Opium and cardiovascular health: A devil or an angel?

Association between prescription opioid use and heart failure: Cohort studies and Mendelian randomization analysis

BACKGROUND

Prescription opioid use (POU) has been shown to lead to cardiovascular disease (CVD), but its association with heart failure has not been well studied. We investigated the potential causal association between POU and HF using cohort studies and Mendelian Randomization (MR) analysis.

METHODS

Initially, we examined the longitudinal association between POU and HF using the data from the Health and Retirement Study (HRS) and the UK biobank. Next, we employed a two-sample MR analysis using summary statistics from genome-wide association studies (GWAS) to assess the potential causal associations between POU and HF.

RESULTS

During a median of 3.8 and 13.8 years of follow-up, there were 441(8.04 per 1000 person-year) and 16,170 (3.96 per 1000 person-year) HF cases in the HRS and the UK biobank, respectively. After adjusting for covariates, participants who used prescription opioids had a 32% increased risk of developing HF, compared with non-users (HR = 1.32, 95%CI: 1.26-1.38, P < 0.001). In the MR analysis, summary statistics for POU were obtained from 78,808 UK Biobank study participants, and summary data for HF were obtained from 218,792 participants of a European population. A causal effect of genetic liability for POU on an increased risk of HF (OR = 1.16, 95% CI = 1.06, 1.27, P = 0.001) was suggested. The results were generally consistent in the sensitivity analysis, and no pleiotropy or heterogeneity were observed.

CONCLUSIONS

POU is associated with a high risk of HF. Our findings provide new insight into prescription opioid use among populations at risk of heart failure. More studies are needed to validate our results and further investigate the underlying mechanisms.

Potential impact of controlling opium use prevalence on future cancer incidence in Iran

Background

The International Agency for Research on Cancer (IARC) recently classified opium consumption as carcinogenic to humans. This study aimed to estimate the potential reduction in incident cancers by 2035 in Iran, which accounts for 42% of global opium consumption, through decreasing opium use prevalence.

Methods

The population attributable fraction (PAF) of opium-related cancers was projected using national cancer incidence, age- and gender-specific opium use prevalence, relative cancer risks associated with opium use, and annual percentage changes in cancer incidence rates in Iran. Opium-related cancers were defined based on IARC monographs as cancers of lung, larynx, bladder, esophagus, stomach, pancreas, and pharynx. The number of preventable cancer cases under different opium prevalence scenarios was determined by subtracting attributable cases in each year based on current prevalence from those in alternative scenarios.

Findings

By 2035, an estimated 3,001,421 new cancer cases are expected in Iran, with 904,013 (30.1%) occurring in opium-related sites. Maintaining the current opium prevalence (5.6%) is projected to cause 111,130 new cancer cases (3.7% of all cancers, 12.3% of opium-related). A 10%, 30%, and 50% reduction in opium prevalence could prevent 9,016, 28,161, and 49,006 total incident cancers by 2035 in Iran, respectively. Reducing opium use prevalence by 10%-50% is projected to have the highest impact on lung cancer (prevention of 2,946-15,831 cases), stomach cancer (prevention of 2,404-12,593 cases), and bladder cancer (prevention of 1,725-9,520 cases).

Interpretation

Our results highlight the significant benefits that can be achieved through effective cancer prevention policies targeting opium use in Iran. Neglecting this risk factor is estimated to pose a significant burden on cancer incidence in the next decade in this population.

Funding

None.

Long-Term Effects of Opium Consumption Following Percutaneous Coronary Intervention: A 10-year Follow-Up Study

Background

Opium consumption has been an overlooked health issue in the Iranian population, and the prognostic role of opium consumption in patients undergoing coronary revascularization is unknown.

Hypothesis

We aimed to assess the association between opium consumption and long-term cardiovascular outcomes after percutaneous coronary intervention (PCI).

Methods

We screened 2203 consecutive patients who underwent elective PCI between April 2009 and April 2010 at Tehran Heart Center. Exclusion criteria were unsuccessful PCI, non-elective PCI, and missing opium use data. Opium consumption was defined as self-reported ever use of any traditional opium substances. Outcomes of interest were all-cause mortality and a composite of major adverse cardiac and cerebrovascular events (MACCE). The association between opium use and study outcomes was evaluated using the inverse probability of treatment weighting (IPTW) method. Cumulative hazard curves were demonstrated to further assess the association visually. Furthermore, the effect of opium consumption on individual components of MACCE was evaluated in a competing risk setting.

