MENSTRUAL ABNORMALITIES ASSOCIATED WITH HEROIN ADDICTION

Sexual Dysfunctions in Patients Receiving Opioid Agonist Treatment and Heroin-Assisted Treatment Compared to Patients in Private Practice-Identifying Group Differences and Predictors

BACKGROUND AND AIMS

Sexual dysfunctions (SDs) show a marked impact on a person's general wellbeing. Several risk-factors like physical and mental illnesses as well as alcohol and tobacco use have to date been identified to contribute to the occurrence of SDs. The impact of opioid-agonist treatment (OAT) on SDs remains unclear, with some studies demonstrating an improvement after methadone maintenance treatment (MMT) initiation. However, no studies on the prevalence and predictors of SDs in heroin-assisted treatment (HAT) exist to date.

METHODS

A cross-sectional study was conducted with patients from a MMT center (n = 57) and a center specializing in HAT (n = 47). A control group of patients with mild transient illnesses (n = 67) was recruited from a general practitioner (GP). The International Index of Erectile Function, the Female Sexual Function Index, as well as measurements for psychological distress, depressive state, nicotine dependence, and high-risk alcohol use were employed. Patients also completed a self-designed questionnaire on help-seeking behavior regarding sexual health. Mann-Whitney-U tests and chi-square tests were performed for group comparisons and binary logistic regression models were calculated.

RESULTS

Twenty-five percent of the GP sample (n = 17), 70.2% (n = 40) of the MMT sample, and 57.4% (n = 27) of the HAT sample suffered from SDs at the time of study conduction. OAT patients differed significantly from GP patients in depressive state, high-risk alcohol use, nicotine dependence, and psychological distress. Age, depressive state, and opioid dependence predicted the occurrence of SDs in the total sample. No differences between OAT and GP patients were found regarding help-seeking behavior.

DISCUSSION

Age, depressive state, and opioid dependence predicted the occurrence of SDs in the total sample. It remains unclear whether SDs are caused by opioid intake itself or result from other substance-use related lifestyle factors, that were not controlled for in this study. A lack of help-seeking behavior was observed in our sample, underlining the importance of clinicians proactively inquiring about the sexual health of their patients.

CONCLUSION

The high prevalence of SDs observed in MMT does not differ from the prevalence in HAT. Clinicians should actively inquire about their patients' sexual health in GP and OAT centers alike.

The effects of maternally administered methadone, buprenorphine and naltrexone on offspring: review of human and animal data

Most women using heroin are of reproductive age with major risks for their infants. We review clinical and experimental data on fetal, neonatal and postnatal complications associated with methadone, the current "gold standard", and compare these with more recent, but limited, data on developmental effects of buprenorphine, and naltrexone. Methadone is a micro-opioid receptor agonist and is commonly recommended for treatment of opioid dependence during pregnancy. However, it has undesired outcomes including neonatal abstinence syndrome (NAS). Animal studies also indicate detrimental effects on growth, behaviour, neuroanatomy and biochemistry, and increased perinatal mortality. Buprenorphine is a partial micro-opioid receptor agonist and a kappa-opioid receptor antagonist. Clinical observations suggest that buprenorphine during pregnancy is similar to methadone on developmental measures but is potentially superior in reducing the incidence and prognosis of NAS. However, small animal studies demonstrate that low doses of buprenorphine during pregnancy and lactation lead to changes in offspring behaviour, neuroanatomy and biochemistry. Naltrexone is a non-selective opioid receptor antagonist. Although data are limited, humans treated with oral or sustained-release implantable naltrexone suggest outcomes potentially superior to those with methadone or buprenorphine. However, animal studies using oral or injectable naltrexone have shown developmental changes following exposure during pregnancy and lactation, raising concerns about its use in humans. Animal studies using chronic exposure, equivalent to clinical depot formulations, are required to evaluate safety. While each treatment is likely to have maternal advantages and disadvantages, studies are urgently required to determine which is optimal for offspring in the short and long term.

Menopause symptoms in HIV-infected and drug-using women

OBJECTIVE

To examine the association of HIV infection, drug use, and psychosocial stressors with type and frequency of menopause symptoms.

DESIGN

In a cross-sectional study, HIV-infected and HIV-uninfected midlife women underwent standardized interviews on menopause status and symptoms, demographic characteristics, depressive symptoms, negative life events, and substance abuse. Body mass index (BMI), HIV serostatus, and CD4 count were measured. Associations between study variables and menopause symptoms were assessed using generalized estimating equations.

