Risks of non-Hodgkin's lymphoma, multiple myeloma, and leukemia associated with common medications

We utilized data from two Kaiser Permanente medical care programs to evaluate risks of hematopoietic and lymphoproliferative (HLP) malignancies after use of 14 common medications. The subjects were adult cases of non-Hodgkin's lymphoma (NHL) (N = 94), multiple myeloma (N = 159), and leukemia (N = 257) and individually matched controls (N = 695). Abstractors reviewed medical records and recorded medication notations. Using a minimum 5-year exposure lag between first notation and malignancy diagnosis, the risk of NHL was greater among plan members who were prescribed amphetamines [odds ratio (OR) = 2.2; 95% confidence interval (CI) = 1.1-4.8], lidocaine (OR = 2.6; 95% CI = 1.2-5.5), and meprobamate (OR = 2.1; 95% CI = 1.03-4.3). The risk of NHL rose with increasing number of medical record notations for amphetamines; however, there was no association with number of notations for lidocaine or meprobamate. The odds ratio for total leukemia was decreased among patients who took chloramphenicol (OR = 0.4; 95% CI = 0.2-0.97).

Taiwan National Poison Center: epidemiologic data 1985-1993

The Taiwan National Poison Center has received more than 30,000 telephone calls since its establishment in July 1985.

OBJECTIVE

To obtain more information about poisoning exposures in Taiwan, a retrospective analysis was conducted of all telephone calls to the center concerning human poisoning exposures July 1985 through December 1993.

METHODS

The following data were tabulated: age, sex, intent of exposure, route of exposure, substances ingested and clinical severity.

RESULTS

During the eight years (1985-1993), 23,436 telephone calls concerning human poisoning exposure were recorded. Adults accounted for most cases (75.2%) and exposures involving males (54.2%) were somewhat more prevalent than female poisoning exposures (44.7%). Intentional poisonings (54.6%) were more common than unintentional poisonings (40.1%), with an inverse relationship in pediatric poisoning exposures. After amphetamines, the most frequently ingested poisons were pesticides, benzodiazepines, and cleaning products. Fatalities occurred most frequently following ingestion of pesticides. The mortality rate was 5.7% for all exposures.

CONCLUSIONS

Human poisoning is a serious problem in Taiwan. The reduction of suicide attempts is a major objective. Childhood poisonings are underreported and of high mortality.

[Main cardiotoxic drugs]

A review of the most important iatrogenic pictures is reported. Chemotherapeutic agents, antidepressants, cocaine and amphetamine, oral contraceptives and antiarrhythmic drugs are examined.

Cleft palate, mortality and morbidity in infants of substance abusing mothers

OBJECTIVE

To investigate a high incidence of congenital malformations, morbidity and mortality in infants of drug abusing mothers.

METHODOLOGY

In a 10 and a half year period from 1984-95, 497 such babies were reviewed whose mothers had abused a variety of drugs.

RESULTS

Thirty babies died or had serious disability. There were five cases of SIDS and 19 babies had major malformations, including seven with cleft lip/palate. Six babies had significant gastrointestinal disorders or feeding difficulties.

CONCLUSION

The incidence of clefting was 10 times the normal rate and SIDS five times the expected incidence. In a group of mainly socially disadvantaged women, the abuse of narcotics, amphetamines and other substances, with possible suboptimal nutrition, may have been contributory to this high morbidity and mortality. No specific drug could be implicated.

International renal-cell cancer study. III. Role of weight, height, physical activity, and use of amphetamines

Although numerous studies have identified obesity or high relative weight as a risk factor for renal-cell cancer in women, the degree to which this effect is present in men remains unclear. A multicenter population-based case-control study concerning incident cases of histologically verified renal-cell cancer (n = 1,732) and age- and sex-matched controls (n = 2,309) was conducted in Australia, Denmark, Germany (2 centers), Sweden and the United States. Relative weight was estimated by the body mass index, and the association between this factor and other factors, such as height, physical activity and use of amphetamines, was measured by the relative risk estimated in logistic regression models. Body mass index was found to be a risk factor among women and, to a lesser extent, among men. A 3-fold increased risk (RR = 3.6, 95% CI = 2.3-5.7) was observed for women with a relative weight in the top 5% compared with those in the lowest quartile. Rate of weight change (estimated as weight change per annum in kilograms) appeared to be an independent risk factor among women but not among men. Physical activity and height were unrelated to risk of renal-cell cancer regardless of level of BMI, while use of amphetamines was associated with an increased risk among men, although no dose or duration effect was seen. Our findings verify the link between high relative weight and risk of renal-cell cancer, particularly among women. The mechanism that underlies this association is, however, still unclear, although the rate of weight change may play a role.

