Cardiovascular manifestations of substance abuse part 1: cocaine

Acute Cardiovascular Toxicity of Cocaine

Cocaine is one of the most commonly abused drugs and represents a major public health concern. Cocaine users frequently present to the emergency department, with chest pain being the most common presenting complaint. The incidence of acute myocardial infarction in patients with cocaine-associated chest pain is often quoted as 6%, but it is highly variable depending on the included population. Risk assessment can be challenging in these patients; serial assessment of electrocardiograms and troponins is often required. This review focuses on the assessment and management of patients presenting with cocaine-associated chest pain and cardiotoxicity. Specific treatments are discussed, including benzodiazepines, nitroglycerin, calcium channel blockers, and phentolamine, and how treatment priorities differ from patients with noncocaine presentations. The use of beta-blockers in this population remains controversial, and the literature around its use is reviewed. The most recent literature and recommendations for the use of percutaneous coronary intervention and fibrinolytics in cocaine-associated myocardial infarction is discussed as well. Cocaine-associated dysrhythmias are suggested to be the cause of sudden cardiac death in some users. The pathophysiology and evidence-based treatments for dysrhythmias are reviewed. This review provides evidence-based recommendations for the assessment and management of patients presenting with cocaine-associated cardiovascular toxicity.

[Lethal Heatstroke with Disseminated Intravascular Coagulopathy]

We report on a case of severe heat stroke due to extended exposure to the sun in an enclosed glass cabin of an agricultural vehicle. Patient treatment, lab results and complications are reported and we examine the current literature on heat stroke.Heat stroke is a very rare and highly severe condition mostly suffered by vulnerable individuals or individuals exposed to extreme physical strain. Per definition a heat stroke is characterized by neurological deficit (especially loss of consciousness), and a high body temperature. Most important treatment is to lower the body temperature below 40 °C as quickly as possible. The best method is cold water immersion, but there are several other physical and invasive means that can be used. If performed within 30 minutes after the beginning of the incident this treatment decreases mortality considerably.Heat damage affects every organ and organ system. Most important are neurologic deficits, cardiovascular failure, liver failure and kidney failure. The excessive heat triggers a systemic inflammatory response syndrome (SIRS) which can lead to a disseminated intravascular coagulopathy (DIC). Haemostasis is also directly affected by the elevated temperature.Besides physical cooling, there is no known specific treatment to prevent secondary damage from heat stroke. Additionally, supportive care and ICU monitoring should be applied.

The Impact of Substance Use Disorder on COVID-19 Outcomes

OBJECTIVE

The goal of this study was to examine the impact of substance use disorder on the risk of hospitalization, complications, and mortality among adult patients diagnosed as having COVID-19.

METHODS

The authors conducted a propensity score (PS)-matched double-cohort study (N=5,562 in each cohort) with data from the TriNetX Research Network database to identify 54,529 adult patients (≥18 years) diagnosed as having COVID-19 between February 20 and June 30, 2020.

RESULTS

Primary analysis (PS matched on demographic characteristics and presence of diabetes and obesity) showed that substance use disorder was associated with an increased risk of hospitalization (odds ratio [OR]=1.84, 95% confidence interval [CI]=1.69-2.01), ventilator use (OR=1.45, 95% CI=1.22-1.72), and mortality (OR=1.30, 95% CI=1.08-1.56).

CONCLUSIONS

The findings suggest that COVID-19 patients with substance use disorders are at increased risk for adverse outcomes. The attenuation of ORs in the model that matched for chronic respiratory and cardiovascular diseases associated with substance abuse suggests that the observed risks may be partially mediated by these conditions.

Depression and its association with adverse childhood experiences in people with substance use disorders and comorbid medical illness recruited during medical hospitalization

AIMS

People who have experienced adverse childhood experiences (ACEs) are more susceptible to substance use disorder (SUD) and depression. The present study examined depression prevalence in hospitalized patients with SUD and examined the association of individual ACEs with major depression. Depression rates 3 months after discharge were also examined.

METHODS

Medical inpatients with SUD were recruited from Temple University Hospital. Depression was assessed using the Patient Health Questionnaire-9 (PHQ-9) at baseline and 3 months post-discharge. Participants were also assessed using an ACE scale at baseline.

RESULTS

Of 79 baseline participants, 48% (38) had moderate to severe major depressive disorder (MDD) with PHQ-9 scores ≥15. Among those with baseline MDD, 38% (9/24) continued to have MDD 3 months post discharge, and 42.9% (12/28) of those without MDD at baseline met criteria at 3 months. Sixty-three percent (50/79) of the participants reported 4+ ACEs at baseline. Two ACEs, Household Incarceration and Household Mental Illness, were significantly associated with having MDD at baseline and 3 months (adjusted mean PHQ-9 total score increase (SE) and p-value: 2.97 (1.35), p < .05; 5.32 (1.37), p < .005, respectively).

