Intravenous Heroin Addicts Research Articles

Heroin-induced osteoporosis presented with bilateral femoral neck insufficiency fractures in a male adult: a case report

BackgroundOsteoporosis has been associated with several disorders; however, there have been only a limited number of reports on heroin-induced osteoporosis. We report a rare case presented with bilateral femoral neck insufficiency fractures without trauma history, caused by heroin-induced osteoporosis. We collect sufficient clinical data and further shed light on the potential mechanism of how heroin affects bone formation and decreases bone density.Case presentationA 55-year-old male patient with normal body mass index (BMI) suffered from bilateral hips pain gradually without trauma history. He had intravenous heroin addiction for more than 30 years. Radiography revealed bilateral femoral neck insufficiency fractures. Laboratory tests showed elevated alkaline phosphatase levels (365 U/L) and decreased inorganic phosphate (1.7 mg/dL), calcium (8.3 mg/dL), 25-(OH)D3 (20.3 ng/ml) and testosterone levels (2.12 ng/ml). Magnetic resonance imaging (MRI) revealed increased signals on STIR images over the sacral ala and bilateral proximal femur, and multiple band-like lesions at the vertebrae of the thoracic and lumbar spine. Bone densitometry revealed osteoporosis with a T score of minus 4.0. The screen for urine morphine was positive (> 1000 ng/ml). Through assessment of the patient, the diagnosis was insufficiency fractures of bilateral femoral neck caused by opioid-induced osteoporosis. After hemiarthroplasty, regular medication with vitamin D3 and calcium, and detoxification treatment, and the patient recovered well after 6 months of follow-up.ConclusionThe aim of this report is to highlight the laboratory and radiology findings in a case of osteoporosis caused by opioid addiction and discuss the potential pathway by which osteoporosis is induced by opioids. When an unusual osteoporosis presents with insufficiency fractures, heroin-induced osteoporosis should be considered.

Evidence on the Heroin-Mediated Impairment of the Oxidative Status of Erythrocytes.

Away from hemorheological properties, the effect of heroin addiction on erythrocytes is poorly investigated. This study aimed to investigate the oxidative impacts of heroin administration on erythrocytes. Study subjects included chronic intravenous heroin addicts and control subjects. Hematological analysis and redox parameters were measured, including serum concentration of methemoglobin ([MethHb]), serum glutathione peroxidase-1 ([GPX-1]), serum glutathione peroxidase (GPX) activity, erythrocytic protein carbonyl content, and oxidized to reduced glutathione (GSSG/GSH) ratio. Hematological analysis revealed that addicts had a significantly higher red cell distribution width, consistent with the mild anisocytosis and poikilocytosis of erythrocytes. As compared to control subjects, significantly higher levels of serum [Met-Hb], [GPX-1], and GPX activity (p < 0.001) were reported among addicted subjects. A significant association between [MetHb] and GPX activity was observed with r = 0.764 (p < 0.001). Furthermore, significantly higher erythrocytic protein carbonyl contents and GSSG/GSH ratio were evident among heroin addicts (p < 0.005) that were significantly associated with r = 0.429 (p=0.01). Results demonstrate preliminary evidence that heroin addiction is implicated in impaired redox status of erythrocytes. Considering the pharmacokinetics of heroin, erythrocytic antioxidant mechanisms, and turnover rate, further investigation is required to evaluate the extent and clinical outcomes, especially upon over-dose administration.

Self-perceived oral symptoms and periodontal status among young intravenous heroin addicts: A cross-sectional case-control study.

