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Underner M, Perriot J, Peiffer G, Brousse G, Jaafari N. [Bronchial diseases and heroin use. A systematic review]. Rev Mal Respir 2023; 40:783-809. [PMID: 37925326 DOI: 10.1016/j.rmr.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 09/11/2023] [Indexed: 11/06/2023]
Abstract
INTRODUCTION Heroin use can cause respiratory complications including asthma, chronic obstructive pulmonary disease (COPD) and bronchiectasis (BD). OBJECTIVES A general review of the literature presenting the data on the relationships between heroin consumption and bronchial complications, while underlining the difficulties of diagnosis and management. DOCUMENTARY SOURCES Medline, 1980-2022, keywords "asthma" or "bronchospasm" or "COPD" or "bronchiectasis" and "heroin" or "opiate" or "opiates", with limits pertaining to "Title/Abstract". Concerning asthma, 26 studies were included, as were 16 for COPD and 5 for BD. RESULTS Asthma and COPD are more prevalent among heroin addicts, who are less compliant than other patients with their treatment. The authors found a positive association between frequency of asthma exacerbations, admission to intensive care and heroin inhalation. Late diagnosis of COPD worsens the course of the disease; emphysema and BD are poor prognostic factors. CONCLUSION Bronchial diseases in heroin users can be identified by means of respiratory function exploration and chest CT scans. These tests should be performed frequently in view of optimizing their care, which includes their weaning themselves from addictive substances.
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Affiliation(s)
- M Underner
- Unité de recherche clinique Pierre-Deniker, centre hospitalier Laborit, 370, avenue Jacques-Cœur, CS 10587, 86021 Poitiers cedex, France.
| | - J Perriot
- Dispensaire Émile-Roux, CLAT, centre de tabacologie, 63100 Clermont-Ferrand, France
| | - G Peiffer
- Service de pneumologie, CHR Metz-Thionville, 57038 Metz, France
| | - G Brousse
- Service d'addictologie, CHU de Clermont-Ferrand, université Clermont Auvergne, 63100 Clermont-Ferrand, France
| | - N Jaafari
- Unité de recherche clinique Pierre-Deniker, centre hospitalier Laborit, 370, avenue Jacques-Cœur, CS 10587, 86021 Poitiers cedex, France
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2
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Agarwal A, Evans M, Mogallapu R, Kothe N, Ang-Rabanes M. Toxic Leukoencephalopathy After "Chasing the Dragon" With a Non-Heroin Opioid. Cureus 2023; 15:e45774. [PMID: 38188695 PMCID: PMC10770636 DOI: 10.7759/cureus.45774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2023] [Indexed: 01/09/2024] Open
Abstract
In the United States, the rate of opioid use increases each year. With this, users are engaging in more non-traditional methods of usage. "Chasing the dragon" is a term used to describe opioid inhalation, where the user heats the opioid and then inhales the smoke. While this method of usage is typically associated with a quicker high and fewer adverse effects, it can also lead to toxic leukoencephalopathy (TLE). TLE is defined as a structural alteration of the brain's white matter due to toxic exposure, such as heroin. A 57-year-old woman with a history of polysubstance abuse was admitted to the hospital after weeks of erratic behavior. At presentation, her urine drug screen was found to be positive for oxycodone (which was prescribed to her) and fentanyl. A brain MRI was eventually done, which showed a periventricular leukoencephalopathy characteristic of opioid inhalation. Traditionally, opioid-related TLE is due to heroin, and patients are found to have very dramatic motor issues. As this patient did not report a history of heroin use and did not present with significant motor deficits, this report highlights the need to maintain a level of suspicion for TLE. As levels of opioid use continue to rise, it is likely that many presentations like that of the patient outlined in this report will be seen.
