substance missue Flashcards
role of GDP
- Recognise substance missuse in pts and colleagues
- Emergency dental tx
- Comprehensive care
- Signpost to addiction services
- Referral to hospital services
- Maintain dental health during rehabilitation
- Provide stigma and judgement free dental care
- Have empathy and awareness of potentially manipulative behaviour
- Realistic tx plan
how to recognise substance missuse
- Loss of reliability
- Mood and behavior changes – present defensively, angry or challenging
- Impaired ability to drive
- Subjective symptoms with no objective evidence (e.g. presenting with trigeminal neuralgia but not wanting to get dx or special investigation just painkillers)
- Requesting specific drugs
- Progressive deterioration in personal appearance and hygiene
- Tremors
- Constricted or dilated pupils
- Puncture marks, scars or pigmentation over veins
possible barriers to dental services for substance users
- Professionals’ negative perception of these people
- Pathways are not established for access
- Low priority of oral health compared with drug use
- Fear of dentists including needle phobia,
- Self-medication
- Chaotic lifestyles.
- Fear judgment or prejudice from the dental team
- Poor attendance and compliance
- Cost: frequent changes in or loss of employment
- Behavior
facilitator to access for substance users
If enrolled in an addiction program, the patient may have a key worker assigned to them
Key workers can encourage attendance, bring and accompany patients to appointments.
history taking in substance use
Detailed history is essential in assessing risk and patients motivation for treatment planning
Sensitive questioning without judgement is required regarding alcohol consumption: including number of units consumed per week; the use of drugs – prescription or recreational – along with quantity and duration; smoking status and living arrangements
medical conditions assoc with substance misuse
- Increased rates of infection (TB, BBV, STI)
- General health neglect
- Oral health neglect
- Chronic liver disease in alcohol abuse – impaired drug metabolism and bleeding risk
- Blood borne viruses in IVDU
- Infective Endocarditis SDCEP
- Venous thromboses
substance misuse pts may be at risk of
SHx
- Assaults, theft and prostitution can be used to fund a drug addiction
- Maxillofacial injuries
- Sharing of needles results in BBV
- Family disruptions
- Change in or no address
- Prison
- History of attempted rehabilitation/in hospital detox
- Chaotic lifestyle
consent and substance misuse pts
Drug users share risk factors for mental health issues and many of these patients may have fluctuating capacity
Capacity is unlikely when the patient is under the influence of drugs or alcohol
Postpone treatment
Capacity assessment
* Act
* Make
* Communicate
* Understand
* Remember
Alcohol related brain damage (ARBD) encompasses a range of conditions, including Wernicke’s encephalopathy (acute episodes pt confused, impaired consciousness and mobility issues), if delayed tx can cause Korsakoffs syndrome – permanent deficit
capacity assessment involves
- Act
- Make
- Communicate
- Understand
- Remember
AMCUR
alcohol and capacity
Alcohol related brain damage (ARBD) encompasses a range of conditions,
* Wernicke’s encephalopathy (acute episodes pt confused, impaired consciousness and mobility issues),
* if delay in tx can cause Korsakoffs syndrome – permanent deficit
tx plan for substance misuse pts
Assess patient expectations prior to planning
Have a flexible approach: the patient may present with unexpected symptoms requiring additional treatment during a course of planned treatment
Initial Stabilisation phase often required: remove active caries and place provisional restorations in a quadrant approach. Extirpate and temporise teeth that require endodontic treatment
All management should include: diet and oral hygiene advice, high strength fluoride tooth paste, fluoride varnish, alcohol free fluoride mouthwash, tooth mousse, sugar-free chewing gum
Keep treatment as simple as possible during active substance misuse: ART and use of SDF
pain control and LA in substance misuse pts
This can be challenging due to LA resistance (opiod users) and anxiety
Substance dependent patients often have low pain thresholds
Pain severity is an objective experience – each patient must be treated carefully and sensitively.
cannabis and LA
LA with adrenaline can prolong acute tachycardia
alcohol and LA
care with LA that is metabolised in the liver (keep dose to minimum)
even 2 cartridges can trigger CNS toxicity signs in severe liver disease
avoid IDB - coagulation defect
anxiety management in substance misuse pts
Behavior management techniques can alleviate anxiety, establishing trust and make the patient feel understood
Inhalation is the safest type of sedation – very little impact systemically and no escort required
Patients may have developed a tolerance to effects of sedative drugs and require large doses for adequate anxiolysis to be achieved (inappropriate in dental setting)
Alcohol and opioids have a synergistic effect with sedative agents and so IV sedation should be avoided if the patient is using these substances
* IV Sedation may be an option for the patient in rehabilitation; however, it should be used with caution and may require referral to anaesthetist led services.
GA and IV Sedation can trigger relapse – use with caution(last resort)
Venous access may pose a difficulty due to collapse of veins in a patient with history of intravenous drug use.
Disulfiram inhibits metabolism of benzodiazepines and leads to increased sedative effects if used together - AVOID
