Comparative cardiac pathology among deaths due to cocaine toxicity, opioid toxicity and non-drug-related causes

Impact of puberty, sex determinants and chronic inflammation on cardiovascular risk in young people

Worrying trends of increased cardiovascular disease (CVD) risk in children, adolescents and young people in the Modern Era have channelled research and public health strategies to tackle this growing epidemic. However, there are still controversies related to the dynamic of the impact of sex, age and puberty on this risk and on cardiovascular health outcomes later in life. In this comprehensive review of current literature, we examine the relationship between puberty, sex determinants and various traditional CVD-risk factors, as well as subclinical atherosclerosis in young people in general population. In addition, we evaluate the role of chronic inflammation, sex hormone therapy and health-risk behaviours on augmenting traditional CVD-risk factors and health outcomes, ultimately aiming to determine whether tailored management strategies for this age group are justified.

Exploring protective associations between the use of classic psychedelics and cocaine use disorder: a population-based survey study

Cocaine Use Disorder (CUD) is a significant public health problem associated with elevated morbidity and mortality within the United States. Current behavioral treatments have limited efficacy and there are currently no FDA approved pharmacological treatments for CUD. Classic psychedelics might be associated with lowered odds of substance misuse and may effectively treat various forms of addiction. Thus, the goal of this study is to assess protective associations that lifetime use of classic psychedelics may share with CUD within a nationally representative sample of the U.S. We used data from The National Survey on Drug Use and Health (NSDUH) (2015–2019) and conducted survey-weighted multivariable logistic regression to test whether each of four classic psychedelics (peyote, mescaline, psilocybin, LSD) conferred lowered odds of CUD and its related 11 sub-criteria. Participants were 214,505 adults in the NSDUH (2015–2019) aged 18 and older. Peyote conferred lowered odds of CUD, reducing the odds of CUD by over 50% (aOR: 0.47). All other substances (including other classic psychedelics) either shared no association to CUD or conferred increased odds of CUD. Furthermore, sensitivity analyses revealed peyote to confer sharply lowered odds of the majority (seven of 11) of CUD criteria as well (aOR range: 0.26–0.47). Peyote use is associated with lowered odds of CUD. Future inquiries into third variable factors (i.e., demographic/personality profiles of individuals who use peyote, motivational/contextual factors surrounding peyote use) that may underlie our observed associations may reveal protective factors that can inform treatment development for CUD. Additionally, future longitudinal studies can shed further light on whether there is a temporal link between peyote use and lowered odds of CUD.

Oxidative Stress and Cocaine Intoxication as Start Points in the Pathology of Cocaine-Induced Cardiotoxicity

Psychomotor stimulants are the most commonly used prohibited substances after cannabis. Globally, their use reaches epidemiological proportions and is one of the most common causes of death in many countries. The use of illicit drugs has negative effects on the cardiovascular system and is one of the causes of serious cardiovascular pathologies, ranging from abnormal heart rhythms to heart attacks and sudden cardiac death. The reactive oxygen species generation, toxic metabolites formation, and oxidative stress play a significant role in cocaine-induced cardiotoxicity. The aim of the present review is to assess acute and chronic cocaine toxicity by focusing on the published literature regarding oxidative stress levels. Hypothetically, this study can serve as a basis for developing a rapid and effective method for determining oxidative stress levels by monitoring changes in the redox status of patients with cocaine intoxication.

The Role of Risk or Contributory Death Factors in Methadone-Related Fatalities: A Review and Pooled Analysis

Methadone-related deaths are characterized by a wide range of post-mortem blood concentrations, due to the high pharmacokinetic/dynamic inter-individual variability, the potential subjective tolerance state and to other risk factors or comorbidities, which might enhance methadone acute toxicity. In the present study, the association among pre-existing and external conditions and diseases and the resultant methadone death capacity have been investigated. Beside a systematic literature review, a retrospective case-control study was done, dividing cases in which methadone was the only cause of death (controls), and those with associated clinical-circumstantial (naive/non-tolerant state), pathological (pulmonary or cardiovascular diseases) or toxicological (other drugs detected) conditions. Methadone concentrations were compared between the two groups and the association with conditions/diseases was assessed by multiple linear and binomial logistic regressions. Literature cases were 139, in house 35, consisting of 22 controls and 152 cases with associated conditions/diseases. Mean methadone concentrations were 2122 ng/mL and 715 ng/mL in controls and cases respectively, with a statistically significant difference (p < 0.05). Lower methadone concentrations (by 24, 19 and 33% respectively) were detected in association with naive/non-tolerant state, pulmonary diseases and presence of other drugs, and low levels of methadone (<600 ng/mL) might lead to death in the presence of the above conditions/diseases.

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

OBJECTIVES

Cocaine use has been linked to stroke in several studies. However, few studies have considered the influence of cocaine use on stroke mechanisms such as small vessel disease (SVD). We conducted a study to assess associations between the toxicology-confirmed use of multiple drugs, including cocaine, and a marker of SVD, white matter hyperintensities (WMH).

MATERIALS AND METHODS

We conducted a nested case-control study (n = 30) within a larger cohort study (N = 245) of homeless and unstably housed women recruited from San Francisco community venues. Participants completed six monthly study visits consisting of an interview, blood draw, vital sign assessment and baseline brain MRI. We examined associations between toxicology-confirmed use of multiple substances, including cocaine, methamphetamine, heroin, alcohol and tobacco, and WMH identified on MRI.

