Discrimination of opium from Afghanistan and Myanmar by infrared spectroscopy coupled with machine learning methods

Afghanistan and Myanmar are two overwhelming opium production places. In this study, rapid and efficient methods for distinguishing opium from Afghanistan and Myanmar were developed using infrared spectroscopy (IR) coupled with multiple machine learning (ML) methods for the first time. A total of 146 authentic opium samples were analyzed by mid-IR (MIR) and near-IR (NIR), within them 116 were used for model training and 30 were used for model validation. Six ML methods, including partial least squares discriminant analysis (PLS-DA), orthogonal PLS-DA (OPLS-DA), k-nearest neighbour (KNN), support vector machine (SVM), random forest (RF), and artificial neural networks (ANNs) were constructed and compared to get the best classification effect. For MIR data, the average of precision, recall and f1-score for all classification models were 1.0. For NIR data, the average of precision, recall and f1-score for different classification models ranged from 0.90 to 0.94. The comparison results of six ML models for MIR and NIR data showed that MIR was more suitable for opium geography classification. Compared with traditional chromatography and mass spectrometry profiling methods, the advantages of MIR are simple, rapid, cost-effective, and environmentally friendly. The developed IR chemical profiling methodology may find wide application in classification of opium from Afghanistan and Myanmar, and also to differentiate them from opium originating from other opium producing countries. This study presented new insights into the application of IR and ML to rapid drug profiling analysis.

Metabolic syndrome: a population-based study of prevalence and risk factors

The association between personal habits and metabolic syndrome (MetS) remains controversial. This study aimed to assess the prevalence of MetS among youths and its association with cigarette, tobacco, opium, and alcohol consumption in the Rafsanjan Youth Cohort Study (RYCS). The current cross-sectional study was based on data from RYCS, as part of the Rafsanjan Cohort Study (RCS). RCS is a branch of the prospective epidemiological research studies in Iran (PERSIAN). In the present study, 2843 youths aged 15-35 were included. MetS was diagnosed using the international diabetes federation (International IDF), National Cholesterol Education Panel- Adult Treatment Panel III (NCEP-ATPIII), and Iranian criteria (IDF Iranian). Binary logistic regression models were performed to estimate odds ratios (ORs) and confidence intervals (CIs). The prevalence of MetS was 7.67%, 7.14%, and 10.13% based on NCEP-ATPIII, IDF Iranian, and International IDF criteria respectively. The odds of MetS according to international IDF and Iranian IDF in the alcohol-drinking group in the last 12 months (OR: 1.51, 95%CI 1.02-2.21, OR: 1.66, 95%CI 1.11-2.48 respectively) were greater compared with the non-drinking group. The odds of having high TG in the alcohol-drinking group in the last 12 months was 1.53 times higher than the control group (OR = 1.53, 95% CI: 1.20-1.94). Furthermore, the odds of having high waist circumference (WC) according to IDF International was significantly higher in the tobacco-smoking group in the last 12 months and in the tobacco-smoking group in the last 12 months daily (OR: 1.23, 95%CI 1.01-1.49 and OR: 1.41, 95%CI 1.01-1.98 respectively) compared to the control groups. The prevalence of MetS was 7.67%, 7.14%, and 10.13% based on NCEP-ATPIII, IDF Iranian, and International IDF criteria respectively. The odds of MetS and high TG were greater in the alcohol-drinking group in the last 12 months compared with the non-drinking group. The odds of high WC in the last 12 months, were greater in the tobacco-smoking group compared with the non-smoking group. However, more longitudinal studies are needed to verify the associations observed in the current study.

Epidemiology of substance and opium use among adult residents of Tehran; a comprehensive report from Tehran cohort study (TeCS)

BACKGROUND

The prevalence and burden of substance and opium use have increased worldwide over the past decades. In light of rapid population changes in Tehran, we aimed to evaluate the prevalence of opium and other substance use among adult residents in Tehran, Iran.

METHOD

From March 2016 to March 2019, we utilized data from 8 296 participants in the Tehran Cohort Study recruitment phase (TeCS). We calculated the age-sex-weighted prevalence of substance use and the geographic distribution of substance use in Tehran. We also used logistic regression analysis to determine possible determinants of opium use.

RESULT

We analyzed data from 8 259 eligible participants with complete substance use data and the average age of participants was 53.7 ± 12.75 years. The prevalence of substance use was 5.6% (95% confidence interval [CI]: 4.6- 7.1%). Substance use was more common in males than females (Prevalence: 10.5% [95% CI: 8.6- 12.6%] vs. 0.5% [95% CI: 0.2- 1.2%], respectively). The age-sex weighted prevalence of substance use was 5.4% (95% CI: 4.6-7.1%). Moreover, opium was the most frequently used substance by 95.8% of substance users. Additionally, we found that male gender (Odds ratio [OR]: 12.1, P < 0.001), alcohol intake (OR: 1.3, P = 0.016), and smoking (OR: 8.5, P < 0.001) were independently associated with opium use.

CONCLUSIONS

We found that the prevalence of substance use in Tehran was 5.6%, and opium was the most frequently used substance. In addition, male gender, lower levels of education, alcohol, and tobacco consumption are the main risk factors for substance use in Tehran. Healthcare providers and policymakers can utilize our results to implement preventive strategies to minimize substance use in Tehran.

Narcotic analgesics

There is documentation of the use of opium derived products in the ancient history of the Assyrians: the Egyptians; in the sixth century AD by the Roman Dioscorides; and by Avicenna (980-1037). Reference to opium like products is made by Paracelsus and by Shakespeare. Charles Louis Derosne and Fredrich Wilhelm Adam Serturner isolated morphine from raw opium in 1802 and 1806 respectively, and it was Sertürner who named the substance morphine, after Morpheus, the Greek God of dreams. By the middle 1800s, Opium and related opioid derived products were the source of a major addiction in USA, and to some extent in the United Kingdom. Opioid products are of major therapeutic value in the treatment of pain from injury, post surgery, intractable pain conditions, and some forms of terminal cancer.

Peptic ulcer characteristics in oral opium and non-opium user patients with upper gastrointestinal bleeding

BACKGROUND/AIMS

Upper gastrointestinal bleeding (UGIB) is a frequent medical issue. The primary risk factors for bleeding peptic ulcers are Helicobacter pylori infection and non-steroidal anti-inflammatory drugs. The association between acute gastric/duodenal ulcer and opium use has been previously proposed; however, there is no available data on endoscopic findings of patients with acute UGIB who use opium.

MATERIALS AND METHODS

In the present descriptive cross-sectional study, endoscopic data of 50 consecutive patients with oral opium use and 50 consecutive patients without any opium use who were admitted for UGIB were recorded. The size (5-10 mm, 11-20 mm, or more than 20 mm), number (single, double, or multiple), and location of the ulcers (esophagus, gastric corpus including the fundus and body, antrum, angulus, or duodenum) were examined by endoscopy in both groups.

RESULTS

Three or more ulcers were observed in 46% and 16% of patients with oral opium use and without opium use, respectively (P-value = 0.001). The rate of giant ulcers (> 20 mm) was significantly higher in patients who used oral opium (40% vs. 12%; P-value = 0.007). Esophageal ulcers were also more common in oral opium users (30%) than non-users (8%) with UGIB (P-value = 0.01). Nevertheless, the location of the ulcers between the two groups generally was not statistically different.

CONCLUSIONS

This study has demonstrated that multiple, large peptic ulcers in GIB are potential complications of oral opium use. This could aid the needed modifications in the treatment protocol for these patients.

Prevalence and determinants of opioid use disorder among long-term opiate users in Golestan Cohort Study

BACKGROUND

Number of opiate users worldwide has doubled over the past decade, but not all of them are diagnosed with opioid use disorder. We aimed to identify the prevalence and risk factors for OUD after ten years of follow-up.

METHODS

Among 8,500 chronic opiate users at Golestan Cohort Study baseline (2004-2008), we recalled a random sample of 451 subjects in 2017. We used three questionnaires: a questionnaire about current opiate use including type and route of use, the drug use disorder section of the Composite International Diagnostic Interview lifetime version, and the validated Kessler10 questionnaire. We defined opioid use disorder and its severity based on the DSM-5 criteria and used a cutoff of 12 on Kessler10 questionnaire to define psychological distress.

RESULTS

Mean age was 61.2 ± 6.6 years (84.7% males) and 58% were diagnosed with opioid use disorder. Starting opiate use at an early age and living in underprivileged conditions were risk factors of opioid use disorder. Individuals with opioid use disorder were twice likely to have psychological distress (OR = 2.25; 95%CI: 1.44-3.52) than the users without it. In multivariate regression, former and current opiate dose and oral use of opiates were independently associated with opioid use disorder. Each ten gram per week increase in opiate dose during the study period almost tripled the odds of opioid use disorder (OR = 3.18; 95%CI: 1.79-5.63).

CONCLUSIONS

Chronic opiate use led to clinical opioid use disorder in more than half of the users, and this disorder was associated with psychological distress, increasing its physical and mental burden in high-risk groups.

