’s condition in his or her dental Explain the environmental repercussions of flushing any medication into record [234]. Requesting a photo ID such as a driver’s license can the toilet or pouring it down a sink. These drugs flow into the nation’s indicate how far an out-of-town patient has traveled to come to the water supply and cannot be filtered out, causing the water supply to office. Patients traveling a significant distance can be asked why they become increasingly medicated. The Office of National Drug Control chose this office rather than one closer to their home [235]. Policy’s guidelines for the disposal of unused or expired prescription drugs instructs patients not to flush prescription drugs down the toilet or In many states, prescription-monitoring programs (PMPs) track drain unless the label or accompanying patient information specifically prescriptions and are able to provide accurate, up-to-date information instructs them to do so. Some areas have established community about the dispensing of controlled substances. Dental professionals can [239] consult these statewide electronic databases to check the controlled prescription drug return programs, which accept donations .

Pain management Because opioid abusers develop a tolerance to the drug’s analgesic involving pain. Nonopioid analgesic agents should be considered the effects, it can be very difficult to manage their dental pain.There are first option in alternative strategies for addressing acute short-term risks and treatment concerns not only for current drug users, but also pain. If appropriate, a long-acting anesthetic, such as bupivacaine, patients in recovery. Patients with histories of substance abuse include can be used to address localized pain for a longer period. NSAID those who currently abuse, former abusers, those in drug-free recovery analgesics can be very effective for postoperative, as well as or rehabilitation, and those in treatment programs that administer prophylactic use, for moderate pain. In studies comparing patients methadone or buprenorphine [240]. If the patient is in recovery for using NSAIDs and opioids following dental impaction surgery, opioid abuse, administering or prescribing an opioid‐containing some patients found ibuprofen and naproxen, taken for an average analgesic can potentially cause relapse [241]. period of 4 to 6 days, as effective as opioid analgesics in addressing It is best for the patient’s welfare if dental professionals can identify postoperative symptoms of sensitivity or pain. Postoperative communication and follow-up with the patient are critical to ensure the current and former users, and determine their status in the recovery [243][244] process. Opioid abuse poses unique challenges for pain management; patient is not experiencing any discomfort or pain . dental professionals must ensure that the analgesic effects of the drug Nonopioid pain relievers, such as NSAIDs, do not produce tolerance or are sufficient, without exposing the patient to any unnecessary risks. It physical dependence and are not associated with abuse or addiction, but is highly recommended that dentists [242]: have an upper threshold where additional medication will not produce ●● Consult with these patients’ primary care physicians or substance additional analgesic effects. This is called the ceiling effect. abuse treatment centers to coordinate treatment. This upper threshold makes nonopioids inappropriate for severe pain in ●● Work with patients’ family members or support networks. This is most people. Opioids do not have a ceiling effect; more taken means more crucial if a family member or other trusted individual is required to pain relief. However, after a point, excessive amounts will likely result dispense controlled medication to the patient. in overdose. When indicated, opioids are an extremely important tool Encourage patients to seek support and professional care in treatment for addressing dental pain, but should not be prescribed indiscriminately, programs before and after dental procedures, especially those especially if a nonopioid analgesic can instead be used [245].