RESULTS

Mean study participant age was 53 years, 70% of participants were ethnic minority women and 86% had a history of cocaine use. Brain MRIs indicated the presence of WMH (i.e., Fazekas score>0) in 54% (18/30) of imaged participants. The odds of WMH were significantly higher in women who were toxicology-positive for cocaine (Odd Ratio=7.58, p=0.01), but not in women who were toxicology-positive for other drugs or had several other cerebrovascular risk factors.

CONCLUSIONS

Over half of homeless and unstably housed women showed evidence of WMH. Cocaine use is highly prevalent and a significant correlate of WMH in this population, while several traditional CVD risk factors are not. Including cocaine use in cerebrovascular risk calculators may improve stroke risk prediction in high-risk populations and warrants further investigation.

Sniff of coke breaks the heart: cocaine-induced coronary vasospasm aggravated by therapeutic hypothermia and vasopressors after aborted sudden cardiac death: a case report

Introduction

Coronary vasospasm and sudden cardiac death are a frequently reported complication of cocaine abuse. We present a case with uniquely severe clinical and angiographic presentation.

Case presentation

A 39-year-old patient was presented to the cath lab after out-of-hospital cardiac arrest. Coronary angiography revealed focal coronary vasospasm in the proximal LCx, well responsive for intracoronary nitrates. Accordingly, no coronary intervention was performed and the patient was transferred to the cardiac intensive care unit. There, after systematically cooling sudden haemodynamic deterioration and massive ST-elevation was observed. Repeated coronary angiography revealed subocclusive LAD and LCx vasospasm, which again recovered after intracoronary injection of nitric oxide.

Discussion

Coronary-spastic effect of cocaine and its potentially dreadful clinical consequences are well-described phenomena. As novelty this case emphasizes that standard of care, including systematic hypothermia and vasopressor administration after out-of-hospital cardiac arrest can potentiate cocaine-induced coronary spasm with dramatic outcomes.

Cross-sectional cause of death comparisons for stimulant and opioid mortality in San Francisco, 2005-2015

BACKGROUND

Opioids and stimulants (e.g., cocaine or methamphetamine/amphetamine [MAMP]) are major contributors to acute substance toxicity deaths. Causes of stimulant death have received little attention. We sought to characterize and compare causes of death and significant contributing conditions among persons who died from acute opioid, cocaine, or MAMP toxicity.

METHODS

We identified all opioid, cocaine, or MAMP deaths in San Francisco from 2005 to 2015 through the California Electronic Death Reporting System. Multivariable logistic regression analyses were used to estimate associations between acute substance toxicity deaths (opioid versus stimulant; cocaine versus MAMP), additional reported causes of death, and significant contributing conditions most often linked to opioid and stimulant use.

RESULTS

From 2005-2015, there were 1252 opioid deaths and 749 stimulant deaths. Cocaine accounted for most stimulant deaths. Decedents with cardiac or cerebral hemorrhage deaths had higher adjusted odds of death due to acute stimulant toxicity versus acute opioid toxicity (aOR = 4.79, 95%CI = 2.88-7.96, p < 0.01; aOR = 58.58, 95%CI = 21.06-162.91, p < 0.01, respectively); no statistically significant associations were found for cocaine compared to MAMP deaths. Significant contributing cardiac conditions were associated with higher adjusted odds of stimulant compared to opioid (aOR = 1.46, 95%CI = 1.19-1.79, p < 0.01) and cocaine compared to MAMP death (aOR = 1.66, 95%CI = 1.13-2.45, p = .01).

CONCLUSIONS

Stimulant compared to opioid deaths tended to involve cardiac or cerebrovascular causes of death, and cocaine deaths were more likely than MAMP deaths to involve significant contributing cardiac conditions. Mounting evidence suggests that stimulant use be considered a cardio/cerebrovascular risk factor and clinical care be adjusted to address this heightened risk.

Cardiovascular effects of methadone and concomitant use of diazepam during methadone maintenance treatment induction: low concentration risk

BACKGROUND

The aim is to evaluate the role of diazepam concentrations in development of low-concentration-methadone-associated QTc prolongation in patients with opioid use disorder during methadone maintenance treatment (MMT) induction.

RESEARCH DESIGN AND METHODS

Individuals with addiction disorder on MMT were studied before the beginning of MMT and after one and six months of MMT. Serum concentrations of methadone, diazepam, electrolytes and ECG were analyzed.

RESULTS

Thirty patients were enrolled. The mean methadone concentration at time points was 177 ± 119 ng/ml and 343 ± 182 ng/ml, while the mean diazepam concentration was 561 ± 437 ng/ml and 1045 ± 933 ng/ml. The QTc interval before the introduction of MMT, after 1 and 6 months of MMT were 412 ± 27 ms, 425 ± 18 ms and 424 ± 15 ms, respectively, showing statistically significant increase in the length of QTc interval after 1 and 6 months of MMT. Statistically significant correlation between the concentration of methadone and QTc interval length at observed time points (R² = 0.239, p = 0.018; R² = 0.513, p = 0.006) was shown, and it remained so if the concentration of diazepam was included (R² = 0.347, p = 0.026, R² = 0.513, p = 0.009).

