Drug and Alcohol Abuse

The abusive use of drugs and alcohol is a huge and growing public health problem in the United States, as well as in many other countries worldwide. Drug and alcohol abuse has far-reaching effects on persons engaging in such activity, as well as their families and communities, with a consequent heavy impact on law enforcement, the judicial system, politics, and health care. It is inevitable that dental practitioners will encounter abusers of drugs and alcohol among their patients, and, unfortunately, some practitioners will themselves turn to such abuse. This chapter discusses the effects of drug and alcohol abuse as they pertain to dental management. Another legal drug of abuse, nicotine, is discussed in Chapter 8 .

COMPLICATIONS: Patients who have substance abuse problems may be unable to function in the workplace and have increased risk in hazardous situations, increased risk of liver disease and excessive bleeding, respiratory depression, infectious diseases, overdoses, death, and increased risk of suicide.

Definitions

According to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), of the American Psychiatric Association, a diagnosis of substance abuse requires the recurrent use of a substance over the past 12 months with subsequent adverse consequences (e.g., failure to fulfill a major role at work, school, or home; legal problems; persistent interpersonal problems) or placement of the affected person in high-risk physically hazardous situations. Dependence involves tolerance and withdrawal in addition to certain patterns of drug use, the effect on life activities, and the uncontrollable need for use of the substance despite adverse consequences. Tolerance is defined as either a need for increased amounts of a substance to achieve the desired effect or a diminished effect with continued use of the same amount of the substance. Withdrawal is manifested by a characteristic syndrome emerging upon abstinence from a habitually used substance. There is confusion over the use of the term addiction . Addiction is equated with dependence in the DSM-IV. Some authors, however, advocate separating the terms dependence and addiction, with addiction being a distinct disease characterized by compulsive substance use despite serious negative consequences. Tolerance, dependence, and withdrawal all may occur with addiction but are not necessary for the diagnosis. In addition, addicted persons remain at high risk for relapse long after detoxification and the cessation of withdrawal symptoms.

Alcoholism is a term commonly used to describe a condition of substance abuse focused on consumption of alcohol. A more precise definition, however, has been proposed by O’Conner: “a primary chronic disease with genetic, psychosocial, and environmental factors … often progressive and fatal … characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite future consequences, and distortions of thinking, most notably denial.” It is estimated that as many as 92% of people with alcohol use disorders also smoke tobacco. Gender differences in drug abuse occur, and it is more evident in adults than adolescents. Adult men are two to three times more likely than women to develop drug abuse or dependence disorders and about four times as likely to have alcohol use disorder.

Epidemiology

Illicit drugs of abuse include marijuana and hashish, heroin, cocaine (including crack), methamphetamine and its analogues, so-called club drugs, hallucinogens, and dissociative drugs ( Table 30.1 ). Legally prescribed opioids and sedative–hypnotics are abused when used nonmedically. Alcohol is legal but is abused when consumed inappropriately or in excessive amounts. According to the 2009 National Survey on Drug Use and Health (NSDUH), an estimated 21.8 million Americans 12 years of age and older were current illicit drug users, which is higher than in 2008. This number represents approximately 8.7% of the population. Illicit drug use is highest among young persons 18 to 25 years of age. In a dental practice of 2000 patients, it can be expected that approximately 175 of them abuse at least one type of drug or other substance.

