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Brust JC. Stroke and Substance Abuse. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00039-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Alambyan V, Pace J, Miller B, Cohen ML, Gokhale S, Singh G, Shun MC, Hammond A, Ramos-Estebanez C. The Emerging Role of Inhaled Heroin in the Opioid Epidemic: A Review. JAMA Neurol 2019; 75:1423-1434. [PMID: 29987325 DOI: 10.1001/jamaneurol.2018.1693] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Importance Opioid addiction affects approximately 2.4 million Americans. Nearly 1 million individuals, including a growing subset of 21 000 minors, abuse heroin. Its annual cost within the United States amounts to $51 billion. Inhaled heroin use represents a global phenomenon and is approaching epidemic levels east of the Mississippi River as well as among urban youth. Chasing the dragon (CTD) by heating heroin and inhaling its fumes is particularly concerning, because this method of heroin usage has greater availability, greater ease of administration, and impressive intensity of subjective experience (high) compared with sniffing or snorting, although it also has a safer infectious profile compared with heroin injection. This is relevant owing to peculiar and often catastrophic brain complications. Following the American Medical Association Opioid Task Force mandate, we contribute a description of the pharmacology, pathophysiology, clinical spectrum, neuroimaging, and neuropathology of CTD leukoencephalopathy, as distinct from other heroin abuse modalities. Observations The unique spectrum of CTD-associated health outcomes includes an aggressive toxic leukoencephalopathy with pathognomonic neuropathologic features, along with sporadic instances of movement disorders and hydrocephalus. Clinical CTD severity is predominantly moderate at admission, frequently unmodified at discharge, and largely improved in the long term. Mild cases survive with minor sequelae, while moderate to severe presentations might deteriorate and progress to death. Other methods of heroin use may complicate with stroke, seizure, obstructive hydrocephalus, and (uncharacteristically) leukoencephalopathy. Conclusions and Relevance The distinct pharmacology of CTD correlates with its specific clinical and radiological features and prompts grave concern for potential morbidity and long-term disability costs. Proposed diagnostic criteria and standardized reporting would ameliorate the limitations of CTD literature and facilitate patient selection for a coenzyme Q10 therapeutic trial.
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Affiliation(s)
- Vilakshan Alambyan
- Neurocritical Care and Stroke Division, Department of Neurology, The Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Jonathan Pace
- Department of Neurosurgery, The Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Benjamin Miller
- Department of Neurology, University of Minnesota, Minneapolis
| | - Mark L Cohen
- Department of Pathology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Sankalp Gokhale
- Departments of Neurology and Anesthesiology, Banner University Medical Center, University of Arizona College of Medicine, Tucson
| | - Gagandeep Singh
- Neurocritical Care and Stroke Division, Department of Neurology, The Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Ming-Chieh Shun
- Department of Molecular Biology and Microbiology, Case Western Reserve University, Cleveland, Ohio
| | - Anthony Hammond
- Department of Emergency Medicine, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Ciro Ramos-Estebanez
- Neurocritical Care and Stroke Division, Department of Neurology, The Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
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Iqbal I, Alam Khan MA, Ullah W. Can inhaled heroin be a cause of bilateral globus pallidus ischemic injury? Turk J Emerg Med 2019; 19:39-41. [PMID: 31414070 PMCID: PMC6686133 DOI: 10.1016/j.tjem.2018.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 11/07/2018] [Accepted: 11/15/2018] [Indexed: 11/30/2022] Open
Abstract
Introduction Bilateral globus pallidus lesions have been characteristically thought to be associated with global cerebral hypoperfusion and hypoxic changes. One of the important causative factors that need to be considered is the opiate drug abuse. Case presentation We present a case of a 50-year-old male who came to the hospital after being found down for 3 hours. He was found to have weakness of right upper and lower extremity. MRI showed bilateral globus pallidus infarcts. He later admitted to inhalation of heroin. Over the next few days, weakness started to improve and he was eventually discharged to rehabilitation. This case is a unique presentation of bilateral globus pallidus lesions after a one-time inhalation of heroin. Conclusion We, therefore, advocate that inhaled heroin should be considered as one of the causes of bilateral globus pallidus lesions, in addition to IV heroin and cocaine and physicians should be aware of the possibility of alternate forms of heroin abuse in such patients.
