Methamphetamine

Sally Preston, D.M.D Assistant Professor University of Colorado School of Dental Medicine Director, Emergency Clinic aka meth, tina, crystal, crank, tweak, glass, ice Meth (Crank, Ice) Facts —meth for short—is a white, bitter powder. Sometimes it's made into a white pill or a clear or white shiny rock (called a crystal).

Meth powder can be eaten or snorted up the nose. It can also be mixed with liquid and injected into your body with a needle. Crystal meth is smoked in a small glass pipe.

Meth lasts 6-24 hours and at first causes a rush of good feelings, but then users feel edgy, overly excited, angry, or afraid. Their thoughts and actions go really fast. They might feel too hot. rush of good feelings

Causes release of dopamine, the ‘feel good’ neurotransmitter

An orgasm releases the equivalent of 250 ‘units’ of dopamine

From a dose of methamphetamine, 1250 ‘units’ of dopamine are released

There is no natural event that mimics this level of dopamine release

Dopamine depletion changes brain chemistry

Experiences no longer give pleasure and leads to more desire for meth

Dopamine deletion leads to depression

Dopamine production may take years to recover and in one reason for difficulty in curbing .

Meth users also exhibit negative behaviors

•Anxiety

•Paranoia

•Mood swings

•Violent behavior

•Depression

•Irritability

•Cognitive impairment Physical Effects with Meth

•Dry skin/mouth •Skin lesions •Weight loss •Increased heart rate •Hypertension •Arryrhymias •Liver damage •Convulsions •Hyperthermia may lead to brain damage •Lowered resistance to illness

Because meth is like a super Sudafed, it dries out the user's skin completely. Addicts begin to believe they are suffering from "Crystal Meth lice". This leads to frantic scratching of the face using fingernails or any other tool such as tweezers. ‘Picking’ can lead to serious self-inflicted wounds, especially in the face.

Meth and Sex and Infectious Diseases • Increased libido, increased stamina and energy lowered sexual inhibitions

• Sex with multiple partners, people they do not know, unprotected sex and sex with people who may have sexually transmitted diseases

• Needles may be used which increases transmission of HIV, hepatitis C etc.

• Meth users may have ‘rough’ and prolonged sexual experiences which may cause damage to anal or vaginal tissue and thus increase likelihood of infection

• Chronic meth users may experience erectile dysfunction as a side effect. Viagra etc. may be used prolonging erections

• HIV meth users are more likely to develop AIDS

Meth and Erectile Dysfunction Drugs

• Study from the San Francisco Department of Public Health (reported in Alpert JS, Viagra: The Risks of

Recreation Use. Am J Med; 26 May 2005, 569-570.) indicates that MSM using Viagra 54% used Viagra in conjunction with other drugs to enhance sexual experience 23% used meth with Viagra

History • Post WWII used to decrease fatigue called ‘work pills’ in Japan

• 1960’s or “speed” became favorite among truckers, bikers and college students ‘Speed Kills’

• 1974 Drug Control Act curbed medicinal use

• 1980’s a new variation of amphetamine…d- methamphetamine was developed

• Production increased in the 1980’s due to the easy availability of ephedrine mostly from foreign sources CA

• 1990’s due to regulations, ephedrine imports decreased. Pseudoephedrine replaced ephedrine and retail stores became source

• Various regs, blister packs, behind counter have reduced availability of pseudoephedrine

• Production moved to Mexico where ephedrine was still available when that changed…recipes changed etc.

• Landscape is constantly changing and with it addiction rates Oral Manifestations of Chronic Meth Use

Xerostomia

Rampant caries

Periodontal disease

Bruxism/fractures

Muscle

Mouth Sores or Burns MY TEETH ARE: Blackened

Stained

Rotting

Crumbling

Falling apart

Falling out

Pattern of Caries of

•Buccal Smooth surfaces

•Interproximal surfaces of anterior teeth

•Cervical areas

Contributing Factors .

.

.Poor

.Poor Nutrition

.Caustic materials/heat

http://www.methproject.org/answers/what-is- meth-mouth.html#.UkHhQxyqwR0.mailto

Xerostomia Xerostomia

.Meds: HIV, anti-HPT, anti-depressants, anti-histamines, etc. etc. .Parotid impairment i.e. trauma, ca, HIV .Radiation/Chemotherapy .Autoimmune diseases .Drug use i.e. , methamphetamine Xerostomia

Vasoconstriction in vasculature leads to decrease in flow

Stimulation of inhibitory adrenoreceptors in salivary nuclei decreases flow

Dehydration due to increased (heat) and physical activity

Methamphetamine abuse and oral health: A pilot study of "meth mouth" Ravenel, Michele C. / Salinas, Carlos F. / Marlow, Nicole M. / Slate, Elizabeth H. / Evans, Zachary P. / Miller, Peter M.

No significant difference in salivary flow rates were noted, yet results showed significant trends for lower pH and decreased buffering capacity. These findings suggest that salivary quality may play a more important role in meth mouth than previously considered. Salivary analysis may be useful when managing a dental patient with history of methamphetamine abuse.

28 subjects, meth users had higher caries rate missing teeth

Periodontal Disease

Reduced blood flow leads to:

• Increased risk of infection

• Slow healing

• Xerostomia and poor nutrition and hygiene also contribute to poor periodontal health

Bruxism/Clenching

• Increased energy and neuromuscular activity

• Parafunctional habits

• Temporomandibular disorder symptoms

• Muscle tenderness

• Fractured teeth and wear patterns

Poor Oral Hygiene

An individual who is high on meth can go for days and days, just running on meth and pretty much nothing else. These day or even week long meth binges are called "tweeking" in the drug community. "Tweekers", as they are so called, will either ingest by mouth, snort, and smoke or inject meth repeatedly during these binges, and will typically forego eating and sleeping during this time. Once they finally do fall asleep, a tweeker will sleep for days only to wake up and do it all over again.