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Affiliation(s)
- Aayushi Agarwal
- Psychiatry, West Virginia University School of Medicine, Martinsburg, USA
| | - Megan Evans
- Psychiatry, West Virginia University School of Medicine, Martinsburg, USA
| | - Raja Mogallapu
- Psychiatry, West Virginia University School of Medicine, Martinsburg, USA
| | - Nycole Kothe
- Psychiatry, West Virginia University School of Medicine, Martinsburg, USA
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3
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Xavier CG, Kuo M, Desai R, Palis H, Regan G, Zhao B, Moe J, Scheuermeyer FX, Gan WQ, Sabeti S, Meilleur L, Buxton JA, Slaunwhite AK. Association between toxic drug events and encephalopathy in British Columbia, Canada: a cross-sectional analysis. Subst Abuse Treat Prev Policy 2023; 18:42. [PMID: 37420239 PMCID: PMC10329314 DOI: 10.1186/s13011-023-00544-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 06/03/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND Encephalopathy can occur from a non-fatal toxic drug event (overdose) which results in a partial or complete loss of oxygen to the brain, or due to long-term substance use issues. It can be categorized as a non-traumatic acquired brain injury or toxic encephalopathy. In the context of the drug toxicity crisis in British Columbia (BC), Canada, measuring the co-occurrence of encephalopathy and drug toxicity is challenging due to lack of standardized screening. We aimed to estimate the prevalence of encephalopathy among people who experienced a toxic drug event and examine the association between toxic drug events and encephalopathy. METHODS Using a 20% random sample of BC residents from administrative health data, we conducted a cross-sectional analysis. Toxic drug events were identified using the BC Provincial Overdose Cohort definition and encephalopathy was identified using ICD codes from hospitalization, emergency department, and primary care records between January 1st 2015 and December 31st 2019. Unadjusted and adjusted log-binomial regression models were employed to estimate the risk of encephalopathy among people who had a toxic drug event compared to people who did not experience a toxic drug event. RESULTS Among people with encephalopathy, 14.6% (n = 54) had one or more drug toxicity events between 2015 and 2019. After adjusting for sex, age, and mental illness, people who experienced drug toxicity were 15.3 times (95% CI = 11.3, 20.7) more likely to have encephalopathy compared to people who did not experience a drug toxicity event. People who were 40 years and older, male, and had a mental illness were at increased risk of encephalopathy. CONCLUSIONS There is a need for collaboration between community members, health care providers, and key stakeholders to develop a standardized approach to define, screen, and detect neurocognitive injury related to drug toxicity.
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Affiliation(s)
- Chloé G Xavier
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada.
| | - Margot Kuo
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
- Overdose Emergency Response Centre, Ministry of Mental Health and Addictions, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Roshni Desai
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Heather Palis
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
- Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC, V6T 2A1, Canada
| | - Gemma Regan
- Faculty of Medicine, University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, BC, Canada
- Woodward Instructional Resource Centre, Vancouver, BC, V6T 1Z3, Canada
| | - Bin Zhao
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Jessica Moe
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
- Department of Emergency Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
- Department of Emergency Medicine, Vancouver General Hospital, 899 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Frank X Scheuermeyer
- St Paul's Hospital and the Department of Emergency Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
- Centre for Health Evaluation & Outcomes Sciences, St Paul's Hospital, 588-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Wen Qi Gan
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Soha Sabeti
- Health Surveillance, First Nations Health Authority, 100 Park Royal S, West Vancouver, BC, V7T 1A2, Canada
| | - Louise Meilleur
- Health Surveillance, First Nations Health Authority, 100 Park Royal S, West Vancouver, BC, V7T 1A2, Canada
| | - Jane A Buxton
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
- School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Amanda K Slaunwhite
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
- School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC, V6T 1Z3, Canada
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4
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Macchi ZA, Carlisle TC, Filley CM. Prognosis in substance abuse-related acute toxic leukoencephalopathy: A scoping review. J Neurol Sci 2022; 442:120420. [PMID: 36156344 PMCID: PMC11008924 DOI: 10.1016/j.jns.2022.120420] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/26/2022] [Accepted: 09/07/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Abuse of opiates, cocaine, and lipophilic inhalants (e.g., toluene) can damage brain myelin and cause acute toxic leukoencephalopathy (TL), but little is known about recovery or prognosis in this condition. In light of the ongoing opiate epidemic in the United States, it is important to understand the natural history of patients who have acute neurological complications from illicit drug exposure. Our aim was to conduct a scoping review of the literature regarding prognosis in described cases of substance abuse-related TL. METHODS A strategic search of PubMed, Ovid, Cumulative Index to Nursing, and Allied Health Literature (CINAHL) databases yielded adult cases of acute TL from opiates, cocaine, or inhalants. Cases and case series were eligible for inclusion if they described acute leukoencephalopathy with a clear temporal association with opiate, cocaine, or inhalant abuse. Inclusion was contingent on availability of clinical descriptions until death or ≥ 4 weeks follow-up with neuroimaging consistent with TL. RESULTS Among 52 cases from 14 articles, 21 (40.4%) individuals died with mean time to death of 28.2 days; with mean follow-up of 12.8 months, 10 (19.2%) survived with no recovery, 17 (32.7%) had partial recovery, and 4 (7.7%) individuals had full recovery. CONCLUSION Substance abuse-related acute TL often has a poor prognosis, but partial or even full recovery is possible in a subgroup of individuals over months to years.