It is hypothesized that (a) self-perceived oral symptoms (OSs) are worse in intravenous heroin addicts (IHA) than controls; and (b) clinical periodontal inflammatory parameters (plaque index [PI], bleeding on probing [BOP], PD and clinical attachment loss [AL]), number of missing teeth (MT), and radiographic marginal bone loss (MBL) are higher in IHA compared with controls. The aim was to compare the self-perceived OSs and periodontal parameters among young IHA and controls. Sociodemographic data, self-perceived OSs and duration and daily frequency of intravenous heroin use was gathered using a structured questionnaire. Full-mouth PI, BOP, PD, and clinical AL were measured, and number of MT were recorded. Mesial and distal MBL on all teeth was measured on digital radiographs. Odds ratios (OR) with 95% confidence intervals (CI) were computed for self-perceived OSs and periodontal parameters were assessed using the Mann Whitney U-test and logistic regression analysis. Sample-size was estimated, and level of significance was set at P<0.05. OR (95% CI) for self-perceived loose teeth (P<0.001), pain in teeth (P<0.001), dry mouth (P<0.001), burning sensation in mouth (P<0.001), bleeding gums (P<0.001) and pain during chewing (P<0.001) were significantly higher in the test than control group. Number of MT (P<0.05), PI (P<0.05), clinical AL (P<0.05), and mesial (P<0.05) and distal (P<0.05) MBL were statistically significantly higher among individuals in the test group compared with the control group. Self-perceived OSs and periodontal inflammatory parameters were worse in IHA than controls.

Severe Osteomalacia Related to Long-Term Intravenous Drug Abuse.

Objective. We present the clinical, biochemical, and imaging findings of a woman with vitamin D deficiency and severe osteomalacia related to intravenous heroin addiction. Results. A 54-year-old woman with a medical history significant for long-standing heroin abuse presented with complaints of bone pain, muscle cramping, and a left hip ulcer. She had been bed bound for approximately 1 year secondary to pain of uncertain etiology, and her husband was bringing her both food and drugs. She was admitted to the hospital for debridement of a right ischial ulcer. Further workup revealed osteomyelitis of the left hip and severe vitamin D deficiency. Radiologic evaluation demonstrated diffuse osteopenia with pseudofractures, as well as true fractures. Conclusion. This is the first case reported in the English literature of advanced osteomalacia resulting from a debilitating narcotic dependency. Vitamin D deficiency should be considered in patients with poor nutrition and prolonged sunlight deprivation from any cause.

Puffy Hand Syndrome Revealed by a Severe Staphylococcal Skin Infection

Puffy hand syndrome develops after long-term intravenous drug addiction. It is characterized by a nonpitting edema, affecting the dorsal side of fingers and hands with puffy aspect. Frequency and severity of the complications of this syndrome are rarely reported. Local infectious complications such as cellulitis can be severe and can enable the diagnosis. Herein, we report the case of a 41-year-old man who went to the emergency department for abdominal pain, fever, and bullous lesions of legs and arms with edema. Bacteriologic examination of a closed bullous lesion evidenced a methicillin sensitive Staphylococcus aureus. The abdomen computed tomography excluded deep infections and peritoneal effusion. The patient was successfully treated by intravenous oxacillin and clindamycin. He had a previous history of intravenous heroin addiction. We retained the diagnosis of puffy hand syndrome revealed by a severe staphylococcal infection with toxic involvement mimicking a four limbs cellulitis. Puffy hand syndrome, apart from the chronic lymphedema treatment, has no specific medication available. Prophylactic measures against skin infections are essential.

Tridimensional Personalities and Polymorphism of Dopamine D2 Receptor Among Heroin Addicts

