The use and abuse of recreational drugs is not a topic routinely found, or at least not covered in depth, in the dental curriculum. It is a subject in which information is usually obtained and shaped from cultural and sociological attitudes, media reports or just hearsay.1 Although, probably more understood (and prevalent) today than at any other time the stigma attached to illicit drug use limits the information readily available to the practitioner about these substances. Dentists have a responsibility to include questions regarding a history of chemical dependency or substance abuse in their health questionnaire. A positive response should not be approached with shock or discrimination. The informed dentist may not condone the activity but can establish an honest rapport in a nonjudgmental atmosphere to provide safe and effective patient care. Recreational illicit drugs are not found in the Compendium of Pharmaceuticals and Specialties (CPS). The intent of this article is to provide an overview of the most commonly used recreational illicit drugs and how patients using these substances may influence your dental management.
Psychoactive drugs or substances are chemicals that alter brain function to produce temporary changes in perception, mood, consciousness or behaviour.2 Recreational drug use has been defined as the casual use of a psychoactive substance for reasons other than work, medical or spiritual purpose.3 Abuse may begin to develop when the user avoids financial responsibility to buy drugs, or social commitments to have enough time to use them. Other definitions incorporate an increasing frequency, the use of excessive amounts or draw the line at legality.3 It is important to point out that tolerance; physical dependence and withdrawal are all natural consequences of drug use, even with those taking medications for appropriate medical conditions. These parameters do not always imply problematic use or abuse.4 For the purposes of our discussion recreational drug use involves a casual use that has negligible health or social effects and becomes abuse with the appearance of health problems, socioeconomic plight, physical dependence or psychological addiction.5 We have also introduced illicit or legality into the format of this article. This term will separate alcohol, tobacco and caffeine from our discussions. Currently, these three substances are the most popular recreational drugs and certainly the most widespread drugs used throughout human history. The abuse of the many prescription drugs and narcotics can be referenced in a current CPS, textbook chapter or journal article and has been extensively researched and documented elsewhere. It is outside the scope of this discussion.
Why do people use recreational drugs? It is not a new phenomenon and some cite marketing, availability or the pressures of modern life as reasons why individuals use and abuse psychoactive drugs in daily life. The answer is most likely simple; the urge to alter one’s consciousness is as primary as the drive to satisfy thirst, hunger or play.6 Unfortunately these base urges are resulting in an increase in adolescent substance use. The Ontario Student Drug Use Survey published in the Canadian Medical Association Journal,7 is a cross-sectional survey of students in grades 7, 9, 11, and 13. It has been conducted every two years since 1977 and is the longest ongoing study of adolescents in Canada. The survey measures the prevalence of use of 17 drugs such as cannabis, cocaine, ecstasy and alcohol. No drug had a decline in use from the previous survey two years prior. Over 35 percent of respondents admitted to the use of an illicit drug within the last year.
The characteristics of recreational drugs (Table 1) represents the most commonly used recreational illicit drugs in Canada.8,9 The chemical name and mechanism of action is provided. The street names are numerous but not all inclusive. The clinical appearances and forms are detailed. Wikipedia, is a free online encyclopedia and proved to a valuable resource for much of the information provided in the following sections on individual drugs.9
Cannabis is the dried (marijuana) or processed (hashish) plant of Cannabis sativa, C. indica and C. ruderalis. It is a mild hallucinogen and relaxant and has been used for its medicinal and psychoactive effects for thousands of years.10 It is available by prescription in Canada to treat glaucoma, malnutrition of the HIV patient and the nausea of cancer chemotherapy. Cannabis can be smoked in cigarettes (joints), pipes, or baked in brownies or cakes, then ingested.1 Recreational use produces euphoria and a humorous state with appetite stimulation and a time and spatial distortion. The pharmacologic effects of inhaled marijuana occur within minutes but rarely persist more than two to three hours. Clinical signs may include drowsiness, an increased resting heart rate and conjunctival reddening.
Ecstasy is a synthetic hallucinogenic amphetamine. Medically it is used by psychotherapists to treat post-traumatic stress disorder. Recreationally its popularity in the 1990s rave subculture was due to its entactogenic effect defined as a sense that the world is a favorable place to be. Ecstasy causes a feeling of openness, energy and well being. It is usually ingested in pill form and is referred to as pilling, pinging, or rushing. It may lead to acute dehydration as the drug masks the normal senses of exhaustion and thirst. Long term effects include the potential for neurotoxicity, shown in animal studies and the hallucinogen persisting perception disorder, a permanent condition of intermittent perceptual distortion.11
Lysergic acid diethylamide is a powerful semisynthetic psychedelic hallucinogen. It is synthesized from lysergic acid derived from ergot, a grain fungus that grows on rye. It is by weight the most potent drug yet discovered. It is used in medicine as an analgesic for chronic cancer pain and cluster headaches. It is ingested as a liquid on blotter paper or sugar cubes and causes an expansion and alteration of senses, emotions and memories for 8 to 12 hours. It produces illusionary visual effects and moving geometric patterns. Although tolerance is seen, users do not develop dependence or addiction.