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Affiliation(s)
- Zachary A Macchi
- Department of Neurology, University of Colorado School of Medicine, 1635 Aurora Ct, Aurora, CO 80045, USA; Behavioral Neurology Section, University of Colorado School of Medicine, 12649 E 17(th) Place, Aurora, CO 80045, USA.
| | - Tara C Carlisle
- Department of Neurology, University of Colorado School of Medicine, 1635 Aurora Ct, Aurora, CO 80045, USA; Movement Disorders Center, University of Colorado School of Medicine, 12631 E 17(th) Ave, Aurora, CO 80045, USA
| | - Christopher M Filley
- Department of Neurology, University of Colorado School of Medicine, 1635 Aurora Ct, Aurora, CO 80045, USA; Behavioral Neurology Section, University of Colorado School of Medicine, 12649 E 17(th) Place, Aurora, CO 80045, USA; Department of Psychiatry, University of Colorado School of Medicine, 1890 N Revere Ct, Suite 4020, Aurora, CO 80045, USA; Marcus Institute for Brain Health, University of Colorado, 12348 E Montview Blvd, Aurora, CO 80045, USA
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5
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Diefenbach C, Lorenz C, Weidauer S. Toxic Spongiform Leukoencephalopathy After Intravenous Heroin Abuse: Unusual But Important Differential Diagnosis of Acute Impairment of Consciousness. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2022; 90:523-528. [PMID: 35584766 DOI: 10.1055/a-1778-3662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Abuse of heroin vapour inhalation known as "chasing the dragon" is associated with toxic spongiform leukoencephalopathy. However, similar clinical and imaging findings may occur also after intravenous heroin abuse. We report on a 32-year-old male suffering from extensive toxic spongiform leukoencephalopathy after intravenous heroin abuse resulting in acute impairment of consciousness and a global state of confusion. MRI disclosed broad and nearly symmetrical diffusion restriction of the supratentorial white matter indicating cytotoxic oedema. In an emergency setting, differential diagnosis of acute impairment of consciousness and broad symmetrical white matter lesions in neuroimaging should also include toxic leukoencephalopathy due to intravenous heroin application.
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Affiliation(s)
- Camilla Diefenbach
- Sankt Katharinen Krankenhaus, Neurologie, Goethe-Universität Frankfurt am Main, Fachbereich 16 Medizin, Frankfurt am Main, Germany
| | - Christine Lorenz
- Abteilung der Radiologie, Sankt Katharinen Krankenhaus, Frankfurt am Main, Germany
| | - Stefan Weidauer
- Sankt Katharinen Krankenhaus, Neurologie, Goethe-Universität Frankfurt am Main, Fachbereich 16 Medizin, Frankfurt am Main, Germany
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6
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Herlinger K, Lingford-Hughes A. Opioid use disorder and the brain: a clinical perspective. Addiction 2022; 117:495-505. [PMID: 34228373 DOI: 10.1111/add.15636] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/16/2021] [Accepted: 06/18/2021] [Indexed: 02/06/2023]
Abstract
Opioid use disorder (OUD) has gained increasing publicity and interest during recent years, with many countries describing problems of epidemic proportions with regard to opioid use and deaths related to opioids. While opioids are not themselves acutely neurotoxic, the chronic relapsing and remitting nature of this disorder means that individuals are often exposed to exogenous opioids for lengthy periods of time (either illicit or prescribed as treatment). We are increasingly characterizing the effect of such long-term opioid exposure on the brain. This narrative review aims to summarize the literature regarding OUD and the brain from a clinical perspective. Alterations of brain structure and function are discussed, as well as neurological and psychiatric disorders in OUD. Finally, we review current and new directions for assessment and treatment.
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Affiliation(s)
- Katherine Herlinger
- MRC Addiction Research Clinical Training Programme, Imperial College London, London, UK
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7
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Bitar AN, Khan AH, Sulaiman SAS, Ali IABH, Khan I. The Association between Chronic Heroin Smoking and Chronic Obstructive Pulmonary Disease. J Pharm Bioallied Sci 2021; 13:S1215-S1223. [PMID: 35017959 PMCID: PMC8687033 DOI: 10.4103/jpbs.jpbs_353_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 04/25/2021] [Accepted: 05/10/2021] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Little is known about the correlation between chronic obstructive pulmonary disease (COPD) and heroin smoking. Heroin smoking is a recent underinvestigated problem. The goal of this study is to study the impact of heroin smoking among COPD patients. METHODS This is a descriptive clinical study. A combination of self-reporting questionnaires and data extraction tools were used to collect information during baseline tests, interviews, and follow-ups. Patients' medical, clinical, and socioeconomic history were recorded. Participants were recruited using random sampling from multiple centers. RESULTS Out of 1034 COPD patients, heroin smokers represented the vast majority of addiction cases (n = 133). Heroin smokers were leaner than non-addicts (19.78 ± 4.07 and 24.01 ± 5.6, respectively). The most common type of comorbidities among heroin smokers was emphysema (27%). Both the forced expiratory volume (FEV1)/forced vital capacity ratio and FEV1% predicted were lower among heroin smokers than non-addicts (52.79 ± 12.71 and 48.54 ± 14.38, respectively). The majority of heroin smokers (55%) had advanced COPD, and at least 15% of heroin smokers suffered from frequent respiratory failure. The mean ± SD for COPD onset age among heroin smokers was 44.23 ± 5.72, and it showed a statistically significant correlation (P < 0.001). CONCLUSION Heroin smoking might be linked to the onset of COPD. Heroin smokers showed a significantrespiratory impairment compared to tobacco smokers of the same age group.
