The major medical complications of heroin addiction

Rhabdomyolysis and concomitant neurological lesions after intravenous heroin abuse

Seven cases of rhabdomyolysis in heroin addicts are presented. All patients showed concomitant neurological symptoms suggesting mononeuropathy, incomplete plexus lesions or myelopathy. In most cases rhabdomyolysis occurred without preceding trauma to the muscles (for example tissue compression or coma). Five patients had a history of recently resumed heroin abuse after prolonged abstinence. An allergic or toxic reaction to heroin or adulterants seems to be more likely than trauma in the pathogenesis of these complications. Severe rhabdomyolysis can occur without visible muscular swelling. Routine screening of creatine kinase is recommended in heroin addicts with neurological complications, as rhabdomyolysis may lead to fatal renal failure and may easily fail to be diagnosed.

Heroin myelopathy: a case report

Acute transverse myelitis was observed as a complication of intravenous heroin addiction in a young man. Recovery within seven weeks was good, but not complete. The literature is reviewed and the possible pathogenetic mechanisms are discussed.

Morphine and methadone impact on human phagocytic physiology

Human subjects submitted to treatment with morphine show a severe depression of phagocytosis, killing properties and superoxide production both of their polymorphonuclear leukocytes and monocytes. Polymorphonuclear leukocyte adherence, chemotaxis, random migration, myeloperoxidase content, lysozyme content and lymphocyte Rosette E formation were poorly influenced. Methadone-treated subjects show a similar effect at phagocytic level but far less evident. These results confirm those previously found in animals and reinforce the evidence of a depressive role of morphine on phagocytic physiology.

Evidence for the activation of the endogenous opiate system in hamsters infected with human blood flukes, Schistosoma mansoni

Nociceptive thresholds were investigated in golden hamsters infected with the human blood fluke, Schistosoma mansoni. Increases in thermal thresholds suggestive of analgesia were evident by 20-25 days of infection. These increased further during a 40-42 day period. The altered responses were suppressed by the opioid antagonist naloxone. Non-invasive inhibition of the activity of the pineal gland by exposure to light also reduced nocturnal analgesia in schistosome infected animals. Naloxone antagonism and pineal inhibition of morphine- induced analgesia was obtained similarly in control, uninfected animals. Taken together, these findings suggest strongly that infection with S. mansoni results in a chronic activation of the endogenous opiate system.

Heroin-related deaths: new epidemiologic insights

Deaths associated with injected street preparations of heroin increased substantially in the District of Columbia between April 1979 and December 1982. The 1981 population-based mortality rate (17.4 per 100,000) is possibly the highest ever reported. A case-control study based on toxicologic analyses of postmortem blood samples indicates that concentrations of both heroin and ethanol are substantial risk factors for heroin-related deaths. Analyses of the composition of street-level preparations of heroin and quarterly mortality indicate that the quantity of heroin in packages sold on the street, the price of heroin in these packages, and the quinine weight per package each predict deaths equally as well. An increase in the causal use of heroin in combination with ethanol and quinine is the probable cause of this epidemic.

Cardiac fungal infections: review of autopsy findings in 60 patients

An autopsy study of 60 patients with fungal infections of the heart was undertaken. The patients ranged in age from 2 months to 79 years. Fifteen of the patients had undergone cardiac surgery; neoplasms were found in 13, renal failure in eight, bacterial infections in five, liver disease in five, gastrointestinal disorders in five, and immune disease in four; two had been intravenous drug abusers; other miscellaneous disorders were observed in three. The fungal infection was limited to the myocardium in 27 patients and to the endocardium in 17 patients. Myocardium and endocardium were involved in nine patients and pericardium and myocardium in five; two patients had pericarditis alone. The most frequent organism was Candida (62 per cent). Aspergillus (12 per cent) and Phycomycetes (12 per cent) were also found frequently. In 51 patients (85 per cent) other deep organs, usually lung, kidney, brain, or spleen were involved. Cultures for fungus had been positive in 26 patients prior to death, and postmortem cultures were positive in 29 patients. Patients who had undergone cardiac surgery had a higher incidence of endocarditis (93 per cent), with Candida (53 per cent) being the most frequent cause. Patients who had received antineoplastic drugs, antibiotics, or corticosteroids had a higher incidence of myocarditis (79 per cent), again most often due to Candida (60 per cent).

