The Patient with a Substance-Related Disorder










The Patient with a
Substance-Related Disorder
Ernestine R. Daniels, RDH, BS
INTRODUCTION
ALCOHOL CONSUMPTION
I. Clinical Pattern of Alcohol Use
II. Etiology
METABOLISM OF ALCOHOL
I. Ingestion and Absorption
II. Liver Metabolism
III. Diffusion
IV. Blood Alcohol Concentration
HEALTH HAZARDS OF ALCOHOL
I. Liver Disease
II. Immunity and Infection
III. Digestive System
IV. Nutritional Deficiencies
V. Cardiovascular Diseases
VI. Neoplasms
VII. Nervous System
VIII. Reproductive System
FETAL ALCOHOL SPECTRUM DISORDERS
I. Alcohol Use During Pregnancy
II. Criteria for FASD Diagnosis
III. Characteristics of an Individual with FASD
ALCOHOL WITHDRAWAL SYNDROME
I. Predisposing Factors
II. Signs and Symptoms
III. Complications
TREATMENT FOR ALCOHOLISM
I. Early Intervention
II. Detoxification
III. Pharmacotherapy
IV. Rehabilitation
ABUSE OF PRESCRIPTION AND STREET
DRUGS
RISK MANAGEMENT FOR LEGAL
PRESCRIPTIONS
I. Dental Team Responsibilities
II. Prevention of Prescription Drug Abuse
MOST COMMON DRUGS OF ABUSE
I. Cannabinoids (Marijuana)
II. Depressants
III. Dissociative Anesthetics
IV. Hallucinogens
V. Opioids and Morphine Derivatives
VI. Stimulants
VII. Other Compounds
MEDICAL EFFECTS OF DRUG ABUSE
I. Cardiovascular Effects
II. Neurological Effects
III. Gastrointestinal Effects
IV. Kidney Damage
V. Liver Damage
VI. Musculoskeletal Effects
VII. Respiratory Effects
VIII. Prenatal Effects
IX. Infections
TREATMENT METHODS
I. Behavioral Change Interventions
II. Drug Withdrawal Medications
DENTAL HYGIENE PROCESS OF CARE
I. Assessment
II. Intraoral Examination
III. Dental Hygiene Diagnosis
IV. Planning
V. Implementation
VI. Evaluation
DOCUMENTATION
EVERYDAY ETHICS
FACTORS TO TEACH THE PATIENT
REFERENCES
CHAPTER OUTLINE
65
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1086 SECTION IX | Patients with Special Needs
Moderate alcohol use: two drinks per day for men
and one drink per day for women is not considered
harmful for the average adult.
2
The individual is able
to function appropriately in work, family, and social
situations.
Unhealthy alcohol use: early-stage problems such as
hypertension, depression, insomnia, heartburn, and ab-
senteeism develop.
3
Alcohol dependency and alcoholism develop after pe-
riods of unhealthy alcohol use followed by pathologic
abuse.
4
The spectrum of alcohol use is illustrated by
Figure 65-1.
Volume and alcohol content in a standard drink of vari-
ous alcoholic beverages is shown in Box 65-2.
A. Effects of Alcohol Intoxication
4
Behavioral changes: aggressiveness, mood instability,
impaired judgment; impaired social or occupational
functioning; impaired attention and memory; stupor or
coma.
Physical characteristics: slurred speech, lack of coordi-
nation, unsteady gait, and nystagmus.
Complications: irresponsible actions in work and fam-
ily settings.
Accidents with resultant bruises, fractures, or brain
trauma.
Vehicular accidents.
Suicide.
B. Consequences of Underage Drinking
5
Drinking and driving.
Suicide.
Sexual assault.
High-risk sex.
Alcohol-induced mental impairment.
C. Signs of Alcoholism
6
Alcoholism, also known as alcohol dependence, includes
four main symptoms:
Craving: A strong need or compulsion to drink.
Loss of control: The inability to limit one’s drinking on
any given occasion.
INTRODUCTION
Drug and alcohol dependence often go hand in hand;
people who are dependent on alcohol are more likely
than the general population to use other drugs, and people
with drug dependence are more likely to drink alcohol.
1
Substance abuse reflects a complex interaction between
the individual, the abused drugs, and society.
Drug use varies from recreational use to addiction; peo-
ple from various stages of drug use appear as patients
needing dental and dental hygiene care.
Patients who use drugs recreationally may “premedi-
cate” themselves when a stressful situation such as a
dental appointment is anticipated; therefore, questions
at each appointment are required to determine clinical
procedure and prevent complications.
There is no classic cultural, socioeconomic, or educa-
tional profile for a substance abuser.
A patient’s medical and dental history does not al-
ways provide the information necessary to determine
whether the patient uses substances at all, or the level
of dependency.
It is a professional responsibility of the dental hygienist to:
• View chemical dependency as an illness and to be
aware of the characteristics that suggest possible sub-
stance use.
• Address the issues of an appropriate dental hygiene
care plan for the chemically dependent patient.
Key words and terminology related to the use and abuse
of drugs are defined in Box 65-1.
Alcohol use is common in a large percentage of the pop-
ulation and varies from social drinking to alcoholism.
Physical dependence and tolerance are both present in
an individual suffering from alcoholism.
Alcohol used for consumption purposes is ethyl alcohol
or ethanol. Other alcohols are methyl, an industrial sol-
vent, and isopropyl, used for rubbing alcohol.
ALCOHOL CONSUMPTION
I. Clinical Pattern of Alcohol Use
Abstinence and low-risk use.
Increased consumption.
LEARNING OBJECTIVES
After studying this chapter, the student will be able to:
1. Explain key terms and concepts related to the metabolism,
intoxication effects, and use patterns of alcohol.
2. Identify physical health hazards, medical effects, and oral
manifestations associated with alcohol and other drug
abuse.
3. List the names of the most commonly abused drugs and
describe their intoxication effects and methods of use.
4. Describe methods for clinical assessment of potential
substance abuse.
5. Recognize risk management principles to prevent
prescription pad theft and abuse.
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CHAPTER 65 | The Patient with a Substance-Related Disorder 1087
Abstinence: refrain from use; complete abstinence from alco-
hol is the objective of a recovering alcoholic.
Abuse: substance abuse; with respect to alcohol abuse
involves persistent patterns of heavy alcohol intake
associated with health consequences and/or impairment
in social functioning.
Acne rosacea: facial skin condition usually characterized by a
flushed appearance; often accompanied by puffiness and
a “spider-web effect of broken capillaries.
Addiction: habitual psychologic and physiologic depen-
dence on a substance or practice that is beyond voluntary
control.
Alcohol intoxication: results from recent ingestion of ex-
cessive amounts of alcohol; characterized by behavioral
changes that alter the usual behavior of the individual.
Alcoholism: a chronic progressive behavioral disorder char-
acterized by a strong urge to consume ethanol and inabil-
ity to limit the amount despite adverse consequences.
Amnesia: impairment of long- and/or short-term memory.
Anterograde amnesia: difficulty in recalling new
information.
Retrograde amnesia: difficulty in remembering old
information.
Amethystic agents: a class of substances capable of coun-
teracting the acute effects of alcohol on the central ner-
vous system.
Analgesia: loss of sensibility to pain without loss of
consciousness.
Antabuse: brand name of the generic drug disulfiram; used
to deter consumption of alcohol by persons being treated
for alcohol dependency by inducing vomiting.
Blackout: temporary amnesia occurring during periods of
intensive drinking; person is not unconscious.
DEA drug schedules: drugs, substances, and certain chemi-
cals used to make drugs are classified by the U.S. Drug
Enforcement Administration (DEA) into five (5) distinct
categories or schedules depending upon the drugs ac-
ceptable medical use and the drugs abuse or dependency
potential (see Box 65-5).
DEA registration number: assigned by DEA allowing health
care providers to write prescriptions for controlled sub-
stances (drugs that have been assigned a DEA drug sched-
ule category).
Delirium: extreme mental and usually motor excitement
marked by a rapid succession of confused and uncon-
nected ideas; often with illusions and hallucinations; may
be accompanied by tremors.
Delirium tremens: “DTs”; a serious acute condition associated
with the last stages of alcohol withdrawal.
Dementia: condition of deteriorated mentality characterized
by a marked decline of intellectual functioning.
Dependence: drug or substance dependence; with respect
to alcohol refers to a physical and psychological depen-
dence on alcohol that results in impaired ability to control
drinking behavior; dependence is differentiated from
abuse by manifestations of craving tolerance and physical
dependence, as well as an inability to exercise restraint
over drinking.
Chemical dependence: the interaction between a drug
and the individual when there is a compulsion to take
the drug to obtain its effects and/or to avoid the dis-
comforts of withdrawal.
Physical dependence: when a drug becomes necessary
for continued body functioning. An altered physiologic
state has developed from repeatedly increasing drug
concentrations.
Polysubstance dependence: addiction to at least three
categories of psychoactive substances (not including
nicotine or caffeine) but in which no single psychoac-
tive substance predominates.
Psychologic dependence: refers to the state of mind in
which the individual believes the drug is required for
maintaining well-being.
Detoxification: treatment designed to assist in recovery from
the toxic effects of a drug; involves withdrawal and may
include pharmacologic and/or nonpharmacologic treat-
ment with psychotherapy and counseling.
Drug: a chemical substance used for diagnosis, prevention, or
treatment of disease. Drugs are classified by biochemical
action, physiological effect, or organ system involved.
Euphoria: feeling of well-being, elation; without fear or worry.
Hallucination: a sensory impression (sight, sound, touch, smell,
or taste) that has no basis in external stimulation; may have
psychological causes, or may result from the use of drugs,
(including alcohol), a brain tumor, senility, or exhaustion.
Hyperthermia: body temperature higher than normal.
Illicit: illegal; not authorized, not sanctioned by law.
Micrognathia: abnormal smallness of the jaws, especially of
the mandible.
Nystagmus: involuntary, rapid, rhythmic movements of the
eyeball.
Opiate antagonist: examples include naltrexone and nalox-
one. These drugs have a high affinity for opiate receptors
but do not activate them and block the effect of exog-
enously administered opioids (e.g., morphine, heroin, and
methadone) or of endogenously released endorphins.
Opioid: synthetic narcotic that has opiatelike activities but is
not derived from opium.
Psychotropic drug: a drug capable of modifying mental ac-
tivity; used in the treatment of mental illness.
Recovering alcoholic: a person afflicted with the disease
of alcoholism who is abstaining from the use of alcohol;
recovering alcoholics prefer the term “recovering to re-
formed, cured, or recovered because recovering implies an
ongoing process.
Saddlenose deformity: a collapse of the nasal bridge.
Substance abuse: The regular use of a drug for other than
its accepted medical purpose or in dosages greater than
those that are considered appropriate.
Tolerance: ability to endure without effect or injury. Increased
amount of the drug is needed to achieve the same effect.
Drug tolerance: the need for higher and higher dosages
of a drug to achieve the same effect.
Withdrawal syndrome: a group of signs and symptoms,
both physiologic and psychologic, that occurs on abrupt
discontinuation of drug use.
BOX 65-1 KEY WORDS: Alcoholism and Drug Abuse
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1088 SECTION IX | Patients with Special Needs
B. Biopsychosocial
Alcohol-specific parenting is a distinct and influential
predictor of adolescent alcohol use partially shaped by
parents’ own drinking experiences.
Parental conversations about their own personal ex-
periences with alcohol may not represent a form of
parent–child communication about drinking that de-
ters adolescent drinking.
8
Children of alcohol-dependent parents are exposed to a
higher level of multiple risk factors that lead to alcohol-
related problems:
• Mental and behavioral disorders and adverse family
environments.
• Decreased sensitivity to intoxication effects of
alcohol.
C. Environmental
Psychological stress, family, peers, and social forces.
Current lifestyle, culture, advertisements, and
economics.
Motivational factors: both emotional (stress reduction,
mood enhancement, social rewards) and cognitive
(conscious and unconscious beliefs about alcohol) may
play a role in an individual’s decision to drink.
METABOLISM OF ALCOHOL
2
I. Ingestion and Absorption
Upon intake, alcohol is absorbed promptly from the
stomach and small intestine into the bloodstream.
Transported to liver for metabolism.
Physical dependence: Withdrawal symptoms, such as
nausea, sweating, shakiness, and anxiousness, when al-
cohol use is stopped after a period of heavy drinking.
Tolerance: The need to drink greater amounts of alcohol
in order to get intoxicated. Other signs include amnesia
and binge drinking.
II. Etiology
A. Genetics
The Collaborative Study on the Genetics of Alcohol-
ism has successfully identified GABRA2 and CHRM2
as two genes involved in the predisposition to alcohol
dependence.
7
A defective allele (variant) of the gene ALDH2 sub-
stantially (although not completely) protects carriers
from developing alcoholism by making them ill after
drinking alcohol.