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Affiliation(s)
- Iqra Iqbal
- Abington Memorial Hospital, Abington, PA, USA
| | | | - Waqas Ullah
- Abington Memorial Hospital, Abington, PA, USA
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McCann UD, Lowe KA, Ricaurte GA. REVIEW ■ : Long-lasting Effects of Recreational Drugs of Abuse on the Central Nervous System. Neuroscientist 2016. [DOI: 10.1177/107385849700300613] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although a wealth of knowledge exists regarding the acute pharmacological effects of recreational drugs on the CNS, much less is known about the long-term toxic effects of recreational drugs on the CNS. Recent findings in nonhuman primates treated with amphetamine analogs, such as ±3,4-methylenedioxymetham phetamine (MDMA), indicate that these drugs can produce long-lasting, probably permanent, changes in brain serotonin innervation. Similarly, animals treated with phencyclidine (PCP) and related drugs develop neurodegenerative changes in selected brain regions. It seems clear, then, that some psychoactive drugs have the potential to produce persistent changes in CNS structure and, possibly, function. The goal of this article is to summarize current knowledge regarding the long-term effects of several popular recreational drugs, including MDMA and related amphetamine analogs, cocaine, marijuana, alcohol, PCP, lysergic acid (LSD), and opiates. Gaps in the current knowledge base are identified, and areas ripe for future research efforts are suggested. NEUROSCIENTIST 3:399-411, 1997
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Affiliation(s)
- Una D. McCann
- Biological Psychiatry Branch NIMH-IRP Bethesda, Maryland
| | - Kelly A. Lowe
- Department of Neurology Johns Hopkins Medical Institutions
Baltimore, Maryland
| | - George A. Ricaurte
- Department of Neurology Johns Hopkins Medical Institutions
Baltimore, Maryland
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Benoilid A, Collongues N, de Seze J, Blanc F. Heroin inhalation-induced unilateral complete hippocampal stroke. Neurocase 2013; 19:313-5. [PMID: 22624985 DOI: 10.1080/13554794.2012.667125] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
A 33-year-old man presented to our clinic with amnesia 48 hours after his first heroin inhalation. Examination showed lateral tongue biting and anterograde amnesia demonstrated by impaired performance on verbal and visual Wechsler Memory Scale-Revised tests carried out 10 days after onset, suggesting hippocampal involvement. Magnetic resonance imaging (MRI) of the brain was performed 48 hours after heroin snorting and evoked cortical laminar necrosis (CLN) of the left hippocampus without vascular abnormality. This is the first description of complete hippocampal CLN as a complication subsequent to acute intranasal heroine abuse. While the pathogenic mechanism remains uncertain, our case provides a very specific MRI lesion pattern and highlights the risk of intranasal heroin uptake-induced neurological complication.
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Affiliation(s)
- Aurélien Benoilid
- Department of Neurology, Strasbourg University Hospital, Strasbourg, France.
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Abstract
AbstractHypoxic brain injury is an under-recognised consequence of heroin overdose. This article documents the disability experienced by 10 people with hypoxic brain injuries following heroin overdose who presented in the 2-year period July 1997 to June 1999 at the Royal Talbot Rehabilitation Centre, a brain injury rehabilitation facility in Melbourne, Australia. Medical histories of these clients were reviewed and follow-up interviews were conducted between 2 and 4 years postinjury. Measures included the Functional Independence Measure (FIM) and the Community Integration Questionnaire (CIQ). The results showed that there were significant and enduring consequences for most of the 10 participants. At follow-up two participants had died from subsequent overdose, three required support to live in the community and one lived in an aged care facility. Only one participant was able to return to work. Cognitive problems were present in most of the group and problem solving and social interaction difficulties were the most commonly recorded problems. Three cases are described in detail to highlight some of the significant issues identified in this sample. Implications for the rehabilitation of people with brain injury following heroin overdose are discussed.
