Estimating the impact of drug addiction causes heart damage

To date, few studies have investigated the toxicological effects of the combined use of amphetamine and heroin in the heart. Hence, the aim of this study was to identify indicators for clinical evaluation and prevention of cardiac injury induced by the combined use of amphetamine and heroin. Four different groups were analyzed: (1) normal group (n＝25；average age＝35 ± 6.8); (2) heart disease group (n＝25；average age＝58 ± 17.2); (3) drug abusers (n = 27; average age = 37 ± 7.7); (4) drug abstainers (previous amphetamine-heroin users who had been drug-free for more than two weeks; n = 22; average age = 35 ± 5.6). The activity of MMPs, and levels of TNF-α, IL-6, GH, IGF-I, and several serum biomarkers were examined to evaluate the impact of drug abuse on the heart. The selected plasma biomarkers and classic cardiac biomarkers were significantly increased compared to the normal group. The zymography data showed the changes in cardiac-remodeling enzymes MMP-9 and MMP-2 among combined users of amphetamine and heroin. The levels of TNF-α and IL-6 only increased in the heart disease group. Growth hormone was increased; however, IGF-I level decreased with drug abuse and the level was not restored by abstinence. We speculated that the amphetamine-heroin users might pose risk to initiate heart disease even though the users abstained for more than two weeks. The activity change of MMP-9 and MMP-2 can be a direct reason affecting heart function. The indirect reason may be related to liver damage by drug abuse reduce IGF-1 production to protect heart function.

Prevalence of ADHD in a Sample of Heroin Addicts Receiving Agonist Treatment-Study Conducted in a Public Addiction Service

Attention-deficit/hyperactivity disorder (ADHD) is a childhood neurodevelopmental disorder that can persist into adulthood. The co-occurrence of ADHD and substance use disorders is very frequent and has received considerable attention in recent clinical/scientific investigations. However, few studies have investigated the prevalence of ADHD in heroin addicts. This study aimed to investigate the prevalence of attention-deficit/hyperactivity disorder (ADHD) in a sample of heroin addicts treated with opioid agonists and to report this clinical experience in a public service for addiction. Outpatients over 18 years old and being treated with opioid agonists for heroin addiction were enrolled. Each patient took part in a psychiatric examination and completed an ASRS (Adult ADHD Self-Report Scale) self-assessment. Subjects with positive results were called in for another psychiatric visit, and the Brown ADD scale was used as a second-level test for ADHD; furthermore, the Mini International Neuropsychiatric Interview (MINI) and Hypomania/Mania Checklist (HCL-32) were used for differential diagnoses and to assess comorbidities. In total, 111 patients were enrolled. All were followed up by the psychiatrist, who is also the author of this report and the person who formulated the diagnoses. The prevalence of ADHD in this sample was 18%. Among the 20 patients diagnosed with ADHD, 5 (25%) were female and 15 (75%) were male. The most frequent psychiatric comorbidity was major depression, found in 11 patients (55%), of which 4 presented with hypomania (bipolar disorder). In this sample, making diagnoses was very difficult. Frequently, multiple comorbidities further complicated these cases. In conclusion, the results of this study are consistent with the literature: There seems to be a significant prevalence of ADHD even among heroin addicts, and often, the diagnosis is difficult to make. We also do not know the exact effect of opioid agonist therapy on ADHD symptoms. Hypotheses have been put forward, but studies are needed.

Coinfection dynamics of heroin transmission and HIV infection in a single population

We propose a model of a joint spread of heroin use and HIV infection. The unique disease-free equilibrium always exists and it is stable if the basic reproduction numbers of heroin use and HIV infection are both less than 1. The semi-trivial equilibrium of HIV infection (heroin use) exists if the basic reproduction number of HIV infection (heroin use) is larger than 1 and it is locally stable if and only if the invasion number of heroin use (HIV infection) is less than 1. When both semi-trivial equilibria lose their stability, a coexistence equilibrium occurs, which may not be unique. We compare the model to US data on heroin use and HIV transmission. We conclude that the two diseases in the US are in a coexistence regime. Elasticities of the invasion numbers suggest two foci for control measures: targeting the drug abuse epidemic and reducing HIV risk in drug-users.

[Asthma and cannabis, cocaine or heroin use]

INTRODUCTION

The use of cannabis, cocaine or heroin can be responsible for many respiratory complications including asthma.

OBJECTIVES

The aim of this systematic literature review of data was to expose the relations between cannabis, cocaine or heroin use and asthma.

RESULTS

Cannabis, cocaine or heroin use by inhalation may be responsible for respiratory symptoms (cough, wheezing), asthma onset, acute asthma exacerbations (which may require intubation and invasive ventilation) or deaths related to asthma. Lower adherence to asthma treatment is also observed. Cannabis induces a rapid bronchodilator effect. In contrast, its chronic use may induce a decrease in specific airway conductance. Studies on forced expiratory volume in one second (FEV1) reduction or decline are discordant.

CONCLUSION

Cannabis, cocaine or heroin use must be considered in cases of acute respiratory symptoms or asthma exacerbation in young persons and practitioners must help illicit substance users to stop their consumption.

Vascular Injuries in Intravenous Drug Addicts-A Single-Center Experience

BACKGROUND

Infected false aneurysms (IFA) caused by intravenous drug abuse are uncommon but challenging lesions. The best approach for the surgical management of this condition is still unknown. The aim is to present a single-center 14-year experience in the IFA treatment in intravenous drug abusers, thus providing additional data regarding the treatment options and outcome in these patients.

METHODS

A retrospective analysis of 32 consecutive patients with vascular injuries secondary to intravenous drug abuse, during the period from January 2004 to April 2018, was performed. Data of interest were extracted from patients' medical history records, anesthesia charts, and database implemented in daily practice, or were obtained by personal contact. The diagnosis was set based on history, physical examination and/or color Doppler sonography, multidetector computed tomographic angiography, and digital subtraction angiography. The outcome included graft patency, limb amputation, and mortality.

RESULTS

During study period, 32 heroin abusers, predominantly males (81%), were surgically treated due to vascular injuries, with mean age of 35.2 years. The vast majority of patients have had an injury of the lower extremity blood vessels (84.3%) and the common femoral artery was the most common site of injury (59.4%). Three-quarters of patients underwent resection of the false aneurysm and ligation of the artery without reconstruction of the blood vessel. In 7 cases (21.9%), arterial reconstruction was performed with overall failure rate of 42.86%. The overall mortality rate was 6.25% and the rate of extremity salvage was 96.7%.