Laser-induced fluorescence spectroscopy of plant-based drugs: Opium and hashish provoking at 405 nm

Here, the fluorescence properties of some plant-based drug samples are characterized using a coherent excitation source at 405 nm. The laser-induced fluorescence (LIF) spectroscopy is examined to analyze opium and hashish. In order to improve traditional fluorescence methods for better analysis of optically dense materials, we have proposed five characteristic parameters based on solvent densitometry assay as the fingerprints of drugs of interest. The signal emissions are recorded in terms of various drug concentrations, such that the best fitting over experimental data determines the fluorescence extinction (α) and self-quenching (k) coefficients according to the modified Beer-Lambert formalism. The typical α value is determined to be 0.30 and 0.15 mL/(cm∙mg) for opium and hashish, respectively. Similarly, typical k is obtained 0.390 and 1.25 mL/(cm∙mg), respectively. Furthermore, the concentration at max fluorescence intensity (Cp) is determined for opium and hashish to be 1.8 and 1.3 mg/mL, respectively. Results reveal that opium and hashish benefit their own characteristic fluorescence parameters to discriminate those illicit substances promptly using the present method.

Relationship between lead concentration in maternal and umbilical cord blood and some neonatal outcomes in primiparous opium-dependent mothers in Zahedan, Southeast of Iran in 2022

BACKGROUND

There are limited studies on maternal and umbilical cord blood lead levels and their relationship with each other and with pregnancy outcomes in women addicted to opium. The present study was conducted with the aim of investigating the relationship between lead concentrations in maternal blood and umbilical cord blood with some neonatal outcomes in primiparous opium-dependent mothers.

METHOD

The present study is a cross-sectional and analytical research. A total of 35 mothers addicted to opium and 35 women without addiction from Zahedan city of Iran participated in this study in 2022. Convenience sampling was done, lead levels were measured and pregnancy outcomes checked by a checklist to collect information. Data analysis was done by independent t-tests, Pearson's correlation coefficient, Point-Biserial Correlation Coefficient, multivariate linear regression and multivariate logistic regression using SPSS version 26 software.

RESULTS

There was a significant difference in maternal blood lead levels (24.97 ± 8.45 in addicted mothers and 7.5 ± 4.25 in healthy mothers) and in umbilical cord blood lead concentrations (18.68 ± 6.95 in the addicted group and 5.7 ± 2.84 in the healthy group) between the two groups (P < 0.0001 and P < 0.0001, respectively).The lead concentration of all the samples in the addicted group was higher than the high-risk levels. Birth weight, Apgar score, admission to NICU and need for resuscitation were significantly different between the two groups (P < 0.0001, P < 0.0001, p = 0.03 and p = 0.04, respectively). Based on the results of multivariate linear regression test, only addiction can reversely predict the birth weight (Beta= -0.74, P < 0.0001), 1-minute Apgar score (Beta = -0.47, P = 0.004) and 5th minute (Beta= -0.62, P = 0.001). According to multivariate logistic regression test, OR of none of the predictor variables was significant with the outcomes. Maternal and umbilical cord blood lead concentrations were not predictors of pregnancy outcomes.

CONCLUSION

The use of opium during pregnancy leads to an increase in the level of lead in maternal blood and umbilical cord blood. Addiction increased adverse pregnancy outcomes but lead concentration did not predict pregnancy complications. It is recommended that the addiction treatment program be included in pre-pregnancy and pregnancy care plans.

Opium Effects on Pancreatobiliary System in Opium Abusers Evaluated by Endoscopic Ultrasonography

Background: Opium use is a significant social and public health issue. There are numerous effects of opium documented as affecting the pancreatobiliary system. The aim of the study was to assess the pancreatobiliary changes in patients with opium addiction by endoscopic ultrasonography (EUS). Methods: During the study period, consecutive patients who were referred for EUS of submucosal upper gastrointestinal lesions were included. The history of opium addiction and clinical symptoms were recorded prospectively. Diameters of the common bile duct (CBD), pancreatic duct (PD), size of the ampulla of Vater, and gallbladder abnormalities were evaluated using EUS. Results: A total of 254 patients (53.1% male, mean age of 55.4±14.2 years) were studied. A history of opium addiction was present in 56 patients (22.0%). Choledocholithiasis was found in two patients (3.6%) and one control (0.5%) patient (P=0.06). Gallbladder stones were found in 13 opium-addict (23.2%) and 16 control (8.1%) patients (P=0.002). The mean diameter of the CBD, size of the ampulla of Vater (P<0.001), and PD (P=0.04) were all significantly greater in patients with opium addiction. Conclusion: Dilation of the biliary and PDs is seen more commonly in patients addicted to opium. However, the clinical implications of these findings need to be further evaluated in future studies.

Differences in clinical and lab characteristics of sepsis between opium user patients and patients with no illicit drug addiction

BACKGROUND

Sepsis is a significant cause of mortality worldwide. This study aimed to compare clinical and laboratory characteristics of sepsis in patients addicted to illicit drugs versus patients with no illicit drug addiction.

METHODS

In this cross-sectional study, all patients hospitalized with sepsis diagnosis were recruited within six months from September to March 2019. Sixty patients for each group (illicit drug-addicted and non-addicted individuals) were selected. The data relating to illicit drug consumption, serum indices, the current focus of infection, duration of hospitalization, and disease outcomes were collected. Patients who had an illicit drug addiction were compared with non-addicted patients in terms of clinical and laboratory parameters. The data collected were analyzed using SPSS software (version 19).

RESULTS

The bacterial load in the urine culture was statistically significant in both groups and higher in the non-addicted group. The frequency distributions of focus of infection, duration of hospitalization, and outcome were not significantly different between the two groups. The serum sodium and total neutrophils were significantly higher in the addicted group. However, the MCHC level was significantly lower (p<0.05).

CONCLUSION

Opium may have stimulated the immune system and reduced bacterial infection in septic patient users.

Oral candidiasis and cigarette, tobacco, alcohol, and opium consumption in Rafsanjan, a region in the southeast of Iran

BACKGROUND

We investigated the association between oral candidiasis prevalence and cigarette, tobacco, alcohol, and opium consumption in Rafsanjan, a region in the southeast of Iran.

METHODS

This cross-sectional study was conducted using the data of Oral Health Branch of Rafsanjan Cohort Study (OHBRCS) as a part of the Rafsanjan Cohort Study (RCS). RCS included in Prospective Epidemiological Research Studies in IrAN (PERSIAN) was begun in 2015 in the Rafsanjan. A full-mouth examination was done by trained dental specialists. Oral candidiasis was diagnosed based on clinical examination. Information about cigarette, tobacco, and opium smoking and alcohol consumption were collected based on data from self-reported questionaries. Univariate and multivariate dichotomous logistics regression were used to assess the association between oral candidiasis and cigarette, tobacco, alcohol, and opium consumption.

RESULTS

Among 8682 participants with mean age of 49.94 years, the prevalence of oral candidiasis was 7.94%. There was a direct association between cigarette smoking in current and former cigarette smokers with an increased odds of oral candidiasis (OR: 3.26, 95% CI: 2.46-4.33 and OR: 1.63, 95% CI: 1.18-2.25 respectively) in fully adjusted models. There was a dose-response relationship between the odds of oral candidiasis and dose (OR: 3.31, 95% CI: 2.38-4.60), duration (OR: 2.48, 95% CI: 2.04-3.95) and number (OR: 3.01, 95% CI: 2.02-4.50) of cigarette smoking in the 4th quartile compared to reference group.

CONCLUSIONS

A dose-response relationship was shown between cigarette smoking and increased odds of oral candidiasis.

Promoter Methylation of Two HOXA9 and NISCH Genes in Opium Users

BACKGROUND

Opiate abuse has been critically increased in the world, especially in Iran. Owing to the association of opiate use with multiple human cancers and neurological disorders, seeking for genetic and epigenetic effects of opium can pave the way for early diagnosis of major health defects in addicted users. Accordingly, the present study aimed to determine the methylation status of the promoter of two genes, which are actively involved in neurodevelopment and cancer evolution.

METHODS

DNA was isolated from peripheral blood of 28 opium abusers and 19 healthy controls and then subjected to sonication. Sonicated DNAs undergone methylated DNA immunoprecipitation-real time polymerase chain reaction (MeDIP-Real Time PCR) using specific primer pairs designed for HOXA9 and NISCH genes. Obtained data were analyzed using SPSS software.

FINDINGS

HOXA9 and NISCH genes were found to be significantly methylated in addicted users compared to controls (P<0.001) which was significantly associated with the mean of the age regarding HOXA9 gene (P=0.002). Neither opium amount nor duration or route of using was associated with the methylation status of HOXA9 or NISCH genes.

CONCLUSION

Hypermethylation of HOXA9 and NISCH genes as tumor suppressor in opium-addicted individuals can be considered as confirmatory evidence for carcinogenesis of opium. Further studies are required to figure out the role of epigenetic alterations in cancer evolution among opium users.