Results

A total of 2025 elective PCI patients were included (age: 58.7 ± 10.67, 29.1% women), among whom 297 (14.6%) patients were opium users. After a median follow-up of 10.7 years, opium consumption was associated with a higher risk of all-cause mortality (IPTW-hazard ratio [HR] = 1.705, 95% CI: 1.125-2.585; P = 0.012) and MACCE (IPTW-HR = 1.578, 95% CI: 1.156-2.153; P = 0.004). The assessment of MACCE components suggested a non-significant borderline trend for higher non-fatal myocardial infarction (IPTW-sub-distribution HR [SHR] = 1.731, 95% CI: 0.928-3.231; P = 0.084) and mortality (IPTW-SHR = 1.441, 95% CI: 0.884-2.351; P = 0.143) among opium users.

Conclusions

Opium consumption is associated with a more than 50% increase in long-term risk of mortality and MACCE in patients undergoing PCI. These findings accentuate the importance of preventive strategies to quit opium addiction in this population.

Prevalence of major non-communicable diseases and their associated risk factors in Afghanistan: a systematic review and meta-analysis

Background

Non-communicable diseases (NCDs) are the leading cause of mortality worldwide, and increasingly so in low- and middle-income countries. Afghanistan is dealing with a double burden of diseases, yet there has been no evidence synthesis on the prevalence of major NCDs and their risk factors.

Objective

This study aims to provide a comprehensive synthesis of the existing data on the prevalence of major NCDs and the common related risk factors in Afghanistan.

Method

We systematically reviewed scientific articles from 2000 to 2022 that reported the prevalence of diabetes, chronic respiratory diseases (CRDs), cardiovascular diseases (CVDs) or cancer, and their risk factors in Afghanistan. Four online databases (PubMed, Web of Science, Cochrane and Google Scholar) and two local journals in Afghanistan (not indexed online) were systematically searched and screened. Two reviewers independently screened and appraised the quality of the articles. Data extraction and synthesis were performed using tabulated sheets.

Results

Among 51 eligible articles, 10 (19.6%) focused on cancer, 10 (19.6%) on diabetes, 4 (7.8%) on CVDs, 4 (7.8%) on CRDs and 23 (45.1%) on risk factors as the primary outcome. Few articles addressed major NCD prevalence; no evidence of CVDs, cancer was 0.15%, asthma ranged between 0.3% and 17.3%, and diabetes was 12%. Pooled prevalence of hypertension and overweight were 31% and 35%, respectively. Central obesity was twice as prevalent in females (76% versus 40%). Similarly, gender differences were observed in smoking and snuff use with prevalence rates of 14% and 25% among males and 2% and 3% among females, respectively. A total of 14% of the population engaged in vigorous activity. Pooled prevalence for physical inactivity, general obesity, fruit and vegetable consumption, dyslipidaemia and alcohol consumption couldn't be calculated due to the heterogeneity of articles.

Conclusion

Only little evidence is available on the prevalence of major NCDs in Afghanistan; however, the NCD risk factors are prevalent across the country. The quality of the available data, especially those of the local resources, is poor; therefore, further research should generate reliable evidence in order to inform policymakers on prioritizing interventions for controlling and managing NCDs.

Major adverse cardiovascular events and mortality with opioids versus NSAIDs initiation in patients with rheumatoid arthritis

OBJECTIVE

Assess major adverse cardiovascular event (MACE) risk with opioids compared with non-steroidal anti-inflammatory drugs (NSAIDs) in patients with rheumatoid arthritis (RA) METHODS: We conducted a new-user active comparator cohort study among patients with RA within FORWARD, The National Databank for Rheumatic Diseases, with ≥1 year participation between 1998 and 2021. Each opioid initiator was matched to two NSAID initiators by propensity scores (PSs). Patients were followed until the occurrence of the composite endpoint of MACE (myocardial infarction, stroke, heart failure, cardiovascular disease (CVD) death, venous thromboembolism (VTE)) and all-cause mortality. The risk of outcomes was estimated using Cox proportional hazards with adjustment for PS weights and imbalanced covariables.