CONCLUSIONS

The best treatment option is yet to be found, but based on the results of the present study, ligation of affected artery without revascularization seems to be an efficient, safe, and optimal treatment method, with minor risk of the extremity loss.

Self-care habits among people who inject drugs with skin and soft tissue infections: a qualitative analysis

BACKGROUND

Injection drug use is on the rise in the USA, and skin and soft tissue infections (SSTI) are a common complication, resulting in significant morbidity and mortality. Due to structural barriers to care-seeking, many people who inject drugs avoid formal care and resort to self-care techniques, but little is known about the nature of these techniques, or more generally about the accuracy or breadth of this population's knowledge of SSTIs.

METHODS

Semi-structured qualitative interviews were conducted with 12 people who inject heroin in two metropolitan areas: Sacramento and Boston, USA.

RESULTS

These interviews reveal a robust and accurate knowledge base regarding skin infections, including the progression from simple cellulitis to an abscess, and acknowledgment of the possibility of serious infections. Nonetheless, there remains a reticence to seek care secondary to past traumatic experiences. A step-wise approach to self-care of SSTI infections was identified, which included themes of whole-body health, topical applications, use of non-prescribed antibiotics, and incision and drainage by non-medical providers.

CONCLUSIONS

The reported SSTI self-care strategies demonstrate resilience and ingenuity, but also raise serious concerns about inappropriate antibiotic consumption and complications of invasive surgical procedures performed without proper training, technique, or materials. Harm reduction agencies and health care providers should work to obviate the need for these potentially dangerous practices by improving healthcare access for this population. In the absence of robust solutions to meet the needs of this population, education materials should be developed to optimize the efficacy and minimize the harms of these practices, while empowering and supporting the autonomy of people who use drugs and providing clear guidance on when self-care should be abandoned in favor of formal medical care.

Prescription drug monitoring programs operational characteristics and fatal heroin poisoning

BACKGROUND

Prescription drug monitoring programs (PDMP), by reducing access to prescribed opioids (POs), may contribute to a policy environment in which some people with opioid dependence are at increased risk for transitioning from POs to heroin/other illegal opioids. This study examines how PDMP adoption and changes in the characteristics of PDMPs over time contribute to changes in fatal heroin poisoning in counties within states from 2002 to 2016.

METHODS

Latent transition analysis to classify PDMPs into latent classes (Cooperative, Proactive, and Weak) for each state and year, across three intervals (1999-2004, 2005-2009, 2010-2016). We examined the association between probability of PDMP latent class membership and the rate of county-level heroin poisoning death.

RESULTS

After adjustment for potential county-level confounders and co-occurring policy changes, adoption of a PDMP was significantly associated with increased heroin poisoning rates (22% increase by third year post-adoption). Findings varied by PDMP type. From 2010-2016, states with Cooperative PDMPs (those more likely to share data with other states, to require more frequent reporting, and include more drug schedules) had 19% higher heroin poisoning rates than states with Weak PDMPs (adjusted rate ratio [ARR] = 1.19; 95% CI = 1.14, 1.25). States with Proactive PDMPs (those more likely to report outlying prescribing and dispensing and provide broader access to law enforcement) had 6% lower heroin poisoning rates than states with No/Weak PDMPs (ARR = 0.94; 95% CI = 0.90, 0.98).

CONCLUSION

There is a consistent, positive association between state PDMP adoption and heroin poisoning mortality. However, this varies by PDMP type, with Proactive PDMPs associated with a small reduction in heroin poisoning deaths. This raises questions about the potential for PDMPs to support efforts to decrease heroin overdose risk, particularly by using proactive alerts to identify patients in need of treatment for opioid use disorder. Future research on mechanisms explaining the reduction in heroin poisonings after enactment of Proactive PDMPs is merited.

Infective Endocarditis of a Left Ventricular Myxoma in a Heroin User

Infected cardiac myxomas are rare and can have disastrous sequelae; urgent surgical resection is typically indicated. We report the case of a 43-year-old user of intravenous heroin who presented with weakness and dyspnea. He was diagnosed with infective endocarditis of a myxoma attached to the left ventricular lateral wall. The patient underwent successful surgical resection of the myxoma and then completed 4 weeks of antibiotic therapy. In addition to discussing this patient's case, we briefly review the relevant medical literature, in which we found only 4 previous reports of left ventricular myxoma associated with infective endocarditis.

Pneumatosis intestinalis and pneumoretroperitoneum post steroid use in a patient with superior mesenteric artery syndrome

Pneumatosis intestinalis (PI) refers to the presence of gas within the wall of the small or large intestine. PI can be both asymptomatic and life-threatening. The patient was a 50-year-old man with previous cervical spine abscess and osteomyelitis post debridement 4 years ago, with a heroin abuse history. He presented with abdominal distension ongoing for 4 days and vomiting for 3 times with fluid content. Abdominal computed tomography revealed pneumatosis with pneumoretroperitoneum. A surgeon was contacted and antibiotic treatment was started. The patient was kept on nothing per os and intravenous fluid supply. A drainage tube was inserted into retroperitoneum space on the same day. Tracing back his history, our patient was discharged from the hospital recently with a diagnosis of superior mesenteric artery dyndrome (SMAS), hypersensitivity pneumonitis, and asbestosis with soft tissue pleural plaques and calcified pleural plaques. During the hospitalization period, hydrocortisone dexamethasone and methylprednisolone were prescribed for hypersensitivity pneumonitis. Steroid use and SMAS maybe the cause of PI. Finally, he was discharged 5 days later with a nasojejunal and drainage tubes and was arranged for OPD follow-up. PI can be asymptomatic or life-threatening, and patient management varies based on the clinical condition. Although in this case PI was found in the emergency department, a patient's past history of underlying disease and medication should be reviewed to find the most possible etiology.

Profiles of visuospatial memory dysfunction in opioid-exposed and dependent populations

BACKGROUND

Chronic opioid exposure is common world-wide, but behavioural performance remains under-investigated. This study aimed to investigate visuospatial memory performance in opioid-exposed and dependent clinical populations and its associations with measures of intelligence and cognitive impulsivity.