Drug addiction is a multifactorial disorder. Researchers have posited that an individual's inherited behavioral propensity or temperament contributes to the disorder by shaping a personality strongly linked with the risk of drug abuse. Further, they hypothesize that the polymorphism of dopamine D2 receptor increases the susceptibility to and severity of addiction. We, therefore, investigated possible associations between dopamine D2 receptor (DRD2) and personality traits among intravenous heroin addicts. We assessed 93 intravenous heroin addicts and controls using Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) and the Tridimensional Personality Questionnaire (TPQ). We confirmed drug-dependence status using a questionnaire based on DSM-IV criteria. We extracted DNA from the subjects' whole blood and genotyped it for DRD2 allelic variants. Genotype analysis showed a significantly higher frequency for the TaqIA polymorphism among the addicts (69.9%) compared to control subjects (42.6%; Fisher's exact χ(2), p < .05). We observed no significant differences for other variants between the addicts and controls. The addicts had higher scores for novelty seeking (NS) and harm avoidance (HA) personality traits but lower scores for reward dependence (RD) when compared to control subjects. The environmental cues are different for the addicts, and the healthy university students we used as controls. We recommend that researchers employ a gene-environment interaction approach to study factors associated with addictive behaviors in future studies. Taq1A may be implicated for an increased vulnerability to addiction. Screening of this marker might be useful for identifying individuals at risk of addiction.

Ultrastructural changes in the liver of intravenous heroin addicts.

The ultrastructural research has a decisive role in gathering the knowledge on the liver's response to the influence of some drugs. The aim of the study was to perform an ultrastructural analysis of the liver in chronic intravenous heroin addicts.The study involved the autopsy conducted on 40 bodies of intravenous heroin addicts and 10 control autopsies. The liver tissue was fixed in glutaraldehyde and moulded with epon for investigation purposes of ultrastructural changes. The analysis was performed using the method of transmission electron microscopy.In the group of intravenous heroin addicts, the liver autopsy samples showed degenerative vesicular and fat changes, chronic active and persistent hepatitis, cirrhosis, reduction in the amount of glycogen in hepatocytes, as well as the Kupffer cell's dominant hypertrophy. Various changes occur in organelles, plasma membrane of hepatocytes and biliary channels as well as in the nucleus. The most important ultrastructural findings include: hyperplasia and hypertrophy of the smooth endoplasmic reticulum, which is histologically proven vesicular degeneration of hepatocyte occurring as a result of the increased synthesis of enzymes of smooth endoplasmic reticulum due to chronic intravenous heroin intake, and the presence of continuous basal membrane followed by transformation of the sinusoids into capillaries (in the cases of chronic active hepatitis and cirrhosis) which leads to a disorder of microcirculation and further progress of cirrhosis.

Renal amyloidosis in intravenous heroin addicts with nephrotic syndrome and renal failure

Renal amyloidosis has emerged as an important differential diagnosis when heroin addicts are admitted to renal clinics with proteinuria and nephrotic syndrome. We present nine heroin addicts with renal AA amyloidosis, a condition previously not encountered in Norway, who were admitted to our renal clinic during the last 3.5 years. In the same time period a total of 209 patients were biopsied from native kidneys. Heroin abuse was associated with 70% of all biopsy-verified renal AA amyloidosis during this time period. Renal amyloidosis was found in 9 of the 12 heroin addicts that were biopsied. 6 of the 9 heroin addicts with amyloidosis required dialysis within 13 months after admission. Renal AA amyloidosis among heroin addicts seems to be associated with chronic suppurative skin infections. AA amyloidosis should always be considered in chronic heroin addicts presenting with proteinuria and renal impairment.

Bartonella spp. antibodies in forensic samples from Swedish heroin addicts.

A high frequency of Bartonella elizabethae seropositivity (39%) was recorded among intravenous heroin addicts in Stockholm, Sweden, who died from a lethal injection. Some of the B. elizabethae-seropositive individuals also had antibodies to B. henselae Houston-1, B. grahamii, and B. quintana, but none had antibodies to B. henselae Marseille or B. vinsonii subsp. vinsonii. Hepatitis was a frequent finding but no case had peliosis hepatitis. There was no case of endocarditis, but in three persons active subacute-to-chronic myocarditis was found; two of these cases were Bartonella-positive and HIV-negative.

A study on forensic samples of Bartonella spp antibodies in Swedish intravenous heroin addicts.