CONCLUSIONS

The prolongation of QTc below the risk threshold in low methadone therapeutic doses has been recorded and concomitant use of diazepam could be a co-factor in such issue.

An exploratory study of information sources and key findings on UK cocaine-related deaths

Cocaine-related deaths have increased since the early 1990s in Europe, including the UK. Being multi-factorial, they are difficult to define, detect and record. The European Monitoring Centre for Drugs and Drug Addiction commissioned research to: describe trends reported to Special Mortality Registries and General Mortality Registers; provide demographic and drug-use characteristic information of cases; and establish how deaths are identified and classified. A questionnaire was developed and piloted amongst all European Monitoring Centre for Drugs and Drug Addiction Focal Point experts/Special Mortality Registries: 19 (63%) responded; nine countries provided aggregated data. UK General Mortality Registers use cause of death and toxicology to identify cocaine-related deaths. Categorisation is based on International Classification of Diseases codes. Special Mortality Registries use toxicology, autopsy, evidence and cause of death. The cocaine metabolites commonly screened for are: benzoylecgonine, ecgonine methyl ester, cocaethylene and ecgonine. The 2000s saw a generally accelerating upward trend in cases, followed by a decline in 2009. The UK recorded 2700-2900 deaths during 1998-2012. UK Special Mortality Registry data (2005-2009) indicate: 25-44 year-olds account for 74% of deaths; mean age=34 (range 15-81) years; 84% male. Cocaine overdoses account for two-thirds of cases; cocaine alone being mentioned/implicated in 23% in the UK. Opioids are involved in most (58%) cocaine overdose cases.

Vascular disease in cocaine addiction

Cocaine, a powerful vasoconstrictor, induces immune responses including cytokine elevations. Chronic cocaine use is associated with functional brain impairments potentially mediated by vascular pathology. Although the Crack-Cocaine epidemic has declined, its vascular consequences are increasingly becoming evident among individuals with cocaine use disorder of that period, now aging. Paradoxically, during the period when prevention efforts could make a difference, this population receives psychosocial treatment at best. We review major postmortem and in vitro studies documenting cocaine-induced vascular toxicity. PubMed and Academic Search Complete were used with relevant terms. Findings consist of the major mechanisms of cocaine-induced vasoconstriction, endothelial dysfunction, and accelerated atherosclerosis, emphasizing acute, chronic, and secondary effects of cocaine. The etiology underlying cocaine's acute and chronic vascular effects is multifactorial, spanning hypertension, impaired homeostasis and platelet function, thrombosis, thromboembolism, and alterations in blood flow. Early detection of vascular disease in cocaine addiction by multimodality imaging is discussed. Treatment may be similar to indications in patients with traditional risk-factors, with few exceptions such as enhanced supportive care and use of benzodiazepines and phentolamine for sedation, and avoiding β-blockers. Given the vascular toxicity cocaine induces, further compounded by smoking and alcohol comorbidity, and interacting with aging of the crack generation, there is a public health imperative to identify pre-symptomatic markers of vascular impairments in cocaine addiction and employ preventive treatment to reduce silent disease progression.

Cocaine cardiovascular effects and pharmacokinetics after treatment with the acetylcholinesterase inhibitor donepezil

BACKGROUND

In rodents, cholinesterase inhibitors can cause sustained decreases in the reinforcing effects of cocaine. Nonetheless, cocaine is metabolized by butyrylcholinesterase (BuChE), raising concerns that cholinesterase inhibition could increase its peripheral concentrations, perhaps augmenting toxicity. Although donepezil is approved for use in patients and selective for inhibiting acetylcholinesterase over BuChE, no studies have reported cocaine bioavailability in human subjects receiving donepezil.

METHODS

Twelve cocaine-dependent veterans received three days of treatment with either oral placebo or 5 mg daily of donepezil, followed by cross-over to the opposite treatment. During both oral treatments, double-blind intravenous cocaine was administered at .0, .18, and .36 mg/kg in a laboratory setting, followed by determinations of heart rate, blood pressure, and plasma concentrations of cocaine and major metabolites.

RESULTS

Intravenous cocaine produced dose-related increases in systolic blood pressure that were most pronounced over the initial 30 minutes after treatment. Oral donepezil attenuated drug-induced elevations of systolic blood pressure following low-dose cocaine (.18 mg/kg). No significant difference in blood pressure following treatment with placebo or donepezil after high-dose cocaine (.36 mg/kg). Peak values of blood pressure and heart rate were unaffected by donepezil. Plasma concentrations of cocaine and metabolites did not differ in donepezil- and placebo-treated participants.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

We conclude that donepezil can attenuate drug-induced increases in systolic blood pressure following low-dose cocaine, but does not otherwise modify the cardiovascular effects of intravenous cocaine. Clinically significant changes in cocaine bioavailability and cardiovascular effects do not occur following this dose of donepezil. (Am J Addict 2016;25:392-399).

