Opioids, it’s Overdose, Dental repercussions and management in Dentistry

Opioids are the opium like substances/drugs that acts on the opioid receptors in our body. Medically they are prescribed for managing chronic, moderate to severe pain and for anesthesia. However there is potential for its addiction and misuse. Nowadays, few people ( mostly younger generation) use it for recreational purposes to bring euphoric effects. This article is focused primarily on use, misuse (overdose and abuse) and management of opioid drug overdose only and does not include any information on other controlled substances that leads to abuse or overdose such as cannabis, LSD, cocaine, amphetamine like stimulants, tobacco chewing, smoking, alcohol drinking and any other illicit drugs.

Opioids are included in Schedule 2 & Schedule 3 of controlled substances category of narcotic drug classification under the controlled substance act.

Which drugs are included in opioids group and how are they classified?

Following is the classification of opioid drugs :-

Natural opioids: Morphine, Codeine, Thebaine

Easters of Morphine: Diacetyl morphine, Nicomorphine, Dipropanoylmorphine, Desomorphine, Acetyl morphine, Dibenzoyl morphine.

Semi synthetic opioids: Hydromorphone, Hydrocodone, Oxycodone, Oxymorphone, Ethyl morphine, Buprenorphine.

Fully Synthetic Opioids: Fantanyl, Pethidine, Methadone, Tramadol, Levorphanol, Topentadol, Dextropropoxyphene.

Endogeneous opioid peptides: ( produced naturally in the body) Endorphins, Enkephalins, Dynorphins, Endomorphines.

Note: 1)Heroine is also an opioid but it is illegal to use in any form.

2) Dextromorphan and its metabolite Dextrorphan have no opioid analgesic effect at all, despite its structural similarity to other opioids. Instead they are used in over-the-counter cough suppressants because they are NMDA Antagonists and Sigma 1&2 receptor agonists.

3) Currently, Nalbuphine remains the only opioid analgesic in the U.S that is not a controlled substanced under the controlled substance act. It was approved for marketing in U.S in 1979. It is an opioid agonist-antagonist which is chemically related to widely used opioid antagonists Naloxone and Naltrexone and potent opioid analgesic Oxymorphone. It is available in 2 concentrations 10mg and 20 mg per ml Nabuphine hydrochloride.

4) Loperamide ( Immodium) is an opioid but it does not penetrate the CNS like other opioids such as Codeine. Thus, it can be sold over the counter. It is an anti-diarrheal agent which act on intestinal muscle to inhibit peristalsis.

Loperamide used to be a prescription drug and a controlled substance in the same class as cocaine and methadone. The F.D.A approved it in 1976 and it became the over the counter drug in 1988. It has some potential for addiction if used in larger quantities for sustained period of time. But it is not a controlled substance under controlled substance act. There is no known evidence of drug abuse.

For medical use, Some of the Opioid Drugs (with various degrees of potential for dependence /addiction) are included in the medications under the following brand names:-

Oxycontin, Percocet, Palladone ( taken off market 7/2005), Vicodin, Percodan, Tylox, Demerol etc.

Heroin ( used for recreational and euphoric purpose) is sold with street names:- Smack, Horse, Brown Sugar, Dope, H, skag, skunk, white horse, china white, cheese ( with OTC cold medicine and antihistamines).

Opioid use in Dentistry:

Although the primary pain medication of choice remains NSAIDS and acetaminophen, now-a-days opioids prescriptions have increased multiple folds. In United States, family physicians prescribe 15% of the immediate release opioids, while dentists prescribe 12% of immediate release opioids. Most frequently abused prescription opioids are immediate release (IR) opioids particularly hydrocodone and oxycodone. In a survey done by ADA, it was found out that 64% of dental surgeons’ choice of opioid prescription was hydrocodone with acetaminophen. On an average 20 tablets were prescribed, although the instruction for this prescription was “as needed for pain”. The narcotics prescribed from highest to lowest are hydrocodone followed by oxycodone then by codeine and later by tramadol. Other opioids are also used to certain extent based on availability. Usually they are prescribed in combination with acetaminophen or other NSAIDS.