Mescaline is a psychedelic hallucinogenic drug of the phenethylamine family. It is either synthesized or extracted from various forms of cactus and its use dates back to early Native American religious ceremonies.12 Mescaline powder is consumed orally or insufflated nasally (snorted) to produce euphoria and dream-like visual hallucinations. These effects may last up to 12 hours. It is not believed to be physically addictive. Negative side effects can include headaches, tachycardia, vomiting and occasionally feelings of panic and impending death.
Psilocybin is a psychedelic alkaloid of the tryptamine family. It may be synthesized but is present naturally in many species of fungi, primarily of the genus Psilocybe. Currently it is being studied to treat obsessive compulsive disorder (OCD). Recreationally it is used for hallucinatory effects: walls that appear to breathe, vivid enhancement of colors and the animation of organic shapes. The drug is absorbed though the lining of the mouth and may be chewed and held in the oral cavity or mixed as a tea and swallowed. The effects may persist for 24 hours after administration. If combined with other drugs or taken at a time of mental instability it may produce anxiety and frightening hallucinations.13
Crystal methamphetamine hydrochloride is a synthetic amphetamine and potent central nervous system (CNS) stimulant. It is produced from ephedrine and pseudoephedrine by chemical reduction. Medica
lly it has been used to treat attention deficit hyperactivity disorder, narcolepsy and obesity. It is used to increase mental alertness, motivation, euphoria and a heightened sexual stimulation. It can be swallowed, insufflated, smoked or dissolved in water and injected.14 Toxicity can manifest as seizures, dysrhythmia and encephalopathy.8
Cocaine is a crystalline tropane alkaloid obtained from the leaves of the coca plant. It is a CNS stimulant. In its various forms it is second only to cannabis as the most popular illegal drug. Medically it is useful as a topical anesthetic and vasoconstrictor in ophthalmic and ENT surgery. Recreationally it is highly addictive creating a euphoric happiness and increased energy. Cocaine is a pearl white salt adulterated or cut to increase its surface area with baking soda or sugar. Crack cocaine is prepared with ammonia or sodium bicarbonate to form a light brown crumbly crystalline substance. Cocaine may be insufflated or administered by IV injection. Crack cocaine is smoked. Chronic use has been associated with hypertension, cardiac dysrhythmia and myocardial infarction.15
Heroin or diacetylmorphine is a semi-synthetic opioid. It is synthesized from morphine by acetylation. Opium poppies are grown in the Middle East, India and Asia; however, the major supply to North America is Mexico and Columbia.16 Black market opium refinement is a relatively simple process requiring only moderate technical knowledge and common chemicals. In Canada, heroin is illegal for any purpose. In the United Kingdom it is available by prescription for the treatment of acute and chronic pain, myocardial infarction and in palliative cancer care. Heroin is an addictive drug producing intense euphoria. Its recreational popularity comes from its rapid onset, within 10 seconds intravenously. The euphoric stage (high) lasts 3 to 4 hours. With the chronic abuser, approximately 8 hours after heroin use withdrawal symptoms may begin. It can also be ingested, insufflated or smoked by inhaling the vapors when heated from below.
Gamma-hydroxybutryrate has been used as a general anesthetic agent and CNS depressant in the treatment of insomnia. As an intoxicant it gained notoriety as a date-rape drug in the 1990s.17 Recreational use at low doses induces a state of euphoria, sociability, and intoxication. Effects progress to dizziness, visual disturbances, amnesia, and eventual unconsciousness. It is a powder, mixed in a liquid, sold in vials and taken orally. The effects last one to three hours. When taken on a regular basis physical dependence and psychological addiction develop.
It is a dissociative general anesthetic agent valued for its minimal respiratory depressant and potent analgesic properties. It is popular for both human and veterinary use. Recreationally it produces hallucinatory effects, impairing the senses of sight, balance and time. It is a sympathomimetic and users characteristically demonstrate impaired motor function, nystagmus and catalepsy. Ketamine is usually obtained by the diversion of legitimate supplies or theft from veterinary clinics. In the liquid form it is typically injected intramuscularly, or it can be heated to a powder form that can be insufflated or mixed in beverages.
Phencyclidine is a dissociative psychedelic drug formerly used as an anesthetic agent. It was commercially developed and patented in the 1950s but was withdrawn due to unfavorable side-effects.18 Recreationally, as a powder, it is insufflated. In liquid form it is typically sprayed onto marijuana and smoked. Users feel detached from surroundings with a sense of strength and invulnerability. High doses can cause seizures, coma and death usually by suicide rather than intoxication.