Methadone and buprenorphine Methadone and buprenorphine are prescription drugs primarily known to treat chronic pain; while methadone use is associated with increased as treatments for withdrawal from opioid addiction. Methadone risk of arrhythmia, anecdotal evidence suggests adverse events and maintenance therapy, for example, is one method in which a controlled fatalities associated with its use occur more often among those taking substance is used in combination with therapeutic practices, such as methadone for chronic pain, rather than assistance in recovery [246]. counseling, to control withdrawal symptoms. Both drugs are also used

Page 66 Dental.EliteCME.com A chief concern in treating patients receiving buprenorphine or effects than natural opioids as they do not allow blood opioid levels methadone maintenance therapy is adequately managing their pain to drop between doses, as occurs in natural opioid use. Because the and minimizing risks associated with the drug. An opioid analgesic mouth is deprived of saliva for even longer periods, there is more (including heroin, methadone, or buprenorphine) should never be potential for decay and other adverse effects [248]. combined with alcohol or other prescribed medications. Drugs that Dental professionals can recommend products that relieve dry mouth, pose a high risk of drug interaction include fluvoxamine, which encourage the patient to drink plenty of water, use sugarless gum or increases the patient’s exposure to methadone by inhibiting its candy to increase saliva, tend to personal oral hygiene, and see a dental metabolism, and Lopinavir/ritonavir [247]. professional regularly. While methadone is available in a sugar-free Methadone and buprenorphine are synthetic opioids, and like natural form, the version containing sugar is more commonly used. Dentists opioids, they reduce saliva. It has been suggested that the long-acting can inform patients that methadone syrup is a risk factor for caries that synthetic opioids used in treatment may have even greater damaging can be reduced by switching to a sugarless version of the drug [249].

Section V: General Intervention Strategies

Identification The dental professional must be aware of the signs of substance use, recommends a caries evaluation as standard protocol in patients who are have the knowledge to recognize and treat dental concerns in patients substance abusers or suspected of excessive drug use [251]. who abuse them, and provide the patient with cessation information. Patients may express their concerns to staff members more readily Identifying many kinds of drug abuse can be difficult because patients than to the dentist, so an educated, empathetic, and nonjudgmental are unlikely to be truthful about their drug use or admit to a drug dental team can be key in encouraging disclosure. Dental hygienists, dependency. The most effective screening and intervention strategies who often spend the most time with patients, can integrate screening require the participation of all office and clinic personnel, who should into their practice. Dentists can review this information and discuss the become competent in recognizing potential signs of abuse, especially issue privately with the patient, if necessary. if a patient is under the influence. The patient’s general appearance, As this course has detailed, many drugs are inherently dangerous behavior, and demeanor before and during the appointment should to oral surfaces and/or diminish the immune system, but infrequent provide clues of substance abuse to the trained eye. dental hygiene, poor diet, and other behavioral factors combine to Dental personnel should review the patient’s medical history carefully, increase the patient’s susceptibility to chronic tooth decay, cracked with the understanding that important information may be missing. teeth, gingivitis, or other forms of gum disease. The severity of these Clinicians should be familiar with the oral symptoms of substance conditions is compounded because substance abusers are likely to abuse discussed in this course including the appearance of poor oral delay seeking professional medical attention for as long as possible, health habits, xerostomia, oral infections and lesions, periodontal until the condition becomes too serious or painful to ignore. disease, missing teeth, and severe decay, with a higher incidence of Denial and fear of discovery are significant barriers to identification caries than nonusers. of substance abuse among patients. Most dentists do not consider Comparison studies examining the effects of heroin, methadone, asking patients directly about their illegal drug use or abuse, even amphetamine, and cannabis on the oral cavity show drug users with when behaviors or physical symptoms strongly suggest substance consistently higher numbers of caries compared with nonusers. Data abuse. To the surprise of many medical professionals, the direct show methamphetamine users having an average of nine times as many approach has proven one of the most effective ways to encourage seriously decayed teeth as nonusers; heroin abusers have five times as patients to disclose illegal drug use. There is strong evidence that the many seriously decayed teeth as nonusers; and cocaine abusers have simple act of asking patients with characteristic oral patterns about four times as many seriously decayed teeth as nonusers [250]. The ADA their use or abuse of drugs would identify many more patients with substance abuse disorders [252].