2
A standard drink contains about 14 grams (0.6 oz. or
1.2 Tablespoons) of pure alcohol.
12 oz. (355 mL) of beer or wine cooler (5% alcohol
content)
5 oz. (148 mL) of wine (12% alcohol content)
1.5 oz. (44 mL) of 80-proof distilled spirits (40% alcohol
content)
Source: National Institute on Alcohol Abuse and Alcoholism. What is
a standard drink? http://pubs.niaaa.nih.gov/publications/Practitioner/
PocketGuide/pocket_guide2.htm. Accessed August 9, 2015.
A Standard Drink
BOX 65-2
FIGURE 65-1 The Spectrum of Alcohol Use. As clinicians, the shaded categories in the upper portions of the pyramid are of primary concern while treating patients. These catego-
ries reflect unhealthy alcohol use. (Source: Saitz R. Clinical practice. Unhealthy alcohol use. N Engl J Med. 2005;352(6):596–607.)
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CHAPTER 65 | The Patient with a Substance-Related Disorder 1089
drinker tolerates a higher level of alcohol without
nausea.
BAC measurement reflects a person’s drinking rate and
rate of metabolism.
Alcohol is metabolized more slowly than it is absorbed.
The BAC increases when alcohol is consumed faster
than previous drinks are metabolized.
The rate at which the body will absorb and metabolize
alcohol is based on factors such as age, gender, percent-
age of fatty tissue in the body, and whether food is also
being metabolized.
Ethanol is a powerful depressant of the central nervous
system; in low doses, alcohol can act as a disinhibitor
and as a relaxant. Euphoria may be produced.
In high doses, alcohol can produce analgesic effects
with reduction of anxiety generally accompanied by re-
duced alertness and reduced judgment.
The characteristic effects exhibited at various levels of
blood alcohol can be seen in Table 65-1.
HEALTH HAZARDS OF ALCOHOL
Prolonged alcohol use causes many serious medical dis-
orders. The alcohol-dependent person is most seriously
afflicted, but even unhealthy alcohol use may have com-
plications. Alcohol-related illnesses may involve any body
system. A few are mentioned here.
I. Liver Disease
Chronic alcohol abuse is the most frequent cause of mor-
bidity and mortality from liver diseases. Alcoholic liver
disease (ALD) includes the following conditions
10
:
Fatty liver with degeneration: early stages are reversible
with abstinence.
II. Liver Metabolism
More than 90% of ingested alcohol is converted into
acetaldehyde, then acetone, and finally into carbon di-
oxide and water by action of various liver enzymes.
High acetaldehyde levels and chronic alcohol consump-
tion impair liver function and lead to liver damage.
III. Diffusion
Within 5 minutes after ingestion, alcohol can be de-
tected in the blood.
Alcohol is quickly diffused into all cells and intercel-
lular fluid of the body.
Less than 10% is excreted directly through the lungs,
skin, and kidney (breath, sweat, and urine).
A person’s alcohol level can be determined by several
tests of the blood, urine, saliva, or water vapor in the
breath.
IV. Blood Alcohol Concentration (BAC)
9
In the United States, law enforcement agencies pri-
marily test the BAC of automobile drivers using the
breath test. The results are then converted to equiva-
lent BACs.
A BAC of 0.08% has been established as the legal level
of intoxication.
• The amount of alcohol by weight, in a set volume
of blood.
• Measured in milligrams per deciliter (mg/dL).
• A BAC of 0.10% is the equivalent of 0.10 g of alco-
hol per 100 mL of blood.
The tolerance level varies among individuals. The in-
experienced drinker may lose self-control and become
nauseated with low levels of alcohol. The experienced
TABLE 65-1 Effects of BACS at Various Levels
DOSE EFFECT
50 mg/dL Sedation, tranquility, fine motor coordination reduced, unsteadiness on standing.
50–100 mg/dL Reduced anxiety, alertness, and critical judgment; enhanced self-esteem, slowed reaction time, and impulsive risk-
taking behavior.
100–300 mg/dL Slowed reaction time, slurred speech, staggering; mood swings, memory deficits, blackouts; increased aggressive
behavior.
300–400 mg/dL Labored breathing, nystagmus, lowered blood pressure and body temperature; loss of consciousness.
400–500 mg/dL Depressed respiration, alcoholic coma, possibly fatal.
Source: National Institute on Alcohol Abuse and Alcoholism. 8th Special Report to the U.S. Congress on Alcohol and Health. Rockville, MD: National Institute on Alcohol Abuse
and Alcoholism; 1993:89.
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1090 SECTION IX | Patients with Special Needs
VII. Nervous System
A. Central and Peripheral
Early changes affect intellectual actions, judgment, and
learning ability.
Long-term alcohol abuse combined with malnutrition
can lead to damage of both central and peripheral ner-
vous systems.
Prolonged and heavy alcohol consumption leads to
chronic brain damage.
B. Wernicke–Korsakoffs Syndrome
14
Brain disorder of the cerebellum is the result of a thiamine
deficiency associated with chronic alcohol consumption.
Two syndromes are involved as follows:
Wernicke’s encephalopathy: symptoms of mental confu-
sion, ocular dysfunction, and gait disturbances.
Korsakoffs psychosis: persistent knowledge and memory
problems characterized by forgetfulness, easy frustra-
tion, lack of muscle coordination, and retrograde and
anterograde amnesia.
VIII. Reproductive System
Alcohol affects every branch of the endocrine system,
directly and indirectly, through the body’s organization
of the endocrine hormones.
Female: increased risk for menstrual disturbances, infer-
tility, and miscarriage, stillbirth, or premature delivery.
15
Male: diminished testicular function and male hor-
mone production resulting in increased risk for im-
potence, infertility, and reduction of secondary sex
characteristics.
16
FETAL ALCOHOL SPECTRUM
DISORDERS (FASD)
The significant incidence and prevalence of FASD
highlights the need for dental professionals to recognize
symptoms and characteristics.
Patients with FASD have orofacial characteristics and
various psychological and physical symptoms that may
affect a dental hygiene treatment plan.
The offspring of women who use alcohol to excess dur-
ing pregnancy have an increased risk for developmen-
tal disorders that range from subtle to lifelong serious
effects.
17
I. Alcohol Use During Pregnancy
There is no known safe amount of alcohol use during
pregnancy.
• The amount of alcohol required to produce adverse
fetal consequences varies among fetuses. When
Alcoholic hepatitis: inflammation of the liver.
Early fibrosis: healthy cells replaced by scar tissue.
Cirrhosis: scarring of the liver with irreversible damage.
Individuals with hepatitis C virus are more susceptible
to ALD.
11
II. Immunity and Infection
Those who abuse alcohol have diminished immune
response, suppression of immune system defense, and
disturbed function of neutrophils.
Risk for many bacterial infections is increased, particu-
larly pulmonary diseases (pneumonia, tuberculosis) and
viral infections (hepatitis B and C).
III. Digestive System
Alcohol ingestion alters the stomach mucosa, stimu-
lates gastric acid secretion, and affects gastric function.
Lesions that bleed may develop with desquamation of
the stomach lining (acute gastritis).
Injury to small intestines: diarrhea, weight loss, and vi-
tamin deficiencies.
IV. Nutritional Deficiencies
Alcohol provides an excess of caloric intake. With
the intake of large quantities of alcohol, the individ-
ual loses interest in regular mealtime nutritious food,
which leads to many deficiencies.
Deficiencies result from malabsorption of vitamins and
essential nutrients.
Secondary malnutrition develops from direct effects
of alcohol on the gastrointestinal tract; malabsorption
and maldigestion occur after cellular changes in the in-
testinal wall.
V. Cardiovascular Diseases
Risk for cardiomyopathy, coronary artery disease, hy-
pertension, arrhythmias, and hemorrhagic stroke.
Decreased risk for heart attack and stroke is associated
with light-to-moderate alcohol use.
2
Heavy consumption increases the death rate from car-
diovascular disease.
Associated with early coronary calcification in young
adults.
12
VI. Neoplasms
Alcohol use increases the risk for many types of can-
cers, notably of the alimentary and respiratory tracts.
13
Alcohol combined with tobacco use has long been as-
sociated with increased neoplasms of the oral cavity,
pharynx, and larynx.
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The Patient with a Substance-Related DisorderErnestine R. Daniels, RDH, BSINTRODUCTIONALCOHOL CONSUMPTION I. Clinical Pattern of Alcohol Use II. EtiologyMETABOLISM OF ALCOHOL I. Ingestion and Absorption II. Liver Metabolism III. Diffusion IV. Blood Alcohol ConcentrationHEALTH HAZARDS OF ALCOHOL I. Liver Disease II. Immunity and Infection III. Digestive System IV. Nutritional Deficiencies V. Cardiovascular Diseases VI. Neoplasms VII. Nervous System VIII. Reproductive SystemFETAL ALCOHOL SPECTRUM DISORDERS I. Alcohol Use During Pregnancy II. Criteria for FASD Diagnosis III. Characteristics of an Individual with FASDALCOHOL WITHDRAWAL SYNDROME I. Predisposing Factors II. Signs and Symptoms III. ComplicationsTREATMENT FOR ALCOHOLISM I. Early Intervention II. Detoxification III. Pharmacotherapy IV. RehabilitationABUSE OF PRESCRIPTION AND STREET DRUGSRISK MANAGEMENT FOR LEGAL PRESCRIPTIONS I. Dental Team Responsibilities II. Prevention of Prescription Drug AbuseMOST COMMON DRUGS OF ABUSE I. Cannabinoids (Marijuana) II. Depressants III. Dissociative Anesthetics IV. Hallucinogens V. Opioids and Morphine Derivatives VI. Stimulants VII. Other CompoundsMEDICAL EFFECTS OF DRUG ABUSE I. Cardiovascular Effects II. Neurological Effects III. Gastrointestinal Effects IV. Kidney Damage V. Liver Damage VI. Musculoskeletal Effects VII. Respiratory Effects VIII. Prenatal Effects IX. InfectionsTREATMENT METHODS I. Behavioral Change Interventions II. Drug Withdrawal MedicationsDENTAL HYGIENE PROCESS OF CARE I. Assessment II. Intraoral Examination III. Dental Hygiene Diagnosis IV. Planning V. Implementation VI. EvaluationDOCUMENTATIONEVERYDAY ETHICSFACTORS TO TEACH THE PATIENTREFERENCESCHAPTER OUTLINE65Wilkins9781451193114-ch065.indd 1085 07/10/15 11:39 AM 1086 SECTION IX | Patients with Special Needs ▶ Moderate alcohol use: two drinks per day for men and one drink per day for women is not considered harmful for the average adult.2 The individual is able to function appropriately in work, family, and social situations. ▶ Unhealthy alcohol use: early-stage problems such as hypertension, depression, insomnia, heartburn, and ab-senteeism develop.3 ▶ Alcohol dependency and alcoholism develop after pe-riods of unhealthy alcohol use followed by pathologic abuse.4 ▶ The spectrum of alcohol use is illustrated by Figure 65-1. ▶ Volume and alcohol content in a standard drink of vari-ous alcoholic beverages is shown in Box 65-2.A. Effects of Alcohol Intoxication4 ▶ Behavioral changes: aggressiveness, mood instability, impaired judgment; impaired social or occupational functioning; impaired attention and memory; stupor or coma. ▶ Physical characteristics: slurred speech, lack of coordi-nation, unsteady gait, and nystagmus. ▶ Complications: irresponsible actions in work and fam-ily settings. ▶ Accidents with resultant bruises, fractures, or brain trauma. ▶ Vehicular accidents. ▶ Suicide.B. Consequences of Underage Drinking5 ▶ Drinking and driving. ▶ Suicide. ▶ Sexual assault. ▶ High-risk sex. ▶ Alcohol-induced mental impairment.C. Signs of Alcoholism6Alcoholism, also known as alcohol dependence, includes four main symptoms: ▶ Craving: A strong need or compulsion to drink. ▶ Loss of control: The inability to limit one’s drinking on any given occasion.INTRODUCTION ▶ Drug and alcohol dependence often go hand in hand; people who are dependent on alcohol are more likely than the general population to use other drugs, and people with drug dependence are more likely to drink alcohol.1 ▶ Substance abuse reflects a complex interaction between the individual, the abused drugs, and society. ▶ Drug use varies from recreational use to addiction; peo-ple from various stages of drug use appear as patients needing dental and dental hygiene care. ▶ Patients who use drugs recreationally may “premedi-cate” themselves when a stressful situation such as a dental appointment is anticipated; therefore, questions at each appointment are required to determine clinical procedure and prevent complications. ▶ There is no classic cultural, socioeconomic, or educa-tional profile for a substance abuser. ▶ A patient’s medical and dental history does not al-ways provide the information necessary to determine whether the patient uses substances at all, or the level of dependency. ▶ It is a professional responsibility of the dental hygienist to:• View chemical dependency as an illness and to be aware of the characteristics that suggest possible sub-stance use.