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Affiliation(s)
- Ahmad Naoras Bitar
- Department of Clinical Pharmacy, Universiti Sains Malaysia, Gelugore 11800, Penang, Malaysia
| | - Amer Hayat Khan
- Department of Clinical Pharmacy, Universiti Sains Malaysia, Gelugore 11800, Penang, Malaysia,Address for correspondence: Dr. Amer Hayat Khan, Department of Clinical Pharmacy, Universiti Sains Malaysia, Gelugore 11800, Penang, Malaysia. E-mail:
| | - Syed Azhar Syed Sulaiman
- Department of Clinical Pharmacy, Universiti Sains Malaysia, Gelugore 11800, Penang, Malaysia,Advanced Medical and Dental Institute, Universiti Sains Malaysia, Bertam, Jln Tun Hamdan Sheikh Tahir, 13200 Kepala Batas, Penang, Malaysia
| | - Irfhan Ali Bin Hyder Ali
- Department of Clinical Pharmacy, Universiti Sains Malaysia, Gelugore 11800, Penang, Malaysia,Chest Department, Penang General Hospital, Georgetown 10990, Penang, Malaysia
| | - Irfanullah Khan
- Department of Clinical Pharmacy, Universiti Sains Malaysia, Gelugore 11800, Penang, Malaysia
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8
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Mahintamani T, Ghosh A, Jain R. Serious health threats of novel adulterants of the street heroin: a report from India during the COVID-19 pandemic. BMJ Case Rep 2021; 14:14/8/e242239. [PMID: 34433525 PMCID: PMC8388263 DOI: 10.1136/bcr-2021-242239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The COVID-19 pandemic and a consequent nationwide lockdown in India for several weeks had restricted the access to street heroin and treatment for substance abuse. Use of cutting agents to increase the volume or psychoactive effect has been widely practised under such circumstances. Our patient with opioid use disorder chased heroin with an unknown cutting agent to enhance psychoactive effect from the limited quantities of heroin. He suffered from an abrupt onset sedation, weakness, postural imbalance, slurred speech, cognitive dysfunctions and disinhibited behaviour. Symptoms rapidly reversed following abstinence and initiation of buprenorphine–naloxone. Gas chromatography-mass spectrometric analysis of the adulterant revealed high concentrations of benzodiazepines and barbiturates, alongside the usual cutting agents—caffeine and acetaminophen. Abrupt reduction in availability of ‘street drugs’ in conjunction with poor healthcare access can lead to the use of novel adulterants with potentially serious clinical and public health implications.
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Affiliation(s)
- Tathagata Mahintamani
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Abhishek Ghosh
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajeev Jain
- Toxicilogy Department, Central Forensic and Science Laboratory, Chandigarh, India
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9
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Burke H, Jiang S, Cohen-Oram A. Heroin-Induced Toxic Leukoencephalopathy From "Chasing the Dragon" and the Proposed Synergistic Effect of Amantadine and Antioxidants in Its Treatment. J Acad Consult Liaison Psychiatry 2021; 62:353-356. [PMID: 34102131 DOI: 10.1016/j.jaclp.2020.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Heather Burke
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, FL.
