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Drug Testing Disparities Found Among Stroke Patients — Is it Racial Profiling?

Samson, Kurt

doi: 10.1097/01.NT.0000431666.62876.6d
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Figure. D

Figure. D

An analysis of drug screening for patients with stroke from a hospital database in Detroit revealed that black men under the age of 50 were tested almost twice as often as young white men, even though cocaine was detected in patients across all demographic strata, including patients in their 70s. The study authors contend that all patients should be screened.

If practices at one urban hospital are representative of others around the country, younger male African-American stroke patients are much more likely than others to be screened for illegal drug use, according to a retrospective chart review of stroke patients at Henry Ford Hospital in Detroit, MI.

Lead author Brian Silver, MD, associate professor of neurology at Brown University's Warren Alpert Medical School and director of the Stroke Center at Rhode Island Hospital in Providence, examined data on 1,024 stroke patients in Henry Ford's stroke database.

Black men under the age of 50 were tested almost twice as often as young white men, he found, even though cocaine was detected in patients across all demographic strata, including patients in their 70s.

The findings were reported in the April 30 edition of Neurology.

“We found that while only 40 percent of all patients underwent urinalysis, they were more likely to be screened if they were young black men,” he told Neurology Today. “This despite the fact that a broad range of patients had positive screens and there were no significant differences in admission based on scores on the NIH Stroke Scale [NIHSS], stroke etiology, or discharge status between toxicology-positive and -negative patients.”

Among black men younger than 50, 48 percent underwent screening, and 13 percent tested positive for cocaine, compared with 25 percent of white males, 4 percent of whom tested positive. In all, 43 percent of men under age 50 were screened and 16 percent tested positive, compared with 38 percent of women in that age bracket, 6 percent of whom tested positive for drugs. Among patients 60-69 years of age, 40 percent were screened and 4 percent were positive, while 25 percent of those between 70 and 79 years old underwent urinalysis and 3 percent tested positive for cocaine.

“The majority of patients tested negative, but we had positive tests for all ages, race, and genders, including one patient who was 71 years old. I personally have had an 89-year-old patient test positive for cocaine, so this is clearly not something that is restricted to younger individuals,” said Dr. Silver.

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Patients who tested positive for cocaine had similar stroke severities, as measured by the NIHSS, and similar stroke mechanisms, including evidence of large-vessel atherosclerosis, cardioembolic, lacunar, and other etiologies. Those with intracerebral hemorrhage had the highest rate of cocaine-positive results at 24.6 percent, followed by 10.1 percent among ischemic stroke patients and 5.3 percent of those with a transient ischemic attack (TIA). And while the total number of patients was relatively small, the researchers observed a higher rate of lacunar mechanism of ischemic stroke (43 percent) among cocaine-positive patients than in all other subgroups, ranging from 26 percent to 28 percent.

Among 21 patients with ischemic stroke who tested positive for cocaine, none received tissue plasminogen activator (tPA) compared with 10 percent of those with negative test results, Dr. Silver noted.

“Patients who tested positive for cocaine were less likely to receive thrombolytic therapy, despite having similar stroke severities at admission, and it was unclear from their charts why this was so. In many cases the toxicology results came after the therapeutic treatment window had passed, so there may have been other factors leading to a decision not to treat,” he noted.

“The current guidelines on toxicology screening in stroke patients leave the decision to the treating physician, and are rather broad and vague,” Dr. Silver told Neurology Today in a telephone interview. “We are suggesting that all stroke and TIA patients be tested for illicit drug use in order to eliminate health care disparities and create an opportunity to treat a potentially modifiable stroke risk factor.”

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The results are very similar to those observed by Sheryl Martin-Schild, MD, PhD, clinical assistant professor of medicine and director of the stroke program at Tulane University Hospital and Clinic in New Orleans.

“We study drug screening here and have found almost the same rates of patients with ischemic stroke, intracerebral hemorrhage, and TIA, as well as similar patient profiles and proportions of positive tests, although we include all illicit drugs and not just cocaine,” she told Neurology Today.

“At Tulane [Hospital], we screen everyone, regardless of age, and our findings are spot-on with those at Henry Ford Hospital, but then Detroit and New Orleans have similar racial demographics in terms of black males. However, we see cocaine use in all ages, including one 81-year-old woman.”

She said she also has found similar rates in delay of tPA among patients who test positive for drugs.

“Fewer ischemic stroke patients with positive screens receive tPA, but they tend to have delayed presentation. Essentially all patients at our hospital get toxicology screens — there is no difference between men and women, race, or ethnicity. While we test more, we also have more black patients here.”

She said she believes there is age and racial selection bias at many hospitals and that it would help if testing were more ubiquitous across the country, especially given what is known about the etiology of cocaine and methamphetamine in ischemic stroke and ICH.

“Stroke among younger persons is rapidly becoming a serious problem and drug abuse is a major contributor, especially the use of cocaine and methamphetamine and the known risks of hypertensive surge, cardiomyopathy, and vasospasm with their abuse,” she said.

“I feel we are missing an opportunity for counseling younger patients about stroke risks and illicit drugs. Here, we have built counseling into our patient stroke education program.”

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Neeraj S. Naval, MD, assistant professor of neurology, neurosurgery & anesthesia critical care medicine and the director of the Neurosciences Critical Care Unit at the Johns Hopkins Bayview Medical Center in Baltimore, said that while data on stroke mortality among cocaine users is far from comprehensive, there is growing evidence that points to elevated risk.

“What is certain is that cocaine use is more common in younger patients, and it seems that there may be racial and ethnic differences in drug testing practices. Unfortunately, there is no clear guideline on drug screening in stroke. I believe testing for drug use should be routine in all patients presenting with ischemic or hemorrhagic stroke,” he told Neurology Today.

Dr. Naval has also seen screening disparities similar to those reported in the study. “I think this sends out an important message, and needs to be studied prospectively and replicated in a larger and more diverse group of stroke patients.”

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•. Silver B, Miller D, Jankowski M, et al. Urine toxicology screening in an urban stroke and TIA population. Neurology 2013;80:1702–1709; E-pub 2013 Apr 17
    •. Merino JG. Profiling patients. Neurology 2013; 80:1632; E-pub Apr 17.
      •. AAN annual meeting abstract (2013): Impact of acute cocaine use on aneurysmal subarachnoid hemorrhage:
        •. Martin-Schild S, Albright KC, Misra V, et al. Intravenous tissue plasminogen activator in patients with cocaine-associated acute ischemic stroke. Stroke 2009; 40:3635–3637.
        •. Westover AN, McBride S, Haley RW. Stroke in young adults who abuse amphetamines or cocaine: a population-based study of hospitalized patients. Arch Gen Psychiatry 2007;64(4):495–502.
        ©2013 American Academy of Neurology