Neurological%20Complications%20of%20Heroin

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Neurological Complications of Heroin

• Department of Neurology
• Alfred Hospital
• 26 April, 2000.

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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

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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

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DIFFICULTIES OF ANALYSISIS 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

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SOURCE OF INFORMATIONLANDMARK 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

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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

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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

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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.

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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

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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

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TRANSVERSE MYELITISCASE ILLUSTRATION

• Rare
• Within 24 hours of intravenous use
• Pathology extensive necrosis of cervical
  thoracic cord involving grey sparing white
  matter.
•  
• Pathophysiology
• Watershed infarction
• Hypersensitivity reaction to heroin or its
  contaminants
• Direct toxic effect of heroin its contaminants
• Hyperextension injury
•  
• Differential Diagnosis
• Embolism, demyelination, hyperextension injury,
  infection (HSV, Mycoplasma, VZV)

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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

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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

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OTHER NEUROLOGIC COMPLICATIONS OFHEROIN ADDICTION

• Heroin related spongiform encephalopathy from
  chasing the dragon
• Toxic (quinine) amblyopia
• Endocarditis
• Epidural abscesses
• HIV neurology
• Etc

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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.