Barry Stimmel

The effect of heroin and multiple drug abuse on the electrocardiogram

Abstract The electrocardiograms (ECG) of 75 asymptomatic individuals admitted to a methadone treatment program were analyzed to determine the effect of street heroin and other drugs of abuse. All patients were free of cardiac, renal, or pulmonary disease and had no laboratory abnormalities. Two groups of patients were studied. In Group I there were 34 patients on heroin only which was taken within 24 hours of the ECG. Abnormalities were noted in 55 per cent; QT c prolongation was found in 19 per cent, and significant bradyarrhythmias were found in 19 per cent. In Group II there were 41 patients on methadone with multiple drug abuse; changes were found in 66 per cent. QT c prolongation was noted in 34 per cent, prominent U waves in 32 per cent, and bradyarrhythmias were found in 32 per cent. It is now a well-known fact that the sudden death syndrome in addicts may not be a pharmacologic or dosage-related phenomenon. The existence of conduction, depolarization, and repolarization abnormalities, as well as bradyarrhythmias in a significant number of drug-dependent individuals may play a role in the production and facilitation of lethal arrhythmias and may be the mechanism of the acute fatal reaction.

Effectiveness of pacemaker treatment in the bradycardia-tachycardia syndrome

Thirty-one patients with the bradycardia-tachycardia syndrome treated with permanent ventricular pacemakers were studied. All were symptomatic before pacemaker insertion, and their symptoms were not controlled with drug therapy alone. Bradycardia and tachycardia associated with multiple arrhythmias were present in all cases; heart rate was less than 40 beats/min in 58 percent of patients and more than 140 beats/min in 71 percent. Conduction abnormalities were present in 61 percent. After insertion of a demand pacemaker, 27 patients (87 percent) were symptom-free for 1 month to 5 years. Although four patients with a normally functioning pacemaker continued to have recurrent arrhythmia, the presence of a pacemaker facilitated further pharmacologic treatment of the disturbance. Pacemaker insertion has been found to be a satisfactory method of treating the symptoms and preventing the recurrence of arrhythmias in patients with the bradycardia-tachycardia syndrome by allowing the use of digitalis and other antiarrhythmic agents.

Adequacy of sexual performance in men maintained on methadone.

Impairment of sexual performance may occur in men on methadone maintenance. A random sample of 50 of 355 men enrolled in a methadone program was interviewed with respect ot sexual activity. Seventeen (33%) reported sexual dysfunction, occurring in 50% within 1 month after initiating methadone therapy. A comparison between these individuals and those without a reported change in sexual activity revealed no differences with respect to demographic parameters, methadone dose, or presence of polydrug abuse. Inadequate sexual function on heroin, however, was reported in 12 (71%) of those experiencing similar difficulties on methadone. This finding was present in only one person (3%) of those individuals whose sexual function on methadone maintenance was considered adequate. This study suggests that those persons with altered sexual function while on street heroin represent a high risk group for the development of inadequate sexual function upon initiation of methadone maintenance.

Mortality Rates of Persons Entering Methadone Maintenance: A Seven-Year Study

An analysis of all deaths occurring over a 79-month period in patients enrolled in methadone maintenance (MM) revealed an overall mortality rate of 20/1,000. Over a similar period 510 persons were discharged from MM. Follow-up able to be performed in 80% revealed at least 22 deaths to have occurred subsequent to discharge. Survival curves calculated on the basis of these data indicate that even under the best possible assumption, age adjusted mortality rates of heroin addicts are not only above the national mean but are one and a half times that of the population in the community surrounding the clinic. None of the deaths could be directly attributed to methadone. Alcohol was prominent in 60% of all deaths, being responsible for 89% of medical deaths and present in 35% of violent deaths. These findings emphasize the persistent risk associated with heroin addiction as well as the role of alcoholism in the production of excessive mortality.

Asymptomatic electrocardiographic alterations in sarcoidosis

Abstract Among 80 patients with tissue-confirmed sarcoidosis attending the sarcoidosis clinic of the Mount Sinai Hospital, electrocardiographic abnormalities of varying degree were noted in 41 patients, despite the fact that these patients were entirely without cardiac complaints and exhibited no evidence of previous or current cardiac disease on thorough examination. All these patients were under 40 years of age. The ECG alterations included repolarization abnormalities and alterations in rhythm and conduction. Because of the potential hazards of some of these abnormalities, prospective studies are being undertaken to determine which of them may represent precursors of dangerous intrinsic cardiac sarcoidosis.

