Rhythmic tongue play and its possible correlation with the use of highly potent opioids and psychotropic drugs

Abstract:
This article examines the association between so-called rhythmic tongue play – repetitive, sometimes unconscious orofacial movement patterns – and the use or discontinuation of highly potent opioids and centrally acting psychotropic drugs. The aim is to determine the neurophysiological mechanisms that lead to these movements and to differentiate between pharmacologically induced dyskinesias, compensatory movement strategies, and psychomotor restlessness.

1. Introduction

Involuntary movements in the tongue and oral cavity can be an expression of dopaminergic dysregulation, which is often observed in the context of psychoactive substance use. Particularly with opioids (e.g., fentanyl, oxycodone, methadone), as well as neuroleptics, antidepressants, and benzodiazepines, stereotypical motor patterns are observed, ranging from simple chewing movements to rhythmic tongue beats.

2. Neurophysiological Basis

Tongue motor function is controlled by a network of cortical and subcortical structures. Relevant areas are:

• Hypoglossal nucleus: primary motor center of the tongue.

• Basal ganglia: modulate movement rhythm and inhibition of repetitive patterns.

• Dopaminergic pathways: particularly the nigrostriatal system.

Opioids and many psychotropic drugs influence these systems indirectly via receptor binding (μ-, κ-, δ-receptors) and via the modulation of dopaminergic transmission. Dopaminergic hypersensitivity after prolonged drug exposure can cause so-called tardive dyskinesias – a syndrome characterized by rhythmic tongue movements.

3. Pharmacological Influences

3.1 Opioids:
High doses or withdrawal of opioids lead to dysregulation of the central pattern generator in the brainstem. Studies show increased neuronal oscillatory activity in the 4-6 Hz range, which promotes rhythmic motor movements.

3.2 Psychotropic Drugs:
Antipsychotics, especially classic dopamine D2 antagonists (haloperidol, fluphenazine), are predisposed to orofacial dyskinesias. Atypical substances (clozapine, olanzapine) reduce the incidence, but can have a synergistic effect when combined with opioids or benzodiazepines.

3.3 Combination Effects:
Polypharmacy – especially the concurrent use of opioids and antipsychotics – significantly increases the risk of motor dysregulation. Neuroadaptations in the striatum lead to disinhibition of automated movement patterns.

4. Psychological and Behavioral Aspects

Some rhythmic tongue play can also be psychogenic. Under the sedative or dissociative effects of the medication, repetitive movements arise as a form of self-stimulation or a calming mechanism. Similar phenomena occur in autistic and post-traumatic states.

5. Diagnosis and Differential Diagnosis

The following procedures are suitable for distinguishing pharmacologically induced from psychogenic motor activity:

• Electromyography (EMG): Frequency analysis of muscle activity.

• Video analysis: Recording of the movement pattern under standardized conditions.

• Medication history: Medication course, dosage fluctuations, withdrawal phases.

6. Clinical and Therapeutic Relevance

The observation of rhythmic tongue movements can be an early indicator of dopaminergic dysregulation. Early dose adjustment, switching to medications with lower extrapyramidal stress, and adjuvant therapy (e.g., vitamin E, tetrabenazine) are clinically relevant.

7. Conclusion

Rhythmic tongue movements represent a visible correlate of neurochemical imbalances, particularly in the interaction of highly potent opioids and psychotropic drugs. They can serve as a diagnostic window for the early detection of incipient dyskinesias or withdrawal symptoms. Further interdisciplinary research is needed to understand the precise neurophysiological circuits and their pharmacological modulation.

Keywords: Tongue motor function, dyskinesia, opioids, psychotropic drugs, dopamine, neurophysiology, movement disorder

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