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Paur R, Wallner C, Hermann P, Stöllberger C, Finsterer J. Neurological Abnormalities in Opiate Addicts with and without Substitution Therapy. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2012; 38:239-45. [DOI: 10.3109/00952990.2011.644001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Stroke and Substance Abuse. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10042-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Vannemreddy P, Caldito G, Willis B, Nanda A. Influence of cocaine on ruptured intracranial aneurysms: a case control study of poor prognostic indicators. J Neurosurg 2008; 108:470-6. [DOI: 10.3171/jns/2008/108/3/0470] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The purpose of this study was to determine whether cocaine use is a significant prognostic factor for outcome measures such as Hunt and Hess grade and Glasgow Outcome Scale (GOS) score among patients presenting with ruptured intracranial aneurysms (IAs).
Methods
The authors performed a MEDLINE/PubMed search for cases of ruptured IAs associated with cocaine use. Fourteen cases from the authors' experience were combined with 50 from a literature review, for a total of 64 cases associated with cocaine use. These 64 cases were compared with 65 cases without cocaine use (controls), which had been obtained from an aneurysm database. Logistic regression analysis was performed to determine significant prognostic factors for a poor Hunt and Hess grade and a poor GOS score, and a general linear model was applied to identify significant factors for these measures among cocaine users.
Results
There were 40 women in each group. The mean age was 32.3 ± 8.1 years in the cocaine group and 49.7 ± 10.6 years in the control group; thus, patients in the cocaine group were significantly younger (p < 0.01). Cocaine was snorted in 21% of cases, smoked in 55%, and intravenously injected or taken in through a combination of routes in 24%. Fifty-one percent of cocaine users and 7.7% of nonusers presented with a poor GOS score (p < 0.01). Fifty-six percent had ictus during cocaine abuse. At the end of a 30-day follow-up, 51% of the patients in the cocaine group had a good GOS score compared with 92% in the control group (p < 0.01). Controlling for the effects of other significant factors, cocaine use had a significant effect on Hunt and Hess grade (p < 0.03) and GOS score (p < 0.01). The odds of having a poor Hunt and Hess grade among cocaine users were 4.2 times greater than those in nonusers, and the odds of having a poor GOS score among cocaine users were 38.8 times greater.
Conclusions
Aneurysms were significantly smaller and ruptured at a younger age among cocaine users compared with nonusers. Although the poor clinical grade was not significantly different between the 2 groups, outcome was significantly worse in cocaine users.
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Nanda A, Vannemreddy P, Willis B, Kelley R. Stroke in the young: relationship of active cocaine use with stroke mechanism and outcome. ACTA NEUROCHIRURGICA. SUPPLEMENT 2006; 96:91-6. [PMID: 16671433 DOI: 10.1007/3-211-30714-1_22] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Cocaine and other vasoactive substances are known causes of cerebrovascular disease. Ictus during drug intake adversely affects outcome. MATERIALS AND METHODS A retrospective review revealed 42 patients with cocaine abuse and stroke. Aneurysmal bleed occurred in 15 patients; the rest had stroke. The outcome of stroke because of cocaine intoxication was analyzed. RESULTS Mean age for stroke was 38 (+/- 8.5 SD) years; males out-numbered females (20 : 7) similar to the pattern seen in subarachnoid hemorrhage (SAH) following aneurysm rupture. Nine had intracerebral hematomas, 6 had SAH with intracerebral hemorrhage (ICH)/ infarct, I had transverse myelopathy. Transient ischemic attack was identified in 4. Carotid occlusion was found in 2, and slow-flow in the vertebrobasilar system in 1. Fifteen were known hypertensives. Cocaine was the principal substance in all patients; 7 used other substances including marijuana and heroin. Three patients had HIV, 3 had hepatitis, 2 had syphilis, and 1 had tuberculosis. Urinalysis was positive for cocaine metabolites in 15; 2 had late analysis. Nine had ICH or SAH with poor neurological status at admission and died. Cocaine intoxication correlated with fatal cerebrovascular accident (CVA) (p < 0.001) and poor Glasgow Outcome Score (GOS) (p < 0.001). CONCLUSION Stroke and cocaine use correlated with fatal CVA and poor outcome. Prompt diagnostic intervention may reveal the incidence of CNS injury with cocaine abuse.
