Substance abuse & conscious sedation PDF

GENERAL Substance abuse and conscious sedation: theoretical and practical considerations Aliya Hasan*1 and Valmiki Sharma2 Key points Educates dental professionals of the Illustrates the practical considerations Discusses the management of drug Provides...

GENERAL Substance abuse and conscious sedation: theoretical and practical considerations Aliya Hasan*1 and Valmiki Sharma2 Key points Educates dental professionals of the Illustrates the practical considerations Discusses the management of drug Provides an overview of indications for conscious sedation of substance abuse and conscious tolerance and those undergoing non-pharmacological anxiety methods. sedation. conscious sedation. management. Abstract Substance abuse is an issue that has been widely recognised both in the medical and dental professions. Many different recreational drugs exist and their use can have important consequences in relation to conscious sedation. As the use of illicit drugs is growing, it is important to have an understanding of the impact of substance abuse on determining if a patient is a suitable candidate for conscious sedation. It is important to appreciate that while human studies in this area are limited, animal studies and observation of the reactions of substance abusers to sedative agents demonstrate a potential link between illicit drug use and conscious sedation through drug interaction. This paper aims to discuss the importance of understanding substance abuse, the potential effects such substances can have in relation to conscious sedation and appropriate management techniques for substance abusers in order to provide optimum safe care when undergoing conscious sedation techniques. Introduction reflex, those with certain adverse medical common reasons for the use of conscious conditions, and in special care dentistry.2 The sedation. The Adult Dental Health Survey in Conscious sedation is defined as: use of conscious sedation dates back to the 2009 reported that 12% of the adult population ‘A technique in which the use of a drug or 1800s, when Horace Wells sedated a patient stated that they have extreme anxiety in relation drugs produces a state of depression of the for a tooth extraction using nitrous oxide.3 A to dental treatment.5 Therefore, dentally phobic central nervous system enabling treatment century later, conscious sedation techniques patients may undertake conscious sedation for to be carried out but during which verbal advanced with the creation of the Jorgensen dental procedures. Of this subset, many are contact is maintained throughout the period Technique, named after Professor Niels Bjorn referred for specialist dental treatment under of sedation. The drugs and techniques used Jorgensen, a dentist working in Los Angeles. sedation in secondary care settings. to provide conscious sedation for dental This involved incremental doses of intravenous Another indication for the use of conscious treatment should carry a margin of safety wide pentobarbital to a patient in combination sedation is for patients with a severe gag reflex. enough to render the loss of consciousness with meperidine and scopolamine in saline.4 Patients who are unable to tolerate treatment unlikely’.1 Since then, many improvements to conscious secondary to this issue may be offered Encompassing different routes of sedation techniques have been, and continue conscious sedation; notably, intravenous administration, including oral, inhalation and to be, developed. sedation can help to overcome an overactive intravenous conscious sedation, can be used Various challenges exist when carrying out gag reflex.6 Other indications for conscious to aid in the provision of dental treatment conscious sedation for dental procedures. sedation include patients with adverse medical to anxious patients, those with a severe gag However, in the author’s opinion, one of conditions that may benefit from the effects the increasingly prevalent issues is the risk of the sedative agents, such as uncontrolled assessment and determination of the effects epilepsy or movement disorders, both of which 1 Former Dental Core Trainee in Paediatric Dentistry, Dental and Maxillofacial Department, Great Ormond Street Hospital, of substance abuse on the use of conscious respond favourably to midazolam.7 Great Ormond Street, London, WC1N 3JH; 2Consultant in Oral sedation. More subjectively, conscious sedation can and Maxillofacial Surgery, Royal Free London NHS Foundation Trust, Hampstead, London, NW3 2QG also be used to enable more anxiety provoking *Correspondence to: Aliya Hasan Indications for the use of conscious dental procedures to be completed with greater Email: [email protected] sedation in dentistry comfort. For example, with the surgical Refereed Paper. There are several indications for the use of removal