Inhaled Heroin Tied to 'Peculiar, Often Catastrophic' Brain Damage

Megan Brooks

July 09, 2018

"Chasing the dragon" (CTD) — a method of inhaling heroin in which users heat heroin over aluminium foil with a lighter and then chase the fumes — is growing in popularity and may lead to "peculiar and often catastrophic brain complications," new research shows.

"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," write Vilakshan Alambyan, MD, from The Neurological Institute, University Hospitals Cleveland Medical Center in Ohio, and colleagues.

Roughly 2.4 million Americans are addicted to opioids and nearly 1 million abuse heroin, costing the US $51 billion annually. Inhaled heroin is approaching epidemic levels east of the Mississippi River as well as among urban young people. CTD is of particular concern because it is easier to administer and provides a greater high compared with injected heroin.

Alambyan and colleagues review the emerging role of inhaled heroin, specifically CTD, in the opioid epidemic in an article published online July 9 in JAMA Neurology.   

They say CTD is associated with a "unique spectrum" of health outcomes, including an aggressive toxic leukoencephalopathy with pathognomonic neuropathologic features, along with sporadic instances of movement disorders and hydrocephalus.

For example, CTD led to spongiform leukoencephalopathy in 116 of 141 reported cases (82.3%), as compared with 25 cases (17.7%) arising from other forms of heroin inhalation (ie, sniffing, smoking, and snorting).

The literature suggests three distinct degrees of CTD clinical severity. Among 88 patients, 18 (21%) developed a mild syndrome consistent with inattentiveness, confusion, ataxia, and psychomotor symptoms; 46 (52%) exhibited moderate severity with corticospinal or extrapyramidal involvement and impaired alertness ranging from severe confusion to delirium; and 24 patients (27%) developed the most severe form involving generalized motor impairment, abulia without concomitant language disorders or apraxia, and noticeable alertness deficits.  Mild cases typically survive with minor sequelae, while moderate to severe presentations may deteriorate and lead to death.

As for treatment, preliminary evidence suggests a role for coenzyme Q10. For example, among nine patients with CTD administered coenzyme Q10, five improved to varying degrees, and four remained unchanged or deteriorated. Given its negligible adverse effect profile, Alambyan and colleagues recommend a coenzyme Q10 trial regimen of 300 mg four times a day in all patients meeting criteria for possible or probable CTD.

They propose the following clinical diagnostic criteria and categories for CTD leukoencephalopathy.

Inclusion criteria
1. Presence of a clinical syndrome suggestive of leukoencephalopathy
2. Positive results on heroin toxicologic testing
3. Confirmed report of CTD inhalation by the patient, his or her next of kin, or a witness
4. Supportive neuroimaging
5. Neuropathology findings consistent with spongiform leukoencephalopathy
Exclusion Criteria
1. Confirmed history of acute intoxication or exposure to a toxin other than heroin that is capable of producing a CTD-like outcome
2. Overt clinical picture suggesting an infectious, demyelinating, vascular, or paraneoplastic cause
3. Neuroimaging consistent with a predominantly cortical involvement along with sparing of subcortical areas and posterior fossa
Diagnostic Category
Definite CTD: Patient fulfills all the inclusion criteria
Probable CTD: Patient fulfills inclusion criteria 1 through 4
Possible CTD: Only inclusion criteria 1 through 3 are met, or criteria 1 through 4 are accompanied by confirmed polysubstance or polyroute heroin abuse


The investigators suggest establishing a case registry or database using these suggested criteria as a means to further clarify the syndrome. "However, clinical utility necessitates a permissive approach, where even a possible suspicion for CTD leukoencephalopathy should prompt appropriate therapy," they advise.

This research had no commercial funding. The authors have disclosed no relevant financial relationships.

JAMA Neurol. Published online July 9, 2018. Abstract

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