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Images courtesy of Shawn Hempel | Dreamstime.com (top), Wikimedia Commons/Dozenist (bottom left), Tichauer M, Fagan S, Goverman J. Eplasty. 2014;14:ic39. [Open access.] PMID: 25525486, PMCID: PMC4206057 (bottom right).

Physical Manifestations of 9 Drugs of Abuse

Michael J. Payette, MD, MBA | January 5, 2017 | Contributor Information

Discussion of substance abuse generally revolves around addiction, with a focus on the neurologic, psychosocial, and medicolegal consequences of this disorder. It is known that most drugs of abuse can alter a person's thinking and judgment, as well as lead to health risks that include addiction, drugged driving, and infectious disease.[1,2]

One important issue that may not be considered as often in individuals who abuse drugs is that physical manifestations ranging from mild to severe may occur as a result of their excessive use of certain substances. Do you know the various physical signs that can be associated with the following nine drugs of abuse?

Images courtesy of Wikimedia Commons.

Physical Manifestations of 9 Drugs of Abuse

Michael J. Payette, MD, MBA | January 5, 2017 | Contributor Information

Kratom (Mitragyna speciosa), also called herbal speedball, biak-biak, or ketum, is a tropical tree that is found in Southeast Asia that contains opioid compounds causing aphrodisiac effects. The leaves can be chewed or brewed into tea, as well as smoked or eaten.[3] The leaves are commonly boiled and mixed with cough syrup, cola and ice; a cocktail known as 4x100. There has been an epidemic of such practices in Thailand since 2010, causing policy changes aimed at eradicating the tree from the forests due to the deleterious effects of consumption.[4] Currently in the United States, it is considered a drug of concern and multiple states have banned its use.

There are two particular compounds naturally derived from the plant that interact with opioid receptors in the brain, mitragynine and 7-hydroxymitragynine.[5] The resulting effect consists of pleasure, decreased pain sensation, increased energy, and sociability. The compounds are addictive and withdrawal can cause symptoms such as hostility, insomnia, muscle aches, aggression and runny nose.

The reported health effects of kratom include sensitivity to sunburns, nausea, itching, sweating, dry mouth, constipation, increased urination, darkening of the skin and loss of appetite. More severe effects may include seizure, psychosis, tachycardia, liver toxicity and hypertension. Similar to other opioid compounds, Kratom can cause life threatening respiratory depression.

Deaths due to use seem to be rare and are thought to be related to lacing with prescription pain relievers.

Image courtesy of Wikimedia Commons/Radspunk.

Physical Manifestations of 9 Drugs of Abuse

Michael J. Payette, MD, MBA | January 5, 2017 | Contributor Information

Methamphetamine

Methamphetamine, also called "meth," "crystal meth," and "ice," is a stimulant drug that is similar in structure to amphetamine.[6] It is often abused for its long-lasting euphoric effects, which can increase sexual desire and thus has contributed to its reputation as an aphrodisiac.[3,4]

Methamphetamine can be found in various different forms, including a crystalline form (shown) that can be smoked, a powder that can be snorted, and a pill that can be ingested.[1,6] This drug can also be mixed with liquids and injected intravenously (IV).

Common short-term effects of methamphetamine include tachycardia, arrhythmia, hypertension, hyperthermia, and convulsions.[1,6] Long-term effects include agitation, insomnia, anxiety, seizures, and psychotic behavior.[1,6] Overdoses can result in death from stroke, myocardial infarction, and hyperthermia-related multiorgan complications.[6]

Images courtesy of DermNet NZ[9] (top row) and Wikimedia Commons/Dozenist (bottom row).