Management and clinical implications If abuse is suspected, management strategies will depend on the patients may behave erratically or inappropriately, and, in very rare individual’s demeanor. If, for example, he or she appears to be under cases, aggressive or violent. These patients will require additional the influence, shows signs of chronic drug use, or asks any questions attention and care. Scheduling should ensure the dental team has regarding drug abuse or addiction, effective clinical management time to accommodate unexpected incidents, as well as complete the would strongly recommend raising the issue in the most caring and following necessary tasks [254]: therapeutic way possible. All dental facilities should have policies and ●● Unhurried review of the medical history, medical consultations, procedures in place for addressing these situations, as well as other and assessment of the patient’s current status. issues that may arise with a chemically dependent patient [253]. ●● Comprehensive monitoring of vital signs (such as blood pressure), Time management is a common concern with patients who abuse before, during, and after, even very routine treatment. drugs. One of the most common, albeit least dangerous, complaints ●● A caries assessment, according to recommended ADA standards of about patients who are excessive drug or alcohol users, is their care for patients with substance abuse disorders. unpredictable behavior and lack of reliability in keeping appointments. Scheduling concerns pale in comparison to the potential medical risks Patients who abuse drugs are more likely to arrive late or miss associated with undisclosed drug use and abuse. Patients with liver appointments without notice. They may be difficult to contact damage due to drug and alcohol abuse have the potential for excessive regarding appointment reminders or outstanding balances. Chemically bleeding. If this occurs, treatment should be stopped and digital dependent patients are likely to consider dental care a very low priority pressure applied immediately. Referral for medical evaluation and unless they are in pain or the situation becomes critical. blood coagulation testing is necessary before treatment can resume. In scheduling the patient’s appointment, staff should allow sufficient Recommended practices for addressing suspected drug use include time for potential delays (a patient may arrive late, or experience a requiring the individual to sign a statement indicating drugs have not complication or adverse event during the procedure). In rare cases, been used within the previous 24 hours and administration of a saliva

Dental.EliteCME.com Page 67 test or urinary drug test (UDT), if necessary, to ensure the patient’s important that the office institute a policy for checking and recording safety during a procedure [255]. the number of prescription pads, who is taking them, and when they Dentists should establish office policies that reduce the potential for are taken. More than one person should be made responsible for illegal prescription drug use, such as reducing prescription leftovers prescription pad oversight to discourage any office worker or clinician [256]. and keeping prescription pads in a secure, locked location. It is with an opportunity to take one

Screening rationale While many dentists feel questions about drug use are intrusive or ●● The vast majority of individuals addicted to drugs and alcohol go unnecessary, there are a number of important benefits to the patient unidentified and untreated by a health care professional. Routine that make screening an important responsibility of the dental team. screening for substance abuse is likely the most effective strategy Support for screening is based on the following rationale: to identify excessive drug use, protect the patient from unnecessary ●● There is a proven association between many types of substance medical risks, or present a possibility for intervention. abuse and adverse health consequences [257]. ●● Research data support the theory that screening and brief ●● Drug abuse is increasingly common; in 2010, an estimated 9% of intervention can significantly reduce substance abuse among those all individuals aged 12 or older in the United States were current who use alcohol and tobacco. There is strong evidence to suggest illegal drug users, with about one in five between the ages of 18 the same benefits of screening and brief intervention would assist and 25 reporting use of an illegal drug in the past month [258]. in identification and intervention of illegal substance abuse, including nonmedical prescription drug use [259]. Screening methods and practices Most medical and health history forms include a section devoted Dental care professionals familiar with the devastating effects of to drug use, but it is estimated that half of patients do not disclose substance abuse on oral health are more likely to participate in information about their history due to