By Genni Burkhart
Dr. Feck, a co-founder of DOCS Education and lead faculty member, is a dentist, mentor, educator, author, and talented speaker. He also founded Sunrise Dental Solutions in Lexington, KY, and recently published the book, "The Prosperous Dental Practice: A Guide to Building Financial Success."
A Timely and Open Discussion
After California legalized medical marijuana (aka cannabis) in 1996, 39 states and the District of Columbia have since legalized it for medical use, while 21 states and the District of Columbia have legalized cannabis for recreational use.
Following in the footsteps of cannabis, there's a growing movement (from both sides of the political aisle) to decriminalize and legalize psychedelic drugs known as psilocybin (magic mushrooms) or LSD. In fact, Oregon (in 2020) and Colorado (in 2022) legalized psilocybin and microdosing LSD under certain conditions.
Since the 1960s and 1970s, certain recreational drugs have experienced a psychedelic renaissance. Back then, psychedelics carried a negative stigma that kept them out of mainstream healthcare – and conversations. However, thanks to technological advancements in medicine and the increased popularity of having health benefits, their negative stigma has dissipated, as has the suppression of discussing them. As attitudes toward these drugs continue to evolve, patients are more likely to share with you that they're using them.
Therefore, the dental team providing safe sedation must have a working knowledge of their patient's medications and substances, whether prescribed or otherwise. The reason for this is that recreational drugs impact the primary goals of sedation dentistry, which are:
- To keep patients safe.
- Ensure the comfort of patients while receiving care.
We'll review the key points of Dr. Feck's "Recreational Drugs and Dentistry" webinar and explain how you can watch this online course to earn 1.5 CE hours.
Alcohol contains ethanol, produced through fermentation of sugar-containing sources, of 3-50%. Thirty-three percent of people worldwide consume alcohol, and 86% of Americans have consumed it in their lifetime. Knowing a patient's alcohol intake before a procedure can give you helpful clues, such as how much they'll bleed during the surgery. Alcohol also acts as a competitive inhibitor of other medications, making other drugs more potent.
Pharmacodynamic: Alcohol enhances the effects of the medication, particularly in the CNS (for example, sedation medications). Combining alcohol with other CNS depressants increases the risk of overdosing.
Many medications interact with alcohol, including antibiotics, antidepressants, barbiturates, benzodiazepines, Warfarin, anticonvulsants, and more. Therefore, sedation candidates should not consume alcohol the day before and the day of the sedation appointment. Furthermore, alcoholics (those who are physically dependent) and not in successful recovery are not acceptable candidates for sedation in the outpatient setting.
Federally illegal but legal state-by-state in the U.S., it's crucial for dentists to realize that cannabis use (either recreational or medical) is highly common. However, it's also something dentists shouldn't assume patients will voluntarily reveal themselves. Instead, medical professionals should be forthcoming in asking the question. Given its commonality, patients now feel more comfortable openly discussing cannabis use with their doctors once they feel it's safe and confidential to do so.
Tetrahydrocannabinol (THC), the psychoactive component of cannabis, causes euphoria, an altered sense of time, difficulty concentrating, and impaired short-term memory and coordination. Its impact on sedation is relaxation, antiemetic, and increased heart rate. When combined with sedative medications, some science suggests cannabis will worsen nausea, while others suggest it will lessen it. However, nausea and vomiting in sedation patients can be dangerous, so precautions are advised. Additionally, despite being a CNS depressant, cannabis can cause tachycardia, discomfort, and a potentially hazardous situation in sedation patients.
Cannabis Use and Sedation Patients:
- Dentists should ask patients how long they've used cannabis. How often? How much? And in what form?
- Evaluate for respiratory disease.
- If they are a heavy or long-term user, ask about nausea and vomiting and consider using antiemetic prophylactically.
- Patients must withhold use on the day of sedation.
- Whenever possible, keep sedation appointments to three hours or less.
- Monitor HR closely when using vasoconstrictors.
