Flashcards in Exam 4 Principles of Addiction and Drugs of Abuse Deck (123):
What factors increase the potential for abuse?
1) Potency of the drug= greater potency = more likely to abuse
2) Quick/rapid onset of action
4) Easy to obtain/distribute
What is drug abuse?
When drugs are used in a manner or ant inconsistent with medical or social patterns of a culture
What is Physical dependence?
-Changes that have occurred in the body after repeated use of a drug that necessitates the continued administration of a drug to prevent a withdrawal syndrome
-NOT an addiction (can exist without addiction)
-Addicts are usually physically dependent on drug they are abusing
-pt’s who use opiates for chronic pain management are likely to be physically dependent
What is Psychologic dependence?
-Perceived “need” or “craving” for a drug
-often feel that they cannot function w/o continued use of that substance
-Physical dependence disappears w/in days or weeks after drug use stops, but psychological dependence can last much longer
-Psychological dependence is primarily reason for relapse (initiation of drug use after period of abstinence).
What is Tolerance?
***With repeated dosing, the dose of drug must be increased to produce same effect
--or w/ consecutive dosing, same dose of drug produces less of an effect
-Need a HIGHER dose to produce the desired effect
**Psychoactive drugs produce “central” tolerance (function or behavioral)
-definite decrease in the response of brain tissue to constantly increasing amounts of the drug
-NOT the same as metabolic tolerance (as we discussed in basic principles) caused by accelerated rate of metabolism of drug
--insignificant factor in tolerance observed in humans to most psychoactive drugs
What is withdrawal syndrome?
-Can range from mildly unpleasant to life-threatening
--dependent on a number of factors:
1) drug being used
2) dose and route of administration
3) concurrent use of other drugs
4) frequency and duration of drug use
5) age, sex, health and genetics of the individual user
What is addiction?
-Compulsive drug-seeking behavior where acquiring and using a drug becomes most important activity in user’s life
-loss of control regarding drug use
-Continued use despite serious medical and/or social consequences
w/ addiction, there is always psychological dependence
What are the Behavioral signs of addiction?
1) preoccupation with obtaining the drug
2) compulsive use in spite of adverse consequences
3) relapse following periods of abstinence
4) anal retentive
5) obsessive compulsive
What is Habituation?
physiological tolerance to or psychological dependence on a drug, short of addiction
What is enabling?
-The behavior of others (e.g. family and friends) who are associated w/ drug addict, results in continued drug abuse
--this is an inappropriate coping mechanism by the “enabler” that negatively reinforces that addict’s behavior
--often requires family counseling
What is abstinence?
-The state of being free of drugs
--goal of drug treatment programs
What is abuse?
-non-sanctioned use of controlled substances
-use of legal pharmaceuticals outside of the scope of sound medical practice
All controlled substances substances have abuse potential or are immediate precursors to substances with abuse potential what can they alter?
abused to alter:
4) actions on CNS
5) alleviate pain, anxiety, depression, induce sleep, energize
What is the Treatment: for Abuse?
1) Multifactorial approach
-counseling for behavioral change
2) Individual must have the desire to stop for best chance of success
Drug abuse in Kids?
-Access to store medications at home
--contributing factor to prescription medication abuse
--especially problematic for children and teenagers
-a leading cause of visits to the ER due to accidental or intentional overdose
What are the Considerations for Children:
-many drugs must be given to children in doses that are smaller than the adult dose
-children have increased membrane permeability
-allows drugs to be absorbed more quickly and more easily
-doses are determined by the manufacturer
-dosing is based on the weight of the child
-typically, children receive half of the adult dose
What are the Trends for abuse?
1) more children are abusing prescription drugs than cocaine, heroin, hallucinogens and Ecstasy combined
2) Opiates cause more overdoses in adolescents than cocaine and heroin combined
What is misuse?
-misuse of a drug differs from abuse, as misuse implies that drug is being used inappropriately for patient’s disease state
--using the wrong drug for wrong problem, or the wrong dose for a longer period that prescribed
What is Chemical dependency for abuse?
-a primary, chronic, progressive, relapsing disease process with genetic, psychosocial and environmental factors influencing its development and manifestations
-progressive nature of addiction
■ experimental→ social use → abuse → addiction
■ majority of “social users” will become addicted
What are the gateway drugs?