METHODS

We recruited 109 participants: (i) patients with a history of opioid dependence due to chronic heroin use (n = 24), (ii) heroin users stabilised on methadone maintenance treatment (n = 29), (iii) participants with a history of chronic pain and prescribed tramadol and codeine (n = 28) and (iv) healthy controls (n = 28). The neuropsychological tasks from the Cambridge Neuropsychological Test Automated Battery included the Delayed Matching to Sample (DMS), Pattern Recognition Memory, Spatial Recognition Memory, Paired Associate Learning, Spatial Span Task, Spatial Working Memory and Cambridge Gambling Task. Pre-morbid general intelligence was assessed using the National Adult Reading Test.

RESULTS

As hypothesised, this study identified the differential effects of chronic heroin and methadone exposures on neuropsychological measures of visuospatial memory (p < 0.01) that were independent of injecting behaviour and dependence status. The study also identified an improvement in DMS performance (specifically at longer delays) when the methadone group was compared with the heroin group and also when the heroin group was stabilised onto methadone. Results identified differential effects of chronic heroin and methadone exposures on various neuropsychological measures of visuospatial memory independently from addiction severity measures, such as injecting behaviour and dependence status.

The mediating and moderating effects of resilience on the relationship between perceived stress and depression in heroin addicts

The purpose of this study was to examine the mediating and moderating roles of resilience on the relationship between perceived stress and depression among heroin addicts. A total of 138 heroin addicts completed the measures of perceived stress, resilience, and depression. Correlation analysis indicated that perceived stress was positively associated with depression. Resilience was negatively correlated with perceived stress and depression. Mediation analysis revealed that resilience partially mediated the relationship between perceived stress and depression. However, resilience did not moderate the influence of perceived stress on depression. These findings might provide a better understanding of the mental health among heroin addicts.

OPRD1 gene affects disease vulnerability and environmental stress in patients with heroin dependence in Han Chinese

Exposure to stress not only increases the vulnerability to heroin dependence (HD) but also provokes relapse. The etiology of HD and the role of life stress remain unclear, but prior studies suggested that both genetic and environmental factors are important. Opioid related genes, including OPRM1, OPRD1, OPRK1, and POMC, are obvious candidates for HD. Therefore, this study was conducted to explore whether the genetic polymorphisms of the candidates could affect vulnerability to HD and response to life stress in patients with HD. Ten polymorphisms of the opioid related genes were analyzed in 801 patients and 530 controls. The Life Event Questionnaire was used to assess the perspective and response to life stress in the past year. The genotype distribution and allelic frequency analyses showed that the minor C allele of rs2234918 in OPRD1 is over-represented in the HD group (P = .006 and P = .002, respectively). This finding was further confirmed by logistic regression analysis, showing that C allele carriers have a 1.42 times greater risk for HD compared to T/T homozygotes. A subgroup of 421 patients and 135 controls were eligible for life stress assessment. Patients with HD have a higher occurrence of negative events (No), negative events score (Ns), and average negative event score (Na) than those of controls (all P < .001), but there was no difference regarding positive recent events between the two groups. Gene-stress assessment in the HD group showed that T/T homozygotes of OPRD1 rs2236857 have more severe stress than C allele carriers (Ns, P = .004 and Na, P = .047). Our results indicate that the OPRD1 gene may not only play a role in the pathogenesis of HD but also affect the response to life stress among patients with HD in our Han Chinese population. Patients with the risk genotype may need additional psychosocial intervention for relapse prevention.

Wound Botulism Outbreak Among Persons Who Use Black Tar Heroin - San Diego County, California, 2017-2018

During September 29-October 6, 2017, the County of San Diego Public Health Services (COSD) was notified of two patients with suspected wound botulism and a history of using black tar heroin. On October 9, COSD, which had reported an average of one wound botulism case per year during 2001-2016, sent a health alert through the California Health Alert Network, notifying Southern California providers of these two patients, including their signs and symptoms and black tar heroin exposure. In collaboration with the California Department of Public Health, COSD conducted an investigation to identify additional cases, determine risk factors for illness, estimate cost of medical care, and develop recommendations to prevent further illness. By April 18, 2018, nine (eight confirmed and one probable) patients with wound botulism were identified, all of whom were hospitalized; one of the nine died. All nine were persons who inject drugs; seven specifically reported using black tar heroin and six practiced subcutaneous injection known as skin popping. Clinically compatible signs and symptoms included muscle weakness, difficulty swallowing, blurred vision, drooping eyelids, slurred speech, difficulty breathing, loss of facial expression, or descending paralysis. All patients were treated with heptavalent botulism antitoxin (BAT). Wound botulism is likely underrecognized because of its rarity and the overlapping signs and symptoms with opioid intoxication, overdose, and other neurologic syndromes including Guillain-Barré syndrome, the Miller Fisher variant of Guillain-Barré syndrome, and myasthenia gravis. Prompt diagnosis, administration of BAT, and provision of supportive care can help stop the progression of paralysis and be lifesaving.

Screening Heroin Smokers Attending Community Drug Services for COPD

BACKGROUND

Heroin smoking is associated with deprivation, early onset severe emphysema, premature morbidity and mortality, and high use of health care, but individuals engage poorly with traditional health services.

METHODS

In this cross-sectional study, we screened a population of heroin smokers, prescribed opiate substitution therapy by community drug services, for airway disease. We assessed drug exposure, respiratory symptoms, health status, and COPD prevalence. Subjects completed spirometry, completed Medical Research Council (MRC) Dyspnea Scale, COPD Assessment Tool (CAT) questionnaire, recorded drug exposure, and provided feedback.

RESULTS

A total of 753 people (73% of those approached) completed screening, with 260 participants (35%) having COPD using FEV₁/FVC < 0.7 and 293 (39%) participants having COPD using the lower limit of normal. A further 112 participants (15%) had asthma-COPD overlap (ACO) with features of COPD and asthma. Compared with those with normal spirometry, participants with COPD were more breathless (MRC score 3.1 vs 1.9; P < .001) and had worse health status (CAT score 22.9 vs 13.4; P < .001), respectively. Individuals with COPD had smoked cigarettes (P < .001), heroin (P < .001), and crack (P = .03) for longer and were more likely to still be smoking heroin (P < .01). Feedback was strongly positive, with 92% of respondents happy for other health-care appointments to be colocated with drug key worker appointments.

