Heroin inhalation complicated by refractory hydrocephalus: A novel presentation

Dastur, Cyrus K.; Ramos-Estébanez, Ciro; Chang, Gregory Youngnam; Pace, Jonathan; Gokhale, Sankalp; Miller, Benjamin R.; Manjila, Sunil

doi:10.1212/wnl.0000000000002207

Cited by 2 publications

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“…Third, German, British, and Dutch programs have provided inhaled heroin heated on aluminum foil for patients as a public health strategy designed to prevent intravenous use. Notably, no further epidemic outbreaks have been reported in these areas to date . Therefore we expect newer detection techniques will acquit aluminum as a putative associated factor (eTable 3 in the Supplement).…”

Section: Methodsmentioning

confidence: 99%

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The Emerging Role of Inhaled Heroin in the Opioid Epidemic

et al. 2018

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IMPORTANCE Opioid addiction affects approximately 2.4 million Americans. Nearly 1 million individuals, including a growing subset of 21 000 minors, abuse heroin. Its annual cost within the United States amounts to $51 billion. Inhaled heroin use represents a global phenomenon and is approaching epidemic levels east of the Mississippi River as well as among urban youth. Chasing the dragon (CTD) by heating heroin and inhaling its fumes is particularly concerning, because this method of heroin usage has greater availability, greater ease of administration, and impressive intensity of subjective experience (high) compared with sniffing or snorting, although it also has a safer infectious profile compared with heroin injection. This is relevant owing to peculiar and often catastrophic brain complications. Following the American Medical Association Opioid Task Force mandate, we contribute a description of the pharmacology, pathophysiology, clinical spectrum, neuroimaging, and neuropathology of CTD leukoencephalopathy, as distinct from other heroin abuse modalities.OBSERVATIONS The unique spectrum of CTD-associated health outcomes includes an aggressive toxic leukoencephalopathy with pathognomonic neuropathologic features, along with sporadic instances of movement disorders and hydrocephalus. Clinical CTD severity is predominantly moderate at admission, frequently unmodified at discharge, and largely improved in the long term. Mild cases survive with minor sequelae, while moderate to severe presentations might deteriorate and progress to death. Other methods of heroin use may complicate with stroke, seizure, obstructive hydrocephalus, and (uncharacteristically) leukoencephalopathy. CONCLUSIONS AND RELEVANCEThe distinct pharmacology of CTD correlates with its specific clinical and radiological features and prompts grave concern for potential morbidity and long-term disability costs. Proposed diagnostic criteria and standardized reporting would ameliorate the limitations of CTD literature and facilitate patient selection for a coenzyme Q10 therapeutic trial.

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Section: Methodsmentioning

confidence: 99%

“…The clinical manifestations of CTD have been so far limited to toxic leukoencephalopathy (eTable 1 in the Supplement), movement disorders, and communicating hydrocephalus . Although strokes, seizures, and obstructive or mixed hydrocephalus occur in other inhaled heroin modalities, such an association has not been reported in isolated CTD.…”

Section: Introductionmentioning

confidence: 99%