of a lower third molar, the use of Accepted 22 July 2019 conscious sedation in dentistry. As previously conscious sedation can help to reduce anxiety https://doi.org/10.1038/s41415-019-0897-z mentioned, dental anxiety is one of the most and awareness during the procedure.7 BRITISH DENTAL JOURNAL | VOLUME 227 NO. 10 | November 22 2019 923 © The Author(s), under exclusive licence to British Dental Association 2019  GENERAL The properties of sedative agents What is substance abuse? interactions with sedative agents and steps that Sedative agents have multiple properties The World Health Organisation (WHO) define may be employed to mitigate complications in that make conscious sedation a treatment substance abuse as: ‘The harmful or hazardous dental practice. of choice for many patients. With safe use of psychoactive substances including therapeutic margins, benzodiazepines alcohol and illicit drugs’.11 Cannabis and alcohol have favourable anxiolytic properties. Benzodiazepines bind to GABAA receptors Substance abuse statistics One of the most common recreational drugs (gamma amino-butyric acid) in the brain In England currently, the use of recreational used worldwide is cannabis. The United which augments the opening of chloride ion drugs is growing in popularity. The term Nations published The World Drug Report channels thereby potentiating the inhibitory ‘Recreational Drug’ refers to any drug used in 2016 where it was evidenced that in effects of GABA.8 This allows for a patient socially and not for medical reasons. 12 2014, 183 million people worldwide were to be maintained in a relaxed state and thus, Examples of the types of recreational drugs using cannabis.15 This is a Class B drug with the procedure to continue without difficulty. used in England are shown in the table below. the effects of producing a ‘dream-like’ state Some sedative agents can also act as anti- In 2015 in England and Wales, there were with an altered state of mind.16 Cannabis hypertensives. For example, benzodiazepines 2,479 deaths from the use of illicit drugs. is a hallucinogenic drug containing 66 have vasodilatory effects. In one study by This is the highest number of recreational cannabinoids which are active components of Klockgether-Radke et al., it was shown drug-related deaths since 1993.13 Between the drug that bind to cannabinoid receptors that midazolam has vasodilatory effects 2015 and 2016, 8.4% of adults aged between in the brain to produce the desired effect.17 In on coronary arteries. 9 This can be useful 1659 years admitted to using illicit drugs and England between 2014 and 201, 6.7% of adults in patients with a history of hypertension, in 2014, 24% of 15-year-olds also admitted to admitted to taking cannabis.18 as their blood pressure will decrease as the this.13 The UK Drug Strategy was introduced Another popular recreational drug is alcohol. sedative agent is administered. in 2017 in a bid to reduce substance abuse in The Department of Health, recommends Other beneficial effects of benzodiazepines the UK and support those who are addicts into weekly consumption of alcohol should not include a degree of inhibition of the gag recovery.14 Currently, literature on the effect exceed 14 units of alcohol; the equivalent of reflex and anterograde amnesic properties.10 of recreational drugs in relation to conscious seven pints of low strength (4%) lager, beer or This can result in a patient seemingly not sedation is sparse. cider.19 Alcohol misuse is common, with 6,813 being able to recall the dental procedure This paper aims to focus on two very deaths in 2015 in England being due to alcohol therefore allaying their anxiety somewhat commonly used recreational drugs; cannabis consumption.20 Patients who have increased for future dental visits. and alcohol to highlight their potential alcohol intake may present to general dental Table 1 Common names for popular recreational drugs22 Drug UK street names UK street appearance Effect Marijuana, Weed, Skunk, Dope Resin, Bhang, Soft black resin, Furry green leaves, Sedated and relaxed (stoned), can feel Cannabis Grass, Hash, Ganja, Herb, Hashish Hard brown lumps, Dark oil. time is slower, hallucination Coke: Fine white powder Blow, Crack, Coke, Snow, White Lady, Charlie, Happy, excited, confident, wide awake, Cocaine Crack: White rocks Ching, Chang, Freebase, Aunt Nora increased sex drive Freebase: Crystals Phencyclidine Oily yellow liquid, White to brown crystals ‘Numb’ feeling, can be euphoriant or PCP, Angel Dust, Hog, Peace pills (PCP) and powders. depressant. Can lead to psychosis Smack, Skag, Horse, China White, Big H, Brown Usually ‘cut’ with different substances so can Dizziness initially. Heroin Sugar, Junk, Thunder, Gear, Brown, Speedball be brownish white to brown powder. Happiness, relaxed, euphoric, sleepy (mixed with cocaine) LSD, Acid, Tab, Dot, Drops, Rainbow, Smiles, World