CONCLUSIONS

In this exploratory study, nearly half of medical inpatients with substance use disorder had moderate to severe major depression, with a similar percentage of participants having MDD as outpatients at 3 months. Approximately two thirds of participants reported four or more adverse childhood experiences at baseline. Inpatient medical hospitalization should be utilized as an opportunity to engage people with SUD in multidisciplinary treatment including psychiatric, trauma informed care, and substance abuse treatment.

Comorbidity of Physical Disorders Among Patients With Severe Mental Illness With and Without Substance Use Disorders: A Systematic Review and Meta-Analysis

Objective: Physical disorders in patients with severe mental illness (SMI) are common and they tend to be underdiagnosed by clinicians, which might lead to negative treatment outcomes. The presence of substance use disorders could further aggravate the situation. There are existing systematic reviews on physical disorders among individuals with SMI in general but none of these previous reviews stratified their findings by substance use disorder status. This study aimed to synthesize the evidence on the frequency of comorbid physical disorders among patients with SMI with or without substance use disorders. Methods: We searched for studies published in English between 1988 and 2017 in MEDLINE, Embase, CINAHL, PsycINFO, Global Health, Web of Science, Scopus, WHO Global Health Library (Global Index Medicus), Google Scholar, OpenGrey, the Grey Literature Report, Cochrane Library, International Standardized Randomized Controlled Trial Number Registry, WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, Australian and New Zealand Clinical Trials Registry, and PROSPERO. There was no geographical restriction and the target population was adults (≥18 years) with diagnosed SMI including schizophrenia, bipolar disorder, and other psychotic illnesses. The outcome of interest was physical disorder. Results: A total of 6,994 records were retrieved. Only 30 papers (representing 24 studies) met our inclusion criteria and 13 studies were included in the meta-analysis. The prevalence of most of the reported physical disorders was higher in SMI patients with substance use disorders than in those without substance use disorders. When ranked according to pooled prevalence level, hypertension (35.6%), tardive dyskinesia (35.4%), and hepatitis C (26.9%) were the most prevalent physical disorders among SMI patients with substance use disorders. For SMI patients without substance use disorders, hypertension (32.5%), tardive dyskinesia (25.1%), and endocrine disease (19.0%) were more common. Estimates for diabetes (7.5% vs. 7.5%) and cardiovascular diseases (11.8% vs. 11.3%) were similar across groups. Conclusions: Physical disorders among SMI patients vary by substance use disorder status. Clinicians managing SMI in patients should screen for physical disorders and substance use disorders and provide treatment or referral. Registration: International Prospective Register of Systematic Reviews (PROSPERO) registration number CRD42017072286.

Prevalence and risk factors for hypertensive crisis in a predominantly African American inner-city community

PURPOSE

A 3-year case control study was conducted to determine the prevalence of hypertensive crisis and its subtypes, hypertensive emergency and hypertensive urgency. The secondary objectives were to identify risk factors for hypertensive emergencies and to determine the odds of developing acute target organ damage among predominantly African American patients with a confirmed diagnosis of hypertension.

MATERIALS AND METHODS

Using emergency department medical records, patients with a confirmed diagnosis of hypertension were identified. From the pool of hypertensive patients, cases and controls were selected and matched 1:1 for age, gender and race. Cases were hypertensive patients with hypertensive crisis, defined as BP ≥ 200/120 mmHg. Controls had a diagnosis of hypertension and BP < 200/120 mmHg. Cases and controls, as well as cases with hypertensive emergencies and hypertensive urgencies were compared based on important demographic and clinical variables.

RESULTS

Almost 90% of study population were African Americans. The prevalence of hypertensive crisis was 11.4% and hypertensive emergencies was 3.2%. Hypertensive emergencies accounted for 28% of patients with crisis. The predictors for hypertensive emergencies were older age (p = .002), male gender (p < .007), anemia (p < .0001), history of coronary artery disease (p < .001), congestive heart failure (p < .001) and chronic renal insufficiency (p < .001). Having healthcare insurance and access to medical care did not reduce the odds of developing hypertensive emergencies. Race was not a significant risk factor in the progression from hypertensive crisis to hypertensive emergencies (p = .47).

CONCLUSIONS

The study highlights the high prevalence of hypertensive crisis and hypertensive emergencies in the predominantly African American urban population, which is 5 times the United States average. However, race is not a predictor of development of hypertensive emergencies and acute target organ damage in patients with already severely elevated blood pressure.

