The face of hillbilly heroin and other images of narcotic abuse.
Abstract: The nationally recognized popularity of recreational intranasal oxycodone abuse among rural Appalachians is apparent to West Virginian healthcare providers. Three recent cases of narcotic-induced injury at WVU Ruby Memorial Hospital demonstrate the facial bone necrosis associated with "hillbilly heroin" abuse as well as other imaging features of narcotic-induced intracranial ischemia. This paper shows how diagnostic imaging may facilitate clinical evaluation of patients with narcotic abuse.
Article Type: Report
Subject: Narcotic abuse (Prognosis)
Narcotic abuse (Demographic aspects)
Narcotic abuse (Care and treatment)
Narcotic abuse (Diagnosis)
Authors: Lagos, Rachel
Hogan, Michael
Raghuram, Karthikram
Pub Date: 07/01/2010
Publication: Name: West Virginia Medical Journal Publisher: West Virginia State Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 West Virginia State Medical Association ISSN: 0043-3284
Issue: Date: July-August, 2010 Source Volume: 106 Source Issue: 4
Organization: Government Agency: United States. Department of Health and Human Services
Geographic: Geographic Scope: West Virginia Geographic Code: 1U5WV West Virginia
Accession Number: 237942591
Full Text: Introduction

The West Virginia Prescription Drug Abuse Quitline reports that fatal drug overdoses increasingly occur in rural areas. West Virginians own the greatest increase, a 550% increase in fatal drug overdoses. (1) Suspecting, recognizing and treating narcotic abuse, including prescription narcotic abuse, is a growing priority among local health care providers. The US Department of Health and Human Services compiles a national survey on drug use and health. (2) The statistical data portray the "typical" drug abuser. Most illicit drug users are sixteen to twenty-five years-olds with a multi-ethnic background and a full-time job. Men and women have similar rates of nonmedical use of pain relievers, stimulants and methamphetamine. Diagnostic cross-sectional images acquired at West Virginia University Ruby Memorial Hospital illustrate their problems.

The Face of Hillbilly Heroin

The first report on "hillbilly heroin" written by Greg Stone in 2001 credits a pharmaceutical representative for this epigram connoting the regional popularity of "a potentially lethal" and "highly abused painkiller", oxycodone. (3) The heroin-quality high of this synthetic opiate prescription painkiller earns notoriety locally and throughout the United States as an addiction often affecting impoverished rural Appalachians. (4,5,6) Regional predilection for this addiction is due in large part to its availability through Medicaid prescription coverage. Recent narcotic indictments report that a single 80-milligram oxycodone tablet can sell for $120 on the street." (7) Although the Schedule II controlled substance is manufactured as a sustained-release formula, intranasal use of a crushed oxycodone tablet foils the sustained-release mechanism and affords more intense and instantaneous opiate effects. These include a lessened sensation of pain, dreamy euphoria, pinpoint pupils and respiratory depression. A patient with chronic recreational oxycodone abuse may present with nasal congestion.

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A twenty-three-year-old man with a history of intranasal oxycodone abuse presents to his primary care provider with sinusitis. Unenhanced computed tomography of the sinuses demonstrates a bony defect of the anteroinferior nasal septum with prominent mucosal soft tissues and nasal secretions in this region (image A). In addition, there is thinning and necrosis of the hard palate (image B).

Destructive midfacial lesions subsequent to narcotic abuse are documented as early as a 1912 case of cocaine-induced hard palate perforation. The local vasoconstrictive effect of inhaled cocaine compounds the mucosal irritation from the powdered substances used to cut the cocaine. (8) Such irritants include talc, lactulose, mannitol, plaster of paris, borax and amphetamines. Resultant nasal mucosal ischemia and inflammation may progress to ulceration and mucosal necrosis within three weeks of repetitive abuse. With prolonged cocaine inhalation, osteocartilaginous necrosis may extend to the turbinates, paranasal sinuses and hard palate. Nasal septal perforations are the most common complication of intranasal cocaine abuse, occurring in 5% of recreational cocaine abusers. Nasal septal perforation, lateral nasal wall destruction and hard palate necrosis may all occur. The presence of any two of these findings constitutes the diagnosis of CIMDL, cocaine-induced midline destructive lesion. (9,10) Similar changes are more recently described in cases of oxycodone inhalation. (11,12)

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Narcotic-induced palatal necrosis presents similar to angiocentric nasal-type natural killer/T-cell lymphoma, Wegener's granulomatosis and infectious diseases. When histopathology, flow cytometry, T-cell rearrangement, gram stain and culture studies are negative, narcotic-induced osteocartilaginous necrosis may be confirmed by biopsy demonstrating the presence of polarizable foreign material. An elevated classical antineutrophil cytoplasmic antibody (c-ANCA), although 90% specific for an inflammatory systemic vasculitis, may also be present in the setting of intranasal narcotic abuse. (10)