Infection with Bartonella, an emerging bacterial pathogen which often affects immunodeficient patients, has been reported in Sweden over the past few years, with a high seroprevalence of B. elizabethae. A high prevalence of antibodies against B. elizabethae has also been found in urban intravenous drug users in the USA. Using immunofluorescence, we retrospectively examined serum samples taken at autopsy from 59 Swedish intravenous drug addicts from the Stockholm area for evidence of antibodies against 6 pathogenic strains of Bartonella. The 59 addicts died following heroin injection during the years 1987-1992 and include 24 individuals (41%) who were additionally HIV-positive. An overall seropositivity rate for Bartonella spp. of 39% (23/59) was found with the following antigenic reactivities: B. elizabethae, 39% (23/59); B. grahamii, 3% (2/59); B. henselae (Houston-1), 14% (8/59); and B. quintana, 3% (2/59). There were no positive reactions for B. henselae (Marseille) or B. vinsonii subsp. vinsonii. The Bartonella-seropositive cases included 11/23 (48%) individuals who were HIV-positive. Subacute to chronic myocarditis was seen in 2/11 microscopically investigated Bartonella-seropositive cases that were HIV-negative and in 1/14 seronegative cases. No cases of endocarditis or other common manifestations of Bartonella infection were found. An overall Bartonella seropositivity of 21% (9/44) was observed in control forensic autopsy samples.

Death attributed to methadone.

Besides its other effects, MMT (methadone maintenance treatment) reduces the high mortality of intravenous heroin addicts to about 30% of controls. On the other hand, deaths of patients and non-patients have been attributed to methadone. Here, we will report on the major reasons for deaths attributed to methadone and discuss suggestions for their prevention. 69% of deaths attributed to methadone occurred in subjects not on MMT at the time of their death. 51% of deaths attributed to methadone in subjects in MMT occurred during the dose-finding period of MMT. Further apparent risk situations are methadone intake in addition to that received for MMT, discharge from prison and intravenous injection of methadone. Intake of methadone in non-patients is almost entirely due to abuse of diverted take-home methadone. Not giving methadone as take-home should reduce methadone deaths most effectively. Replacing take-home methadone by substances acting longer than one day, such as LAAM (levacetylmethadol) or buprenorphine, should also be effective. Restriction of take-home prescriptions to substances with a slow onset of action, such as LAAM, or to partial agonists with an extended safety margin such as buprenorphine should be partly effective. Meticulous evaluation of substance history, slow dose increases and strict supervision of the patient by experienced personal should prevent methadone overdose during the dose-finding period. Discharge from prison closely corresponds to this situation; informing addicts shortly before discharge and psychosocial help during the first months out of prison may reduce this risk. Naloxone as an adjunct to oral agonist preparations should effectively prevent high-risk intravenous injection, for example of methadone syrup. This has been the case with tilidine plus naloxone in Germany. Reducing deaths attributable to methadone increases the net benefit of MMT. Also, reducing deaths attributable to methadone avoids decreases in the public acceptance of MMT.

Hepatitis C, B, D, and A

Over 90% of intravenous heroin addicts (IVHAs) carry the hepatitis C virus (HCV). The other hepatitis viruses, A, B, D, and G are relatively unimportant in IVHAs compared to HCV although active hepatitis B may demonstrate a chronic, degenerative course identical to that of HCV. The clinical course of HCV and active hepatitis B may span three or more decades. It is helpful to classify patients as in the active, cirrhosis, or liver failure stages. Only in the active, early stage are the liver enzymes, ALT and AST, likely to be elevated. It is this stage that will most likely respond to antiviral therapy. HCV has so many extra-hepatic manifestations including immune suppression, collagen diseases, and possibly lymphoma and leukemia that the disease is best termed HCV syndrome rather than simple hepatitis.

Pathogenesis of heroin-associated glomerulonephritis: Correlation between the inflammatory activity and renal deposits of immunoglobulin and complement?

