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 Methamphetamine—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 addiction. 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 Amphetamine 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 Trismus Mouth Sores or Burns MY TEETH ARE: Blackened Stained Rotting Crumbling Falling apart Falling out Pattern of Caries of Meth Mouth •Buccal Smooth surfaces •Interproximal surfaces of anterior teeth •Cervical areas Contributing Factors .Xerostomia .Bruxism .Poor Oral Hygiene .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. cocaine, methamphetamine Xerostomia Vasoconstriction in salivary gland vasculature leads to decrease in flow Stimulation of inhibitory adrenoreceptors in salivary nuclei decreases flow Dehydration due to increased metabolism(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 saliva in meth users Caustic Materials/Heat Ephedrine or Pseudoephedrine Acetone Alcohol 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