CONCLUSIONS

Most heroin smokers had COPD or ACO, most commonly mild to moderate disease. In high-risk areas, screening this population provides an opportunity to reduce symptoms and risk. Anchoring respiratory health screening to drug center appointments delivers high completion and satisfaction and is an appropriate model for screening other hard-to-reach populations.

Heroin Use Is Associated with AA-Type Kidney Amyloidosis in the Pacific Northwest

BACKGROUND AND OBJECTIVES

AA-type kidney amyloidosis is classically associated with chronic autoimmune or inflammatory disorders. However, some urban centers have reported a high prevalence of injection drug use among patients with kidney AA amyloidosis. Previous reports lack control groups to quantify associations and most predate the opioid epidemic in the United States.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a case-control study of 38 patients with biopsy-confirmed kidney AA amyloidosis and 72 matched control individuals without this condition from two large hospital systems in Seattle, Washington. We ascertained the pattern and duration of heroin use by medical chart review and determined associations using logistic regression.

RESULTS

Among case patients, 95% had a prior history of heroin use, 87% had skin abscesses, and 76% and 27% had evidence of muscling and skin popping, respectively. After adjustment for age, race, sex, site, and year of biopsy, any heroin use (past or current) was associated with an estimated 170-times higher risk of kidney AA amyloidosis compared with no heroin use (95% confidence interval, 28 to 1018 times higher; P<0.001). Chronic autoimmune disorders were uncommon among case patients in this study. The median time to ESKD among patients with AA amyloidosis was 2.4 years (interquartile range, 0.5-7.5 years).

CONCLUSIONS

Injection heroin use is strongly associated with kidney AA amyloidosis in the Pacific Northwest. Unique aspects of heroin use, in particular geographic regions or frequent associated soft-tissue infections, may be an important cause of this progressive kidney disease.

A survival case of intravenous paraquat intoxication: A case report

RATIONALE

Paraquat, an agent highly toxic to humans and animals, is a widely used herbicide and also commonly used for suicide attempts in Taiwan. The most common route of intoxication is oral ingestion, and parenteral poisoning is respectively rare.

PATIENT CONCERNS

A 39-year-old illicit abuser of heroin and amphetamine injected 0.5 mL of 24% paraquat directly into his right cephalic vein due to hallucination. The patient was brought to our emergency department for management 4 hours after injection. He was fully conscious and had normal vital signs. Systemic review showed mild dyspnea, abdominal pain and right wrist pain over the injection site. The only abnormal physical finding was erythema over the injection site and epigastric tenderness.

DIAGNOSIS

Laboratory investigations, including complete blood count, liver and renal function, and electrolytes initially yielded normal results. Urinalysis showed normal findings except a positive urine paraquat test (4+). The initial plasma paraquat concentration was 0.51 μg/mL.

INTERVENTIONS

He was admitted to the intensive care unit and underwent one session of charcoal hemoperfusion therapy. Acute kidney injury developed on the fourth day after intoxication, with the level of serum creatinine rising rapidly from 0.96 to 4.57 mg/dL and the daily urine output decreased noticeably from > 2000 to 900 mL. The serum creatinine level improved gradually with adequate fluid supplementation.

OUTCOMES

The patient was discharged 13 days later in a stable condition.

LESSONS

Intravenous paraquat intoxication is rare. Patients who suffer from intravenous intoxication may not directly suffer from mucosal irritation, but the clinical onset of systemic effects is more immediate and lethal. The prognosis of paraquat poisoning is determined by the time of poisoning and the plasma paraquat concentration before treatment. Proudfoot's curve provides a simple method of predicting the survival rate. The most effective mode of management is extracorporeal therapy, and immunosuppressive or antioxidant therapies have shown insufficient evidence of benefit.

Opioid substitution treatment and heroin dependent adolescents: reductions in heroin use and treatment retention over twelve months

BACKGROUND

Opioid dependence is a major health concern across the world and does also occur in adolescents. While opioid substitution treatment (OST) has been thoroughly evaluated in adult populations, very few studies have examined its use in adolescents. There are concerns that OST is underutilised in adolescents with heroin dependence. We sought to measure changes in drug use among adolescents receiving OST and also to examine treatment attrition during the first 12 months of this treatment.

METHODS

We included all heroin dependent patients aged under 18.5 years commencing OST at one outpatient multidisciplinary adolescent addiction treatment service in Dublin, Ireland. Psycho-social needs were also addressed during treatment. Drug use was monitored by twice weekly urine drugs screens (UDS). Change in the proportion of UDS negative for heroin was examined using the Wilcoxon signed rank test. Attrition was explored via a Cox Regression multivariate analysis.

RESULTS

OST was commenced by 120 patients (51% female and mean age 17.3 years). Among the 39 patients who persisted with OST until month 12, heroin abstinence was 21% (95% confidence interval [CI] = 9-36%) at month three and it was 46% (95% CI = 30-63%) at month 12. Heroin use declined significantly from baseline to month three (p < 0.001) and from month three to month 12 (p = 0.01). Use of other drugs did not change significantly. People using cocaine during month 12 were more likely to be also using heroin (p = 0.02). Unplanned exit occurred in 25% patients by 120 days. The independent predictors of attrition were having children, single parent family of origin, not being in an intimate relationship with another heroin user and evidence of cocaine use just before treatment entry.

CONCLUSIONS

We found that heroin dependent adolescent patients achieved significant reductions in heroin use within three months of starting OST and this improved further after a year of treatment, about half being heroin abstinent at that stage. Patient drop out from treatment remains a challenge, as it is in adults. Cocaine use before and during treatment may be a negative prognostic factor.

Polydrug use and its association with drug treatment outcomes among primary heroin, methamphetamine, and cocaine users

BACKGROUND

Polydrug use may challenge effective treatment for substance use disorders. We evaluate whether secondary substance use modifies the association between treatment and primary drug use among primary heroin, cocaine and methamphetamine (MA) users.

METHODS

Data were obtained from prospective cohort studies on people who use illicit drugs (PWUD) in California, USA. Using repeated monthly data on self-reported secondary substance use (heroin, cocaine, MA, alcohol or marijuana; ≥1day in a month), primary drug use (≥1day in a month), and treatment participation, collected via timeline follow-back, we fitted generalized linear mixed multiple regression models controlling for potential confounders to examine the interactions between treatment and secondary substance use on the odds of primary heroin, cocaine and MA use, respectively.

