DRUG USE AND ABUSE

Kyle J. Kramer
DDS, MS
8/12/11

GOALS
Discuss drug use and abuse for patients
Define and discuss
Tolerance
Dependence
Withdrawal

Discuss drug use and abuse for healthcare providers

DRUG USE
Common problem in the United States
Drug overuse
OTC
Prescription

Drug abuse
Legal
Illegal

Polydrug abuse
Alcohol + tobacco + OTC drugs
Percocet + ritalin

DRUG USE
A problem that can effect all types of patients
Not restricted to:
Age
Sex
Race
Socio-economic class

TOLERANCE

TOLERANCE
Definition:
The need for progressively higher doses to achieve the same desired
effect

Similar to tachyphylaxis
Repeated doses have less or no effect

Does NOT apply to all clinical effects

Example: Opioid-induced analgesia and GI effects

TOLERANCE
Two Main Mechanisms:
Increased drug metabolism
Induction of hepatic enzymes (CYP 450)
Leads to less drug available at the receptor sites

Receptor down-regulation
Long-term desensitization
Decrease in number of available receptors

TOLERANCE
Clinical signs and symptoms can include:
Reduction in duration
Decreased sedation time (benzodiazepines)
Decreased length of analgesia (opioids)

Reduction in peak effect

Analgesic effects (opioids)

TOLERANCE
Rate of development depends on:
Specific drug used
Frequency of dosing
Dose (amount)
Length of exposure
Opioid tx >5-7 days
Beginning signs of tolerance

Patient-specific
Nonpharmacologic factors

TOLERANCE
Can occur with legal and illegal drugs
Examples:
Prescription opioids
Vicodin
Oxycodone

Illicit opioids
Heroin

Cocaine
Alcohol

DEPENDENCE

DEPENDENCE
Condition in which withdrawal symptoms occur when the
abused drug is withheld
Physical
Psychological
Both

Can involve chronic use of legal and/or illegal drugs

Alcohol
Prescription opioids
Percocet

Illicit opioids
Heroin

DEPENDENCE
Physical
Involves biological
adaptations
Cellular
Synaptic
Systemic

Easier to manage

Psychological
Addiction
Reward center in the brain

Drug-seeking behavior
Continued use
Impaired control over drug
use
Craving despite harm

Difficult to manage

DEPENDENCE
Rate of development depends on:
Specific drug used
Dependence liability

Frequency of dosing
Dose (amount)
Length of exposure
Patient-specific
Nonpharmacologic factors

DEPENDENCE LIABILIT Y
How likely is the drug to produce significant dependence over
others?

percocet:
oxycodone/acetaminophen

Drug

Route

Dependence
Liability

Codeine

Oral

Low-Moderate

Fentanyl

IM/IV

High

Heroin

IM/IV

High

Morphine

IM/IV

High

Oral

Moderate

Nalbuphine*

IM/IV

Low

Oxycodone

Oral

High

Tramadol

Oral

Low

* Mixed agonist-antagonist

WITHDRAWAL

WITHDRAWAL SYNDROME
Potential causes:
Abrupt cessation
Rapid dose reduction
Decreasing blood content of the drug
Administration of an antagonist

WITHDRAWAL SYNDROME
Preoperative and perioperative concerns
Want to avoid withdrawal
This is not the time to start treating chemical dependence!

Unstable
Psychologically
Physiologically

WITHDRAWAL SYNDROME
Management
Ensure patient has usual maintenance dose
Avoid withdrawal until after stress of surgery

Withdrawal protocols
Addictions specialist
May require hospitalization
CIWA protocol
Monitoring

WITHDRAWAL SYNDROME
CNS Depressants

Non-CNS Depressants

Alcohol, benzos,
barbiturates

Opioids, cocaine,
marijuana

Life-threatening

Not life-threatening

Seizures
DTs
Death

DELIRIUM TREMENS (DTS)

Caused by CNS depressants
Alcohol***
Benzodiazepines
Barbiturates

Imbalance of neurotransmitters
Down-regulation
GABA

Up-regulation

Glutamate
Norepinephrine
Dopamine
Serotonin
Epinephrine

DELIRIUM TREMENS
Signs and symptoms
Autonomic instability
Seizures
Confusion
Dizziness

DELIRIUM TREMENS
Treatment
Hospitalization
Monitoring
Stabilization of vital signs

CIWA or Alcohol Withdrawal protocol

Slow taper with benzodiazepines

DRUG ABUSE AND

SEDATION

DRUG ABUSE AND SEDATION

Determine patient sobriety
Delay treatment if intoxication is suspected
Medical-legal
Consent issues
Patient honesty
PMH