- Not psychoactive compared to THC.
- May reverse THC intoxication or sedation.
- Inconclusive data to support its use in the treatment of anxiety or pain.
- Epidiolex was approved in 2018 by the FDA for treating two different epilepsy disorders.
- Same drug interactions as THC.
- Same treatment recommendations with sedation as with THC.
Patients should not use recreational CBD and cannabis on the day of the sedation appointment. However, medically approved cannabis and CBD should be treated like every other medically prescribed drug and should be taken on the day of the appointment.
Lysergic Acid Diethylamide (LSD)
- More commonly known as "Acid."
- Potent psychedelics are used primarily as recreational drugs.
- Causes mental, visual, and auditory hallucinations.
- Long duration of action of up to 20 hours.
- The mechanism of action is not precise, although agonism of serotonin and dopamine receptors is suspected.
- A low dose to increase creativity and productivity is called microdosing.
- Considered to have low addiction potential for use.
- LSD is designated as a Schedule 1 drug. (Federally illegal for medical and recreational use)
Side Effects Include:
- Cardiovascular stimulation.
- Respiratory impairment.
- Nausea and vomiting.
- Psychological aberrations.
LSD Use and Sedation Patients:
- CNS depressants tend to dull the effects of LSD.
- Benzodiazepines treat LSD overdose as they decrease central and peripheral sympathomimetic drug effects.
- Mixing lithium, TCAs, or CNS stimulants with LDS can be lethal.
- Providing sedation to any patient under the influence of a psychedelic drug is contraindicated, highlighting how the pattern of LSD used must be determined.
- The half-life of LSD is 3.6 hours. At 14.4 hours, 90% of the drug is expected to have been eliminated.
Dentists should ask about this drug use, specifically if practicing in Colorado, Oregon, or California. If the patient answers yes, have them withhold use the day before and the day of the appointment. Monitor vasoconstrictors carefully and proceed judiciously.
Psilocybin (Magic Mushrooms)
Psilocybins, aka "magic mushrooms," are substances obtained from certain types of naturally occurring mushrooms. These mushrooms are consumed by ingesting fresh or dried fruit bodies that cause hallucinogenic effects. Activity occurs once it is metabolized into psilocin, which acts on serotonin receptors in the brain. Magic mushrooms have 2-6 hours of action and do not cause physical dependence.
- Pupil dilation.
- Panic attacks.
- LD50 is 280 mg/kg or 150% of the LK50 for caffeine.
Psilocybin Use and Sedation Patients:
- Patients should refrain from using it on the day of sedation.
- As a precaution, use vasoconstrictors judiciously and monitor closely.
- Due to additive CNS depression, administer sedation medications low and slow.
According to the Substance Abuse and Mental Health Services Administration (SAMHSA), more than 59.3 million people (ages 12 or older) used "illicit" drugs in 2021. While opinions can vary on recreational drugs, as dentists, it's crucial to know all the drugs (legal or otherwise) your patients are taking. Another aspect to consider is how recreational drugs interact with other medications, mainly analgesics and sedatives. Dentists must be aware of the patient's drug use so their heart rate can be more closely monitored when using vasoconstrictors.
Scientific support and additional resources are available here.
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In the full online course, Dr. Feck reviews additional recreational drugs – such as ketamine, methamphetamines, and fentanyl – and their impact on dentistry. This online course qualifies for 1.5 CE hours. Members and trial members get free access for the first 60 days.
DOCS Members can download and watch this course anywhere using the DOCS APP. Get it on Google Play or the Apple Store. Sign up or log in to watch the entire online course and complete the quiz to earn 1.5 CE credit here.
Author: With over 13 years as a published journalist, editor, and writer Genni Burkhart's career has spanned politics, healthcare, law, business finance, technology, and news. She resides on the western shores of the idyllic Puget Sound, where she works as the Editor in Chief for the Incisor at DOCS Education out of Seattle, WA.