feelings of shame, fear of intervention efforts and offer cessation assistance because they see a judgment, and concern about legal prosecution. Because the interaction clear link between the patient’s drug-taking behavior and the painful between commonly abused drugs and those used in professional dental and physically damaging results. care is potentially very hazardous (e.g., cocaine and vasoconstrictors An encouraging finding from a study of participants in substance in local anesthetics), office staff and dental team members must rely abuse treatment noted that patients referred to treatment by their on other clues to ascertain if a patient is using excessive amounts doctors reported improved general and mental health, employment of a drug. All members of the dental team and office staff should and housing status, and less illegal behavior after the intervention. familiarize themselves (ideally through office- or clinic-sponsored Acting in the patient’s best interests to ensure his or her well-being is training) with the signs of drug abuse. In some cases, urine or saliva the dental professional’s ethical obligation and central to all health care drug testing may be necessary to know conclusively if the patient used professions. Learning to talk about drug use with a patient can be the drugs in the critical timeframe before a dental appointment [260]. first step in getting them help. Because dentists frequently develop long-term relationships with Some dentists choose not to ask because they assume the patient does patients, they are in a unique position to assist in public health efforts not seem like a drug user. It is important to note that an individual’s to screen for substance abuse and direct patients to available resources. preconceived notions regarding substance abuse and abusers can inhibit Although brief interventions provide a real possibility for improving his or her ability to recognize actual abuse or addiction in a patient. patient outcomes by addressing excessive drug use, a recent study Excessive drug users can be highly functional, capable individuals, found one-third of all dentists do not ask questions regarding current whose pattern of substance use is known only to the people closest or past substance abuse, missing a crucial opportunity to address a to them. Those who have a family member with a personal history of potential health risk [261]. drug abuse, or are themselves in recovery, are likely to have a special Many dental professionals find it difficult to ask a patient about his awareness or sensitivity to symptoms of addiction. or her illegal drug use. Some dental professionals are concerned In some cases, dentists prefer not to ask about illegal drug use about prying, particularly if he or she does not see a direct connection because they are unsure how to respond to an affirmative answer. The between excessive drug use and potentially adverse consequences. following sections discuss some common intervention strategies. Educational interventions Excessive drug users have long had a reputation for poor oral similar brushing frequency and duration. The drug-using group did hygiene habits, as well as other behaviors that exacerbate the already not benefit from their brushing and flossing practices to the degree negative effect of substance abuse on the teeth and gums. Those the nonusers did, because the counterbalancing effects of xerostomia who experience oral pain may find it excruciating to brush and floss. outweighed the benefits from good oral hygiene. These findings Excessive drug use is likely to minimize or numb the pain, allowing suggest that the combination of less effective dental hygiene habits, the individual to ignore his or her dental condition even longer, until possibly due to impaired motor activity, and reduced saliva flow it progresses to an extreme state [262]. negatively reinforce one another, creating increased oral decay and Because the dental condition of substance abusers often appears neglected, disease among substance abusers. many have hypothesized that drug abusers had little interest or concern in Many drugs stimulate a sweet tooth, leading to consumption of higher maintaining good oral hygiene. Findings from a recent study suggest this levels of refined carbohydrates in snacks, alcoholic beverages, and may not be the case, providing strong evidence that good oral health and soft drinks, which demineralize tooth enamel. The majority of sugary the appearance of teeth are important to alcohol and drug abusers. Data snacks are consumed late in the day, which combined with a lack of also suggest financial/economic factors are a primary reason substance nighttime brushing and flossing before going to sleep, causing rapid abusers do not seek necessary treatment for dental care [263]. build-up of plaque and calculi. The study found that similar oral hygiene habits in drug users If a drug-dependent patient presents for dental treatment and chooses compared with