Cocaine Use and White Matter Hyperintensities in Homeless and Unstably Housed Women

Stroke Risk in Unstably Housed Women: The Role of Cocaine and Alcohol Co-Use

BACKGROUND

Sex and social determinants of health predict stroke, yet few studies focus exclusively on women at high social risk. Understanding associations between stroke and modifiable risk factors that are disproportionately common in high-risk populations may aid in tailoring primary and secondary prevention services. We sought a better understanding of the association between polysubstance use, with an emphasis on stimulant use, and stroke in women who experience homelessness and unstable housing.

METHODS

We recruited women who experience homelessness and unstable housing from San Francisco community-based venues to participate in a cohort study. We identified stroke from electronic health records during the 2.5-year study period and prospectively for up to 2 years after study completion. We then assessed associations with baseline study factors, including social determinants of health, toxicology-confirmed use of multiple substances, and traditional stroke risk factors. We used multiple logistic regression and the Akaike Information Criterion to construct the most parsimonious adjusted model to determine independent relationships between study factors and stroke risk.

RESULTS

Of 245 participants, 238 had a complete data set and were included. The median participant age was 53.4 (interquartile range, 45.4-59.4) years. Nine (3.8%) participants had documented strokes. After adjusting for age, hyperlipidemia, and opioid use, cocaethylene-a biomarker signaling alcohol and cocaine concurrent co-use-had a particularly strong association with stroke (odds ratio, 3.22 [95% CI, 1.02-10.20]).

CONCLUSIONS

Cocaethylene and opioids were strongly associated with stroke among women who experience homelessness and unstable housing. This suggests 2 possible opportunities for prevention in an environment where opioid use is already closely monitored. First, women reporting cocaine and alcohol co-use should be counseled about the especially harmful effects of this substance combination on their cerebrovascular health. Second, the utility of cocaethylene to assess stroke risk in high-risk populations may be currently underestimated.

Addressing the Health Needs of People Who Inject Drugs: A Descriptive Analysis of an Inpatient Integrated Care Team Within an Acute Hospital in Scotland

Background

People who inject drugs (PWID) experience poor health outcomes secondary to infective sequelae with lengthy hospitalizations, high rates of unplanned discharge, and frequent readmissions. Challenges arranging and engaging with outpatient services compound these issues.

Methods

An integrated team consisting of infectious diseases, drug liaison, and assertive outreach was established in January 2023 at a secondary-care hospital in Edinburgh, Scotland. We assessed the medical needs of patients hospitalized with injection-related infections and considered the impact of this service by comparing health outcomes of patients seen by the integrated team against a historic cohort. Primary descriptive analysis included type and severity of infection, and outcomes included referral to outpatient services and meeting recommended care standards such as blood-borne virus (BBV) screening.

Results

The integrated team saw 37 patients (43 hospital admissions), and 65 patients (73 admissions) were identified as historic controls. Patients seen by the integrated team experienced more severe and complex infections including 37.2% (16/43) of patients having a bacteremia compared to 11% (8/73) in the control group, and a high prevalence of cocaine injection (81% [30/37]). Under the integrated team, higher proportions of patients had a BBV screening (90.7% [39/43] vs 64.4% [47/73]) and were offered outpatient care (81% [35/43] vs 6% [4/73]) with supported attendance.

Conclusions

These results suggest a background of increasingly complicated injection behavior and subsequent infections in Scotland; however, a patient-centered, multidisciplinary care model can effectively address the health need of PWID, offering safer and more appropriate treatment pathways.

Multiple substance use and blood pressure in women experiencing homelessness

Background

Substance use increases risk of cardiovascular events, particularly among women with additional risk factors like housing instability. While multiple substance use is common among unstably housed individuals, relationships between multiple substance use and cardiovascular risk factors like blood pressure are not well characterized.

Methods

We conducted a cohort study between 2016 and 2019 to examine associations between multiple substance use and blood pressure in women experiencing homelessness and unstable housing. Participants completed six monthly visits including vital sign assessment, interview, and blood draw to assess toxicology-confirmed substance use (e.g., cocaine, alcohol, opioids) and cardiovascular health. We used linear mixed models to evaluate the outcomes of systolic and diastolic blood pressure (SBP; DBP).

Results

Mean age was 51.6 years; 74 % were women of color. Prevalence of any substance use was 85 %; 63 % of participants used at least two substances at baseline. Adjusting for race, body mass index and cholesterol, cocaine was the only substance significantly associated with SBP (4.71 mmHg higher; 95 % CI 1.68, 7.74) and DBP (2.83 mmHg higher; 95 % CI 0.72, 4.94). Further analysis found no differences in SBP or DBP between those with concurrent use of other stimulants, depressants, or both with cocaine, compared to those who used cocaine only.

Conclusions

Cocaine was the only substance associated with higher SBP and DBP, even after accounting for simultaneous use of other substances. Along with interventions to address cocaine use, stimulant use screening during cardiovascular risk assessment and intensive blood pressure management may improve cardiovascular outcomes among women experiencing housing instability.

Methamphetamine use increases the risk of cerebral small vessel disease in young patients with acute ischemic stroke

Methamphetamine use causes spikes in blood pressure. Chronic hypertension is a major risk factor for cerebral small vessel disease (cSVD). The aim of this study is to investigate whether methamphetamine use increases the risk of cSVD. Consecutive patients with acute ischemic stroke at our medical center were screened for methamphetamine use and evidence of cSVD on MRI of the brain. Methamphetamine use was identified by self-reported history and/or positive urine drug screen. Propensity score matching was used to select non-methamphetamine controls. Sensitivity analysis was performed to assess the effect of methamphetamine use on cSVD. Among 1369 eligible patients, 61 (4.5%) were identified to have a history of methamphetamine use and/or positive urine drug screen. Compared with the non-methamphetamine group (n = 1306), the patients with methamphetamine abuse were significantly younger (54.5 ± 9.7 vs. 70.5 ± 12.4, p < 0.001), male (78.7% vs. 54.0%, p < 0.001) and White (78.7% vs. 50.4%, p < 0.001). Sensitivity analysis showed that methamphetamine use was associated with increased white matter hyperintensities, lacunes, and total burden of cSVD. The association was independent of age, sex, concomitant cocaine use, hyperlipidemia, acute hypertension, and stroke severity. Our findings suggest that methamphetamine use increases the risk of cSVD in young patients with acute ischemic stroke.

A Chronic Condition Disguised as an Acute Event: the Case for Re-thinking Stimulant Overdose Death

Recent reports indicate that stimulant-related deaths are increasing dramatically. People who die from acute stimulant toxicity have high rates of pre-existing cardiovascular disease (CVD), much of which is undiagnosed. Moreover, people who use stimulants with CVD often remain asymptomatic until presenting to an emergency department with an acute event. Prior research shows that symptoms of stimulant toxicity may occur on a regular basis, and that people who die from stimulant toxicity are older than those who die of opioid toxicity. Taken collectively, the existing evidence suggests that death from acute stimulant toxicity is often an outcome of long-term, cumulative exposure leading to cardiovascular dysfunction rather than acute intoxication. Strategies tailored to the distinct etiology of stimulant overdose are needed. We propose a three-part approach including (1) implementing stimulant use interventions that promote not only abstinence, but also use reduction, (2) treating ongoing stimulant use as a chronic cardiovascular condition, and (3) making stimulant toxicity interventions relevant to the populations most affected, which includes people outside of the traditional health-care system. In short, to reduce stimulant-related fatality, we need to transform our approach in ways that are tailored to address its natural history.