appears distorted including Lysergic acid diethylamide Paper squares with pictures (tabs), Tiny Paper Mushroom, Trip, Tripper, Lucy, Micro Dot, time, giggly, euphoric, awestruck with (LSD) pellets, Liquid. Blotter surrounding things Speed, Billy, Whizz, Addys, Uppers, Zing, Smart Off white pinkish powder that can look like Alert, energised, excited, can lead to Amphetamine sulphate Pills, Study Buddys crystals, Can be a white/grey paste. delusion and psychosis Spice, Mary Joy, K2, K3, Black Mamba, Blue Spice commonest in UK: sachets describing Effects similar but more potent to Synthetic cannabinoids Cheese, X, Ecsess, Amsterdam Gold, Bombay contents as incense/herbal smoking mixture. cannabis but can lead to paranoia Blue Methylene dioxy Monographed pills: Ecstasy. Ecstasy, E, Dizzle, Molly, Superman, Mandy, Very happy, ‘loved up’, energetic, more methamphetamine White powder usually in cigarette wrapper: Dolphins, Beans, MD, Cowies, Mitsubishis in tune with surroundings and music (MDMA) MDMA. Grainy white or brown crystalline powder. Chilled and relaxed, dreamlike, Ketamine Vitamin K, Special K, Wonk, K, Super K, Ket Unusually tablet. detached, happy. Downers, Jellies, Eggs, Roofies, Rohypnol, Calm and relaxed. Tablets, Capsules, Injections and Benzodiazepines Norries, Mazzies, Vallies, Blues, Benzos, Sometimes used to ‘come down’ off Suppositories Moggies speed, cocaine, crack etc... 924 BRITISH DENTAL JOURNAL | VOLUME 227 NO. 10 | November 22 2019 © The Author(s), under exclusive licence to British Dental Association 2019  GENERAL practitioners and may have complications Fig. 1 A diagrammatic representation of a detailed drug history such as alcohol-related liver disease, the most severe of which may require liver transplants. Complications of liver disease particularly relevant to dentistry include impaired hepatic What drug/drugs? (Including alcohol) metabolism of metabolites from conscious sedation drugs as well as local anaesthetics (amides), immunosuppression and post- Any help being When did they given fro drug start/stop using operative bleeding risks. 21 Additionally, habit the drugs? alcohol can cause a myriad of mental health disorders (eg, anxiety, depression and anti- social behaviour) either during intoxication Drug history or withdrawal. On the more extreme end of the spectrum, it can lead to alcohol induced Admissions to psychotic disorder (AIPD) that may impact on Frequency of hospitals for drug the patient’s capacity and therefore consent and drug use? related condition safeguarding issues may arise. Any medical conditions relating Pre-assessment considerations for to use drug use intravenous conscious sedation in relation to drug misuse Prior to carrying out intravenous conscious sedation in a patient using recreational drugs alcoholic liver disease are classified as ASA in inadvertent over-sedation, where a sedation it is important to undertake a comprehensive Grade 4. With such patients, it is important practitioner pursues a suitable level of sedation pre-assessment in relation to drug use. This to understand how hepatic impairment relates to allow treatment to continue. Secondly, involves a detailed drug history ensuring that to the metabolism and removal of sedatives.24 some drug dependant patients will develop the patient fully comprehends the questions Dental professionals should be mindful cross tolerance. Essentially this means that and encouraging them to be explicitly clear that not all patients will declare their entire tolerance to one drug may result in tolerance in their answers. Due to several recreational medical history. If one suspects a patient may to another that acts in a similar way. It has been drugs having various names for the same not be disclosing their full medical history, shown that cross tolerance can exist between drug, it is important to have a knowledge of the importance and relevance of disclosing benzodiazepines and alcohol. The consequence this as patients may only know one name for a issues should be emphasised for ensuring of this is that a patient becomes very difficult particular drug. A table of alternative common safe treatment and prevention of harm. If to sedate as normal doses of sedative do names for some popular recreational drugs is there are further difficulties, permission not work.26 For the dental practitioner or shown in Table 1 below. Points to include in the should be sought to contact the patient’s anaesthetist, this can be very challenging in drug history are shown in Figure 1. general medical practitioner (GP) to obtain terms of maintaining safe sedation practice Being aware of the drug history of a patient a comprehensive medical and drug history, while achieving adequate patient response. allows safe management tailored to their although even then the GP may be unaware of needs. In