Poor Diet

• High intake of refined carbohydrates

• Highly caloric carbonated beverages

• Regurgitation or vomiting

• Increased acidity of in meth users

Caustic Materials/Heat Ephedrine or Pseudoephedrine

Acetone Battery acid Benzene Anhydrous ammonia Camp stove fuel Ether Lithium from batteries Iodine Freon Drain cleaner Paint thinner Toluene Lye Red phosphorous Salt Muriatic acid ETC. Chemicals Used in “meth” Production • Acetone • Red phosphorous • Anhydrous ammonia • Muriatic acid • Sodium hypochlorite • Ether (starting fluid) (bleach) • Trichloroethane (gun • Sulfuric acid (drain cleaning fluid) cleaner) • Isopropyl alcohol • Heet and Iso-Heet • Sulfuric acid (battery (gasoline additives) acid) amphethamines.com/meth lab-terrorism Chemicals Used in “meth” Production • Coleman fuel • Hydrogen (white gas) peroxide • Sterno (ethanol, • Mineral spirits methanol & • Sodium amphoteric • Lithium (including acid) lithium batteries • Red Devil lye

Meth mouth is one of the most visible consequences of Journal of the California Dental Association methamphetamine use. In (June 2013) “Meth Mouth Severity in Response to Drug-Use Patterns & Dental Access in this Methamphetamine Users” Vol 41, No. 6, pp study, we identified risk 421-428, R Brown et al. Retrieved from factors http://www.cda.org/Portals/0/journal/journal that influence the severity of _062013.pdf meth mouth. We found that an oral route 99 patients controlled for of use (smoking) is a stronger alcohol use users vs non users predictor of meth mouth severity than non-oral routes (intravenous or intranasal) and duration of use. How mouth sores are formed by meth use may include the following possible culprits:

Chemical burn Caustic and Hot

Cottonmouth Stimulants, including methamphetamine, deplete salivary secretions and raise body temperature to a much higher level than normal.

Tissue damage Constriction of blood vessels in the mouth harms tissues initially, but after recurrent episodes, can cause tissues to die.

Continuous friction between the tongue and Skinned raw the inside of the mouth

Rampant Caries is not always meth mouth TAKING A THOROUGH Taking a thorough medical history and MEDICAL HISTORY AND ORAL AND PHYSICAL EXAMINATION IS IMPERATIVE •Poverty •Medications •Poor dental IQ •Systemic Illness •Neglect •Abuse •Psychiatric Issues Xerostomia related caries

“meth mouth” or not?

Caries in the HIV patient Treatment Objectives

•Improve nutrition

•Reduce consumption of highly caloric beverages and refined carbohydrates

•Improve oral hygiene

•Decrease xerostomia and high acidity of saliva

•Decrease bruxism

STOP USING METH • Meth abusers who become abstinent experience a reduction in dopamine

• Lowest point may be after several months

• Dopamine levels may take a year or longer to fully return to baseline levels

• Most substance abuse tx involves immediate intervention, but support services are important months/years after abstinence from meth use. Meth Mouth

Emergency /Urgent Care Situations Patients ‘high’ on meth should not receive dental treatment for at least 6 hours after last administration of drug (Goodchild and Donaldson 2007) • Seek immediate medical attention

• Monitor vital signs

• Administer oxygen

• Be prepared to administer CPR

• Pt may be experiencing paranoia and the potential for violent behavior Local Anesthetics with vasoconstrictor Use with Care

Hypertensive crisis

Cardiac dysrhythmias

Myocardial Infarction

Strokes Pain Control Important to know other drugs being used

When meth was used last

Evaluate for drug seeking behavior

NSAIDS can be used

Opioids are not contraindicated unless other CNS depressants are being used or if actively using meth

Assess and Treat

• Comprehensive oral exam

• Thorough medical history

• Concern for oral health and dental findings

• Preventive Measures

• Address xerostomia

• Occlusal Guards

• Nutrition counseling (Adapted from ADA) Xerostomia Therapies

.Adequate water intake .Sugarless candy or gum .Artificial saliva substitutes .Avoid caffeine and alcohol .Topical fluoride: varnish, gels, . Pilocarpine (Salagen) •Cholinergic agonist

•Increases endocrine secretions

•Has been approved by FDA for use in Sjogren’s Syndrome

•Dosage is 5mg tid

•Side effects include chills, nausea, diaphoresis

•Caution in patients with cardiac dysrhythmias, hypertension, renal disease Fluoride /gels

Fluoride applications such as cavity varnish/trays

Xylitol /mints

Sealants

MI paste calcium/phosphates

Saliva substitutes Occlusal guards

Dual purpose:

• Administering Fluoride Treatments

• Minimizing deleterious effects of bruxism

Educate Encourage drinking water instead of sugary drinks

Risks of meth use

Be aware of drug interactions

Risk reduction strategies i.e. clean works, drug tx

Risk of co infection with HIV hep B, C (adapted from ADA) Consult and Refer

• Know medical referral and consultative resources

• Be familiar with treatment facilities and what pt can expect

• Encourage testing and refer for potential infections such as HIV,

Hepatitis and STD’s (adapted from ADA) Meth Project www.Methproject.org

Methamphetamine and the mouth(ADA) www.ada.org

Meth Awareness Prevention Project www.mappsd.org

Methresources.gov www.methresouces.gov

Office of National Drug Control Policy www.whitehousedrugpolicy.gov

Methamphetamine Treatment Project www.methamphetamine.org

Hazelden Foundation www.hazelden.org/meth

Crystal Meth Anonymous www.crystalmeth.org