Physical Manifestations of 9 Drugs of Abuse

Michael J. Payette, MD, MBA | January 5, 2017 | Contributor Information

The cutaneous effects of methamphetamine are typically due to delusional parasitosis, in which the meth abuser experiences the sensation of insects creeping on or beneath the skin—leading to compulsive skin picking, with subsequent abscess formation (top images) and even cellulitis.[1,6,8] Other cutaneous effects include hyperhidrosis as well as drug-induced allergic eruptions.[9]

Methamphetamine abusers also appear to have higher rates of dental disease compared to the general population, with those who inject the drug affected more often than those who inhale and/or smoke it.[10] Manifestations of dental or oral disease include missing, broken, or loose teeth, as well as dental caries and periodontal abscesses—thereby forming the characteristic "meth mouth" often seen in these individuals (bottom images).[10] Methamphetamine users with poor oral hygiene and caries are at higher risk for infections in the maxilla, including sinusitis and dangerous abscesses that may require surgical intervention.[11]

Images courtesy of Bakhshaee M, Khadivi E, Naseri Sadr M, Esmatinia F. Iran J Otorhinolaryngol. 2013;25(70):53-6. [Open access.] PMID: 24303420, PMCID: PMC3846244.

Physical Manifestations of 9 Drugs of Abuse

Michael J. Payette, MD, MBA | January 5, 2017 | Contributor Information

These images are from a patient with nasal septal perforation due to methamphetamine abuse. The left image is a radiographic view of the patient's paranasal sinus; the right image is an endoscopic view of the patient's nasal cavity.

Images courtesy of Wikimedia Commons/Hendrike (top) and the US Drug Enforcement Administration (DEA) (bottom left and right).

Physical Manifestations of 9 Drugs of Abuse

Michael J. Payette, MD, MBA | January 5, 2017 | Contributor Information

Heroin

Heroin, also known as "dope" and "big H," is a synthetic opioid drug that can be smoked, snorted, or injected IV.[1,6] It can be found in several forms, of which the two primary ones seen in the United States are a white or brownish powder and a sticky black formulation ("black tar")[1,6] that may be pure or, commonly, diluted ("cut") with other drugs or substances (eg, sugar, starch, powdered milk, quinine).[6]

Physical findings of heroin use include pupillary miosis, mild hypotension, and bradycardia.[12] Overdose can lead to respiratory depression and lethargy that can progress to hypoxia, hypercarbia, and coma; respiratory depression also greatly increases the risk for aspiration pneumonia.[12] Other complications include infection with human immunodeficiency virus (HIV) and/or hepatitis C virus (HCV), endocarditis, chronic constipation, and hepatorenal disease.[1,12,13]

Images courtesy of Dreamstime/Katarzyna Bialasiewicz (top) and Medscape (bottom left and right).

Physical Manifestations of 9 Drugs of Abuse

Michael J. Payette, MD, MBA | January 5, 2017 | Contributor Information

One of the most common cutaneous findings of intravenous heroin use is scarring or "track marks" (bottom right) that follow along the course of veins, often in the arms and legs.[14,15] Chronic IV heroin use can also manifest with abscesses, cellulitis, and necrotizing fasciitis (bottom left), a rare but life-threatening complication; these features are particularly associated with the use of black tar heroin. The bottom left image depicts gaseous distention in the tissue on the inferior aspect of the image.[14]

Image courtesy of Wikimedia Commons.

Physical Manifestations of 9 Drugs of Abuse

Michael J. Payette, MD, MBA | January 5, 2017 | Contributor Information

Data from the National Institute on Drug Abuse (NIDA) indicate that between 2001 and 2014, mortality due to heroin overdose increased six-fold.[16] There were more than 10,000 deaths related to heroin in 2014 alone, a 439% increase from 1999.[17,18] Moreover, nearly half of young injection heroin users reported using prescription opioid agents prior to initiating heroin use, some of whom noted that heroin is cheaper and easier to obtain than prescription narcotics.[13] Thus, the rise in heroin-related mortality appears to be one of the many consequences of the excessive prescription of narcotic agents, which has led to the current prescription opioid overdose epidemic.[17]

In response to the epidemic of heroin use, cities across the United States are installing safe-injection sites, supervised injection centers where users can control their dosing and intake. Other initiatives to deter IV heroin abuse outright include increasing access to Suboxone and prescribing Naloxone to users and their families so that opioid overdoses can be reversed: a potentially lifesaving treatment.[17] Recognizing the many signs and symptoms of heroin abuse, including common skin findings, will be increasingly important in order to connect users with available programs and slow the growth of the epidemic.