Accelerated development of pulmonary complications due to illicit intravenous use of pentazocine and tripelennamine

To gain information concerning the natural history and prevalence of pulmonary gas exchange abnormalities resulting from intravenous drug abuse, 45 intravenous drug users were studied. Twenty subjects used a mixture of the synthetic opiate pentazocine and the antihistamine tripelennamine, which, under the street name T's and B's, has become very popular in some urban areas as an available substitute for heroin. Compared with the 19 heroin addicts studied, the pentazocine and tripelennamine users had a significantly shorter mean duration of intravenous drug abuse (2.7 +/- 0.4 years versus 7.6 +/- 0.9 years, p less than 0.01), a greater frequency of respiratory symptoms (75 percent versus 36 percent, p less than 0.05), a significant reduction in the mean diffusing capacity of the lung for carbon monoxide (58.4 +/- 3.3 percent predicted versus 75.5 +/- 5.6 percent predicted, p less than 0.01), and abnormal responses to submaximal steady-state exercise testing. The intravenous use of pentazocine and tripelennamine and probably most other drug preparations intended for nonparenteral use represents a particularly noxious form of drug abuse that may lead to early respiratory complications in a large proportion of users.

Immunological status in heroin addicts: effects of methadone maintenance treatment

In opiate addicts specific and unspecific immune responses were examined, before and after methadone treatment. Anomalous immune responses were characterized by compromised cellular immunity (functional deficits of polymorphonuclear leukocytes and T-lymphocytes) in association with efficient production of antibodies. After methadone treatment an elevation of leukocyte functions was noted. The presence of elevated titres of circulating immune complexes observed in all the patients tested could bring about a functional exhaustion of neutrophils. The defects of cellular immunity can be considered important risk factors in the pathogenesis of infectious diseases in addicts.

Overwhelming pneumonia

A classification of normal-abnormal hosts and pathogens forms the basis for discussion of the diagnosis and management of pneumonia in the critical care setting. In order to arrive at the appropriate therapy for the unusual as well as the usual causative organisms of pneumonia, individual assessment of the need for invasive procedures must be made. The critical feature, however, is to consider the wide spectrum of possibilities for each individual patient.

The immediate management of overdose

Success in reviving victims of overdose may be achieved by careful attention to cardiovascular and respiratory support and a high urinary output. In addition to these general principles, special measures may be indicated in cases of specific drug overdose. Such measures are outlined for various drugs, including acetaminophen, aspirin, phencyclidine, barbiturates, and organophosphates.

Intravenous drug addiction--staphylococcal septicemia--pulmonary embolism: a triad pathognomonic for tricuspid valve endocarditis?

28 patients (29 episodes) presenting the triad of intravenous narcotic drug addiction, Staphylococcus aureus septicemia and septic pulmonary embolism were examined for the presence of tricuspid valve endocarditis. In a prospective study, 12/13 patients examined by echocardiography had vegetations on the tricuspid valve, in 6 detected by M-mode, in 5 by 2-D technique, and in one by both methods. In 4 patients with tricuspid endocarditis, no significant murmurs were heard. Similarly, in a retrospective study, 5/16 patients not subjected to echocardiography had no murmurs consistent with tricuspid valve endocarditis. One of these patients died. In 2/16 patients the diagnosis was verified at autopsy and in 1 at heart surgery. In both groups, altogether 11 patients never developed murmurs, in 7 of them despite demonstrable vegetations. Therefore, we consider the triad to be pathognomonic for tricuspid valve endocarditis, provided that no peripheral source of emboli is present. Consequently, patients fulfilling these criteria should be treated as suffering from endocarditis. Echocardiographic examination does not seem necessary in patients with a typical clinical picture but may be helpful when chest X-rays are inconclusive or complications are suspected.

Drug "overdoses" among U.S. soldiers in Europe, 1978-1979. II. autopsies following deaths and near-deaths

On-site investigations involving interviews with spouses, friends, coworkers, supervisors, and commanders were conducted following 37 deaths or near-deaths by drug overdose among U.S. soldiers stationed in Europe. Subjects were all active-duty soldiers put on the seriously ill list at any Army hospital with an initial diagnosis which included suspected drug overdose. Victims were typically single Black males, less than 22, high school graduates in excellent health. They had been in Germany 7-24 months, liked their jobs, and were judged better than average workers by both peers and supervisors. Fifty percent played on a unit sports team, 6 of 10 had German girlfriends, and one-third had prior disciplinary problems. Although nearly half had been previously identified as having a drug or alcohol problem, only two or three could be called addicts in even the broadest sense. Six cases were suicide gestures, and only these six cases did not involve heroin and/or alcohol. The modal case followed a party, with substantial drinking. In only 25% of the cases did the victim collapse upon injection. More often he went to bed, vomited during the night, and choked on or inhaled vomitus. The data suggest reexamination of two common myths: that heroin users comprise a very unique, albeit undesirable, sample of the general population; and that "overdose" deaths are the result of ignorance, incompetence, or indifference.