• Address the issues of an appropriate dental hygiene care plan for the chemically dependent patient. ▶ Key words and terminology related to the use and abuse of drugs are defined in Box 65-1. ▶ Alcohol use is common in a large percentage of the pop-ulation and varies from social drinking to alcoholism. ▶ Physical dependence and tolerance are both present in an individual suffering from alcoholism. ▶ Alcohol used for consumption purposes is ethyl alcohol or ethanol. Other alcohols are methyl, an industrial sol-vent, and isopropyl, used for rubbing alcohol.ALCOHOL CONSUMPTIONI. Clinical Pattern of Alcohol Use ▶ Abstinence and low-risk use. ▶ Increased consumption.LEARNING OBJECTIVESAfter studying this chapter, the student will be able to:1. Explain key terms and concepts related to the metabolism, intoxication effects, and use patterns of alcohol.2. Identify physical health hazards, medical effects, and oral manifestations associated with alcohol and other drug abuse.3. List the names of the most commonly abused drugs and describe their intoxication effects and methods of use.4. Describe methods for clinical assessment of potential substance abuse.5. Recognize risk management principles to prevent prescription pad theft and abuse.Wilkins9781451193114-ch065.indd 1086 07/10/15 11:39 AM CHAPTER 65 | The Patient with a Substance-Related Disorder 1087Abstinence: refrain from use; complete abstinence from alco-hol is the objective of a recovering alcoholic.Abuse: substance abuse; with respect to alcohol abuse involves persistent patterns of heavy alcohol intake associated with health consequences and/or impairment in social functioning.Acne rosacea: facial skin condition usually characterized by a flushed appearance; often accompanied by puffiness and a “spider-web” effect of broken capillaries.Addiction: habitual psychologic and physiologic depen-dence on a substance or practice that is beyond voluntary control.Alcohol intoxication: results from recent ingestion of ex-cessive amounts of alcohol; characterized by behavioral changes that alter the usual behavior of the individual.Alcoholism: a chronic progressive behavioral disorder char-acterized by a strong urge to consume ethanol and inabil-ity to limit the amount despite adverse consequences.Amnesia: impairment of long- and/or short-term memory.Anterograde amnesia: difficulty in recalling new information.Retrograde amnesia: difficulty in remembering old information.Amethystic agents: a class of substances capable of coun-teracting the acute effects of alcohol on the central ner-vous system.Analgesia: loss of sensibility to pain without loss of consciousness.Antabuse: brand name of the generic drug disulfiram; used to deter consumption of alcohol by persons being treated for alcohol dependency by inducing vomiting.Blackout: temporary amnesia occurring during periods of intensive drinking; person is not unconscious.DEA drug schedules: drugs, substances, and certain chemi-cals used to make drugs are classified by the U.S. Drug Enforcement Administration (DEA) into five (5) distinct categories or schedules depending upon the drug’s ac-ceptable medical use and the drug’s abuse or dependency potential (see Box 65-5).DEA registration number: assigned by DEA allowing health care providers to write prescriptions for controlled sub-stances (drugs that have been assigned a DEA drug sched-ule category).Delirium: extreme mental and usually motor excitement marked by a rapid succession of confused and uncon-nected ideas; often with illusions and hallucinations; may be accompanied by tremors.Delirium tremens: “DTs”; a serious acute condition associated with the last stages of alcohol withdrawal.Dementia: condition of deteriorated mentality characterized by a marked decline of intellectual functioning.Dependence: drug or substance dependence; with respect to alcohol refers to a physical and psychological depen-dence on alcohol that results in impaired ability to control drinking behavior; dependence is differentiated from abuse by manifestations of craving tolerance and physical dependence, as well as an inability to exercise restraint over drinking.Chemical dependence: the interaction between a drug and the individual when there is a compulsion to take the drug to obtain its effects and/or to avoid the dis-comforts of withdrawal.Physical dependence: when a drug becomes necessary for continued body functioning. An altered physiologic state has developed from repeatedly increasing drug concentrations.Polysubstance dependence: addiction to at least three categories of psychoactive substances (not including nicotine or caffeine) but in which no single psychoac-tive substance predominates.Psychologic dependence: refers to the state of mind in which the individual believes the drug is required for maintaining well-being.Detoxification: treatment designed to assist in recovery from the toxic effects of a drug; involves withdrawal and may include pharmacologic and/or nonpharmacologic treat-ment with psychotherapy and counseling.Drug: a chemical substance used for diagnosis, prevention, or treatment of disease. Drugs are classified by biochemical action, physiological effect, or organ system involved.Euphoria: feeling of well-being, elation; without fear or worry.Hallucination: a sensory impression (sight, sound, touch, smell, or taste) that has no basis in external stimulation; may have psychological causes, or may result from the use of drugs, (including alcohol), a brain tumor, senility, or exhaustion.Hyperthermia: body temperature higher than normal.Illicit: illegal; not authorized, not sanctioned by law.Micrognathia: abnormal smallness of the jaws, especially of the mandible.Nystagmus: involuntary, rapid, rhythmic movements of the eyeball.Opiate antagonist: examples include naltrexone and nalox-one. These drugs have a high affinity for opiate receptors but do not activate them and block the effect of exog-enously administered opioids (e.g., morphine, heroin, and methadone) or of endogenously released endorphins.Opioid: synthetic narcotic that has opiatelike activities but is not derived from opium.Psychotropic drug: a drug capable of modifying mental ac-tivity; used in the treatment of mental illness.Recovering alcoholic: a person afflicted with the disease of alcoholism who is abstaining from the use of alcohol; recovering alcoholics prefer the term “recovering” to re-formed, cured, or recovered because recovering implies an ongoing process.Saddlenose deformity: a collapse of the nasal bridge.Substance abuse: The regular use of a drug for other than its accepted medical purpose or in dosages greater than those that are considered appropriate.Tolerance: ability to endure without effect or injury. Increased amount of the drug is needed to achieve the same effect.Drug tolerance: the need for higher and higher dosages of a drug to achieve the same effect.Withdrawal syndrome: a group of signs and symptoms, both physiologic and psychologic, that occurs on abrupt discontinuation of drug use.BOX 65-1 KEY WORDS: Alcoholism and Drug AbuseWilkins9781451193114-ch065.indd 1087 07/10/15 11:39 AM 1088 SECTION IX | Patients with Special NeedsB. Biopsychosocial ▶ Alcohol-specific parenting is a distinct and influential predictor of adolescent alcohol use partially shaped by parents’ own drinking experiences. ▶ Parental conversations about their own personal ex-periences with alcohol may not represent a form of parent–child communication about drinking that de-ters adolescent drinking.8 ▶ Children of alcohol-dependent parents are exposed to a higher level of multiple risk factors that lead to alcohol-related problems:• Mental and behavioral disorders and adverse family environments.• Decreased sensitivity to intoxication effects of alcohol.C. Environmental ▶ Psychological stress, family, peers, and social forces. ▶ Current lifestyle, culture, advertisements, and economics. ▶ Motivational factors: both emotional (stress reduction, mood enhancement, social rewards) and cognitive (conscious and unconscious beliefs about alcohol) may play a role in an individual’s decision to drink.METABOLISM OF ALCOHOL2I. Ingestion and Absorption ▶ Upon intake, alcohol is absorbed promptly from the stomach and small intestine into the bloodstream. ▶ Transported to liver for metabolism. ▶ Physical dependence: Withdrawal symptoms, such as nausea, sweating, shakiness, and anxiousness, when al-cohol use is stopped after a period of heavy drinking. ▶ Tolerance: The need to drink greater amounts of alcohol in order to get intoxicated. Other signs include amnesia and binge drinking.II. EtiologyA. Genetics ▶ The Collaborative Study on the Genetics of Alcohol-ism has successfully identified GABRA2 and CHRM2 as two genes involved in the predisposition to alcohol dependence.7 ▶ A defective allele (variant) of the gene ALDH2 sub-stantially (although not completely) protects carriers from developing alcoholism by making them ill after drinking alcohol.2A standard drink contains about 14 grams (0.6 oz. or 1.2 Tablespoons) of pure alcohol. ▷ 12 oz. (355 mL) of beer or wine cooler (5% alcohol content) ▷ 5 oz. (148 mL) of wine (12% alcohol content) ▷ 1.5 oz. (44 mL) of 80-proof distilled spirits (40% alcohol content)Source: National Institute on Alcohol Abuse and Alcoholism. What is a standard drink? http://pubs.niaaa.nih.gov/publications/Practitioner/PocketGuide/pocket_guide2.htm. Accessed August 9, 2015.A Standard DrinkBOX 65-2FIGURE 65-1 The Spectrum of Alcohol Use. As clinicians, the shaded categories in the upper portions of the pyramid are of primary concern while treating patients. These catego-ries reflect unhealthy alcohol use. (Source: Saitz R. Clinical practice. Unhealthy alcohol use. N Engl J Med. 2005;352(6):596–607.)Wilkins9781451193114-ch065.indd 1088 07/10/15 11:39 AM CHAPTER 65 | The Patient with a Substance-Related Disorder 1089drinker tolerates a higher level of alcohol without nausea. ▶ BAC measurement reflects a person’s drinking rate and rate of metabolism. ▶ Alcohol is metabolized more slowly than it is absorbed. The BAC increases when alcohol is consumed faster than previous drinks are metabolized. ▶ The rate at which the body will absorb and metabolize alcohol is based on factors such as age, gender, percent-age of fatty tissue in the body, and whether food is also being metabolized. ▶ Ethanol is a powerful depressant of the central nervous system; in low doses, alcohol can act as a disinhibitor and as a relaxant. Euphoria may be produced. ▶ In high doses, alcohol can produce analgesic effects with reduction of anxiety generally accompanied by re-duced alertness and reduced judgment. ▶ The characteristic effects exhibited at various levels of blood alcohol can be seen in Table 65-1.HEALTH HAZARDS OF ALCOHOLProlonged alcohol use causes many serious medical dis-orders. The alcohol-dependent person is most seriously afflicted, but even unhealthy alcohol use may have com-plications. Alcohol-related illnesses may involve any body system. A few are mentioned here.I. Liver DiseaseChronic alcohol abuse is the most frequent cause of mor-bidity and mortality from liver diseases. Alcoholic liver disease (ALD) includes the following conditions10: ▶ Fatty liver with degeneration: early stages are reversible with abstinence.II. Liver Metabolism ▶ More than 90% of ingested alcohol is converted into acetaldehyde, then acetone, and finally into carbon di-oxide and water by action of various liver enzymes. ▶ High acetaldehyde levels and chronic alcohol consump-tion impair liver function and lead to liver damage.III. Diffusion ▶ Within 5 minutes after ingestion, alcohol can be de-tected in the blood. ▶ Alcohol is quickly diffused into all cells and intercel-lular fluid of the body. ▶ Less than 10% is excreted directly through the lungs, skin, and kidney (breath, sweat, and urine). ▶ A person’s alcohol level can be determined by several tests of the blood, urine, saliva, or water vapor in the breath.IV. Blood Alcohol Concentration (BAC)9 ▶ In the United States, law enforcement agencies pri-marily test the BAC of automobile drivers using the breath test. The results are then converted to equiva-lent BACs. ▶ A BAC of 0.08% has been established as the legal level of intoxication.• The amount of alcohol by weight, in a set volume of blood.• Measured in milligrams per deciliter (mg/dL).• A BAC of 0.10% is the equivalent of 0.10 g of alco-hol per 100 mL of blood. ▶ The tolerance level varies among individuals. The in-experienced drinker may lose self-control and become nauseated with low levels of alcohol. The experienced TABLE 65-1 Effects of BACS at Various LevelsDOSE EFFECT50 mg/dL Sedation, tranquility, fine motor coordination reduced, unsteadiness on standing.50–100 mg/dL Reduced anxiety, alertness, and critical judgment; enhanced self-esteem, slowed reaction time, and impulsive risk-taking behavior.100–300 mg/dL Slowed reaction time, slurred speech, staggering; mood swings, memory deficits, blackouts; increased aggressive behavior.300–400 mg/dL Labored breathing, nystagmus, lowered blood pressure and body temperature; loss of consciousness.400–500 mg/dL Depressed respiration, alcoholic coma, possibly fatal.Source: National Institute on Alcohol Abuse and Alcoholism. 8th Special Report to the U.S. Congress on Alcohol and Health. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism; 1993:89.Wilkins9781451193114-ch065.indd 1089 07/10/15 11:39 AM 1090 SECTION IX | Patients with Special NeedsVII. Nervous SystemA. Central and Peripheral ▶ Early changes affect intellectual actions, judgment, and learning ability. ▶ Long-term alcohol abuse combined with malnutrition can lead to damage of both central and peripheral ner-vous systems. ▶ Prolonged and heavy alcohol consumption leads to chronic brain damage.B. Wernicke–Korsakoff’s Syndrome14Brain disorder of the cerebellum is the result of a thiamine deficiency associated with chronic alcohol consumption. Two syndromes are involved as follows: ▶ Wernicke’s encephalopathy: symptoms of mental confu-sion, ocular dysfunction, and gait disturbances. ▶ Korsakoff’s psychosis: persistent knowledge and memory problems characterized by forgetfulness, easy frustra-tion, lack of muscle coordination, and retrograde and anterograde amnesia.VIII. Reproductive System ▶ Alcohol affects every branch of the endocrine system, directly and indirectly, through the body’s organization of the endocrine hormones. ▶ Female: increased risk for menstrual disturbances, infer-tility, and miscarriage, stillbirth, or premature delivery.15 ▶ Male: diminished testicular function and male hor-mone production resulting in increased risk for im-potence, infertility, and reduction of secondary sex characteristics.16FETAL ALCOHOL SPECTRUM DISORDERS (FASD) ▶ The significant incidence and prevalence of FASD highlights the need for dental professionals to recognize symptoms and characteristics. ▶ Patients with FASD have orofacial characteristics and various psychological and physical symptoms that may affect a dental hygiene treatment plan. ▶ The offspring of women who use alcohol to excess dur-ing pregnancy have an increased risk for developmen-tal disorders that range from subtle to lifelong serious effects.17I. Alcohol Use During Pregnancy ▶ There is no known safe amount of alcohol use during pregnancy.• The amount of alcohol required to produce adverse fetal consequences varies among fetuses. When ▶ Alcoholic hepatitis: inflammation of the liver. ▶ Early fibrosis: healthy cells replaced by scar tissue. ▶ Cirrhosis: scarring of the liver with irreversible damage. ▶ Individuals with hepatitis C virus are more susceptible to ALD.11II. Immunity and Infection ▶ Those who abuse alcohol have diminished immune response, suppression of immune system defense, and disturbed function of neutrophils. ▶ Risk for many bacterial infections is increased, particu-larly pulmonary diseases (pneumonia, tuberculosis) and viral infections (hepatitis B and C).III. Digestive System ▶ Alcohol ingestion alters the stomach mucosa, stimu-lates gastric acid secretion, and affects gastric function. ▶ Lesions that bleed may develop with desquamation of the stomach lining (acute gastritis). ▶ Injury to small intestines: diarrhea, weight loss, and vi-tamin deficiencies.IV. Nutritional Deficiencies ▶ Alcohol provides an excess of caloric intake. With the intake of large quantities of alcohol, the individ-ual loses interest in regular mealtime nutritious food, which leads to many deficiencies. ▶ Deficiencies result from malabsorption of vitamins and essential nutrients. ▶ Secondary malnutrition develops from direct effects of alcohol on the gastrointestinal tract; malabsorption and maldigestion occur after cellular changes in the in-testinal wall.V. Cardiovascular Diseases ▶ Risk for cardiomyopathy, coronary artery disease, hy-pertension, arrhythmias, and hemorrhagic stroke. ▶ Decreased risk for heart attack and stroke is associated with light-to-moderate alcohol use.2 ▶ Heavy consumption increases the death rate from car-diovascular disease. ▶ Associated with early coronary calcification in young adults.12VI. Neoplasms ▶ Alcohol use increases the risk for many types of can-cers, notably of the alimentary and respiratory tracts.13 ▶ Alcohol combined with tobacco use has long been as-sociated with increased neoplasms of the oral cavity, pharynx, and larynx.Wilkins9781451193114-ch065.indd 1090 07/10/15 11:39 AM CHAPTER 65 | The Patient with a Substance-Related Disorder 1091ALCOHOL WITHDRAWAL SYNDROME4 ▶ Withdrawal consists of the disturbances that occur af-ter abrupt cessation of alcohol intake in the alcohol-dependent person. ▶ Withdrawal signs appear within a few hours after drink-ing has stopped.genetically different twins are exposed to the same levels of alcohol, one twin can be born with FASD while the other twin is normally developed.18• Complete abstinence during pregnancy is safest to prevent FASD. ▶ Prenatal alcohol exposure is cited as the leading preventable cause of birth defects and intellectual disability. ▶ Box 65-3 contains terminology and abbreviations for FASD.A. No Placental Barrier ▶ Alcohol passes freely across the placenta. ▶ Increased incidence of spontaneous abortions and still-births associated with alcohol consumption.B. Other Factors ▶ Other poor health habits often accompany the use of alcohol, including inadequate diet and use of tobacco. ▶ The use of prescription or illicit drugs with alcohol can increase risk of adverse outcomes.II. Criteria for FASD Diagnosis19 ▶ Facial dysmorphology as shown in Figure 65-2. ▶ Growth deficits. ▶ Central nervous system problems.III. Characteristics of an Individual with FASDCommon characteristics of an individual with FASD are listed in Box 65-4.FIGURE 65-2 Facial Features of Fetal Alcohol Syndrome. Child presenting with the characteristic pattern of abnormal facial features diagnostic for FASD, including short palpebral fissure lengths (distance from A to B), smooth philtrum, and thin upper lip. (Photo courtesy of Susan Astley, PhD, University of Washington.)FAS: Fetal alcohol syndrome. A characteristic pattern of abnormal growth, minor facial anomalies, and abnormal central nervous system (CNS) development resulting from maternal consumption of alcohol during pregnancy.PFAS: Partial fetal alcohol syndrome. FAS without the growth deficiency.FASD: Fetal alcohol spectrum disorder. An umbrella term describing the range of effects that can occur in an individual whose mother drank alcohol while pregnant. Diagnoses that fall under the umbrella include FAS, PFAS, ARND, static encephalopathy/alcohol exposed (SE/AE), and neurobehavioral disorder alcohol exposed (ND/AE).ARND: Alcohol-related neurodevelopment disorder. In-dividuals with ARND have confirmed prenatal alcohol exposure and present with significant structural and/or functional CNS abnormalities. They do not present with the FAS facial phenotype. Alternate terms used to define this outcome include SE/AE and ND/AE.FASD Terminology and AbbreviationsBOX 65-3Abnormal facial features, for example, small eyes, a smooth ridge between the nose and upper lip (ridge entitled the philtrum), and thick upper lip. ▷ Small head size; shorter-than-average height; low body weight ▷ Problems with the heart, kidneys, or bones ▷ Vision or hearing problems ▷ Poor coordination ▷ Hyperactive behavior ▷ Speech and language delays; learning difficulties (especially with math) ▷ Poor memory; difficulty paying attention ▷ Poor reasoning and judgment skillsSource: Centers for Disease Control and Prevention (CDC): Fetal Alcohol Spectrum Disorders (FASDs). Facts about FASDs. http://www .cdc.gov/ncbddd/fasd/facts.html. Accessed September 30, 2014.Common Characteristics of an Individual with FASDBox 65-4Wilkins9781451193114-ch065.indd 1091 07/10/15 11:39 AM 1092 SECTION IX | Patients with Special NeedsI. Early InterventionWhen problem drinkers who are not yet dependent can be identified, counseling may help to reduce and perhaps eliminate the use of alcohol.II. DetoxificationThe term detoxification applies to the management of acute intoxication and the withdrawal syndrome. A vari-ety of treatments may be involved.A. Treatment for Immediate Emergencies ▶ Accident or medical emergency other than withdrawal symptoms. ▶ Fractures, head injury, internal bleeding, or other prob-lems may require initial attention. ▶ Alcohol dependency may be revealed after hospital ad-mittance for other causes.B. Removal from Source of Alcohol: Abstinence ▶ Advantages of hospitalization:• Supervision is available.• No access to sources of alcohol.C. Goals of Therapy ▶ Treat medical complications. ▶ Restore general physical health: rest, sleep, and exercise. ▶ Treat nutritional deficiencies: proper diet.D. Relief from Acute Withdrawal Signs ▶ Tranquilizers may be prescribed for short-term use. ▶ Vitamins, particularly thiamine, are usually administered.III. Pharmacotherapy2A. Medications Used in Alcoholism TreatmentAgents for withdrawal management include: ▶ Alcohol-sensitizing agents (cause aversive reactions in combination with alcohol). ▶ Anticraving agents (decrease desire for and consump-tion of alcohol). ▶ Amethystic agents (reverse the acute intoxicating and depressant effects of alcohol). ▶ Medications for treatment of coexisting psychiatric dis-orders, such as depression and anxiety.B. Disulfiram (AntabuseØ): Alcohol-Sensitizing Agent ▶ Interferes with the metabolism of alcohol by acting on the enzyme that converts acetaldehyde to acetone in the liver. ▶ Effect: acetaldehyde accumulates in the tissues. ▶ Even a relative decline in blood concentration can pre-cipitate the syndrome.I. Predisposing Factors ▶ Malnutrition, fatigue, depression, and physical illnesses aggravate withdrawal symptoms.II. Signs and Symptoms ▶ Tremor of hands, tongue, and eyelids. ▶ Nervousness and irritation; anxiety. ▶ Malaise, weakness, and headache. ▶ Dry mouth. ▶ Autonomic hyperactivity: sweating, rapid pulse rate, and elevated blood pressure. ▶ Transient visual, tactile, or auditory hallucinations. ▶ Insomnia. ▶ Grand mal seizures. ▶ Nausea or vomiting.III. ComplicationsA. Alcohol Withdrawal Delirium (Delirium Tremens) ▶ May occur within 1 week of cessation of heavy alcohol intake. ▶ Features: marked autonomic hyperactivity: rapid heart-beat and sweating. ▶ Vivid hallucinations (visual, auditory, tactile). ▶ Delusions and agitated behavior; tremor. ▶ Confusion and disorientation.B. Alcohol Hallucinosis ▶ Auditory and visual hallucinations can develop within 48hours after the abrupt stop or reduction of heavy al-cohol intake of long-standing dependency. ▶ Symptoms: may last weeks or months. ▶ Impairment is severe with schizophrenic symptoms, al-though schizophrenia is not a predisposing factor. ▶ Delirium is not present.TREATMENT FOR ALCOHOLISM ▶ The overall objective of treatment is to help the person achieve and maintain total abstinence. ▶ An alcohol-dependent person can never drink even small amounts of alcohol without an eventual return to dependency. ▶ Treatment includes a combination of medical and psy-chiatric therapy with self-help. ▶ Patients are encouraged not to take other psychoactive drugs, including minor tranquilizers and caffeine.Wilkins9781451193114-ch065.indd 1092 07/10/15 11:39 AM CHAPTER 65 | The Patient with a Substance-Related Disorder 1093 ▶ Relapse more likely when a recovering alcoholic leaves a treatment system too early. ▶ Typical follow-up includes weekly aftercare group meet-ings for 9–12 months.ABUSE OF PRESCRIPTION AND STREET DRUGS ▶ Drug abuse: habitual use of drugs not needed for thera-peutic purposes. ▶ Prescription drug abuse: taking prescription medication that is not prescribed for that person; using a prescrip-tion for reasons or in dosages other than prescribed. ▶ Street drug abuse: taking drugs or substances purchased illegally from nonmedical sources and/or for nonmedi-cal reasons. ▶ Drugs interfere with the function of the brain and cre-ate long-term effects on brain metabolism and activity. ▶ Dependency develops after periods of drug use followed by pathologic abuse. ▶ An increase in the amount and frequency of a drug is needed to alleviate withdrawal responses; the with-drawal symptoms become more severe and require a greater intake of the drug. ▶ Brain circuitry becomes altered with this cyclic process and the voluntary use of drugs becomes drug addiction: a compulsive craving for drugs, seeking, and use.RISK MANAGEMENT FOR LEGAL PRESCRIPTIONS ▶ A major problem facing health care is the diversion of prescription medications with a high potential for abuse. ▶ Substances are classified in the US Drug Enforcement Administration (DEA) drug schedule according to use and abuse potential as listed in Box 65-5. ▶ Prescription drugs may become a very valuable product for drug traffickers. ▶ The theft of prescription pads and medication occurs in a variety of ways. ▶ Healthcare professionals need to safeguard against be-coming an easy target for drug diversion.20 ▶ To avoid prescription pad theft and abuse, certain risk management principles need to be strictly observed, in-cluding the following:• Secure inventory of prescription pads in locked area.• Number the prescription pads; keep count of all pre-scription pads by having a staff member appointed to document a weekly inventory count.