TABLE 30.1
Most Common Illicit Drugs of Abuse
Substance of Abuse Street Names How Administered Acute Effects
CANNABINOIDS
Marijuana Blunt, dope, ganja, grass, herb, joint, bud, Mary Jane, pot, reefer, green, trees, smoke, sinsemilla, skunk, weed Smoked, swallowed Euphoria; relaxation; slowed reaction time; distorted sensory perception; impaired balance and coordination; increased heart rate and appetite; impaired learning, memory; anxiety; panic attacks; psychosis or cough, frequent respiratory infections; possible mental health decline; addiction
OPIOIDS
Heroin Smack, horse, brown sugar, dope, H, junk, skag, skunk, white horse, China white; cheese (with OTC cold medicine and antihistamine) Injected, smoked, snorted Euphoria; drowsiness; impaired coordination; dizziness; confusion; nausea; sedation; feeling of heaviness in the body; slowed or arrested breathing/constipation; endocarditis; hepatitis; HIV; addiction; fatal overdose
STIMULANTS
Cocaine Blow, bump, C, candy, Charlie, coke, crack, flake, rock, snow, toot Snorted, smoked, injected Increased heart rate, blood pressure, body temperature, metabolism; feelings of exhilaration; increased energy, mental alertness; tremors; reduced appetite; irritability; anxiety; panic; paranoia; violent behavior; psychosis or weight loss, insomnia; cardiac or cardiovascular complications; stroke; seizures; addiction
Cocaine—also nasal damage from snorting
Methamphetamine—also severe dental problems
Amphetamine Bennies, black beauties, crosses, hearts, LA turnaround, speed, truck drivers, uppers Swallowed, snorted, smoked, injected
Methamphetamine Meth, ice, crank, chalk, crystal, fire, glass, go fast, speed Swallowed, snorted, smoked, injected
CLUB DRUGS
MDMA Ecstasy, Adam, clarity, Eve, lover’s speed, peace, uppers Swallowed, snorted, injected MDMA—mild hallucinogenic effects; increased tactile sensitivity; empathic feelings; lowered inhibition; anxiety; chills; sweating; teeth clenching; muscle cramping or sleep disturbances; depression; impaired memory; hyperthermia; addiction
Flunitrazepam—sedation; muscle relaxation; confusion; memory loss; dizziness; impaired coordination/addiction
GHB—drowsiness; nausea; headache; disorientation; loss of coordination; memory loss or unconsciousness; seizures; coma
Flunitrazepam Forget-me pill, Mexican Valium, R2, roach, Roche, roofies, roofinol, rope, rophies Swallowed, snorted
GHB G, Georgia home boy, grievous bodily harm, liquid ecstasy, soap, scoop, goop, liquid X Swallowed
DISSOCIATIVE DRUGS
Ketamine Cat, Valium, K, Special K, vitamin K Injected, snorted, smoked Feelings of being separate from one’s body and environment; impaired motor function or anxiety; tremors; numbness; memory loss; nausea
Ketamine—also analgesia; impaired memory; delirium; respiratory depression and arrest; death
PCP and analogues—also analgesia; psychosis; aggression; violence; slurred speech; loss of coordination; hallucinations
PCP and analogues Angel dust, boat, hog, love boat, peace pill Swallowed, smoked, injected
HALLUCINOGENS
LSD Acid, blotter, cubes, microdot yellow sunshine, blue heaven Swallowed, absorbed through oral mucosa Altered states of perception and feeling; hallucinations; nausea
LSD and mescaline—also increased body temperature, heart rate, blood pressure; loss of appetite; sweating; sleeplessness; numbness, dizziness, weakness, tremors; impulsive behavior; rapid shifts in emotion
LSD—also flashbacks, hallucinogen, persisting perception disorder
Mescaline Buttons, cactus, mesc, peyote Swallowed, smoked
GHB, γ-Hydroxybutyrate; LSD, lysergic acid diethylamide; PCP, phencyclidine.
Adapted from the National Institutes of Health, National Institute on Drug Abuse (website), www.drugabuse.gov/DrugPages/DrugsofAbuse.html ; accessed on March 3, 2011.

Based on the September 2015 report from the 2014 NSDUH, the numbers of people who initiated many substances has generally remained the same in most recent years. For example, the number of recent marijuana initiates in 2014 (2.6 million) was greater than the numbers in 2002 to 2008 but was similar to the numbers from 2009 to 2013. Recently, some states have made the use of marijuana legal (Colorado, Washington, Oregon, and Alaska), and other states have made marijuana use for medical purposes acceptable.

In the context of the entire United States, marijuana is still the most commonly used “illicit” drug. In 2009, there were 16.7 million past-month users. Among persons aged 12 or older, the rate of past-month marijuana use and the number of users in 2009 (6.6%, or 16.7 million) were higher than in 2008 (6.1%, or 15.2 million) and in 2007 (5.8%, or 14.4 million). In 2009, there were 1.6 million current cocaine users aged 12 or older, comprising 0.7% of the population. These estimates were similar to the number and rate in 2008 (1.9 million, or 0.7%) but were lower than the estimates in 2006 (2.4 million, or 1.0%). An estimated 3.7 million people have reported previous use of heroin, with an estimated 150,000 persons becoming new users every year. The level of heroin use is relatively stable, with an approximate 1.5% annual increase. Methamphetamine is a synthetic drug that is easily manufactured, and its use is spreading across the United States at alarming rates. The number of past-month methamphetamine users decreased between 2006 and 2008 but then increased in 2009. The reported figures were 731,000 (0.3%) in 2006, 529,000 (0.2%) in 2007, 314,000 (0.1%) in 2008, and 502,000 (0.2%) in 2009.