Nicotine and Alcohol
-caution w/ dental patients who report a history of this disease
****remember: relapsing disease***
-NO opiates, benzodiazepines, or nitrous oxide
-could make a recovered patient w/ alcoholism relapse
How do you determine? Drug choice
-Strength and efficacy of a given drug play important roles in whether a drug is selected by the drug abuser
-Effects vary significantly (largely dependent on dose and route of administration)
-concurrent use of other drugs is common
-boost desired effects or counter unwanted effects
-when comparing drugs in the same group, the time required to produce physical dependence is _________with a rapidly metabolised drug and _________ with a slowly metabolized drug
-The time course of withdrawal reactions is related to the ___________of the drug
-shorter the half life, the __________the withdrawal occurs
- half-life of the drug
What are the common reasons for relapse following treatment for drug addiction?
-Primary reason = psychological dependence
-perceived “need” or “craving” for a drug, often feel that they cannot function w/o continued use of substance
-Physical dependence disappears w/in days or weeks after drug use stops, but psychological dependence can last much longer
-Caution w/ dental patients who report a history of disease (chemical dependency)
--No opiates, benzodiazepines or nitrous oxide - could make a recovered patient w/ alcoholism relapse
What is the cardiovascular considerations for treating children who abuse inhalants?
-Difluoroethane - contains halogenated hydrocarbons
--INCREASES heart muscle sensitivity to epinephrine
--Can lead to sudden death
-Sniffing correction fluid can stop your heart
What are the consequences of IV drug abuse?
-IV injection of opioid drugs often results in:
--Damaged heart valves (IV drug users require antibiotics premed prior to receiving any dental treatment)
-Never provide treatment to patients who are under the influence
-Use good infection control and PPE when treating
What is the Poison Prevention Act of 1970s?
1) to prevent accidental drug intoxication in children
2) prescription must be dispensed in **child-resistant containers**
3) Exceptions= arthritis patients
What are the trends in children?
-More children are abusing prescription drugs than cocaine, heroin, hallucinogens + Ecstasy combined.
-Opiates cause more overdoses in adolescents than cocaine and heroin combined
Inhalants are ______ to abuse. "huffing" out of can or sniffing or bagging.
They are readily ___________
Manufacturers of difluroethane add _______ to discourage use.
What are the harmful effects of inhalants?
1) Permanent brain damage memory loss
2) hearing loss
3) nose bleeds loss of smell
4) slurred speech
5) suffocation sudden death
6) irregular heart beat and heart attack (death)
7) nausea and vomiting
8) liver/kidney damage
9) muscle weakness and cramping
10) abdominal pain
11) involuntary passing of urine and feces
12) bone marrow depression
What are the causes of death of inhalants?
2) respiratory depression
3) **Hepatotoxicity = cumulative damage
4) sudden sniffing death
What are other OTC drugs abused by children?
1) cough meds w/ dextromethorphan (DXM)
3) Coricidin HBP (w/o acetaminophen) "Triple C" skittles
4) Energy and diet drinks
What are the conclusions of monitoring the future study?
-alcohol use continues to decline (41%)
-binge drinking declined (12%)
-Cigarette use reached historical lows in 2014
-Increasing peer disapproval
-E-cigarettes surpass tobacco cigarettes among teens
-illicit drug use declined (synthetic marijuana)
-Most students do NOT recognize synthetic marijuana as a dangerous drugs
-Bath salts = amphetamine-like sim
What are the Symptoms of withdrawal from opiate analgesics?
5) cold flashes
6) muscle spasms
11) muscle/bone pain
What is the treatment of opiate addiction?
1)** naloxone (Narcan)
■ used to reverse respiratory depression, pinpoint pupils and coma
■ oral surgeons have this drug in office emergency
■ Used for acute narcotic overdose
■ **long-acting opioid that can replace heroin then be gradually withdrawn
■ **physiologically equivalent drug to heroin that is used during long-term rehabilitation
What are the Dental implications of opioid users?
-They may require higher levels of pain meds to get desired effect
-Watch for drug-seeking behaviors: pts will ask for potent meds
**IV drug users require ABX premed prior to receiving dental treatment
What are the signs of acute opioid overdose?