Renal specimens from 19 autopsies of persons known to be intravenous heroin-addicts and with severe lympho-monocytic glomerulonephritis were investigated to correlate the inflammatory activity and deposits of immunoglobulin and complement. In all sections, there were 10 or more LCA-positive cells/glomerulum, counted in 20 glomerula but only up to 3 LCA-positive cells in a control-group of 10 autopsied persons without drug addiction and any renal diseases. In some cases diffuse granular deposits of immunoglobulin were found together with deposits of Clq. Although these changes cannot be demonstrated in all cases, deposits of Clq point to an activation of the classical way of the complement binding system in heroin-associated glomerulonephritis. The underlying process, activation of the complement binding system by heroin/morphin itself and adulterants or by hepatitis B and C infection, which are frequent in heroin-addicts, is still unclear.

Morphine promotes apoptosis in Jurkat cells.

Patients with intravenous heroin addiction are prone to recurrent infections and at times these infections are fatal. We evaluated the effect of morphine on the apoptosis of Jurkat cells and freshly isolated human T lymphocytes. Morphine promoted apoptosis of both the Jurkat cells and the freshly isolated T lymphocytes in a dose-dependent manner. DAGO, a specific mu receptor agonist, also promoted Jurkat cell apoptosis. DNA isolated from morphine-treated Jurkat cells and T lymphocytes also showed integer multiples of 200 base pairs. Superoxide dismutase (SOD) enhanced lymphocyte apoptosis; whereas catalase attenuated the morphine-induced apoptosis of Jurkat cells as well as of T lymphocytes. Morphine-treated Jurkat cells also showed a decreased expression of bcl-2 and an enhanced expression of bax. In addition, morphine-treated Jurkat cells showed activation of caspase-3. These results indicate that morphine-induced T lymphocyte apoptosis may be mediated through the generation of reactive oxygen species. The change in ratio of bax and bcl-2 seems to tilt the balance toward apoptosis, leading to the activation of caspase-3. This study provides further support for the hypothesis that morphine may be directly compromising immune function by enhancing apoptosis of T lymphocytes in patients with heroin addiction.

Thymus alterations related to intravenous drug abuse.

It has been noticed on forensic material that Hassall's corpuscles of the thymus are more often calcified in intravenous drug abusers than in healthy persons. Thymuses of 15 intravenous heroin addicts were histologically examined and compared with thymuses of 15 healthy persons. Acute bleeding and dystrophic calcification in the thymocyte's parenchyma were more common among intravenous drug abusers (p = .005 and p = .001, respectively). The degree of physiologic involution measured by fatty replacement and the clarity of border between cortex and medulla was equal. No significant diversity was found in the features of Hassall's bodies. Our study emphasizes the necessity for a defined criteria of morphologic changes in the thymus that could be expected in intravenous drug abusers. In that way it would be possible to complete the forensic findings as well as to examine immunologic system alterations of that risk population.

Hypoxic/ischaemic brain damage, especially pallidal lesions, in heroin addicts

The occurrence of pallidal lesions with or without other hypoxic/ischaemic brain injuries was evaluated in 100 intravenous (i.v.) heroin addicts. The brains were collected consecutively from forensic autopsies during the period from January 1995 to June 1996. The autopsies were required by the police and performed at The Institute of Forensic Medicine, The National Hospital, Oslo. There were 21 women and 79 men, median age 32 (range 21–47) and 34 (19–60) years, respectively. Of 38 brains with abnormalities, twenty-five cases showed isolated or combined lesions of hypoxic/ischaemic origin. Pallidal lesions were found in nine brains; six lesions were old, one was subacute (a couple of weeks), and two were part of recent, generalized hypoxia/ischaemia. Six persons had old infarcts in the hippocampal formation, and one of them in combination with old pallidal infarcts. In seven brains small and old infarcts were found in watershed areas in the cerebellum. Between five and ten percent of i.v. heroin addicts might have pallidal infarcts, either as the sole lesion, or combined with other manifestations of hypoxic/ischaemic brain injury. This might give severe mental disturbances in the affected persons.