Histologic Changes In Recreational Drug Misuse

Use of recreational drugs is associated with a number of histologic changes. These may be related to the method of administration or due to systemic effects of the drugs. This paper reviews the histopathological features seen following recreational drug use. With injection, there may be local effects from abscess formation and systemic effects may result in amyloidosis. Injections have been associated with necrotizing fasciitis, anthrax, and clostridial infections. Systemic effects include infective endocarditis, with the risk of embolization, and abscesses may be seen in organs in the absence of infective endocarditis. Viral complications of injection include hepatitis and human immunodeficiency virus (HIV) infection. Injecting crushed tablets can result in intravascular granulomata in the lungs. Smoking drugs is associated with intraalveolar changes, including blackand brown-pigmented macrophages in crack cocaine and cannabis smoking, respectively. Snorting may result in intraalveolar granulomata forming when crush tablets are used and there may be systemic granulomata. Stimulants are associated with cardiovascular and cerebrovascular pathology, including contraction band necrosis and myocardial fibrosis, as well as coronary artery dissection. Stimulants may cause hyperpyrexia and rhabdomyolysis, which may be associated with changes in multiple organs including myoglobin casts in the kidney. Opioids cause respiratory depression and this can be associated with inhalational pneumonia and hypoxia in other organs if there is resuscitation and a period of survival. Ketamine use has been associated with changes in the urothelium and the liver. This paper reviews histology changes that may be seen in drug-related deaths using illustrative cases.

Relationship between marijuana and other illicit drug use and depression/suicidal thoughts among late middle-aged and older adults

BACKGROUND

Despite growing numbers of older-adult illicit drug users, research on this topic is rare. This study examined the relationship between marijuana and/or other illicit drug use and major depressive episode (MDE) and serious suicidal thoughts among those aged 50+ years in the USA.

METHODS

The public use files of the 2008 to 2012 US National Survey on Drug Use and Health (NSDUH) provided data on 29,634 individuals aged 50+ years. Logistic regression analysis was used to test hypothesized associations between past-year marijuana and/or other illicit drug use and MDE and serious suicidal thoughts.

RESULTS

Nearly 6% of the 50+ years age group reported past-year marijuana and/or other illicit drug use. Compared to non-users of any illicit drug, the odds of past-year MDE among those who used marijuana only, other illicit drugs only, and marijuana and other illicit drugs were 1.54 (95% CI = 1.17-2.03), 2.75 (95% CI = 1.75-4.33), and 2.12 (95% CI = 1.45-3.09), respectively. Those who used marijuana and other drugs also had higher odds (2.44, 95% CI = 1.58-3.77) of suicidal thoughts than non-users of any illicit drug. However, among users of any illicit drug, no difference was found among users of marijuana only, marijuana and other illicit drugs, and other illicit drugs only. Among marijuana users, marijuana use frequency was a significant correlate of suicidal thoughts only among those with MDE.

CONCLUSIONS

Health and mental health (MH) service providers should pay close attention to the potential reciprocal effects of marijuana and other illicit drug use and MDE and suicidal thoughts among late middle-aged and older adults.

Early use of beta blockers in patients with cocaine associated chest pain

BACKGROUND

The most common symptom of cocaine abuse is chest pain. Cocaine induced chest pain (CICP) shares patho-physiological pathways with the acute coronary syndromes (ACS). A key event is the increase of activity of the adrenergic system. Beta blockers (BBs), a cornerstone in the treatment of ACS, are felt to be contraindicated in the patient with CICP due to a potential of an "unopposed alpha adrenergic effect (UAE)".

OBJECTIVES

Identify signs of UAE and in-hospital complications in patients who received BB while having cocaine induced chest pain.

METHODS

We performed a retrospective review of 378 patients admitted to a medical unit because of CICP. Twenty six of these were given a BB at the time of admission while having CICP. We compared these patients to a control group paired by age, sex, race and history of hypertension who did not received a BB while having CICP. Blood pressure, heart rate, length of stay and in-hospital cardiovascular complications were compared.

RESULTS

No statistically significant differences were found between the two groups except for a longer length of stay in the case group. This was felt to be due to unrelated causes.

CONCLUSIONS

This study does not support the presence of an UAE in patients with continuing CICP and treated early with BB. There were no in-hospital cardiovascular complications in the group of patients who had an early dose of BB while having CICP.

IMPLICATIONS

BB appeared safe when given early on admission to patients with CICP.

Cardiovascular risk factors and 30-year cardiovascular risk in homeless adults with mental illness

Background

Cardiovascular disease (CVD) is a leading cause of death among homeless people. This study examines CVD risk factors and 30-year CVD risk in a population of homeless individuals with mental illness.

Methods

CVD risks factors were assessed in 352 homeless individuals with mental illness in Toronto, Canada, at the time of their enrollment in the At Home/Chez Soi Project, a randomized trial of a Housing First intervention. The 30-year risk for CVD (coronary death, myocardial infarction, and fatal or nonfatal stroke) was calculated using published formulas and examined for association with need for mental health services, diagnosis of psychotic disorder, sex, ethnicity, access to a family physician and diagnosis of substance dependence.

