Opioids are an all-inclusive grouping of synthetic and naturally occurring peptide drugs. Opioids bind to the various physiological receptors recognized by endogenous opioid peptides. Side effects with opioid drug use include nausea, vomiting, and constipation.
Opioids are an all-inclusive grouping of synthetic and naturally occurring peptide drugs. Opioids bind to the various physiological receptors recognized by endogenous opioid peptides. Side effects with opioid drug use include nausea, vomiting, and constipation.
Direitos autorais:
Attribution Non-Commercial (BY-NC)
Formatos disponíveis
Baixe no formato PDF, TXT ou leia online no Scribd
Opioids are an all-inclusive grouping of synthetic and naturally occurring peptide drugs. Opioids bind to the various physiological receptors recognized by endogenous opioid peptides. Side effects with opioid drug use include nausea, vomiting, and constipation.
Direitos autorais:
Attribution Non-Commercial (BY-NC)
Formatos disponíveis
Baixe no formato PDF, TXT ou leia online no Scribd
Abstract Should a drug dependent suddenly terminate the use of
The oral consequences of opioid drug use are a strong opioid, they may precipitate a withdrawal commonly attributed to personal neglect of general syndrome characterized initially by restlessness, health and financial constraint. These factors are anxiety, insomnia, sweating, lacrimation, rhinorrhoea compounded by the increasingly recognized range of and craving for the drug. Such withdrawal signs usually physical effects exerted by opioid drugs. The dental commence within about six hours of abstinence, before management of opioid drug dependents is further reaching a peak between 36 to 72 hours and then complicated by a variety of infections and behavioural modifications commonly associated subside over one to two weeks. However, there may be with opioid use. Adequate strategies for the oral care residual craving for the drug, insomnia, anxiety and of opioid users need to take cognisance of the broad depression for many months and even years after the medical issues for these people along with an cessation of opioid intake.2 appropriate personal approach. Recent data indicate that approximately 2 per cent of Key words: Opioid, methadone, morphine, tooth, all Australians have tried heroin, with the highest infection. incidence of use occurring in young adult males (Accepted for publication 17 August 2001.) between the ages of 25 and 39 years. In females, the 14 to 24 year old group has the highest frequency of use.3 The pattern is similar in New Zealand where 3 per cent INTRODUCTION of people between the ages of 15 and 45 years have The term opioid is an all-inclusive grouping of tried drugs for non-medicinal purposes. Again, such use synthetic and naturally occurring peptide drugs that act is most prevalent in young adult males.4 on various membrane-bound receptors to produce For the past 25 years, national protocols have been morphine-like effects. It has replaced the term opiates, established throughout Australasia for the management which is now reserved to describe alkaloids derived of opioid dependency with the opioid substitute, naturally from the opium poppy (Papaver somniferum). methadone.5 Currently, there are approximately 15 000 Opioid drugs bind to the various physiological individuals in Australia and about 1300 individuals in receptors recognized by endogenous opioid peptides, New Zealand participating in such methadone such as enkephalins, endorphins and dynorphins. programmes.6,7 Methadone is a synthetic, potent opioid Although three main classes of receptor have been agonist drug prescribed for the treatment of opioid- identified and cloned, i.e.: mu (m ); kappa (k); delta (d), dependent injecting drug users. Being an orally other receptor types exist which have not been as well administered drug, daily methadone obviates the need characterized.1 to use injectable narcotics, while its long half-life The primary incentives for opioid use are its ability prevents the occurrence of withdrawal symptoms. The to induce a state of euphoria as well as mental detach- primary aim of such therapy is to achieve a transition ment. These effects are primarily mediated by the m from methadone maintenance into a drug-free lifestyle receptors that are also largely responsible for the in a manner designed to minimize relapse and the development of tolerance and addiction with repeated consequences of injecting narcotics. However, not all opioid use.2 Table 1 lists the principal opioids used, patients can be weaned off methadone due to the with patterns of their abuse varying from country to chronic and relapsing nature of established opioid country according to local availability and demand.2 dependence. As such, secondary goals of life-long methadone maintenance include encouraging opioid Side effects with opioid drug use are