Stroke associated with drug abuse

Michael T Mullen MD (Dr. Mullen of the University of Pennsylvania School of Medicine has no relevant financial relationships to disclose.)
Steven R Levine MD, editor. (Dr. Levine of the SUNY Health Science Center at Brooklyn has received honorariums from Genentech for service on a scientific advisory committee and a research grant from Genentech as a principal investigator.)
Originally released September 23, 1996; last updated June 12, 2017; expires June 12, 2020

This article includes discussion of stroke associated with drug abuse, stroke associated with substance abuse, ischemic stroke, intracerebral hemorrhage, infarct, ICH, intraparenchymal hemorrhage, and drug abuse. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Drugs of abuse are frequently associated with stroke, especially in the young. In this article, the author reviews the clinical features and pathophysiology of stroke related to drug abuse.

Key points

 

• Drugs of abuse increase the risk of both ischemic stroke and intracerebral hemorrhage.

 

• Stimulants such as amphetamines, cocaine, and phencyclidine cause a sympathetic surge with elevated blood pressure and vasospasm.

 

• Heroin-associated strokes are most often attributed to infectious complications such as endocarditis or ruptured mycotic aneurysm.

Historical note and terminology

Although often considered a peculiarly modern problem, the use of drugs for their psychoactive effects dates back thousands of years. Drugs derived from the ingestion of plants have the longest history of abuse. Abuse of synthetic and semi-synthetic drugs dates to the pharmaceutical development of these substances in the early 20th century. The major classes of drugs of abuse include opiates, stimulants (cocaine, amphetamine and related agents), hallucinogens (LSD, phencyclidine, etc.), marijuana, barbiturates and other sedatives, and inhalants. Alcohol and tobacco, the 2 most widespread drugs of abuse, will not be discussed in this article. This certainly should not be taken as minimizing their addictive potential or clear impact on stroke risk. Each of the broad classes of drugs of abuse produces a distinct clinical intoxication and is associated with a limited spectrum of cerebrovascular disease. Familiarity with these patterns is important to the evaluation and treatment of patients with stroke. Several difficulties arise in any discussion about drugs of abuse. First, a variety of common street names exist to describe various drugs. As no standard definitions of these terms exist, they may at times mean different things to different people. Second, given the illicit nature of most drugs of abuse, patients' perception of the drug ingested must be considered of limited reliability. Tainted and substituted compounds are common, and only toxicological confirmation or direct testing of the substance itself can confirm the true identity of the ingested drug. Finally, a variety of different means of administration of individual drugs exist, and the effects of the drug, both desired and undesired, vary considerably based on this fact.

Table 1. Street Names and Methods of Administration for Drugs of Abuse

Agent

Administration

Common name(s)

Methamphetamine

Orally, intravenously, intranasally

Meth, speed, dexies, crystal, ice

Amphetamine derivatives

Orally, intranasally

MDMA, Ecstasy, X, molly, bath salts, plant food, jewelry cleaner, ivory wave, purple wave, zoom, cloud nine

Cocaine hydrochloride

Intranasally

Blow, nose candy, snow, dust, coke

Cocaine, alkaloidal

Inhaled or smoked; intravenously

Crack, rock, base, white pipe

Phencyclidine

Orally

PCP, angel dust, trank, DOA

Heroin

Intravenously, inhaled, or smoked

Smack, junk, skag, black tar

Cannabis

Inhaled, smoked, or ingested

Marijuana, hashish, pot, grass, weed

Synthetic cannabis

Inhaled, smoked, or ingested

Spice, K2, black mamba, Bombay blue, bliss, blaze

Amphetamines are synthetic sympathomimetics whose anorectic action led to their initial use as diet pills. They have also been used as mental stimulants by long-distance drivers, students, and others trying to preserve cognitive performance in the face of sleep deprivation. Athletes have used them to enhance physical performance. The euphoriant effect of higher doses has broadened their abuse potential. Methamphetamine is typically taken orally, although it can be smoked and injected. Intravenous users crush tablets of "speed," dissolve them in a liquid, filter them through cotton, and then inject them. Cerebrovascular complications arise from the more rapid onset of sympathomimetic action, and from foreign body reactions to "diluents" or filler substances like talc or cornstarch.