Narcotic maintenance for chronic pain. Medical and legal guidelines

Narcotic maintenance may be needed to relieve chronic pain in ambulatory patients who fail to respond to other pain therapies. Oral, long-acting narcotics are preferred, and nonnarcotic pain therapies can be administered simultaneously to reduce the narcotic dosage. To legally undertake narcotic maintenance, the physician must document the presence of an incurable, painful medical condition. We recommend that the patient give informed consent, since narcotic maintenance may lead to dependence and addiction. When done properly, narcotic maintenance is an appropriate medical-legal procedure that is safe and may provide humanitarian pain relief.

Addict death rates during a four-year posttreatment follow-up

Mortality rates were examined among 3,324 Black and White daily opioid drug users for a four-year period following treatment in community-based agencies located across the United States. A total of 179 of these addicts died during this follow-up period, yielding a death rate of 15.2 per 1,000 person-years at risk. When adjusted for age, addict death rates were found to be three to 14 times higher than those in the general US population. Life table analysis was also used to examine these rates in relation to client demographic, background, and treatment variables obtained prospectively, both prior to and during treatment. Age, alcohol use, and criminal history were positively associated with higher death rates. With regard to causes of death, age proved to be the only significant predictor; older addicts (over 30) had the highest percentages of deaths due to "natural" causes, while over three-fourths of the deaths among younger addicts were drug related or involved violence.

Heroin "overdose" death: contribution of drug-associated environmental cues

A model of "overdose" deaths among heroin addicts is proposed which emphasizes recent findings concerning the contribution of drug-associated environmental cues to drug tolerance. Results of animal experiments performed to evaluate this model suggest that conditioned drug-anticipatory responses, in addition to pharmacological factors, affect heroin-induced mortality.

Immunity and nutrition in heroin addicts

An immunological and nutritional survey was conducted on 16 heroin addicts and 16 control subjects matched for age and sex. Skin testing showed none of the addicts to be anergic. Three of four individuals who had positive purified protein derivative (PPD) skin tests failed to produce leucocyte migration inhibition factor (LMIF) to PPD in vitro; in contrast, four of five PPD skin test positive controls produced LMIF. A relative lymphocytosis was found in the heroin addicts although the percentage of 'T' lymphocytes (E-rosetting techniques) was similar to that of the control population. A significant elevation of serum IgG and IgM (p less than 0.0005) was present. Although none of the addicts studied were nutritionally deficient, the serum vitamin C, B6 and albumin levels were significantly lower than in the controls. Elevation of serum aminotransferase values occurred in half the patients, but there was no correlation with presence of serum markers of hepatitis B infection or absent LMIF production. The results suggest that heroin addicts are capable of responding to antigens when their nutritional status in normal, despite the presence of liver enzyme abnormalities.

Acute myelopathy in association with heroin addiction

The occurrence of spinal cord lesions in association with self-administration of heroin is a recognised entity in the United States of America which has not up to now been reported in British literature. Three cases are described, the literature reviewed and possible aetiological factors discussed.

Hematogenous staphylococcal pneumonia secondary to soft tissue infection

Staphylococcal pneumonia is rare, has a high mortality and morbidity rate, and occurs commonly during influenza epidemics (airborne) or during the course of right sided bacterial endocarditis in drug addicts (blood borne). In recent years, much emphasis has been given to the staphylococcal infections in intravenous drug abusers. This report describes ten patients with staphylococcal pneumonia resulting from soft tissue infection who were previously healthy and had no history of drug abuse. They were 12 to 45 years old. Eight were male patients. Soft tissue infection was community-acquired in nine and was most commonly located in the lower extremities. Three patients had diabetes. All presented with a clinical picture of acute pneumonia. Hemoptysis occurred in three. Chest roentgenogram showed multiple large or small round discrete densities in most of the patients. Lobar involvement was notably absent. Eight developed cavitary lesions in their lungs. The average length of hospital stay was 40 days. One patient died and six developed complications. Staphylococcal etiology should be suspected in patients with acute pneumonia who have soft tissue infection or have characteristic chest roentgenogram findings; antistaphylococcal agents should be included in the therapeutic regimens of such patients until the results of the cultures are known.