common and dependents to attend treatment clinics, reducing deaths include nausea, vomiting, and constipation together and diseases linked with injecting drugs, improving the with the risk of hypotension and respiratory depression. dependents’ ability to function socially, as well as lowering crime and social costs associated with illicit *General Practitioner, Alexandra, New Zealand. †Professor of Oral Medicine and Oral Surgery, University of Otago, drug use.8,9 Based on evidence attributing a reduced New Zealand. mortality associated with opioid use to methadone 94 Australian Dental Journal 2002;47:2. Table 1. Opioids commonly abused Opioid users are highly susceptible to a variety of Buprenorphine Methadone infections. Such common infections include HIV, viral Dextropropoxyphene Morphine hepatitis18,19 and infective endocarditis,20 all of which Diamorphine (heroin) Oxycodone Dihydrocodeine Pentazocine have significance in a dental setting. This increased Dipipanone Pethidine (meperidine) propensity towards infection can be attributed to the sharing of contaminated needles, an increased participation in unsafe sexual activity and a reduced immune competence. The significance of immuno- programmes,8 there is general acceptance of methadone suppression in these patients is clearly demonstrated by as a successful means of management for those unable the fact that opioid users can contract infective or unwilling to control their dependence. Nonetheless, endocarditis on a previously uncompromised methadone users suffer from several undesirable side endocardium.20 Although factors associated with drug effects. Alternate medications to methadone are being use, such as alcoholism,8 dietary deficiency21 and evaluated for substitution regimes to overcome these general personal neglect can all adversely affect the limitations including buprenorphine, 1-alpha-acetyl- immune system, there is a growing body of evidence methadol and naltrexone.10 that certain opioid drugs are capable of directly suppressing aspects of immunity. Such direct opioid Medical problems effects on immune function include a lowering of the Individuals dependent upon opioid drugs are total lymphocyte count, a depression in the CD4:CD8 vulnerable to a number of medical problems that are lymphocyte ratio, a reduction in immunoglobulin and multi-factorial in aetiology. tumour necrosis factor production and suppression of In an attempt to cope with a poorly controlled natural killer (NK) cell activity.22 It appears as though psychological disorder, an individual may resort to the the immunological deficits seen during opioid use of opioid drugs. Often, in such cases, the pre- consumption are reversible after several years of total existing disorder is accentuated rather than tempered opioid abstinence.22 The mechanisms responsible for by the use of opioid drugs.11 Conversely, the habitual these opioid-induced changes remain unclear although use of opioids can itself precipitate the development of surface opioid receptors have been identified on various a psychological disorder other than drug leukocytes. dependency.12,13 Despite there not appearing to be a In light of the range and prevalence of disease in standard psychological profile of drug dependents or opioid dependents, all patients entering into a those likely to become dependent, clinical depression is methadone programme undergo a thorough medical significantly more prevalent amongst opioid users than and psychological assessment and, as part of their it is in the non-opioid using population.14 Due to the initial evaluation, are screened for the above disorders limitations of retrospective analysis, it is difficult to and infections.23 Individual responses to medical determine in which cases the depression preceded the treatment vary considerably but those who take a drug use and in which cases initial drug use gave rise to greater interest in their own welfare often respond well depression. to therapy.24 Commonly associated with opioid dependency are significant changes in social behaviour. Even though Oral conditions these changes appear to be closely related with apathy and financial constraint, it should be borne in mind Opioid dependents are susceptible to a variety of oral that not all drug users are in the lower economic groups diseases, not least of which are dental caries and and that they may lead an apparently normal lifestyle. periodontitis. Despite the frequent citation in the The neglect of personal care is a frequently observed literature of various conditions affecting these patients, behaviour amongst opioid users, irrespective of the underlying pathogenic mechanisms are only economic status.13 Accordingly, opioid users tend to recently being better understood. seek treatment only when the disease is advanced and High rates of generalized dental caries, being the symptoms