RESULTS

Of 536 women not on hormone therapy, 48% were black, 42% were Hispanic, 54% were HIV positive, and 30% recently had used illicit drugs. The mean age was 45 +/- 5 years; 48% of the women were identified as premenopausal, and 37% were perimenopausal. Psychological symptoms were most prevalent (89%), followed by arthralgias (63%) and vasomotor symptoms (61%). Perimenopausal women reported significantly more menopause symptoms than premenopausal women (ORadj 1.34, 95% CI, 1.09-1.65). HIV-infected women were more likely to report menopause symptoms than uninfected women (ORadj 1.24, 95% CI, 1.02-1.51). Among HIV-infected women not on highly active antiretroviral therapy, symptoms decreased as the CD4 count declined. Increased menopause symptoms were significantly associated with depressive symptoms (ie, Center for Epidemiologic Studies Depression scale score > 23, ORadj1.82, 95% CI, 1.46-2.28), and with experiencing more than three negative life events (ORadj 2.08, 95% CI, 1.54-2.81). Increasing BMI (per kg/m) was also associated with more menopause symptoms (ORadj 1.03, 95% CI, 1.02-1.05).

CONCLUSION

HIV-infected women reported more menopause symptoms than HIV-uninfected women, but symptoms were less frequent in women with more advanced HIV disease. Depressive symptoms and negative life events were also highly associated with symptoms. Further study of menopause symptoms and HIV-related factors is warranted. Mental health interventions may also have a role in ameliorating menopause symptoms.

Obstetric and neonatal outcomes associated with maternal naltrexone exposure

Poor maternal and neonatal outcomes are associated with the pregnant heroin user. These include increased antepartum haemorrhage, decreased neonatal birthweight and increased neonatal mortality Medically supervised withdrawal from heroin during pregnancy has, however, been discouraged due to possible risk to the fetus and because of the high incidence of return to regular illicit heroin use by the mother. In recent years, however, a number of withdrawal procedures using anaesthesia, oral sedation, or intravenous sedation, precipitated by naloxone and/or naltrexone have been developed and carried out successfully on pregnant heroin users. We have now collated information on 18 cases (19 detoxifications) from three countries (Portugal, Australia and the United Kingdom). These case study data, although limited, indicate that detoxification of the pregnant heroin user is possible without significant risk to the neonate or mother, with many women not returning to dependent heroin use following detoxification. Naltrexone maintenance has also been used in the non-pregnant heroin user to discourage illicit heroin use. Similarly to methadone, stabilisation on naltrexone may be associated with conception and pregnancy Over the past three years, 26 women have conceived while on the Western Australia naltrexone program. Due to the unknown teratogenic effects, most have ceased naltrexone intake at approximately seven or eight weeks gestation. In a number of instances, however, naltrexone maintenance has been recommenced following return to a dependent pattern of heroin use. As a consequence, neonates have had different periods of naltrexone exposure, building from the initial seven or eight weeks. We now report on seven women who have delivered and three who are well into their third trimester. Neonatal and obstetric features were unremarkable with good Apgar scores, birthweight and head circumference observed. In the three cases still in third-term gestation, normal fetal development has been observed at recent ultrasound examinations. These case data indicate that naltrexone maintenance may have a role in the management of the pregnant heroin user.

Acute and long-term effects of AIDS and injection drug use on gonadal function

Hypogonadism has been observed in both the HIV-infected population and injection drug users (IDUs). Considering these populations in conjunction is essential because IDUs and HIV often occur in the same individual. Additionally, although the etiology of hypogonadism may be different in each population, its treatment with respect to the underlying condition is similar. The philosophy of both AIDS and IDU treatment has changed drastically in recent years, due to several factors. Survival rates of HIV patients have been steadily increasing, forcing a closer examination of the long-term effects of AIDS-related symptoms, and the quality of life issues associated therewith. In comparison, IDU is now viewed as a chronic addiction like that for alcoholism, which must be treated, rather than an untreatable personal problem. Therefore, it is logical that the endocrine and metabolic changes associated with both HIV and IDU should be examined to help alleviate these symptoms in a continuing effort to treat the underlying condition.