• Do not leave prescription pads in dental treatment rooms or at work stations. ▶ Alcohol and disulfiram taken at the same time result in nausea, vomiting, and hypotension. ▶ Drug acts as a deterrent to provide an adjunct to com-prehensive therapy in selected patients.C. Naltrexone (Revia): Anticraving Agent ▶ Interferes with neurotransmitter systems that produce pleasurable effects. ▶ The effect of taking alcohol with an “opiate antago-nist:” no experience of a rewarded high or feelings of euphoria.D. Acamprosate ▶ Affects certain chemical messengers (neurotransmit-ters) in the brain. ▶ Reduces the risk of heavy drinking; doubles the likeli-hood that patients will achieve abstinence.E. Toirimate (Anticonvulsant) ▶ May also be beneficial for cocaine dependence treatment. ▶ Other anticonvulsants, including carbamazepine and valproate, have also shown some effectiveness in the treatment of alcohol use disorders.IV. RehabilitationA. Counseling and Education ▶ Patients need to recognize that alcoholism is a serious disease and be agreeable to accept help. ▶ Family and work associates may be recruited to cooper-ate with the program. ▶ Behavioral therapy and psychotherapy have been used.B. Group Therapy ▶ Alcoholics Anonymous: a fellowship of men and women who help themselves and others to recover from alco-holism; can provide help for motivated individuals. ▶ Some patients prefer treatment through special clinics and centers. ▶ Al-Anon: a separate program for parents, adult children, siblings, and spouses, as well as other persons concerned with the alcoholic patient in recovery. ▶ Alateen: a program for teenage children.C. Psychiatric Treatment ▶ An increased frequency of schizophrenia, psychoneuro-sis, sociopathy, and manic-depressive diseases is being recognized among alcohol-dependent people.D. Aftercare Services ▶ Recovery takes a long time; extended treatment required.Wilkins9781451193114-ch065.indd 1093 07/10/15 11:39 AM 1094 SECTION IX | Patients with Special Needs• Ensure opioids are available only to the patients who need them.• Implement policies to limit instances of abuse and diversion.II. Prevention of Prescription Drug Abuse ▶ The ADA suggestions to help parents prevent medi-cations from becoming a source of abuse are listed in Box65-6.23MOST COMMON DRUGS OF ABUSEThe most common drugs of abuse are alcohol and those found in the categories in this section.24 Examples of the substance names in each category and the commercial and street names are listed in Table 65-2.I. Cannabinoids (Marijuana) ▶ Organic substances present in the plants of Cannabis sativa that have a variety of pharmacologic properties. ▶ Upper leaves, tops, and stems are cut, dried, and rolled into cigarettes (marijuana).• Omit the prescriber’s DEA registration number on preprinted prescription pads.• Do not give DEA registration number to anyone in the office or family members.• Write out the quantity (in words not a number) of doses on the prescription and indicate “No Refills.” Never add extra doses: only minimum number that may be needed.• The provider cannot allow anyone besides her/ himself to sign a prescription.• Know employees; conduct a pre-employment crimi-nal background investigation and pre-employment drug screening for potential employees; include a policy for random drug testing in the office policy manual.• Dental hygienists, dental assistants, and front office staff can query prescription monitoring programs, which are statewide electronic databases of data about controlled substances dispensed.• Establish an office policy to ensure all risk manage-ment principles are met and understood by the en-tire dental team, reviewed frequently, and included for instruction of all new employees.21I. Dental Team Responsibilities ▶ All members of the dental team are responsible to:• Educate the patient about how to safeguard prescrip-tion given for pain medication.• Be mindful of the inherent abuse potential of opioids.• Understand and comply with federal and state regu-lations regarding legitimate prescribing and admin-istration of controlled substances. ▶ The ADA encourages dentists to22:• Obtain continuing education to promote respon-sible prescribing practices.Schedule ClassificationsSchedule I: no accepted medical use; extremely high po-tential for abuse; high potential for psychological and physical dependency.Schedule II: has medical use but high potential for abuse; relative potential for psychological and physical dependency.Schedule III: has medical use; moderate abuse potential but less than Schedule II.Schedule IV: abuse potential exists, but less than Schedule III.Schedule V: abuse potential exists, but less than Schedule IV.Source: U.S. Drug Enforcement Administration. Drug scheduling. http://www.justice.gov/dea/druginfo/ds.shtml. Accessed September 18, 2014.United States Drug Enforcement Administration Drug Box 65-5Communicate: Talk to children or anyone in the household about the dangers of using prescription drugs for non-medical purposes.Prescription drugs: ▷ Can be just as addictive and dangerous (even fatal) as illegal street drugs. ▷ Are only legal for the person for whom they are prescribed.Secure: Properly secure prescription medications or lock up commonly abused medications to control access.Monitor: Take note of how many pills are in each prescrip-tion bottle and routinely count the pills to assure that no one is taking them.Dispose: Properly dispose of unused and/or expired prescription medications. For suggestions on how to dispose of Rx medication, access the Partnership for Drug-Free Kids website: (http://medicineabuseproject.org/what-you-can-do/medicine-disposal).Spread the word: Tell family, friends, and neighbors about how teens are now using prescription drugs to get high. Encourage them to talk with their children.Source: American Dental Association, Mouth Healthy. Prescription drugs. http://www.mouthhealthy.org/en/az-topics/p/prescription-drugs. Accessed April 15, 2014..Strategies to Prevent Commonly Abused Prescription Medications from Becoming a Source of AbuseBox 65-6Wilkins9781451193114-ch065.indd 1094 07/10/15 11:39 AM CHAPTER 65 | The Patient with a Substance-Related Disorder 1095TABLE 65-2 Most Commonly Abused Prescription DrugsDRUG CATEGORY AND DEA SCHEDULEaSTREET NAMES AND COMMERCIAL NAME HOW ADMINISTEREDbINTOXICATION EFFECTSDepressantsBarbituratesDEA schedule: II, III, VaBarbs, reds, red birds, phennies, tooies, yellows, yellow jackets;Amytal, Nembutal, Seconal, PhenobarbitalInjected, swallowed Reduced pain and anxiety; feeling of well-being; lowered inhibitions; slowed pulse, breathing; lowered blood pressure; poor concentrationBenzodiazepines (other than flunitrazepam)DEA schedule: IVaCandy, downers, sleeping pills, tranks; Ativan, Halcion, Librium, Valium, XanaxSwallowed Sedation, drowsiness; also for barbituratesFlunitrazepamc,dDEA schedule: IVaForget-me pill, Mexican Valium, R2, Roche, roofies, roofinol, rope, rophies;RohypnolSwallowed, snorted Sedation, drowsiness/dizziness increased heart rate and blood pressure, impaired motor function/memory lossDissociative AnestheticsKetamineDEA schedule: IIIacat Valium, K, Special K, vitamin K; Ketalar SVInjected, snorted, smokedAt high doses, delirium, depression, respiratory depression and arrest pain relief, euphoria, drowsinessOpioids and Morphine DerivativesCodeineDEA schedule: II, III, IVaCaptain Cody, Cody, schoolboy; (with glutethimide) doors & fours, loads, pancakes and syrup;Empirin with Codeine, Fiorinal with Codeine, Robitussin A-C, Tylenol with CodeineInjected, swallowed Less analgesia, sedation, and respiratory depression than morphineFentanylDEA schedule: IIaApache, China girl, China white, dance fever, friend, goodfella, jackpot, murder 8, TNT, Tango and Cash;Actiq, Duragesic, SublimazeInjected, smoked, snortedMorphineDEA schedule: IIaM, Miss Emma, monkey, white stuff;Roxanol, DuramorphInjected, swallowed, smokedOpiumDEA schedule: II, IIIabig O, black stuff, block, gum, hop; laudanum, paregoric;Swallowed, smokedOther opioid pain relievers (oxycodone, meperidine, Hydromorphone, Hydrocodone, Propoxyphene)DEA schedule: II, III, IVaoxy 80s, oxycotton, oxycet, hillbilly heroin, percs;Tylox, OxyContin, Percodan, Percocet demmies, pain killerDemerol, meperidine hydrochloride juice, dilliesDilaudid, Vicodin, Lortab, Lorcet; Darvon, DarvocetSwallowed, injected, suppositories, chewed, crushed, snorted(continued )Wilkins9781451193114-ch065.indd 1095 07/10/15 11:39 AM 1096 SECTION IX | Patients with Special NeedsIV. Hallucinogens ▶ Chemical substances that produce mind-altering or mental perception-altering properties. ▶ A popular example is LSD (lysergic acid diethylamide). ▶ A disorder associated with the use of these substances can produce hallucinogen persisting perception disor-der, commonly known as “flashbacks.” ▶ MDMA (3,4 dimethoxymethamphetamine) or Ecstasy, a popular drug among teens and young adults, widely used at nightclubs and bars (a club drug). ▶ MDMA is classified as a stimulant, but is known for its hallucinogenic effects.V. Opioids and Morphine Derivatives ▶ Narcotic substances made from the Asian poppy or pro-duced as synthetic drugs with the effects of opium: they result in analgesic and euphoric effects. ▶ Dried exudate that seeps from the tops and undersides of cannabis leaves (hashish oil). ▶ Marijuana smoke, similar to tobacco smoke, is associ-ated with increased risk of cancer, lung damage, and oral health disease, such as oral cancers, periodontitis, and dental caries.25II. Depressants ▶ An agent (such as a sedative or anesthetic) that reduces nervous or functional activity. ▶ Examples are downers, sleeping pills, ludes, rophies.III. Dissociative Anesthetics ▶ A form of general anesthesia that promotes dissociation from the environment but not necessarily complete un-consciousness. Sometimes used for short diagnostic or surgical procedures. ▶ Street names: angel dust, Special K.TABLE 65-2 Most Commonly Abused Prescription Drugs (Continued)DRUG CATEGORY AND DEA SCHEDULEaSTREET NAMES AND COMMERCIAL NAME HOW ADMINISTEREDbINTOXICATION EFFECTSStimulantsAmphetaminesDEA schedule: IIaBennies, black beauties, crosses, hearts, LA turnaround, speed, truck drivers, uppers;Biphetamine, DexedrineInjected, swallowed, smoked, snortedIncreased heart rate, blood pressure, metabolism; feelings of exhilaration, energy, increased mental alertnessCocaineDEA schedule: IIaBlow, bump, C, candy, Charlie, coke, crack, flake, rock, snow, toot;Cocaine hydrochlorideInjected, smoked, snortedRapid breathing; hallucinations; also, for amphetaminesMethamphetamineDEA schedule: IIaChalk, crank, crystal, fire, glass, go fast, ice, meth, speed;DesoxynInjected, swallowed, smoked, snortedAggression, violence, psychotic behavior; also for methylphenidateMethylphenidateDEA schedule: IIaJIF, MPH, R-ball, Skippy, the smart drug, vitamin R; RitalinInjected, swallowed, snortedIncrease or decrease in blood pressure, psychotic episodesOther CompoundsAnabolic steroidsDEA schedule: IIIaRoids, juice;Anadrol, Oxandrin, Durabolin, Depo-Testosterone, EquipoiseInjected, swallowed, applied to skinNo intoxication effectsaSee Box 65-5 for explanation of DEA schedule classifications.bTaking drugs by injection can increase the risk of infection through needle contamination with staphylococci, HIV, hepatitis, and other organisms.cAssociated with sexual assaults.dNot available by prescription in the United States.Source: National Institute on Drug Abuse: The Science of Drug Abuse and Addiction. Commonly abused drugs. http://www.drugabuse.gov/drugs-abuse/commonly-abused-drugs-charts-0. Accessed August 9, 2015.Wilkins9781451193114-ch065.indd 1096 07/10/15 11:39 AM CHAPTER 65 | The Patient with a Substance-Related Disorder 1097 ▶ Causes relaxation of the smooth muscle and a decrease in oxygen-carrying capacity of the blood. ▶ Toxic reactions: vomiting, headache, hypotension, and dizziness.MEDICAL EFFECTS OF DRUG ABUSEI. Cardiovascular EffectsThere is a connection between the abuse of most addictive drugs and adverse cardiovascular effects that may range from arrhythmias to heart attacks. Cocaine in particular can: ▶ Increase blood pressure. ▶ Cause vasoconstriction. ▶ Alter electroactivity of the heart. ▶ Promote a cardiac stimulant effect. ▶ Induce angina; precipitate myocardial infarction. ▶ Cause a variety of arrhythmias and palpitations includ-ing sudden cardiac death.4 ▶ Contribute to early subclinical atherosclerotic cardio-vascular disease.27II. Neurological Effects ▶ Drug use can cause changes in the brain leading to:• Memory lapses• Decision-making or attention problems.• Euphoric effects.• Seizures, stroke, or intracerebral hemorrhage.28,29• Depression, paranoia, aggression, or hallucinations. ▶ Substance-induced disorders can include:• Amnesia, delirium, or dementia.• Mood or anxiety disorders.