RESULTS

Included in our study were 587 primary heroin, 444 primary MA, and 501 primary cocaine users, with a median of 32.4, 13.3 and 18.9 years of follow-up, respectively. In the absence of secondary substance use, treatment was strongly associated with decreased odds of primary drug use (adjusted odds ratios (aORs): 0.25, 95% CI: 0.24, 0.27, 0.07 (0.06, 0.08), and 0.07 (0.07, 0.09)) for primary heroin, MA, and cocaine users, respectively. Secondary substance use of any kind moderated these associations (0.82 (0.78, 0.87), 0.25 (0.21, 0.30) and 0.53 (0.45, 0.61), respectively), and these findings were consistent for each type of secondary substance considered. Moreover, we observed different associations in terms of direction and magnitude between secondary substance use and primary drug use during off-treatment periods across substance types.

CONCLUSION

This study demonstrates secondary substance use moderates the temporal associations between treatment and primary drug use among primary heroin, MA and cocaine users. Disparate patterns of polydrug use require careful measurement and analysis to inform targeted treatment for polydrug users.

What is the connection between serum phosphorus, cancer and heroin? A medical hypothesis based on observational studies

Considering the results of a previous study in which 2321 regular heroin addicts who died without having stopped taking the drug since they had started - from various causes but none from cancer, may mean something. Our first thought was: Can't we hypothesize, reinforcing our previous view that heroin is a "barrier" against cancer and as the user gets in the methadone program he/she lacks the "barrier" and therefore is liable to develop cancer? We have already reported that the amount of blood phosphorus in heroin addicted is significantly lower than in healthy ones. Additionally we have introduced the potential clinical impact of serum phosphorus as a screening test for cancer. Phosphorus regulated by heroin might be the key for preventing the development of cancer in human organism, in terms of keeping the phosphorus in normal levels in the blood. Cases of cancer patients after methadone detox treatment are reported. In the present study, in 200 cancer patients who underwent radical radiotherapy (RT), the phosphorus level is generally returning to normal levels three months postirradiation. Phosphorus and cancer seem to be significantly associated, with heroin adapting phosphorus in normal values. The pharmaceutical companies should look deep inside the molecule of heroin, by means of an analogue with the potential impact against cancer but without the addictive effect to humans. It's obvious that further research is needed to obtain reliable statistical data.

Heroin-Related Compartment Syndrome: An Increasing Problem for Acute Care Surgeons

Heroin use has been increasing in the United States with the rate of heroin overdose nearly quadrupling in the last 10 years. Heroin overdose can occasionally lead to compartment syndrome (CS) because of extended periods of immobility and pressure tissue injury. Heroin-related compartment syndrome (HRCS) has previously been described, but has been limited to isolated case reports. We sought to examine our experience with HRCS in the climate of rising rates of heroin use among the general population. Medical records of all patients undergoing operative decompression for a CS at our academic medical center over a six-year period (2010-2015) were examined. Patient demographics, operation performed, and etiology were recorded. Cases of HRCS were identified, and clinical outcomes examined. A total of 213 patients undergoing fasciotomy were identified. Twenty-two of these patients had HRCS. Heroin was the second most common etiology of CS after trauma. Only one case of HRCS presented during the first three years of the study period, with the remaining 95 per cent of cases occurring within the last three years. The most common single location for HRCSs was gluteal (31.8%); 36 per cent of HRCS patients needed dialysis and 27 per cent suffered complications such as tissue loss. The incidence of HRCS has increased dramatically over the past several years and is now the second most common etiology for CS in our patient population. Patients with HRCS may present with severe manifestations of CS and different body areas affected.

Naloxone for heroin, prescription opioid, and illicitly made fentanyl overdoses: Challenges and innovations responding to a dynamic epidemic

Community-based overdose prevention programs first emerged in the 1990's and are now the leading public health intervention for overdose. Key elements of these programs are overdose education and naloxone distribution to people who use opioids and their social networks. We review the evolution of naloxone programming through the heroin overdose era of the 1990's, the prescription opioid era of the 2000's, and the current overdose crisis stemming from the synthetic opioid era of illicitly manufactured fentanyl and its analogues in the 2010's. We present current challenges arising in this new era of synthetic opioids, including variable potency of illicit drugs due to erratic adulteration of the drug supply with synthetic opioids, potentially changing efficacy of standard naloxone formulations for overdose rescue, potentially shorter overdose response time, and reports of fentanyl exposure among people who use drugs but are opioid naïve. Future directions for adapting naloxone programming to the dynamic opioid epidemic are proposed, including scale-up to new venues and social networks, new standards for post-overdose care, expansion of supervised drug consumption services, and integration of novel technologies to detect overdose and deliver naloxone.

Heroin uncertainties: Exploring users' perceptions of fentanyl-adulterated and -substituted 'heroin'

BACKGROUND

The US is experiencing an unprecedented opioid overdose epidemic fostered in recent years by regional contamination of the heroin supply with the fentanyl family of synthetic opioids. Since 2011 opioid-related overdose deaths in the East Coast state of Massachusetts have more than tripled, with 75% of the 1374 deaths with an available toxicology positive for fentanyl. Fentanyl is 30-50X more potent than heroin and its presence makes heroin use more unpredictable. A rapid ethnographic assessment was undertaken to understand the perceptions and experiences of people who inject drugs sold as 'heroin' and to observe the drugs and their use.

METHODS

A team of ethnographers conducted research in northeast Massachusetts and Nashua, New Hampshire in June 2016, performing (n=38) qualitative interviews with persons who use heroin.

RESULTS

(1) The composition and appearance of heroin changed in the last four years; (2) heroin is cheaper and more widely available than before; and (3) heroin 'types' have proliferated with several products being sold as 'heroin'. These consisted of two types of heroin (alone), fentanyl (alone), and heroin-fentanyl combinations. In the absence of available toxicological information on retail-level heroin, our research noted a hierarchy of fentanyl discernment methods, with embodied effects considered most reliable in determining fentanyl's presence, followed by taste, solution appearance and powder color. This paper presents a new 'heroin' typology based on users' reports.