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Affiliation(s)
- A Nanda
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA 71130, USA
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Lyoo IK, Pollack MH, Silveri MM, Ahn KH, Diaz CI, Hwang J, Kim SJ, Yurgelun-Todd DA, Kaufman MJ, Renshaw PF. Prefrontal and temporal gray matter density decreases in opiate dependence. Psychopharmacology (Berl) 2006; 184:139-44. [PMID: 16369836 DOI: 10.1007/s00213-005-0198-x] [Citation(s) in RCA: 147] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2005] [Accepted: 08/19/2005] [Indexed: 10/25/2022]
Abstract
RATIONALE There have been only a few structural brain-imaging studies, with varied findings, of opiate-dependent subjects. Voxel-based morphometry (VBM) is suitable for studying whole brain-wise structural brain changes in opiate-dependent subjects. OBJECTIVES The objective of the current study is to explore gray matter density in opiate-dependent subjects. METHODS Gray matter density in 63 opiate-dependent subjects and 46 age- and sex-matched healthy comparison subjects was compared using VBM. RESULTS Relative to healthy comparison subjects, opiate-dependent subjects exhibited decreased gray matter density in bilateral prefrontal cortex [Brodmann areas (BA) 8, 9, 10, 11, and 47], bilateral insula (BA 13), bilateral superior temporal cortex (BA 21 and 38), left fusiform cortex (BA 37), and right uncus (BA 28). CONCLUSIONS This study reports that opiate-dependent subjects have gray matter density decreases in prefrontal and temporal cortex, which may be associated with behavioral and neuropsychological dysfunction in opiate-dependent subjects.
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Affiliation(s)
- In Kyoon Lyoo
- McLean Hospital Brain Imaging Center and Department of Psychiatry, Harvard Medical School, Belmont, MA, USA.
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Klous MG, Van den Brink W, Van Ree JM, Beijnen JH. Development of pharmaceutical heroin preparations for medical co-prescription to opioid dependent patients. Drug Alcohol Depend 2005; 80:283-95. [PMID: 15916865 DOI: 10.1016/j.drugalcdep.2005.04.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2004] [Revised: 04/06/2005] [Accepted: 04/27/2005] [Indexed: 11/18/2022]
Abstract
Presently, there is a considerable interest in heroin-assisted treatment: co-prescription of heroin to certain subgroups of chronic, treatment-resistant, opioid dependent patients. In 2002, nine countries had planned (Australia, Belgium, Canada, France, Spain) or ongoing (Germany, The Netherlands, Switzerland, United Kingdom) clinical trials on this subject. These trials (and the routine heroin-assisted treatment programs that might result) will need pharmaceutical heroin (diacetylmorphine) to prescribe to the patients. Research into the development of pharmaceutical forms of heroin for prescription to addicts can benefit from the large amount of knowledge that already exists regarding this substance. Therefore, in this paper we review the physicochemical and pharmaceutical properties of diacetylmorphine and the clinically investigated routes of administration, as well as routes of administration utilised on the street in the context of developing pharmaceutical heroin formulations for prescription to addicts. Patient acceptability of the formulation is essential, because heroin-assisted treatment is aimed at treatment-resistant addicts, who often have to be encouraged to participate (or to maintain participation) in a treatment program. This means that the most suitable products would have pharmacokinetic profiles mimicking that of diacetylmorphine for injection, with rapid peak concentrations of diacetylmorphine and 6-acetylmorphine, ensuring the 'rush effect' and the sustained presence of morphine(-6-glucuronide) creating the prolonged euphoria. Diacetylmorphine for inhalation after volatilisation (via 'chasing the dragon') seems to be a suitable candidate, while intranasal and oral diacetylmorphine are currently thought to be unsuitable. However, oral and intranasal delivery systems might be improved and become suitable for use by heroin dependent patients.
