The Emerging Role of Inhaled Heroin in the Opioid Epidemic

Abstract

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.

Female rats self-administer heroin by vapor inhalation

“…Inhalation presently continues to be a common route of administration among individuals that abuse opioids (Alambyan et al, 2018) and some newer users will first choose inhalation as a means of administering opioids because of the perceived safety compared with injection (Stover and Schaffer, 2014). Although some degree of safety is achieved, such as in the prevention of bloodborne pathogen transmission, inhalation and injection both similarly facilitate progression into dependence (Barrio et al, 2001).…”

Bilateral middle cerebellar peduncle lesions: Neuroimaging features and differential diagnoses

“…Oligodendrocyte apoptosis-induced demyelination in the white matter is more sensitive to ischemia/hypoxia because the axons and myelin sheaths in this area are thin (Yin et al, 2013). Therefore, in agreement with the pathological findings, brain MRI abnormalities caused by heroin inhalation often result in extensive, symmetrical lesions of the cerebral and cerebellar white matter, posterior limbs of the internal capsules, and splenium of the corpus callosum, which helps distinguish it from other causes of leukoencephalopathy such as toluene toxicity or reversible posterior leukoencephalopathy (Alambyan et al, 2018;Offiah & Hall, 2008). Our patient, who had an extensive medical history of heroin inhalation with presentations ranging from confusion to coma, exhibited these specific bilateral symmetrical lesions in the posterior limbs of the internal capsules, while the anterior limbs were spared, consistent with the aforementioned observations.…”

“…Toxic leukoencephalopathy is an uncommon but critical neurological disorder seen in heroin abusers. There are various routes of heroin misuse, including inhalation, IV injection, intranasal (snorting), and subcutaneous injection (Alambyan et al, 2018). "Chasing the dragon," an inhalation method that involves heating heroin over aluminum foil and inhaling the resultant fumes, has recently become the most popular route of heroin intake due to its availability, greater ease of administration, and safer infectious profile compared to the other routes (Cicero, Ellis, Surratt, & Kurtz, 2014).…”

“…magnetic resonance imaging, middle cerebellar peduncle, multiple system atrophy, neuromyelitis optica, stroke, Wallerian degeneration periventricular white matter or the cerebellum, and the exclusion of alternative diagnoses (Alambyan, Pace, & Miller, 2018), (e) Patients with primary central nervous system lymphoma (PCNSL) met the guidelines for the diagnosis and management of primary central nervous system diffuse large B-cell lymphoma: stereotactic biopsy and contrast-enhanced brain MRI (Fox, Phillips, & Smith, 2019).…”

Mimicking a Psychiatric Disorder: Heroin-Induced Leukoencephalopathy

“…Toxic leukoencephalopathy is a broad term that refers to the damage of the white matter caused by exposure to a variety of agents, including drugs of abuse such as heroin as well as irradiation, chemotherapy, and environmental toxins [ 1 - 4 ]. The inhalation of heroin vapor, historically known as “chasing the dragon”, has been associated with toxic leukoencephalopathy in many reported cases [ 2 ].…”