Neurological Complications of Neurological Complications of HeroinHeroin

Department of Neurology

Alfred Hospital

26 April, 2000.

HEROINHEROIN

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”

EPIDEMIOLOGYEPIDEMIOLOGY

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 ANALYSISDIFFICULTIES OF ANALYSISIS IT TRULY A COMPLICATION OF HEROIN?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 INFORMATIONSOURCE OF INFORMATIONLANDMARK STUDYLANDMARK STUDY

In 1972, necropsy studies of 899 acute narcotic deaths541 narcotic related deaths - 327 homicide

48 infections         166 other causesDepartment of Forensic Medicine of New York University J. Pearson & R. Richter, 1975 in Medical Aspects of Drug

Abuse

NEUROLOGICAL COMPLICATIONS OF NEUROLOGICAL COMPLICATIONS OF ADDICTION TO HEROIN ADDICTION TO HEROIN

Part IPart IAddictionCerebral complications of narcotic overdose

Coma without complicationsComa with neurological sequelae

SeizuresIncreased intracranial pressureAcute deliriumDelayed postanoxic encephalopathyStrokeInvoluntary movement disorderDeaf ness

Toxic (quinine) amblyopiaTransverse myelitis

NEUROLOGICAL COMPLICATIONS OF NEUROLOGICAL COMPLICATIONS OF ADDICTION TO HEROIN ADDICTION TO HEROIN

Part IIPart IIPeripheral nerve lesions

Brachial & lumbosacral plexitisAtraumatic & traumatic mononeuropathyPolyneuropathy

Muscle disordersAcute rhabdomyolysisChronic myopathyCrush syndrome & other forms of localized muscle damage

Infectious & Postinfectious neurological ComplicationsCerebral complications of endocarditis & other septic statesLocal abscesses with muscle or nerve involvementCerebral complications of hepatitisTetanusHIV

HEROIN ADDICTION 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 CEREBRAL COMPLICATION OF HEROIN OVERDOSEOVERDOSE

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 CEREBRAL COMPLICATION OF HEROIN OVERDOSEOVERDOSE

COMA WITH NEUROLOGICAL SEQUELAE

NeuropathologicallyBrain 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 MYELITISTRANSVERSE MYELITISCASE ILLUSTRATIONCASE ILLUSTRATION

RareWithin 24 hours of intravenous usePathology: extensive necrosis of cervical & thoracic cord involving grey &

sparing white matter. Pathophysiology1. Watershed infarction2. Hypersensitivity reaction to heroin or its contaminants3. Direct toxic effect of heroin & its contaminants4. Hyperextension injury Differential Diagnosis:Embolism, demyelination, hyperextension injury, infection (HSV, Mycoplasma,

VZV)

PERIPHERAL NERVE LESIONSPERIPHERAL NERVE LESIONSTraumatic or pressure neuropathy: sciatic from lotus position

radial nerve palsiesother pressure palsiesaccidental 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 aboveLumbosacral plexitis are usually painful

MUSCLE DISORDERS MUSCLE DISORDERS

Acute rhabdomyolysis: Vigorous rhabdomyolysis with minimal trauma

Generalized muscle tendernessModerate 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 OFOTHER NEUROLOGIC COMPLICATIONS OFHEROIN ADDICTIONHEROIN ADDICTION

Heroin related spongiform encephalopathy from “chasing the dragon”

Toxic (quinine) amblyopia

Endocarditis

Epidural abscesses

HIV neurology

Etc

SUMMARYSUMMARY

•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.