[Neurobiological principles of drug dependence. Exemplified by opioids and psychostimulants]

New insights into the neurobiological mechanisms underlying drug addition have become available with recent advances in experimental research. This is particularly true for the opioids and psychostimulants: behavioural and biochemical studies have revealed that activation of the mesolimbic "reward pathways", involving the release of dopamine, which acts upon D1 receptors, plays a critical part in the development of addictive behaviour. In the case of the opioids, the differentiation of various types of receptors (and of the corresponding endogenous ligands, the endorphins) revealed a bidirectional role of opioid receptors in this process: stimulation of the reward system, mediated by mu- and delta-opioid receptors, and inhibition of the reward pathways, mediated by the activation of chi-receptors. Thus, a functional equilibrium between these tonically active opioidergic systems appears to provide a neutral motivational state. During drug withdrawal, the decrease in dopamine release most probably reflects a disturbance of this equilibrium. There is increasing evidence that endogenous opioidergic mechanisms also modulate addictive behaviour caused by psychostimulants and other drugs of abuse. This article discusses the implications of these new findings in the context of pharmacotherapeutic strategies in the treatment of addictive behaviours.

The prevention of stimulant misuse

The term 'stimulant' refers to a class of drugs that increase psychophysiological arousal. From the viewpoint of prevention, it is more useful to look primarily at the social consequences and functions of stimulants. Every society has a documented use of stimulants. When planning interventions the dynamics of use must be placed in the foreground. Stimulant epidemics, like problematic stimulant users, have a natural tendency to burn themselves out. Different types of stimulants may differ in their origins, but their epidemiological consequences and use functions tend to be similar. Implications for prevention can be drawn from the characteristics of stimulant use epidemics. Users at risk for socially unacceptable patterns should be targeted for prevention efforts. Mass media campaigns that single out stimulants should be avoided. Much of the harm associated with stimulants is a consequence of life-styles characterized by polydrug use and unhealthy practices. Prevention should be timed to the appropriate period of the epidemic. Interventions useful at period 1 will not work at period 2. The recommendations of the WHO Advisory Group on the Adverse Effects of Cocaine and Coca provide a good model for primary, secondary and tertiary prevention for all forms of stimulant misuse. Stimulant prevention must be creative in finding ways of encouraging the movements of the drug to the periphery of users' lives.

The dangerousness of persons with the Othello syndrome

The Othello syndrome, or delusional jealousy, often raises significant forensic issues, particularly dangerousness. Dangerous patients suffering from the Othello delusion may present with hostility ranging from verbal threats to homicidal acts. We present three cases of individuals suffering from Othello syndrome associated with significant hostility and organic mental factors. We analyze these cases along with Othello syndrome cases culled from the recent anglophonic literature, especially in terms of implications for domestic and public safety.

Stimulant withdrawal

The current paper is a review of the literature on abstinence symptomatology after stimulant use. The studies performed indicate biological and physical changes during abstinence. One outpatient study suggests a phasic model of stimulant abstinence which is characterized by a 'crash', 'withdrawal', and 'extinction' phase. However, two inpatient studies do not confirm these findings. In contrast, these latter two studies did not find a crash phase and reported a gradual improvement of mood during these 21-day and 28-day inpatient stays. Biological measures suggest changes in receptor, endocrinological and neurochemical activity. One study found hyperprolactinemia throughout the 4-week period, while another study using PET and FDG ([18F]-Fluorodeoxyglucose) found increased brain glucose metabolism in the dopamine-rich areas of the basal ganglia and orbitofrontal cortex. Another study using PET and F18-Methylspiroperidol found decreased dopamine D2 receptor binding during cocaine withdrawal and also a separate study using PET and F-18-Dopa discovered low dopaminergic brain activity. To date, few studies have been performed, and the lack of clear-cut physical withdrawal symptoms as seen in alcohol, sedative, and opiate withdrawal makes it difficult to demonstrate definitively the presence of withdrawal during stimulant abstinence. Amphetamine withdrawal has been less studied, but empirical data suggest that the symptoms are similar to cocaine withdrawal. Further studies are needed to better delineate the presence of acute versus chronic post-use symptoms.

