Episode #332: Up in Smoke: Will Cannabis Replace Analgesics in Dental Pain Management? with Dr. Tom Viola, R.Ph., C.C.P.

You might know that one person who really loves their mints. But it turns out, those could be edible cannabis, not Altoids or Tic Tacs! And because so many different forms are available today, it’s almost impossible to know who could be using cannabis. So, why is this important to dentistry? To answer that question, Kirk Behrendt brings back Dr. Tom Viola to explain some of the direct and indirect impacts, as well as some of the ethical dilemmas of cannabis. To learn what dental school didn't teach you about cannabis, listen to Episode 332 of The Best Practices Show!

Main Takeaways:

• Cannabis is still an unknown, and its use has an impact on dentistry.
• There are many myths and misconceptions about cannabis.
• Cannabis actually raises your blood pressure and heart rate.
• In high enough doses, cannabis can increase anxiety.
• Cannabis can cause immunosuppression and increased risk of infection.
• Patients who use cannabis are more resistant to the effects of anesthetics.
• Because cannabis isn't standardized, we don't know how much a patient may be taking.
• Cannabis can span any age group. It’s not just younger people taking it.  
• Always ask patients about their cannabis use.

Quotes:

• “Cannabis is an unknown. I didn't learn about it in school, you didn't learn about it in school, because at the time, cannabis was still a Schedule I substance under the federal law, which meant it was illegal, like heroin, like LSD. So, we didn't learn much about it, and we really didn't anticipate that cannabis was going to get such widespread political and social acceptance — and medical acceptance — as it has now. Honestly, it’s still a quagmire. It’s still illegal, Schedule I, at the federal level, but approved in, if you want to call it that, or legalized or decriminalized in 35 states throughout the country. So, it leaves everybody in a quandary because, again, your patients have never had such widespread access to a drug that we, in our education, never really learned much about.” (07:50—08:37)
• “The first thing you need to know as a dental professional is that what your patient is smoking, consuming as a gummy, vaping, is probably not one of the three original strains but some hybrid of those three strains that specializes in a specific THC or CBD content that the patient is demanding or the patient expects.” (14:57—15:17)
• “The next thing to realize is that many people believe that cannabis, marijuana, mellows you out. And therefore, by logical extension of “mellows you out,” that means it must lower your blood pressure, lower your heart rate, make you calm and less anxious. Actually, that's not true. Actually, cannabis raises blood pressure and raises heart rate, and in high enough doses can actually cause paradoxical effects of dysphoria, anxiety, agitation.” (15:21—15:54)
• “From our perspective as dental professionals, it’s like, ‘Yeah, you're right. If you can use cannabis, why do we need to prescribe an opioid? I'm good with that too.’ But if you look at the legislation in all these states where opioid education is mandatory, what's one of the primary things that’s central to all of those education programs? Did you educate the patient? Did you ask an at-risk patient one question: do you have, or have you had, an issue with substances in your past? And guess what? Cannabis is a substance. Your patient may not agree with it. Heck, you may not agree with it. But at the end of the day, it is. So, all of a sudden, it’s easy for the patient to say, ‘Hey, don't worry about it, doc. I had a gummy an hour ago. I'm good.’ But is that substance abuse?” (18:39—19:28)
• “The big question is about how to take a good medical history. The fourth question [to ask patients] is, ‘Do you use cannabis? And if you do, when was the last time you used it?’ Because that's going to affect the vital signs, increased blood pressure, increased pulse.” (20:06—20:22)
• “Patients who use cannabis are resistant to the effects of anesthetic agents. Okay. Well, then I probably have to use more. Right. So, you're going to use more anesthetics. And you're probably going to have to use epinephrine. Why? Well, the patient is resistant; you want to use the epinephrine to make the anesthesia more profound. That makes sense. So, I use more anesthesia and more epinephrine in a patient who’s a cannabis user because they're resistant to the effects of anesthetics. But by the very use of cannabis, that patient is already hypertensive and tachycardic. So, you just gave more anesthesia and epinephrine to a patient who’s hypertensive and tachycardic. Would you do that to a patient in any other realm? Probably not. With cannabis use, it happens all the time.” (20:31—21:19)
• “[Cannabis] doesn't work in dentistry. And that's the thing, because dental pain is acute inflammatory pain, not chronic pain. So, to treat acute inflammatory pain, what's the drug necessary? An anti-inflammatory. But there's nothing anti-inflammatory about cannabis. So, you could try. But at the end of the day, cannabis just isn't our choice for treating dental pain. However, that's a level of understanding that you, and I, and the people who listen to this podcast have. Your patient, however, a layperson, looks at cannabis sort of through rose-colored glasses as if, ‘Hey, cannabis is good for lots of things. Let's try it out for this too because I don't want to take pills. I don't want to take something that's artificial. I want to take something that's natural.” (22:02—22:53)
• “The biggest deficit is the fact that there's very little information available about cannabis. It’s taken me years to build the information I have into my course. And I've got to pay attention to this every day because something in the cannabis industry changes literally every day.” (23:13—23:28)
• “The fact that the federal government hasn't de-scheduled it and that big pharmaceutical companies don't make a product from it means, what? There's this widespread manufacturer of this drug that's not controlled, that's not standardized. And let's face it, that just asks for the introduction of chemicals and substances that really shouldn't be in those dosage forms that can have an impact on dentistry.” (26:19—26:45)
