Treating Nicotine Dependence with Nitrous Oxide/Oxygen (PAN): A Manual for Health Professionals

By Prof. Mark Gillman

This is an easy-to-read book for professionals and intelligent lay people alike. It outlines a revolutionary technique for treating substance abuse that has a firm scientific basis and which has helped thousands of nicotine, alcohol and other addicts in South Africa, Scandinavia and the USA. Physicians and dentists can improve their knowledge of substance abuse, while allowing dentists to treat nicotine dependence in dental practice. Insights from the book enables doctors to treat nicotine and other forms of substance abuse in a safe, rapid and effective way. Lay people would increase their knowledge on substance abuse and find interesting and informative insights into the technique. Professionals will receive practical details of the use of PAN (psychotropic analgesic nitrous oxide) for treating substance abuse with special emphasis on nicotine addiction.

According to Prof Morris Clark, University of Colorado, Denver, and author of the current gold-standard textbook on the use of nitrous oxide for conscious sedation:'Prof Mark Gillman is a pioneering researcher and leader in the use and application of nitrous oxide' for treating substance abuse. Clark continues that Prof Gillman's 'opinion, experience and advice is much sought after worldwide. He received accolades for this ground breaking insight into this aspect on nitrous oxide use and readers of this text will appreciate the passion and the knowledge of the author and receive inspiration to stand on his shoulders and learn; also to illuminate this knowledge for their profession and their patients just as Mark Gillman has done over a lifetime.'

• Language: English
• Publisher: BookBaby
• Release date: Nov 24, 2012
• ISBN: 9781624885204

Book preview

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Chapter 1

Introduction

This manual was prompted by the approval in principle, of a new indication in dentistry for conscious sedation with nitrous oxide/oxygen in South Africa. Nonetheless, what is covered here has equal application to physicians. Indeed, some trained physicians have been using nitrous oxide/oxygen sedation since the mid-1980s to treat substance dependence, including nicotine dependence.

Practitioners may not be aware that nitrous oxide/oxygen sedation, otherwise known as psychotropic analgesic nitrous [PAN] (Gillman & Lichtigfeld, 1994) sedation is also listed in the Health Professions Council of SA (HPCSA) tariff list for medical practitioners. These codes are for treating alcohol and other withdrawal states, viz. codes 0203/0204 (Anonymous, 2008).

The majority of practitioners will be aware that there are also approved codes for inhalation sedation with nitrous oxide/oxygen or PAN sedation, viz. codes 8141/8143 (Anonymous, 2007).

Since there is a medical tariff for using PAN to assist with acute nicotine withdrawal (Anonymous, 2008) there is now a way for dentists to start charging patients when assisting them to quit.

This can be done by using the applicable medical practitioners’ codes for the use of PAN for withdrawal states (i.e. 0203/0204) plus the modifier 007. The latter modifier (i.e. code 007) allows dental practitioners to use an appropriate fee listed on the Reference Price List (RPL) for medical practitioners, when a procedure is performed that is not listed on the dental tariff schedule. Similarly, medical practitioners may use code 007 as a modifier when undertaking procedures on the dental tariff schedule.

Currently, it is unlikely that medical schemes will allocate benefits for treating nicotine dependence therapy for dentists. Nevertheless, practitioners who use PAN sedation are able to charge fees for assisting patients to abandon the use of tobacco.

However, practitioners are advised to always make it clear that patients themselves are personally liable for such fees in case their medical aid repudiates their claim.

Clearly, before embarking on this treatment modality, further information as well as training on the subject of PAN and acute nicotine dependence withdrawal is essential.

This manual has been produced to give practitioners a good theoretical background to this new dental indication for PAN sedation. As already mentioned, although aimed principally at dentists the manual can also be used by physicians, particularly if they have been trained in the use of PAN for other indications.

Assisting your patient to stop smoking or using tobacco products may be your most important contribution to you patient’s health. This applies to their systemic as well as their oral health. All tobacco products are harmful, both smoked tobacco - whether it is via cigarettes, pipes or cigars - or smokeless tobacco in the form of snuff or chewing tobacco (Anonymous, 2004).

Importantly, it has been said that there is no safe dose of tobacco. In other words, no matter how little is used, tobacco products are potentially harmful to the users’ health. Currently, the most effective method of reducing the accelerating increase in the morbidity and mortality due to tobacco products (for more information on this topic, see chapter 2)is by assisting smokers to stop the use of nicotine (Hatsukami et al, 2008).

Fortunately, there is some evidence that advice from health professionals about tobacco use and its dangers - plus assistance with quitting - has an important influence on patients’ decision to quit (Mecklenburg, 1995).

The health effects of using tobacco range from very minor to severe and even fatal. Tobacco has been linked to severe and often fatal diseases such as cancer, heart and respiratory diseases. It also seems to undermine foetal health during pregnancy. (Britton &Edwards, 2008).

Secondhand smoke is also deleterious to infant, child, adolescent and adult health. (Anonymous,2004).

