Transcript Neurological Complications of Heroin

Neurological Complications of
Heroin
Department of Neurology
Alfred Hospital
26 April, 2000.
HEROIN
Diacetyl derivative of morphine
Usual route of administration is intravenous. Other routes
include intramuscular, subcutaneous, rectal & intranasal
After absorption, rapidly converted into morphine or
monoacetylmorphine which is highly lipid soluble
allowing good BBB penetration to cause morphine
euphoria or “high”
EPIDEMIOLOGY
Onset of use usually in late adolescence peaking at age 18-20
2/3 addicts start using the drug before 21 years of age
changing spectrum
route:
intranasal “chasing the dragon” becoming
more popular
contaminants:
increasing purity of supplies
safety profile:
clean needles
culture:
no longer confined to lower socioeconomic
classes
DIFFICULTIES OF ANALYSIS
IS IT TRULY A COMPLICATION OF HEROIN?
Contaminants: Chinese heroin has caffeine
Iran heroin has strychnine
Lactose, mannitol, quinine
Talcum powder, starch, Ajax, curry powder
Abuse of other drugs concomitantly
Pathophysiology as direct toxicity / drug induced vasculitis /
hypersensitivity
SOURCE OF INFORMATION
LANDMARK STUDY
In 1972, necropsy studies of
899 acute narcotic deaths
541 narcotic related deaths -
327 homicide
48 infections
166 other causes
Department of Forensic Medicine of New York University
J. Pearson & R. Richter, 1975 in Medical Aspects of Drug
Abuse
NEUROLOGICAL COMPLICATIONS OF
ADDICTION TO HEROIN
Part I
Addiction
Cerebral complications of narcotic overdose
Coma without complications
Coma with neurological sequelae
Seizures
Increased intracranial pressure
Acute delirium
Delayed postanoxic encephalopathy
Stroke
Involuntary movement disorder
Deaf ness
Toxic (quinine) amblyopia
Transverse myelitis
NEUROLOGICAL COMPLICATIONS OF
ADDICTION TO HEROIN
Part II
Peripheral nerve lesions
Brachial & lumbosacral plexitis
Atraumatic & traumatic mononeuropathy
Polyneuropathy
Muscle disorders
Acute rhabdomyolysis
Chronic myopathy
Crush syndrome & other forms of localized muscle damage
Infectious & Postinfectious neurological Complications
Cerebral complications of endocarditis & other septic states
Local abscesses with muscle or nerve involvement
Cerebral complications of hepatitis
Tetanus
HIV
HEROIN ADDICTION
Medical, social & psychiatric disease
Features:
Episodic intoxication or “euphoria”
Pharmacological dependence (tolerance, physical
dependence)
Drug seeking behavior
Propensity to relapse after abstinence
The most common neurological complication of heroin in the
community.
CEREBRAL COMPLICATION OF HEROIN
OVERDOSE
COMA WITHOUT COMPLICATIONS
Hypercapnia, hypoxia, cardiorespiratory arrest
5% have seizures which stop permanently at time of recovery
from overdose
Most recover & discharged
CEREBRAL COMPLICATION OF HEROIN
OVERDOSE
COMA WITH NEUROLOGICAL SEQUELAE
Neuropathologically
Brain edema, myelin damage, astrocytic
clasmatodendrosis, globus pallidus cysts & reduced
neuronal populations.
Watershed infarction
Delayed anoxic encephalopathy: residual weakness, cognitive
impairment, spasticity.
Movement disorders: Parkinsonism, dystonias
TRANSVERSE MYELITIS
CASE ILLUSTRATION
Rare
Within 24 hours of intravenous use
Pathology: extensive necrosis of cervical & thoracic cord
involving grey & sparing white matter.
Pathophysiology
1.
Watershed infarction
2.
Hypersensitivity reaction to heroin or its contaminants
3.
Direct toxic effect of heroin & its contaminants
4.
Hyperextension injury
Differential Diagnosis:
Embolism, demyelination, hyperextension injury, infection
(HSV, Mycoplasma, VZV)
PERIPHERAL NERVE LESIONS
Traumatic or pressure neuropathy: sciatic from lotus position
radial nerve palsies
other pressure palsies
accidental injection into a nerve
Atraumatic neuropathy:
painless weakness beginning 2-3 hrs
after iv injection usually remote from
the symptomatic extremity
EMG/NCS: general slowing rather than focal slowing
Plexitis:
similar to above
Lumbosacral plexitis are usually
painful
MUSCLE DISORDERS
Acute rhabdomyolysis:
Vigorous rhabdomyolysis with minimal trauma
Generalized muscle tenderness
Moderate to severe weakness
Chronic myopathy:
chemical toxic effect of direct intramuscular
injection & infection eg long term “skin
poppers”
Crush syndrome:
due to pressure or injection into enclosed
fascial compartment eg forearm
OTHER NEUROLOGIC COMPLICATIONS OF
HEROIN ADDICTION
Heroin related spongiform encephalopathy from “chasing the
dragon”
Toxic (quinine) amblyopia
Endocarditis
Epidural abscesses
HIV neurology
Etc
SUMMARY
•Commonest neurological complication in the community is addiction
• Commonest neurological complication in the hospital is coma due to
overdose
• An unusual neurological contribution should not be immediately
attributed to heroin.
• Diagnosis of heroin related neurological complication should bear in
mind temporal relationship to the use, other drugs or diseases that
could mimic the condition should be excluded.
• Spectrum of disease may change with the change in drug culture, routes
of administration & changing purity of the drug.
• Treating a patient with an interesting heroin related neurological
complication is insufficient unless social & rehabilitative as well as
medical issues are addressed with a view to returning the patient to a
more complete life.