Results

The 30-year CVD risk for study participants was 24.5 ± 18.4%, more than double the reference normal of 10.1 ± 7.21% (difference = −13.0% 95% CI −16.5% to −9.48%). Univariate analyses revealed 30-year CVD risk was greater among males (OR 3.99, 95% CI 2.47 to 6.56) and those who were diagnosed with substance dependence at baseline (OR 1.94 95% CI 1.23 to 3.06) and reduced among those who were non-white (OR 0.62 95% CI 0.39 to 0.97). In adjusted analyses, only male sex (OR 4.71 95% CI 2.76 to 8.05) and diagnosis of substance dependence (OR 1.78 95% CI 1.05 to 3.00) remained associated with increased CVD risk.

Conclusions

Homeless people with mental illness have highly elevated 30-year CVD risk, particularly among males and those diagnosed with substance dependence. This study adds to the literature by reporting on CVD risk in a particularly vulnerable population of homeless individuals experiencing mental illness, and by using a 30-year CVD risk calculator which provides a longer time-frame during which the effect of modifiable CVD risk factors could be mitigated.

Trial registration

Current Controlled Trials ISRCTN42520374

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1472-4) contains supplementary material, which is available to authorized users.

Identifying patients with problematic drug use in the emergency department: results of a multisite study

STUDY OBJECTIVE

Drug-related emergency department (ED) visits have steadily increased, with substance users relying heavily on the ED for medical care. The present study aims to identify clinical correlates of problematic drug use that would facilitate identification of ED patients in need of substance use treatment.

METHODS

Using previously validated tests, 15,224 adult ED patients across 6 academic institutions were prescreened for drug use as part of a large randomized prospective trial. Data for 3,240 participants who reported drug use in the past 30 days were included. Self-reported variables related to demographics, substance use, and ED visit were examined to determine their correlative value for problematic drug use.

RESULTS

Of the 3,240 patients, 2,084 (64.3%) met criteria for problematic drug use (Drug Abuse Screening Test score ≥ 3). Age greater than or equal to 30 years, tobacco smoking, daily or binge alcohol drinking, daily drug use, primary noncannabis drug use, resource-intense ED triage level, and perceived drug-relatedness of ED visit were highly correlated with problematic drug use. Among primary cannabis users, correlates of problematic drug use were age younger than 30 years, tobacco smoking, binge drinking, daily drug use, and perceived relatedness of the ED visit to drug use.

CONCLUSION

Clinical correlates of drug use problems may assist the identification of ED patients who would benefit from comprehensive screening, intervention, and referral to treatment. A clinical decision rule is proposed. The correlation between problematic drug use and resource-intense ED triage levels suggests that ED-based efforts to reduce the unmet need for substance use treatment may help decrease overall health care costs.

A fatal case of commotio cordis caused by an accidental fall on the beach

Sudden cardiac death is a major health problem and a recurring issue in forensic medicine. Most cases are attributed to congenital heart disease, cardiomyopathy, myocarditis, pathology of the coronary arteries, long or short QT interval syndromes, Brugada syndrome or secondary toxic effects of cardioactive drugs. Sudden death caused by Commotio cordis after an accidental fall is very rare in women. Victims are essentially young people who die following a direct blow to the chest sustained during physical activity. In the following, we report a case of an adult with no significant past medical history, walking on the beach with friends, who died from commotio cordis following an accidental fall on the wet sand. This article deals with post-mortem diagnosis, and demonstrates the importance of a detailed understanding of the circumstances surrounding the death, as well as systematic histological examination of the heart, as the heart will generally appear normal under macroscopic examination. It is important to note that commotio cordis can also occur in adults.

CVD risk among men participating in the National Health and Nutrition Examination Survey (NHANES) from 2001 to 2010: differences by sexual minority status

BACKGROUND

Recent research indicates that sexual minority women are at increased risk for cardiovascular disease (CVD) compared with heterosexual women; however, few studies of CVD risk exist for sexual minority men (SMM). This study aimed to determine whether disparities in CVD risk exist for SMM and if CVD risk is consistent across subgroups of SMM.

METHODS

This study utilised publicly available data from the National Health and Nutrition Examination Survey (NHANES), pooled from 2001 to 2010. CVD risk was calculated using the Framingham General CVD Risk Score and operationalised as the ratio of a participant's vascular and chronological age. Differences in this ratio were examined between heterosexual and SMM as a whole, and within subgroups of SMM.

RESULTS

SMM had vascular systems that were, on average, 4% (95% CI -7.5% to -0.4%) younger than their heterosexual counterparts; however, adjustment for education and history of hard drug use rendered this difference statistically insignificant. Analysis of SMM subgroups revealed increased CVD risk for bisexual men and decreased CVD risk for both gay and homosexually experienced heterosexual men when compared with heterosexual men. Differences in CVD risk persisted for only bisexual and homosexually experienced heterosexual men after adjustment for education and history of hard drug use.

CONCLUSIONS

Subgroups of SMM are at increased risk for CVD compared with heterosexual men, and this increased risk cannot be completely attributed to differences in demographic characteristics or negative health behaviours.