Pathophysiological mechanisms of catecholamine and cocaine-mediated cardiotoxicity

Overactivation of the sympatho-adrenergic system is an essential mechanism providing short-term adaptation to the stressful conditions of critical illnesses. In the same way, the administration of exogenous catecholamines is mandatory to support the failing circulation in acutely ill patients. In contrast to these short-term benefits, prolonged adrenergic stress is detrimental to the cardiovascular system by initiating a series of adverse effects triggering significant cardiotoxicity, whose pathophysiological mechanisms are complex and only partially elucidated. In addition to the development of myocardial oxygen supply/demand imbalance induced by the sustained activation of adrenergic receptors, catecholamines can damage cardiomyocytes by fostering mitochondrial dysfunction, via two main mechanisms. The first one is calcium overload, consecutive to β-adrenergic receptor-mediated activation of protein kinase A and subsequent phosphorylation of multiple Ca(2+)-cycling proteins. The second one is oxidative stress, primarily related to the transformation of catecholamines into "aminochromes," which undergo redox cycling in mitochondria to generate copious amounts of oxygen-derived free radicals. In turn, calcium overload and oxidative stress promote mitochondrial permeability transition and cardiomyocyte cell death, both via the apoptotic and necrotic pathways. Comparable mechanisms of myocardial toxicity, including marked oxidative stress and mitochondrial dysfunction, have been reported with the use of cocaine, a common recreational drug with potent sympathomimetic activity. The aim of the current review is to present in detail the pathophysiological processes underlying the development of catecholamine and cocaine-induced cardiomyopathy, as such conditions may be frequently encountered in the clinical practice of cardiologists and ICU specialists.

Eligibility of persons who inject drugs for treatment of hepatitis C virus infection

In this decade, an increase is expected in end-stage liver disease and hepatocellular carcinoma, most commonly caused by hepatitis C virus (HCV) infection. Although people who inject drugs (PWID) are the major source for HCV infection, they were excluded from antiviral treatments until recently. Nowadays there is incontrovertible evidence in favor of treating these patients, and substitution therapy and active substance use are no longer contraindications for antiviral treatment. The viral clearance in PWID after HCV antiviral treatment with interferon or pegylated interferon combined with ribavirin is comparable to the viral clearance in non-substance users. Furthermore, multidisciplinary approaches to delivering treatment to PWID are advised, and their treatment should be considered on an individualized basis. To prevent the spread of HCV in the PWID community, recent active PWID are eligible for treatment in combination with needle exchange programs and substitution therapy. As the rate of HCV reinfection is low after HCV antiviral treatment, there is no need to withhold HCV treatment due to concerns about reinfection alone. Despite the advances in treatment efficacies and data supporting their success, HCV assessment of PWID and initiation of antiviral treatment remains low. However, the proportion of PWID assessed and treated for HCV is increasing, which can be further enhanced by understanding the barriers to and facilitators of HCV care. Removing stigmatization and implementing peer support and group treatment strategies, in conjunction with greater involvement by nurse educators/practitioners, will promote greater treatment seeking and adherence by PWID. Moreover, screening can be facilitated by noninvasive methods for detecting HCV antibodies and assessing liver fibrosis stages. Recently, HCV clearance has become a major endpoint in the war against drugs for the Global Commission on Drug Policy. This review highlights the most recent evidence concerning HCV infection and treatment strategies in PWID.

Are there national strategies, plans and guidelines for the treatment of hepatitis C in people who inject drugs? A survey of 33 European countries

BACKGROUND

Hepatitis C virus (HCV) infection represents a major global health problem, which in high-income countries now mostly affects people who inject drugs (PWID). Many studies show that the treatment of HCV infection is as successful among PWID as among other populations and recently PWID have been included in the international guidelines for the treatment of HCV infection. The aim of this survey was to collect data from European countries on the existence of national strategies, action plans and clinical guidelines for HCV treatment in the general population and PWID in particular.

METHODS

Thirty-three European countries were invited to participate. Data on available national strategies, action plans and guidelines for HCV treatment in general population and in PWID specifically were collected prospectively by means of a structured electronic questionnaire and analyzed accordingly.

RESULTS

All of the 33 invited European countries participated in the survey. Twenty-two responses came from non-governmental organizations, six from public health institutions, four from university institutions and one was an independent consultant. Fourteen (42.4%) of the countries reported having a national strategy and/or national action plan for HCV treatment, from which ten of them also reported having a national strategy and/or national action plan for treatment of HCV infection in PWID. Nearly three-quarters reported having national HCV treatment guidelines. PWID were included in the majority (66.7%) of the guidelines. Fourteen (42.4%) countries reported having separate guidelines for the treatment of HCV infection in PWID.

CONCLUSIONS

Given the high burden of HCV-related morbidity and mortality in PWID in Europe, the management of HCV infection should become a healthcare priority in all European countries, starting with developing or using already-existing national strategies, action plans and guidelines for this population.

Cocaine use and risk of stroke: a systematic review

BACKGROUND

Both cocaine use and strokes impact public health. Cocaine is a putative cause of strokes, but no systematic review of the scientific evidence has been published.

METHODS

All relevant bibliographic-databases were searched until January 2014 for articles on the epidemiological association between cocaine use and strokes. Search strings were supervised by expert librarians. Three researchers independently reviewed studies for inclusion and data extraction following STROBE recommendations. Quality appraisal included study validity and bias. Both ischemic and hemorrhagic strokes were considered.