• Sleep disorders.III. Gastrointestinal Effects ▶ Cocaine in particular has been associated with gastro-intestinal complications and abdominal pain, including the possibility of life-threatening hemorrhage.30,31 ▶ Cocaine that is ingested can cause severe bowel gan-grene due to reduced blood flow. ▶ Many drugs of abuse have been known to cause nausea and vomiting soon after use.IV. Kidney Damage ▶ Chronic drug use causes toxicity to several organs in-cluding the kidney. ▶ Drugs affect renal function either through the toxic ef-fects of the drug or by a reduction in kidney function. ▶ Pain medications, alcohol, antibiotics, and illegal drugs can all cause kidney damage if not used properly. ▶ Toluene can affect the liver and kidneys severely.32 ▶ Opioids are prescribed as analgesics, anesthetics, antidi-arrheal agents, and cough suppressants. ▶ Heroin is one of the most commonly abused drugs of this class: it can be injected, smoked, or snorted. ▶ Hydrocodone is a schedule III drug and its potency is between codeine and oxycodone. ▶ Oxycodone is a schedule II drug, and codeine is a moder-ate opioid with genetic impact on metabolism.VI. Stimulants ▶ A class of drugs that enhances brain activity.• Stimulants cause an increase in mental alertness, at-tention, and energy; they improve motor skills and elicit a general sense of well-being.• Stimulants increase cardiac and respiratory function and speed up metabolism. ▶ Cocaine hydrochloride powder can be “snorted” through the nostrils, or, when mixed with water, can be injected intravenously.• Crack cocaine is a cocaine alkaloid in the form of a small rock.• Crack is cocaine that has been processed from co-caine hydrochloride to a free base for smoking. It is easily vaporized and inhaled and exhibits an ex-tremely rapid onset of effects. ▶ Methamphetamine (meth, speed) is taken orally, intrana-sally (snorting the powder), by intravenous injection, or by smoking. Meth users are resistant to local anesthesia.26 ▶ Ice, a very pure form of methamphetamine (seen as crystals under a high magnification), produces an im-mediate and powerful stimulant when smoked.VII. Other CompoundsA. Steroids ▶ Used to build muscles and increased performance. ▶ May produce a feeling of well-being or euphoria, fol-lowed by lack of energy and irritability. ▶ More severe symptoms include depression and liver disease.B. Inhalants ▶ A breathable chemical vapor that produces psychoac-tive effects. ▶ Capable of producing intoxication, abuse, and dependence. ▶ Available in a wide variety of commercial products: paint thinners, gasoline, and glue. ▶ A substance-soaked cloth or substance placed in a pa-per or plastic bag is applied to the nose and mouth and vapors are breathed in. ▶ Intoxication is characterized by a mild euphoria and a change in perception of time.Wilkins9781451193114-ch065.indd 1097 07/10/15 11:39 AM 1098 SECTION IX | Patients with Special Needs• Musculoskeletal infections, septic arthritis, and osteomyelitis, a local extension of soft tissue infection. ▶ Poor nutrition and human immunodeficiency virus (HIV) infection can result in immunosuppression and increase the risk for:• Infective endocarditis.• Pulmonary tuberculosis (increased in crowded living quarters, crack houses, and homeless shelters).• Respiratory tract infections, including community-acquired pneumonia. ▶ Role in disease transmission between drug users and their partners:• Major mode for transmission of HIV, other sexually transmitted diseases, and viral hepatitis.• Blood-borne diseases by way of shared needles and other paraphernalia.• Transmission through drugs, drug adulterants, or unique drug preparations.• Poor hygiene may exacerbate the risk of infection. ▶ Prevention• Eliminate drug use.• Utilize risk-reducing strategies.• Medically supervised injection facilities; needle ex-change programs.• Street-based education programs aimed at the use of sterile injection practices.• Clean the injection site with alcohol and the drug paraphernalia with bleach.• Avoid contamination by never sharing needles.• Avoid the use of dangerous injection sites such as the neck and groin.• Avoid high-risk behavior such as unprotected sex and sex with multiple partners.• Vaccinations and routine screening for tuberculosis, HIV, and other sexually transmitted diseases help to reduce disease transmission and prevent bacterial infections.TREATMENT METHODS ▶ Drug addiction is a treatable disorder. ▶ Treatment is tailored to the individual needs of the patient and may involve behavioral changes and medications. ▶ Medications help to suppress craving for drugs and withdrawal symptoms. ▶ The principles that characterize the most effective drug abuse treatment can be found in Box 65-7.I. Behavioral Change Interventions ▶ Counseling ▶ Support groupsV. Liver Damage2 ▶ The liver detoxifies drugs, chemicals, and alcohol that are ingested. ▶ Changes in liver function due to drug abuse decrease the metabolism of drugs: when not able to break down properly, the drug can remain at a toxic level. ▶ Chronic abuse of heroin, inhalants, and steroids may cause significant liver damage. ▶ The consumption of alcohol and cocaine together com-pound the danger each drug poses.• The liver combines cocaine and alcohol to form a third substance: cocaethylene.33• Cocaethylene intensifies cocaine’s euphoric effects, potentially increases the risk of sudden death.VI. Musculoskeletal Effects2 ▶ When rising levels of testosterone and other sex hor-mones, which trigger the growth spurt during puberty, reach a certain level, they signal the bones to stop growing.• Steroid use during childhood or adolescence can re-sult in artificially high hormone levels; bone growth culminates earlier than usual, which results in a short stature. ▶ Other drugs may cause severe muscle cramping and overall weakness.VII. Respiratory Effects ▶ Drug abuse can lead to a variety of respiratory problems. ▶ The use of smoking tobacco, marijuana, and inhalants all damage sensitive lung tissue. ▶ A compromised respiratory system can result in a re-duced respiration rate, asthma, bronchitis, emphysema, and lung cancer.VIII. Prenatal Effects ▶ Prenatal drug abuse has been associated with:• Miscarriage.• Premature birth.• Low birth weight. ▶ Inhalant abuse by expectant women can result in fetal solvent syndrome with abnormalities similar to those occurring in FASD.34IX. Infections35 ▶ Drug users are at risk for acquiring a large range of infections. ▶ Common bacterial infections among drug users include:• Skin and soft tissue: abscesses and cellulitis located at injection sites.Wilkins9781451193114-ch065.indd 1098 07/10/15 11:39 AM CHAPTER 65 | The Patient with a Substance-Related Disorder 1099 ▶ Does not eliminate drug craving so is not the preferred treatment for those addicted. ▶ This drug works best with highly motivated patients.D. Phenobarbital or Diazepam ▶ Longer-acting sedatives used to treat sedative with-drawal symptoms. ▶ The dose is reduced gradually until there are no signs of withdrawal.DENTAL HYGIENE PROCESS OF CARE ▶ Millions of people in the United States meet the diag-nostic criteria for alcoholism and drug abuse. ▶ Dental professionals often have the first opportunity to treat early signs and symptoms of oral complications for the substance abuser. ▶ It is necessary to recognize the characteristics of each patient before treatment since it is rare that a patient will disclose information about an addiction.36 ▶ Many drug-dependent people continue to maintain home, work, and social relationships, at least initially, and even for a span of years. ▶ The spectrum of substance use found in dental and dental hygiene patients varies from abstinence to dependence. ▶ Many patients with an alcohol use disorder may use psychoactive drugs such as cocaine, heroin, amphet-amines, marijuana, and assorted sedatives or hypnotics.I. AssessmentA. Patient History ▶ Carefully prepared personal, medical, and dental histo-ries are needed to provide information for comprehen-sive patient care. ▶ A reluctance of the patient to reveal symptoms of alcoholism presents a danger because of alcohol’s ef-fect on oral and systemic health and an enhanced risk of medically related adverse events and drug interactions.2 ▶ Many patients with a drug abuse problem are in denial, which makes their medical history less reliable. ▶ The medical history is updated with an interview at each continuing care appointment. ▶ Patients that abuse drugs may have many general health-related problems. ▶ Precautions, modifications, or adaptations may be needed to prevent an emergency situation. ▶ Other conditions may be identified that require further diagnosis, treatment, or referral. ▶ Psychotherapy ▶ Family therapyII. Drug Withdrawal Medications ▶ The primary medically assisted withdrawal method for narcotic addiction is to switch the patient to a compa-rable drug with milder withdrawal symptoms, and then gradually taper off the substitute medication. ▶ Some patients cannot continue to abstain from opiates and are therefore given a maintenance therapy. ▶ The following drugs are used in maintenance therapy:A. Methadone ▶ Suppresses withdrawal symptoms and drug craving, as-sociated with narcotic addiction. ▶ In methadone maintenance programs, a daily dose (usually a minimum of 60 mg) is administered.B. LAAM (Levo-Alpha-Acetyl-Methadol) ▶ Suppresses withdrawal symptoms and drug cravings. ▶ Administered three times per week only.C. Naltrexone ▶ Competes with opioids at the opioid receptor sites, therefore blocking the effects of heroin. ▷ No single treatment is appropriate for all individuals. ▷ Medical detoxification is only the first stage of treatment. ▷ Treatment does not have to be voluntary to be effective. ▷ Remaining in treatment for an adequate period of time is essential. ▷ Recovery can be a long-term process and relapses can occur. ▷ Effective treatment includes: ▷ Individual, group counseling, and behavioral therapies ▷ Use of treatment medications ▷ integration treatment for any coexisting mental disorders ▷ Infectious disease assessment and counseling (HIV/AIDS, Hepatitis) ▷ Monitoring of possible drug use during treatment. ▷ Medical, social, vocational, legal and family counseling.Source: National Institute on Drug Abuse. Principles of Drug Addiction Treatment: A Research-Based Guide (Rep 2000). Bethesda, MD: National Institute on Drug Abuse; 1999. NIH Publication No. 00-4180.Basic Principles of Effective Drug Addiction TreatmentBox 65-7Wilkins9781451193114-ch065.indd 1099 07/10/15 11:39 AM 1100 SECTION IX | Patients with Special NeedsB. The Interview ▶ Practice a motivational interviewing approach (Chapter 26).• Keep the lines of communication open; refrain from comments that place the patient on the defensive.• Remain empathetic, respectful, and nonjudgmen-tal; patients may be far more likely to respond to questions.• Discuss the effects of drug use on physical, psychoso-cial, and economic well-being at a level appropriate for patient understanding. ▶ Obtain patient confidence• Patients may hesitate to reveal personal informa-tion about substance use because of a social stigma attached to users.• Patients need to understand the information is re-quired as a health-safety measure.• The patient needs to be assured that personal infor-mation will remain confidential.C. Screening: The CAGE Questionnaire37 ▶ Dental providers concerned about a patient’s use of alcohol or other drugs can screen for potential abuse and/or dependence using the CAGE questionnaire as shown in Box 65-8. ▶ The questionnaire is most effective when used during a routine medical history.QuestionnaireC Have you ever felt you ought to Cut down on your drinking or drug use?A Have people Annoyed you by criticizing your drinking or drug use?G Have you ever felt Guilty about your drinking or drug use?E Have you ever had a drink or used drugs first thing in the morning (Eye-Opener) to steady your nerves or to get rid of a hangover or to get your day started?Scoring ▷ Each positive response receives one point. ▷ A score of 2 or more is considered probable for alcoholism. ▷ The predictive value of two positive responses is 30%–60%. ▷ Three positive responses is 60%–75%. ▷ Four positive responses is higher than 90.aaRefer all patients with test results that suggest alcohol dependence to their primary care physician for a more in-depth evaluation.Source: Schorling JB, Buchsbaum DG. Screening for alcohol and drug abuse. Med Clin North Am. 1997;81:845–865.CAGE Questionnaire and ScoringBOX 65-8 ▶ The patient’s answers may not provide a positive diag-nosis, but can alert the interviewer to a need for follow-up questions. ▶ One positive reply can be followed by additional ques-tions as suggested in Box 65-9.D. Screening: The Five A’s ▶ The “Five A’s” (Ask, Advise, Assess, Assist, Arrange): a screening intervention used in tobacco counseling also can be used in substance abuse screening (See Chapter34).E. The Older Adult Patient38 ▶ The number of older adult alcohol consumers is in-creasing; some of these are addicted. ▶ Potential for substance abuse in the older adult is high because of the number and variety of medications used. ▶ Physiological changes associated with aging permit the harmful effects of alcohol consumption to occur at lower levels than with a younger person. ▶ Excessive use of alcohol exacerbates medical and emotional problems and predisposes the person to drug reactions with medications used to control other illnesses. ▶ Memory lapses can upset routine prescription drug use. ▶ Use of over-the-counter medications and alcohol, com-bined with prescribed medications, can increase poten-tial health risks associated with substance abuse. ▷ Last time patient drank alcohol or used drugs. ▷ Pattern of substance use: consumption, frequency, or amount in a given time period. ▷ Any instances of five or more drinks at one time. ▷ Systemic conditions related to substance abuse. ▷ Accidents or hospital admittances due to substance abuse. ▷ Use of medications including prescribed, over-the-counter, and illicit drugs. ▷ Prescription drugs from multiple doctors or dentists. ▷ Taking prescription medications for reasons other than prescribed. ▷ Taking or buying prescriptions intended for another person.Source: Trachtenberg AI, Fleming MF. Diagnosis and treatment of drug abuse in family practice. National Institute on Drug Abuse Website. http://archives.drugabuse.gov/diagnosis-treatment/diagnosis.html. Accessed June 27, 2014.Additional Information to Obtain from a Patient Suspected of Drug UseBOX 65-9Wilkins9781451193114-ch065.indd 1100 07/10/15 11:39 AM CHAPTER 65 | The Patient with a Substance-Related Disorder 1101F. Vital Signs ▶ Record in patient record. ▶ Blood pressure frequently is increased when alcohol and other drugs are used; fluctuations can be particu-larly significant.G. Clinical Examination39 ▶ Information in the patient history may not reveal ac-curately the extent of a patient’s drug use. ▶ Clinical observations along with the medical history may provide a high degree of suspicion. ▶ Specific oral manifestations are associated with particu-lar drugs.40–49 Examples are found in Box 65-10.H. Extraoral Examination ▶ Alcohol signs• Breath and body odor of alcohol and of tobacco: Many alcohol users are also heavy tobacco users.