Amphetamine look-alikes encompass a broad range of drugs with sympathomimetic action. Methylenedioxymethamphetamine or “ecstasy” has become extremely popular over the last decade at late-night dance clubs, used both for its stimulant and euphoric properties. Other synthetic amphetamine-like substances, such as mephedrone, pyrovalerone, and methylenedioxypyrovalerone, are gaining popularity as well. These drugs can be purchased online or in drug paraphernalia stores. They are variably labeled as “bath salts,” or “plant food,” and there has been a dramatic increase in calls to United States poison control centers related to these substances (Jerry et al 2012). Ephedrine is used for the treatment of asthma and nasal decongestion (Goodman Gilman et al 1990) and is contained in the form of ephedra in the Chinese herbal preparation ma huang, frequently sold as an herbal stimulant. Over-the-counter sympathomimetics, such as phenylpropanolamine and pseudoephedrine, have been used to treat nasal congestion or facilitate weight loss (Brust 1986; Goodman Gilman et al 1990). The abuse potential and link to cerebrovascular disease associated with these drugs has been recognized only since the 1980s (Stoessl et al 1985; Brust 1986). Phenylpropanolamine was voluntarily withdrawn from the market in 2000 after the FDA reviewed a number of reports of hemorrhagic stroke associated with its therapeutic use (Kernan et al 2000). Methylphenidate is increasingly used to treat hyperactivity and attention deficit disorder in children and adults, and its widespread availability has resulted in an increase in its misuse.

Cocaine is derived from the leaves of the shrub Erythroxylon coca, which grows in the Peruvian and Bolivian Andes. For many centuries, the leaves of this plant were chewed or sucked by inhabitants to decrease hunger, increase endurance, and generate a sense of well-being. Addiction was not described until more concentrated forms of cocaine became available. Alkaloidal cocaine was first purified in 1860 by Niemann. Sigmund Freud and Hans Koller explored the physiological actions of cocaine. Freud first successfully employed the euphoriant effects of cocaine to wean a patient addicted to morphine. The unforeseen result was to create the first person addicted to cocaine (Goodman Gilman et al 1990).

Phencyclidine was popular in the 1980s as a stimulant that heightened sensory perception. Strokes were reported in several users (Bessen 1982; Brust 1986). The risk of psychosis and violent behavior with higher doses or chronic use decreased its popularity.

Heroin (diacetylmorphine) is a semisynthetic derivative of morphine, 1 of the substances contained in opium. Opium is derived from the unripe seed capsules of the poppy plant, Papaver somniferum. Opium addiction is recorded as early as the third century BC, and during the early part of the 20th century it was estimated that 1 out of every 400 Americans was addicted to opium or related agents. Heroin abuse did not develop until the advent of hypodermic needles (Goodman Gilman et al 1990). Although it is most frequently injected intravenously, increases in purity have allowed users to smoke heroin, a method of administration that appears to be growing in popularity.

Cannabis, from the plant Cannabis sativa, is the most widely used recreational drug in the world. It is most often prepared as marijuana or hashish, which are subsequently smoked, inhaled, or ingested. The psychoactive ingredient in cannabis is delta-9-tetrahydrocannabinol (THC). Potency can vary widely across preparations based on the THC content, which is generally higher in hashish than in marijuana (Wolff et al 2013). Synthetic drugs that bind to the same cannabinoid receptors as THC have been developed. These drugs are sold as synthetic cannabis under brand names such as spice or K2. Similar to synthetic amphetamines, synthetic cannabis can be purchased online or in drug paraphernalia stores (Brust 2013).

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