Intravenous Drug Abuse

Many drugs can be injected intravenously. The drugs themselves may have the major effect of impairment of mental function, but the route of administration can have serious complications. Injection of drugs with needles that are not sterile leads to the potential for a wide variety of infections. Such infections include: human immunodeficiency virus (the causative agent for AIDS), viral hepatitis (particularly hepatitis B and C), and bacterial infections.

Persons with a history of intravenous drug abuse also are more likely to have tuberculosis of the lungs. The drug heroin can produce a nephropathy in the kidney that resembles focal segmental glomerulosclerosis. In addition, a "talc granulomatosis" can occur because many injected drugs have been adulterated with an inert substance (such as talcum powder) to "cut" or dilute the amount of drug.

Cocaine

Cocaine can exert a variety of effects. The major acute effects producing pathologic conditions result from the increased circulating catecholamine levels with cocaine use. These increased catecholamines can produce vasoconstriction. The lesions can include acute hemorrhages and infarction in the brain. Ischemic changes in the heart from small artery narrowing and sclerosis lead to contraction band necrosis of the myocardium and possible sudden death. Combining cocaine use with ethanol use can compound the myocardial damage. Pregnant mothers who use cocaine can affect their fetuses from abnormalities of placental function leading to low birth weight babies or an increased risk for placental abruption. Maternal cocaine use increases the risk for spontaneous abortion.

Persons with cocaine intoxication (not necessarily related to the drug level) may develop a state of iatrogenic psychosis (cocaine psychosis) with "excited delerium" in which they are markedly agitated and combative and develop hyperthermia, often of a severe degree (to 106 F ). Organ damage can accompany this state of excited delerium and may include rhabdomyolysis of muscle, hepatotoxicity, and renal failure. Disseminated intravascular coagulation (DIC), hypotension, and sudden death are additional complications.

Methamphetamine

Methampetamine is a stimulant drug with inotropic effects upon the cardiovascular system. Methamphetamine is metabolized to amphetamine, which is also a stimulant. The heart may have such stress placed upon it that there are ischemic changes to the myocardial fibers. The myocardial effects are made worse by concomitant ethanol use.

GHB

Gamma-hydroxybutyrate (GHB) is a metabolite of the neurotransmitter gamma aminobutyric acid (GABA) and also functions as a neurotransmitter by affecting the dopaminergic system. GHB may also potentiate the effects of endogenous or exogenous opiates. GHB was introduced into the U.S. in 1990 as a purported stimulant to muscle growth during sleep, but it was soon banned because of problems with overdose and adverse reactions. Moreover, GHB is no longer used as an anesthetic agent because of the risks. The effects of GHB can be potentiated by alcohol and by benzodiazepines. The ingestion of GHB results in drowsiness and dizziness with the feeling of a "high" within 10 to 20 minutes and lasting up to 4 hours. There are a multitude of adverse effects that can occur within 15 minutes to an hour, including: headache, nausea, vomiting, hallucinations, loss of peripheral vision, nystagmus, hypoventilation, cardiac dysrhythmias, seizures, and short-term coma. These findings generally subside in 2 hours to 4 days. It is difficult to predict how much GHB will produce an overdose. Withdrawl from GHB can have an onset in 12 hours and last up to 12 days. In rare instances, deaths have occurred from these adverse effects.

Ecstasy

The methylene-dioxy derivatives of amphetamine and methamphetamine are "designer drugs" that generically are termed "ecstasy" and include 3,4-methylenedioxy-methamphetamine (MDMA), also known as "Adam," 3,4-methylenedioxy-ethylamphetamine (MDEA), also known as "Eve," and N-methyl-1-(3,4-methylenedioxyphenyl)-2-butanamine (MBDB), also known as "Methyl-J" or "Eden." A "designer drug" is a compound that is chemically altered from the form of a controlled substance in order to produce special effects and to bypass legal regulations. MDMA and similar compounds are "entactogens" that act upon dopaminergic and serotonergic pathways in the brain to give users a felling of euphoria, energy, and a desire to socialize. These immediate effects last approximately 3 to 6 hours.

The adverse effects of ecstasy use may include hyperthermia, liver toxicity, and neuropsychiatric effects. Severe dehydration leading to excessive fluid intake and water intoxication. There can be memory deficits, confusion, depression, and sleep problems even weeks after taking this drug. Long term use may be accompanied by long-lasting brain damage and memory impairment.

A syndrome including hyperthermia, disseminated intravascular coagulation, rhabdomyolysis, hepatic failure, and renal failure has been reported with MDMA use, findings similar to the excited delirium of cocaine use. In addition persons using MDMA may develop acute fulminant hepatitis with liver failure, and possible death, that can occur days to weeks following drug use.

Anabolic-Androgenic Steroids

The use of anabolic-androgenic steroids (AAS) has increased substantially over the past two decades. These drugs are used mainly for their effect of increasing muscle mass for the desired goal of increasing athletic performance and enhancing physical appearance. However, such drugs do not increase the level of skill in performance and cardiovascular function--the major enhancers to most sports-related activities. There are many adverse effects to AAS use. In men these include: testicular atrophy, decreased testosterone production, gynecomastia, hypertension, fluid retention, tendon injuries, nosebleeds, more frequent colds, and sleep disorders. In women, the adverse effects reported include: decreased breast size, fluid retention, hypertension, and sleep disorders. The major psychiatric effects of AAS use include major mood disorders including depression and mania. Such adverse effects could significantly impact athletic performance negatively and decrease sexual function. In short, anabolic steroids can prevent the very things that they are supposed to enhance.

The most serious complication of AAS use is an increased risk for heart disease and sudden death. Anabolic steroids decrease HDL cholesterol and increase cardiac size. Myocardial fibrosis can occur, similar to cardiomyopathy. Hypertension induced by AAS further increases heart size. These effects may persist even after use of AAS has been stopped, increasing the risk for morbidity and mortality. Anabolic steroids have been shown to enhance the coronary artery response to catecholamines released during periods of stress, and this may play a role in the sudden cardiac deaths reported with their use. Contraction band necrosis, indicative of ischemia, has been observed in such deaths.