• Tremor of hands, tongue, eyelids: Signs of withdrawal.• Skin: Redness of forehead, cheeks, dilated blood ves-sels that produce spider petechiae on the nose; may worsen pre-existing acne rosacea.• Face color: Light yellowish brown may indicate jaun-dice from liver disease.• Eyes: Red, baggy eyes or puffy facial features; bloated appearance.• Evidences of trauma: Facial injuries related to falls when intoxicated. Alcohol abusers are especially prone to traumatic accidents.• Lips: Angular cheilitis related to poor nutrition.• Parotid glands: Swelling. ▶ Personal appearance• Lack of interest in proper dress and personal hygiene.• Wears long sleeves to cover needle marks.• Small blood stains on clothes from previous injections.• Dramatic weight loss. ▶ Eyes• Wears sunglasses to conceal dilated or constricted pupils and eye redness, or to avoid bright light be-cause of eye sensitivity.• Pupils dilated (amphetamine, LSD, cocaine, marijuana).• Pupils constricted (heroin, morphine, methadone), as shown in Figure 65-3.• Red, inflamed, bloodshot (marijuana). ▶ Arms• Needle marks may be noted when determining blood pressure. ▶ Behavior• Sneezing, itching.• Tendency to gaze into space; moodiness.• Drowsiness, yawning; may sleep long hours.A. “Meth mouth”: key ingredients used in meth manufac-turing are corrosive.40,41 ▷ Meth smoker swirls heated, vaporized substances in the mouth. ▷ Oral mucosa is irritated and burned, creating sores and leading to infection. ▷ Chronic meth smoker: teeth decayed to the gingiva. ▷ Snorting meth also causes chemical damage to teeth. ▷ Symptoms: xerostomia, dryness of the mouth from a lack of normal secretions. ▷ Rampant dental caries on proximal surfaces and at the gingival margin. ▷ Cracked teeth caused from grinding and clenching. ▷ Enamel erosion: corrosive acids in ingredients. ▷ Periodontal infection: reduced blood supply and tis-sue breakdown.B. Cocaine abuse42–45 ▷ Perforation of the nasal septum and/or perforation of the palate (Figure 65-4). ▷ Saddlenose deformity. ▷ Erosive carious lesions. ▷ Rapid gingival recession and mucosal ulcerations. ▷ Trismus.C. “Speed” and “ecstasy,” amphetamine-based drugs46–48 ▷ Xerostomia. ▷ Tooth wear associated with chewing and grinding. ▷ Temporomandibular joint tenderness. ▷ Bruxism leading to trismus. ▷ Rampant dental caries.D. Cannabis abusers generally have poorer oral health than nonabusers49 ▷ Increased dental caries. ▷ Increased periodontal infections. ▷ Dysplastic changes: a premalignant stage in cellular structures. ▷ Premalignant lesions of the oral mucosa. ▷ Leukoplakia. ▷ Increased oral infections due to immunosuppressive effects.Oral Manifestations of Particular DrugsBOX 65-10• Appearance of intoxication with or without the odor of alcohol.• Slurred speech.• Changes in habits, attitudes, and efficiency. Irregular attendance at appointments by one who was previ-ously prompt.• Possession of pills, capsules.• Hallucinations or convulsions indicate need for im-mediate emergency care.Wilkins9781451193114-ch065.indd 1101 07/10/15 11:39 AM 1102 SECTION IX | Patients with Special NeedsFIGURE 65-3 Examination of the Pupils. A: Dilated; occurs in shock, heart failure, other emergencies, and in the use of hallucinogens and amphetamines. B: Normal. C: Pinpoint; occurs in the use of morphine and related drugs, heroin, barbiturates. (Source: The American National Red Cross: Standard First Aid and Personal Safety.)II. Intraoral Examination ▶ Mucosa, lips, tongue• Dry; drug-induced xerostomia, soft tissue abnormalities.• Tongue coated; glossitis related to nutritional deficiencies. ▶ Gingiva• Generalized poor oral hygiene; heavy biofilm not unusual.• Calculus deposits may be generalized, depending on patient neglect.• Moderate to severe gingival inflammation.• Gingiva that bleeds spontaneously or on probing.• Gingival lesions resulting from the direct applica-tion of cocaine.50• Higher incidence of periodontal infections than peers. ▶ Palate• Perforation of palate due to chronic cocaine snort-ing (Figure 65-4). ▶ Teeth• Chipped and fractured from falls and injuries; stained from tobacco use.• Attrition secondary to bruxism.• Erosion secondary to frequent vomiting, wine con-sumption,51 and meth mouth.FIGURE 65-4 Nasopalatal Defect. The problems due to chronic cocaine snorting began to manifest themselves as nosebleeds followed by recurring sinus infections. Within 4 months, the patient discovered a pinhole in his palate. Each time he tried to swallow liquid it came out of his nose. (Photo courtesy of Peter Villa, DDS, FRDC.)• Removable or fixed partial dentures: chipped or bro-ken, may require frequent repairs. ▶ Dental caries• Increased risk factors: poor diet, lack of dental care, accumulation of biofilm, and xerostomia.• Diet high in cariogenic substances.• Root caries when gingival recession is evident.• Open rampant carious lesions: abuse of metham-phetamine, diet of sweets, alcohol and sugar sweet-ened beverages as shown in Figure65-5.52• Tooth loss. ▶ Minimal professional care• Substance abuse patients tend to delay dental and dental hygiene care.• Any available money is used in the purchase of drugs.FIGURE 65-5 Rampant dental caries due to methamphetamine use in a 24-year-old patient who presented for treatment after serving time in prison and going to rehab; patient started using meth at age 16, initially snorting the powder and progressed to smoking the drug. Although some teeth could have been saved, the patient chose to have all remaining teeth extracted in order to receive full dentures. (Photo courtesy of Kessler BH, Dinnen M. Methamphetamine: oral effects and treatment. Inside Dent. 2010;6(2):44–46.)Wilkins9781451193114-ch065.indd 1102 07/10/15 11:39 AM CHAPTER 65 | The Patient with a Substance-Related Disorder 1103• Dental care is used on an emergency basis to allevi-ate any pain or discomfort, and to obtain prescrip-tions for drugs.III. Dental Hygiene DiagnosisExamples of dental hygiene diagnosis for drug users are suggested as follows: ▶ Rampant caries related to the changes in the addicted patient’s lifestyle including:• Diet (multiple daily exposures to sucrose-containing foods and beverages).• Neglect of daily care of the oral cavity (lack of bio-film removal and use of fluoride dentifrice and other fluoride sources). ▶ Periodontal infections related to:• Changes resulting in infection due to reduced blood supply and tissue breakdown as a result of metham-phetamine use.• Rapid gingival recession and mucosal ulcerations due to cocaine abuse. ▶ Xerostomia related to methamphetamine use (many drugs have dry mouth as a side effect).IV. Planning ▶ Develop strategies to meet the individual needs of the patient as identified from the dental hygiene diagnosis. ▶ Priorities and goals are determined by the immediacy of the condition, severity of the problem. ▶ Examples of interventions to reduce, eliminate, or pre-vent rampant caries due to drug use:• Use of fluoride toothpaste and fluoride mouthrinse without alcohol.• Apply fluoride applications such as fluoride varnish in office and custom trays for home use if the patient will be compliant.• Do not administer local anesthetic for any procedure if unsure whether the patient has taken metham-phetamine within the last 24 hours, as the patient may be resistant to local anesthesia.26V. ImplementationThe clinical procedures for dental hygiene care are greatly influenced by the many health problems that can result from drug use.A. Preparation for Treatment ▶ Consult with patient’s physician to determine whether prophylactic antibiotic premedication is indicated. ▶ Precaution is needed for potential drug interactions be-tween specific drugs. ▶ Preprocedural rinse, antibacterial agents, and oral hygiene products that contain alcohol are to be avoided for all pa-tients suffering from a past or current alcohol use problem. The smallest amount of alcohol ingested by a patient be-ing treated with disulfiram can cause an emergency.B. Scaling and Debridement ▶ Use of anesthesia: drug interactions, use of epineph-rine, and choice of nitrous oxide/oxygen versus local Mr. Phillips is 20 minutes late for his continuing care ap-pointment. The patient has previously missed two consec-utive appointments. As he is being seated, he tells Christy, “Just hurry up and clean my teeth.” He also tells her he can’t eat because it is sore on the left side of his mouth. Mr. Phil-lips presents with an odor of smoke and appears quite agitated. The receptionist alerts Christy that the patient re-fused to update and sign his medical history; Christy begins to review the patient’s medical history. Significant findings are (1) BP 160/110 (2) a cluster of ulcerated lesions on man-dibular left buccal fold, (3) CAGE score of 3, (4) OHI-S index of 3. Christy consults with Dr. Franks who then examines the patient and questions Mr. Phillips about his medical history, including the CAGE questionnaire.Dr. Franks is concerned about the patient’s health and tells Mr. Phillips he is referring him for a complete physi-cal examination and is recommending a mouthrinse with benzocaine to help reduce pain on the left side of his mouth. Dr. Franks requests that the patient stop by the receptionist to reschedule his appointment for further treatment. Mr. Phillips becomes very aggressive because no treatment was performed; he verbally abuses the staff before storming out of Dr. Franks’ office without making a follow-up appointment. Dr. Franks and Christy both re-cord Mr. Phillips’ behavior in the patient chart.Questions for Consideration1. Does the decision to postpone treatment for today violate Mr. Phillip’s rights? Why or why not?2. If Dr. Frank decides to terminate his practitioner–client relationship with Mr. Phillips could this be considered “abandonment”? Answer the questions provided in the Questions to Ask column of Table VI-1 in the Section VI Introduction to determine at least one other ethical alternative action that Christy might recommend for Dr. Frank to take.3. How might each of the professional issues listed in Table VII-1 in the Section VII Introduction apply to a de-cision whether or not to terminate the patient–client relationship with Mr. Phillips?EVERYDAY ETHICSWilkins9781451193114-ch065.indd 1103 07/10/15 11:39 AM 1104 SECTION IX | Patients with Special NeedsExample Documentation: Patient with Substance AbuseS – A 35-year-old male patient presents for continuing care appointment. Patient commented, “Hurry up and clean my teeth.” Patient states he cannot eat due to pain on the left side of his mouthO – BP 160/100, pulse 98 bpm, CAGE score of 3, OHI-S index of 3, observed cluster of ulcerations on mandibular left buccal fold.A – Possible hypertension; three positive responses on CAGE indicates 60%–75% possibility of alcoholism; score of 3 on OHI-S indicates soft debris covering more than two-thirds of exposed tooth surface. Ulcerated lesions con-tributing to patient’s inability to consume solid foods.P – Referred patient for medical consult to discuss possible hypertension and alcohol addiction. Recommended mouthrinse containing benzocaine to relieve pain of oral ulcerations. Reinforced biofilm removal. Reschedule in 2 weeks to evaluate the oral lesions. If medical clearance has been provided, provide continuing care treatment at this appointment.Signed: _____________________________________, RDHDate: _______________________________________BOX 65-11anesthesia is reviewed and discussed with the patient’s physician. ▶ Contraindications for use of nitrous oxide/oxygen and medical considerations for local anesthesia with or without epinephrine are in Chapter 38.C. Power-Driven Instruments ▶ Patients with respiratory problems, hepatitis, tubercu-losis, HIV/AIDS, and diabetes may have increased risk for complications resulting from aerosols or contami-nated water lines in power-driven instruments. ▶ Use ultrasonic scalers and air-powder stain-removal de-vices with caution to prevent inhalation of oral micro-organisms by the patient. ▶ High-powered suction is essential. ▶ Patients with immunosuppression resulting from poor nutrition and HIV are more susceptible to lung infec-tions caused by bacteria taken into the lungs from the oral cavity.D. Response to TherapyThe usual oral tissue response expected following peri-odontal instrumentation may be limited by the changes in the patient’s tissues such as: ▶ Prolonged bleeding time; impaired clotting mechanism from chronic liver disease. ▶ Resistance to local anesthetic. ▶ Impaired healing. ▶ Interference with collagen formation and deposition. ▶ Decreased immune system function. ▶ Increased susceptibility to postcare infection.E. Dental Biofilm Control ▶ Maintaining oral health and cleanliness is essential for the prevention of infections. ▶ Motivation may be difficult because many patients with substance abuse problems are preoccupied with drugs and place less priority on personal hygiene. ▶ A preventive oral care program for a recovering sub-stance abuse patient is a necessary part of the total re-habilitation process.F. Diet and Nutrition ▶ Use of alcohol and abusive use drugs can affect nutri-tion intake.53 ▶ Alcoholic beverages contain calories; a day’s allotment of calories may be ingested when alcohol is used in ex-cess and essential nutrients such as, minerals, proteins, and vitamins are lost. ▶ Deficiencies in proteins and vitamins, in particular vi-tamin A, may contribute to liver disease and other dis-orders related to drug use.Instruction for the patient with a substance-related dis-order includes:• Review dietary assessment.