1) Fixed, pinpoint pupils (miosis)
2) Depressed respiration
5) Slow or absent reflexes
What are the important drugs used as antidotes to manage opiate overdose?
1) naloxone (Narcan)
What are the important drugs used as antidotes to manage BDZ overdose?
■ BDZ antagonist = “blocker” drug
■ Will not block CNS effects from alcohol, barbiturates, general anesthetics or opiates
■ May not reliably reverse respiratory depression/hypoventilation
● Establish airway
● Provide ventilation
2) BDZ reversal may cause seizures = be prepared to manage
What its the Pharmacology of alcohol?
-Most frequently abused drug
-Ethyl alcohol is rapidly and completely absorbed from the GI tract
-Oxidized in the liver to acetaldehyde, which is then metabolized to CO2 + H2O
-Excreted in lungs + urine
-Eliminated by zero order kinetics
--a constant amount of alcohol is metabolized and eliminated per unit of time regardless of how much alcohol has been ingested - 1g per hour
-Excessive intake of alcohol can produce a prolonged effect
What are the signs of Intoxication?
1) Impaired judgment
2) Emotional instability
4) Slurred speech
5) Dilated pupils
What are the signs of Severe Intoxication?
What are the Oral complications of alcoholism? (know these!)
2) Loss of tongue papillae
3) Angular cheilitis
4) Fungal infections
5) Bleeding (from liver damage)
6) Oral cancer (squamous cell)
7) Leukoplakia and ulceration of lateral borders of the tongue
What are the Considerations of alcohol use in older adults?
1) **Decreased body water and lean body mass
-Higher concentration of alcohol, 20% increase in peak blood level
2) **Decline in liver and kidney function
3) Malnutrition/weight loss (caused by cirrhosis, heart disease, pancreatitis, pancreatic carcinoma)
The elderly more sensitive to the alcoholic effects of what ?
1) **Metabolize alcohol more slowly
2) Alcohol stays in body longer
3) **Decreased body water = alcohol more concentrated
4) Aging lowers body’s tolerance
5) ***Older people develop problems with alcohol even if drinking habits have not changed
What are the consequences of chronic alcoholism in elderly individuals?
1) Biological brain disorder
2) Systemic health problems
3) Fatigue, weight loss
4) Worsening of existing conditions
What are the Biological brain disorder associated with chronic alcoholism in the elderly ?
-DTs (Delirium tremens)
What are the Systemic Health problems associated with chronic alcoholism in the elderly ?
-increased risk for certain cancers and immune disorders
What is the fatigue, weight loss of chronic alcoholism in the elderly caused by?
What is the worsening of existing conditions of chronic alcoholism in the elderly caused by?
What are the psychological/other consequences of chronic alcoholism in elderly individuals caused by?
What are the Drug Interactions and Alcohol?
**Aspirin/NSAIDS + alcohol = GI bleeding
**Acetaminophen + alcohol = liver damage
**Cold/allergy Meds and antihistamines + alcohol = drowsiness, impaired judgment/reaction time/coordination
**CNS drugs + alcohol = sleepiness, poor coordination, dyspnea, tachycardia, memory problems
What are the Chronic Signs of Alcoholism?
3) Liver damage/cirrhosis - watch problems with bleeding
5) Cancer - oropharyngeal/liver
6) Peripheral neuropathy
7) Amnesic syndrome
What is Fetal Alcohol Syndrome?
-Retarded body growth
-Small head (microencephaly), underdevelopment of mid-face,
-Poor coordination and joint anomalies
What is withdrawal for alcoholism?
***Occurs in stages
- Psychomotor agitation
- Autonomic nervous system hyperactivity
***Grand mal seizures
***DTs = delirium tremens = shaky tremor movements
What is the TX for alcoholism?
1) Ventilation support
2) Fluids and electrolytes
3) Vitamin B6
5) Sodium bicarbonate
7) disulfiram (Antabuse
What signs should you look for in a patient with chronic alcoholism?
***WATCH PROBLEMS w/ BLEEDING
Describe the disulfiram (Antabuse) drug
-This drug inhibits metabolism of aldehyde dehydrogenase, which increases serum levels of acetaldehyde
-High acetaldehyde levels causes flushing, nausea, thirst, palpitations, chest pain, vertigo (dizziness), headache, and vomiting
-Adverse drug effects increase when drug is taken w/ alcohol, which is why it is used for tx of chronic alcoholism (deters person from wanting to drink) = drinking+ medication = vomit
What are the symptoms of overdose with CNS stimulants (meth)?