The carcinogenicity of opium consumption: a systematic review and meta-analysis

The carcinogenicity of opium consumption was recently evaluated by a Working Group convened by the International Agency for Research on Cancer (IARC). We supplement the recent IARC evaluation by conducting an extended systematic review as well as a quantitative meta-analytic assessment of the role of opium consumption and risk for selected cancers, evaluating in detail various aspects of study quality on meta-analytic findings. We searched the published literature to identify all relevant studies on opium consumption and risk of selected cancers in humans through 31 October, 2022. Meta-relative risks (mRRs) and associated 95% confidence intervals (CIs) were estimated using random-effects models for studies of cancer of the urinary bladder, larynx, lung, oesophagus, pancreas, and stomach. Heterogeneity among studies was assessed using the I2 statistic. We assessed study quality and conducted sensitivity analyses to evaluate the impact of potential reverse causation, protopathic bias, selection bias, information bias, and confounding. In total, 2 prospective cohort studies and 33 case-control studies were included. The overall pooled mRR estimated for 'ever or regular' versus 'never' use of opium ranged from 1.50 (95% CI 1.13-1.99, I2 = 0%, 6 studies) for oesophageal cancer to 7.97 (95% CI 4.79-13.3, I2 = 62%, 7 studies) for laryngeal cancer. Analyses of cumulative opium exposure suggested greater risk of cancer associated with higher opium consumption. Findings were robust in sensitivity analyses excluding studies prone to potential methodological sources of biases and confounding. Findings support an adverse association between opium consumption and cancers of the urinary bladder, larynx, lung, oesophagus, pancreas and stomach.

Opium may affect coronary artery disease by inducing inflammation but not through the expression of CD9, CD36, and CD68

The molecular mechanisms of opium action with regard to coronary artery disease (CAD) have not yet been determined. The aim of this study was to evaluate the effect of opium on the expression of scavenger receptors including CD36, CD68, and CD9 tetraspanin in monocytes and the plasma levels of tumor necrosis factor alpha (TNF-α), interferon gamma (IFN-γ), malondialdehyde (MDA), and nitric oxide metabolites (NO_x) in CAD patients with and without opium addiction. This case-control study was conducted on three groups: (1) opium-addicted CAD patients (CAD + OA, n = 30); (2) CAD patients with no opium addiction (CAD, n = 30); and (3) individuals without CAD and opium addiction as the control group (Ctrl, n = 17). The protein and mRNA levels of CD9, CD36, and CD68 were evaluated by the flow cytometry and quantitative polymerase chain reaction (RT-qPCR) methods, respectively. The consumption of atorvastatin, aspirin, and glyceryl trinitrate was found be higher in the CAD groups compared with the control group. The plasma level of TNF-α was significantly higher in the CAD + OA group than in the CAD and Ctrl groups (p = 0.001 and p = 0.005, respectively). MDA levels significantly increased in CAD and CAD + OA patients in comparison with the Ctrl group (p = 0.010 and p = 0.002, respectively). No significant differences were found in CD9, CD36, CD68, IFN-γ, and NO_x between the three groups. The findings demonstrated that opium did not have a significant effect on the expression of CD36, CD68, and CD9 at gene and protein levels, but it might be involved in the development of CAD by inducing inflammation through other mechanisms.

Effects of opium use on one-year major adverse cardiovascular events (MACE) in the patients with ST-segment elevation MI undergoing primary PCI: a propensity score matched - machine learning based study

BACKGROUND

Considerable number of people still use opium worldwide and many believe in opium's health benefits. However, several studies proved the detrimental effects of opium on the body, especially the cardiovascular system. Herein, we aimed to provide the first evidence regarding the effects of opium use on one-year major adverse cardiovascular events (MACE) in the patients with ST-elevation MI (STEMI) who underwent primary PCI.

METHODS

We performed a propensity score matching of 2:1 (controls: opium users) that yielded 518 opium users and 1036 controls. Then, we performed conventional statistical and machine learning analyses on these matched cohorts. Regarding the conventional analysis, we performed multivariate analysis for hazard ratio (HR) of different variables and MACE and plotted Kaplan Meier curves. In the machine learning section, we used two tree-based ensemble algorithms, Survival Random Forest and XGboost for survival analysis. Variable importance (VIMP), tree minimal depth, and variable hunting were used to identify the importance of opium among other variables.

RESULTS

Opium users experienced more one-year MACE than their counterparts, although it did not reach statistical significance (Opium: 72/518 (13.9%), Control: 112/1036 (10.8%), HR: 1.27 (95% CI: 0.94-1.71), adjusted p-value = 0.136). Survival random forest algorithm ranked opium use as 13th, 13th, and 12th among 26 variables, in variable importance, minimal depth, and variable hunting, respectively. XGboost revealed opium use as the 12th important variable. Partial dependence plot demonstrated that opium users had more one-year MACE compared to non-opium-users.

CONCLUSIONS

Opium had no protective effects on one-year MACE after primary PCI on patients with STEMI. Machine learning and one-year MACE analysis revealed some evidence of its possible detrimental effects, although the evidence was not strong and significant. As we observed no strong evidence on protective or detrimental effects of opium, future STEMI guidelines may provide similar strategies for opium and non-opium users, pending the results of forthcoming studies. Governments should increase the public awareness regarding the evidence for non-beneficial or detrimental effects of opium on various diseases, including the outcomes of primary PCI, to dissuade many users from relying on false beliefs about opium's benefits to continue its consumption.

Association between Nontraditional Risk Factors and Calculated 10-Year Risk of Atherosclerotic Cardiovascular Disease in a Large General Population: Based on the Pars Cohort Study

Background

While the traditional risk factors of atherosclerotic cardiovascular disease (ASCVD) have been well-established, the evolving role of nontraditional risk factors is not apparent. This study aimed to evaluate the association between nontraditional risk factors and the calculated 10-year ASCVD risk in a general population.

Methods

This cross-sectional study was conducted using the Pars Cohort Study data. All inhabitants of the Valashahr district in southern Iran, aged 40-75 years, were invited (2012-2014). Patients with a history of cardiovascular disease (CVD) were excluded. The demographic and lifestyle data were collected using a validated questionnaire. Multinomial logistic regression analysis was used to evaluate the association between the calculated 10-year ASCVD risk and the nontraditional risk factors of CVD, including marital status, ethnicity, educational level, tobacco and opiate consumption, physical inactivity, and psychiatric disorders.

Results

Of 9264 participants (mean age =52.2±9.0 y; 45.8% male), 7152 patients met the inclusion criteria. In total, 20.2%, 7.6%, 36.3%, 56.4%, and 46.2% of the population were cigarette smokers, opiate consumers, tobacco consumers, ethnically Fars, and illiterate, respectively. The prevalence rates of low, borderline, and intermediate-to-high 10-year ASCVD risks were 74.3%, 9.8%, and 16.2%, respectively. In multinomial regression, anxiety (adjusted odds ratio [aOR], 0.58; P<0.001) was significantly associated with a lower ASCVD risk, whereas opiate consumption (aOR, 2.94; P<0.001) and illiteracy (aOR, 2.48; P<0.001) were significantly associated with a higher ASCVD risk.

Conclusion

Nontraditional risk factors are associated with the 10-year ASCVD risk and, thus, might be considered besides traditional ones for ASCVD in preventive medicine and health policies.

Opium consumption and pancreatic cancer: A meta-analysis

Pancreatic cancer represents a serious public health problem worldwide. Due to its high mortality, efforts on identifying risk factors are very important since only a few risk-related factors have been well established. The present study aimed to address this knowledge gap by estimating the risk of pancreatic cancer associated with opium use. We performed a thorough literature search of PubMed, Web of Science and Scopus, which yielded 3 case-control and 1 cohort study which were included in the analysis. A meta-analysis was conducted using the DerSimonian and Laird inverse-variance approach as the random effects method. The pooled risk ratio for pancreatic cancer in opium users was significantly increased (RR=1.98, 95 % CI 1.33-2.96, p = 0.0008) compared to never users. Subgroup analyses identified a significantly increased risk for pancreatic cancer in men (RR=1.74, 95 % CI 1.22-2.47, p = 0.002), in persons who consumed both raw teriak and refined shireh opium (RR=4.21, 95 % 1.27-13.93, p = 0.02) and in persons who smoked opium (RR=4.21, 95 % 1.27-13.93, p = 0.02). The findings of this study will help in efforts aimed at prevention of pancreatic cancer. Still, further epidemiological research is necessary.

The association of opioid consumption and osteoporosis in old men: Bushehr Elderly Health (BEH) program

In a population of 1156 men aged ≥ 60 years, opioid drug use was reported by 4.1% (n = 47) of participants. Among opioids, opium was the most prevalent consuming drug (83%). Adjusting for potential confounders, opioid consumption showed a positive association with osteoporosis.

PURPOSE

Limited evidence suggest a relationship between opioid consumption and osteoporosis. This study aims to investigate the possible association of osteoporosis and drug use among older adult men of Bushehr, Iran.