CONCLUSION

Massachusetts' heroin has new appearances and is widely adulterated by fentanyl. Persons who use heroin are trying to discern the substances sold as heroin and their preferences for each form vary. The heroin typology presented is inexact but can be validated by correlating users' discernment with drug toxicological testing. If validated, this typology would be a valuable harm reduction tool. Further research on adaptations to heroin adulteration could reduce risks of using heroin and synthetic opioid combinations.

[Asthma and heroin use]

INTRODUCTION

Heroin use can be responsible for many respiratory complications including asthma.

OBJECTIVES

Systematic literature review of data on asthma in heroin users.

DOCUMENTARY SOURCES

Medline®, on the period 1980-2017 with the following keywords: keywords: "asthma" or "bronchospasm" and "heroin" or "opiate" or "opiates", limits "title/abstract"; the selected languages were English or French. Among 97 articles, 67 abstracts have given use to a dual reading to select 23 studies.

RESULTS

The seven case reports included 21 patients (mean age: 28 years [19-46 years]; sex-ratio: 2.5 [males: 71.5%]). Heroin was inhaled (71.4%), sniffed (19%) or injected by intravenous route (9.5%). Associated addictive substances were tobacco (81%), cannabis (38%), alcohol (4.7%) and cocaine (4.7%). Outcome was fatal in 3 subjects (14.3%). Other studies included one cross-sectional study, 3 case-control studies and 12 longitudinal studies (11 retrospective studies and one prospective study). The proportion of heroin users was higher in asthmatic subjects and the prevalence of asthma and bronchial hyperreactivity was higher in heroin users. Heroin use can be responsible for asthma onset, with a temporal relationship between the onset of heroin use and asthma onset in 28 to 31% of subjects. A positive association between inhaled heroin use and acute asthma exacerbation was observed. Asthma treatment observance was lower in heroin users. In case of asthma exacerbation, heroin users were more likely to seek care in the emergency department, to be admitted in intensive care units and to require intubation and invasive ventilation. Asthma deaths related to heroin use mainly occurred following an intravenous injection (especially in the case of overdose), but also following heroin use by nasal (sniff) or pulmonary route.

CONCLUSION

Heroin use may be responsible for asthma onset, acute asthma exacerbations (which may require intubation and invasive ventilation) or deaths related to asthma. Heroin use must be sought in case of asthma exacerbation in young persons and practitioners must help heroin users to stop their consumption.

Pharmacogenomics study on cadherin 2 network with regard to HIV infection and methadone treatment outcome

Heroin dependent patients have a high incidence of HIV infection. In contrast to the gene expression method, we developed a systemic correlation analysis method built upon the results of pharmacogenomics study in a methadone maintenance treatment (MMT) cohort consisting of 344 Taiwanese heroin dependent patients. We identified genetic variants and their encoding proteins that may be involved with HIV infection and MMT treatment outcome. Cadherin 2 (CDH2) genetic determinants were identified through the genome-wide pharmacogenomic study. We found significant correlations among HIV infection status, plasma levels of CDH2, cytokine IL-7, ADAM10, and the treatment responses to methadone. Two single nucleotide polymorphisms located within CDH2 gene showed associations with blood pressure and plasma CDH2 concentration. Plasma concentration of CDH2 showed correlations with the level of cytokine IL-7, status of HIV infection, and urine morphine test result. Plasma level of IL-7 was correlated with corrected QT interval (QTc) and gooseflesh skin withdrawal symptom score, while level of ADAM10 was correlated with plasma concentrations of vitamin D metabolite, nicotine metabolite, and R-methadone. The results suggest a novel network involving HIV infection and methadone treatment outcome.

Identifying possible reasons why female street sex workers have poor drug treatment outcomes: a qualitative study

AIMS

To explore street sex workers (SSWs) views and experiences of drug treatment, in order to understand why this population tend to experience poor drug treatment outcomes.

DESIGN

In-depth interviews.

SETTING

Bristol, UK.

PARTICIPANTS

24 current and exited SSWs with current or previous experience of problematic use of heroin and/or crack cocaine.

FINDINGS

Participants described how feeling unable to discuss their sex work in drug treatment groups undermined their engagement in the treatment process. They outlined how disclosure of sex work resulted in stigma from male and female service users as well as adverse interactions with male service users. Participants highlighted that non-disclosure meant they could not discuss unresolved trauma issues which were common and which emerged or increased when they reduced their drug use. As trauma experiences had usually involved men as perpetrators participants said it was not appropriate to discuss them in mixed treatment groups. SSWs in recovery described how persistent trauma-related symptoms still affected their lives many years after stopping sex work and drug use. Participants suggested SSW-only services and female staff as essential to effective care and highlighted that recent service changes were resulting in loss of trusted staff and SSW-only treatment services. This was reported to be reducing the likelihood of SSWs engaging in drug services, with the resultant loss of continuity of care and reduced time with staff acting as barriers to an effective therapeutic relationship.

CONCLUSIONS

SSWs face many barriers to effective drug treatment. SSW-only treatment groups, continuity of care with treatment staff and contact with female staff, particularly individuals who have had similar lived experience, could improve the extent to which SSWs engage and benefit from drug treatment services. Service engagement and outcomes may also be improved by drug services that include identification and treatment of trauma-related symptoms.

Tricuspid Valve Replacement in an HIV-Infected Patient with Severe Tricuspid Regurgitation Secondary to Remote Endocarditis

Surgical intervention for severe tricuspid regurgitation secondary to remote infective endocarditis has been infrequent, especially in patients also infected with the human immunodeficiency virus (HIV). We describe the case of a 62-year-old HIV-positive man, with a 24-year history of endocarditis caused by intravenous heroin use, who presented with severe tricuspid regurgitation. The patient was initially asymptomatic, was taking antiretroviral medications, and had a satisfactory CD4 count and an undetectable viral load, so we decided to manage the regurgitation conservatively. Two years later, he presented with biventricular heart failure and dyspnea. After surgical tricuspid valve replacement, his condition improved substantially. This case illustrates that HIV-infected patients with complex medical conditions can successfully undergo cardiac surgery.