| | - Shixie Jiang
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, FL
| | - Alexis Cohen-Oram
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, FL
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10
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Bardwell G, Austin T, Maher L, Boyd J. Hoots and harm reduction: a qualitative study identifying gaps in overdose prevention among women who smoke drugs. Harm Reduct J 2021; 18:29. [PMID: 33678163 PMCID: PMC7937364 DOI: 10.1186/s12954-021-00479-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/26/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Smoking or inhaling illicit drugs can lead to a variety of negative health outcomes, including overdose. However, most overdose prevention interventions, such as supervised consumption services (SCS), prohibit inhalation. In addition, women are underrepresented at SCS and are disproportionately impacted by socio-structural violence. This study examines women's experiences smoking illicit drugs during an overdose epidemic, including their utilization of a women-only supervised inhalation site. METHODS Qualitative research methods included on-site ethnographic observation and semi-structured interviews with 32 participants purposively recruited from the women-only site. Data were coded and analyzed using NVivo 12 and thematic analysis was informed by gendered and socio-structural understandings of violence. RESULTS Participants had preferences for smoking drugs and these were shaped by their limited income, inability to inject, and perceptions of overdose risk. Participants expressed the need for services that attend to women's specific experiences of gendered, race-based, and structural violence faced within and outside mixed-gender social service settings. Results indicate a need for sanctioned spaces that recognize polysubstance use and drug smoking, accommodated by the women-only SCS. The smoking environment further fostered a sociability where participants could engage in perceived harm reduction through sharing drugs with other women/those in need and were able to respond in the event of an overdose. CONCLUSIONS Findings demonstrate the ways in which gendered social and structural environments shape women's daily experiences using drugs and the need for culturally appropriate interventions that recognize diverse modes of consumption while attending to overdose and violence. Women-only smoking spaces can provide temporary reprieve from some socio-structural harms and build collective capacity to practice harm reduction strategies, including overdose prevention. Women-specific SCS with attention to polysubstance use are needed as well as continued efforts to address the socio-structural harms experienced by women who smoke illicit drugs.
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Affiliation(s)
- Geoff Bardwell
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.
- Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - Tamar Austin
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
| | - Lisa Maher
- Faculty of Medicine, Kirby Institute for Infection and Immunity, UNSW Sydney, Wallace Wurth Building, Sydney, NSW, 2052, Australia
| | - Jade Boyd
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
- Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
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11
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Kashyap S, Majeed G, Bowen I, Beamer Y, Miulli D. Toxic Leukoencephalopathy due to Inhalational Heroin Abuse. Ann Indian Acad Neurol 2020; 23:542-544. [PMID: 33223675 PMCID: PMC7657301 DOI: 10.4103/aian.aian_446_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 10/25/2018] [Accepted: 11/14/2018] [Indexed: 11/04/2022] Open
Abstract
Heroin-induced spongiform leukoencephalopathy (HSLE) is a rare condition that is strongly associated with heroin vapor inhalation which has become a popular method among heroin addicts because it poses a less immediate danger to the user and makes the drug much easier to use. We present a case of a 22-year-old male who presented with dysarthria and cerebellar symptoms starting, after 3 months of heroin inhalation. Diagnosis was confirmed to be HSLE after extensive diagnostic testing. HSLE is a rare complication of which the pathogenesis is poorly understood. Clinical history and characteristic findings on magnetic resonance imaging (diffuse, symmetric T2-hyperintensity, and diffusion restriction in frontal, parietal, occipital lobs, basal ganglia, and superior cerebellum) are diagnostic; however, care should be taken to exclude other etiologies. Treatment is primarily supportive; however, there is anecdotal evidence that coenzyme Q10 may be of benefit. The growing number of victims of the opioid crisis requires that physicians be aware of and counsel patients on the devastating neurological complications that can occur with abuse of these drugs.
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Affiliation(s)
- Samir Kashyap
- Department of Neurosurgery, Arrowhead Regional Medical Center, Colton, CA, USA.,Department of Neurosurgery, Riverside University Health System, Riverside, CA, USA
| | - Gohar Majeed
- Department of Neurosurgery, Arrowhead Regional Medical Center, Colton, CA, USA.,Department of Neurosurgery, Riverside University Health System, Riverside, CA, USA
| | - Ira Bowen
- Department of Neurosurgery, Arrowhead Regional Medical Center, Colton, CA, USA.,Department of Neurosurgery, Riverside University Health System, Riverside, CA, USA
| | - Yancey Beamer
- Department of Neurosurgery, Arrowhead Regional Medical Center, Colton, CA, USA.,Department of Neurosurgery, Riverside University Health System, Riverside, CA, USA
| | - Dan Miulli
- Department of Neurosurgery, Arrowhead Regional Medical Center, Colton, CA, USA.,Department of Neurosurgery, Riverside University Health System, Riverside, CA, USA
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12
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Al-Chalabi M, Lateef S, Gharaibeh K, Saraiya P, Ghannam M. Mimicking a Psychiatric Disorder: Heroin-Induced Leukoencephalopathy. Cureus 2020; 12:e10805. [PMID: 33163309 PMCID: PMC7641477 DOI: 10.7759/cureus.10805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Toxic leukoencephalopathy is a rare cause of encephalopathy. We describe two cases of toxic leukoencephalopathy associated with opiate abuse where they were misdiagnosed and admitted to the psychiatric ward. In our case series, both patients presented with behavioral changes, restlessness, pressured speech, and cognitive impairment for which they were initially labeled as psychiatric patients and were treated as such. However, after an extensive workup to elucidate the etiology of alteration in mental status, toxic leukoencephalopathy associated with heroin abuse was found to be the culprit in both cases. Toxic leukoencephalopathy is a rare condition that can be caused by inhalation of heroin. Clinically, it may present with confusion, behavioral changes, extrapyramidal symptoms, generalized motor deficit, unresponsiveness and even death. Our cases highlight the importance of recognizing the psychiatric presentation of toxic leukoencephalopathy.