The use of prescription opioids (e.g., OxyContin) for nonmedical reasons is currently one of the fastest growing dimensions of drug abuse in the United States, with a 225% increase from 1992 to 2000. The lifetime nonmedical use of OxyContin increased from 1.9 million to 3.1 million in the 2-year period from 2002 to 2004. From 2002 to 2009, there was an increase among young adults 18 to 25 years of age in the rate of current nonmedical use of prescription-type drugs (from 5.5% to 6.3%), driven primarily by an increase in pain reliever misuse (from 4.1% to 4.8%). Opioid analgesics in high doses caused 21,314 deaths in the United States in 2011. The nonmedical use of opioids has become epidemic in certain parts of the nation, especially in regions on the east coast.

According to the National Institute on Alcohol Abuse and Alcoholism, in 2014, 87.6% of people ages 18 or older drank alcohol at some point in their lifetime, 71% reported they drank in the past year, and 56.9% drank in the past month. Binge drinking (consumption of five or more drinks on the same occasion) was reported by 24.7% of people 18 years old or older. Alcohol use disorder (AUD) was reported in 6.8% of these adults. Only 8.9% of adults (9.8% of men and 7.4% of women) who needed treatment for AUD received it. Nearly 88,000 people die from alcohol-related causes each year, making alcohol the fourth leading preventable cause of death in the United States. In 2014, alcohol-impaired driving fatalities accounted for 9.967 deaths (31% of overall driving fatalities).

The prevalence of problem drinking in general outpatient and inpatient medical settings has been estimated to be between 15% and 40%. The lifetime prevalence of an alcohol use disorder in the United States is about 18.6% (13.2% for abuse and 5.4% for dependence). Surveys assessing past-year prevalence of these disorders indicate that nearly 8.5% (18 million) of American adults meet standard diagnostic criteria for one of the DSM-IV alcohol use disorders. Of these, 4.7% (10 million) meet criteria for alcohol abuse, and 3.8% (8 million) for dependence. Gender-specific rates of abuse and dependence differ within the general population, with men exhibiting higher rates of both abuse and dependence (8.5%) than those reported for women (4%). Although problem drinking is seen primarily in adults, the prevalence among teenagers is alarmingly high. Alcoholism among older adults also is a significant problem. A dental practice comprising 2000 adult patients could include as many as 170 patients who have a problem with alcohol.

Etiology

The neurobiology of addiction and dependence is complex and involves a unique set of variables. Disruption of the endogenous reward systems in the brain is a common feature of all of the major drugs of abuse; most of these drugs act by disrupting dopamine circuits in the brain. Acute changes increase synaptic dopamine and disrupt circuits that mediate motivation and drive, conditioned learning, and inhibitory controls. This enhancement of synaptic dopamine is particularly rewarding for persons with abnormally low density of the D 2 dopamine receptor (D 2 DR). A complex neural circuitry underlies the valuation and pursuit of rewards ( Fig. 30.1 ). Although dopamine is the primary neurotransmitter involved in drug abuse and addiction, many other neurotransmitters are involved, depending on the drug of abuse ( Fig. 30.2 ). Evidence suggests that inherited genetic factors are involved in alcoholism. Psychological factors such as depression, self-medication (to relieve psychic distress), personality disorder, and poor coping skills appear to be involved in addictive behavior. Social factors that may be involved include interpersonal, cultural, and societal influences.

FIG 30.1
Brain reward circuits. The major dopaminergic projections to the forebrain that underlie brain reward are shown superimposed on a diagram of the human brain: projection from the ventral tegmental area to the nucleus accumbens and prefrontal cerebral cortex. Also shown are projections from the substantia nigra to the dorsal striatum, which play a role in habit formation and in well-rehearsed motor behavior, such as drug seeking and drug administration.
(From Hyman SE: Biology of addiction. In Goldman L, Ausiello D, editors: Cecil medicine, ed 23, Philadelphia, 2008, Saunders.)