become severe.15 Such late-presenting particularly prevalent on smooth and cervical surfaces, patients with severe symptoms may be anxious and have been widely described in opioid users.25-27 There is demanding, consequently making their management a growing body of evidence to suggest that this high considerably more challenging. The altered social prevalence of caries is due to a complex, dynamic behaviour of drug users often leads to increased sexual relationship between multiple factors. General personal activity without the use of precautionary measures. neglect combined with a shortage of money may lead Such unsafe practices generally occur during periods of an opioid user to consume a diet made up largely of euphoria when users become more promiscuous as well convenience foods high in simple sugars. The ingestive as during prostitution, which drug dependents may behaviour of opioid users is also directly modulated by resort to for necessary income.16 Opioid users also central opioid receptors, most probably the k and m demonstrate a propensity to be exposed to violent receptors.28 Such modulation includes the mediation of situations, which may be responsible for the higher the increased palatability and rewarding aspects of rates of trauma experienced by these individuals.17 sweet substances experienced by opioid users.29 This Australian Dental Journal 2002;47:2. 95 opioid-induced taste preference for sucrose can be Several other oral conditions have been associated reversed in mice with the administration of the with opioid addiction, namely candidosis, mucosal antagonist naltrexone. Consequently, the ability of dysplasia and bruxism. Oral candidosis has been opioids to directly induce a heightened craving for frequently observed in such users. Morphine is known sweet carbohydrates15,30,31 may be a significant to exert an inhibitory effect on the phagocytosis of contributing factor to the consumption of a diet rich in Candida by macrophages, which together with salivary simple sugars. gland hypofunction, may predispose to oral candidosis Any concomitant altered self-image, depression in these people.37 and/or lack of motivation will likely result in lowered Opioid dependents tend to be high users of tobacco standards of oral hygiene. The impact of poor oral and alcohol.8 Despite both of these agents being well- hygiene and an altered taste preference for sweet foods established aetiological factors in leukoplakia and oral on the development of carious lesions is compounded carcinoma and despite studies that demonstrate a by the xerostomic effects of opioid and medicinal facilitation of tumour growth in mice chronically drugs. While it is well established that opioids, exposed to morphine38 there are no data to support a including methadone, reduce pancreatic, biliary and greater incidence of oral carcinoma specifically in gastric secretion, it is not widely recognized that opioid users.39 However, the concomitant smoking of opioids can also result in xerostomia.1,32 Opioid induced cannabis and/or cocaine may be an additional xerostomia does not appear universally to be of a aetiological factor in the onset of mucosal dysplasia. severe magnitude on its own but the concomitant use of These substances contain many carcinogens that are antidepressants33 may accentuate this condition. postulated to render the epithelium more susceptible to Although there are no studies seeking to demonstrate exogenous carcinogens.40,41 certain microbial profiles specific for opioid addicts, Bruxism, which has been reported to be more frequent altered microbial populations are known to exist in in opioid dependents, may be attributed to a general patients with salivary gland hypo-function. Such increase in neurosis in this group of individuals.42 A alterations may render the plaque more cariogenic, similar tendency for bruxism with resultant dental particularly in an environment of readily available attrition is also recognized in alcoholics.42,43 sugars. Other problems of chronic salivary hypo- function include a dry or burning mouth, taste Dental management impairment, eating difficulties, mucosal infections and The dental management of opioid dependents is periodontal disease. often complex. Not only does this group of individuals The frequent intake and prolonged retention of suffer high rates of various oral diseases, they also sucrose-syrup-based oral methadone preparations is demonstrate behavioural and pathological changes that possibly another potentiating factor in the progression greatly impact upon their dental treatment. As such, the of dental caries in methadone patients.34 Methadone dental professional needs to be aware of the wider patients may adopt a habit of retaining this syrup in issues associated with these patients in order to manage their mouths for long periods of time in order to them