METHODS

In this study, 1156 men aged ≥ 60 years of Bushehr Elderly Health (BEH) were included. Bone density and trabecular bone score (TBS) were measured using dual-energy X-ray absorptiometry. Total osteoporosis was noted based on osteoporosis at either site of the lumbar spine, femoral neck, and total hip densitometry. Drug use was defined as a self-reported current use of opioid drugs, either regular (daily) use or irregular consumption. Multivariable modified Poisson regression analysis was used for investigating the association of opioids and osteoporosis, reporting the adjusted prevalence ratio (APR) with 95% confidence interval (CI). The association between drug use and TBS was evaluated using a linear regression model.

RESULTS

Opioid drug use was reported by 4.1% (n = 47) of participants. Among drug users, opium was the most prevalent consuming drug (83%). In all, 38.3% of drug users and 22.4% of non-users had osteoporosis (p-value = 0.011). Multivariable analysis showed that adjusting by age, education, smoking, alcohol consumption, body mass index, diabetes, and physical activity, a positive and significant association was detected between opioid drug use and the likelihood of osteoporosis (APR: 1.46, 95%CI: 1.02-2.10). Considering the potential confounders, the results also showed a negative association between drug consumption and TBS (β: - 0.027, 95%CI: - 0.053, - 0.001).

CONCLUSION

Opioid drug use has a positive association with osteoporosis in elderly men, independent of other conventional risk factors. Elderly drug users might be at a higher risk for osteoporotic fractures, given the effect of substance use on cognition. So, osteoporosis among drug users would be of importance, especially in countries where opium consumption is prevalent.

Gastric Obstruction by Opium Packets: A Case Report

BACKGROUND

We reported a case of gastric obstruction in a body packer who swallowed a large number of opium packets.

CASE REPORT

A 36-year-old man opium addict visited the emergency department with epigastric pain for three days. He swallowed nearly 90 packets of opium for smuggling purposes four days earlier. He self-administered laxatives. In contrast, many times vomiting, he defecated only four packets and vomited one packet. The abdominal X-rays showed some amounts of fluid-air levels and multiple cylindrical opacities with the double-condom sign, corresponding to the distended stomach. Due to the worsening of his abdominal symptoms, he underwent an urgent laparotomy and 84 packets (4-6 cm in size and 8-10 g/ packet of opium) with a total weight of 870 g. They were wrapped in some layers of plastic and tied at the ends. He was discharged in stable condition.

CONCLUSION

A large number of ingested drug packets can induce gastrointestinal obstruction.

Frequency and Predictors of Opioid Use in Rheumatoid Arthritis and Seronegative Spondyloarthropathy Patients

BACKGROUND

Pain is one of the most challenging symptoms in patients with rheumatoid arthritis (RA) and spondyloarthropathies (SpAs), and pain relief is one of the top priorities for improving health-related quality of life. When medication therapy does not significantly reduce pain, chronic opioid consumption becomes more prominent in such patients. This study aimed to evaluate the state of opioid use in RA and SpA patients.

METHODS

This cross-sectional study was performed on 316 patients with RA and spondyloarthropathies (SpAs) from January to March 2014. The convenience sampling method was used to select the participants, and by obtaining verbal consent, everyone was given 15 minutes to complete a checklist independently. Demographic and opioid use data were evaluated in terms of opioid use and its predictors. In this regard, univariate and multivariate logistic regressions were used to evaluate the predictors of opioid consumption in patients. All analyses were conducted using SPSS 21 and the significance level was set at P<0.05.

FINDINGS

About 9.5% of all participants, including 8.8% of RA and 22.6% of SpA cases, were opioid abusers. In the first step of the analysis, it was observed that opioid abuse was significantly higher in men, married participants, urban residents, patients with no biological therapy, and patients with a negative family history of addiction. The most prevalent ways of drug abuse were smoking and ingestion. The results of univariate logistic regression analysis revealed SpA and other factors significantly increase the chance of opioid abuse. Furthermore, multivariate logistic regression analysis showed male gender (OR=10.4) and negative family history of addiction (OR=3.19) significantly affected addiction in RA and SpA patients with a 95% confidence interval.

CONCLUSION

Lack of suitable responsiveness to medication therapy to relieve pain, inconsistent pain evaluation, and shame of asking direct questions about addiction in RA and SpA patients may lead to opioid consumption in some cases. Seronegative SpA may make patients more prone to addiction. However, in this study, male gender and no family history of addiction were related to opioid abuse.

Prevention, diagnosis, and treatment of opioid use disorder under the supervision of opioid stewardship programs: it's time to act now

The third opium war may have already started, not only due to illicit opioid trafficking from the Golden Crescent and Golden Triangle on the international front but also through indiscriminate opioid prescription and opioid diversion at home. Opioid use disorder (OUD), among unintentional injuries, has become one of the top 4 causes of death in the United States (U.S.). An OUD is defined as a problematic pattern of opioid use resulting in clinically significant impairment or distress, consisting of 2 or more of 11 problems within 1 year, as described by the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition. Observation of aberrant behaviors of OUD is also helpful for overworked clinicians. For the prevention of OUD, the Opioid Risk Tool and the Current Opioid Misuse Measure are appropriate screening tests before and during opioid administration, respectively. Treatment of OUD consists of 3 opioid-based U.S. Food and Drug Administration-approved medications, including methadone, buprenorphine, and naltrexone, and non-opioid-based symptomatic medications for reducing opioid withdrawal syndromes, such as α2 agonists, β-blockers, antidiarrheals, antiemetics, non-steroidal anti-inflammatory drugs, and benzodiazepines. There are at least 6 recommendable guidelines and essential terms related to OUD. Opioid stewardship programs are now critical to promoting appropriate use of opioid medications, improving patient outcomes, and reducing misuse of opioids, influenced by the successful implementation of antimicrobial stewardship programs. Despite the lack of previous motivation, now is the critical time for trying to reduce the risk of OUD.

Association of Opium Consumption and Coronary Artery Ectasia: A Propensity Score-Matched Study

BACKGROUND

Opium consumption is associated with increased risk of atherosclerosis and a hyper-inflammatory state which are suggested as contributing factors to the development of coronary artery ectasia (CAE). We aimed to determine if opium consumption is an independent risk factor of CAE. This study aimed to explore the relationship between opium consumption and CAE.

METHODS

In this propensity score-matched study, we enrolled patients who underwent elective coronary angiography between September 2004 and March 2017 in Tehran Heart Center. We studied patients with CAE and without coronary artery disease (CAD) as cases. The control group, patients with normal coronary angiograms, were selected after applying the propensity score matching to match for age, sex, diabetes mellitus, hypertension, hyperlipidemia, family history of coronary artery disease, and cigarette smoking.

RESULTS

We studied 242 patients with pure CAE and selected 968 control patients. The prevalence of opium consumption was not significantly different across these groups: 17 (7.5%) in the pure CAE group compared to 76 (8.6%) in the control group (Odds ratio: 0.81; P=0.455). Amongst the patients with pure CAE, Markis scores were not significantly different between opium consumers and non-consumers (P=0.136).

CONCLUSION

We found no significant difference regarding opium consumption between patients with pure CAE and those with normal coronary angiograms. In addition, there was no correlation between opium consumption and Markis scores in patients with pure CAE.

Factors Determining Primary Coronary Slow Flow Phenomenon among Opium Users and Non-users: A Case Control Study in Northern Iran

Background

Coronary slow flow phenomenon (CSFP) represents a clinical entity with recurrent chest pain leading to living impairment. The present study aimed to investigate whether opium use correlates with primary CSFP.

Methods

This study included Iranian patients with suspected coronary artery disease who underwent myocardial perfusion imaging. Coronary blood flow was measured quantitatively using the thrombolysis in myocardial infarction (TIMI) frame count and slow flow was defined as TIMI grade 2 standard deviations. Age and clinical conditions including diabetes mellitus (DM), hypertension (HTN), hyperlipidemia (HLP), history of chest pain, and opium use were recorded. First, the characteristics of the two groups were compared and then the main analyses were conducted to examine the relationship between CSFP and opium use. Data were analyzed using t test and chi-square test via SPSS 25.0. The significance level was set at P<0.05.

Findings

This study was conducted on 44 male patients with documented CSFP who had no stenotic lesions and 134 control group male patients who had normal coronary arteries with normal flow. The mean age was similar in the two groups (54.25 vs.52.69, P=0.474). Two groups were significantly different in terms of history of chest pain (P=0.003), but there was no significant difference in HTN (P=0.084), DM (P=0.284), HLP (P=0.183), smoking (P=0.696), and opium use (P=0.107).

Conclusion

This study indicated that opium use is not associated with primary CSFP.

Lead poisoning among asymptomatic individuals with a long-term history of opiate use in Golestan Cohort Study

BACKGROUND

Recent reports of lead poisoning suggest that people who use opium may be exposed to high amounts of lead. Here, we investigate the association between opium use and blood lead levels (BLL) in a population-based cohort study.