Images courtesy of Dreamstime/Maxim Evdokimov (main) and the DEA (inset).

Physical Manifestations of 9 Drugs of Abuse

Michael J. Payette, MD, MBA | January 5, 2017 | Contributor Information

Cocaine

Cocaine, also called "coke," "snow," and "blow," is a central nervous system (CNS) stimulant that is frequently abused for its effects of euphoria and perceived increase in libido (in actuality, cocaine may reduce inhibition, which can lead to high-risk sexual behavior[7]).[1,6] Common formulations include a white powder that is snorted or injected (after dissolving in water), as well as a white crystalline form that can be smoked ("crack cocaine," "crack").[1,6] As is the case with heroin, cocaine can be cut with other substances (eg, sugar, local anesthetic).

Effects of cocaine use include tremors, garrulousness, restlessness, anorexia, insomnia, anxiety, and psychosis.[1,20] Other features of cocaine use include pupillary mydriasis, hypertension, tachycardia, arrhythmias, headache, stroke, and seizures.[1,6]

Image courtesy of Vatadoshu (left) and FarmerYo (right), both via Wikimedia Commons.

Physical Manifestations of 9 Drugs of Abuse

Michael J. Payette, MD, MBA | January 5, 2017 | Contributor Information

Long-term cocaine abusers who snort the drug can suffer from nasal damage and nasal septal necrosis and perforation (right).[1,6] Those who smoke cocaine as crack can have blackened, hyperkeratotic palmar and dorsal-surface lesions secondary to burns from a crack pipe[20]; this is sometimes referred to as "crack hands."

Similar to other stimulant drugs, cocaine use can also lead to parasitic delusions and secondary excoriations (left),[1,6] and overdose can result in hyperthermia, convulsions, cardiovascular collapse, and death.[6]

Images courtesy of Arora NP, Jain T, Bhanot R, Natesan SK. Addict Sci Clin Pract. 2012;7:19. [Open access.] PMID: 23186390, PMCID: PMC3509389.[23]

Physical Manifestations of 9 Drugs of Abuse

Michael J. Payette, MD, MBA | January 5, 2017 | Contributor Information

Levamisole-associated manifestations in cocaine abuse

Levamisole is a veterinary antihelminthic agent that is commonly found as a cocaine contaminant[21]; a 2011 DEA report estimated that 82% of seized cocaine was contaminated with levamisole.[19] It is thought that cutting cocaine with this drug may increase the euphoric effects of cocaine.[22]

Systemic complications of levamisole include agranulocytosis and leukopenia.[21,23,24] Its adverse effects include nausea, abdominal cramps, alterations in taste, alopecia, arthralgia, and a flulike syndrome.[25]

The photographs show recurrent purpuric and necrotic lesions on the lower-extremity amputation stumps of a patient with a history of repeated cocaine use.

Images courtesy of Arora NP, Jain T, Bhanot R, Natesan SK. Addict Sci Clin Pract. 2012;7:19. [Open access.] PMID: 23186390, PMCID: PMC3509389.[23]

Physical Manifestations of 9 Drugs of Abuse

Michael J. Payette, MD, MBA | January 5, 2017 | Contributor Information

Levamisole can also cause a constellation of dermatologic complications in cocaine users who are exposed to the adulterant, including leukocytoclastic vasculitis, cutaneous necrotizing vasculitis, and thrombotic vasculopathy without vasculitis.[21,23,24,26,27] These complications commonly manifest in the earlobes but can involve all areas of the body.[24,26]

These photographs are from the same patient as in the previous slide. Extensive levamisole-induced necrosis of the skin, soft tissue, and cartilage eventually resulted in nasal self-amputation, earlobe necrosis, and bilateral above-knee amputation (AKA).