nonusers yielded strikingly different results; alcoholics to discuss his or her current dependency, provide a safe, accepting and drug abusers brushed less effectively than nonusers, despite environment for discussion. Having support materials on hand from Page 68 Dental.EliteCME.com a resource such as Narcotics Anonymous (NA)at http://www.na.org/, It is important for the dental team to provide informational materials can provide a link to that support system. Further communication regarding substance abuse, and support the patient’s efforts to stop using. suggestions are available on the websites for Partnership for a Drug- Educational interventions can include teaching good oral hygiene practices, Free America (http://www.drugfree.org/) and The National Registry of observing the patient brushing and flossing, and suggesting changes in Evidence-based Programs and Practices (NREPP), a searchable online the patient’s diet and routine that might reduce decay. Education is not database of mental health and substance abuse interventions, at http:// just for the patient. Training in effective intervention should include all www.nrepp.samhsa.gov/. (Licensed Alcohol, Tobacco, and Other Drug members of the dental office team, including dentists, hygienists, assistants, (ATOD) treatment facilities are available in most communities [264]). receptionists, and other office and medical personnel. Brief intervention Screening and brief intervention provide an opportunity for A’s create a helpful structure for a brief intervention in the form of a short dental professionals to address drug abuse as early as possible, to conversation, which may be useful in screening for drug use [266]. They are: communicate its risks, and reduce the consequences of excessive use ●● Ask one or more questions related to drug use. for general and dental health. ●● Advise the patient to make a change or quit if drug use is likely to cause the individual’s health to suffer. Studies suggest many more patients are amenable to discussing ●● Assess the patient’s willingness to change his or her behavior. substance abuse with their dentists than are approached with the topic. ●● Assist the patient in making a change or quitting if he or she About half of general dentists provide their patients with tobacco appears amenable. cessation information, but far fewer raise the issue of alcohol or drug ●● Arrange a referral for further assessment and treatment, and/or a dependency. Many dentists hesitate to screen for drug abuse because follow-up appointment, as appropriate. they feel patients will find it unacceptable, although data suggest the majority of patients would welcome screening and referrals for The 5 A’s are widely accepted as the standard for tobacco cessation substance abuse from dental care practitioners. These results suggest interventions, and have proven useful for many other types of that not implementing drug use screening and brief intervention in a substance abuse. In the medical sector, a model for screening, brief dental practice represents a lost opportunity to prevent the potential intervention, referral, and treatment (SBIRT) has proven effective in health risks that are associated with substance abuse [265]. reducing rates of drug and alcohol abuse among patients. The program, In 2000, a study by the U.S. Public Health Service released revised which is integrated with reimbursable insurance Current Procedural clinical practice guidelines, recommending medical professionals Terminology (CPT), Medicare G, and Medicaid coding systems, and health care organizations implement a new treatment model for is intended to make screening for substance abuse a routine part of addressing dependence in a health care setting, known as the The Five medical care. Implementing similarly structured programs in the dental [267]. A’s of Intervention or 5 A’s (ask, advise, assess, assist, arrange). The 5 sector could prove very useful Making referrals Dentists have an ethical obligation to discuss their concerns about Substance Abuse Treatment Facility Locator, at http://findtreatment. substance abuse with their patients and recommend individuals and samhsa.gov, which lists local community treatment centers and organizations that provide the best services and care for the patient. resources[269]. The ADA also provides materials and guidelines for This action is consistent with the ADA’s Principles of Ethics and Code discussing drug use with patients and providing referrals [270]. of Professional Conduct, which states that “dentists shall be obliged When referring a patient to a treatment program or substance abuse to seek consultation, if possible, whenever the welfare of patients will specialist, the practitioner should use the same manner and wording be safeguarded or advanced by using those who have special skills, used to refer them to any other type of specialist: [268]. knowledge and experience” ●● Express and explain concerns. If a drug-using patient