successfully. prolong the absorption time or to enable later Opioid users often suffer from psychological degurgitation for sale or parenteral administration. To problems that are frequently accompanied by general negate these detrimental effects, sorbitol is being anxiety. Under the influence of intense pain, any usual substituted for sucrose to render methadone anxiety associated with a psychological disorder may preparations sugar-free, as well as methylcellulose or be dramatically magnified.45 This may explain the gum tragacanth being added to render the preparation heightened dental fear often exhibited by opioid less cariogenic and more difficult to inject, dependents.45 Surprisingly, patients taking methadone respectively.26,34 may exhibit a phobia for needles, especially in the Once established, any pain arising from dental hands of others, which further accentuates a heightened lesions may be masked and/or ignored due to the anxiety.45 In such instances, the clinician needs to be analgesic and mental detachment effects of opioids, mindful of the importance of managing the patients’ respectively. Accordingly, help may be sought only for anxiety as well as the primary dental concern. Dental extreme pain, which may account for the observed high anxiety may become potentially life threatening should prevalence of dental caries when addicts first present to the patient suffer from chronic hypo-adrenocorticalism, a dentist.25,27 which may be present due to the metabolism of the Periodontal disease is also frequently seen in drug adrenal cortex being altered by the exogenous opioids. dependents. The pattern is typically one of adult With chronic abuse, an adrenal crisis may ensue periodontitis, although acute necrotizing gingivitis has consequent to a diminished adrenocortical reserve also been reported.35,36 It seems that the effects on the when an opioid user is faced with surgical stress.46 periodontium due to a high rate of plaque The successful management of pain and anxiety in an accumulation, resulting from neglect and xerostomia, opioid dependent may be difficult to achieve. Opioid may be exacerbated by the immuno-suppressive effects users may demonstrate a reduced responsiveness to of opioids and potentially altered microbial profiles. local anaesthetics, most likely due in part to the 96 Australian Dental Journal 2002;47:2. pharmacological properties of the opioids used as well someone taking an opioid agonist such as methadone. as to general fear and anxiety.47 However, it should be Rather, an alternative goal may be to accept the borne in mind, that drug dependents may present with patients’ craving of sweet foods while simultaneously a fictitious history of pain and allergy and feign educating them about the significance of frequency of inadequate analgesia in order to obtain specific classes sugar intake as well as artificial sweeteners and safe of analgesics or sedatives.48 Should pain control not be snacks. achievable with local analgesia, the clinician may resort to other forms of sedation. Pain control using CONCLUSION intravenous sedation techniques may also prove The oral manifestations along with the general unsuccessful due to tolerance and difficult cannulation, medical problems of opioid use are increasingly being particularly in intravenous drug users.49,50 Even the recognized and understood. It is important to develop a administration of a general anaesthetic may not be high awareness of the implications for oral health care desirable on the basis that it is potentially capable of in societies where such drug dependency is widespread. inducing a relapse in a recovering drug user.51 Individuals will be seen at various phases, from states When treating drug dependents, the dentist needs to of neglect and advanced ill health to those undergoing be aware of the fact that these individuals might be rehabilitation, including those on methadone carrying infections that have particular implications for programmes. While the former group generally dental treatment.52 Even though a thorough medical presents only in severe pain and may prove to be history may not reveal the presence of such infections, unreliable for ongoing care, the latter group, in general, standard precautions must be observed when treating is responsive to well-structured delivery of oral health opioid addicts due to the high prevalence of such care, incorporating it as an integral component in infectious diseases in this group of patients. attaining a healthy lifestyle. Intravenous drug users are also known to have an increased incidence of infective endocarditis,52,53 which REFERENCES has led to a number of centres adopting the principal 1. Reisine T, Pasternak G. Opioid analgesics and antagonists. In: that all parenteral drug users should be viewed as Hardman JG, Limbird LE, Molinoff PB, Ruddon RW, Goodman vulnerable to infective endocarditis.53 As such, these Gillman A, eds. Goodman and Gillman’s The Pharmacological Basis of Therapeutics. 