1) Dilated pupils
3) Elevated pulse
4) Cardiac arrhythmias (leads to heart attacks)
5) Extreme sweating
6) Hyperthermia = leads to brain damage, seizures and even death
7) Hyperactive behavior
What are the dental Tx considerations for alcoholism?
**poor oral hygiene from neglect
**bilateral enlarged parotid glands
**liver failure = increases risk for bleeding
**difficulty metabolizing drugs
What are examples of abused opioids?
-hydrocodone w/acetaminophen (Vicodin)
**oxycodone (Oxycontin) = widely abused by dentists
Why are opioids abused?
-B/c they produce complete satiation of all drives in the body
1) elevate mood
2) cause euphoria
3) relieve fear/anxiety/apprehension
4) produce feeling of peace/tranquility
5) suppress hunger
6) reduce sexual desires
7) diminished response to provocation
What is the result of opioid dependance?
-increases motivation to obtain drug
-fear of withdrawal overrides motivation to stop
-addicts often resort to criminal activity to obtain drug
What is oxycodone?
-designed for morphine tolerant pts
-"layered" dissolve slowly for extended release
-very potent dosing and die
-volatile (smoked in foil)
What is oxycodone and acetaminophen?
Why do addicts prefer roxicet?
-It has less binder (easier to dissolve)
What is the REMS program?
-Risk Evaluation and Mitigation Strategy (REMS)
-Benefits should outweigh risk
--fentanyl and buprenorphine
Number of women dying from opioid painkiller overdose has increased _______ .
______ is the percentage increase in deaths for women compared to men _________
What is the CDC opioid recommendations?
-follow guidelines for responsible opioid prescribing
-use states' prescription drug monitoring programs
-discuss pain tx options
-avoid prescribing combinations of prescription painkiller and benzodiazepines
What are some examples of popular BDZ drugs?
-lorazepam (Ativan) *
-alprazolam (Xananx) *
What is "benzo-abstinence" syndrome?
-Due to unavailability of drug or during hospitalization for other medical problem
What are the indications for BDZ?
1) Chronic anxiety
3) Sleep disturbance
4) Long-term use = significant physical dependence or addiction
What are the complications with BDZ?
1) Significant additive effect
2) Prolonged half-life
3) Withdrawal syndrome
What are the adverse effects of BDZs?
1) Alcohol and BDZ (Teach patents to avoid alcohol)
2) Respiratory depression
3) Long-half life means that risk persists for days after dose (Valium = 20-50 hrs)
What are examples of stimulants?
CNS stimulant with local anesthetic properties, it is a POTENT __________.
Produces profound sense of __________.
Also causes feelings of __________ and has a short duration of ______.
**Produces intense psychological dependency, but no ________or _________
What are the adverse runs with cocaine?
What are the signs of use for Cocaine?
1) Nasal bleeding/necrosis
2) Dilated pupils (this effect peaks at 45 minutes after taking cocaine)
3) Hypertension = never give epinephrine within 24 hours of cocaine use
8) Localized gingival recession, bleeding and alveolar bone necrosis in maxillary premolar area if users rub cocaine on gums
Emergency management of cocaine users?
5) Cooling measures
6) Drugs needed to combat multiple effects = blood pressure, arrhythmias, correct metabolic disturbances
What are the therapeutic indications of amphetamines?
--ADHD (When other stimulants have failed)
--Obesity (short term use
Most common abused form of amphetamine is __________.
Made by cooking down_______.
Methamphetamine produces longer duration of action than ____________.
- methamphetamine (crystal meth)
- pseudoephedrine (Sudafed)
What are the Amphetamine effects?
-Amphetamines are sympathomimetics
-Produce euphoric mood
-Increase sense of energy
What is MDMA? (Methylenedioxymethamphetamine)
-1st used an appetite suppressant
**Stimulant psychedelic drug = drug of abuse
-alters serotonin and dopamine neurotransmission
-duration of action = 4-6 hrs
What are the side effects of Ecstasy?
1) Later effects = fatigue and insomnia
4) Long-term psychiatric problems
5) Fatal side effects (cardiovascular toxicity)
Methamphetamine acts as a _________to the CNS.