Roles and Functions of Social Networks Among Men Who Use Drugs in ART Initiation in Vietnam

Support from social network members may help to facilitate access to HIV medical care, especially in low resourced communities. As part of a randomized clinical trial of a community-level stigma and risk reduction intervention in Thai Nguyen, Vietnam for people living with HIV who inject drugs (PWID), 341 participants were administered a baseline social network inventory. Network predictors of antiretroviral therapy (ART) initiation at the 6-month follow-up were assessed. The social networks of PWID were sparse. Few participants who reported injectors in their networks also reported family members, whereas those who did not have injectors were more likely to report family members and network members providing emotional support and medical advice. In multivariate models, having at least one network member who provided medical advice predicted ART initiation at 6 months (OR 2.74, CI 1.20-6.28). These results suggest the importance of functional social support and network support mobilization for ART initiation among PWID.

The Oral and Dental Significance of Heroin and its Resurgence in New York State

Heroin is a highly addictive, illegal drug, which is processed from the resin of poppy plants. It was first manufactured in 1898 as a treatment for tuberculosis and morphine addiction. Its use poses both direct and indirect consequences for oral health. An increased incidence of dental caries and periodontal disease is seen in heroin users. This is in addition to a number of systemic manifestations. Currently, New York State is experiencing an epidemic of fatal or near-fatal incidents involving heroin use. This is largely due to the convergence of two deadly influences: the transition by many abusers from prescription opioid pain relievers to heroin; and the lacing of heroin with fentanyl. It is imperative that dentists in this state be aware of this epidemic and the oral/dental significance of heroin use.

Development and Initial Examination of a Brief Intervention for Heightened Anxiety Sensitivity Among Heroin Users

Anxiety sensitivity (AS) recently has been identified as a potential cognitive vulnerability underlying substance use problems, with some evidence specifically indicating its relevance to heroin. Focusing on the potential utility of interventions centered on increasing willingness to have anxiety-related sensations reduce vulnerability for relapse following substance use treatment, the current article describes the development of a brief (6 session) behavioral treatment for heightened AS among heroin users. The treatment consists of the following components: (a) psychoeducation about anxiety; (b) interoceptive exposure exercises; and (c) skills-training focused on heightening emotional acceptance, tolerance, and nonevaluative awareness (to facilitate willingness). Preliminary data on this treatment are provided in the form of a case study with a 46-year-old African American man in an inner-city residential substance use treatment facility. Results indicate reductions in AS (especially physical concerns), as well as corresponding decreases in heroin cravings and improvements in emotion regulation.

Predictors of seeking emergency medical help during overdose events in a provincial naloxone distribution programme: a retrospective analysis

OBJECTIVES

This study sought to identify factors that may be associated with help-seeking by witnesses during overdoses where naloxone is administered.

SETTING

Overdose events occurred in and were reported from the five regional health authorities across British Columbia, Canada. Naloxone administration forms completed following overdose events were submitted to the British Columbia Take Home Naloxone programme.

PARTICIPANTS

All 182 reported naloxone administration events, reported by adult men and women and occurring between 31 August 2012 and 31 March 2015, were considered for inclusion in the analysis. Of these, 18 were excluded: 10 events which were reported by the person who overdosed, and 8 events for which completed forms did not indicate whether or not emergency medical help was sought.

PRIMARY AND SECONDARY OUTCOME MEASURES

Seeking emergency medical help (calling 911), as reported by participants, was the sole outcome measure of this analysis.

RESULTS

Medical help was sought (emergency services-911 called) in 89 (54.3%) of 164 overdoses where naloxone was administered. The majority of administration events occurred in private residences (50.6%) and on the street (23.4%), where reported rates of calling 911 were 27.5% and 81.1%, respectively. Overdoses occurring on the street (compared to private residence) were significantly associated with higher odds of calling 911 in multivariate analysis (OR=10.68; 95% CI 2.83 to 51.87; p<0.01), after adjusting for other variables.

CONCLUSIONS

Overdoses occurring on the street were associated with higher odds of seeking emergency medical help by responders. Further research is needed to determine if sex and stimulant use by the person who overdosed are associated with seeking emergency medical help. The results of this study will inform interventions within the British Columbia Take Home Naloxone programme and other jurisdictions to encourage seeking emergency medical help.

Case 17: intravenous drug user injection-site wound

This patient presented with a painful, malodorous, infected wound on his right leg, which was also his main heroin injection site. Following treatment with octenilin Wound Irrigation Solution and a superabsorbent dressing, within 3 weeks all of the symptoms of infection and non-healing had gone.

Characteristics of heroin-dependent patients seeking asthma care in the ED

BACKGROUND

Limited data suggest that heroin worsens asthma severity, but little is known about heroin-dependent patients who seek emergency department (ED) care for asthma.

OBJECTIVES

To describe what heroin-dependent patients know about their asthma and how they use health care resources.

METHODS

A prospective study of heroin-dependent patients seeking care for "asthma" at an urban ED with 130000 annual visits was conducted. Eligible subjects were English-speaking heroin-dependent adults seeking care for mild to moderate asthma symptoms. A closed-format survey instrument to assess opioid use, asthma knowledge, and health care use was developed by content experts, piloted for study performance, revised, and then administered to eligible patients prior to ED discharge. Descriptive analysis was done.

RESULTS

Thirty subjects participated. Mean age was 47.5 years; 21 (70%) were male. Most used heroin several times weekly. Intranasal was the most common route (93%). Almost half (47%) stated that their asthma was diagnosed in the ED, 13% by a primary care physician, 13% by a lung specialist, and 27% did not know how diagnosed. The ED was used as the primary source for asthma medications in 73% cases; 43% used the ED for breathing issues at least once per month. Most subjects (77%) felt that heroin worsened their asthma symptoms. Only 7 (23%) also abused prescription opioids, and only 7 (23%) knew about prescription naloxone.

CONCLUSION

Patients with heroin dependence frequently use the ED for their health care needs related to asthma. Most do not have other health care providers, most have limited health literacy, and all would benefit from referral to a primary care provider and substance abuse resources.

Saturday Night Retinopathy: Characterization of a Rare Ophthalmic Condition

A 48-year-old, black female with a history of heroin and daily alcohol abuse presented to the emergency room in a lethargic state with severe right eye pain and vision loss. She had been unconscious for 10 hours prior to presentation. On exam she was found to have no light perception vision, severe retinal edema, and complete ophthalmoplegia of the right eye. Imaging and clinical course confirmed the diagnosis of Saturday Night Retinopathy--only the second documented case to be published.