• Provide information about basic dietary needs.• Encourage use of foods from the MyPlate Food Guidelines as shown in Chapter 35.VI. Evaluation ▶ Develop continuing care program to prevent progres-sion or reoccurrence of disease. ▶ Evaluate treatment plans and goals with patient. ▶ Make changes according to the patient’s progress. ▶ Evaluate to determine the frequency of continuing care appointment.DOCUMENTATION ▶ Patient record medical alert box for possible substance abuse alerts dental personnel to:• Use a nonalcoholic mouthrinse.• Review score of CAGE questionnaire.• Avoid using local anesthetic with vasoconstrictors if patient is identified as an active user or has a positive CAGE score.• Possible aggressive behavior.Wilkins9781451193114-ch065.indd 1104 07/10/15 11:39 AM CHAPTER 65 | The Patient with a Substance-Related Disorder 1105(DSM-IV-TR). Washington, DC: American Psychiatric As-sociation; 2000:497, 499–501, 502.5. National Institute on Alcohol Abuse and Alcoholism. Al-cohol Alert Number 59: Underage Drinking: A Major Public Health Challenge. Bethesda, MD: U.S. Department of Health and Human Services; 2003.6. National Institute on Alcohol Abuse and Alcoholism. Al-coholism, Getting the Facts. Bethesda, MD: U.S. Department of Health and Human Services; 2004:2–4. NIH Publication No. 96-4153.7. Dick DM, Jones K, Saccone N, et al. Endophenotypes suc-cessfully lead to gene identification: results from the collab-orative study on the genetics of alcoholism. Behav Genet. 2006;36(1):112–126.8. Handley, ED, Chassin, L. Alcohol-specific parenting as a mechanism of parental drinking and alcohol use disorder risk on adolescent alcohol use onset. J Stud Alcohol Drugs. 2013;74:684–693.9. Hingson R, Winter M. Epidemiology and consequences of drinking and driving. Alcohol Res Health. 2003;27(1): 63–78.10. National Institute on Alcohol Abuse and Alcoholism. Alco-hol Alert Number 64: Alcoholic Liver Disease. Bethesda, MD: U.S. Department of Health and Human Services; 2005.11. Schiff ER, Ozden N. Hepatitis C and alcohol. Alcohol Res Health. 2003;27(3):232–239.12. Pletcher MJ, Varosy P, Kiefe CI, et al. Alcohol consumption, binge drinking and early coronary calcification: findings from the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Am J Epidemiol. 2005;161(5):423–433.13. Lieber CS. Medical disorders of alcoholism. N Engl J Med. 1995;333(16):1058–1065.14. National Institute on Alcohol Abuse and Alcoholism. Alco-hol Alert Number 63: Alcohol’s Damaging Effect on the Brain. Bethesda, MD: U.S. Department of Health and Human Ser-vices; 2004:3.15. Centers for Disease Control and Prevention (CDC): Alcohol and Public Health. Fact sheet—excessive alcohol use and risks to women’s health. http://www.cdc.gov/alcohol/ fact-sheets/womens-health.htm. Accessed September 30, 2014.16. Centers for Disease Control and Prevention (CDC): Alco-hol and Public Health. Fact sheet—excessive alcohol use and risks to men’s health. http://www.cdc.gov/alcohol/fact-sheets/mens-health.htm. Accessed September 30, 2014.17. Itthagarum A, Nair RG, Epstein JB, et al. Fetal alcohol syn-drome: case report and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007; 103(3):e20–e25.18. Astley, SJ. Diagnostic Guide for Fetal Alcohol Spectrum Disor-ders: The 4-Digit Diagnostic Code. 3rd ed. Seattle, WA: Uni-versity of Washington Publication Services; 2004.19. Astley SJ. Diagnosing fetal alcohol spectrum disor-ders (FASD). In: Adubato SA, Cohen DE, eds. Prenatal Alcohol Use and Fetal Alcohol Spectrum Disorders; Diagnosis Assessment and New Directions in Research and Multimodal Treatment. Oak Park, IL: Bentham Science Publishers Ltd., Bentham eBooks; 2011:3–29.20. Rapp C. Risk Management for the Medical Practice. Jackson-ville, FL: First Professionals Insurance Co; 2009. ▶ Key concepts: documentation for sign/symptoms of early identification of substance abuse. Include in the permanent record:• Oral examination: with attention to ulcerations, in-fections, and xerostomia.• Dental examination: especially cervical dental caries.• Periodontal examination: noticing rapid changes in periodontal status.• Patient education: regarding relapse of previously good oral hygiene.• Psychological reactions and/or aggressive behavior. ▶ Example of documentation for the patient with sub-stance abuse is shown in Box 65-11. ▷ Drug abuse is a great risk to overall health. ▷ Risk of oral cancer is increased by the use of alcohol, tobacco, and marijuana. ▷ Need for routine oral screening at least twice a year for signs of early cancer. ▷ Drinking alcohol and using other drugs (prescription or over the counter) can lead to medical emergencies. Always check each drug and its actions before using it in combination with alcohol or in combination with another drug. ▷ Commercial antimicrobial and fluoride mouthrinse may contain up to 30% alcohol. Labels must be read care-fully. Keep mouthrinse bottles out of reach of children. ▷ Alcohol and other drugs readily enter the breast milk and are transmitted to the infant during nursing. ▷ Illicit drug use during pregnancy can pose serious risks for unborn babies. ▷ Access The Medicine Abuse Project at http://medicinea-buseproject.org/to teach teenagers about falling victim to prescription drug abuse. ▷ Discard unused prescription pain medication that may be additive to young children or others within the household.Factors To Teach The PatientReferences1. National Institute on Alcohol Abuse and Alcoholism. Al-cohol Alert Number 76: Alcohol and Other Drugs. Bethesda, MD: U.S. Department of Health and Human Services; 2008.2. United States Department of Health and Human Services; Secretary of Health and Human Services. Alcohol and Health: 10th Special Report to the U.S. Congress on Alcohol and Health. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism; 2000:4, 169–190, 197–205, 240, 258–266, 334, 430, 451.3. Saitz R. Unhealthy alcohol use. N Engl J Med. 2005; 352(6):596–607.4. American Psychiatric Association. Substance-related disor-ders. In: Diagnostic and Statistical Manual of Mental Disorders Wilkins9781451193114-ch065.indd 1105 07/10/15 11:39 AM 1106 SECTION IX | Patients with Special Needs39. Friedlander AH, Marder SR, Pisegna JR, et al. Alcohol use and dependence: psychopathology, medical management, and dental implications. J Am Dent Assoc. 2003;134(6):731–740.40. Rhodus NL, Little JW. Methamphetamine abuse and “meth mouth”. Northwest Dent. 2005;84(5):29, 31, 33–37.41. National Institute on Drug Abuse. The science of drug abuse and addiction: commonly abused drugs. http://www .drugabuse.gov/publications/media-guide/commonly-abused-drugs. Accessed September 13, 2014.42. Vilela RJ, Langford C, McCullagh L, et al. Cocaine-induced oronasal fistulas with external nasal erosion but without pal-ate involvement. Ear Nose Throat J. 2002;81(8):562–563.43. Villa PD. Midfacial complications of prolonged cocaine snorting. J Can Dent Assoc. 1999;65(4):218–223.44. Driscoll SE. A pattern of erosive carious lesions from co-caine use. J Mass Dent Soc. 2003;52(3):12–14.45. Kapila YL, Kashani H. Cocaine-associated rapid gingival recession and dental erosion. A case report. J Periodontol. 1997;68(5):485–488.46. Shaner JW. Caries associated with methamphetamine abuse. J Mich Dent Assoc. 2002;84(9):42–47.47. Richards JR, Brofeldt BT. Patterns of tooth wear associ-ated with methamphetamine use. J Periodontol. 2000; 71(8):1371–1374.48. McGrath C, Chan B. Oral health sensations associated with illicit drug abuse. Br Dent J. 2005;198(3):159–162.49. Cho CM, Hirsh R, Johnstone S. General and oral health implications of cannabis use. Aust Dent J. 2005;50(2):70–74.50. Yukna RA. Cocaine periodontitis. Int J Periodontics Restor-ative Dent. 1991;11(1):72–79.51. Mandel L. Dental erosion due to wine consumption. J Am Dent Assoc. 2005;136(1):71–75.52. Kessler BH, Dinnen M. Methamphetamine: oral effects and treatment. Inside Dent. 2010;6(2):44–46.53. Lieber CS. Relationships between nutrition, alcohol use, and liver disease. Alcohol Res Health. 2003;27(3):220–231.21. Denisco RC, Kenna GA, O’Neil MG, et al. Prevention of prescription opioid abuse. The role of the dentist. J Am Dent Assoc. 2011;142(7):800–810.22. American Dental Association. Statement on the use of opioids in the treatment of dental pain. http://www.ada .org/en/about-the-ada/ada-positions-policies-and-state ments/statement-on-opioids-dental-pain. Accessed June 25, 2014.23. American Dental Association, Mouth Healthy. Prescription drugs. http://www.mouthhealthy.org/en/az-topics/p/prescrip-tion-drugs . Accessed April 15, 2014.24. U.S. National Institute on Drug Abuse. Methamphetamine Abuse and Addiction (Revised). Bethesda, MD: National In-stitute on Drug Abuse. NIH Publication Number 06-4210.25. Ditmyer MM, Demopulos CA, Mobley C. Under the influ-ence: an in-depth look at the association between tobacco and marijuana use and dental caries. Dimens Dent Hyg. 2013;11(7):41–43.26. Kelsch NB. Methamphetamine abuse: oral implications and care. RDH. 2010;30(2):75.27. Lai S, Lima JA, Lai H, et al. Human immunodeficiency virus 1 infection, cocaine, and coronary calcification. Arch Intern Med. 2005;165(6):690–695.28. Ohta K, Mori M, Yoritaka A, et al. Delayed ischemic stroke associated with methamphetamine use. J Emerg Med. 2005;28(2):165–167.29. McGee SM, McGee DN, McGee MB. Spontaneous intra-cerebral hemorrhage related to methamphetamine abuse: autopsy findings and clinical correlation. Am J Forensic Med Pathol. 2004;25(4):334–337.30. Bellows CF, Raafat AM. The surgical abdomen associated with cocaine abuse. J Emerg Med. 2002;23(4):383–386.31. Devitt E, Carroll R, Donnelly C, et al. An unusual cause of abdominal pain. Ir Med J. 2005;98(3):88–89.32. Voss JU, Roller M, Brinkmann E, et al. Nephrotoxicity of organic solvents: biomarkers for early detection. Int Arch Occup Environ Health. 2005;78(6):475–485.33. U.S. National Institute On Drug Abuse. NIDA Infofacts: Cocaine. Bethesda, MD: National Institute on Drug Abuse. Revised 2010:5.34. Bowen SE, Hannigan JH. Developmental toxicity of prena-tal exposure to toluene. AAPS J. 2006;8(2):E419–E424.35. Gordon RJ, Lowy FD. Bacterial infections in drug users. N Engl J Med. 2005;353(18):1945–1954.36. National Institute on Alcohol Abuse and Alcoholism. Alcoholism, Getting the Facts. Bethesda, MD: National In-stitute on Drug Abuse; 2004:2–4. NIH Publication No. 96-4153. http://www.drugabuse.gov/DrugPages/DrugsofAbuse .html. Accessed June 21, 2014.37. Schorling JB, Buchsbaum DG. Screening for alcohol and drug abuse. Med Clin North Am. 1997;81:845–865.38. Friedlander AH, Norman DC. Geriatric alcoholism: patho-physiology and dental implications. J Am Dent Assoc. 2006;137(3):330–338.ENHANCE YOUR UNDERSTANDINGDIGITAL CONNECTIONS(see the inside front cover for access information)• Audio glossary• Quiz bankSUPPORT FOR LEARNING(available separately; visit lww.com)• Active Learning Workbook for Clinical Practice of the Dental Hygienist, 12th EditionINDIVIDUALIZED REVIEW(available separately; visit lww.com)• Adaptive quizzing with prepU for Wilkins’ Clinical Practice of the Dental HygienistWilkins9781451193114-ch065.indd 1106 07/10/15 11:39 AM

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