A population-based study of cardiovascular disease risk in sexual-minority women

OBJECTIVES

We sought to determine if sexual-minority women were at greater risk for cardiovascular disease (CVD) than their heterosexual counterparts.

METHODS

We aggregated data from the 2001-2008 National Health and Nutrition Examination Surveys to examine differences in CVD risk between heterosexual and sexual-minority women by using the Framingham General CVD Risk Score to calculate a ratio of vascular and chronological age. We also examined differences in the prevalence of various CVD risk factors.

RESULTS

Sexual-minority women were more likely to be current or former smokers, to report a history of drug use, to report risky drinking, and to report a family history of CVD. On average, sexual-minority women were 13.9% (95% confidence interval [CI] = 8.5%, 19.3%) older in vascular terms than their chronological age, which was 5.7% (95% CI = 1.5%, 9.8%) greater than that of their heterosexual counterparts. Family history of CVD and history of drug use were unrelated to increased CVD risk, and this risk was not fully explained by either risky drinking or smoking.

CONCLUSIONS

Sexual-minority women are at increased risk for CVD compared with heterosexual women.

Older methadone patients achieve greater durations of cocaine abstinence with contingency management than younger patients

BACKGROUND AND OBJECTIVES

Contingency management (CM) interventions are efficacious in treating cocaine abusing methadone patients, but few studies have examined the effect of age on treatment outcomes in this population. This study evaluated the impact of age on treatment outcomes in cocaine abusing methadone patients.

METHODS

Data were analyzed from 189 patients enrolled in one of three randomized studies that evaluated the efficacy of CM versus standard care (SC) treatment.

RESULTS

Age was associated with some demographics and drug use characteristics including racial composition, education, and methadone dose. Primary drug abuse treatment outcomes did not vary across age groups, but CM had a greater benefit for engendering longer durations of abstinence in the middle/older and older age groups compared to the younger age groups. At the 6-month follow-up, submission of a cocaine positive urine sample was predicted by submission of a cocaine positive sample at intake, higher methadone doses, and assignment to SC rather than CM treatment.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

As substance abusers are living longer, examination of the efficacy of pharmacological and psychosocial treatments specifically within older age groups may lead to a better understanding of subpopulations for whom enhanced treatments such as CM are warranted.

Electrocardiographic findings associated with cocaine use in humans: a systematic review

Cocaine remains highly prevalent and accessible in the general population, continues to represent one of the most commonly reported substances in drug-related presentations to emergency departments, and is frequently implicated in drug-related deaths. Fatal cardiac arrhythmias are often suspected in the latter cases. In spite of this, its complex effects on the human cardiac conduction system remain poorly elucidated. In this article we sought to systematically review the medical literature to identify the electrocardiographic findings that have been linked to cocaine use in humans in an effort to highlight what physicians can expect to encounter when managing patients using the drug. The evidence is discussed, common findings are emphasized and clinical recommendations are proposed.

[Ischemic strokes in young adults and illegal drugs]

One out of four ischemic strokes in France occurs in adults under 65 years old. About a third of them remain unexplained even after an extensive etiological assessment. A large part of these unexplained strokes could be linked to illegal drug abuse, and 10 % are estimated to be directly linked to illegal drugs in some international studies. The most frequently incriminated recreational drug remains cocaine, via several mechanisms. However, several other illegal drugs, some very commonly used such as cannabis, are suspected to have an important role in neurovascular diseases. In this article, we reviewed the epidemiological, pathophysiological and clinical studies, published in the international literature over the past 30 years. The drug-caused stroke epidemiology needs to be more precisely studied, as well as the underlying mechanisms depending on each drug. This is a public health issue that affects an economically active population, as stroke is the first cause of acquired handicap in adults.

Interaction effects of age and contingency management treatments in cocaine-dependent outpatients

As the American population ages, older adults are accounting for a larger percentage of the drug-abusing population, but little attention has been given to this age group especially in regards to evaluating responsivity to different treatment modalities. Contingency management (CM) is a highly effective behavioral treatment that provides positive tangible reinforcers for objective evidence of behavior change. The purpose of this study was to examine main and interactive effects of age on outcomes in cocaine-dependent patients receiving CM with standard care (SC) or SC alone. Patients (N = 393) participating in 1 of 3 randomized trials of CM for cocaine dependence were divided into young, middle, and older age cohorts. Baseline characteristics and outcomes were compared across the age groups. The oldest age group had more medical problems than the youngest and middle age groups but had fewer legal difficulties and psychiatric symptoms. The oldest age group remained in treatment significantly longer than the other age groups, regardless of the type of treatment received. Although all age groups benefited from CM in terms of retention and longest duration of abstinence achieved, a significant age by treatment interaction effect emerged, with the older cohort improving relatively less from CM than the younger age groups. These findings demonstrate that age may play a role in moderating intervention outcomes, and tailoring CM to the needs of older and middle-aged substance abusers may be important for improving outcomes in this growing population.