FIG 30.2
Converging acute actions of drugs of abuse on the ventral tegmental area and nucleus accumbens. DA, Dopamine; GABA, γ-aminobutyric acid; LDT, laterodorsal tegmentum; NAc, nucleus accumbens; PCP, phencyclidine; PPT, pedunculopontine tegmentum; VTA, ventral tegmental area.
(From Renner JA, Ward EN: Drug addiction. In Stern TA, et al, editors: Massachusetts General Hospital comprehensive clinical psychiatry, Philadelphia, 2008, Mosby.)

Epidemiology

Illicit drugs of abuse include marijuana and hashish, heroin, cocaine (including crack), methamphetamine and its analogues, so-called club drugs, hallucinogens, and dissociative drugs ( Table 30.1 ). Legally prescribed opioids and sedative–hypnotics are abused when used nonmedically. Alcohol is legal but is abused when consumed inappropriately or in excessive amounts. According to the 2009 National Survey on Drug Use and Health (NSDUH), an estimated 21.8 million Americans 12 years of age and older were current illicit drug users, which is higher than in 2008. This number represents approximately 8.7% of the population. Illicit drug use is highest among young persons 18 to 25 years of age. In a dental practice of 2000 patients, it can be expected that approximately 175 of them abuse at least one type of drug or other substance.

TABLE 30.1
Most Common Illicit Drugs of Abuse
Substance of Abuse Street Names How Administered Acute Effects
CANNABINOIDS
Marijuana Blunt, dope, ganja, grass, herb, joint, bud, Mary Jane, pot, reefer, green, trees, smoke, sinsemilla, skunk, weed Smoked, swallowed Euphoria; relaxation; slowed reaction time; distorted sensory perception; impaired balance and coordination; increased heart rate and appetite; impaired learning, memory; anxiety; panic attacks; psychosis or cough, frequent respiratory infections; possible mental health decline; addiction
OPIOIDS
Heroin Smack, horse, brown sugar, dope, H, junk, skag, skunk, white horse, China white; cheese (with OTC cold medicine and antihistamine) Injected, smoked, snorted Euphoria; drowsiness; impaired coordination; dizziness; confusion; nausea; sedation; feeling of heaviness in the body; slowed or arrested breathing/constipation; endocarditis; hepatitis; HIV; addiction; fatal overdose
STIMULANTS
Cocaine Blow, bump, C, candy, Charlie, coke, crack, flake, rock, snow, toot Snorted, smoked, injected Increased heart rate, blood pressure, body temperature, metabolism; feelings of exhilaration; increased energy, mental alertness; tremors; reduced appetite; irritability; anxiety; panic; paranoia; violent behavior; psychosis or weight loss, insomnia; cardiac or cardiovascular complications; stroke; seizures; addiction
Cocaine—also nasal damage from snorting
Methamphetamine—also severe dental problems
Amphetamine Bennies, black beauties, crosses, hearts, LA turnaround, speed, truck drivers, uppers Swallowed, snorted, smoked, injected
Methamphetamine Meth, ice, crank, chalk, crystal, fire, glass, go fast, speed Swallowed, snorted, smoked, injected
CLUB DRUGS
MDMA Ecstasy, Adam, clarity, Eve, lover’s speed, peace, uppers Swallowed, snorted, injected MDMA—mild hallucinogenic effects; increased tactile sensitivity; empathic feelings; lowered inhibition; anxiety; chills; sweating; teeth clenching; muscle cramping or sleep disturbances; depression; impaired memory; hyperthermia; addiction
Flunitrazepam—sedation; muscle relaxation; confusion; memory loss; dizziness; impaired coordination/addiction
GHB—drowsiness; nausea; headache; disorientation; loss of coordination; memory loss or unconsciousness; seizures; coma
Flunitrazepam Forget-me pill, Mexican Valium, R2, roach, Roche, roofies, roofinol, rope, rophies Swallowed, snorted
GHB G, Georgia home boy, grievous bodily harm, liquid ecstasy, soap, scoop, goop, liquid X Swallowed
DISSOCIATIVE DRUGS
Ketamine Cat, Valium, K, Special K, vitamin K Injected, snorted, smoked Feelings of being separate from one’s body and environment; impaired motor function or anxiety; tremors; numbness; memory loss; nausea
Ketamine—also analgesia; impaired memory; delirium; respiratory depression and arrest; death
PCP and analogues—also analgesia; psychosis; aggression; violence; slurred speech; loss of coordination; hallucinations
PCP and analogues Angel dust, boat, hog, love boat, peace pill Swallowed, smoked, injected
HALLUCINOGENS
LSD Acid, blotter, cubes, microdot yellow sunshine, blue heaven Swallowed, absorbed through oral mucosa Altered states of perception and feeling; hallucinations; nausea
LSD and mescaline—also increased body temperature, heart rate, blood pressure; loss of appetite; sweating; sleeplessness; numbness, dizziness, weakness, tremors; impulsive behavior; rapid shifts in emotion
LSD—also flashbacks, hallucinogen, persisting perception disorder
Mescaline Buttons, cactus, mesc, peyote Swallowed, smoked
GHB, γ-Hydroxybutyrate; LSD, lysergic acid diethylamide; PCP, phencyclidine.
Adapted from the National Institutes of Health, National Institute on Drug Abuse (website), www.drugabuse.gov/DrugPages/DrugsofAbuse.html ; accessed on March 3, 2011.