presents for dental treatment and wants to ●● Ask the patient if he or she is agreeable to a referral. discuss his or her chemical dependency, it is important to provide a ●● Provide the name of the referral, his or her area of expertise, safe accepting environment. The dental team should make the referral in pertinent information including any charges associated with process as easy and convenient as possible, with an established services, if there is a wait time required for an appointment, referral protocol already in place. Resources for addiction services whether insurance applies, and the best way to contact the include state dental societies, local hospitals, and state governments. individual or schedule an appointment. Clinicians can refer to The Substance Abuse and Mental Health ●● Contact the patient or referral to see if the patient made an Services Administration (SAMHSA) website (http://www.samhsa. appointment. gov/) for treatment and referral recommendations, and SAMHSA’s Communication with other caregivers Communication and collaboration among all health care professionals ●● With whom it will be shared. and family members is the best-case scenario for ensuring the ●● The timeframe for which the authorization is valid. patient’s interests are served. Freedom of information among medical The written approval must be on a privacy authorization form personal is limited by state and federal privacy laws that safeguard the that conforms to all applicable state and federal requirements for confidentiality of patient records and limit the disclosure of protected safeguarding the confidentiality of patient records. health information to other health care professionals treating the patient. Patients who choose not to release personal information to another Current privacy regulations such as the Health Insurance Portability medical professional can put a dentist in an untenable position; the and Accountability Act (HIPAA), United States Code of Federal practitioner is ethically bound to respect the patient’s privacy, but also Regulations, Title 42 (42 C.F.R.), governing confidentiality of professionally obligated to ensure the patient’s physical well-being. substance abuse treatment records, ) and many state laws, require a Specialists who have relatively short-term relationships with patients patient authorizing release of his or her personal information to sign a may not recognize the signs of substance abuse that the family dentist form specifying [271]: knows. The clinician who knows his or her patient is a substance ●● The particular information to be released. abuser and is seeking treatment from an oral or maxillofacial surgeon, ●● The reason for its release.

Dental.EliteCME.com Page 69 but does not disclose this information to the surgeon potentially puts standards, or implementation specifications of the more stringent rule the patient at increased risk of complications and adverse outcomes. (the law more protective of privacy) should apply [274]. If drug or alcohol use exposes the patient to higher rates of risk for In summary, HIPAA provides the following: any treatment or procedure, the dental professional has an obligation ●● It permits widespread sharing of treatment information without to share this information in an appropriate, respectful manner with the consent (with the exception of psychotherapy files). other medical professional. This communication is approved under ●● The substance abuse confidentiality law does not permit sharing HIPAA (45 C.F.R. § 164.502), which states that a health care provider of records relating to substance abuse treatment or rehabilitation can disclose protected health information for treatment purposes [272][273] organizations conducted, regulated, or funded by the federal without patient consent . government, without consent, except within a program or with an C.F.R. § 164.506(c) (1) and (2) Treatment is defined as: entity with administrative control over a program. “… the provision, coordination, or management of health care and ●● Whenever a state law is more protective of privacy than the federal related services by one or more health care providers, including the HIPAA regulations or the federal substance abuse confidentiality coordination or management of health care by a health care provider statute and regulations, the state law takes precedence (the more with a third party; consultation between health care providers stringent law applies). relating to a patient; or the referral of a patient for health care from In nearly all situations, the patient should be informed about and one health care provider to another” (45 C.F.R. § 164.501). authorize communication between his or her health care professionals. In cases where there is a conflict between two applicable laws, such as Sharing information without the patient’s consent should only occur in state and federal regulation of information disclosure, or the privacy very rare cases, when absolutely