METHODS

In 2017, we studied a random sample of 410 people who currently (both within the past year and the past month) used opium and 104 who did not from participants of the Golestan Cohort Study in northeast Iran. Participants were stratified by sex and tobacco use history, completed a comprehensive opiate and tobacco use questionnaire and provided blood. BLL was measured by Lead Care® II Blood Lead Test Kit, validated by inductively coupled plasma triple quadrupole mass spectrometry. BLL was categorized as "<5 µg/dL", "elevated" (5-10 µg/dL), "high" (10-50 µg/dL), and "very high" (above 50 µg/dL). To assess the association between BLL categories and opiate use, route of consumption and weekly use, we used ordered logistic regression models, and report OR (odds ratio) and 95% CI (confidence interval) adjusted for age, sex, place of residence, education, occupation, household fuel type, and tobacco use.

RESULTS

In the cohort, participants used only raw (teriak) or refined (shireh) opium, which were smoked (45%, n = 184), taken orally (46%, n = 189), or both (9%, n = 37), for a mean duration of 24.2 (standard deviation: 11.6) years. The median BLL was significantly higher in people who currently used opium (11.4 µg/dL; IQR: 5.2-23.4) compared with those who did not (2.3 µg/dL; IQR: 2.3-4.2), and the highest median BLL was seen in oral use (21.7 µg/dL; IQR: 12.1-34.1). The BLL was <5 µg/dL among 79.8% of people with no opiate use, compared with only 22.7% in those using opium. BLL was elevated in 21.7%, high in 50.5% and very high in 5.1% of people using opium. About 95% of those with oral (180/189) or dual use (35/37) and 55% (102/184) of those who smoked opium had levels of blood lead above 5 µg/dL. The OR for the association between any opium use and each unit of increase in BLL category was 10.5 (95%CI: 5.8-19.1), and oral use of opium was a very strong predictor of increasing BLL category (OR=74.1; 95%CI: 35.1-156.3). This odds ratio was 38.8 (95%CI: 15.9-95.1) for dual use and 4.9 (95%CI: 2.6-9.1) for opium smoking. There was an independent dose-response association between average weekly dose and BLL among people using opium, overall and when stratified by route of use.

CONCLUSION

Our results indicate that regular use of lead-adulterated opium can expose individuals to high levels of lead, which may contribute to mortality and cancer risks associated with long-term opium use.

Herbal therapy in opioid withdrawal syndrome: A systematic review of randomized clinical trials

Background

Medicinal plants have revealed much attention as an alternative or complementary treatment for opioid withdrawal syndrome. The current review collects all available literature to verify the efficiency of herbal remedies in the management of symptoms associated with opioid withdrawal.

Methods

A systematic literature search was conducted from January 1990 to May 2021 on four bibliographic databases (Scopus, PubMed, Embase, and Web of Science) using the search terms "medicinal plant", "withdrawal syndrome", "opioid", and all their equivalents. All randomized controlled trials (RCTs), published in the English language were included for data synthesis. The search was performed according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA). The Cochrane risk of bias tool was used to verify the quality of the included clinical trials.

Findings

A total of 12 RCTs were collected and used for data synthesis. The results of these studies indicated that herbal medicines were effective in treating opioid withdrawal syndrome and could alleviate the withdrawal symptoms, such as abdominal constrictions, diarrhea, bone pain, perspiration, and insomnia, when compared to conventional medications such as buprenorphine, clonidine, and methadone. However, more than 30% of RCTs were found to be at high risk of bias in the areas of selection, performance, detection, attrition, and reporting.

Conclusion

Although several RCTs have proven that herbal remedies are effective in reducing opioid withdrawal symptoms, the findings need to be viewed more carefully. Further RCTs with more participants, longer duration, and less risk of bias are needed in the claimed cases.

Multivariate statistical evaluation of heavy metals in the urine of opium individuals in comparison with healthy people in Western Iran

The current study aimed to evaluate the levels of some toxic and essential elements (Pb, Cd, Cu, Ti, Ni, Cr, Co, Fe, Ca, Hg, Mn, Se, and Zn) in the urine of opium-addicted compared to non-addicted cases. In this study, 126 participants were recruited and their fasting urine samples were collected (63 opium-addicted and 63 non-addicted subjects served as the reference group). ICP-MS was utilized to detect the concentration of trace elements. Results exhibited that the concentration of all elements than Ni, Cu, and Zn was markedly different between the addicted and non-addicted groups. Compared to controls, the Cd, Cr, Co, Hg, Mn, Pb, Se, and Ti levels were higher among opium-addicted cases (p < 0.05) whereas the Fe and Ca concentrations were higher among controls (p < 0.05). Robust regression analysis showed no statistically significant effect of gender on element levels. It revealed that age was associated with the levels of Ni and Cu only and also the route of administration was related to the urinary levels of Co, Cr, Hg, and Mn. In conclusion, results confirmed that it is opium consumption that affects the concentration levels of most elements.

Examining the association between opium use, cigarette smoking and alcohol consumption with the liver enzyme levels in a population-based study: Fasa Persian cohort data

Objectives

Opium use, cigarette smoking, and alcohol consumption are serious health problems in many countries including Iran. The present study aimed to examine the association between the opium use, cigarette smoking and alcohol consumption with liver enzyme levels in Southern Iran. This analytical cross-sectional study was conducted in 2020. The entire population of the Fasa Persian cohort study in the southern region of Iran was selected as the sample. Accordingly, 10,145 people participated in the study.

Results

Results indicated that there was a significant relationship between cigarette smoking and alcohol consumption with liver enzymes (AST, ALT, and ALP). There was also a significant relationship between inhaled opium and liver enzymes, but oral opium revealed no significant relationship with the activity of liver enzymes. Accordingly, policymakers of the health care system are recommended to hold educational programs to improve the health literacy level of the society and take effective preventative strategies in reducing the use of these substances.

Does Opium Consumption Have Shared Impact on Atherosclerotic Cardiovascular Disease and Cancer?

Although atherosclerotic cardiovascular disease (ASCVD) and cancer are seemingly different types of disease, they have multiple shared underlying mechanisms and lifestyle-related risk factors like smoking, unhealthy diet, excessive alcohol consumption, and inadequate physical activity. Opium abuse is prevalent in developing countries, especially the Middle East region and many Asian countries. Besides recreational purposes, many people use opium based on a traditional belief that opium consumption may confer protection against heart attack and improve the control of the risk factors of ASCVD such as diabetes mellitus, hypertension, and dyslipidemia. However, scientific reports indicate an increased risk of ASCVD and poor control of ASCVD risk factors among opium abusers compared with nonusers. Moreover, there is accumulating evidence that opium consumption exerts potential carcinogenic effects and increases the risk of developing various types of cancer. We conducted a review of the literature to review the current evidence on the relationship between opium consumption and ASCVD as well as various kinds of cancer. In addition, we will discuss the potential shared pathophysiologic mechanisms underlying the association between opium abuse and both ASCVD and cancer.

Opium Addiction: Practical Issues in ICU

How to cite this article: Das AK, Sharma A, Kothari N, Goyal S. Opium Addiction: Practical Issues in ICU. Indian J Crit Care Med 2021;25(9):1082–1083.

The effect of opium on severity of COVID-19 infection:An original study from Iran

Background: The COVID-19 infection is a novel virus without any specific targeted therapies; thus, focusing on primary epidemiologic concerns, preventive strategies, risk factors, exacerbation factors, and mortality-related factors are of great importance to better control this disorder. There are some controversies about the factors associated with COVID-19 in different theories, and addiction is no exception.

Methods: We conducted a large cross-sectional study of 513 hospitalized Iranian patients with COVID-19 infection to evaluate the severity of disease courses in patients with or without history of opium addiction. We recorded these data retrospectively after patients’ discharge from the hospital. For the quantitative data, we used independent-samples t and Mann-Whitney tests. The qualitative data were calculated using Fisher exact and chi-square tests in IBM SPSS Statistics Version 22. Also, p<0.05 was considered statistically significant.

Results: There was no significant difference regarding mean days of hospitalization in opium positive and negative groups (7.95±8.39 vs 8.35±5.11, respectively) (p=0.771); however, the need for intensive care unit (ICU) admission was significantly higher in the opium positive group (36% vs 11%) (p=0.005). The mean days of ICU stay was significantly higher in the opium positive group (2.36±3.81 vs 0.86±2.90) (p=0.026). The percentage of febrile patients, anosmia/hyposmia, and dysgeusia at the initiation of hospitalization was significantly lower in the opium positive group (39% vs 66%; 8% vs 23%; 8% vs; 20%, respectively) (p=0.002, 0.018, and.031, respectively). In the laboratory tests, only the white blood cell (WBC) count and the segmented cells were higher in the opium positive group (10.1±6.60 vs 7.38±4.14 and 73±20.47 vs 56.5±32.60, respectively) (p=0.018 and.001, respectively) and lymphocytes were lower in the opium positive (15.60±8.25 vs18.70±10.12) (p=0.048). Opium addicts had a significantly lower rate of azithromycin and lopinavir/ritonavir prescription in their initiation therapy (19% vs 34%, and 47% vs 70%, respectively) (p=0.038 and 0.012, respectively).