Dextromethamphetamine = ________ use.
What is the MOA of methamphetamine?
-Brain is flooded with dopamine
-brain structure/function becomes altered with chronic use
-resembles fight or flight response
Methamphetamine is ________ especially to ___________ neurons.
Degradation of dopamine produces _________.
Skin lesions come from __________ . This is a result of the symptom known has __________= sensation of insects craving beneath skin.
-reactive oxygen species (free radicals--causes toxic damage)
Describe the psychological effects of meth
What are the dependency and addiction symptoms of meth?
-Withdrawal accuses depression which is longer and deeper than that seen from cocaine (relapse is common)
-No comparable drugs to break addiction like wave for heroin addicts
What are the clinical signs of meth use?
1) Dilated pupils
2) Hypertension and tachycardia
3) Anorexia due to decreased appetite
4) INCREASED sweating (diaphoresis)
What is meth mouth?
-drug toxic, acidic ingredients (anhydrous ammonia); lithium batteries)
-erosion of teeth
-poor oral hygiene
-ulcerations and infections
-oral burns if snorted/smoked
What are the withdrawal reactions to CNS stimulants?
-Modest abuser = fatigue/prolonged sleep
-Heavy abuser= aching muscles, appetite, **prolonged periods of sleep, **depression and **suicidal tendency
What is Nicotine?
-Highly addictive (physical and psychological)
What are the desired effects of Nicotine?
1) increased alertness
2) muscle relaxation
3) Facilitation of concentration and memory
4) decreased appetite (weight loss = primary reason why girls smoke)
What are the harmful effects of Nicotine?
● camel face
● increase pulse rate
● induces nausea and vomiting
● coronary artery disease
● lung cancer
● oral cancer
What are the withdrawal symptoms from Nicotine ?
These symptoms make it hard to quit smoking :
● difficulty concentrating
● increased appetite (fear of gaining weight
● sleep disturbances
● craving tobacco
What is Tobacco cessation ?
-dental professionals play an important role in tobacco cessation education
-requires behavioral modification
-person must be ready to quit
-people often require 5-8 quit attempts before they are finally successful
-use of support group significantly improves chance for success
What are Hallucinogens
■ Have NO medical use
■ known as **psychodelics
■ **Alter ALL sensory input
■ perceive heightened awareness
■ sounds brighter/clearer
■ colors are more brilliant
■ taste, smell and touch are more acute
■ **Psychological dependence
■** Tolerance develops quickly
■ **Long-term use leads to mental disturbances (depression, panic disorders, schizophrenia)
What are examples of Hallucinogens?
Hullucinogens are powerful _______. They have adverse _____ effects.
They cause delusions, ________ and ________.
They are Sympathomimetics and have adverse ________ effects = no _____________.
They cause _______ pupils and abnormal ______ movement, and muscle _________.
- panic, paranoia
What is Marijuana (Cannibis) ?
--What are the MAJOR psychoative chemicals:
-Derived from hemp plant
-Contains over 500 defferent chemicals
**** 1) Delta-9- tetrahydrocannabinnol (THC) "RECREATIONAL "
**** 2) Cannabidiol (CBD)
-Female plant contains HIGHER concentrations of psychoactive chemicals
-Ingested or smoke
What are the Effects of THC?
■ Muscle relaxation
■ appetite stimulation
■ mood alteration
■ alertness, perception
■ high dose: anticholinergic
What are the Effects of CBD?
■ muscle relaxant
■ decrease psychotic and other CB receptor-mediated effects of THC
--Works in concert with THC to produce clinical benefits
What are the Potential Uses of Medical Marijuana ?
■ analgesic (neuropathic pain)
■ Seizures (High CBD)
■ Glaucoma = reduces intraocular pressure
● used for treatment of resistant glaucoma
■ Sleep apnea
■ Tourette’s syndrome
What are the Pharmacological Effects of Marijuana
1) Disoriented behavior
3) increased appetite (the muchies)
4) enhanced sensory perception
5) distortion of place and time
6) followed by sedation and altered consciousness (dreamlike state)
What are the Short-term effects of Marijuana?
1) Problems with memory and learning
2) distorted perception
3) difficulty in thinking and problem-solving
4) loss of coordination
What are the long-term chronic use effects of Marijuana?