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13
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Ferreira C, Almeida C, Tenreiro S, Quintas A. Neuroprotection or Neurotoxicity of Illicit Drugs on Parkinson's Disease. Life (Basel) 2020; 10:life10060086. [PMID: 32545328 PMCID: PMC7344445 DOI: 10.3390/life10060086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 12/20/2022] Open
Abstract
Parkinson's Disease (PD) is currently the most rapid growing neurodegenerative disease and over the past generation, its global burden has more than doubled. The onset of PD can arise due to environmental, sporadic or genetic factors. Nevertheless, most PD cases have an unknown etiology. Chemicals, such as the anthropogenic pollutant 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) and amphetamine-type stimulants, have been associated with the onset of PD. Conversely, cannabinoids have been associated with the treatment of the symptoms'. PD and medical cannabis is currently under the spotlight, and research to find its benefits on PD is on-going worldwide. However, the described clinical applications and safety of pharmacotherapy with cannabis products are yet to be fully supported by scientific evidence. Furthermore, the novel psychoactive substances are currently a popular alternative to classical drugs of abuse, representing an unknown health hazard for young adults who may develop PD later in their lifetime. This review addresses the neurotoxic and neuroprotective impact of illicit substance consumption in PD, presenting clinical evidence and molecular and cellular mechanisms of this association. This research area is utterly important for contemporary society since illicit drugs' legalization is under discussion which may have consequences both for the onset of PD and for the treatment of its symptoms.
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Affiliation(s)
- Carla Ferreira
- Molecular Pathology and Forensic Biochemistry Laboratory, Centro de Investigação Interdisciplinar Egas Moniz, P-2825-084 Caparica, Portugal; (C.F.); (C.A.)
- Laboratório de Ciências Forenses e Psicológicas Egas Moniz, Campus Universitário–Quinta da Granja, Monte de Caparica, P-2825-084 Caparica, Portugal
- Faculty of Medicine of Porto University, Al. Prof. Hernâni Monteiro, P-4200–319 Porto, Portugal
| | - Catarina Almeida
- Molecular Pathology and Forensic Biochemistry Laboratory, Centro de Investigação Interdisciplinar Egas Moniz, P-2825-084 Caparica, Portugal; (C.F.); (C.A.)
| | - Sandra Tenreiro
- CEDOC–Chronic Diseases Research Center, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, P-1150-082 Lisboa, Portugal;
| | - Alexandre Quintas
- Molecular Pathology and Forensic Biochemistry Laboratory, Centro de Investigação Interdisciplinar Egas Moniz, P-2825-084 Caparica, Portugal; (C.F.); (C.A.)