Based on the September 2015 report from the 2014 NSDUH, the numbers of people who initiated many substances has generally remained the same in most recent years. For example, the number of recent marijuana initiates in 2014 (2.6 million) was greater than the numbers in 2002 to 2008 but was similar to the numbers from 2009 to 2013. Recently, some states have made the use of marijuana legal (Colorado, Washington, Oregon, and Alaska), and other states have made marijuana use for medical purposes acceptable.

In the context of the entire United States, marijuana is still the most commonly used “illicit” drug. In 2009, there were 16.7 million past-month users. Among persons aged 12 or older, the rate of past-month marijuana use and the number of users in 2009 (6.6%, or 16.7 million) were higher than in 2008 (6.1%, or 15.2 million) and in 2007 (5.8%, or 14.4 million). In 2009, there were 1.6 million current cocaine users aged 12 or older, comprising 0.7% of the population. These estimates were similar to the number and rate in 2008 (1.9 million, or 0.7%) but were lower than the estimates in 2006 (2.4 million, or 1.0%). An estimated 3.7 million people have reported previous use of heroin, with an estimated 150,000 persons becoming new users every year. The level of heroin use is relatively stable, with an approximate 1.5% annual increase. Methamphetamine is a synthetic drug that is easily manufactured, and its use is spreading across the United States at alarming rates. The number of past-month methamphetamine users decreased between 2006 and 2008 but then increased in 2009. The reported figures were 731,000 (0.3%) in 2006, 529,000 (0.2%) in 2007, 314,000 (0.1%) in 2008, and 502,000 (0.2%) in 2009.

The use of prescription opioids (e.g., OxyContin) for nonmedical reasons is currently one of the fastest growing dimensions of drug abuse in the United States, with a 225% increase from 1992 to 2000. The lifetime nonmedical use of OxyContin increased from 1.9 million to 3.1 million in the 2-year period from 2002 to 2004. From 2002 to 2009, there was an increase among young adults 18 to 25 years of age in the rate of current nonmedical use of prescription-type drugs (from 5.5% to 6.3%), driven primarily by an increase in pain reliever misuse (from 4.1% to 4.8%). Opioid analgesics in high doses caused 21,314 deaths in the United States in 2011. The nonmedical use of opioids has become epidemic in certain parts of the nation, especially in regions on the east coast.

According to the National Institute on Alcohol Abuse and Alcoholism, in 2014, 87.6% of people ages 18 or older drank alcohol at some point in their lifetime, 71% reported they drank in the past year, and 56.9% drank in the past month. Binge drinking (consumption of five or more drinks on the same occasion) was reported by 24.7% of people 18 years old or older. Alcohol use disorder (AUD) was reported in 6.8% of these adults. Only 8.9% of adults (9.8% of men and 7.4% of women) who needed treatment for AUD received it. Nearly 88,000 people die from alcohol-related causes each year, making alcohol the fourth leading preventable cause of death in the United States. In 2014, alcohol-impaired driving fatalities accounted for 9.967 deaths (31% of overall driving fatalities).