Pseudomonas infection of the symphysis pubis in a heroin user: a case report

This article reports a case of Pseudomonas aeruginosa infection of the symphysis pubis in a heroin user. Cultures showed the organism to be sensitive to gentamicin, and cure was effected after the use of intravenous gentamicin therapy and operative curetting of joint debris and affected bone. The patient remained asymptomatic at the nine-month followup.

Effect of chronic administration of morphine on primary immune response in mice

The effect of 3 different doses of chronically-administered morphine on the primary immune response was studied in mice by estimating spleen/body weight ratio and serum hemolysin production against sheep red blood cells (SRBC). It was observed that morphine exerted a dose-dependent inhibitory effect on the immune response which was antagonized by the concomitant administration of naloxone. The findings suggest that the inhibitory effect of morphine is specific.

Candida endophthalmitis and drug abuse

Candida endophthalmitis after intravenous heroin is described. Our patient had an initial rapid deterioration on systemic corticosteroids. Systemic amphotericin B, 5 flucytosine, vitrectomy and retinal surgery were required to achieve a final visual acuity of 6/24. The difficulty of an early diagnosis and the deleterious effect of corticosteroid use are emphasized.

Listeria monocytogenes empyema and bacteremia complicating chronic lymphocytic leukemia

A 60-year-old man receiving corticosteroid and cyclophosphamide therapy for chronic lymphocytic leukemia developed an empyema and bacteremia due to Listeria monocytogenes. The rapidly fulminant course of Listeria infections in immunosuppressed hosts and the necessity of prompt treatment of Listeria empyemas are emphasized.

The impact of heroin abuse on a regional end-stage renal disease program

The causes for end-stage renal disease (ESRD) in 148 consecutive patients 18-45 years of age were analyzed over a five-year period in the Buffalo-SMSA. Incidence, diagnostic category specific, prevalence, age patterns, and life expectancy are provided by sex, race, and heroin abuse status. A striking correlation between heroin abuse, glomerulonephritis, and ESRD among Blacks was discovered, demonstrating the impact of heroin abuse on both the cost and statistical interpretation of the causes for ESRD.

Candida myocarditis in a young heroin addict

A twenty-year-old male heroin addict was found dead in his home. Histological examination of numerous myocardial samples lead to a diagnosis of purulent myocarditis due to Candida albicans.

Infective endocarditis in the narcotic addict

As long as the illicit use of heroin and other drugs continues in our society, infective endocarditis will remain a significant medical problem in the drug-using population. The majority of infections are produced by S. aureus, and the tricuspid valve is most commonly involved. Addicts, unlike the general population, may also develop endocarditis with a variety of gram-negative bacilli and have a higher incidence of fungal infection. The outcome of each individual infection is dependent on the prompt recognition of the underlying valvular infection and the institution of antimicrobial therapy. Infection of the tricuspid valve has a much more favorable prognosis than does infection of the aortic or mitral valves. Fungal endocarditis, and frequently gram-negative bacillary endocarditis, require valvular surgery to effect a cure.

Cardiac lesions in intravenous drug addicts

Postmortem findings in 25 intravenous addicts of centrally stimulating amines and centrally depressive narcotics (opiates) have been analysed with special reference to the presence of pathologic findings in the heart, and the cause of death. Most cases exhibited myocardial lesions of varying age, consistent with various phases of myofibrillar degeneration, such as hemorrhages, contraction bands, focal necroses, granulation tissue, stromal condensation, and scarring, indicating an active chronic process in the myocardium and the subendocardium, with a bias toward the conduction system of the heart. The lesions have been found in drug addicts who died immediately following an injection of narcotics as well as in those who, irrespective of their drug influence, have died following intervening injuries or disease. Cardiac lesions in drug addicts seem to have a variety of causative factors: infections, toxic influence, hypersensitivity, influence of catecholamines and general hypoxia. The authors feel that the two latter suggested causes appear most regularly and deserve special attention. The significance of these heart lesions seems to vary, but at times they may be the determining factor in the fatal outcome of a case.