Opioids have been prescribed for following reasons in dentistry:

After 3^rd molar extraction for pain relief.
Chronic , severe dental pain of unknown cause
Pain associated with oral cancer
Chronic pain for non-cancer reasons such as inflammatory conditions like arthritis pain, TMJ pains (after other treatment modalities have not been effective). Note: Opiates do not have anti-inflammatory properties.
After surgeries like orthognathic surgeries and after fractures reduction and splinting.
For burns patients. Recent research has shown that morphine and related opioids have peripheral effects as well due to the newly discovered opioid receptors on peripheral sensory nerves. In some cases morphine and related opioids have been used as topical analgesics. But this is still under extensive research.
To produce analgesic effects as they are very effective analgesics.
They suppress the cough so used prior to surgeries as antitussive.
When used as pre-anesthetic medication, opiates permit reduction in amount of general anesthesia required for surgical anesthesia.

However long-term use of narcotic analgesics can lead to physical dependence, tolerance and addiction. It is absolutely essential and critical to find out about the patient’s potential of dependence or abuse of the prescribed drugs. Dentist’s judgment in good faith plays a vital role. Detailed investigation should be done by asking the patients to fill out the form containing the questionnaire before the beginning of the treatment to diagnose potential dependence and abuse.

Overall health related Side Effects of opioid consumption in large amounts:-

Common side-effects include :

Sedation, Somnolence/ Drowsiness, Dizziness, Nausea, Vomiting, Constipation, orthostatic hypotension, mental clouding, delayed response for any stimulus, Respiratory depression, Depression of cough reflexes, agitation, Physical and psychological dependence and addiction.

The most significant and commonly observed adverse reaction is respiratory depression.

Less common side effects:

Delayed gastric emptying, Hyperalgesia, Immunologic and Hormonal Dysfunction, Muscle rigidity and myoclonus.

Opioid Over dosage:

Due to its potential for dependence and addiction, now-a-days there is increased number of cases of opioid over dosage. It is also seen that opioids used for recreational or euphoric purposes drags the people using them towards addiction resulting in opioid over dosage. Which is why they are included in the controlled substances in the controlled substance act and it is mandatory for doctors to get a specialized license to prescribe these drugs to their patients under strict regulations and monitoring.

Currently United States is suffering from opioid overdose epidemic. Misuse and addiction of opioids like prescription pain killers, heroin, synthetic opioids like fentanyl is a serious national crisis. Around 4-6% who misuse prescription opioid transition to Heroin. Because of misuse of pediatric dosage of prescription opioid by patients and doctors have raised the devastating consequence such as rising incidence of neonatal abstinence syndrome due to opioid use or misuse during pregnancy. Increase in use of drugs via injections have increased spread of HIV and Hepatitis C.

Chronic opioid overdose can lead to clouding of memory, memory loss, permanent damage to memory, seizures, delayed response of a patient to any stimulus, psychological problems like substance use disorder, bipolar disorder, cardiac complications, cirrhosis of the liver, prolonged respiratory depression and if goes un-noticed then death. People with opioid overdose usually show symptoms of spectrum of addictive behavior such as risk-taking behavior, carelessness, absence of time management , poor oral hygiene and others.

Oral / Dental Repercussions of opioid drug abuse:-

Oral health care is often a neglected aspect by a drug addict. There are many related oral and dental repercussions of opiate overdose.

Teeth:- Grossly decayed teeth with extensive caries, Generalized tooth decay covering most of the dentition. In this case, the caries is mostly initiated as cervical and smooth surface lesions. As the opioid abusers neglect proper dental care, the caries extent increases and eventually they end up having grossly decayed teeth. Also resulting in tooth loss or teeth requiring extractions , for example ,as required in cases where root stumps/ root tips are the only remaining parts of a particular tooth in the oral cavity.

Pain: Pain perception in these patients is reduced due to the effects of opioids, as a result of which they do not feel pain until it is exacerbated to a point where the tolerance level has exceeded. Also these patients have delayed response to any stimulus. Thus most of the caries detection tests are ineffective and cannot differentiate between initial caries and advanced caries or pulpal involvement, if the patient comes into office for a routine dental checkup.