RESULTS

Among 6866 opioid initiators and 13 689 NSAID initiators, 212 vs 253 MACE (20.6/1000 person-years (PY) vs 18.9/1000 PY) and 144 vs 150 deaths (13.5/1000 PY vs 10.8/1000 PY) occurred, respectively. The risk of MACE with opioids was similar to NSAIDs (HR=1.02, 95% CI 0.85 to 1.22), whereas all-cause mortality with opioids was 33% higher than NSAIDs (HR=1.33, 95% CI 1.06 to 1.67) in PS-weighted models. Among the individual outcomes of MACE, VTE risk tended to be higher in opioid initiators than NSAID initiators (HR=1.41, 95% CI 0.84 to 2.35). Strong opioids had a higher risk for all-cause mortality and VTE than weak opioids compared with NSAIDs suggesting a dose-dependent association.

CONCLUSION

Opioids had similar MACE risk compared with NSAIDs in patients with RA with increased all-cause mortality and likely VTE, which suggests that opioids are not safer than NSAIDs, as clinicians have perceived.

Challenges to Lifestyle Medicine for Type 2 Diabetes in Iran: A Synoptic Review

Type 2 diabetes (T2D) is a major public health issue in Iran. The principal context for T2D management is the prevention of cardiovascular disease development and progression. These preventive strategies can be enhanced with routine implementation of comprehensive lifestyle modification, guideline-directed medical therapies, and creation of infrastructure that considers social determinants of health, ethnocultural variables, and financial challenges. In this synoptic review, scientific evidence sourced from Iran is analyzed to identify tactics to optimize the lifestyle medicine component of T2D care in Iran. Important evidence-based factors gleaned from the literature were curated into 9 categories: self-care, dietary adherence, mental health, self-comparison, transcultural adaptation, family support and community engagement, physical activity, the global pandemic, and service delivery. These categories were then assigned to 1 of 4 a priori aspects challenging diabetes care in Iran: behavioral factors, belief system, drivers, and implementation. By codifying discussion points and individual tactics, the improvement and optimization of T2D care in Iran can be facilitated. This reductionist model of approaching lifestyle medicine and complex chronic disease such as T2D can be applied to other ethnocultural populations.

Investigating the Relationship between Carotid Intima-Media Thickness (CIMT), Opium Addiction, and Components of the Metabolic Syndrome

BACKGROUND

Atherosclerosis has an essential role in causing cardiovascular diseases. Various factors affect the risk of coronary artery atherosclerosis, and the increase in the carotid intima-media thickness (CIMT) is a primary marker for detecting atherosclerotic changes in the artery wall. Since opioid use is one of the leading social and health problems in many countries, this study aimed to detect the factors influencing the increase in CIMT in opium consumers.

METHODS

This cross-sectional study was conducted on 350 participants of the phase 2 of the KERCADRS cohort study who visited Besat clinic in Kerman and were divided into addicted and non-addicted groups. The participants in both groups underwent carotid artery ultrasound, and the Philips IU22 ultrasound machine was used to measure the CIMT.

FINDINGS

The mean age of the participants was 42.28±12.58 in the addicted group and 35.99±15.38 in the non-addicted group (P=0.001). CIMT was similar in the two groups (P=0.170). Moreover, CIMT had a significant positive correlation with age, waist circumference, systolic blood pressure (SBP), body mass index (BMI), fasting plasma glucose (FPG), and triglyceride in both addicted and non-addicted groups. Age, weight, waist circumference, SBP, and BMI in the multivariate model were significant determinants of CIMT in the addicted group.

CONCLUSION

The results revealed that age, weight, waist circumference, SBP, and BMI were the factors influencing intima thickness in opium consumers, and no significant relationship was observed between addiction to opium and CIMT.

Effects of opium use on one-year major adverse cardiovascular events (MACE) in the patients with ST-segment elevation MI undergoing primary PCI: a propensity score matched - machine learning based study

BACKGROUND

Considerable number of people still use opium worldwide and many believe in opium's health benefits. However, several studies proved the detrimental effects of opium on the body, especially the cardiovascular system. Herein, we aimed to provide the first evidence regarding the effects of opium use on one-year major adverse cardiovascular events (MACE) in the patients with ST-elevation MI (STEMI) who underwent primary PCI.