A more detailed discussion of the diseases caused by tobacco will be found in chapter 2.It will also provide evidence showing that tobacco is the important aetiological factor in the pathogenesis of these conditions.

Tobacco is also associated with numerous negative effects related specifically to oral health. These range from common and relatively harmless conditions such as tooth staining and halitosis to severe and often fatal rarer conditions such as oral cancer (Mecklenburg, 1995).

Less severe conditions that are aggravated by tobacco include gingivitis and periodontitis. Tobacco also hinders treatment of gingivitis and periodontitis (Reibel, 2008, Sham et al, 2003).Other oral conditions associated with tobacco include smoker’s melanosis, smoker’s palate, and possibly caries and candidosis (Reibel, 2008). These will be dealt with in more detail in chapter 3.

Chapter 4 deals with the understanding of the concept of addiction from the perspective of the terminology and underlying principles of substance dependence and abuse. It also covers the historical development of modern concepts and definitions of substance abuse and dependence.

Chapter 5 discusses the biology of addiction and its relationship to the use of PAN for treating nicotine dependence.

Following on the biology of substance abuse and its relationship to PAN, chapter 6 considers the principles and technique of using PAN to treat nicotine dependence.

The final chapter of the manual deals with a schedule which details how to treat nicotine dependence, including the use of other adjunctive therapies with PAN. Some basic psychological aspects of nicotine dependence are also discussed here.

The manual ends with a compendium of useful tips entitled ‘Helpful hints for quitters’, which can easily be reproduced as a booklet for your patients to assist them during their attempted escape from nicotine dependence.

Dentists are in a unique position to assist patients quit tobacco use, because patients can very easily see some of the superficial and unpleasant consequences of smoking, such as halitosis and tooth staining. This is an excellent starting point from which dentists can go on to suggest that the patient should quit.

Because these stigmata are readily noticed the dentist can amplify the message by explaining that these are only the obvious and minor effects of tobacco. From here it is easy to begin to discuss the conditions associated with tobacco use, beginning with the relatively harmless and common conditions such as halitosis, tooth staining and the loss of taste. Thereafter, the practitioner can detail the rarer but severe effects such as cancer and even death. Although many patients are aware of the association between cancer and smoking, many are unaware of the other pathological conditions related to tobacco use. It is therefore helpful from a general health perspective to give patients such information. However, apart from a health education standpoint, there is a more important aspect of this discussion: it has been shown that patients take a lot more notice of matters relating to their health if it comes from a health practitioner.

Readers will probably be interested in some historical background on the development of the PAN therapy for substance dependence withdrawal. The PAN method is identical to minimal sedation. Other terms for PAN are relative analgesia or inhalation sedation (Langa, 1968; Clark & Brunick, 2008), or conscious sedation with nitrous oxide. As the sole sedative agent combined with local anaesthesia, it has been used successfully and safely for more than 50 years by dentists (Langa, 1968; Clark & Brunick, 2003).

The term PAN was introduced to differentiate the use of nitrous oxide for conscious sedation from its use for anaesthesia. The use of nitrous oxide for conscious sedation in dentistry is often confused with the anaesthetic use of nitrous oxide. It is further confounded by the number of terms used for it in dentistry (Gillman & Lichtigfeld, 1994).

The problems surrounding the terminology used to discuss PAN will be covered in more detail later in this manual.

The PAN therapy for acute addictive withdrawal from alcohol, opioids, cannabis, cocaine, sedatives (e.g. Valium) and nicotine was pioneered, researched and developed by the South African Brain Research Institute (SABRI). It was first used at Wedge Farm and then Wedge Gardens (Rand Aid Association, Johannesburg) starting in 1979. Wedge Gardens was until recently, the largest non-governmental alcoholic facility in South Africa.

The major funding for the research came from the Anglo-American and De Beers Chairman’s Fund. Numerous other large corporations have contributed to the research, including First National Bank, Johannesburg Consolidated Investments, Barlows, BHP Billiton and others.

Over the last 25 years, these corporations have donated research funding, as part of their corporate responsibility programmes, without commercial interest. Research funding over the years has also come from the S.A. Medical Research Council (MRC) and National Research Foundation (NRF).

Since the initial discovery of the therapy, more than 50,000 patients have been successfully treated. It has also been used in Scandinavia (since 1990) and more recently in the USA. In South Africa, it is used at an ever increasing number of SANCA (SA National Council for Alcoholism and Drug Dependence) societies, and in private medical practice.

Physicians began using PAN for treating tobacco and other addictions in the mid-1980’s(Gillman & Shevel, 1988). In 1992 it was given recognition by both the then Medical Association of SA (now SAMA) and the medical aid (insurance) movement by receiving an official medical aid code and fee (namely codes 0203/0204). As such, it is also recognised by the Health Professionals Council of SA (HPCSA) (Anonymous, 2008).

This treatment is unique in South African medical history. It is the first treatment that was officially recognised by the medical authorities which had been wholly conceptualised and developed in SA without input from elsewhere. The therapy is safe and exerts it therapeutic effect rapidly. It has proved effective for treating acute withdrawal states from all presently known dependence producing substances: alcohol,