Periodontium:- Periodontal disease is evidently seen in opioid overdose cases due to the poor oral health and poor oral hygiene. Adult periodontitis is commonly seen both in acute and chronic forms. Reports have also been found stating the presence of necrotizing gingivitis. It is also observed that these patients lack hygiene habits such as flossing in between teeth.

Salivary Glands:- It is commonly seen that prolonged use or abuse of opioids have resulted in salivary gland hypo function over the period of time. Xerostomia, difficulty in swallowing food because of less salivary lubrication in the oral cavity and Esophagus.

Oral Mucosa:- In initial stages, red and inflamed mucosa is seen but then in later stages severe Mucositis followed by ulcerations can be seen.Mucosal dysplasia is also observed in few cases. Burning mouth syndrome is commonly seen. In later stages, mucosal infections are evident as a result of excessive use of opioid, the inflammatory response is altered and poor oral hygiene and plaque-calculus provides niche for bacterial harbor and multiplication leading to mucosal infection in the area where the mucosa comes in contact with the plaque on the tooth or root.

Other Findings:-

Bruxism is most commonly seen symptom in the oral cavity of the opioid abusers especially during nights.

Altered and diminished taste sensation and eventually loss of taste sensations are also reported by the opioid abusers.

Candidal infections in the form of Oral thrush has been observed in several cases.

If the patient is diagnosed with HIV or Hepatitis C , respective oral clinical signs and symptoms can be found in the oral cavity.

Management of Opioid overdose Cases in Dental setting:-

Recognize overdose cases:

While filling the initial form at the front desk in the dental office, an additional form must be requested to be filled by the patient and that form must contain the detailed information about medications. Following information can be included in the form (the below is just an example template and not the standard questionnaire)-

1) Type of medication previously taken

2) Duration of medication and when was it last taken?

3) Refills duration and requirement

4) Any willingness to continue the same medication

5) Allergy to any medication

6) Reactions ( positive , negative) to any medication

7) Have you taken any self prescribed medication? If yes what are the names and what is the duration and how many? When was it last taken?

8) History of smoking – Do you smoke? How much per day? For how many days?

9) Alcohol history – Type of alcohol, amount consumed each time and frequency.

10) If the patient is on chronic pain medication for more than 6 months then do they have a license to use that prescription opioid?

11) What do you do to relieve your pain of any kind?

This form gives us a rough idea whether or not the patient has potential for drug misuse. But the above questionnaire is not the standard template for use. Having the history of prescription of opioid pain medication increases the risk for opioid overdose and develop opioid use disorder.

Screening Programs:

Once the dental team suspects that the patient has drug misuse potential , it becomes our responsibility to encourage the patient to undergo screening for opioid use disorder. There are various screening programs provided by the government for adolescents and adults. We need to inform them about the benefits of the screening programs and encourage them to get screening done.

Screening must also be encouraged for HIV and Hepatitis C.

ADA encourages dentists to seek continuing education in screening, brief intervention, and referral to the treatment for patients who may be at risk for substance abuse and are prone to addiction.

Case Selection: Case selection usually plays a crucial role in overall care for the patient and ease of treatment for the dentist/ doctor. Dental professionals usually have a negative attitude towards opioid abuse patients and are unwilling to provide the necessary care and treatment to the addicted dental patients owing to patent’s negligence towards the oral care. There is a chance, patients won’t return for the follow-up appointments or delay the appointments for no valid reasons. Thus can result in financial as well as time loss to the dental office.

Dentists must remember that we all have taken Hippocratic oath while obtaining a dental degree. Although we make a careful choice of patients, we must make sure that we provide the appropriate dental treatment to addicted patients too. It is necessary that we don’t refuse them the oral care, as some of them will be suffering from serious health conditions. These patients are not able to cope up with their daily work, they lose their job and end up having financial crisis. It becomes our responsibility to provide them proper guidance and help them in which ever possible way we can, especially in oral care.

Multidisciplinary approach:

Multidisciplinary approach is the key in management of these patients.

An initiative called as “HEAL” ( Helping to End Addiction Longterm) has been launched in April 2018 in USA by the National Rx Drug Abuse and Heroin Summit. This initiative is an aggressive, trans-agency effort to speed scientific solutions to stem the national opioid public health crisis.