- Laboratório de Ciências Forenses e Psicológicas Egas Moniz, Campus Universitário–Quinta da Granja, Monte de Caparica, P-2825-084 Caparica, Portugal
- Correspondence:
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Ghosh A, Shah R, Naskar C, Prasad S, Sharma N. Dystonia after Shooting Street Heroin: An Underreported Matter of Concern. Indian J Psychol Med 2019; 41:588-591. [PMID: 31772449 PMCID: PMC6875830 DOI: 10.4103/ijpsym.ijpsym_193_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Abhishek Ghosh
- Department of Psychiatry, Drug Deaddiction and Treatment Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Raghav Shah
- Department of Psychiatry, Drug Deaddiction and Treatment Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Chandrima Naskar
- Department of Psychiatry, Drug Deaddiction and Treatment Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sambhu Prasad
- Department of Psychiatry, Drug Deaddiction and Treatment Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nidhi Sharma
- Department of Psychiatry, Drug Deaddiction and Treatment Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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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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Metabolism and metabolomics of opiates: A long way of forensic implications to unravel. J Forensic Leg Med 2019; 61:128-140. [DOI: 10.1016/j.jflm.2018.12.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 12/15/2018] [Accepted: 12/17/2018] [Indexed: 12/27/2022]
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Goodnough R, Li K, Fouladkou F, Lynch KL, Shah M, Smollin CG, Blanc PD. Notes from the Field: Toxic Leukoencephalopathy Associated with Tianeptine Misuse - California, 2017. MMWR. MORBIDITY AND MORTALITY WEEKLY REPORT 2018; 67:769-770. [PMID: 30001559 PMCID: PMC6047469 DOI: 10.15585/mmwr.mm6727a5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Achamallah N, Wright RS, Fried J. Chasing the wrong dragon: A new presentation of heroin-induced toxic leukoencephalopathy mimicking anoxic brain injury. J Intensive Care Soc 2018; 20:80-85. [PMID: 30792768 DOI: 10.1177/1751143718774714] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Toxic leukoencephalopathy associated with heroin inhalation has been extensively described in the literature. This syndrome is characterized by progressive motor symptoms and dysautonomia that develop over weeks to months. We present three cases of abrupt-onset inhaled heroin-associated toxic leukoencephalopathy, a previously undescribed entity. These likely represent a subset of "found down" patients with acute neurologic changes not attributable to hypoxemic encephalopathy. All three had magnetic resonance imaging findings characteristic of toxic leukoencephalopathy, which has a relatively favorable prognosis. Prolonged unresponsiveness in patients "found down" after heroin overdose is often attributed to hypoxic brain injury. Brain magnetic resonance imaging is not generally included as part of routine workup. It should, however, be considered in patients with suspected inhaled heroin use due to the relatively favorable prognosis of toxic leukoencephalopathy. This is especially relevant in the setting of the current opioid epidemic and related increase in overdose-related intensive care unit admissions. The result may have significant impact on decisions about therapeutic options or continuation of care.
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Affiliation(s)
- Natalie Achamallah
- Department of Medical Education, Santa Barbara Cottage Hospital, Santa Barbara, CA, USA
| | - Robert S Wright
- Department of Medical Education, Santa Barbara Cottage Hospital, Santa Barbara, CA, USA.,Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jeffrey Fried
- Department of Medical Education, Santa Barbara Cottage Hospital, Santa Barbara, CA, USA.,Department of Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
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Abstract
Purpose
In South Africa, many illicit drugs have only recently been introduced and drug-related complications are often new to treating physicians. Heroin-induced leukoencephalopathy has been reported elsewhere in patients who inhale heated heroin vapors, a method known as “chasing the dragon.” The purpose of this paper is to present two patients, known to have inhaled heroin a few weeks prior to presenting with progressive neurological deficits.
Design/methodology/approach
Case presentations: two young males presented independently within eight weeks of one another with progressive slurring of speech, incoordination and weakness of the limbs over a period of two to three weeks. Both were known heroin addicts, and were known to one another, and both had inhaled heroin prior to the onset of symptoms.
Findings
The patients presented with a pancerebellar syndrome with marked bilateral upper motor neuron signs. CT scans showed diffuse symmetrical hypodense lesions involving the cerebral and cerebellar white matter with normal CSF. Both patients deteriorated neurologically, became cardiovascularly unstable and demised. Postmortem in one of the patients showed a prominent spongiform leukoencephalopathy consistent with reports of heroin-inhalation injury to the brain.
Research limitations/implications
Toxic leukoencephalopathy due to heroin vapor inhalation was first described in the Netherlands in 1982. It has not been reported to occur with other modes of heroin use; an unknown toxin contained in heroin pyrolysate which forms when heroin is heated, may be causative. Brain MRI typically shows diffuse, symmetrical white matter hyperintensities on T2 and fluid-attenuated inversion recovery sequences in the cerebellum, posterior cerebrum and posterior limbs of the internal capsule with a posterior-anterior gradient. Pathologically, spongiform degeneration with relative sparing of subcortical U-fibers is seen. No treatment has been proven effective, but antioxidants and Vitamin E may be beneficial. Mortality is high at 23-48 percent.
Practical implications
This report emphasizes that spongiform leukoencephalopathy as a rare consequence of inhaling heroin vapors does occur in South Africa and clinicians should consider this disorder in their differential diagnosis of acutely developing leukoencephalopathy.
Social implications
An awareness program regarding this grave condition is planned.
Originality/value
The cardiovascular complications of patients inhaling heroin vapor has not been highlighted previously. These are the first patients from Africa described with this condition. A toxic component appears likely.