Images courtesy of Tichauer M, Fagan S, Goverman J. Eplasty. 2014;14:ic39. [Open access.] PMID: 25525486, PMCID: PMC4206057.

Physical Manifestations of 9 Drugs of Abuse

Michael J. Payette, MD, MBA | January 5, 2017 | Contributor Information

These photographs are from an IV cocaine and heroin user. The patient had cutaneous necrosis of the bilateral anterior and posterior thighs, buttocks, and left upper extremity—which was determined to be a complication of levamisole-induced antineutrophil cytoplasmic antibody (ANCA) vasculitis.

Image courtesy of the DEA.

Physical Manifestations of 9 Drugs of Abuse

Michael J. Payette, MD, MBA | January 5, 2017 | Contributor Information

Anabolic Steroids

Anabolic steroids, also referred to as "Arnolds," "juice," and "roids," are synthetically produced variants of testosterone.[1,6] Their clinical use has been for hormone replacement therapy and for illness-related cachexia.[28]

As drugs of abuse, anabolic steroids are used as performance enhancing agents—for promoting muscle growth, enhancing athletic and/or sexual performance, and improving physical appearance.[1,6] Although these substances are not associated with overdoses, long-term use may lead to a variety of adverse effects that generally do not occur in a controlled clinical setting, such as extreme mood swings and aggressive behavior, sometimes referred to as "roid rage." Other manifestations of chronic illicit anabolic steroid use include infertility, female virilization, male gynecomastia, decreased testicular volume, short stature in adolescents, tendon rupture, striae, hepatic carcinoma, and myocardial infarction.[1,6]

Common formulations of the illicit drugs include liquid drops, tablets and capsules, gels, creams, transdermal patches, subdermal implant pellets, and water- and oil-based injectable solutions.[1,6]

Image courtesy of DermNet NZ.

Physical Manifestations of 9 Drugs of Abuse

Michael J. Payette, MD, MBA | January 5, 2017 | Contributor Information

Cutaneous manifestations of anabolic steroid abuse often include acne and oily scalp.[1,6] If hepatic injury or malignancy has occurred, jaundice may be present.

Because anabolic steroids are structurally similar to natural endogenous androgens, they stimulate enlargement of sebaceous glands, increasing sebum excretion and resulting in acne.[26] An estimated 50% of all steroid abusers are affected with acne, ranging in severity level from mild papulopustular acne to acne fulminans (shown).[30]

Image courtesy of Wikimedia Commons/Marler.

Physical Manifestations of 9 Drugs of Abuse

Michael J. Payette, MD, MBA | January 5, 2017 | Contributor Information

Ethanol

Ethanol is a CNS depressant and an intoxicating ingredient found in liquor, wine, and beer as the result of fermentation of yeast, sugars, and starches.[31] Short-term effects include impaired cognitive and motor function; long-term use can raise the risk of certain malignancies, stroke, and hepatic disease.[31,32]

Other features associated with acute alcohol intoxication include tachycardia, diuresis, loss of behavior inhibitions, and hypoglycemia.[33] High doses of ethanol can cause acute pancreatitis, hypotension, arrhythmias, congestive heart failure (CHF), pulmonary edema, and cardiovascular collapse. These conditions, especially in combination with an increased risk for aspiration and loss of consciousness, can result in death.[33]

Chronic effects of heavy alcohol use can lead to chronic pancreatitis, cardiomyopathy, hypertension, malnutrition, and obesity.[33] Because ethanol is primarily metabolized by the liver, abusers of alcohol also have an increased risk for hepatic cirrhosis and hepatic carcinoma.[32,33]

Image courtesy of DermNet NZ.