9th edn. New York: McGraw Hill, patients may need to be assessed for the need for an 1996:521-555. antibiotic prophylactic regime prior to oral surgery or 2. O’Brien CP. Drug addiction and drug abuse. In: Hardman JG, other dental procedures in which a significant Limbird LE, Molinoff PB, Ruddon RW, Goodman Gillman A, bacteraemia may arise.54 eds. Goodman and Gillman’s The Pharmacological Basis of Therapeutics. 9th edn. New York: McGraw Hill, 1996:557-577. 3. Department of Health, Housing and Community Services, DISCUSSION Statistics on drug abuse in Australia 1992. Canberra: Australian Uncontrolled opioid dependents who present late Government Publishing Service, 1992. with intense pain may place unrealistic demands on the 4. Black S, Cresswell S. Drugs in NZ – A survey 1990. Alcohol and dental health provider and may not be considered Public Health Research Unit, Auckland University. 1991. reliable with regard to regular dental treatment. 5. National Protocol for Methadone Programmes in New Zealand. Drug Advisory Committee: Department of Health. New Zealand. Nonetheless, the clinician has an obligation to inform 1992. all patients of their dental health status and offer them 6. Ward J, Mattick RP, Hall W. Key Issues In Methadone the opportunity to return for comprehensive care. Maintenance Treatment. Glebe: New South Wales University At the other end of the spectrum, methadone patients Press, 1992. who take a greater interest in their own welfare may 7. New Zealand survey of methadone treatment: May-October present for comprehensive dental treatment, even in the 1992. In Methadone Treatment Information. Drugs Advisory Committee, 1992. absence of dental pain. Despite this, the issues 8. Gossop M, Marsden J, Stewart D, et al. Substance use, health and associated with the management of dental anxiety are social problems of service users at 54 drug treatment agencies. still relevant in this group of patients. A caring and Intake data from the National Treatment Outcome Research empathetic approach adopted by the clinician will often Study. Br J Psychiatry 1998;173:166-171. gain the trust of the patient, which in turn should 9. Healey A, Knapp M, Astin J, et al. Economic burden of drug dependency. Social costs incurred by drug users at intake to the facilitate more effective pain control and ensure a more National Treatment Outcome Research Study. Br J Psychiatry reliable attendance. In addition to restoring the oral 1998;173:160-165. tissues to health, the clinician should emphasize the 10. Wodak A. Managing illicit drug use. A practical guide. Drugs importance of prevention from the outset. An 1994;47:446-457. individualized preventive regimen should be formulated 11. Mirin SM, Weiss RD, Michael J, Griffin ML. Psychopathology in and implemented, considering factors such as regular substance abusers: diagnosis and treatment. Am J Drug Alcohol Abuse 1988;14:139-157. hygiene appointments, the use of fluoride and/or casein products, dietary advice, sialagogues, anti-fungals and 12. Levinson I, Galykner II, Rosenthal RN. Methadone withdrawal psychosis. J Clin Psychiatry 1995;56:73-76. bite splints. With regard to dietary advice, the clinician 13. Affinnih YH. A preliminary study of drug abuse and its mental needs to take cognisance of the fact that the eradication health and health consequences among addicts in Greater Accra, of sweet foods from the diet may not be practical in Ghana. J Psychoactive Drugs 1999;31:395-403. Australian Dental Journal 2002;47:2. 97 14. Brienza RS, Stein MD, Chen M, et al. Depression among needle 36. Davis RK, Baer PN. Necrotizing ulcerative gingivitis in drug exchange program and methadone maintenance clients. J Subst addict patients being withdrawn from drugs: Report of two Abuse Treat 2000;18:331-337. cases. Oral Surg Oral Med Oral Pathol 1971;31:200-204. 15. Santolaria-Fernandez FJ, Gomez-Sirvent JL, Gonzalez-Reimers 37. Szabo I, Rojavin M, Bussiere JL, Eisenstein TK, Adler MW, JN, et al. Nutritional assessment of drug addicts. Drug Alcohol Rogers TJ. Suppression of peritoneal macrophage phagycotosis Depend 1995;38:11-18. of Candida albicans by opioids. J Pharmacol Exp Ther 1993;267:703-706. 16. Rhodes T, Quirk A. Drug users’ sexual relationships and the social organization of risk: the sexual relationship as a site of risk 38. Ishikawa M, Tanno K, Kamo A, Takayanagi Y, Sasaki K. management. Soc Sci Med 1998;46:157-169. Enhancement of tumor growth by morphine and its possible mechanism in mice. Biol Pharm Bull 1993;16:762-766. 17. Passeri LA, Ellis E, Sinn DP. Relationship of substance abuse to complications with mandibular fractures. J Oral Maxillofac Surg 39. Llewelyn J, Mitchell R. Smoking, alcohol and oral cancer in 1993;51:22-25. south east Scotland: a 10-year experience. Br J Oral Maxillofac Surg 1994;32:146-152. 