The prevalence of problem drinking in general outpatient and inpatient medical settings has been estimated to be between 15% and 40%. The lifetime prevalence of an alcohol use disorder in the United States is about 18.6% (13.2% for abuse and 5.4% for dependence). Surveys assessing past-year prevalence of these disorders indicate that nearly 8.5% (18 million) of American adults meet standard diagnostic criteria for one of the DSM-IV alcohol use disorders. Of these, 4.7% (10 million) meet criteria for alcohol abuse, and 3.8% (8 million) for dependence. Gender-specific rates of abuse and dependence differ within the general population, with men exhibiting higher rates of both abuse and dependence (8.5%) than those reported for women (4%). Although problem drinking is seen primarily in adults, the prevalence among teenagers is alarmingly high. Alcoholism among older adults also is a significant problem. A dental practice comprising 2000 adult patients could include as many as 170 patients who have a problem with alcohol.

Etiology

The neurobiology of addiction and dependence is complex and involves a unique set of variables. Disruption of the endogenous reward systems in the brain is a common feature of all of the major drugs of abuse; most of these drugs act by disrupting dopamine circuits in the brain. Acute changes increase synaptic dopamine and disrupt circuits that mediate motivation and drive, conditioned learning, and inhibitory controls. This enhancement of synaptic dopamine is particularly rewarding for persons with abnormally low density of the D 2 dopamine receptor (D 2 DR). A complex neural circuitry underlies the valuation and pursuit of rewards ( Fig. 30.1 ). Although dopamine is the primary neurotransmitter involved in drug abuse and addiction, many other neurotransmitters are involved, depending on the drug of abuse ( Fig. 30.2 ). Evidence suggests that inherited genetic factors are involved in alcoholism. Psychological factors such as depression, self-medication (to relieve psychic distress), personality disorder, and poor coping skills appear to be involved in addictive behavior. Social factors that may be involved include interpersonal, cultural, and societal influences.

FIG 30.1
Brain reward circuits. The major dopaminergic projections to the forebrain that underlie brain reward are shown superimposed on a diagram of the human brain: projection from the ventral tegmental area to the nucleus accumbens and prefrontal cerebral cortex. Also shown are projections from the substantia nigra to the dorsal striatum, which play a role in habit formation and in well-rehearsed motor behavior, such as drug seeking and drug administration.
(From Hyman SE: Biology of addiction. In Goldman L, Ausiello D, editors: Cecil medicine, ed 23, Philadelphia, 2008, Saunders.)

FIG 30.2
Converging acute actions of drugs of abuse on the ventral tegmental area and nucleus accumbens. DA, Dopamine; GABA, γ-aminobutyric acid; LDT, laterodorsal tegmentum; NAc, nucleus accumbens; PCP, phencyclidine; PPT, pedunculopontine tegmentum; VTA, ventral tegmental area.
(From Renner JA, Ward EN: Drug addiction. In Stern TA, et al, editors: Massachusetts General Hospital comprehensive clinical psychiatry, Philadelphia, 2008, Mosby.)

Clinical Presentation and Medical Management

Substance dependence occurs when the person using the substance takes it in larger amounts or over a longer period than was originally intended. A great deal of time may be spent in activities needed to procure the substance, take it, or recover from its effects. The person gives up important social, occupational, and recreational activities because of substance use. Marked tolerance to the substance may develop; therefore, progressively larger amounts are needed to achieve intoxication or to produce the desired effect. The person with the disorder continues to take the substance despite persistent or recurrent social, psychological, and physical problems that result from its use. The concept of legal highs has been introduced in the past few years. They include a wide range of products, from natural plant-originated substances to synthetic compounds, that can be purchased both online and from street retailers. “Legal highs” mimic psychoactive effects of illicit drugs of abuse. However, these substances are claimed to consist of compounds that are legal to sell, possess, and use, often labeled as “not for human consumption” to circumvent drug abuse legislation.

Substance abuse denotes substance use that does not meet the criteria for dependence ( Table 30.2 ). This diagnosis is most likely to be applicable to persons who have just started to take psychoactive substances. Examples of substance abuse are that of a middle-aged man who repeatedly drives his car while intoxicated (the man has no other symptoms) and that of a woman who keeps drinking even though her physician has warned her that alcohol is responsible for exacerbating the symptoms of a duodenal ulcer (she has no other symptoms).

Sep 3, 2018 | Posted by in General Dentistry | Comments Off on Drug and Alcohol Abuse
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