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Bell S, Nida C. Pyrolysis of drugs of abuse: a comprehensive review. Drug Test Anal 2015; 7:445-56. [PMID: 25865019 DOI: 10.1002/dta.1794] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Revised: 03/01/2015] [Accepted: 03/02/2015] [Indexed: 11/10/2022]
Abstract
This review summarizes the literature to date relating to pyrolysis and heated vapour ingestion of drugs of abuse. In this context, heating is referred to as smoking or pyrolysis, but these are generic descriptors that encompass numerous methods of vapour generation and inhalation. Depending on the amount of drug used, diluents and contaminants present, heating conditions, and the oxidative/reductive environment, many thermal decomposition products can be formed. In addition to the recognized hazard of rapid onset of pharmacological effects of the parent drug, thermal decomposition products may be pharmacologically active as well as acutely/chronically toxic. For example, several published reports have linked heroin smoking to a form of brain encephalopathy and to the development of movement disorders. Early qualitative studies focusing on the thermal decomposition of drugs have evolved into more complex investigations employing mass spectral identification, confirmation, and elucidation of formation mechanism. In most cases, thermal decomposition begins with cleavage of the weakest bond (often C-N) to generate free radicals that then form the most stable sterically favoured products. Several reports of rearrangements at higher temperatures have been identified and hint at an underlying complexity that arises from the variety of smoking methods and conditions. Given that many designer drugs such as synthetic cannabinoids are ingested primarily through smoking, this issue has taken on new importance.
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Affiliation(s)
- Suzanne Bell
- C. Eugene Bennett Department of Chemistry/Department of Forensic and Investigative Sciences, West Virginia University, 1600 University Ave, 208 Oglebay Hall, Morgantown, WV, 26508-6121, USA
| | - Corey Nida
- C. Eugene Bennett Department of Chemistry, West Virginia University, 1600 University Ave, 208 Oglebay Hall, Morgantown, WV, 26508-6121, USA
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Bouso ED, Gardner EA, O'Brien JE, Talbot B, Kavanagh PV. Characterization of the pyrolysis products of methiopropamine. Drug Test Anal 2013; 6:676-83. [DOI: 10.1002/dta.1571] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 09/18/2013] [Accepted: 09/21/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Emily D. Bouso
- Department of Justice Sciences; University of Alabama at Birmingham; 1201 University Blvd Birmingham AL USA
| | - Elizabeth A. Gardner
- Department of Justice Sciences; University of Alabama at Birmingham; 1201 University Blvd Birmingham AL USA
| | | | - Brian Talbot
- School of Pharmacy and Pharmaceutical Sciences; Trinity College; Dublin 2 Ireland
| | - Pierce V. Kavanagh
- Department of Pharmacology and Therapeutics, School of Medicine, Trinity Centre for Health Sciences; St James's Hospital; Dublin 8 Ireland
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Abstract
Leukoencephalopathy is a syndrome of neurologic deficits, including alteration of mental status, caused by pathologic changes in the cerebral white matter. The term, toxic leukoencephalopathy, encompasses a wide variety of exposures and clinical presentations. The diagnosis in these Frontiers in Clinical Neurotoxicology syndromes is made by careful attention to the history, clinical features, and radiologic findings. This article details three of the best-defined toxic leukoencephalopathies: delayed posthypoxic leukoencephalopathy, including delayed neurologic sequelae after carbon monoxide poisoning; heroin inhalation leukoencephalopathy; and posterior reversible encephalopathy syndrome.
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Affiliation(s)
- Laura M Tormoehlen
- Department of Neurology, Indiana University School of Medicine, 545 Barnhill Drive, Indianapolis, IN 46202, USA.
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Li X, Deng L, Ye B. Functional outcomes after home-based rehabilitation for heroin-induced spongiform leukoencephalopathy. Neural Regen Res 2012; 7:534-8. [PMID: 25745441 PMCID: PMC4349001 DOI: 10.3969/j.issn.1673-5374.2012.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Accepted: 01/08/2012] [Indexed: 11/24/2022] Open
Abstract
A 22-year-old man with a 2-year history of heroin vapor inhalation developed spongiform leukoencephalopathy and underwent clinical and home-based rehabilitative treatments. Activities of daily living were measured using the Functional Independence Measure at discharge and at 6, 12, and 24 months after discharge. His neurological symptoms gradually disappeared with rehabilitative treatment, and the functional scale scores increased from 55 on admission to 105 at 24 months after discharge. These results suggest that home-based rehabilitation was effective in ameliorating the pathology and improving activities of daily living in this patient with heroin-induced spongiform leukoencephalopathy.
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Affiliation(s)
- Xuhong Li
- Department of Rehabilitation, Third Xiangya Hospital of Central South University, Changsha 410013, Hunan Province, China
| | - Liming Deng
- Department of Rehabilitation, Third Xiangya Hospital of Central South University, Changsha 410013, Hunan Province, China
| | - Bin Ye
- Department of Radiology, Third Xiangya Hospital of Central South University, Changsha 410013, Hunan Province, China
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