Conclusion: Opium addict patients with COVID infection may be more febrile and experience more disease-specific symptoms and more severe disease course. These patients may show more evidence of laboratory inflammation and probable superinfections, so may manage with more caution and somehow different therapeutic regimen.

Carbon and Nitrogen Isotopic Analysis of Morphine from Opium and Heroin Samples Originating in the Four Major Heroin Producing Regions

The forensic analysis of stable isotopes is a valuable tool to geo-source natural or semi-synthetic drugs such as cocaine and heroin. The present study describes a novel methodology to isolate morphine from opium for isotopic analysis. Furthermore, this isotopic data from regional sources is corroborated with morphine data obtained from seized heroin (de-acetylated to morphine) from the same regions. All five primary alkaloids of opium, namely morphine, codeine, thebaine, noscapine and papaverine, were quantified using high performance liquid chromatography with PDA before the preparative experiment to gather a complete major alkaloidal profile. Morphine fractions of authentic opium submissions from Mexico, South America, Southwest Asia, and Southeast Asia were isolated and collected using preparative high performance liquid chromatography, and the collected morphine samples were subsequently analyzed by isotope ratio mass spectrometry. Carbon and nitrogen isotope data are presented. The data demonstrates that nitrogen ratios are capable of differentiating samples from Mexico and South America while carbon ratios are able to distinguish Southwest Asian samples from other source regions. Analogous results have routinely been observed (as part of Heroin Signature Program analysis) for morphine obtained from de-acetylated authentic heroin samples from the same source regions. The results suggest that the poppy growing region has a greater influence on the carbon and nitrogen isotope values than the heroin manufacturing processes employed. When utilized in conjunction with existing signature methodologies, carbon and nitrogen isotope ratio data can enhance the ability to geo-source heroin.

Association of Opium Addiction with Coronary Artery Ectasia and Coronary Artery Disease

Background

Coronary artery ectasia (CAE) is a rare cardiovascular disorder with unknown mechanisms and related risk factors. The roles played by homocysteine in induction of cardiovascular diseases (CVDs) have also been documented previously. This project was designed to assess the relationship between opium and CAE and coronary artery disease (CAD).

Methods

This cross-sectional study was performed on 46 patients with CAE, 30 patients with CAD, and 42 cases without CAE and CAD (controls). Demographic data and information regarding opium consuming and also smoking were collected using a standard checklist. Serum levels of homocysteine, creatinine (Cr), urea, fasting blood glucose (FBG), low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglyceride (TG), and cholesterol were determined.

Findings

Statistical analysis revealed that opium consumers were significantly higher in patients with CAD and CAE when compared to healthy controls. Opium increased serum levels of Cr in the normal controls, and decreased HDL in the patients with CAD. Homocysteine serum levels were not significantly different between the groups.

Conclusion

The results of study showed that opium addiction was associated with increased risk of CAE and CAD, independent of homocysteine serum levels.

Comparison of Brain Magnetic Resonance Imaging Lesions in Opium Addict and Non-addict Patients with Thrombotic Stroke: A Case-Control Study

Background

There is no consensus on the effect of opium on stroke yet. Some studies show the negative effects of opium on ischemic strokes. Here, we attempt to compare the volume of lesions in opium addict and non-addict patients with thrombotic stroke.

Methods

This case-control study was conducted on patients with thrombotic stroke at Shafa Hospital in Kerman, Iran. The diagnosis was confirmed by clinical examinations, imaging, and laboratory tests. The volume of lesions was calculated by magnetic resonance imaging (MRI), and the data were analyzed by descriptive statistics, Mann-Whitney U test, Chi-square test, and linear regression analysis.

Findings

A total of 60 patients were studied, 30 of whom were opium addicts and the rest were non-addicts. The mean volume of the lesion was 46.008350 ± 7.488990 (in the addict group) and 31.023335 ± 1.441570 (in the non-addict group), indicating a significant difference between the two groups (P = 0.005). Regression analysis results showed a significant relationship between the volume of stroke with opium addiction (P = 0.017), ischemic heart diseases (IHDs) (P = 0.006), hyperlipidemia (HLP) (P = 0.016), age (P = 0.035), and smoking (P = 0.044).

Conclusion

The results of this study showed a higher volume of lesion in opium-addict patients compared to that in non-addicts as an indicator of stroke severity.

Effectiveness and Safety of Haloperidol Add-on Methadone in Acute Opium Withdrawal Symptoms of Opioid-dependent Patients: A Double-blind Randomized Placebo-controlled Clinical Trial

Background

The aim of this double-blind clinical trial was to evaluate the efficacy and safety of haloperidol on acute opioid withdrawal symptoms.

Methods

In this randomized double-blind clinical trial, fifty-two eligible patients were assigned to two groups according to previous opioid consumption, low dose (LD) and high dose (HD). Then, patients in each group were randomly assigned to one of the two subgroups of haloperidol or placebo. Patients in the haloperidol subgroup in LD group received 2.5 mg and in HD group received 5 mg/day haloperidol with methadone. Methadone was discontinued ten days after the beginning of the study and haloperidol or placebo continued for up to two weeks after methadone discontinuation. The severity of opioid withdrawal symptoms was assessed with the Objective Opioid Withdrawal Scale (OOWS) every other day.

Findings

Although both treatment protocols either in LD or HD opioid consumption groups significantly increased the score of the OOWS over the trial period (all subgroups, P < 0.001), the combination of 2.5 mg/day of haloperidol and methadone in LD opioid consumption group showed a significant superiority over methadone alone in decreasing opium withdrawal symptoms during the study (P = 0.001). The frequency of adverse effects was comparable between two treatment protocols in both groups (P > 0.050).

Conclusion

The results of this study suggest that 2.5 mg/day of haloperidol may be an effective adjuvant agent in the management of opium withdrawal symptoms in patients with LD opioid consumption. Nevertheless, results of larger controlled trials are needed before recommendation for a broad clinical application can be made.

A Comparison of the Prevalence Rate of Oral Candida Colonization between Opium Users and Cigarette Smokers in Kerman, Iran

Background

Candidiasis is the most common opportunistic oral infection and smoking is considered as one of its well-known risk factors. However, it remains unknown whether opium users are susceptible to increased oral candida colonization. The aim of the present study is to compare the prevalence rate of oral candida colonization between opium users and cigarette smokers in Kerman, Iran.

Methods

This case-control study included 75 healthy male respondents divided into three groups (25 in each group): cigarette smokers, cigarette and opium users, and non-smokers as control group. The samples were obtained from oral mucosa by scraping the mucosa with a sterile cotton swab then inoculated into Sabouraud Dextrose Agar (SDA) and CHROMagar plates and also examined with the light microscope.

Findings

Candida was identified in 38.70% of respondents. The most frequently isolated species was Candida albicans (90.66%). The highest prevalence of candida carriage was found in cigarette smokers (52.00%). The difference of candida carriage between the two groups of cigarette smokers and cigarette plus opium users and the control group was statistically significant (P = 0.007 and P = 0.015, respectively).

Conclusion

In the present study, it was revealed that the prevalence of oral candida carriage was significantly higher among cigarette and opium users in comparison to the non-users.

Poppies as a sleep aid for infants: The "Hypnos" remedy of Cretan folk medicine

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Cretan traditional Medicine, used Opium poppies as sedatives for children.

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Poppies’ folk preparations were called Hypnos.

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The practice to offer Hypnos to children was alive until the early 20th century.

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Iatrosofia are written collections of traditional remedies.

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Hypnos related recipes are absent in Cretan Iatrosofia after the 17th century.

Opium Poppy (Papaver somniferum L.) is considered as one of the earliest medicinal plants known to mankind. Derived from the Greek name “opos” meaning juice, referring to its psychotropic latex, the plant was known and extensively used since Antiquity during religious rituals and for Medical purposes, mainly as hypnotic and pain reliever agent. In Cretan folk medicine it was recommended along with other poppies until the early 20th century to induce children sedation, by the name: “Hypnos” meaning sleep.

Opium use as an independent risk factor for pancreatic cancer: A case-control study

BACKGROUND

Pancreatic cancer (PC) is ranked as the seventh leading cause of cancer deaths worldwide. The current study was conducted to explore the correlation between the use of opium and its derivatives (opium) and PC in Iran.

METHODS

In this case-control study which was conducted in Kerman province, south east part of Iran; 176 patients with PC, and 352 healthy individuals as the control group were matched in terms of age, sex, and place of residence. A structured questionnaire including questions of opium usage, alcohol usage, cigarette smoking, and diet was used to collect the data. The relation between the use of opium and PC was adjusted for tobacco smoking, education, daily intake of fruit, vegetables, red meat, and hydrogenated fats and analyzed using the conditional logistic regression.

