A Case Report of Myelopathy Following Heroin Overdose in a Child

Neurologic complications secondary to heroin abuse in the adult population have been widely described in the literature. With the recent opioid epidemic and increasing rates of heroin abuse in adolescents, pediatricians are now encountering the diagnostic and management challenge of similar complications in children. We report a case of a 16-year-old girl who presented with complete paraplegia after a heroin overdose. Spinal magnetic resonance imaging showed diffuse thoracic spinal cord abnormalities. She rapidly recovered after high dose intravenous corticosteroids and, upon hospital discharge 2 weeks later, required minimal assistance with ambulation. This case represents the youngest patient reported with the rare complication of myelopathy associated with heroin use.

Cannabis alleviates neuropathic pain and reverses weight loss in diabetic neuropathic cachexia in a previous heroin abuser

Summary Ten years after the successful withdrawal from heroin abuse, a person with diabetes suffered intractable pain and severe muscular emaciation consistent with the syndrome of diabetic neuropathic cachexia. Anti-neuropathic medications failed neither to alleviate suffering and reverse weight loss, nor to stop muscular emaciation. Vigilant evaluation for weight loss aetiologies revealed no responsible aetiology. Prescribing medical cannabis became mandatory, with the intention to alleviate neuropathic pain, regain muscular mass and strengthen legs, enable standing upright and walking normally. Medical cannabis for pain-relief, and the orexigenic properties of tetrahydrocannabinol (THC) ingredient successfully achieved these goals. Learning points: Medical cannabis can serve to promptly alleviate severe diabetic neuropathic pain. Past history of heroin abuse was not an absolute contraindication to medical cannabis use. Medical cannabis increased appetite and reversed muscular emaciation. Medical cannabis decreased chronic pain and hence, its catabolic consequences.

SAT-372 A Case of Hypercalcemia Secondary to Rhabdomyolysis Induced by Heroin Use

Background: Rhabdomyolysis is a potential life threatening condition defined as injury of the skeletal muscle, which results in the release of intracellular contents into the circulation. This muscle injury is often associated with the development of myoglobinuria, electrolyte abnormalities, and often ARF; it can be caused by diverse mechanisms including drugs and toxins. We present a case of rhabdomyolysis complicated by hypercalcemia and ARF in a patient with a history of polysubstance abuse after using intravenous heroin. Case: A 28 y/o male with h/o polysubstance comes to the ED with c/o fatigue, nausea, vomiting and decreased urine output for about 5 days; patient acknowledged using heroin and afterwards he developed weakness and tenderness in upper and lower extremities. Additionally he admitted cocaine and marijuana abuse. On physical exam vital signs were unremarkable and he had some mild tenderness to palpation mostly of the quadriceps bilaterally. Laboratory data was significant for acute kidney injury (cr 11.33 mg/dl, n: 0.7–1.5 mg/dl) and CPK 171920 u/l (n: 22–269 u/l). He received 2 L of NS in the ED and was started on NS at 100cc/hour. He underwent hemodialysis on day 2; initially he was treated for hypocalcemia with calcium and vitamin D supplementation until day 11 were hypercalcemia (calcium 12.7 mg/dl, n: 8.7–10.3 mg/dl; ionized calcium 1.7 mmol/l, n: 1.12–1.32) was noted; this was associated with concomitant suppression of PTH (5 pg/ml, n: 10–65 pg/ml). He remained asymptomatic from calcium abnormalities during his hospitalization, his urine output recovered progressively, hemodialysis was discontinued on day 13. Upon discharge was recommended to f/u with nephrology. Discussion: Various neurological and neuromuscular complications of heroin abuse have been described; one of these is rhabdomyolysis; its pathophysiology in heroin abuse is thought to be multifactorial; including acidosis, hypoxia, muscle compression and adulterants found in heroin. Narcotics may also have direct cell toxicity and alter membrane transport. Usually upon initial presentation hypocalcemia is one of the most common electrolyte imbalances seen with rhabdomyolysis. The proposed mechanism is precipitation of serum calcium salts in necrotic muscle. This may be followed by hypercalcemia during the diuretic phase of ARF which appears to be a relatively unusual complication associated with the presence of severe muscle damage due to metastatic calcium salts that are liberated from the necrotic muscle and the return to the serum. Conclusion: This case report highlights the importance of recognizing potential electrolyte imbalances in patients with rhabdomyolysis; it appears, that concomitant rhabdomyolysis and ARF are needed for a patient to develop hypercalcemia. Serum calcium should always be routinely measured and the appropriate treatment should be implemented to improve outcomes.

Heroin Abuse among IDU and Local PO Dispensing Levels in Ontario Cities

Background: Amid Ontario’s growing opioid crisis, heroin abuse remains widespread in select urban areas and contributes to a large proportion of opioid overdoses provincially. Compared to prescription opioids (POs), heroin is especially hazardous to abuse since it is illicitly manufactured and frequently consumed by injection. PO abuse can also transition to heroin if access to preferred POs is impacted via diversion, dispensing or prescribing. However, the dynamics between preferences for heroin and local PO saturation (in this case, dispensing) are not well understood. Methods: Heroin abuse data were gathered from PHAC’s I-Track surveillance system while PO dispensing data were from the Ontario Drug Benefit (ODB) claims database. Using an unmatched repeated cross-sectional design, datasets spanning 2003 to 2011 were merged. The hierarchical structure consisted of individual-level I-Track responses nested within year and again within five city-level (Kingston, London, Sudbury, Thunder Bay and Toronto) dispensing rates. Mixed-effects multilevel logistic regressions were used to examine relationships. Results: Almost one third (30.5%) of I-Track respondents abused heroin in the previous six months with marked variation by city, from roughly half of Toronto participants (51.0%) to about one in twenty (5.2%) in Thunder Bay. The final multivariate model for heroin abuse contained morphine dispensing (OR=1.04, p=0.011), present age (OR=0.99, p=0.045) and age of first injection (OR=0.97, p≤0.001). That is, considering age and age of first injection, heroin abuse was 4.4% more likely among IDU with each increase in annual morphine dispensing rates in their respective cities. Implications: The connection between heroin abuse and dispensing rates of chemically similar morphine, but not other POs, reflects a substitution effect for specific opioid types regardless of whether illicit or prescription. Precautions should be taken to prevent heroin abuse and establish harm reduction strategies before expected interference to local dispensing levels of any chemically analogous POs (particularly morphine).