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Affiliation(s)
- Marjolein G Klous
- Slotervaart Hospital, Department of Pharmacy & Pharmacology P.O. Box 90440, 1006 BK Amsterdam, The Netherlands.
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Kivisaari R, Kähkönen S, Puuskari V, Jokela O, Rapeli P, Autti T. Magnetic resonance imaging of severe, long-term, opiate-abuse patients without neurologic symptoms may show enlarged cerebrospinal spaces but no signs of brain pathology of vascular origin. Arch Med Res 2004; 35:395-400. [PMID: 15610908 DOI: 10.1016/j.arcmed.2004.05.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2004] [Accepted: 05/27/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND Recreational drug abuse is one of the most important risk factors for stroke in young adults. Abuse of opiates may lead to severe acute neurologic problems due to ischemia or hemorrhage. In contrast, their minor effects on brain structures are not well established. We evaluated brain magnetic resonance images (MRI) of opiate-dependent subjects who had no major neurologic symptoms or psychiatric disorder. METHODS Seventeen opiate-dependent patients and 17 controls underwent 1.5 T MRI. Any abnormalities in signal intensity of the brain were recorded. Areas of vermis, corpus callosum, and midline internal skull surface (MISS) were measured from midline sagittal slice. To evaluate size of cortical sulci, sylvian fissures, and ventricles, axial images were compared with standard sets of reference images. In addition, bifrontal and sylvian-fissure ratios were measured. RESULTS Only one patient had a small subcortical post-traumatic lesion; otherwise, gray and white matter showed normal signal intensities. Opiate-dependent subjects had significantly wider sylvian fissures (p=0.008, Mann-Whitney U) and larger ventricles (p=0.04) than controls. Bifrontal and sylvian-fissure ratios were significantly higher in patient group than in controls (p=0.013 and p=0.005, respectively). CONCLUSIONS No signs of brain pathology of vascular origin were found. From the clinical point of view, we want to emphasize that in the first acute neurologic attack of opiate-dependent patients, any abnormal signal intensity in MRI is most probably associated with the patient's current situation. Sylvian fissures and ventricles were wider in opiate-dependent subjects than in controls, which may be related to brain atrophy located especially in frontal and temporal lobes.
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Affiliation(s)
- Reetta Kivisaari
- Helsinki Medical Imaging Center, Helsinki University Central Hospital, Helsinki, Finland
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Lyoo IK, Streeter CC, Ahn KH, Lee HK, Pollack MH, Silveri MM, Nassar L, Levin JM, Sarid-Segal O, Ciraulo DA, Renshaw PF, Kaufman MJ. White matter hyperintensities in subjects with cocaine and opiate dependence and healthy comparison subjects. Psychiatry Res 2004; 131:135-45. [PMID: 15313520 DOI: 10.1016/j.pscychresns.2004.04.001] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2003] [Revised: 01/03/2004] [Accepted: 04/01/2004] [Indexed: 11/26/2022]
Abstract
The prevalence, severity, and location of white matter signal hyperintensities (WMH) on brain magnetic resonance images were compared in patients with cocaine or opiate dependence and healthy subjects. Patients with cocaine (n=32) and opiate dependence (n=32), whose diagnoses were confirmed with the Structured Clinical Interview for DSM-IV, and age- and sex-matched healthy subjects (n=32) were scanned using a 1.5 T whole body GE magnetic resonance scanner. Axial proton-density and T2-weighted images were obtained as well as fluid-attenuated inversion recovery axial images. The severity of WMH was assessed separately for deep (and insular) and periventricular WMH, using a modified composite version of the rating scales of Fazekas and Coffey. The cocaine-dependent group had greater severity of WMH than the opiate-dependent group, which in turn had greater severity of WMH than the healthy comparison group (odds ratios=2.54 and 2.90, respectively). The cocaine-dependent group had greater lesion severity of deep and insular WMH than the opiate-dependent group and the healthy comparison group (odds ratio>3.25 for deep WMH; odds ratio>4.38 for insular WMH). For periventricular WMH, there were no significant differences between the three groups. The frontal lobes were the predominant locations of WMH in both substance-dependent groups. The greater prevalence and severity of WMH in cocaine-dependent subjects than in opiate-dependent subjects may reflect the fact that cocaine induces more ischemia via vasoconstriction than opiates. Also, there was a trend for lower WMH severity in substance-dependent women relative to the healthy comparison group, possibly due to estrogen's protective effect against cerebrovascular accidents.
