The Emerging Role of Inhaled Heroin in the Opioid Epidemic: A Review

Vilakshan Alambyan, Jonathan Pace, Benjamin Miller, Mark L. Cohen, Sankalp Gokhale, Gagandeep Singh, Ming Chieh Shun, Anthony Hammond, Ciro Ramos-Estebanez

Research output: Contribution to journalArticle

6 Citations (Scopus)

Abstract

Importance: Opioid addiction affects approximately 2.4 million Americans. Nearly 1 million individuals, including a growing subset of 21000 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 Relevance: The 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.

Original languageEnglish (US)
Pages (from-to)1423-1434
Number of pages12
JournalJAMA Neurology
Volume75
Issue number11
DOIs
StatePublished - Nov 1 2018

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Heroin
Opioid Analgesics
Leukoencephalopathies
Heroin Dependence
coenzyme Q10
Hydrocephalus
Minors
Mississippi
Costs and Cost Analysis
Clinical Pharmacology
Poisons
Movement Disorders
American Medical Association
Advisory Committees
Rivers
Neuroimaging
Heating
Inhalation
Patient Selection
Seizures

ASJC Scopus subject areas

  • Clinical Neurology

Cite this

Alambyan, V., Pace, J., Miller, B., Cohen, M. L., Gokhale, S., Singh, G., ... Ramos-Estebanez, C. (2018). The Emerging Role of Inhaled Heroin in the Opioid Epidemic: A Review. JAMA Neurology, 75(11), 1423-1434. https://doi.org/10.1001/jamaneurol.2018.1693

The Emerging Role of Inhaled Heroin in the Opioid Epidemic : A Review. / Alambyan, Vilakshan; Pace, Jonathan; Miller, Benjamin; Cohen, Mark L.; Gokhale, Sankalp; Singh, Gagandeep; Shun, Ming Chieh; Hammond, Anthony; Ramos-Estebanez, Ciro.

In: JAMA Neurology, Vol. 75, No. 11, 01.11.2018, p. 1423-1434.

Research output: Contribution to journalArticle

Alambyan, V, Pace, J, Miller, B, Cohen, ML, Gokhale, S, Singh, G, Shun, MC, Hammond, A & Ramos-Estebanez, C 2018, 'The Emerging Role of Inhaled Heroin in the Opioid Epidemic: A Review', JAMA Neurology, vol. 75, no. 11, pp. 1423-1434. https://doi.org/10.1001/jamaneurol.2018.1693
Alambyan, Vilakshan ; Pace, Jonathan ; Miller, Benjamin ; Cohen, Mark L. ; Gokhale, Sankalp ; Singh, Gagandeep ; Shun, Ming Chieh ; Hammond, Anthony ; Ramos-Estebanez, Ciro. / The Emerging Role of Inhaled Heroin in the Opioid Epidemic : A Review. In: JAMA Neurology. 2018 ; Vol. 75, No. 11. pp. 1423-1434.
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