Risk of anaphylaxis in opioid dependent persons: effects of heroin versus substitution substance

Abstract

Background: Across Europe, illicit drug-related mortality has not declined despite ever increasing prevention measures. The cause of these deaths has traditionally been associated with overdose. Previous findings have revealed the appearance of non-lethal opioid concentrations, leading us to investigate a further cause of death. The symptoms of heroin intoxication with asphyxia and/or cardiovascular involvement resemble anaphylaxis, and therefore it has been speculated that such deaths might be caused by an allergic reaction. The study´s aims were to investigate levels of allergic mediators in long-term injecting drug users (IDU) compared to healthy controls and to determine if oral opioid substitution therapy (OST) resulted in similar allergic symptoms to those reported by IDU after intravenous (IV) heroin use.

Nationwide increase in hospitalizations for heroin-related soft tissue infections: Associations with structural market conditions

“…Understanding PWID’ risk behavior in the context of the structural risk environment enables tailoring structural, behavioral and clinical interventions e.g., syringe exchange programs (Hurley et al, 1997) and harm-reduction oriented SSTI clinics (Grau et al, 2002; Harris and Young, 2002; Messac et al, 2013; Robinowitz et al, 2014). Future investigations into the causes of SSTI among heroin injectors should consider both physiological and chemical mechanisms, including the measurement of histamine as an injection induced inflammatory marker (Maurer et al, 2014), and drug solution acidity (Ciccarone and Harris, 2015). …”

Immune responses in fatalities involving opioids

“…The concentration that denotes elevation due to allergic reaction is not clear; a recent study suggests that 53.8 ng/mL may be an appropriate cut-off [14]. A significant mean baseline elevation of β mast-cell tryptase has been noted in opioid users, however (6.0 ± 4.3 ng/mL), compared to non-opioid users (3.9 ± 1.9 ng/mL), suggesting that the standard threshold used in this study was appropriate [3]. Some studies have furthermore shown that this analyte may be elevated in postmortem serum of persons from whom anaphylactic reactions are not the cause of death [15,16].…”

“…While prescription narcotic abuse is increasing, heroin is still common [1], and designer fentanyls are appearing in many areas [7]. Most fatalities from opioids are due to overdose, but deaths involving opioids with concentrations lower than those associated with fatality are common [3]. In this latter group with apparently sublethal concentrations of opioids, it can be difficult to interpret what the detected concentrations of opioids mean; pertinent factors that may be unanswerable even with comprehensive review of clinical history and medical records include individual tolerance of opioids or relative naïveté to the drugs; metabolism of the opioids if death is prolonged and the drugs remain as active metabolites; drug-drug interactions; and individual genetic factors, such as slow metabolizers.…”

“…However, in some cases the concentrations of opioids present are not detected at toxic concentrations, let alone fatal concentrations [3]. Moreover, evidence of metabolites of the native drugs in these cases can demonstrate that several hours of survival took place after drug use.…”

“…Thus, the mechanism of death may be unknown, even if the cause and manner of death are clear. Immune mediation may be a contributing factor of death in these cases, since immune reactions can be triggered by opioid use [3]. Opioids are known to stimulate mast cells, initiating the release of histamine and other vasoactive substances [4–6].…”