18. Chetwynd J, Brunton C, Blank M, Plumridge E, Baldwin D. Hepatitis C seroprevalence amongst injecting drug users 40. Barsky SH, Roth MD, Kleerup EC, Simmons M, Tashkin DP. attending a methadone programme. NZ Med J 1995;108:364- Histopathologic and molecular alterations in bronchial 366. epithelium in habitual smokers of marijuana, cocaine, and/or tobacco. J Natl Cancer Inst 1998;90:1198-1205. 19. Ogilvie EL, Veit F, Crofts N, Thompson SC. Hepatitis infection among adolescents resident in Melbourne Juvenile Justice Centre: 41. Endicot JN, Skipper P, Hernandez L. Marijuana and head and risk factors and challenges. J Adolesc Health 1999;25:46-51. neck cancer. Adv Exp Med Biol 1993;335:107-113. 20. Ribera E, Miro JM, Cortes E, et al. Influence of human immun- 42. Colon PG Jr. Dental disease in the narcotic addict. Oral Surg Oral odeficiency virus 1 infection and degree of immunosuppression in Med Oral Pathol 1972;33:905-910. the clinical characteristics and outcome of infective endocarditis 43. Hartmann EM. Alcohol and bruxism. N Engl J Med in intravenous drug users. Arch Intern Med 1998;158:2043- 1979;301:333. 2050. 44. Darke S, Sims J, McDonald S, Wickes W. Cognitive impairment 21. Mohs ME, Watson RR, Leonard-Green T. Nutritional effects of among methadone maintenance patients. Addiction marijuana, heroin, cocaine, and nicotine. J Am Diet Assoc 2000;95:687-695. 1990;90:1261-1267. 45. Scheutz F. Anxiety and dental fear in a group of parenteral drug 22. Govitrapong P, Suttitum T, Kotchabhakdi N, Uneklabh T. addicts. Scand J Dent Res 1986;94:241-247. Alterations of immune functions in heroin addicts and heroin withdrawal subjects. J Pharmacol Exp Ther 1998;286:883-889. 46. Tennant F, Shannon JA, Nork JG, Sagherian A, Berman M. Abnormal adrenal gland metabolism in opioid addicts: 23. Ryan CF, White JM. Health status at entry to methadone implications for clinical treatment. J Psychoactive Drugs maintenance treatment using the SF-36 health survey 1991;23:135-149. questionnaire. Addiction 1996;91:39-45. 47. Council on dental practice: Chemical dependency and dental 24. Tobutt C, Oppenheimer E, Laranjeira R. Health of cohort of practice. J Am Dent Assoc 1987;114:509-515. heroin addicts from London clinics: 22 year follow up. BMJ 1996;312:1458. 48. Friedlander AH, Mills MJ. The dental management of the drug- dependent patient. Oral Surg Oral Med Oral Pathol 25. Rees TD. Oral effects of drug abuse. Crit Rev Oral Biol Med 1985;60:489-492. 1992;3:163-184. 49. Randell S, Libman RH. Outpatient intravenous sedation for a 26. Sheedy JJ. Methadone and caries. Case reports. Aust Dent J dental patient with narcotic addiction – report of a case. Anesth 1996;41:367-369. Prog 1976;23:28-30. 27. Fazzi M, Vescovi P, Savi A, Manfredi M, Peracchia M. The effects 50. Gillespie J, Kronish AD, Dubin R. Anesthetic management for of drugs on the oral cavity. Minerva Stomatol 1999;48:485-492. dentistry in patients on methadone maintenance. Anesth Prog 28. Carr KD, Papadouka V. The role of multiple opioid receptors in 1980;27:85-87. the potentiation of reward by food restriction. Brain Res 51. Sadeghi P, Zancy JP. Anesthesia is a risk factor for drug and 1994;639:253-260. alcohol craving and relapse in ex-abusers. Med Hypotheses 29. Badiani A, Leone P, Noel MB, Stewart J. Ventral tegmental area 1999;53:490-496. opioid mechanisms and modulation of ingestive behaviour. Brain 52. Haverkos HW, Lange WR. From the Alcohol, Drug Abuse, and Res 1995;670:264-276. Mental Health Administration. Serious infections other than 30. Zador D, Lyons Wall PM, Webster I. High sugar intake in a human immunodeficiency virus among intravenous drug abusers. group of women on methadone maintenance in South Western J Infect Dis 1990;161:894-902. Sydney, Australia. Addiction 1996;91:1053-1061. 53. Pallasch TJ, Slots J. Antibiotic prophylaxis and the medically 31. Morabia A, Fabre J, Chee E, Zeger S, Orsat E, Robert A. Diet compromised patient. Periodontol 2000. 1996;10:107-138. and opiate addiction: a quantitative assessment of the diet of 54. Cook H, Peoples J, Paden M. Management of the oral surgery non-institutionalized opiate addicts. Br J Addict 1989;84:173- patient addicted to heroin. J Oral Maxillofac Surg 1989;47:281- 180. 285. 32. Odeh M, Oliven A, Bassan H. Morphine and severe dryness of the lips. Postgrad Med J 1992;68:303-304. Address for correspondence/reprints: 33. Darke S, Ross J. The use of antidepressants among injecting drug Dr Angelo Titsas users in Sydney, Australia. Addiction 2000;95:407-417. Rapid 68 34. Meaney PJ. Methadone and caries. Aust Dent J 1997;42:138- Letts Gully Road 139. Alexandra 35. Angelillo IF, Grasso GM, Villari P, D’Errico MM. Dental health in a group of drug addicts in Italy. Community Dent Oral New Zealand Epidemiol 1991;19:36-37. Email: angelo.titsas@bigpond.com