RESULTS

Of 996 articles, 9 were selected: 7 case-control studies (CCS) and 2 cross-sectional (CSS) studies. One CCS (aOR=6.1; 95% CI: 3.3-11.8) and one CSS (aOR=2.33; 95% CI: 1.74-3.11) showed an association between cocaine and hemorrhagic strokes. The latter study also found a positive relationship with ischemic stroke (aOR=2.03; 95% CI: 1.48-2.79). Another CCS found the exposure to be associated with stroke without distinguishing between types (aOR=13.9; 95% CI: 2.8-69.4). One forensic CCS found that deaths with cocaine-positive toxicology presented a 14.3-fold (95% CI: 5.6-37) and 4.6-fold (95% CI: 2.5-8.5) increased risk of atherosclerosis compared to opioid-related deaths and hanging-deaths respectively. One CCS did not provide an aOR but found a statistically significant association between cocaine and hemorrhagic stroke. Three CCS and one CSS did not find any relationship between cocaine and strokes. Inadequate control for confounding was not uncommon.

CONCLUSIONS

Epidemiological evidence suggests that cocaine use increases the risk of stroke. Larger, more rigorous observational studies, including cohort approaches, are needed to better quantify this risk, and should consider stroke type, hypertension variation, frequency/length of cocaine use, amphetamines co-use, and other factors.

Concentrations of cocaine and benzoylecgonine in femoral blood from cocaine-related deaths compared with venous blood from impaired drivers

The concentrations of cocaine and its major metabolite benzoylecgonine (BZE) were determined in femoral blood from 132 cocaine-related deaths and compared with venous blood from 988 apprehended drivers. Cocaine and BZE were determined by solid-phase extraction and isotope dilution gas chromatography-mass spectrometry with limits of quantitation of 0.02 mg/L for both substances. Significantly more men (95-98%) than women (2-5%) abused cocaine, although their mean age was about the same (29-30 years). Mean age (±SD) of cocaine-related deaths was 29 ± 7 years, which was not significantly different from 30 ± 8 years in traffic cases (P > 0.05). The median concentration of cocaine in blood in 61 fatalities was 0.10 mg/L compared with 0.06 mg/L in traffic cases (P < 0.001). In drug intoxication deaths, the median concentration of cocaine was 0.13 mg/L (N = 25), which was not significantly different from 0.09 mg/L (N = 36) in other causes of death. Cocaine-related deaths mostly involved mixed drug intoxications including co-ingestion of heroin, cannabis, amphetamines as well as legal drugs, such as benzodiazepines and/or ethanol. The concentrations of cocaine in blood from living and deceased persons overlapped, which makes it infeasible to predict toxicity from the analytical toxicology results alone.

Xanthine oxidase contributes to mitochondrial ROS generation in an experimental model of cocaine-induced diastolic dysfunction

Recent studies have shown that long-term cocaine use induces diastolic impairment and a myocardial oxidative stress. Recently, we have reported that cocaine-induced cardiac dysfunction may be due to a mitochondrial reactive oxygen species (ROS) overproduction, which occurs at the same time as xanthine oxidase (XO) activation. In this work, we hypothesized that XO activation contributes to mitochondrial ROS overproduction, which in turn contributes to diastolic dysfunction. To test this, we used a well-established in vivo model of cocaine-induced diastolic dysfunction. In this experimental model treated with or without allopurinol, an inhibitor of XO, we measured mitochondrial ROS production and function. Mitochondrial alterations were characterized by an increase in oxygen consumption through complexes I and III, a reduction in ATP production, and an increased ROS production specifically in isolated interfibrillar mitochondria. Allopurinol treatment prevented the rise in mitochondrial ROS levels and the decrease in ATP production. In the same way, allopurinol treatment improved ventricular relaxation with a decrease in Tau, an index of left ventricle relaxation and of end-diastolic pressure volume relation. These results confirmed the critical role of XO in the sequence of events leading to cocaine-induced cardiac dysfunction.

Mortality and causes of death among users of methadone maintenance treatment in Israel, 1999-2008

OBJECTIVES

To determine all-cause and specific-causes mortality, in the years 1999-2008, among opioid-dependent users treated at methadone maintenance treatment (MMT) clinics in Israel and to compare the obtained results with data from relevant studies worldwide.

METHOD

The records of patients treated at MMT units were linked to the nationwide database of causes of death. Information about the Israeli general population from the Central Bureau of Statistics was used for comparison to match sex and age to the cohort under study. Crude mortality rates (CMRs) per 100 persons per year (PY) and standardized mortality ratios (SMRs) with 95% confidence intervals (CIs) were calculated.

RESULTS

The overall CMR for MMT users was 1.49/100 PY (CI 1.40-1.59) and was not associated with gender, age at entering MMT, ethnicity, and immigrant status. The leading causes of mortality were sudden/undefined death (0.31/100 PY, CI 0.26-0.35), overdose (0.22/100 PY, CI 0.17-0.27), and cancer (0.15/100 PY, CI 0.12-0.18). The MMT users were 12.2 times more likely to die from all causes than people from the general population. Overall, our estimates were comparable with the figures pooled from relevant studies.

CONCLUSIONS

The results suggest that the excess mortality of MMT users is associated with an increased morbidity, which alone or in combination with service-related risks, lead to worse outcomes.

