Ecstasy, angel dust, Ts and blues, speedballs, chasing the dragon… The colorful vernacular of substance abuse belies its potentially devastating effects. In this issue of Continuum, chair Dr John Brust and his faculty update the neurologist on the consequences of a plethora of agents-ingested, injected, smoked, and snorted-for both the central and peripheral nervous systems.
Many years ago, I walked onto the wards of Bellevue Hospital in New York City as a young, naïve medical student eager to interview his first patient. Confronting a late adolescent male with obvious jaundice, I proceeded tentatively, but I thought thoroughly, to take a detailed history. As I was about to leave, the young man stopped me and said, "Oh, I think you ought to know. I use heroin." Such was my introduction to the influence of substance abuse on medical illness, a lesson learned over and over again as I completed my residencies in internal medicine and neurology in the New York City Hospital system.
Dr Brust, perhaps the world's foremost authority on the neurologic complications of substance abuse, has worked for many years at Harlem Hospital in New York. In this inner-city setting, he has undoubtedly "seen it all." Yet the problem and epidemic of substance abuse is not confined to this environment. As Dr Brust notes in his introduction, in 2001, 16.6 million Americans aged 12 years or older (7.3% of the population) abused alcohol or illicit drugs. Therefore, community neurologists working among the middle class and affluent must also remain constantly alert to the possibility of covert substance abuse. The personally and socially destructive practice of substance abuse, particularly alcohol, unquestionably the mostly widely abused drug, spares no ethnic, economic, or geographic group.
In his opening chapter, Dr Brust very thoroughly reviews the acute effects and withdrawal syndromes associated with a panoply of abused agents. He and his colleagues from Columbia University and Harlem Hospital then discuss specific complications associated with each of the drugs. Because virtually all abused substances are used for desired central nervous system effects, it is not surprising to find that they often have the potential to result in undesired, and sometimes irreversible, toxicity for the brain. Less obviously, some of these agents produce profound neuromuscular toxicity, as delineated in the chapter by Dr Louis Weimer.
Although many of the neurologic complications associated with substance abuse result from direct neurologic toxicity, indirect effects are also common and frequently devastating. Particularly important in this regard are the infectious and vascular complications, reviewed by Drs Carolyn Barley Britton and Olajide Williams, respectively. Among the infections related to substance abuse, none has been more ravaging than those caused by human immunodeficiency virus, frequently transmitted hematogenously through the shared use of needles.
The personal consequences of substance abuse are tragic enough, but the practice often inflicts severe emotional, and sometimes physical, injury on others. What is particularly sad is that the unborn are sometimes among those victims. In the final chapter of this issue, Dr Claudia Chiriboga reviews the effects of ethanol and other drugs on the fetus.
We are indebted to Dr Brust and his colleagues for providing a very lucid and comprehensive review of the incredibly varied neurologic ramifications of substance abuse. With increased understanding and a higher index of suspicion, we will undoubtedly be better prepared to recognize and treat these complex disorders.
Aaron E. Miller, MD