Unpredictability of sedation

DRUG ABUSE AND SEDATION:

NARCOTICS
Symptoms primarily related to -receptor activity
Respiratory depression
GI (constipation)
Analgesia

Management
Avoid additional opioids if respiratory depression is noted
Adequate local anesthesia
Opioid agonists or agonist-antagonists are acceptable

DRUG ABUSE AND SEDATION:

BENZODIAZEPINES
Symptoms are related to GABA -receptor activity
CNS depressant effects

Management
Chronic use
Increase in anesthetic requirements
Watch for withdrawal symptoms

Acute intoxication
Decrease in anesthetic requirements

DRUG ABUSE AND SEDATION:

AMPHETAMINES
Symptoms
CNS stimulants
Hypertension, tachycardia, etc.

Management
Primarily treated with adrenergic antagonists
Chronic use
Decreases anesthetic requirements
May respond poorly to indirect adrenergic agonists (ephedrine)
Depletion of catecholamine stores

Acute intoxication
Increases anesthetic requirements

DRUG ABUSE AND SEDATION:

COCAINE
Cocaine MOA
Inhibits monoamine active reuptake transporters
Blocks Na channels

Symptoms
CNS stimulant
Hypertension, tachycardia, etc.

DRUG ABUSE AND SEDATION:

COCAINE
Management
Primarily treated with adrenergic antagonists, benzodiazepines
Chronic use
May respond poorly to indirect adrenergic agonists (ephedrine)
Depletion of catecholamine stores

Acute intoxication
Increases anesthetic requirements
Local anesthesia is safe (watch vasoconstrictors)

CHEMICAL DEPENDENCY & HEALTHCARE

PROVIDERS
Chemical Dependency
Occupational hazard for healthcare providers
Anesthesiologists
Sedationists

Ease of access
Highly potent drugs

Morphine
Fentanyl
Midazolam
Propofol

CHEMICAL DEPENDENCY & HEALTHCARE

PROVIDERS
Addicts
Often the last people to recognize that there is a problem
We have to lookout for each other

Friends
Colleagues
Co-workers
Employees

NARCOTIC ABUSE
Can lead to tragic and serious complications
Anoxic brain damage
Death

Workplace use
Common
Usually self-administered

ASA DATA
ASA Survey
Incidence of 0.5% per year of anesthesia training or practice

Drug of choice
Fentanyl
Street name: China white

Meperidine
Sufentanil
Propofol

RECOGNIZING IMPAIRMENT IN A
COLLEAGUE
If left unrecognized and untreated can ultimately lead to:
Loss of career
Health problems
Issues at home
Life-threatening

Note:
Interestingly, while use during work is common, documented harm to
patients is exceedingly rare

RECOGNIZING IMPAIRMENT IN A
COLLEAGUE
Signs may be subtle or hard to recognize
Preserve career
Preserve access to drug

RECOGNIZING IMPAIRMENT IN A
COLLEAGUE
1.

Unusual behavior, mood swings, periods of depression anger

and irritability

2.

Using abnormally high quantities of drugs

3.

Taking frequent breaks

4.

Demonstrating reclusive behavior

5.

Wearing long sleeves

RECOGNIZING IMPAIRMENT IN A
COLLEAGUE
7.

Volunteering for extra work

8.

Patients frequently being in pain despite charting of

typically adequate narcotic dosages

9.

Evidence of withdrawal

Agitation
Seizures
Tremors
Diaphoresis

INTERVENTION
Intervention can be very uncomfortable and stressful
Easier if a departmental policy is in place
VERY difficult in private practice

If evidence exists, may want to get an addictions specialist

involved
Will help facilitate the process

Goals:
Inform practitioner that an evaluation is required
Prior arrangements should be made
Physical escort to facility

RISK OF RELAPSE
Addition to alcohol or benzodiazepines
Fairly good prognosis

Addition to narcotics
High risk of relapse
14-70%

PLAN OF ACTION
Multistep process typically involving medical and legal actions
Notification of dental board
Suspension of license
Voluntary
Involuntary

DEA license
CSR license

Enter an addictions facility/program

Complete the program

PLAN OF ACTION
Comply with additional dental board requirements
Random drug screens
Active participation in support groups
AA
NarcAnon

Prolonged, witnesses use of antagonists

Narcan
Disulfiram

Denial of sedation permit?

QUESTIONS??
Thanks!!