• “The other problem with cannabis is, the stronger you make it, the more it affects what we call CB2 receptors in the body. The CB2 receptors govern two things. They govern the GI and the immune system, to some extent. So, what does that mean? You use cannabis on a regular basis, and in large enough quantities, number one, you're going to get a syndrome called cannabinoid hyperemesis syndrome, constant vomiting from cannabis. These are the folks that take hot showers like ten times a day because a hot shower is the only thing that can break that cycle of nausea. And what do you think they use to treat the nausea? More cannabis. So, that is in itself a problem. Because if anybody knows about the effects of acid on dentition, it would be us.” (26:47—27:33)
• “The other problem is, the CB2 receptors in the immune system, stimulating those in large enough quantities of cannabis means, what? The patient becomes immunosuppressed. So, wait a minute. Did anybody ever anticipate that cannabis would cause immunosuppression, increased risk of infection? So, that means bacterial, fungal, viral, secondary infections after dental procedures. That also means, what? Infection with HPV, which can lead to head and neck cancer. So, all of a sudden, cannabis isn't as easy as, ‘Well, it’s just a drug that mellows you out.’ It becomes very complicated because of its impact on dentistry, whether it’s directly or indirectly. But also, it’s to do with the fact that there's no standardization. So, when a patient identifies as a cannabis user, to be honest, you don't know what that means.” (27:35—28:22)
• “[Today’s cannabis] grows in low-light, moist, warm, conditions. Well, what else grows in low-light, moist, warm conditions? Mold. So, a lot of these cannabis plants are contaminated with mold, and so the growers spray the plants with fungicide to kill the mold. Now, that fungicide doesn't just go away. That's now part of the plant. And then, when you harvest the plant and make products from it, some of those trace chemicals persist in the finished product. So, gummies just aren't gummies. They can contain lots of other chemicals. Same thing with oils.” (33:03—33:39)
• “You won't know if your patient is under the influence, because they took an oral dosage form before you even saw them show up for work.” (34:46—34:52)
• “Know anybody who sucks on a mint every hour or so? Believe me, that may be not just a Tic Tac. That could be a dosage form that contains cannabis.” (35:02—35:12)
• “There are new strains of cannabis that persist for long periods of time. So, I could smoke in the morning, and you won't smell it on me when I'm already at work.” (35:26—35:35)
• “Your patient takes gummies. No smell. I wouldn't know it. If they didn't admit to it, I'd have no idea. But their blood pressure is elevated, and their heart rate is elevated, and they keep getting these recurrent infections of candidiasis. That's interesting. How'd that happen? ‘No, no. This kid is an 18-year-old. I don't have to take his blood pressure and pulse. He’s fine. He’s ASA I.’ Is he? All of a sudden, cannabis opens up a whole new world for us as far as concern because cannabis can span any age group.” (36:02—36:38)
• “‘No, it’s just the young people that do cannabis.’ I hate to tell you this, but people my age and older, cannabis was part of our culture. And now that we have more disposable income to spend on it, and it’s so widely available and so socially acceptable, we’re going to do it too. ‘Well, wait a minute. Your older patients already have cardiovascular issues.’ I know. So, I've just added another element to that part of patient care.” (36:39—37:06)
• “Did you ask the question, ‘Do you use cannabis? Did you use it recently? Did you use it today?’ ‘Okay, I asked the question. Now, wait a minute. What do I do with that information? Do I want to know?’ And that's the problem. A lot of us say, ‘No, I don't want to ask. I don't want to know,’ because that opens up all of this Pandora’s box of, ‘What do I do with the information now that I know it?’ But you can't hide under a rock anymore. You've got to know, and you've got to make those tough calls. Because ultimately, I serve as an expert witness in a lot of litigation, so I can tell you, this comes back to bite us later. Because under oath, you've got to say to somebody, ‘Yeah, I knew the patient used cannabis, and I chose to ignore it.’ Okay, who’s going to admit that they knew it? But if there's reasonable doubt that you should've known, did you ask? That can be damning alone in any litigation.” (43:20—44:18)
• “If your patient wants to use cannabis to replace analgesics, know this: cannabis is not anti-inflammatory, would not be a good substitute for anti-inflammatory and or opioids in the management of odontogenic pain because, at the end of the day, it’s acute inflammatory pain.” (45:55—46:11)
• “Keep in mind that analgesics include opioids. And so, your patient may say, ‘Well, all right. I don't even want an NSAID. I don't want acetaminophen. I'll just use cannabis along with any opioid you prescribe me.’ That's not going to fly either, because combining cannabis with opioids increases the risk of respiratory depression.” (46:14—46:35)
• “The industry is changing. I'm going to give you one word to hold on to: terpene. Essential oils. And for that matter, let's talk about flavonoids, which are flavor compounds. Right now, if you get a cartridge for vaping, more than likely, it’s been artificially flavored and scented to make it attractive to you. But cannabis, as a botanical, contains terpenes and flavonoids. And if I know how to harness those chemicals that are innate to the plant, someday soon, the cannabis industry is going to make vaping solutions naturally flavored like pineapple, naturally scented like pineapple. And let me tell you this. If somebody walked by you vaping a cartridge and they left you with a scent of pineapple, or someone asked you to try it and it tasted like pineapple, would you be interested in using it? You just might be.” (46:39—47:54)