METHODS

We performed a propensity score matching of 2:1 (controls: opium users) that yielded 518 opium users and 1036 controls. Then, we performed conventional statistical and machine learning analyses on these matched cohorts. Regarding the conventional analysis, we performed multivariate analysis for hazard ratio (HR) of different variables and MACE and plotted Kaplan Meier curves. In the machine learning section, we used two tree-based ensemble algorithms, Survival Random Forest and XGboost for survival analysis. Variable importance (VIMP), tree minimal depth, and variable hunting were used to identify the importance of opium among other variables.

RESULTS

Opium users experienced more one-year MACE than their counterparts, although it did not reach statistical significance (Opium: 72/518 (13.9%), Control: 112/1036 (10.8%), HR: 1.27 (95% CI: 0.94-1.71), adjusted p-value = 0.136). Survival random forest algorithm ranked opium use as 13th, 13th, and 12th among 26 variables, in variable importance, minimal depth, and variable hunting, respectively. XGboost revealed opium use as the 12th important variable. Partial dependence plot demonstrated that opium users had more one-year MACE compared to non-opium-users.

CONCLUSIONS

Opium had no protective effects on one-year MACE after primary PCI on patients with STEMI. Machine learning and one-year MACE analysis revealed some evidence of its possible detrimental effects, although the evidence was not strong and significant. As we observed no strong evidence on protective or detrimental effects of opium, future STEMI guidelines may provide similar strategies for opium and non-opium users, pending the results of forthcoming studies. Governments should increase the public awareness regarding the evidence for non-beneficial or detrimental effects of opium on various diseases, including the outcomes of primary PCI, to dissuade many users from relying on false beliefs about opium's benefits to continue its consumption.

Does Opioid Addiction Influence Clinical and Angiographic Outcomes in STEMI Patients Undergoing Emergency PCI?

Background

Despite recognizing the traditional coronary artery disease (CAD) risk factors, some secondary factors, such as opioid substance abuse, have to be considered. We aimed to assess the relationship between opioid consumption and emergency percutaneous coronary intervention (PCI) revascularization results, according to Thrombolysis in Myocardial Infarction (TIMI) flow and in-hospital survival outcomes in ST-elevation myocardial infarction (STEMI) patients.

Materials and Methods

This case-control study was conducted on 186 patients (93 patients in each group) with acute STEMI, who were referred to Chamran Heart Center, Isfahan, Iran. Opioid addiction was diagnosed by patients' records and confirmed by conducting an interview based on the Diagnostic and Statistical Manual of Mental Disorders, 4^th Edition (DSM-IV) criteria. Patients in both groups were evaluated and compared for angioplasty results based on the TIMI flow grade and in-hospital cardiovascular events and complications.

Results

Ninety-one patients (97.84%) of each group were male, and opioid-addicted patients were younger than the non-opioid users (52.95 9.91 vs. 57.90 12.17, P = 0.003). Among the CAD risk factors, prevalence of dyslipidemia was significantly higher in non-opioid users, whereas cigarette smoking was higher in opioid-addicted patients (P < 0.050). There was no significant difference between the two groups regarding pre- and post-procedural myocardial infarction complications as well as mortality rate (P > 0.050). Also, there were no significant differences between the opioid and non-opioid users regarding TIMI flow grading, and successful PCI rate based on achieving TIMI III was 60.21% versus 59.1% in opiate-dependent and non-opioid users, respectively (P = 0.621).

Conclusion

Opioid addiction has no effects on post-PCI angiographic results and in-hospital survival outcomes in STEMI patients which undergoing emergency PCI.

Incidence, early case fatality and determinants of stroke in Iran: Golestan Cohort Study

OBJECTIVES

While few studies investigated the incidence of stroke in Iran, no Iranian cohort has estimated the standardized-incidence rate and early fatality of first-ever-stroke subtypes along with associated factors.