a colonoscopy study by Patel et al., any substance misuse. Management of recreational drug it was shown that although people with a use and sedation history of alcohol misuse may be difficult to Drug tolerance and conscious sedate, chronic opioid users are certainly more sedation It is important to appreciate the potential difficult to sedate.23 Understanding a patient’s relationship between substance abuse and drug history and predicting their response For dental practitioners and anaesthetists, it is conscious sedation in order to correctly to sedation, can help determine which important to be aware of the possible effects manage these patients. For cannabis users, environment is most suitable for providing of recreational drugs with different sedative few studies exist regarding the interaction care or whether or not a patient is a suitable agents. It has been hypothesised that some between cannabis and sedative agents. candidate for conscious sedation at all. In turn, drugs (for example alcohol, amphetamines However, a study by Flisberg et al.27 suggested when assessing a patient for conscious sedation, and opioids) can lead to a tolerance to certain an interaction between cannabis and a sedative an in-depth medical history is also important. sedative agents. This suggests that sedating agent (propofol). Cannabis users in this study For patients with co-morbidities related groups of patients taking said drugs may be needed a significantly higher dose of propofol to recreational drug taking, it is important difficult.25 before a laryngeal mask could be inserted to ascertain their ASA Grade (American There are two important implications of drug compared to the non-cannabis group.27 This Society of Anaesthesiologists) and how the tolerance. Firstly, a standard dose of sedative does suggest that there may be a correlation use of conscious sedation may affect their agent is not always enough to sedate a patient between the use and cannabis and difficulty in wellbeing. For example, patients with severe who is drug dependant and this could result sedating such patients. BRITISH DENTAL JOURNAL | VOLUME 227 NO. 10 | November 22 2019 925 © The Author(s), under exclusive licence to British Dental Association 2019  GENERAL In turn, it is important to remember that Table 2 Recreational drugs and oral manifestations33,34,35,36,37,38 other commonly used drugs such as tobacco, Drug Oral manifestation can have serious oral manifestations. It has been widely evidenced that tobacco smoking Cocaine Xerostomia can have an adverse effect on periodontal Ecstasy Xerostomia, Tooth surface loss health and lead to an increased incidence of Tobacco Periodontal disease, Oral squamous cell carcinoma oral squamous cell carcinoma formation. With regards to periodontal health, tobacco smoking Alcohol Xerostomia, Dental trauma is known to cause vasoconstriction of blood vessels supplying the periodontium. This in The cannabinoids contained in cannabis It would seem sensible to reduce doses of turn can produce a false positive effect of a stable are fat soluble and therefore accumulate in sedative in order to prevent drug toxicity. In periodontium due to the absence of bleeding fatty tissues. The average half-life of cannabis dental sedation with midazolam, for those with on probing.35 Moreover, as a lifestyle factor, is estimated to be between 28 and 56 hours hepatic impairment, the standard protocol those who smoke tobacco are at a 47 times in regular users of the drug; however, once is modified to half the dose of midazolam increased risk of oral cell squamous carcinoma cannabinoids enter adipose tissue it has been increments and double the time between formation compared to non-smokers.36 This risk estimated that there is a prolonged half-life of administering increments. This allows a greater is increased when alcohol and chewed tobacco approximately 7 days.28,29 understanding of the effect of each increment are included (relative risk × 35). Kuczkowski discussed that cannabis use can before administering further doses, enabling a Many recreational drugs lower inhibitions induce tachycardia and myocardial depression. safe level of sedative agent to be given, in order and can alter the cognitive ability of individuals. It is suggested that due to this, cannabis may to reduce the risk of drug toxicity. Metabolism Dental trauma can be as a result of fights, falls or compound the effects of anaesthetic agents and elimination of the sedative may other accidents as a result of recreational drug and thus affect arterial pressure and heart additionally be impaired, increasing recovery use. In alcohol abusers, one of the most common rate.30 Some practitioners request that patients times and this should also be considered when dental side effects is trauma.37 This trauma can who use cannabis refrain from doing so for a