SBIRT is an evidence based practice used to identify , reduce and prevent misuse and addiction of alcohol and illicit drugs. It has 3 basic components screening, brief intervention and referral to treatment.

Funds for the treatment should be raised to help these patients combat financial crisis and get the necessary treatment.

Dental team must consult with the primary care team and addiction control team to keep a track of the patient’s health. Consultation with primary care team and addiction control team and its approval is essential before prescribing any opioid medication for dental / oral pain management. Within dentistry, different disciplines are encouraged to collaborate to address the oral problems to get a better result. Dentist must avoid prescribing opioids until that remains the only option available.

Management in Dental setting:

Only licensed doctors should be allowed to prescribe any opioids and must be monitored thoroughly and refills should not be permitted without the brand new prescription from a licensed doctor.

Management of opioid emergencies must be done first.

It is necessary that every dental office is well equipped with opioid antagonists and emergency response kit. Everyone in the dental office must be trained to manage emergencies.

Following opioid antagonists can be prescribed immediately once an emergency is observed:-

Naloxone ( Brand names-Narcan, Evzio)
Nalmefene ( Selincro)
Naltrexone ( Revia, Vivitrol)
Methylnaltrexone ( Relistor)
Naloxegol ( Movantik, Moventig)

Most commonly used opioid antagonist is Naloxone (Narcan, Evzio). Naloxone, Nalmefene, Naltrexone are centrally acting while Methylnaltrexone and Naloxegol are peripherally acting opioid antagonists and are used to treat constipations caused by opioids. Methylnaltrexone and Naloxegol does not cross the blood brain barriers in sufficient quantities for them to have central effects. Thus they can be used for reversal of loperamide overdose side effects. Naltrexone is usually used in treatment of alcohol and drug abuse relapse cases.

Treatment of specific side effects must be done first and precautions must be taken to prevent any further adverse reaction. We must try to restore the functional ability of the mouth.
Reduce the source of pain, surgery, chemotherapy etc.
Non- opioid medications such as acetaminophen, NSAIDS, Cyclooxygenase inhibitors 2 ( COX-2 inhibitors), selected anticonvulsants, selected antidepressants ( particularly tricyclic,serotonin or nor-epinephrine reuptake inhibitors) should be preferred over opioid analgesics. Please also consider the liver capacity of the patient and overall health of the patient before prescription. Because all these medications come with own side effects.
If at all it becomes necessary to prescribe opioid then following precautions must be taken: reduce the systemic opioid dosage, alter the systemic opioid route of administration, an auxiliary non-opioid analgesic must be added to the prescription, prescribe different systemic opioids at a regular interval and with different route of administration ( for example – transdermal route).
ADA recommends to register with the state and use the state prescription monitoring program to promote appropriate use of controlled substance for legitimate medical purposes.
Most important is to educate the patient with the side effects, potential drugs abuse, if self prescribed interactions between different medications and the lifestyle alterations and disadvantages. Discourage the misuse and abuse of any drug.
Treatment must be provided in order to improve the esthetics and function ability of the patient’s mouth. This will boost patient confidence in smiling and to a certain extent help patient to communicate better with the society. This will eventually help the patient’s mental health and build a better identity for themselves.

Conclusion:

It’s very important to identify and stop illicit use of drugs. It is crucial to identify the drug dependence, tolerance, addiction and its abuse. People surrounding the victim including family, friends, bystanders, doctors and their dentists must be able to recognize the problem, bring it to the notice of the governing authority like centers for disease control and help the victim to overcome the difficulty. A multidisciplinary approach will help to improve the overall health. Dentists play an important role in bring back patient’s smile and contribute towards his/her overall health including mental health. Honoring Hippocratic oath, dentists must try to have a positive attitude towards these patients and should not deny them of any oral care. Dentists can contribute to tackle national opioid crisis. Funds can be raised by charity organisations to enable these patients get the necessary treatment. But mainly it is patient who needs to put in efforts to fight the problem and deter the opioid addiction and overdose. There are challenges but consistent dedication and willingness to cure will help them build a “non-addict” identity and restore good health.