METHODS

Golestan Cohort Study is a prospective study launched in northeastern Iran in 2004, including 50,045 individuals aged 40-75 at baseline. Age-standardized incidence rate of first-ever-stroke was calculated per 100,000 person-years, according to World Standard Population. The 28-day case fatality was calculated by dividing the number of fatal first-ever-stroke during the first 28 days by total events. Cox proportional hazard models were conducted to assess incidence and fatality risk factors. We used Population Attributable Fractions to estimate the incidence and early fatality proportions reduced by ideal risk factor control.

RESULTS

1,135 first-ever-strokes were observed during 8.6 (median) years follow-up. First-ever-stroke standardized incidence rate was estimated 185.2 (95% CI: 173.2-197.2) per 100,000 person-years. The 28-day case fatality was 44.1% (95% CI: 40.4-48.2). Hypertension and pre-stroke physical activity were the strongest risk factors associated with first-ever-stroke incidence (Hazard ratio: 2.83; 2.47-3.23) and 28-day case fatality (Hazard ratio: 0.59; 0.44-0.78), respectively. Remarkably, opium consumption was strongly associated with hemorrhagic stroke incidence (Hazard ratio: 1.52; 1.04-2.23) and ischemic stroke fatality (Hazard ratio: 1.44; 1.01-2.09). Overall, modifiable risk factors contributed to 83% and 61% of first-ever-stroke incidence and early fatality, respectively.

CONCLUSION

Efficient risk factor control can considerably reduce stroke occurrence and fatality in our study. Establishing awareness campaigns and 24-hour stroke units seem necessary for improving the stroke management in this area.

Inflammatory, oxidative stress and cognitive functions in patients under maintenance treatment with methadone or buprenorphine and healthy subjects

BACKGROUND

Methadone and buprenorphine which are widely used for opioid maintenance treatment can affect redox status and also brain functions. The present study aimed to compare inflammation, oxidative stress, and cognitive function in methadone maintenance patients (MMP), buprenorphine maintenance patients (BMP), and healthy participants.

METHOD

Oxidative- antioxidant markers, inflammatory factors were investigated in MMP (n = 30), BMP (n = 30), and healthy participants (n = 30) by evaluating the ferritin, malondialdehyde (MDA), total antioxidant capacity (TAC), and also High-sensitivity C-reactive protein (hs-CRP). Also, executive function was evaluated using Wisconsin Card Sorting Test (WCST).

FINDINGS

MMP and BMP showed impairment in executive function compared to the healthy participants. Both buprenorphine and methadone treatments induced oxidative stress. The ferritin level in BMP was significantly lower compared to MMP and healthy participants (P = 0.01). There was a significant difference between control and MMP and BMP (P > 0.0001) in terms of hs-CRP level. BMP had the highest and healthy participant's lowest MDA level (P < 0.001). The TAC levels in BMP were lower than in MMP (p = 0.002) and healthy participants (p = 0.001). Finally, executive function was significantly correlated with oxidative-antioxidant status.

DISCUSSION

Both methadone and buprenorphine induced severe oxidative activity (especially buprenorphine) and cognitive deficits compared to healthy participants. Stress oxidative can affect normal brain activity and consequently cognitive functions. It's suggested that concomitant antioxidant administration with buprenorphine or methadone can potentially enhance their beneficial action by regulating blood redox status.

Opium Use and Cancer Risk: A Comprehensive Systematic Review and Meta-Analysis of Observational Studies

BACKGROUND

Epidemiological studies have reported inconsistent associations between opium use and cancer risk. We therefore conducted a systematic review and meta-analysis to investigate the relationship between opium use and cancer risk.

METHODS

We searched PubMed, Scopus, ISI Web of Knowledge, and Google Scholar until February 2021 and references of retrieved relevant articles for observational studies that reported the risk of cancer in relation to opium use. Random-effects models were used to calculate pooled effect sizes (ESs) as well as 95% confidence intervals (CIs) for the association between opium use and cancer risk by considering opium doses and types, duration of consumption, and routes of opium use.