The Ability to Remain Abstinent Upon Leaving Methadone Maintenance: A Prospective Study

Methadone maintenance is now an established modality in the management of heroin dependency. The ability of persons detoxified from methadone to remain opiate free has not been clearly defined. Of 490 consecutive admissions to a methadone maintenance program, 198 were subsequently detoxified. Follow-up on 168 persons (85%) was obtained for periods of up to 47 months. At the conclusion of the study, only 34 (17%) of those detoxified who were located were drug free. This represents 7% of the entire group of 490 persons admitted to the program. When ability to remain abstinent was correlated with reason for detoxification, 61% of those persons who the staff felt had received the maximum benefits of methadone maintenance were able to remain abstinent (p < 0.005). These findings suggest that although it is possible to progress from methadone maintenance to abstinence, many persons will be unable to maintain

ALCOHOLISM AND POLYDRUG ABUSE IN PERSONS OF METHADONE MAINTENANCE

It is difficult to arrive at precise figures concerning the number of persons in this country currently being treated for substance abuse. The National Institute of Drug Abuse (NIDA) estimated that in June of 1975, there were approximately 240,000 in treatment for substance abuse of all types, excluding alcohol and tobacco. This figure, however, does not include patients at facilities which are not identified as having specific personnel or programs dedicated to treating drug abusers. Since only a small fraction of those individuals involved in substance abuse are in treatment at any one particular time, the number of effected persons is undoubtedly much higher. Examining opiate abuse, for example, one finds estimates from NIDA which indicate that approximately 170,000 persons are in treatment for narcotic dependency, another 100,000 narcotic addicts are in jail at any one time, and another 300,000 to 400,000 are considered not to be in treatment: a majority of whom have never been in treatment.l These figures represent incomplete data and, not surprisingly, conflict with other estimates of numbers of narcotic addicts which range from 579,000 to 724,000, depending upon the reporting agency. Data with respect to persons enrolled in methadone maintenance, however, are more reliable. This relates to existing federal and state requirements which necessitate the reporting of all individuals receiving maintenance therapy. At present, approximately 32 percent of clients in treatment nationwide are in methadone maintenance programs. In New York City alone, 33,000 people are receiving methadone therapy, with approximately another 3,000 enrolled in methadone-toabstinence or in detoxification programs. Since its inception in 1964, few treatment modalities have met with as much controversy as that of methadone maintenance. Lauded by some and disapproved of by many, methadone maintenance, nonetheless, has become a major treatment modality for the management of heroin addicts. The emergence of methadone maintenance has been accompanied by many myths concerning its hazards as well as its advantages. It might have been anticipated that a therapeutic program requiring careful monitoring on federal, state, and local levels and located primarily within the authority of the medical profession would be a fertile ground for objective scientific testing and observation. Unfortunately, this has not occurred. Although the number of articles pertaining to methadone maintenance have proliferated over the past several years in medical, psychological, sociological, and epidemiological journals, as well as in the public media, these data generated have been

Comparison of infective endocarditis in drug addicts and nondrug users

All cases admitted over a 2-year period with the diagnosis of infective endocarditis were reviewed. Two groups were studied: Group 1—known drug addicts; and Group 2—persons with no history of drug use or cardiac disease before the onset of endocarditis. Group 1 consisted of 13 drug addicts with 17 admissions for endocarditis. Fifty-two percent used heroin, 30 percent amphetamines and 18 percent used both drugs. The infective organism was identified as Staphylococcus aureus in 64 percent, Candida in 17 percent and enterococcus in 11 percent. Respiratory symptoms and pulmonary infiltrates were seen on admission in 70 percent. Aortic valve involvement, either alone or in combination with mitral valve involvement, was seen in 11 instances (65 percent), isolated mitral insufficiency in 5 (29 percent). Complications were seen in 14 (82 percent). Surgical intervention for intractable cardiac failure was performed in 3 patients without operative mortality. Of the 10 patients treated medically, 3 died. Group 2, composed of 7 nondrug users differed from Group 1 in the following variables: (1) greater mean age (52.7 years compared to 27.4 years); (2) longer duration of symptoms, more than 1 week in 86 percent vs. 1 week or less in 94 percent of drug users, and (3) an absence of respiratory symptoms on admission. Surgical intervention was necessary in two patients. There were no deaths. Infective endocarditis in drug users remains a serious disease that may respond to prompt medical and surgical therapy.

Alcoholism as a risk factor in methadone maintenance: A randomized controlled trial

A randomized controlled trial of 625 addicts on methadone maintenance identified 105 (17 percent) as active alcoholics, 47 (8 percent) as inactive alcoholics, and 473 (75 percent) as nonalcoholics. Subjects were followed for up to 29 months (mean 53.7 weeks) to assess the influence of alcoholism on the rehabilitative process. During the study, alcohol consumption significantly decreased (p less than 0.001) in active alcoholics. Indexes of productive activity on entry or during follow-up revealed no significant differences between active alcoholics and other patients with the exception of alcohol-related hospitalizations (p less than 0.001). Behavioral indexes consistently improved with treatment in all patients, being greatest among active alcoholics (p less than 0.01). During the study, 28 (7 percent) of 399 nonalcoholics were recategorized as active alcoholics, and remission from alcoholism was noted in 28 (27 percent) of patients who were initially classified as alcoholic. These findings suggest that alcoholism does not significantly affect rehabilitation from narcotic use and therefore should not be cause for detoxification from methadone maintenance.

Science versus nonscience undergraduate studies for medical school: a study of nine classes.

The undergraduate grade-point average, scores on the Medical College Admission Tests and Parts I and II of the examinations of the National Board of Medical Examiners, medical school grades, and membership in Alpha Omega Alpha, the medical honor society, were compared for four categories of undergraduate majors to determine whether nonscience preparation was a handicap for medical training. Data for nine complete classes at one medical school were used. The results indicated that nonscience students performed as well as or better than traditional science trained students on almost all performance measures. Implications for medical school admissions policies are discussed.