Adolescent heroin use: a review

Use of heroin by American teenagers is beginning to show disturbing increases in national and statewide surveys. According to data from the 1997 National Institute on Drug Abuse monograph Monitoring The Future, heroin use by American high school 12th graders was 100% higher than it was from 1990 to 1996 (0.90-1.8%). In 1997, there was a further increase to 2.1%. Additional support for an increase in heroin use in the United States comes from analysis of recent survey data from California, Texas, and Maryland. Heroin imported from Colombia and from Mexico is now cheaper and of high potency, permitting novices to start with nasal administration of the drug. Most American adolescents now initiate heroin use by snorting it; however, frequent use of heroin by any route rapidly leads to tolerance and intense drug craving. Psychological dependence to heroin, and to the often exciting yet chaotic lifestyle of a heroin addict, is very difficult to overcome. Acute heroin withdrawal syndrome is usually not severe and most addicts in withdrawal can be managed in an outpatient setting. Naloxone must be used with great restraint and in smaller than usual doses in known heroin addicts. Successful long-term management often includes acute detoxification followed by long-term residential drug treatment. Managed care payment issues have impeded placement in appropriate treatment programs. Additional long-term management issues include regular attendance at 12-step meetings (Alcoholics Anonymous or Narcotics Anonymous), biweekly urine tests for drugs of abuse, attention to issues of dual diagnosis (group or family therapy), and reapproachment with family, school, and straight friends.

Drug abuse and reproduction

It is clear that a number of CNS agents, including drugs of abuse, can inhibit reproductive function. Figure 1 shows the chemical diversity of some of the drug groups that affect reproductive hormones. Their structural dissimilarity to the steroid hormones is also readily apparent in the figure. These chemically diverse drugs share an important pharmacologic property: they are highly potent neuroactive drugs, and they can disrupt hypothalamic-pituitary function. Although it is frequently difficult to distinguish between direct drug actions on the hypothalamic-pituitary axis and subsequent effects on gonadal hormones and sex accessory gland function, the distinction is an important one. Most neuroactive drugs produce only transient effects on the central nervous pathways necessary for normal gonadotropin secretion. The disruptive effects of these drugs are likely to be transient and completely reversible, and tolerance to the inhibitory drug effects may occur even with continued drug use. Under these circumstances, normal adults may experience only subtle changes in sexual function. However, individuals with compromised reproductive function may exhibit major problems. It is also likely that adolescents may be at substantial risk for reproductive damage from these neuroactive drugs since the endocrine events associated with puberty are dependent on the normal development of the hypothalamic-pituitary axis.

Opioid biology: the next set of questions

A range of biologically different opioid peptides are synthesised as components of three distinct precursors, pro-opiomelanocortin, proenkephalin, and prodynorphin. They interact with a number of receptors which have so far been characterised as mu, delta, kappa, sigma, and epsilon. It is unclear which ligands bind to which receptors under physiological circumstances, but preferential in vitro interactions include enkephalins with delta receptors, dynorphin with kappa receptors, and beta-endorphin with epsilon receptors. Post-translational processing determines which of several opioid products are produced from each precursor, but the identity of the enzymes involved and regulation of processing is unknown. Opioid involvement in the neuroendocrine and cardiovascular systems is reviewed. Naloxone-sensitive opioid mechanisms are implicated in the control of gonadotrophin and adrenocorticotropic hormone secretion and in the hypotension of various types of shock. The investigation of possible dynorphin involvement in neurohypophysial function is taking place because vasopressin and dynorphin A (1-8) have been shown to coexist in the neurosecretory vesicles of magnocellular neurons.

Enkephalins and Endorphins. Clinical, pharmacological and therapeutic implications

During the past 8 years there has been substantial progress in our understanding of the structure, distribution and action of endogenous opioid peptides. Currently, there appear to be 2 groups of peptides; those derived from beta-lipotropin and an enkephalin-related group. Some of these peptides have been shown to be distributed widely in the central nervous system and in endocrine tissues. The activity of the peptides probably occurs at several receptors but only 1 relatively specific (mu-receptor) antagonist, naloxone, is well studies. Although there have been many clinical studies of the action of opioids in man, no novel therapeutic applications have yet been established in clinical practice. Of the many areas of involvement attributed to opioids, those of analgesia, reproductive endocrinology, opiate dependence, and certain as yet undefined subtypes of major psychoses seem reasonably promising. Speculation surround opioid involvement in other disorders such as spinal trauma, septic shock, alcohol dependence, "functional' gastrointestinal disease, diabetes and asthma is of considerable interest but is supported by less clinical evidence. It seems that as research in opioids advances, the putative physiological opioid "spheres of influence' widen. At the same time, opioid mechanisms of action are being revealed to be more subtle and complex than previously thought. As a consequence, the expectations of rapid therapeutic application of opioid peptides and their antagonists are being modified and refined and realistic research strategies applied. In view of the work reviewed in this paper it seems reasonable to expect that such work will pay dividends in the not too distant future.