necessary. law and substance abuse law, HIPAA provides that the requirements, Dental professionals who abuse drugs or alcohol Ten to fifteen percent of dentists are likely to develop a physical It is unethical to practice dentistry while under the influence of dependency on drugs or alcohol at some point in their lives [275]. Other substances that impair the ability to practice. Dentists who have first- clinic and office personnel also have the potential to abuse drugs.To hand knowledge of a colleague’s impairment are obligated to report the clarify and affirm a commitment to a drug-free workplace for patients violation to a dentist assistance program or the state licensing board. The and employees, the facility should have a written policy strictly ADA‘s Principles of Ethics and Code of Professional Conduct states: prohibiting employees from using or being under the influence of “It is unethical for a dentist to practice while abusing controlled alcohol or drugs at work, and stating that any employee engaging in substances, alcohol or other chemical agents which impair the the illegal diversion, sale, possession, or use of a controlled substance ability to practice. All dentists have an ethical obligation to urge may be subject to immediate termination. chemically impaired colleagues to seek treatment. Dentists with Current research in drug abuse and treatment stresses that a punitive first-hand knowledge that a colleague is practicing dentistry when environment is likely to discourage disclosure of illegal activities. so impaired have an ethical responsibility to report such evidence [276].” The policy must recognize drug dependency and alcoholism as health to the professional assistance committee of a dental society problems, and personnel must act accordingly. The office should Services are available in most states for dentists at risk of or commit to providing help to any chemically dependent employee who experiencing impairment. Resources are listed at the ADA website, seeks it, and protect the individual’s position in the same way as an Substance Use Disorders page, at http://www.ada.org/4503.aspx. All employee with any other illness. 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Page 72 Dental.EliteCME.com 227. Donaldson M, Goodchild JH. Appropriate analgesic prescribing for the general dentist. Gen Dent 257. Babor, T.F.; McRee, B.G.; Kassebaum, P.A.; Grimaldi, P.L.; Ahmed, and K.;Bray, J.; Screening, brief 2010;58(4):291–297. intervention, and referral to treatment (SBIRT): toward a public health approach to the management of 228. Moore. substance abuse. Substance Abuse. 28: 7-30, 2007. 229. Centers for Disease Control and Prevention Adult use of prescription opioid pain medications: Utah, 258. Madras, B.K. ; Compton, W.M. ; Avula, D. ; Stegbauer, T.; Stein, J.B.; and Clark, W.H. Screening, brief 2008. MMWR Morb Mortal Wkly Rep 2010;59(6):153–157. interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: 230. Biron RT, Hersh EV, Barber HD, Seckinger RJ. A pilot investigation: post-surgical analgesic Comparison at intake and 6 months later. 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Patients who abuse drugs. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:12- ba0111d0e35&tpl=/ecfrbrowse/Title42/42cfr2_main_02.tpl. 14. 273. he Confidentiality of Alcohol and Drug Abuse Patient Records Regulation and the HIPAA Privacy 254. Shapiro S, Pollack BR, Gallant D. The Oral health of narcotic addicts. J Pub Health Dent Rule: Implications for Alcohol and Substance Abuse Programs U.S.Department of Health and 1970;49(6):1556. Human Services Substance Abuse and Mental Health Services AdministrationCenter for Substance 255. Gourlay DL, Heit HA, Caplan YH. Urine Drug Testing in Clinical Practice: The Art and Science of Abuse Treatment www.samhsa.gov http://www.samhsa.gov/HealthPrivacy/docs/SAMHSAPart2- Patient Care. 4th ed. Stamford, Conn.: PharmaCom Group; 2010. HIPAAComparison2004.pdf. 256. Substance Abuse and Mental Health Services Administration. (2010). Results from the 2009 National 274. 65 Fed. Reg. 82462, 82482–8248; 45 C.F.R. § 160. (42 U.S.C. § 1320d-2(c)(2). Survey on Drug Use and Health: Volume I. Summary of National Findings (Office of Applied Studies, 275. American Dental Association, Substance Use Disorders http://www.ada.org/4503.aspx. NSDUH Series H-38A, HHS Publication No. SMA 10-4586 Findings). Rockville, MD. http://www.oas. 276. American Dental Association. American Dental Association principles of ethics and code of professional samhsa.gov/NSDUH/2k10NSDUH/tabs/Sect1peTabs1to46.htm#Tab1.1A. http://www.oas.samhsa.gov/ conduct, with official advisory opinions revised to January 2011. Chicago: American Dental Association: NSDUH/2k10NSDUH/tabs/Sect1peTabs1to46.htm#Tab1.1B. Principle: Nonmaleficence, 2.D. A DENTAL PROFESSIONAL’S FIELD GUIDE TO SUBSTANCE ABUSE Final Examination Questions Select the best answer for each question and mark your answers on the online at Dental.EliteCME.com.