Putting cocaine use and cocaine-associated cardiac arrhythmias into epidemiological and clinical perspective

This is the first article in a series of three articles on cocaine-related cardiac arrhythmias, following on from the 2008 British Pharmacological Society Winter Meeting Clinical Section Symposium entitled 'Cocaine induced cardiac arrhythmias - from ion channel to clinical treatment'. We will summarize the epidemiology of cocaine use across the world and in particular will focus on UK, Europe and US use prevalence data. We will discuss the acute cardiac and non-cardiac toxicity associated with cocaine and highlight the lack of data on the true UK prevalence of acute cocaine toxicity and on the incidence of cocaine-related cardiac arrhythmias.

Imaging of illicit drug use

Illicit drug abuse is a continuing menace of epidemic proportions associated with serious medical and social problems. Drug abuse can have a wide variety of presentations some of which can be life-threatening. The clinical diagnosis can be challenging as the history is usually limited or absent. Radiologists need to be familiar with varied imaging presentations and the related complications of illicit drug abuse to ensure correct diagnosis and appropriate timely treatment. This review will illustrate the imaging spectrum of illicit drug abuse involving several organ systems and also discuss the pathophysiological consequences of drug abuse.

[Anesthesia in drug addiction]

The growing social problem of drug abuse has increased the likelihood that anesthesiologists will find acute or chronic drug users among patients requiring anesthesia for elective or emergency surgery. We must therefore be aware of the effects drugs have on the organism and their possible pharmacokinetic and pharmacodynamic interactions with anesthetic agents in order to prevent complications during surgery and postoperative recovery. Such knowledge is required for the management of abstinence syndrome or overdose, which pose the greatest potential dangers for the hospitalized drug addict.

Trends related to aging and co-occurring disorders in HIV-infected drug users

Drug users with HIV infection successfully treated with highly active antiretroviral therapy are now living to older ages. As persons with HIV infection age, they become at risk for comorbidities that occur in any group of aging individuals. However, some of these conditions occur at increased rates, with increasing severity, or pose special problems in older persons with HIV infection. This article discusses the epidemiology of HIV infection in aging drug users, and hormonal, cardiovascular, liver, renal, bone, and cognitive disorders and depression and cancer in these individuals, as well as problems related to taking multiple medications and HIV disease progression.

Drug abuse in plastic surgery patients: optimizing detection and minimizing complications

Drugs of abuse present numerous challenges to plastic surgeons, and detection remains difficult. With rates of drug abuse and misuse on the rise, clinicians must remain especially attentive to drug abusers' verbal and nonverbal cues, and be familiar with treating perioperative complications if they arise. Informed deductions regarding drug abuse can enable a plastic surgeon to identify drug abuse, minimize complications, and optimize patient care.

An analysis of cocaine powder in the Netherlands: content and health hazards due to adulterants

AIMS

To report on trends in the content and adulterants present in street cocaine (powder) in the Netherlands and to describe the associated health hazards.

DESIGN AND PARTICIPANTS

Drug consumers handed in samples of cocaine powder from 1999 to 2007 for analysis. Reports were compiled of users' experiences with the samples received.

MEASUREMENTS AND ANALYSIS

Linear regression analysis was used to assess the trend in adulterated cocaine powder across the study period, and comparison of reported adverse effects of adulterated with those of unadulterated cocaine by Fisher's exact test.

FINDINGS

There has been a statistically significant upward trend in the occurrence of adulterated cocaine powder over the years. Adulterated cocaine was associated more frequently with reported adverse effects than unadulterated cocaine. Phenacetin, hydroxyzine and diltiazem appeared to be three adulterants contributing to these adverse effects.

CONCLUSIONS

An increase in adulterants was detected in the analysed cocaine powder between 1999 and 2007. This increase is associated with relatively more adverse effects with cocaine use. The cardiac and hallucinatory effects that were reported more frequently are not understood clearly. Adverse effects are likely to be due to several factors, including interactions of adulterants with cocaine and the route of administration.

Management of cocaine-induced cardiac arrhythmias due to cardiac ion channel dysfunction

Cocaine use is common in many areas of the world, particularly the United States and Western Europe. Toxicity following the use of cocaine is associated with a wide range of clinical features. In this review, we will focus on the cocaine-associated cardiac arrhythmias and, in particular, some of the controversies in their etiology and management. Cocaine can produce arrhythmias either through the production of myocardial ischemia or as a direct result of ion channel alterations. Excessive catecholamines, combined with sodium and potassium channel blockades, give rise to a wide variety of supra-ventricular and ventricular rhythms. The animal and human evidence for ion channel dysfunction is reviewed, and the effects of catecholamines are followed from the cardiac action potential to the development of arrhythmias. Finally, theoretical constructs are combined with existing evidence to develop a rational treatment strategy for patients with cocaine-induced cardiac arrhythmias. In particular, we review the evidence concerning the controversies relating to the use of lidocaine in comparison with sodium bicarbonate, in terms of QRS prolongation secondary to sodium channel blockade.

