In an Education Spotlight Session at this year’s ASH Annual Meeting, experts will be looking at the potentially devastating hematologic complications of illicit drug use, particularly those associated with adulterants added to enhance or mimic the effect of the illicit drug or to make administration of the drug more efficient. Here, session chair Thomas Ortel, MD, PhD, and speaker Daniel Federman, MD, preview the discussion, from the symptoms associated with contaminants in cocaine to managing the hematologic side effects of synthetic cannabinoids.
This is an interesting area for hematologists to consider – how did the topic of hematologic complications of illicit drugs come about?
Dr. Ortel: Many therapeutic agents that are routinely used in the care of patients are associated with rare hematologic complications, such as heparin with thrombocytopenia and thrombosis, and calcineurin inhibitors with thrombotic microangiopathy. Illicit drugs that introduce the complication are typically not provided by patients in a list of the agents that they have recently used, and the actual offending agent may have been added to the illicit substance during the refining process to potentiate the euphoric effect and/or enhance the appearance of the final product.
What are the potential hematologic complications of illicit drug use? Have you seen these issues in practice?
Dr. Federman: There are a variety of disease entities that arise from illicit drug use. For example, intravenous drug users may develop HIV with its associated wide gamut of complications, including hepatitis B and C, endocarditis, and local infections. All these entities may lead to hematologic abnormalities in addition to myriad other findings.
In my talk, I want to alert clinicians about the high rate of levamisole contamination in cocaine. Levamisole, an antihelminth used in veterinary medicine that is added to cocaine to enhance its euphoric effect, is present in at least 65% of cocaine samples tested worldwide. Exposure to levamisole can cause a variety of complications, including an unusual skin rash, hemorrhagic bullae, and neutropenia.
Dr. Ortel: I’ll be speaking about the hematologic complications associated with the use of synthetic cannabinoids, which have emerged more recently. Brodifacoum, a long-acting anticoagulant rodenticide (LAAR), has been identified as an adulterant in synthetic cannabinoids (also known as “spice” or “K2”) that, like levamisole in cocaine, is added presumably to enhance the effect of the drug. Patients exposed to brodifacoum-laced synthetic cannabinoids present with new-onset hemorrhagic complications and a coagulopathy characterized by a markedly prolonged prothrombin time and elevated international normalized ratio (INR) due to severe deficiency of the vitamin K-dependent coagulation factors.
How are patients with these complications treated?
Dr. Ortel: Treatment for the toxicities associated with levamisole in cocaine is largely supportive and requires cessation of exposure to levamisole. In contrast, treatment of the coagulopathy associated with brodifacoum exposure is more difficult, given the long half-life of the drug and the expense associated with the doses of vitamin K needed to correct the coagulopathy. The cost of the postexposure maintenance phase of therapy, consisting of treatment with high-dose vitamin K, can easily approach tens of thousands of dollars per month, leading to significant problems with patient adherence.
Hematologists need to be aware of the potential complications associated with adulterants added to illicit drugs, as they will be seeing these patients for the hematologic complications identified at initial presentation.
Dr. Federman: It is imperative that hematologists ask the right questions and are able to recognize manifestations of illicit drug use. While hematologists are not expected to manage addiction or abuse, recognition of these problems should warrant prompt referral to other professionals