Nitrous oxide is an inhalational anesthetic agent. It is used in dentistry for its anesthetic and analgesic properties. Recreational use is to induce dizziness, euphoria, sound distortion and mild hallucinations. It is licensed as a food additive specifically as an aerosol spray propellant.19 It is used in whipped cream canisters and as an inert gas to displace oxygen when filling potato chip and snack bags. The inhalation from these commercial tanks and chargers can produce high pressure lung collapse or frostbite.
DENTAL EFFECTS AND MANAGEMENT
There are some oral signs that although not unique, may provide clues to a history of substance use. Many heroin users exhibit multiple carious teeth, particularly class V lesions. This is due to the drug induced xerostomia, poor diet and lack of oral hygiene.1 Bruxism appears to be associated with both methamphetamine and ecstasy. Crystal methamphetamine also increases caries rates and tooth loss as a crystalline cariogenic residue is left on the teeth after smoking, nasal or oral intake.14 Ecstasy users jaw clenching and teeth grinding may lead to severe dental attrition.
Marijuana is the most likely illicit drug to be taken when attending the dental office. However, unlike alcohol, it does not produce any detectable odor on the breath or signs of intoxication. Local anesthetics, analgesics and the antibiotics commonly used in dentistry do not interact with cannabis.1 With administering sedation concerns of chronic bronchitis, a sensitive hyper-reactive airway, tachycardia and orthostatic hypotension should be anticipated. Cocaine presents a potentially life threatening situation in the dental practice. The combination of cocaine use and a local anesthetic with vasoconstrictor may exacerbate a sympathetic response and the development of a hypertensive crisis or cardiac dysrhythmia.1 Twelve hours after cocaine use if the patient has no tachycardia, hypertension or agitation dental treatment or sedation may proceed.15 Heroin and opiate users often complain that analgesics do not work. Nonsteroidal anti-inflammatory drugs should be used to manage discomfort as narcotics may cause relapse in recovering addicts.1 These patients tend to have frequent skin and dental infections and users develop resistant strains to widely used antibiotics. Current or past IV drug use carries the possibility of transmitting hepatitis and HIV. Prophylactic antibiotic coverage with dental procedures is required due to the higher risk of subacute bacterial and fungal endocarditis. In the management of anesthesia, heroin users may prove to have difficult vascular access and demonstrate synergism with anesthetic medications.15 Generally the hallucinogens as a group (PCP, LSD, mescaline, psilocybin) clinical effects peak in one to two hours. There is a tendency for hypertension, tachycardia and other cardiac dysrhythmia. An exaggerated response to sympathomimetic drugs like epinephrine would seem likely. Office anesthesia and surgery have reported to precipitate panic and bizarre violent behaviour.4 As a general rule in the absence of acute intoxication, the chronic recreational use of many of the illicit drugs detailed have not shown to be predictably associated with adverse dental or anesthetic interactions.20 Aside from the dangerous combination of local anesthetic with epinephrine and cocaine most recreational drugs are cleared within 12 hours which should act as a guideline for the safe provision of dental care.
The expansion of dental practice office hours into evenings and weekends has potentially overlapped traditional recreational time. Coupled with a general lack of concern regarding casual drug use, patients may not freely admit their customary illicit substance use or the pre-appointment use of a recreational drug to alleviate dental anxiety. We have attempted to describe some of the characteristic nonverbal signs induced by these agents to encourage a dialogue with those patients that may be acting inapprop
riately. This assessment includes patients who are actively abusing alcohol, prescription drugs or patients who are in recovery. A table has provided a concise reference of the most commonly used recreational illicit drugs in Canada. Individual drugs and their effects have been discussed to provide education and information. Hopefully, an awareness of the prevalence and a familiarity with these substances has provided a foundation to question a patient in a professional and tactful manner. Just as a patient who repeatedly attends your office with undiagnosed hypertension requires a medical referral; perhaps, the recreational drug user by their admission is demonstrating warning signs that warrant further attention. We need look no further than the beneficial influence dentistry continues to have with smoking cessation programs as evidence of that.
Dr. Sands is a specialist in oral and maxillofacial surgery and maintains a private practice in Woodbridge, ON.
Oral Health welcomes this original article.
1.Wynn RL, et al: Drug Information Handbook for Dentistry (10th Ed). Hudson, Ohio, Lexi-comp Inc., 2005, 1576-1581
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20.Stoelting RK, Dierdorf SF: Anesthesia and Co-Existing Disease (3rd Ed). Philadelphia, Pennsylvania, Churchill Livingstone, 1993