Illicit stimulant use in a United States heart failure population presenting to the emergency department (from the Acute Decompensated Heart Failure National Registry Emergency Module)

Illicit stimulant drug use may have a profound clinical impact in acute decompensated heart failure (ADHF). The chronic use of cocaine and methamphetamine may lead to overt cardiomyopathy and ADHF. The Acute Decompensated Heart Failure National Registry Emergency Module (ADHERE-EM) collected data on patients presenting to emergency departments with ADHF at 83 geographically dispersed hospitals in the United States. This registry was queried to determine the rate of self-reported illicit drug use in emergency department patients presenting with ADHF and compare these patients with those without illicit drug use. The registry enrolled 11,258 patients with ADHF with drug use data from January 2004 to March 2006. Of these patients, 594 (5.3%) self-reported current or past stimulant drug use. Compared with nonusers, these patients were more likely to be younger (median age 49.7 vs 76.1 years), to be African American (odds ratio 11.9, 95% confidence interval 9.8 to 14.4), and to have left ventricular ejection fractions <40% (odds ratio 3.4, 95% confidence interval 2.8 to 4.2). Admitted users had no difference in mortality (adjusted odds ratio 0.83, 95% confidence interval 0.25 to 2.72) compared with nonusers. In conclusion, data from ADHERE-EM suggest that a clinically important percentage of patients with ADHF report the use of illicit stimulant drugs. Although these patients are younger with a greater degree of LV dysfunction, they did not have greater risk-adjusted mortality.

Cardiovascular complications of cocaine: imaging findings

Cocaine is the second most commonly abused illicit drug in the US and the most common one involved in emergency department visits, the majority of which are related to the cardiovascular system. Cardiovascular complications related with cocaine abuse include myocardial ischemia and infarction, myocarditis, hypertrophic cardiomyopathy, dilated cardiomyopathy, aortic dissection, thrombosis, stroke and cerebral hemorrhage, and different forms of visceral ischemia, among others. In an era where cocaine use has reached epidemic proportions, it is necessary for the radiologist to understand the pathophysiology, clinical presentation, and imaging characteristics of its cardiovascular complications.

Drugs of abuse and the aging brain

Substance abuse among older adults has received little attention in the past, presumably because this population has traditionally accounted for only a small percentage of the drug abuse problem in the United States. The aging of the baby boomer generation (born 1946-1964), however, will soon swell the ranks of older adults and dramatically alter the demography of American society. Several observations suggest that this expansion will likely be accompanied by a precipitous increase in the abuse of drugs, including prescription medications and illicit substances, among older adults. While it is now evident that the brain changes continuously across life, how drugs of abuse interact with these age-related changes remains unclear. The dynamic nature of brain function, however, suggests that substance abuse during older age may augment the risks and require unique considerations for diagnosis and treatment. In addition to describing current and projected prevalence estimates of substance abuse among older adults, the present review discusses how aging affects brain systems involved in drug abuse, and explores the potential impact of drug abuse on the aging brain. Future directions for substance abuse research among older adults will also be considered.

Prevalence of substance-related disorders in heart transplantation candidates

Substance abuse cessation is one of the leading factors in determining the eligibility for the heart transplantation waiting list, as noncompliance with this issue may seriously endanger posttransplantation outcomes. Yet, the prevalence of substance-related disorders among candidates for heart transplantation has not been evaluated enough. Eighty three heart transplantation candidates were assessed for prior or current substance-related disorders through the Structured Clinical Interview for mental disorders according to DSM-IV. A prior history of at least one substance-related disorder was found in 64% of patients, with nicotine dependence as the most prevalent diagnosis (61.4% of the sample). Ten subjects were currently smokers, despite heart failure. A prior history of alcohol abuse and caffeine intoxication was found in 9.6% and 2.4% of patients, respectively. Substance abuse or dependence behaviors should be monitored during all the phases of heart transplantation program. Early identification of current substance-related disorders may allow better allocation of organ resources and proper lifestyle modification programs provision. A prior history of substance-related disorders should alert physicians to assess patients for possible relapse, especially after transplantation. The inclusion of a specialist in the assessment and treatment of substance-related disorders in the heart transplantation unit may reduce the risk of unsuccessful outcomes due to noncompliance with an adequate lifestyle.

Toxins

Exposures to toxins are prevalent, frequently complicate surgical emergencies, and impact critical care. A fundamental understanding of pathophysiologic principles and management strategies is essential for the anesthesiologist frequently responsible for the acute care of patients who have toxicologic exposures. Given their pervasiveness and ability to confound the clinical presentations in the perioperative or intensive care setting, substances of abuse and asphyxiants warrant particular attention and a high degree of vigilance.