Physical Manifestations of 9 Drugs of Abuse

Michael J. Payette, MD, MBA | January 5, 2017 | Contributor Information

Facial flushing is an easily recognizable, common cutaneous feature of acute ethanol intoxication. This reaction is caused by a build-up of acetaldehyde, a breakdown product of ethanol, which causes histamine release and subsequent dilation of superficial vessels.[34]

Images all courtesy of DermNet NZ.

Physical Manifestations of 9 Drugs of Abuse

Michael J. Payette, MD, MBA | January 5, 2017 | Contributor Information

Heavy alcohol abuse over the long term can lead to alcohol-related cirrhosis. There are several cutaneous findings associated with cirrhosis, including the presence of jaundice (left), spider angiomata/telangiectasias (bottom right), and palmar erythema (top right).[34] Caput medusa, as well as hyperpigmentation around the eyes, mouth, and legs may also be evident.[34]

Spider angiomata, or spider telangiectasias, are vascular lesions often found on the trunk, face, and upper limbs.[35] Although the exact pathophysiology is unclear, they may occur due to an alteration in sex hormones that occurs with hepatic cirrhosis, specifically an increase in estrogen levels.[34,35] However, spider angiomata are not pathognomonic for cirrhosis, as they can also be found in gravid females and people suffering from severe malnutrition; nonetheless, the number and size of these lesions can correlate with the severity of liver disease.[35]

Palmar erythema is also thought to be caused by an estrogen imbalance and, as with spider angiomata, it is not diagnostic or specific for cirrhosis but can be found in this disorder.[34,35]

Image of C sativa courtesy of Wikimedia Commons/Bogdan (top); image of marijuana joint courtesy of Wikipedia/Erik Fenderson (bottom).

Physical Manifestations of 9 Drugs of Abuse

Michael J. Payette, MD, MBA | January 5, 2017 | Contributor Information

Marijuana

Marijuana, also known as cannabis, is derived from the Cannabis sativa plant, and its main psychoactive ingredient is delta-9-tetrahydrocannabinol (THC).[1,6] It has many street names, including "weed," "grass," "dope," "Mary Jane," "hash," and "blunt." Marijuana is commonly smoked through a pipe, bong, cigarette (joint) (shown), or blunt; it can also be ingested orally.[1,6]

Short-term effects of this drug include enhanced sensory perception, euphoria followed by drowsiness/relaxation, disinhibition and impaired judgment, impaired cognitive and sensorimotor function, conjunctival injection, increased appetite, hypertension, tachycardia, and hallucinations.[1,6]

Long-term use has been associated with mental health issues such as an increased risk of depression and schizophrenia, as well as other psychotic disorders; pulmonary conditions that include bronchitis, emphysema, and bronchial asthma; an impaired immune system; and an increased risk of malignancies affecting the head/neck, lungs, and respiratory tract.[1,6]

Marijuana has currently been legalized for medical use in 28 states and for recreational use in eight. In 2016, Colorado is expected to make more than $140 million dollars in tax revenue from marijuana sales, twice that of alcohol taxes.[36] Proponents of marijuana legalization argue that the reform boosts the economy, redistributes spending for law enforcement, and allows for quality standards to be applied to commercially available marijuana. However, counterarguments consider the danger of altered perception and driving under the influence, as well as addictive potential and the implication of long term negative health consequences. The current state of marijuana legalization is a dynamic and controversial topic that will likely continue to evolve as more states are faced with the decision of whether to pass legalization laws or not. While no deaths from marijuana overdose has been reported, there have been some accidental deaths secondary to the effects of marijuana on cognition and ability to operate vehicles.[6]

Images courtesy of the DEA.