Cocaine-induced Cerebral Ischemia

An eighteen-year-old unresponsive man is brought to the emergency department. An emergent head CT scan excludes an acute intracranial injury; however, subsequent magnetic resonance imaging reveals brain parenchyma abnormalities. Abnormal signal intensity occurs within the cranial vertex white matter on the T2-weighted (image C) and FLAIR series (image D). Associated abnormal restriction of diffusion is present in the same area on diffusion-weighted imaging (image E) and apparent diffusion coefficient imaging (image F). There is sparing of the subcortical U-fibers. Differential considerations for such image findings include inhalation injury, toxic injury and metabolic injury, including an inborn error of metabolism. In this patient with a history of cocaine intoxication, these findings most likely represent brain injury from cocaine-induced vasoconstriction and respiratory depression.

Brain Necrosis from Recreational Narcotics

A thirty-five year-old man with a history of psychotropic abuse is transported to the emergency department following a sudden loss of consciousness. Although emergent imaging shows no acute intracranial process, chronic brain necrosis is present. Magnetic resonance imaging demonstrates abnormal foci within the medial globi pallidi. These foci exhibit T2-weighted (image G) and FLAIR hyperintensity (image H) as well as T1-weighted hypointensity (image I). Such bilateral focal areas of chronic necrosis in the globi pallidi are likely due to recreational drug use, such as ecstasy or heroin.

Additional Narcotic-induced Neuroimaging Findings

Sympathomimetic drugs, including cocaine and amphetamines, are commonly associated with intracranial hemorrhage, possibly due to transient hypertension or arteritis-like vascular change. Up to fifty percent of drug abusers who sustain an intracranial hemorrhage have an underlying structural cause such as an aneurysm or arteriovenous malformation. Symptoms may develop within seconds to hours following drug administration. Because of this phenomenon, the authors of the Fundamentals of Diagnostic Radiology facetiously refer to sympathomimetic drug abuse as a "stress test for brain vascular anomalies". This text documents a 21-year-old male who collapses immediately after snorting a line of cocaine. His noncontrast head CT shows cocaine-induced rupture of an anterior communicating artery aneurysm with subsequent subarachnoid and intraventricular hemorrhage. (13)

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Narcotic-induced vascular lesions produce distinctive intracranial image patterns. Heroin and amphetamines cause patchy inflammation within intracranial arterial walls, which can result in large or small-vessel stroke extending through multiple vascular territories. This is an atypical pattern for non-vasculitic strokes.

Mycotic aneurysms can occur subsequent to intravenous drug abuse or trauma. On cross-sectional and angiographic imaging, these aneurysms are characteristically found along distal vascular branches. (13)

Hematogenous spread of infection may result in osteomyelitis of the vertebral bodies with subsequent spinal epidural abscesses. Such abscesses comprise up to 18% of the central nervous system complications from intravenous drug abuse. Progression of vertebral osteomyelitis may result in vertebral body collapse with subsequent cord compression. In addition, meningitis and cerebral abscess are sometimes attributed to intravenous drug abuse. (14)

Imaging the Multi-systemic Effects of Narcotic Abuse

Intravenous drug abuse manifests numerous physical and radiological findings that depend on the particular narcotic, its impurities, the site of administration and the method of administration. Diagnostic imaging recommendations progress from radiographic to cross-sectional examinations, with possible indication for additional fluoroscopy, angiography or interventional procedures. Local and systemic complications of narcotic drug abuse can occur within multiple organ systems as summarized below. (14)

Skeletal complications include septic arthritis and osteomyelitis. The latter may occur through direct contamination such as a pubic bone "groin hit" or clavicular "pocket shot". Pleuropulmonary complications include pneumothorax, hemothorax, pyothorax and septic pulmonary emboli. Gastrointestinal complications include severe colonic ileus, colonic pseudoobstruction, necrotizing enterocolitis and liver abscess. Genitourinary complications include amyloidosis, renal mycotic aneurysms, and in the heroin abuser, focal segmental glomerulosclerosis. (15) Soft tissue complications include hematoma, abscess, foreign body, cellulitis and lymphadenopathy. Cardiovascular complications include endocarditis, embolization of injected substances inadvertently into an artery, intravenous migration of a needle to the heart or lungs, venous thrombosis, arterial occlusion, arteriovenous fistula or arterial pseudoaneurysm. A pseudoaneurysm may progress to rupture with exsanguination and limb loss. (14)