Extent of illicit drug use and dependence, and their contribution to the global burden of disease

This paper summarises data for the prevalence, correlates, and probable adverse health consequences of problem use of amphetamines, cannabis, cocaine, and opioids. We discuss findings from systematic reviews of the prevalence of illicit drug use and dependence, remission from dependence, and mortality in illicit drug users, and evidence for acute and chronic effects of illicit drug use. We outline the regional and global distribution of use and estimated health burden from illicit drugs. These distributions are likely to be underestimates because they have not included all adverse outcomes of drug use and exclude those of cannabis--the mostly widely used illicit drug. In high-income countries, illicit drug use contributes less to the burden of disease than does tobacco but a substantial proportion of that due to alcohol. The major adverse health effects of cannabis use are dependence and probably psychotic disorders and other mental disorders. The health-related harms of cannabis use differ from those of amphetamine, cocaine, and opioid use, in that cannabis contributes little to mortality. Intelligent policy responses to drug problems need better data for the prevalence of different types of illicit drug use and the harms that their use causes globally. This need is especially urgent in high-income countries with substantial rates of illicit drug use and in low-income and middle-income countries close to illicit drug production areas.

Neuroprotective strategies in drug abuse-evoked encephalopathy

Encephalopathy is evidenced as an altered mental state with various neurological symptoms, such as memory and cognitive problems. The type of a substance-evoked encephalopathy will depend on the drug, substance, or combination being abused. The categories into which we could place the various abused substances could be tentatively divided into stimulants, amphetamines, hallucinogens, narcotics, inhalants, anesthetics, anabolic steroids, and antipsychotics/antidepressants. Other factors that may underlie encephalopathy, such as infectious agents, environmental, and other factors have also to be taken into account. Drugs of abuse can be highly toxic to the CNS following acute, but more so in chronic exposure, and can produce significant damage to other organs, such as the heart, lungs, liver, and kidneys. The damage to these organs may be at least partially reversible when drug abuse is stopped but CNS damage from repeated or prolonged abuse is often irreversible. The major pathways for the organ and CNS toxicity could be related to ischemic events as well as increased cell damage due to metabolic or mitochondrial dysfunction resulting in increased excitotoxicity, reduced energy production, and lowered antioxidant potential. These susceptibilities could be strengthened by the use of antioxidants to combat free radicals (e.g., vitamin E, lipoic acid); trying to improve energy generation by using mitochondriotropic/metabolic compounds (e.g., thiamine, coenzyme Q10, carnitine, riboflavin); by reducing excitotoxicity (e.g., glutamate antagonists) and other possible strategies, such as robust gene response, need to be investigated further. The drug-abuse-evoked encephalopathy still needs to be studied further to enable better preventative and protective strategies.

Cocaine-related sudden death: a prospective investigation in south-west Spain

AIMS

With an estimated 12 million consumers in Europe, cocaine (COC) is the illicit drug leading to the most emergency department visits. The aim of this study was to examine a consecutive series of sudden deaths (SDs) to focus on the prevalence, the toxicological characteristics, and the causes of death in COC-related fatalities.

METHODS AND RESULTS

Prospective case-control study of forensic autopsies was carried out in the time interval November 2003 to June 2006 at the Institute of Legal Medicine, Seville, south-west Spain, with a reference population of 1 875 462 inhabitants. Toxicology included blood ethanol analysis and blood and urine investigation for drugs of abuse and medical drugs. Autopsy was performed according to the European standardized protocol. Ten age- and sex-matched patients who died of violent causes with no antecedents of COC consumption and negative toxicology served as controls. During the study period, 2477 forensic autopsies were performed, including 1114 natural deaths. Among the latter, 668 fulfilled the criteria of SD and 21 (all males, mean age 34.6 +/- 7.3 years) resulted to be COC-related (3.1%). Cocaine was detected in 67.1% of the blood (median 0.17 mg/L, interquartile range 0.08-0.42) and in 83.0% of the urine samples (median 1.15 mg/L, interquartile range 0.37-17.34). A concomitant use of ethanol was found in 76.0% and cigarette smoking in 81.0%. Causes of SD were cardiovascular in 62.0%, cerebrovascular in 14.0%, excited delirium in 14.0%, respiratory and metabolic in 5.0% each. Left ventricular hypertrophy was observed in 57.0%, small vessels disease in 42.9%, severe atherosclerotic coronary artery disease in 28.6%, and coronary thrombosis in 14.3%.

CONCLUSION

Systematic toxicology investigation indicates that 3.1% of SDs are COC-related and are mainly due to cardio-cerebrovascular causes. Left ventricular hypertrophy, small vessel disease, and premature coronary artery atherosclerosis, with or without lumen thrombosis, are frequent findings that may account for myocardial ischaemia at risk of cardiac arrest in COC addicts.