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Affiliation(s)
- In Kyoon Lyoo
- McLean Hospital Brain Imaging Center and Department of Psychiatry, Harvard Medical School, 115 Mill Street, Belmont, MA 02478, USA.
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Kendall JM, Latter VS. Intranasal diamorphine as an alternative to intramuscular morphine: pharmacokinetic and pharmacodynamic aspects. Clin Pharmacokinet 2004; 42:501-13. [PMID: 12793836 DOI: 10.2165/00003088-200342060-00001] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Diamorphine is a semisynthetic derivative of morphine that is currently licensed for use in the treatment of moderate to severe acute pain, administered by the intramuscular, intravenous or subcutaneous routes. It is highly water-soluble and has a number of properties that render it suitable for administration via the nasal route. Administration via the intranasal route is well described for other drugs, but has only recently been evaluated in a clinical setting for diamorphine. A well-tolerated and rapidly effective analgesic agent has proven elusive in the paediatric setting. The pharmacokinetic profile of intranasal diamorphine in adults has been systematically studied. It is rapidly and dose-dependently absorbed as a dry powder, with peak plasma concentrations occurring within 5 minutes, and has a similar pharmacokinetic profile to that of intramuscular diamorphine. It is rapidly converted to 6-acetylmorphine (peak concentrations within 5-10 minutes) and thence to morphine (peak concentrations within 1 hour). The pharmacodynamic properties of intranasal diamorphine have also been studied in comparison with intramuscular diamorphine. Intranasal and intramuscular administration of diamorphine resulted in similar physiological responses (including pupil diameter, respiration rate and temperature). Changes in behavioural measures (including euphoria, sedation and dysphoria) were also similar. Intranasal administration of diamorphine, therefore, produces the expected drug effects on the same timescale and of the same magnitude as intramuscular injection. Intranasal diamorphine has been clinically evaluated in a randomised controlled trial versus intramuscular morphine in the setting of acute orthopaedic pain in children with fractures. Intranasal diamorphine provided the same overall degree of pain relief as intramuscular morphine, but with a quicker onset of action. It was found to be well tolerated with an acceptable safety profile. It has also been studied in the setting of patient-controlled analgesia for postoperative pain in adults, with encouraging results. The pharmacokinetic and pharmacodynamic properties of intranasal diamorphine, and particularly the ability to administer it without a needle (and therefore reduce the incidence of transmissible infection), have made this a popular route for abuse amongst opioid addicts. In this setting, however, the intranasal route is not free from adverse events, including deaths. The primary clinical need in the paediatric population is for a well tolerated, effective and expedient analgesic agent that is safe to use; intranasal diamorphine has pharmacokinetic properties that would make it suitable for such a clinical indication and, in clinical evaluations to date, appears to be promising.
