Neurocritical Care and Stroke Division, Department of Neurology, The Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio.
Department of Neurosurgery, The Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio.
JAMA Neurol. 2018 Nov 1;75(11):1423-1434. doi: 10.1001/jamaneurol.2018.1693.
Opioid addiction affects approximately 2.4 million Americans. Nearly 1 million individuals, including a growing subset of 21 000 minors, abuse heroin. Its annual cost within the United States amounts to $51 billion. Inhaled heroin use represents a global phenomenon and is approaching epidemic levels east of the Mississippi River as well as among urban youth. Chasing the dragon (CTD) by heating heroin and inhaling its fumes is particularly concerning, because this method of heroin usage has greater availability, greater ease of administration, and impressive intensity of subjective experience (high) compared with sniffing or snorting, although it also has a safer infectious profile compared with heroin injection. This is relevant owing to peculiar and often catastrophic brain complications. Following the American Medical Association Opioid Task Force mandate, we contribute a description of the pharmacology, pathophysiology, clinical spectrum, neuroimaging, and neuropathology of CTD leukoencephalopathy, as distinct from other heroin abuse modalities.
The unique spectrum of CTD-associated health outcomes includes an aggressive toxic leukoencephalopathy with pathognomonic neuropathologic features, along with sporadic instances of movement disorders and hydrocephalus. Clinical CTD severity is predominantly moderate at admission, frequently unmodified at discharge, and largely improved in the long term. Mild cases survive with minor sequelae, while moderate to severe presentations might deteriorate and progress to death. Other methods of heroin use may complicate with stroke, seizure, obstructive hydrocephalus, and (uncharacteristically) leukoencephalopathy.
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. Proposed diagnostic criteria and standardized reporting would ameliorate the limitations of CTD literature and facilitate patient selection for a coenzyme Q10 therapeutic trial.
阿片类药物成瘾影响约 240 万美国人。近 100 万人，包括越来越多的 21000 名未成年人，滥用海洛因。其在美国的年成本达到 510 亿美元。在密西西比河以东以及城市青年中，吸入海洛因的使用代表了一种全球现象，且正在接近流行水平。加热海洛因并吸入其烟雾的“追龙”（CTD）尤其令人担忧，因为这种海洛因使用方法具有更大的可用性、更易于管理，并且与嗅吸或吸食相比，具有令人印象深刻的主观体验强度（高），尽管与海洛因注射相比，它也具有更安全的传染性特征。这是相关的，因为它会导致奇特且经常是灾难性的大脑并发症。根据美国医学协会阿片类药物工作组的授权，我们对 CTD 性脑白质病的药理学、病理生理学、临床谱、神经影像学和神经病理学进行了描述，与其他海洛因滥用方式不同。
CTD 相关健康结果的独特谱包括具有特征性神经病理学特征的侵袭性毒性脑白质病，以及偶尔出现的运动障碍和脑积水。临床 CTD 严重程度在入院时主要为中度，出院时通常不变，且在长期内有很大改善。轻度病例存活后仅有轻微后遗症，而中度至重度表现可能恶化并进展为死亡。其他海洛因使用方法可能会出现中风、癫痫发作、阻塞性脑积水，以及（非典型）脑白质病。
CTD 的独特药理学与它特定的临床和影像学特征相关，引起了对潜在发病率和长期残疾成本的严重关注。拟议的诊断标准和标准化报告将改善 CTD 文献的局限性，并促进辅酶 Q10 治疗试验的患者选择。