1. According to the U.S. National Survey on Drug Use and Health, 3. According to the 2010 National Survey on Drug Use and Health, about 22 million people aged 12 and older could be classified as about ______of all individuals in the United States aged substance abusers or substance-dependent. The majority (about 15 12 years and older have used at least one form of tobacco. million) are dependent on: a. One-fifth. a. Alcohol. b. One-quarter. b. Alcohol and one or more illegal drugs. c. One-third. c. One or more illegal drugs, but not alcohol. d. One-half. d. Prescription drugs. 4. Of the millions of smokers who vow to quit smoking each year, 2. One recent study found almost ______of all survey more than ______are likely to relapse within 1 week. respondents were not completely truthful on medical forms due to a. 25%. fear of possible embarrassment or judgment by those seeing the b. 35%. form, concerns related to insurance coverage, or general privacy c. 35%. issues. d. 85%. a. One-fifth. b. One-quarter. c. One-third. d. One-half.

Dental.EliteCME.com Page 73 5. Which of the following groups does not show a higher rate of 13. Which of the following physical effects is not associated with smokeless tobacco use than the general public? cocaine ingestion? a. Caucasian males living in Southern United States, between the a. Vasodilation. ages of 10 and 30 years of age. b. Oral lesions. b. White-collar office workers. c. Excessive hemorrhage after tooth extraction. c. Native American men and women living in Canada and d. Increased number of dental caries. Alaska. d. Military personnel. 14. Which of the following is not contraindicated for patients who use cocaine? 6. ______is the most popular form of smokeless tobacco, a. Local anesthetic with vasoconstrictors. with about 75% of the market. b. Epinephrine-impregnated retraction cords. a. Moist snuff. c. Lidocaine. b. Chewing tobacco. d. General anesthesia for patients with normal cardiovascular c. Dry snuff. function. d. Plug. 15. Which of the following is not slang, or a more common term, for 7. Which of the following is the only type of alcohol than can be the drug, 3-4 methylenedioxymethamphetamine? consumed? a. Ecstasy. a. Methyl. b. MDMA. b. Butanol. c. Meth. c. Ethyl. d. Molly. d. Bethyl. 16. Which of the following is not a physical effect of opioid abuse? 8. Recent survey data showed about ______of people aged a. Hormonal dysfunction. 12 or older report binge drinking on a regular basis. b. Hyperalgia. a. 10 million. c. Diarrhea. b. 30 million. d. Slow respiration due to CNS depression. c. 60 million. d. 80 million. 17. Which of the following psychotherapeutic medications is most commonly abused? 9. Which of the following is not a common physical symptom of a. Stimulants. excessive alcohol consumption? b. Pain relievers. a. A coated tongue and significant deposits of plaque and calculi. c. Tranquilizers. b. Shrunken parotid salivary glands. d. Sedatives. c. Xerostomia. d. Signs of bruxism and tooth erosion. 18. Dentists prescribe ______of all immediate-release (IR) opioid mediation in the United States. 10. Which of the following does not typically pose an elevated risk of a. 6%. complications for the patient who abuses alcohol? b. 10%. a. Central nervous system (CNS) depressants, such as sedatives c. 12%. and narcotics. d. 15%. b. Benzodiazepines. c. Amide-based local anesthetics. 19. A 2008 study of opioid prescriptions showed ______d. Vasoconstrictors. of respondents who were prescribed an opioid had leftover medication. 11. Which of the following hazardous substances can be found in a. 17%. cigarette smoke but not in marijuana smoke? b. 22%. a. Tar. c. 56%. b. Nicotine. d. 72%. c. Nitrosomes. d. Carcinogens. 20. Which of the following is a characteristic of non-opioid analgesics? 12. Which of the following is not a stimulant? a. A ceiling effect. a. Caffeine. b. A high. b. Cocaine. c. Constipation. c. Methamphetamine. d. Physical dependence. d. Benzodiazepine.

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