Biological effects of central nervous system stimulants

In both animals and man, stimulants such as the amphetamines and cocaine are reinforcing and thus motivate repeated drug-taking behaviour and leading to abuse. Although this class of drugs seems to act by different biological mechanisms in the central nervous system, it has been suggested that their action to increase dopaminergic neurotransmission is crucial to the reinforcing properties of these compounds. However, increasing evidence suggests that a number of other neurotransmitters/neuroregulators, possibly in conjunction with dopamine, are part of the complex neurochemical systems which underlies various aspects of stimulant abuse behaviours. Examples of possible influences of noradrenaline and corticosterone will be discussed.

The treatment of stimulant dependence

Rehabilitation efforts offered to individuals with stimulant dependence incorporate a series of maneuvers to accomplish three major goals. Following active detoxification, most clinicians attempt to: (1) increase motivation for abstinence and maintain a high level of commitment to this goal; (2) help individuals to rebuild a stable life-style without substances; and (3) actively work toward ways of decreasing the probability of relapse (relapse prevention). While these activities incorporate education, counseling, outreach to families and exposure to self-help groups (e.g. Cocaine Anonymous), numerous pharmacological approaches have been tested. Each mode of drug therapy is based on a reasonable hypothesis, but appropriately controlled and structured clinical trials have not yet revealed any pharmacological approach for rehabilitation of stimulant-dependent individuals for which the risks have been shown to outweight the assets.

Prevalence and demographic factors of stimulant use

The use of stimulants for recreation purposes has increased considerably during the 20th century. Cocaine was first considered to be a drug of potential abuse during the First World War but was only perceived as a serious threat when it became widely used in socially and economically deprived urban areas of the USA in the 1980s. Use of amphetamines was common among certain occupational groups as a means of remaining alert until the 1950s, when they were seen to be abused by a small minority of recreational users. Controls were then introduced in most developed countries. The public health issue of stimulant use is that of finding a balance between the prevention of serious social or personal harm caused by abuse of these drugs while not impeding their beneficial use.

The influence of environmental factors on behavioural problems in 8-year-old children exposed to amphetamine during fetal life

Sixty-five children born to women who all used amphetamine during pregnancy were followed prospectively up to the age of 8 years. There was a statistically significant correlation between the extent (among and duration) of amphetamine exposure during fetal life and psychometric tests, aggressive behavior, adjustment and general assessment, indicating a worse outcome for children who had been more exposed to the drug. Alcohol use during pregnancy as well as attitude towards pregnancy also showed a statistical correlation to the outcome. Predictors of the child's psychosocial environment were few and only maternal psychiatric treatment, alcohol abuse and number of custodians correlated with aggressive behavior and general assessment.

Effects of in utero drug exposure on children's development. Review and recommendations

Effects of in utero drug exposure on pregnancy outcome, infant development, and preschool functioning are reviewed. Six possible mechanisms underlying possible negative outcomes seen in children exposed to drugs in utero are considered. Recommendations and opportunities for future research focus on process-oriented assessments, methodological and procedural issues, research design, and interventions.

Sympathomimetic drug abuse masking an endogenous hyperadrenergic state, Graves' disease

Sympathomimetic drug use or abuse in a thyrotoxic individual can be clinically devastating as a result of enhanced cellular sensitivity to adrenergic stimulation. Thus, it is critical to recognize thyrotoxicosis in a patient with coexistent sympathomimetic drug abuse. This case report describes a patient with Graves' disease and severe hyperadrenergic symptomatology that was thought to result from sympathomimetic drug abuse.

Visual evoked potentials and visual processing in stimulant drug-exposed infants

Prenatal exposure to cocaine and amphetamines has been associated with many adverse effects in infants, including neurological abnormalities. Recent evidence shows that the visual system may be useful in infancy to evaluate neurological functioning. Visual evoked potentials (VEPs) and visual recognition memory testing were carried out on eight infants with prenatal drug-exposure and eight controls, matched for ethnicity and socio-economic status. The drug-exposed infants performed significantly worse on the visual recognition test. However, there were no differences between groups on VEP testing and no correlations between tests. The results suggest that the difficulties found in visual recognition memory of drug-exposed infants are not related to neurological maturity, as measured by VEPs.