Physical Manifestations of 9 Drugs of Abuse

Michael J. Payette, MD, MBA | January 5, 2017 | Contributor Information

Bath Salts

"Bath salts" (not related to the bathing products), are also known as "flakka," "bloom," "bliss," and "cloud nine." They belong to a class of synthetic/designer cathinones similar to natural cathinones found in the khat plant.[1,6] These drugs have CNS stimulant as well as hallucinogenic properties. Common ingredients include methylenedioxypyrovalerone (MDPV) and mephedrone, substances that mimic 3,4-methylenedioxy-methamphetamine (better known as MDMA, "molly," or "ecstasy").[6] However, as with most illicit drugs, compositional variability exists depending on the manufacturers.[6]

Bath salt formulations include white or brown crystalline powders, tablets, capsules, and liquids.[1,6] To circumvent drug-enforcement authorities, manufacturers of bath salts often package and label their products as "not for human consumption" and/or "bath salts," "plant food," "glass cleaner," and "research chemicals."[6] These drugs can be sniffed, snorted, and smoked, as well as taken orally or mixed with a solution and injected.[1,6]

Image courtesy of Dreamstime/Razyph.

Physical Manifestations of 9 Drugs of Abuse

Michael J. Payette, MD, MBA | January 5, 2017 | Contributor Information

Bath salts have gained media attention for the marked effects that they can have on abusers, including extreme aggression, increased sex drive, and self-mutilation, as well as agitation and psychotic and violent behavior.[37-40] Other effects include tachycardia, hypertension, hyperthermia, hyperhidrosis, prolonged mydriasis, rhabdomyolysis, kidney failure, and death.[1,6] Bath salts are particularly dangerous when mixed with other drugs, which is common.[41-43]

The cutaneous effects of bath salts are similar to those of other stimulant drugs, most notably diaphoresis; however, mephedrone (a common constituent of the drugs) causes a characteristically strong body odor.[44-47] When the drugs are snorted, they can cause burns and ulcerations in the nose[46] that may eventually perforate the nasal septum. Complications as severe as necrotizing fasciitis may occur with intramuscular injections.[47,48]

Illustration courtesy of Sam Shlomo Spaeth.

Physical Manifestations of 9 Drugs of Abuse

Michael J. Payette, MD, MBA | January 5, 2017 | Contributor Information

Krokodil

"Krokodil," "crocodil," "poor man's heroin," and "Russian heroin" are street names for illicit desomorphine, a powerful injectable synthetic morphine analogue (about 10 times more potent than morphine) that appears to have originated from Russia in the early 2000s.[49-52] Pure desomorphine has been used in medical practice in Switzerland under the brand name of Permonid; it has a faster onset and shorter duration than morphine, as well as causes less nausea and respiratory depression.[49,53] There is no accepted medical use for desomorphine in the United States, and it has been controlled in the United States (schedule I) since 1936.[49]

Krokodil is often manufactured with a codeine base and an assortment of caustic ingredients—including gasoline, iodine, paint thinner, hydrochloric acid, and lighter fluid—which, when administered as an IV injection, can cause local blood vessel and soft-tissue damage and thrombosis that appear similar to the rugged, scaly, green-black skin of crocodiles, hence its name.[49-52] Eventually, the skin injuries develop into severe tissue damage that result in thrombophlebitis, infectious abscesses, necrosis, and gangrene. Limb amputation and/or death may follow.[49]

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Alcoholics are at increased risk for cirrhosis, GI bleeding, pancreatitis, cardiomyopathy, trauma, mental health disorders, and a wide variety of cancers. Learn more about the devastating short- and long-term complications of alcohol abuse.Slideshows, December 2016
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Opioids are powerful pain killers that are highly addictive. Opioid dependence affects nearly 5 million people in the United States and leads to approximately 17,000 deaths annually.Diseases/Conditions, May 2017
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Cannabis-Related Disorders

While marijuana may have medicinal benefits, its use in excess by some individuals can lead to marked impairment in social and occupational functioning.Diseases/Conditions, March 2017
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References