Snippets:

• Dr. Viola’s background. (04:49—05:46)
• Pharmacology Declassified. (06:02—07:03)
• Why cannabis is a big issue for dentists. (07:49—13:25)
• What cannabis is. (14:00—16:11)
• Dentists need to ask patients about cannabis use. (16:41—21:33)
• Does cannabis really relieve pain at the levels we think? (22:02—22:53)
• Training around cannabis in dental offices. (23:11—24:56)
• Some problems with cannabis. (25:33—28:22)
• The future of cannabis in dentistry. (28:42—31:55)
• Different dosage forms. (32:01—39:12)
• Ethical dilemmas. (39:53—42:10)
• Appeals from Dr. Viola. (42:32—45:26)
• Last thoughts. (45:55—47:54)
• Dr. Viola’s contact information and conclusion. (48:42—53:20)

Reach Out to Dr. Viola:

Dr. Viola’s website: https://www.tomviola.com/

Dr. Viola’s email: [email protected] 

Dr. Viola’s Instagram: @pharmacologydeclassified https://www.instagram.com/pharmacologydeclassified/?hl=en

Dr. Viola’s Facebook: https://www.facebook.com/tomviolarph

Dr. Viola’s podcasts: https://www.tomviola.com/category/podcasts/

ACT U Master Class: https://www.actdental.com/master-classes

Dr. Tom Viola Bio:

THOMAS A. VIOLA, R.Ph., C.C.P.

With over 30 years of experience as a pharmacist, educator, speaker, and author, Tom Viola, R.Ph., C.C.P., has earned his reputation as the go-to specialist for delivering quality continuing education content through his informative, engaging presentations. Tom’s sellout programs provide an overview of the most prevalent oral and systemic diseases and the most frequently prescribed drugs used in their treatment. Special emphasis is given to dental considerations and strategies for effective patient care planning.

As a clinical educator, Tom is a member of the faculty of 12 dental professional degree programs and has received several awards for Outstanding Teacher of the Year. Tom instructs dental hygiene students and practice dental hygienists in pharmacology and local anesthesia in preparation for national board exams. As a published writer, Tom is well-known internationally for his contributions to several professional journals in the areas of pharmacology, pain management, and local anesthesia. In addition, Tom has served as a contributor, chapter author, and peer reviewer for several pharmacology textbooks. As a professional speaker, Tom has presented continuing education courses to dental professionals internationally since 2001. Meeting planners agree that Tom is their choice to educate audiences within this specialty.