Multiple organ dysfunction syndrome, an unusual complication of heroin intoxication: a case report and review of literature

Multiple organ dysfunction syndrome (MODS) has rarely been described in patients with heroin intoxication. Here, we report a rare case of MODS involving six organs, due to heroin intoxication. The patient was a 32-year-old Chinese man with severe heroin intoxication complicated by acute pulmonary edema and respiratory insufficiency, shock, myocardial damage and cardiac insufficiency, rhabdomyolysis and acute renal insufficiency, acute liver injury and hepatic insufficiency, toxic leukoencephalopathy, and hypoglycemia. He managed to survive and was discharged after 10 weeks of intensive care. The possible pathogenesis and therapeutic measures of MODS induced by heroin intoxication and some suggestions for preventing and treating severe complications of heroin intoxication, based on clinical evidence and the pertinent literature, are discussed in this report.

Prevalence of human immunodeficiency virus, hepatitis C virus, and hepatitis B virus infection among heroin injectors in the central region of Saudi Arabia

OBJECTIVES

To calculate the prevalence of hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) infections among inpatient heroin users, and to study the relationships between these infections and patient demographics.

METHODS

In this retrospective study, heroin users' inpatient records from the Alamal Hospital, Riyadh, Saudi Arabia were reviewed for HIV, HBV, and HCV screening results, age, number of admissions, education, and marital and occupational status. The study took place between January 2006 and November 2012. The prevalences of HIV, HBV, and HCV and their associations to demographics were evaluated.

RESULTS

A sample of 357 inpatients Saudi male heroin users (all injectors) aged 40 (±8.6) years with lifetime admissions averaged 5.8 (±5) times were studied. Screening results revealed that 20.1% of subjects were infection-free, 56.6% had a single infection, 13.2% were infected by 2 viruses, and 1.1% were infected by 3 viruses. Prevalence of HBV surface antigen was 7.7%, antibodies for HCV 77.8%, and HIV 9.8%. A significant association was found between positive HCV and positive HIV tests. Furthermore, HCV was more common among patients aged 20-29 years, those who were unemployed, and who had primary, secondary, or postsecondary education. Finally, HBV was associated  in patients aged 30-39 years and those with secondary educations.

CONCLUSION

Contracting serious contagious viral infections is very common among Saudi heroin injectors at rates similar to those seen among injectors in Western countries. Infection control, education, and harm reduction programs are of paramount importance.

Heroin addiction and renal disease

In this paper, renal involvement secondary to other medical complications of heroin addiction is discussed. We review 12 published studies totalling 102 heroin addicts with renal disease. Of these, in only 40 patients could other discernible causes of renal disease be excluded. The existence of 40 reported cases of renal disease from a population of more than half a million is insufficient data upon which to postulate the existence of a type of renal disease unique to heroin addicts.

Factors associated with methadone treatment duration: a Cox regression analysis

This study examined retention rates and associated predictors of methadone maintenance treatment (MMT) duration among 128 newly admitted patients in Taiwan. A semi-structured questionnaire was used to obtain demographic and drug use history. Daily records of methadone taken and test results for HIV, HCV, and morphine toxicology were taken from a computerized medical registry. Cox regression analyses were performed to examine factors associated with MMT duration. MMT retention rates were 80.5%, 68.8%, 53.9%, and 41.4% for 3, 6, 12, and 18 months, respectively. Excluding 38 patients incarcerated during the study period, retention rates were 81.1%, 73.3%, 61.1%, and 48.9% for 3 months, 6 months, 12 months, and 18 months, respectively. No participant seroconverted to HIV and 1 died during the 18-months follow-up. Results showed that being female, imprisonment, a longer distance from house to clinic, having a lower methadone dose after 30 days, being HCV positive, and in the New Taipei city program predicted early patient dropout. The findings suggest favorable MMT outcomes of HIV seroincidence and mortality. Results indicate that the need to minimize travel distance and to provide programs that meet women’s requirements justify expansion of MMT clinics in Taiwan.

Acute Central Vision Loss in an IV Drug User

This report describes the case of a 21-year-old heroin user who presented with a 6-day history of decreased vision in her right eye, preceded by 1 week of headache and tender scalp nodules, neck stiffness, and photophobia. A broad infectious workup for acute vision loss was completed, and she was ultimately presumed to have acquired toxoplasmic chorioretinitis (ocular toxoplasmosis). We review the initial workup for chorioretinitis, and the epidemiology, diagnosis, and treatment of ocular toxoplasmosis. Intravenous drug users may be at increased risk of acquired ocular toxoplasmosis.

Heroin use promotes HCV infection and dysregulates HCV-related circulating microRNAs

Hepatitis C virus (HCV) infection is common among injection drug users (IDUs). There is accumulating evidence that circulating microRNAs (miRNAs) are associated with HCV infection and disease progression. The present study was undertaken to determine the in vivo impact of heroin use on HCV infection and HCV-related circulating miRNA expression. Using the blood specimens from four groups of the study subjects (HCV-infected individuals, heroin users with/without HCV infection, and healthy volunteers), we found that HCV-infected heroin users had significantly higher viral load than HCV-infected non-heroin users (p = 0.0004). Measurement of HCV-related circulating miRNAs in plasma showed that miRs-122, 141, 29a, 29b, and 29c were significantly increased in the heroin users with HCV infection, whereas miR-351, an HCV inhibitory miRNA, was significantly decreased in heroin users as compared to control subjects. Further investigation identified a negative correlation between the plasma levels of miR-29 family members and severity of HCV infection based on aspartate aminotransferase to platelet ratio index (APRI). In addition, heroin use and/or HCV infection also dysregulated a panel of plasma miRNAs. Taken together, these data for the first time revealed in vivo evidence that heroin use and/or HCV infection alter circulating miRNAs, which provides a novel mechanism for the impaired innate anti-HCV immunity among IDUs.

Case records of the Massachusetts General Hospital. Case 35-2014: a 31-year-old woman with fevers, chest pain, and a history of HCV infection and substance-use disorder

A 31-year-old woman with substance-use disorder was admitted to this hospital because of fevers and chest pain. CT of the chest revealed multiple thick-walled nodular opacities throughout both lungs. Diagnostic tests were performed, and management decisions were made.