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Büttner A, Weis S. Central Nervous System Alterations in Drug Abuse. FORENSIC PATHOLOGY REVIEWS 2004. [DOI: 10.1007/978-1-59259-786-4_4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Neiman J, Haapaniemi HM, Hillbom M. Neurological complications of drug abuse: pathophysiological mechanisms. Eur J Neurol 2000; 7:595-606. [PMID: 11136345 DOI: 10.1046/j.1468-1331.2000.00045.x] [Citation(s) in RCA: 126] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Drug abuse is associated with a variety of neurological complications. The use of certain recreational drugs shows a marked temporal association with the onset of both haemorrhagic and ischaemic strokes, the majority of which develop within minutes to 1 h after the administration of the index drug. Delayed onset of stroke has also been observed. Acute, severe elevation of blood pressure, cardiac dysrhythmias, cerebral vasospasm, vasculitis, embolization due to infective endocarditis or dilated cardiomyopathy, embolization due to foreign material injected with the diluents under non-sterile conditions and 'street drug' contaminants with cardiovascular effects have been suggested as possible underlying mechanisms. Rupture of aneurysms and arteriovenous malformations have been detected in up to half of the patients with haemorrhagic stroke due to cocaine abuse. The less common findings reported have included a mycotic cerebrovascular aneurysm in a patient with infective endocarditis and haemorrhagic stroke. In addition to stroke, cocaine seems to provoke vascular headache. Seizures precipitated by recreational drug abuse are usually caused by acute intoxication in contrast to the withdrawal seizures encountered in subjects with alcohol abuse. Movement disorders and cerebral atrophy correlating with the duration of abuse have been described. Snorting of organic solvents may cause encephalopathy. Cases of spongiform leukoencephalopathy in heroin addicts have also been reported. Peripheral neuropathy is occasionally precipitated by drug poisoning after intravenous administration. Impurities of the drug, risky administration techniques, and the use of mixtures of various drugs, frequently with simultaneous alcohol drinking, should be taken into account when assessing the background of the adverse event as well as the overall lifestyle of the addicted subjects.
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Affiliation(s)
- J Neiman
- Northern Stockholm Center for Treatment of Drug and Alcohol Dependence, Danderyd, Sweden.
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19
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Abstract
A broad spectrum of neuropathologic changes are encountered in the brains of heroin abusers. The main findings are due to infections, either due to bacterial spread from bacterial endocarditis, mycoses, or from HIV-1 infection. Other complications include hypoxic-ischemic changes with cerebral edema, ischemic neuronal damage and neuronal loss, which are assumed to occur under conditions of prolonged heroin-induced respiratory depression, stroke due to, for example, thromboembolism, vasculitis, septic emboli, hypotension, and positional vascular compression. Myelopathy is believed to be the result of an isolated vascular accident within the spinal cord due to an as yet unknown mechanism. A distinct entity, spongiform leukoencephalopathy, has been described mainly after inhalation of pre-heated heroin. A lipophilic toxin-induced process was considered to be due to contaminants and to be induced or enhanced by cerebral hypoxia, but a definite toxin could not be identified. At the cellular level, abnormalities in signal transduction systems and changes of various receptor densities have been reported. The exact etiology of the different neuropathological alterations associated with heroin abuse is still unclear, but may also be related to additional substances used as adulterants.
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Affiliation(s)
- A Büttner
- Institute of Legal Medicine, University of Munich, Frauenlobstrasse 7a, 80337, Munich, Germany
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Vila N, Chamorro A. Ballistic movements due to ischemic infarcts after intravenous heroin overdose: report of two cases. Clin Neurol Neurosurg 1997; 99:259-62. [PMID: 9491301 DOI: 10.1016/s0303-8467(97)00088-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Stroke is an infrequent but recognized complication of heroin addiction. Two heroin addicts, aged 34 and 19 years, developed ballistic movements after intravenous heroin overdose. Patient 1 presented bilateral ballism 1 week after intravenous heroin injection. Magnetic resonance imaging (MRI) showed bilateral ischemic lesions of the globus pallidus, suggesting a generalized cerebral hypoxia during the comatose state as pathogenic mechanism. Patient 2 presented an acute left hemiballismus when consciousness was restored with naloxone. MRI demonstrated an ischemic infarct in the right striatum. An embolic mechanism of stroke was suspected in this patient, considering the normal results of blood analysis, echocardiogram and cerebral arteriograms. Ballistic movements ceased after administration of haloperidol; both patients remained without abnormal movements thereafter.
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Affiliation(s)
- N Vila
- Service of Neurology, Hospital Clínic y Provincial, Barcelona, Spain
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