Cocaine-related admissions to an intensive care unit: a five-year study of incidence and outcomes

Cocaine misuse is increasing and it is evidently considered a relatively safe drug of abuse in Ireland. To address this perception, we reviewed the database of an 18-bed Dublin intensive care unit, covering all admissions from 2003 to 2007. We identified cocaine-related cases, measuring hospital mortality and long-term survival in early 2009. Cocaine-related admissions increased from around one annually in 2003-05 to 10 in 2007. Their median (IQR [range]) age was 25 (21-35 [17-47]) years and 78% were male. The median (IQR [range]) APACHE II score was 16 (11-27 [5-36]) and length of intensive care stay was 5 (3-9 [1-16]) days. Ten patients died during their hospital stay. A further five had died by the time of follow-up, a median of 24 months later. One was untraceable. Cocaine toxicity necessitating intensive care is increasingly common in Dublin. Hospital mortality in this series was 52%. These findings may help to inform public attitudes to cocaine.

Electrocardiographic abnormalities in opiate addicts

AIMS

To determine in a cross-sectional study the prevalence of electrocardiographic (ECG) abnormalities in opiate addicts who were therapy-seeking and its association with demographic, clinical and drug-specific parameters.

METHODS

In consecutive therapy-seeking opiate addicts, a 12-lead ECG was registered within 24 hours after admission and evaluated according to a pre-set protocol between October 2004 and August 2006. Additionally, demographic, clinical and drug-specific parameters were recorded.

RESULTS

Included were 511 opiate-addicts, 25% female, with a mean age of 29 years (range 17-59 years). One or more ECG abnormalities were found in 314 patients (61%). In the 511 patients we found most commonly ST abnormalities (19%), QTc prolongation (13%), tall R- and/or S-waves (11%) and missing R progression (10%). ECG abnormalities were more common in males than in females (64 versus 54%, P < 0.05), and in patients with positive than negative urine findings for cannabis (68 versus 57%, P < 0.05). Patients with ST abnormalities were more often males than females (21 versus 11%, P < 0.05), had a history of seizures less often (16 versus 27%, P < 0.05), had positive than negative urine findings for cannabis more often (26 versus 15%, P < 0.01) and had negative than positive urine findings for methadone more often (21 versus 11%, P < 0.05). QTc prolongation was more frequent in patients with high dosages of maintenance drugs than in patients with medium or low dosages (27 versus 12 versus 10%, P < 0.05) and in patients whose urine findings were positive than negative for methadone (23 versus 11%, P < 0.001) as well as for benzodiazepines (17 versus 9%, P < 0.05). Limitations of the data are that in most cases other risk factors for the cardiac abnormalities were not known.

CONCLUSION

ECG abnormalities are frequent in opiate addicts. The most frequent ECG abnormalities are ST abnormalities, QTc prolongation and tall R- and/or S-waves. ST abnormalities are associated with cannabis, and QTc prolongation with methadone and benzodiazepines.

Chronic cocaine-induced cardiac oxidative stress and mitogen-activated protein kinase activation: the role of Nox2 oxidase

Chronic cocaine exposure is associated with severe cardiac complications, but the mechanisms of cocaine cardiotoxicity remain unclear, and current therapies are unsatisfactory. We investigated the hypothesis of oxidative stress-mediated cardiotoxicity and the role of NADPH oxidase in this process in a mouse model of chronic escalating "binge" cocaine administration (milligrams per kilogram): days 1 to 4 at 3 x 15 mg, days 5 to 8 at 3 x 20 mg, days 9 to 12 at 3 x 25 mg, and days 13 to 14 at 3 x 30 mg. Compared with vehicle controls, chronic binge cocaine administration significantly increased the cardiac NADPH-dependent O(2)(.) production (1.96- +/- 0.4-fold) as detected by tiron (an O(2)(.) scavenger)-inhibitable lucigenin chemiluminescence and dihydroethidium fluorescence. Cocaine-induced reactive oxygen species (ROS) production was associated with significant increases ( approximately 2-fold) in the protein expressions of Nox2 (an isoform of NADPH oxidase) and its regulatory subunits: p22(phox), p67(phox), p47(phox), p40(phox), and Rac1, and in p47(phox) phosphorylation as detected by immunoblotting (all p < 0.03). Increased Nox2 activity was accompanied by the activation of extracellular signal-regulated kinase 1/2, p38 mitogen-activated protein kinase (MAPK), and c-Jun NH(2)-terminal kinase, notably in the cardiomyocytes. Cell culture experiments revealed that cocaine-induced ROS production was primarily a direct action of cocaine on cardiac myocytes, which caused severe oxidative damage to myocytes and cell death as detected by terminal deoxynucleotidyl transferase dUTP nick-end labeling assay. These could be inhibited by inhibitors to protein kinase C (bisindolymaleimide) or by depletion of Nox2 using small interfering RNA. In conclusion, chronic cocaine administration directly causes severe myocardial oxidative stress through the activation of Nox2 oxidase. Increased ROS production contributes to MAPK activation and the subsequent myocyte damage. Inhibitors to NADPH oxidase or antioxidants may have therapeutic potential in the treatment of cocaine cardiotoxicity.

Development of the Treatment Outcomes Profile

AIM

To develop the Treatment Outcomes Profile (TOP), a new instrument for monitoring substance misuse treatment.

DESIGN

Prospective cohort, psychometric evaluation with 7-day retest and 1-month follow-up to assess inter-rater reliability, concurrent, discriminant and construct validity, and change sensitivity.

PARTICIPANTS

A sample of 1021 service users, aged 16-62 years. Recruitment from 63 treatment agencies in England, collectively providing opioid substitution treatment, psychosocial interventions, in-patient detoxification and residential rehabilitation.

