drugs of abuse pathology

MDMA (Ecstasy)

Chemical Classification

• 3,4-methylenedioxymethamphetamine (full chemical name)

• Psychedelic amphetamine classification

• Causes catecholamine release

• Prevents catecholamine reuptake

Effects on the Body

Psychological Effects:

• Empathy

• Feelings of comfort

• Increased sex drive

Physiological Effects:

• Excessive sweating

• Dehydration

• Hypoglycemia

• Fluid loss

Street Forms

• Tablet form commonly seen as "Motorola" Ecstasy Tablets

• 3 distinct tablet types identified in pathology imaging

Xylazine

Medical Classification and Uses

• Veterinary sedative

• Analgesic properties

• Muscle relaxant

Clinical Context

• Original legitimate medical use in veterinary medicine

• Now appearing in drug abuse context

Methamphetamine

Street Names

• Meth

• Crystal Meth

• Ice

• Speed

• Crank

• Tweak

Manufacturing Information

• Precursor chemicals:

• Pseudoephedrine or ephedrine

• Red phosphorus (from match strike plates)

• Iodine

• Hydriodic acid formation

• "Cooks" = illicit methamphetamine producers

• Manufacturing equipment often includes:

• Large amounts of cold medicine

• Large quantities of matches

• Road flares

Mechanism of Action

• Effects similar to cocaine

• Produces vasoconstriction (narrowing of blood vessels)

Cardiovascular Pathology

• Contraction band necrosis of the myocardium (microscopic heart muscle injury)

• Coronary artery disease

• Myocyte hypertrophy (enlarged heart cells)

Central Nervous System Effects

• Psychosis

• Agitation

• Violent behavior

• Stroke

Opiates (Heroin)

Chemical Classification

• Semisynthetic morphine derivative

• No FDA-approved medical use

• Very lipid soluble

• Crosses blood-brain barrier rapidly

• Approximately 100× more potent than morphine

Routes of Administration

• Injection (IV)

• Smoking ("chasing the dragon")

Primary Mechanism of Death

• Respiratory depression (main cause)

Fentanyl

Potency

• Approximately 50× more potent than heroin

• Extremely high risk for overdose

Legitimate Medical Forms

• Lozenges

• Lollipops

• Tablets

• Nasal spray

• Injectables

• Transdermal patches (fentanyl patches)

Abuse Methods

• Freezing patches

• Cutting into fragments

• Placing under the tongue

• Removing gel contents

• Injecting contents

• Smoking contents

Opiate-Related Pathological Findings

Cardiac Lesions

• Endocarditis (inflammation of the heart lining)

• Myocardial fibrosis (scar tissue in heart muscle)

• Coronary artery disease

Pulmonary Findings

Pulmonary Edema (Primary Finding)

• Mechanism:

• Hypoxia (oxygen deprivation)

• Increased vascular permeability

• Upper airway obstruction

• Severity indicator: Lungs may weigh ~800 g instead of normal ~350 g

• Associated finding: Foam cone (frothy fluid in airway)

• Caused by:

• Rhabdomyolysis-related injury

• Massive pulmonary edema

• Named finding: "Foam Cone" associated with heroin, fentanyl, and opiate deaths

Renal Findings

• Focal glomerulosclerosis (kidney glomeruli scarring)

Infectious Complications

• Foreign body granulomas

• Infectious complications from IV administration

Other Pathological Possibilities

• Amyloidosis

• Necrotizing angiitis

Intravenous Drug Abuse Physical Indicators

Track Marks

Definition and Characteristics

• Result of repeated injections

• Rope-like scars appearance

• Usually located at antecubital fossa (inside elbow)

• Chronic IV drug use indicator

Skin Popping

Definition

• Subcutaneous injection (under the skin)

• Occurs when veins become inaccessible due to repeated use

Appearance

• Oval scars

• Healed injection sites

• Common finding in chronic IV drug users

Complications

• Lymphatic damage leading to poor drainage

• Results in hand edema (swelling)

• Lymphedema: markedly swollen hands in chronic users

Cocaine and Crack Cocaine

Crack Cocaine

Characteristics

• Smoked form of cocaine

• Inhaled through a crack pipe

• Named because it may "pop" or "crack" when heated

• Produces pulmonary injury from hot smoke exposure

Street Paraphernalia

• Crack pipe: Usually glass with burned ends

• Often contains filter material such as steel wool

• Associated findings from chronic use:

• Crack thumb

• Crack hands

• Burns and calluses from repeated use

Powder Cocaine

Routes of Administration

• Snorted

• Injected

• Mixed in water and injected

Street Packaging

• Present as powder in plastic baggies

• Street dealers package in stamped packets

• Brand names appear for street recognition: Joyride, Cadillac, Homicide

Body Carrying Methods (Smuggler-Packers)

Packaging Method

• Cocaine wrapped in condoms

• Swallowed for transport

Danger

• If packet ruptures: massive cocaine release

• Results in true overdose

• Often causes collapse during transport or shortly after arrival

Cocaine Pathology and Effects

Mechanism of Action

• Blocks reuptake of:

• Dopamine

• Epinephrine

• Norepinephrine

• Serotonin

• Produces catecholamine surge (similar to adrenaline overdose)

• Potent vasoconstrictor

Cardiac Effects

• Hypertension (high blood pressure)

• Vasospasm (blood vessel constriction)

• Arrhythmias (irregular heartbeat)

• Sudden cardiac death

• Coronary artery disease

• Left ventricular hypertrophy (enlarged left heart chamber)

• Aortic dissection (tears in aorta)

Histological Finding

• Contraction band necrosis of the myocardium

• Microscopic myocardial injury caused by overstimulation of the heart

• Visible on histology slides

Nasal/Septal Injury

Mechanism

• Chronic snorting causes:

• Reduced blood flow

• Tissue necrosis

• Cartilage destruction

Findings

• Septal perforation (hole in nasal septum)

• Saddle nose deformity (collapse of nasal bridge)

• Collapse of nasal cartilage