Waldenström's macroglobulinemia in young African-American adults.

We have identified five African-American patients with Waldenström's macroglobulinemia (WM) diagnosed at a young age (ages 35, 38, 38, 40, 51; 4 males, 1 female). All had a history of intravenous heroin abuse and four also used cocaine. Their manner of presentation and clinical course were typical. Three of three patients tested for the hepatitis C virus (HCV) were positive and three of three patients tested were HIV negative. The potential relationship between intravenous drug abuse and/or HCV to development of WM in this group of young patients is provocative, especially since a polyclonal increase in serum IgM is commonly seen in chronic intravenous heroin addicts. More recently, the contribution of HCV is being evaluated in lymphoproliferative disorders. Although WM is typically a disease of older people, it should also be considered in the differential in a young patient with a suggestive clinical picture.

Political Culture and Treatment Strategies in the Nordic Countries

Taking as a point of departure Mary Douglas' grid-group analysis, elaborated on by Aaron Wildavsky in his cultural theory, the article explores the variations in the development of methadone treatment programmes in the Nordic countries from the mid-1960's to the mid-1990's. In Sweden, the first Nordic country to start an organized treatment of heroin addicts with methadone in 1966, the strategy has been characterized by many rules and strong control. In Denmark, methadone treatment was introduced in the late 1960's, and it has been characterized by few rules and weak control. In Norway, methadone treatment was banned in 1979, after some years of occasional experiments. But the spread of HIV among intravenous heroin addicts altered the attitudes and a small and highly regulated program was set up in the beginnings of the 1990's. In Finland, the attitude has been reserved, primarily due to the small population of heroin addicts. The organized treatment in the 1970's was limited, and still is, as it was set up again in 1995. In spite of the differences, however, there are two main patterns of harmonization that should be noticed. Firstly, as a result of HIV, regulated programmes have been developed in all four countries in the 1990's. Secondly, the prevailing abstinence-oriented philosophy has been questioned and supplemented by harm-reducing measures. Today, there is a stronger tendency to treat drug addicts as clients in the Nordic welfare state, entitled to individual treatment in the countries' general health and welfare systems.

Management of tetanus: a review of 18 cases.

Eighteen patients with generalized tetanus seen during an 8-year period in three regional hospitals in Hong Kong are reviewed. Eighty-nine per cent of the patients were intravenous heroin addicts who developed a severe type of generalized tetanus with autonomic dysfunction. Pain or stiffness of the neck or back was the commonest presenting symptom, followed by trismus and dysphagia. Most of the patients developed muscle spasms within 24 h of the onset of presenting symptoms. Early ventilatory support and tracheostomy, together with intensive nursing care, were the mainstay of the treatment. Pulmonary and gastrointestinal complications were common during the course of illness and treatment of autonomic dysfunction was often unsatisfactory. The case fatality rate was 25% among the heroin addicts, but full recovery was the usual outcome for those who survived. The simultaneous administration of intrathecal tetanus immunoglobulin tends to reduce mortality.

Cognitive behavior in asymptomatic (CDC stage II and III) HIV--seropositive intravenous drug users (IVDUs).

To evaluate cognitive impairment in the early stages of HIV infection in intravenous drug users (IVDUs) we have studied 39 consecutive HIV-infected subjects (CDC stage II-III) whose only known risk factor for the infection was intravenous heroin addiction. The control group was represented by 30 seronegative IVDUs. All subjects were tested with an extensive neuropsychological battery assessing general intellectual abilities and single cognitive functions. The patients differed from controls only for tests of attention and visual-motor abilities: 20% of asymptomatic seronegative and PGL patients showed alterations in two or more cognitive tests, as opposed to 3% of controls (p < 0.001). Our findings suggest that cognitive deficits seem to be present in a substantial percentage of IVDUs with asymptomatic HIV infection. Cognitive damage at this stage seems to selectively involve attention and visual-motor abilities, sparing general intellectual performances.