MEASUREMENTS

Thirty-eight frequency, rating scale and period prevalence measures, with 28-day recall, across substance use, health, crime and social functioning domains, administered as personal interview by 163 treatment keyworkers.

FINDINGS

Twenty outcome measures met inter-rater reliability criteria: days used alcohol, opioids, crack cocaine, cocaine powder, amphetamines, cannabis and one other named substance; days injected and period prevalence of direct or indirect needle/syringe sharing; subjective rating of physical and psychological health; days committed shop theft and drug selling, period prevalence of vehicle, property, fraud/forgery and assault/violence offences; rating of quality of life; days worked and attended for education/training; and period prevalence of acute housing problems and risk of eviction. Intraclass correlation coefficients for scale measures and Cohen's kappa for dichotomous measures reached or exceeded 0.75 and 0.61, respectively. There were satisfactory validity assessments and change sensitivity of scale items judged by effect size and smallest detectable difference. The TOP clinical tool contains an additional 10 items for individual treatment planning and review.

CONCLUSIONS

The TOP is a reliable and valid 20-item instrument for treatment outcomes monitoring.

Methamphetamine-related fatalities in Australia: demographics, circumstances, toxicology and major organ pathology

AIM

To examine the demographic characteristics, circumstances of death, toxicological results and major organ pathology of methamphetamine-related deaths in Australia.

DESIGN

Retrospective review of coronial files.

SETTING

Australia.

METHODS

Cases in which methamphetamine was listed as a cause of death were identified from the National Coronial Information System (NCIS).

FINDINGS

A total of 371 cases were identified. The mean age of decedents was 32.7 years; 77% were male and 35% were employed. Route of administration was predominantly by injection (89%). Drugs other than methamphetamine were detected in 89% of cases, most commonly benzodiazepines (41%) and morphine (36%). The median blood methamphetamine concentration was 0.2 mg/l (range 0.02-15.0 mg/l). Deaths were overwhelmingly accidental, with 14% determined to be suicides, and occurred in a private home (71%). Cardiovascular pathology, typically coronary artery atherosclerosis, was detected in 54% of decedents. Cerebrovascular pathology, most commonly cerebral haemorrhage and hypoxia, was present in 20% of cases.

CONCLUSIONS

Methamphetamine has contributed to a substantial number of deaths in Australia. Users need to be informed of the potential harms of methamphetamine use, particularly those associated with the cardiotoxicity of methamphetamine and the use of methamphetamine in conjunction with other drugs.

Current issues in adolescent and young adult cancer survivorship

BACKGROUND

Overall, the survival rate for cancer patients has continued to improve over the past several decades. However, those aged 15 to 29 years have not experienced the same improvements in survival. This review explores some of the challenges faced by adolescent and young adult (AYA) cancer patients and their survivorship needs.

METHODS

Using the OVID Medline database from 1966 to present, a variety of search terms including "adolescent," "young adult," and "cancer survivorship" were entered. Articles related to those obtained by the search were also collected. Additional data were obtained from the SEER database AYA monograph, the Childhood Cancer Survivorship Study, the Report of the Adolescent and Young Adult Oncology Progress Review Group, and the Long-Term Follow-Up Recommendations of the Children's Oncology Group.

RESULTS

Cancer patients in this age-group are at increased risk for second malignancies, cardiotoxicity, and reproductive difficulties. Few data exist concerning intellectual and other psychosocial issues for this specific patient population.

CONCLUSIONS

More research is needed to develop accurate data on treatment and survivorship for AYA patients. A separate cancer discipline focusing on improving outcomes in treatment and survivorship among AYA patients should be developed in major academic cancer centers.

Cocaine use and hypertensive renal changes in HIV-infected individuals

BACKGROUND AND OBJECTIVES

Cocaine causes kidney damage, but data linking cocaine use to chronic kidney disease in HIV patients is not described. This study was conducted to evaluate the possible association of cocaine use and histopathologic findings on biopsy in this population.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Kidney biopsies that were performed in HIV-infected patients during the course of 11 yr were reviewed. Demographic and clinical data were collected. Hypertensive changes were defined on the basis of the Banff 97 classification. Criteria of both arterial intimal fibrosis and thickening and hyaline arteriolosclerosis were used and graded as absent (0), mild (1), moderate (2), and severe (3). Hypertensive renal changes were considered present when the combined pathology score was > or = 2. To minimize confounding, those with hypertension or diabetes were excluded.

RESULTS

Of the 193 HIV patients who underwent kidney biopsy, 53 had no history of hypertension or diabetes with HIV infection. Of those, 29 (55%) had hypertensive renal changes on kidney biopsy. Cocaine use was present in 16 (55%) of 29 with hypertensive renal changes compared with six (25%) of 24 without hypertensive renal changes (odds ratio [OR] 3.7; 95% confidence interval [CI] 1.2 to 11.7). In the adjusted analyses, only age (/yr; OR 1.08; 95% CI 1.00 to 1.16) and cocaine use (OR 3.55; 95% CI 1.04 to 12.14) were significantly associated with hypertensive renal changes on renal biopsy.

CONCLUSIONS

Cocaine use is associated with hypertensive renal changes in HIV-infected patients in the absence of hypertension and diabetes.