RESULTS

There was a positive relationship between the opium use and the increased risk of PC (Adjusted Odds Ratio (AOR) = 4.33, 95 % CI: 2.09-8.95), which was even stronger than its association with cigarette smoking (AOR = 1.67, 95 % CI: 0.86-3.24), although their difference was not statistically significant. A significant dose-response relation was detected between the use of opium; as the relation was stronger in heavy users (AOR low users = 4.93, 95 % CI: 1.79-13.54 and AOR heavy users = 5.10, 95 % CI: 2.10-12.35). Moreover, PC was higher among participants starting the use of opium at a younger age than those who started opium at an older age (AOR = 8.03, 95 % CI: 3.19-20.23).

CONCLUSION

This study demonstrated that opium use is associated with a high and strong risk of PC as an independent risk factor. Further studies should be done to reduce the use of opium in Iran and other world countries.

Comparing Sexual Function between Opioid Dependents Consuming Methadone or Opium Tincture

Objective: Sexual dysfunction is a side effect of methadone maintenance therapy (MMT). Opium Tincture (OT) has been used as a maintenance treatment. This study aimed to determine and compare the trend of sexual function and its related factors during treatment with both drugs. Method : An observational study was designed to measure the blood tests including free and total testosterone, prolactin, and sex hormone-binding globulin and a battery of questionnaires, including demographics and drug use history, in 42 and 53 patients entering MMT and OT treatment before and 1 and 3 months after the treatment. Results: Significant changes in testosterone levels were observed in the MMT but not the OT group. The difference between the two groups was not significant. Neither between nor within changes in the sexual function and premature ejaculation scores were significant (P =0.370& 0.698). Anxiety levels were significantly different (P= 0.001) within and between groups. There was a considerable difference in the trend of depression changes in the OT group, but not different in MMT group and between the two groups. Conclusion: No difference was found between MMT and OT effects on sexual function variables. The decrease in Testosterone during the three months of MMT, was not associated with diminished sexual function. In the MMT group, anxiety levels diminished during treatment. It seems that decreased testosterone in the MMT group was compensated by improved anxiety. Gonadotropin levels may not be the sole determinant in sexual activity, and complex interaction of mood and anxiety, agonist levels, and gonadotropins are involved.

A Systematic Review and Meta-analysis on Blood Lead Level in Opium Addicts: an Emerging Health Threat

This meta-analysis was conducted aiming to summarize the results obtained from the previous studies so that the effect of opium on blood lead levels (BLLs) can be investigated. Scopus, Embase, PubMed, and Web of Science (ISI) were systematically searched up to June 2020. Heterogeneity of the included studies was evaluated using Cochrane's Q test and the I² statistic. A random-effects model was used to pool the weighted mean differences (WMDs) and their 95% confidence intervals (CIs). Out of a total of 2372 citations, eleven articles with 916 participants (487 opium addicts and 429 controls) were included in the study. The meta-analysis results showed that there were higher lead levels (WMD = 14.59 μg/dL, 95% CI = 11.59 to 17.92, Z = 8.60, P < 0.001) in opium addicts than in the control group. The degree of heterogeneity observed (P < 0.001, I² = 98.1%) might be mainly the result of the type of sampling and of consumption. Moreover, the findings of meta-regression analyses indicated that publication year (β = 1.23, P = 0.287), total sample size (β = 0.05, P = 0.728), and quality scores (β = - 2.91, P = 0.546) had no effects on lead levels in opium addicts. In the sensitivity analysis, it was found that the pooled WMDs remained stable after excluding one by one study. Oral opium consumption increased the amount of lead in the bloodstream, and the measurement of lead levels in opium addicts' blood may be regarded as a useful test to diagnosis and prognosis of disorders that may lead poisoning causes.

Morphine alkaloids: History, biology, and synthesis

This chapter provides a short overview of the history of morphine since it's isolation by Sertürner in 1805. The biosynthesis of the title alkaloid as well as all total and formal syntheses of morphine and codeine published after 1996 are discussed in detail. The last section of this chapter provides a detailed overview of medicinally relevant derivatives of the title alkaloid.

Adverse Reactions to Illicit Drugs (Marijuana, Opioids, Cocaine) and Alcohol

Drug allergy has been a research topic within the allergy field for decades. However, many drug reactions presumed to be of allergic nature are not and originate from different mechanisms. Drug-induced reactions can affect numerous organ systems, present with various symptoms, and have more than 1 mechanism of action. In this rostrum article, we want to give an overview of the different allergic and nonallergic reactions that can be expected with the (illicit) use of cannabis, cocaine, opioids, and alcohol. In addition, this article focuses on the different methods available to diagnose allergy related to these 4 drug types and highlight the pitfalls of nonallergic reactions or allergy "mimickers" complicating the diagnosis of true drug allergy. Finally, the impact on current medical practices and future research in support of the allergist in diagnosis and treatment of these medical problems is addressed.

Opium dependence and the potential impact of changes in treatment coverage level: A dynamic modeling study

Background : The most common drug, illegally used in Iran is opium. The treatment of people with substance use disorder is one of the most important strategies in reducing its burden. The aim of this study was to investigate the effect of different increasing and decreasing opium treatment coverage on the patterns of abstinence, transition to heroin dependence and mortality, over 30 years. Methods: This study was a dynamic compartmental modeling conducted in three stages: 1) presenting a conceptual model of opium dependence treatment in Iran, 2) estimating model's parameters value, and 3) modeling of opium dependence treatment and examining the outcomes for different treatment coverage scenarios. The input parameters of the model were extracted from the literature, and secondary data analysis, which were finalized in expert panels. Results: The number of opium dependence will increase from 1180550 to 1522063 [28.93% (95% CI: 28.6 to 29.2)] over 30 years. With a 25% decrease in coverage compared to the status quo, the number of deaths will increase by 459 cases [3.28% (95% CI: 0.91 to 5.7)] in the first year, and this trend will continue to be 2989 cases [15.63% (95% CI: 13.4 to 17.9)] in the 30th year. A 25% increase in treatment coverage causes a cumulative decrease of heroin dependence by 14451 cases [10.1% (95% CI: 9.5 to 10.8)] in the first decade. Conclusion: The modeling showed that the treatment coverage level reduction has a greater impact than the coverage level increase in the country and any amount of reduction in the coverage level, even to a small extent, may have a large negative impact in the long run.

Opium use reporting error in case-control studies: neighborhood controls versus hospital visitor controls

Background: There are relatively scant data to determine whether hospital visitors could serve as a proper source of controls in case-control studies of illicit drug use. The aim of this study was to evaluate using neighborhood versus hospital visitor controls in reporting opium use. Methods: We used data from 2 independent case-control studies of cancer in Iran. In the first study, controls were selected from neighborhoods of the patients. For the second one, controls were selected from among hospital visitors. In the latter study, hospital visitors were companions of the patients or others visiting the hospital for reasons other than disease treatment. We used stata (version 12; Stata Corp( for all analyses and with a significance level of 0.05. Results: Data from 616 of neighborhood controls and 414 of hospital visitor controls were analyzed. Opium point prevalence among men was significantly higher in hospital visitors than neighborhood controls (43.3% vs 32.2%; P = 0.047), while the prevalence of cigarette smoking was very similar in both control groups (46.3% vs 47.2%; P =.847). Using a logistic regression analysis, in an unadjusted analysis, neighborhood controls were less likely to report opium use in both genders, with (unadjusted OR = 0.77; 95% CI: 0.59,1). After adjusting for potential confounders, the differences of opium use between the 2 control groups became more pronounced (Adjusted OR = 0.26; 95% CI: 0.10, 0.69). Conclusion: Because of the similarity of reporting cigarette smoking among neighborhood controls but substantially lower reporting of opium use among them, we concluded that neighborhood controls underreport opium use-a sensitive question- and that using neighborhood control biases the findings in case-control studies. Hospital visitor controls may be more appropriate than neighborhood controls for case-control studies of illicit drugs.

Long-term opiate use and risk of cardiovascular mortality: results from the Golestan Cohort Study

AIMS

Tens of millions of people worldwide use opiates but little is known about their potential role in causing cardiovascular diseases. We aimed to study the association of long-term opiate use with cardiovascular mortality and whether this association is independent of the known risk factors.

METHODS AND RESULTS

In the population-based Golestan Cohort Study-50 045 Iranian participants, 40-75 years, 58% women-we used Cox regression to estimate hazard ratios and 95% confidence intervals (HRs, 95% CIs) for the association of opiate use (at least once a week for a period of 6 months) with cardiovascular mortality, adjusting for potential confounders-i.e. age, sex, education, wealth, residential place, marital status, ethnicity, and tobacco and alcohol use. To show independent association, the models were further adjusted for hypertension, diabetes, waist and hip circumferences, physical activity, fruit/vegetable intake, aspirin and statin use, and history of cardiovascular diseases and cancers. In total, 8487 participants (72.2% men) were opiate users for a median (IQR) of 10 (4-20) years. During 548 940 person-years-median of 11.3 years, >99% success follow-up-3079 cardiovascular deaths occurred, with substantially higher rates in opiate users than non-users (1005 vs. 478 deaths/100 000 person-years). Opiate use was associated with increased cardiovascular mortality, with adjusted HR (95% CI) of 1.63 (1.49-1.79). Overall 10.9% of cardiovascular deaths were attributable to opiate use. The association was independent of the traditional cardiovascular risk factors.