treatment planning. include luxation and avulsion injuries, leading period of time (up to 72 hours) before having to the need for urgent dental care. It has been conscious sedation for a dental procedure to Oral manifestations of substance stated by Bullock, that substance abuse should reduce the likelihood of drug interactions.31 abuse be considered in all patients that present with Alcohol dependence may affect the provision dental trauma.38 Table 2 demonstrates different of conscious sedation due to the damaging The effects of recreational drugs on the orodental recreational drugs and their oral effects. long-term effects of alcohol on the body. tissues must be appreciated. Not only can In England the current mortality rate from recreational drugs affect conscious sedation Non pharmacological anxiety alcoholic liver disease in people under 75 years techniques, but one must also consider the oral management of age is 8.8 per 100,000 population.32 Patients side effects of recreational drug use. An example with a diagnosis of alcoholic liver disease of the oral manifestations of substance abuse In anxious patients who have experienced usually require a higher level of management can be seen in cannabis users. Individuals who substance abuse, the likelihood of conscious not commonly found in primary care frequently use cannabis and ecstasy can develop sedation working effectively is not entirely environments, and this may in part explain why xerostomia.33,34 This can cause multiple oral predictable. In turn, opting for a general these individuals are referred for management side effects including an increase in halitosis, anaesthetic for these patients is often in secondary care and hospital settings. difficulties in swallowing and tasting foods and an undesirable; especially when the risk/benefit When assessing patients with alcoholic liver increased caries risk. The management for these ratio is unfavourable. Therefore, consideration disease for conscious sedation, hepatic function particular patients should include prescription of must be given to other, non-pharmacological must be considered. For milder impairments, saliva substitutes and preventative methods such methods of anxiety management. liver function tests via the patient’s GP or as fluoride varnish application, along with regular Prior to understanding which method of hospital practitioner may be sufficient and review appointments. anxiety management is suitable, it is important treatment can proceed with caution. Patients Another oral manifestation includes the to consider the severity of anxiety that a patient with severe hepatic impairment should be development of tooth surface loss. Many may have. The Modified Dental Anxiety Scale under the care of a local hepatology team recreational drugs (ecstasy in particular) can (MDAS) is a measure of anxiety that uses five and advice from them should be sought cause individuals to grind teeth excessively. questions. This scale is simple to use and can be regarding appropriate drug administration and This was demonstrated by Milosevic et al. In used for adults, with an amended version created modifications to standard sedation protocols. this study, 18 participants who were ecstasy for children; the Modified Child Dental Anxiety As an aside, liver function is also important to users demonstrated tooth surface loss into Scale (MCDAS). As a simple screening tool, surgeons for surgical procedures. Coagulation dentine, while only three non-users had signs MDAS provides an accurate measure of anxiety studies and thrombocytopenia assessment of this. The study also described jaw clenching and is widely accepted by dentists in the UK.39 (FBC) need to be undertaken to ensure as being potential factor in causing tooth For patients with differing levels of anxiety, adequate precautions are made for individuals surface loss; notably of the occlusal surfaces techniques for anxiety management commonly at risk of post-operative haemorrhage. of teeth.34 include the use of distraction. As a non-invasive 926 BRITISH DENTAL JOURNAL | VOLUME 227 NO. 10 | November 22 2019 © The Author(s), under exclusive licence to British Dental Association 2019  GENERAL technique, the use of audio or visual distraction the systemic consequences of substance abuse 20. NHS Digital (Great Britain). Statistics on alcohol: England, 2017. 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Using memory certain recreational drugs may have adverse Available online at https://www.nhs.uk/Livewell/alcohol/ restructuring strategy to enhance dental behaviour. Int effects on different sedative agents. Moreover, Pages/alcohol-units.aspx (accessed 12 January 2019). J Paediatr Dent 2007; 17: 439–448. BRITISH DENTAL JOURNAL | VOLUME 227 NO. 10 | November 22 2019 927 © The Author(s), under exclusive licence to British Dental Association 2019