-Leads to physical dependence and withdrawal and psychological dependence and addiction
What are other Risks associated w/ weed?
- Association between marijuana use and
-- increased risk for depression
-- increased for and earlier onset of schizophrenia
-- other psychotic disorders
*****Risk is greater in teens w/ genetic predisposition
What are the signs and symptoms of Weed?
1) Increased pulse rate
2) blood shot eyes
3) slow to respond
4) slurred speech
5) glazed eyes
6) Odor on breath or clothes
What are oral complication of weed?
4) hyper keratinized tissues
Note: Know these!!!
What are the complications of weed?
-precancerous changes in bronchioles
What are the Medical uses of Marijuana?
(what is synthetic name?)
-dronabinol (Marinol) - synthetic version of THC
-SCHEDULE 3 drug
●nausea and vomiting from chemotherapy (antiemetic properties)
● appetite stimulation in pts w/ AIDS
What are K2 Spices?
-Herbal mixtures (incense, potpourri)
**produce similar effects to marijuana
-Acts on SAME receptor as THC
What are Predatory Drugs?
-Used to identify drugs that can be used to facilitate sexual assault.
- In the late 1990s law enforcement noticed a new, disturbing trend of rape cases that involved the drugging of victims with chemicals such as "rohypnol", "GHB", and" ketamine"
What is Rohypnol ??
***flunitrazepam - benzodiazepine not approved for use in the US
-“date rape drug”
-When mixed with alcohol, incapacitates victim and prevents them from resisting sexual assault
--Muscle relaxation, amnesia, sedative
-Lethal when mixed with alcohol or other depressants
-Nicknames: roofies, roach, rope
What is GHB (gamma hydroxy-butyrate)?
***Sodium oxybate (Xyrem) - CNS depressant
-Analogues to GHB found in industrial solvents and cleaners = not detected in tox screen
(Mixed as liquid)
***Euphoric, sedative, anabolic (bodybuilding)
-Associated w/ sexual assault cases
-Coma + seizures may occur when abused or taken w/ methamphetamine
-Risk of seizure, difficulty breathing; death from overdose
-withdrawal effects: insomnia, anxiety, tremors, sweating
-Nicknames: liquid ecstasy, somatomax, scoop, Georgia Home Boy, grievous bodily harm
What is Ketamine?
-similar to PCP (phencyclidine) but more rapid onset and is less potent
-feelings of pleasant weightlessness to full-fledged out of body or near death experiences
--Nicknames: Special K, Jet, Sharks, Super Acid, Honey Oil, Green, K, Cat Valium, Super C
What is Ketamine used for?
***Used as general anesthetic (also in veterinary medicine)
***sedative hypnotic drug, analgesic and hallucinogenic
--Date rape drug
What are the Signs of drug abuser?
1)** Physical assessment
2)** Poor general hygiene/oral hygiene
3)**Inappropriately dressed for the weather
4)** Changes in behavior/unusual behaviors
5) Appear “under the influence”
What are Drug “Shoppers” ?
- Give an extremely detailed history
- Good storytellers and actors with convincing histories
- Ask for opiates by name
- Tell you about the other analgesic meds that they do not want bc they want something “stronger”
- Schedule appointments at end of the day for pain in hopes of getting a prescription for an opiate without an exam
- Asks dentist to “Call in” prescriptions based on previous history not current problem
What are other signs of a drug abuser?
-Asked to have prescription called in by phone
-After hours requests
-Out of towners
-Look for skin conditions
How to manage these patients that are drug seekers?
-Refuse to give medications without an ____
-Clearly and completely document all clinical ____, _______ and _____
-Request photo ____
-Confirm phone number and _______
-Prescribe in limited_____ only
-Use _____ as often as possible
-Use honest and ____ communication
When dealing with patients that are drug seekers:
Never keep prescription ____ unattended in an operatory
-Never keep any ____ stored in the operatory or in areas ______ to patients
-All controlled substances must be kept in a ____ area away from access by patients
-If possible, do not keep controlled substances _______
○ Never provide treatment to patients who are under the _________
○ Avoid the use of epi due to _____concerns
○ Remember that IV drug users often contract ______, _____ and ____= use good infection control and personal _______equipment when _______