Cocaine-induced inhibition of ATP-sensitive K+ channels in rat ventricular myocytes and in heart-derived H9c2 cells

Cocaine use may cause coronary artery spasm and acute myocardial ischaemia/infarction. However, its effects on ATP-sensitive K+ (KATP) channel, an ion channel responsible for ischaemic preconditioning, remain unknown. In isolated rat ventricular myocytes with whole-cell experiments, cocaine can reverse action potential shortening and increased K+ current caused by the openers of ATP-sensitive K+ (KATP) channels. In inside-out patches, cocaine applied to intracellular surface suppressed KATP-channel activity in a concentration-dependent manner with an IC50 value of 9.2 microM; however, it did not modify the single-channel conductance of this channel. The change in the kinetic behaviour of KATP channels caused by cocaine is primarily the result of an increase in mean closed time and a decrease in mean open time. Cocaine-induced inhibition of KATP channels is independent of change in intracellular ATP concentrations. In heart-derived H9c2 cells, cocaine is also capable of suppressing KATP-channel activity. The present study provides evidence that cocaine can produce a depressant action on KATP channels in cardiac myocytes, and thus disturb ischaemic preconditioning in clinical settings.

A slow-onset, long-duration indanamine monoamine reuptake inhibitor as a potential maintenance pharmacotherapy for psychostimulant abuse: effects in laboratory rat models relating to addiction

Slow-onset, long-lasting dopamine reuptake blockers with reduced abuse potential have been suggested as maintenance therapies for cocaine addiction. We have synthesized a series of 3-(3',4'-dichlorophenyl)-1-indanamine monoamine reuptake inhibitors as candidates for such maintenance pharmacotherapy. The initial lead compound, the N,N-dimethyl analogue 30,640 was then subjected to testing in addiction-relevant animal models. Compound 30,640 (2 mg/kg i.p.) produced a pronounced slow-onset, long-lasting increase (300-400%) in extracellular nucleus accumbens dopamine levels, as measured by in vivo brain microdialysis in awake laboratory rats. Slow-onset, long-lasting decreases (40-80%) in the dopamine metabolites 3,4-dihydroxyphenylacetic acid and homovanillic acid, and the serotonin metabolite 5-hydroxyindoleacetic acid were also seen. Compound 30,640 (3 or 5 mg/kg i.p.) also produced a significant (approximately 30%) slow-onset, long-lasting enhancement of electrical brain-stimulation reward, which was additive with that of cocaine (5 mg/kg i.p.). When given to cocaine-administering rats, 30,640 (2.5, 3, 5, or 10 mg/kg i.p.) significantly inhibited (30-60%) intravenous cocaine self-administration, with a pronounced long-lasting profile. In sum, 30,640 showed cocaine-like effects, but with a marked slow-onset, long-lasting profile. We conclude that the prodrug strategy employed in the design of 30,640 achieved its goal. We suggest that such compounds may be useful as maintenance pharmacotherapies for psychostimulant addiction.

Cocaine-associated chest pain

Current estimates establish that more than 30 million people in the United States use cocaine. Cardiovascular complaints commonly occur among patients who present to emergency departments(EDs) after cocaine use, with chest pain the most common complaint in several studies. Although myocardial ischemia and infarction account for only a small percentage of cocaine-associated chest-pain, physicians must understand the pathophysiology of cocaine and appropriate diagnostic and treatment strategies to best manage these patients and minimize adverse outcomes. This article reviews the pharmacology of cocaine, its role in the pathogenesis of chest pain with specific emphasis on inducing myocardial ischemia and infarction, and current diagnostic and management strategies for cocaine-associated chest pain encountered in the ED.

Underlying causes of cocaine, amphetamine and opioid related deaths in Australia

OBJECTIVE

To examine the characteristics of deaths in Australia where opioids, cocaine or amphetamines were mentioned, taking into account changes in the use and availability of these drugs in recent years.

DESIGN

Data were analysed from the Australian Bureau of Statistics and Causes of Death dataset between 1997 and 2002 on all deaths in which cocaine, amphetamines or opioids were mentioned including deaths where (a) the drugs were considered an underlying cause of death, (b) the drugs contributed to accidental drug-induced death, and (c) deaths primarily due to other causes. Data from the Australian National Drug Strategy Household Survey were also used to examine the prevalence of use of amphetamines, cocaine and opioids in Australia.

RESULTS

Thirteen deaths were attributed primarily to cocaine, 68 to amphetamines, and 4591 to opioids. An increase occurred in mentions of amphetamines, but half of these were primarily attributed to opioids. Opioid related deaths declined dramatically in 2001, consistent with a marked reduction in availability of heroin in Australia. Cocaine mentions remained relatively stable, with most cases primarily attributed to opioids. Of the other underlying causes of death, suicide was the most prevalent underlying factor, particularly for amphetamine and opioid related deaths.

CONCLUSIONS

Compared with opioid-related deaths, there are small numbers of deaths related to psychostimulants in Australia. Accidental drug induced deaths account for the majority of deaths in which these drugs are mentioned, although minorities of drug related deaths are attributed to suicide.