The newborn addict, ante- and postnatal care

An investigation is presented of 87 Danish infants born to 62 drug-addicted mothers who had been pregnant altogether 145 times. In Denmark all pregnant women are offered prophylactic examinations, sometimes by their family doctor, sometimes by the midwife and in special cases by the obstetric clinic. Despite the fact that this antenatal care is considered especially important, not least for the addicted, pregnant woman, these offers were only poorly utilised. There were four perinatal deaths, of which two were stillbirths, further 3 infants died later as a result of abuse or neglect. After discharge from hospital only 43 infants lived at home with their mothers. The rest were either voluntarily or compulsorily placed with the mothers' parents, in family care, or in a childrens home. Only 2 infants were adopted. After their return home from the labour wards the mothers took little advantage of the prophylactic paediatric examinations and the vaccination program which are offered free by the family doctor to all children of pre-school age. The same was true regarding domiciliary visits by the health visitor.

The endocrinology of the opiates and opioid peptides

Since the isolation of the enkephalins five yr ago, there has been an explosive increase in knowledge concerning the effects of the opiates and opioid peptides. This review deals with the interactions of opiates with the endocrine system in rat and man. The opioid peptides have been demonstrated to exert a variety of effects on pituitary hormone secretion in rat and man. In the rat, opiates stimulate growth hormone, prolactin and ACTH release and inhibit the release of the glycoprotein hormones. In man, the physiologic role of the endogenous opiates appears to be involved predominantly in ACTH and gonadotrophin regulation. Opiate effects are mainly exerted at the level of the hypothalamus but further modulating effects may occur at the pituitary and at end-organs. Opiate-induced hormonal effects appear to be mediated through dopaminergic and/or serotonergic mechanisms. Recent studies have also suggested a possible local neuromodulatory role for the opioid peptides in the control of carbohydrate metabolism and reproductive processes.

Difficulties in taking care of business: women addicts as mothers

This paper is devoted to a discussion of women addicts as mothers. Women who are addicted while pregnant begin their careers as mothers with extreme guilt and a sense of initial failure. Heroin becomes a mechanism for coping with the routine difficulties of childraising. Children can also act as a controlling force on their mother's addiction if she has the option to perform her mothering duties in an otherwise "normal" fashion. If the woman is being supported adequately and can be available for her children, it is possible to combine addiction and mothering. Often, however, the woman has to work outside the home (usually in criminal pursuits) and the general chaos of her life greatly impinges on her ability to fulfill her mothering duties. Children are occasionally mistreated, sometimes neglected physically, and often neglected psychologically by a mother who is frequently absent. Addicted mothers feel extreme guilt and remorse over this neglect, and often take stock of their situation when their roles as a mother is threatened; the children are being taken away physically or growing up and she is losing them to time. The woman addict most often wants "out" of the heroin life when her children and her role as mother--her last remaining option--are in jeopardy.

Effects of morphine and methadone on the nuclear uptake of estradiol by the brain

Rats were treated for ten days with morphine (50 microgram/kg) or methadone (10 mg/kg). On the tenth day the animals were injected with 3H-estradiol, and the nuclear uptake of the steroid by the central nervous system was evaluated by autoradiography. Neither of the opiates were found to have any significant effect on the nuclear uptake of 3H-estradiol by the central nervous system. The data suggest that the mechanism by which methadone and morphine inhibit normal reproductive function in addicts is probably not the inhibition of nuclear uptake of estradiol.

The effect of maternal narcotic addiction on the newborn infant

This paper presents a review of the literature on the effects of maternal narcotic addictions upon the foetus and newborn infant. Six children born to 'registered' narcotic addicts were studied, and particular attention was paid to any signs of narcotic withdrawal that might occur after birth. Although all the mothers took heroin or methadone regularly up to the time of delivery, minor physical signs which might have been considered part of the withdrawal syndrome occurred in only one baby. The absence of major withdrawal signs found in this study contrasts with previous findings. The reasons for these differences are discussed, and the implications of these observations for the management of the pregnant narcotic addict and her newborn infant are considered.

Multiple births in drug-addicted women

Two sets of twins and two sets of triplets were delivered in a group of 126 pregnant drug addicts. The over-all multiple-birth incidence of 1:32 is three times more prevalent than that found in the general population. Three of the four multiple births were dizygotic. The mothers with the dizygotic multiple births were on moderate to elevated levels of heroin or methadone at the time of conception. Mechanisms are presented to help explain why narcotics may cause supraovulation and multiple births.