Inhalers of crack cocaine, marijuana and nitrous oxide utilize the Valsalva maneuver. By obstructing expiration, this maneuver may result in a spontaneous pneumomediastinum or pneumothorax. Diffuse alveolar damage histologically identical to early adult respiratory distress syndrome (ARDS) is another common pulmonary manifestation of crack cocaine and heroin abuse. The lungs demonstrate an acute onset of interstitial or air-space opacities. These opacities are indistinguishable from pulmonary edema, although the heart size is typically normal in the non-pulmonary edema, narcotic-induced ARDS. Characteristically, the edema rapidly resolves. (9,13)

Conclusion

West Virginia health care providers must increasingly recognize and treat patients with narcotic abuse. These patients may present urgently with loss of conscious and acute intracranial injury. They may also present with more indolent or allosystemic sequelae. While certain radiologic findings suggest narcotic abuse, a single positive diagnostic study should not assuage further clinical evaluation for comorbid narcotic-induced physical injury. Narcotic abuse predisposes to many healthcare issues, some of which may be permanent and life-altering. Doctors need to be aware of how narcotics alter multiple organ functions, how patients with narcotic abuse may present clinically, and how to best utilize diagnostic imaging for further evaluation of suspected narcotic-induced injury. Specific imaging findings contribute to the diagnosis of narcotic abuse, define the extent of physical injury, and facilitate the most appropriate treatment planning.

Objectives

The following article conveys the information necessary to suspect, diagnose and assess the complications of intranasal oxycodone abuse. There is discussion of three recent cases of narcotic-induced cranial and brain injuries. Cross-sectional neuroimaging demonstrates the severity of physical injury in these cases. In addition, the article summarizes radiological findings of narcotic-induced physical injury to multiple organ systems.

References

(1.) Spickler D. PDA Facts. In: Witmyer B. ed. West Virginia Prescription Drug Abuse Quitline. Vol. 1, 2010. www.wvrxabuse.org

(2.) US DHHR Substance Abuse and Mental Health Services Administration. Results from the 2008 National Survey on Drug Use and Health: National Findings. 2009. www.oas.samhsa.gov/nsduh

(3.) Stone G. This painkiller can kill. In: The Sunday Gazette Mail. March 25, 2001.

(4.) Borger J. Hillbilly heroin: the painkiller abuse wrecking lives in West Virginia. In: The Guardian. June 25, 2001.

(5.) Mehren E. Hooks of 'hillbilly heroin.'" In: Los Angeles Times. 4 October 2001.

(6.) Johnson GC. Make No Mistake About It--This is war! In: Time Magazine Quote of the Day. 5 October 2007.

(7.) Jordan G. Law enforcement targets out-of-state prescriptions. In: Bluefield Daily Telegraph. September 17, 2009.

(8.) Weisleder R, Wittenberg J, Harisinghani M, Chen JW, Jones SE. Primer of Diagnostic Imaging. 4th ed. Mosby Elsevier; Philadelphia, PA. 2007:806.

(9.) Di Cosola M, Turco M, Acero J, Navarro-Vila C and Cortelazzi R . Cocaine-related syndrome and palatal reconstruction: report of a series of cases. In: International Journal of Oral & Maxillofacial Surgery. 2007;36:721-727.

(10.) Seyer BA, Grist W and Muller S.

Aggressive destructive midfacial lesion from cocaine abuse. In: Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics. 2002;92(4):465-470.

(11.) Greene D. Total necrosis of the intranasal structures and soft palate as a result of nasal inhalation of crushed OxyContin. In: Ear Nose and Throat Journal. 2005;84(8):512,514,516.

(12.) Birchenough SA, Borowitz K and Lin KY. Complete soft palate necrosis and velopharyngeal insufficiency resulting from intranasal inhalation of prescription narcotics and cocaine. In: Journal of Craniofacial Surgery. 2007;18( 6):1482-1485.

(13.) Brant WE and Helms CA. Fundamentals of Diagnostic Radiology. Lippincott Williams & Wilkins. 3rd Ed. 2007;1:100,105,110.

(14.) Dahnert W. Radiology Review Manual. Lippincott Williams and Wilkin. Philadelphia, PA. 2003:633-634.

(15.) Hagan IG, Burney K. Radiology of Recreational Drug Abuse. In: RadioGraphics. 2007;27(4):917-949.

CME Post-test

13 . Substance abuse can cause injury to which of the following organ systems?

a. Pleuropulmonary

b. Skeleton

c. Central Nervous System

d. All of the above

14. Depending on the method of narcotic administration and the particular narcotic used, both local and systemic physical injuries may occur to multiple organ systems.

True or False?

15. Intranasal narcotic use may result in bone erosion, brain ischemia and brain necrosis.

True or False?

Rachel Lagos, DO

Radiology Resident, West Virginia University Hospitals

Michael Hogan, MD

Associate Professor of Radiology, West Virginia

University School of Medicine

Karthikram Raghuram, MD

Associate Professor of Radiology, West Virginia

University School of Medicine
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