CONCLUSION

Long-term opiate use was associated with an increased cardiovascular mortality independent of the traditional risk factors. Further research, particularly on mechanisms of action, is recommended.

The Reasons for Higher Mortality Rate in Opium Addicted Patients with COVID-19: A Narrative Review

The outbreak of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) caused COVID-19 has developed into an unexampled worldwide pandemic. The most important cause of death in patients with COVID-19 is Acute Respiratory Distress Syndrome (ARDS). Opium is widely used for its analgesic features in control of acute and chronic pain related to different diseases. Opium consumption is increased over the last three decades and leads to adverse effects on the respiratory system; opium also affects the lungs' functions and respiration. The contemplative issue is the higher mortality rate due to SARS-CoV-2 infection in opium addicts' patients. Studies have shown that despite the decrease in proinflammatory cytokines production in opium addicts, there are at least 4 reasons for this increase in mortality rate: downregulation of IFNs expression, development of pulmonary edema, increase thrombotic factors, increase the expression of Angiotensin-converting enzyme 2 (ACE2). Therefore, identifying the causes of mortality and approved therapies for the treatment of COVID-19 patients who use opium for any reason is an important unmet need to reduce SARS-CoV-2 infection-related mortality. This review study demonstrated the effects of opium on immune responses and the reasons for the higher mortality rate in opium addicts' patients with COVID-19.

Ontological journeys: The lifeworld of opium across the Afghan-Iranian border in/out of the pharmacy

How can we conceive alternative policy models that embrace the empirical potentialities emerging from the lifeworld of drugs? The article reflects on this question, concluding that to reassess and to reinvent current policies on drugs, we need to think with a political ontology. Incidentally, the article also responds to the critique dismissing ontological inquiries as obstructing - or, at best, not informing - alternative drug policies. In an archaeological approach inspired by the work of Giorgio Agamben, the article unearths the case study of opium maintenance programme in Iran (1969-79), a forgotten policy experiment in an understudied and yet crucial geo-cultural environment for the global study of drugs. Mobilising the conceptual framework of ontological journeys, the article recomposes the lifeworld of opium within the horizons of transformative cultural practices, international borders, policy regimes and public ethics. Here, the materiality of drug consumption under the maintenance policy links with the changes in opium's transnational political economy and with shifting regimes of health and bioethical orthodoxy. Ontological journeys, hence, develop in a fluid space and time, making it possible to illuminate the lifeworld of drugs in places and times hitherto deserted by global policy studies. In building theoretical reflections upon a non-Western case, the article also incites the possibility of theory beyond Eurocentric knowledge and Euromerican cases. In this way, the article's purpose is to analyse the be-coming of opium beyond 'good' or 'evil', as a 'medicine' or a 'drug' and its real or perceived classification as 'licit' or 'illicit' across the Afghan-Iranian border. In conclusion, the article reflects upon the significance of this forgotten policy experiment, understood as an ontological journey, for contemporary drug policy and drug studies, but also for reinventing notions of care, welfare and health.

The Iranian Study of Opium and Cancer (IROPICAN): Rationale, Design, and Initial Findings

BACKGROUND

The International Agency for Research on Cancer (IARC) recently classified opium use as a Group 1 carcinogen. However, much remains to be studied on the relation between opium and cancer. We designed the Iranian Opium and Cancer (IROPICAN) study to further investigate the association of opium use and cancers of the head and neck, bladder, lung, and colon and rectum. In this paper, we describe the rationale, design, and some initial results of the IROPICAN Study.

METHODS

The IROPICAN is a multi-center case-control study conducted in 10 provinces of Iran. The cases were all histologically confirmed and the controls were selected from hospital visitors who were free of cancer, were not family members or friends of the cancer patients, and were visiting the hospital for reasons other than their own ailment. The questionnaires included detailed questions on opium use (including age at initiation, duration, frequency, typical amount, and route), and potential confounders, such as tobacco use (e.g., cigarettes, nass and water-pipe), and dietary factors. Biological samples, including blood and saliva, were also collected.

RESULTS

The validation and pilot phases showed reasonably good validity, with sensitivities of 70% and 69% for the cases and controls, respectively, in reporting opium use. The results also showed excellent reliability, with intra-class correlation coefficients of 0.96 for ever opium use and 0.88 (95% CI: 0.80, 0.92) for regular opium use. In the main phase, we recruited 3299 cancer cases (99% response rate) and 3477 hospital visitor controls (89% response rate). The proportion of ever-use of opium was 40% among cases and 18% among controls.

CONCLUSION

The IROPICAN study will serve as a major resource in studies addressing the effect of opium on risk of cancers of the head and neck, bladder, lung, and colon and rectum.

Opium-associated QT Interval Prolongation: A Cross-sectional Comparative Study

Background

Toxicity and side effects of long-term use of opioids are well studied, but little information exists regarding electrophysiological disturbances of opium consumption. While natural opium has been regarded safe to a great extent among traditional communities, concerns are emerging owing to the available evidence of QT prolongation that have been exposed during recent outcome surveillance of patients under opioid use. Potential QT prolonging interactions would raise a higher level of such concern in opium users during COVID pandemic and warrant attention.

Materials and methods

This study was designed to detect the prevalence of QTc prolongation among opium users and nonusers. Two groups were compared with regard to gender, age, and median QTc interval. Normal and prolonged QTc intervals of user group were compared with respect to age, sex, dose of opium consumption, and duration of opium consumption.

Results

123 opium users and 39 controls were investigated. Median QTc interval in opium user and non-user group was 460 vs 386 milliseconds, respectively (p value < 0.001). In all, 59.3%, (95% CI: 50.51–67.62%) of cases and none of non-user had prolonged QTc interval (p value < 0.001). There was no significance between normal and prolonged QTc intervals with respect to dose and duration of opium use.

Conclusion

This study indicated that opium consumption is associated with QTc prolongation. This prolongation does not relate to dose and duration of opium use. Further study is propounded to assess the clinical significance of these results and to determine risk rating of opium compared to other opioids in this regard.

How to cite this article

Javadi HR, Mirakbari SM, Allami A, Yazdi Z, Katebi K. Opium-associated QT Interval Prolongation: A Cross-sectional Comparative Study. Indian J Crit Care Med 2021;25(1):43–47.

Opium Addiction and Correlation with Early and Six-month Outcomes of Presenting with ST Elevation Myocardial Infarction Treated Initially with Thrombolytic Therapy

BACKGROUND

Myocardial infarction is one of the most important causes of mortality worldwide. The role of opium addiction in the outcome of myocardial infarction is not known with many unproven beliefs surrounding it. This study was designed to evaluate the effects of opium addiction on in-hospital and six-month outcomes of patients presenting with ST elevation myocardial infarction (STEMI).

METHODS

This study was performed on STEMI patients who were initially treated medically in two hospitals without any primary percutaneous coronary intervention (PCI) facility. A total 117 opium addicted patients and 217 non-opium-addicted controls were followed during hospitalization and six months thereafter. The primary endpoint of this study was the in-hospital composite of death, heart failure, recurrent chest pain, and recurrent STEMI.

RESULTS

The composite endpoint was not significantly different either in-hospital or after six-month follow up (RR=0.851, 95% CI: 0.578-1.253 and RR=0.899, 95% CI: 0.578-1.253 relatively). Multivariate analysis also confirmed that opium addiction was not a predictor of in-hospital or six-month adverse outcome.

CONCLUSION

The present study revealed that in-hospital and six-month adverse outcomes in opium addicted patients presenting with STEMI were not significantly different in comparison to patients without any opium addiction.

Tracing a path for opium gum from Mexico as a safe supply harm reduction measure for Canada

Historically, the poppy plant has had multiple uses including as a food product and with medical uses in pain relief; today it is most commonly known as the plant from which heroin is derived. The United Nations international drug control regime currently only allows legal poppy production for medical use in 19 countries. Although Mexico is the third largest illegal poppy producer in the world, no Latin American country is currently allowed to legally produce poppies. Meanwhile, the United States and Canada are experiencing an overdose crisis due in large part to the adulteration and substitution of heroin with fentanyl and its analogues, while the price of opium gum has dropped 80% in the last two years in poppy producing areas of Mexico. The prohibition of opium has wide ranging health and development impacts that bring up a moral imperative regarding the safe supply of diverse opium-based products -including opium gum and heroin- that urgently need to be explored and addressed. Opium gum can be used orally or smoked, reducing riskier modes of administration and possible fatal overdoses. This article discusses the political and legal possibilities of safely supplying opium gum and manually extracted heroin from Mexico to Canada as a public health, harm reduction and development policy.