RESULTS

In total, 21 observational articles, with a total sample size of 64,412 individuals and 6,658 cases of cancer, were included in this systematic review and meta-analysis. Ever opium users, compared with never opium users, had 3.53 times greater risk of overall cancer (pooled ES: 3.53, 95% CI: 2.60-4.79, P ≤ 0.01). This positive association was also seen for some individual types of cancers except for esophageal and colon cancers. Also, we found that higher opium doses and higher duration of consumption were associated with an increased risk of overall and individual types of cancer. However, the associations between opium doses and the risk of head and neck and larynx cancers were not significant. In terms of the routes of opium use, both opium ingestion and smoking were positively associated with the risk of cancer. Regarding opium types, we found that using teriak, but not shireh, could increase the risk of cancer.

CONCLUSIONS

Our findings showed that opium use, particularly in the form of teriak, is a risk factor for cancer.

Clusters of the Risk Markers and the Pattern of Premature Coronary Heart Disease: An Application of the Latent Class Analysis

Background: Coronary heart disease (CHD) is the major cause of mortality in the world with a significant impact on the younger population. The aim of this study was to identify prematurity among patients with coronary artery bypass graft surgery (CABG) based on the clustering of CHD risk factors.

Methods: Patients were recruited from an existing cohort of candidates for CABG surgery named Tehran Heart Center Coronary Outcome Measurement (THC-COM). A latent class analysis (LCA) model was formed using 11 potential risk factors as binary variables: cigarette smoking, obesity, diabetes, family history of CHD, alcohol use, opium addiction, hypertension, history of stroke, history of myocardial infarction (MI), peripheral vascular disease (PVD), and hyperlipidemia (HLP). We analyzed our data to figure out how the patients are going to be clustered based on their risk factors.

Results: For 566 patients who were studied, the mean age (SD) and BMI of patients were 59.1 (8.9) and 27.3 (4.1), respectively. The LCA model fit with two latent classes was statistically significant (G2 = 824.87, df = 21, p < 0.0001). The mean (SD) age of patients for Class I and Class II was 55.66 (8.55) and 60.87 (8.66), respectively. Class I (premature) was characterized by a high probability of smoking, alcohol consumption, opium addiction, and a history of MI (P < 0.05), and class II by a high probability of obesity, diabetes, and hypertension.

Conclusion: Latent class analysis calculated two groups of severe CHD with distinct risk markers. The younger group, which is characterized by smoking, addiction, and the history of MI, can be regarded as representative of premature CHD.

Prevalence and trends of coronary artery disease risk factors and their effect on age of diagnosis in patients with established coronary artery disease: Tehran Heart Center (2005-2015)

BACKGROUND

Coronary artery disease (CAD) is a universal public health challenge, more prominently so in the low- and middle-income countries. In this study, we aimed to determine prevalence and trends of CAD risk factors in patients with documented CAD and to determine their effects on the age of CAD diagnosis.

MATERIALS AND METHODS

We conducted a registry-based, serial cross-sectional study using the coronary angiography data bank of the Tehran Heart Center. Adult patients who had obstructive (> 50% stenosis) CAD were included in the study. The prevalence and 11-year trends of conventional CAD risk factors were analyzed by sex and age, and their adjusted effects on the age of CAD diagnosis were calculated.

RESULTS

From January 2005 to December 2015, data for 90,094 patients were included in this analysis. A total of 61,684 (68.5%) were men and 28,410 (31.5%) were women. Men were younger at diagnosis than women, with a mean age of 60.1 in men and 63.2 in women (p < 0.001), and had fewer risk factors at the time of diagnosis. Mean age at diagnosis had an overall increasing trend during the study period. Increasing trend was seen in body-mass index, hypertension prevalence, diabetes mellitus. All lipid profile components (total cholesterol, low-density lipoprotein cholesterol, triglycerides, and high-density lipoprotein cholesterol) decreased over time. Of particular interest, opium consumption was associated with 2.2 year earlier age of CAD diagnosis.

CONCLUSION

The major results of this study (lower age of CAD diagnosis in men, lower age of diagnosis associated with most risk factors, and lower prevalence of serum lipids over time) were expected. A prominent finding of this study is confirming opium use was associated with a much younger age of CAD onset, even after adjusting for all other risk factors. In addition to recommendations for control of the traditional risk factors, spreading information about the potential adverse effect of opium use, which has only recently been associated with higher risk of CAD, may be necessary.