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Lead Toxicity among Oral Opium Addicts with Abdominal Pain: A Case Series of 17 Cases
Abstract
Objective: Lead toxicity is a common health problem worldwide. It is usually occupational but sometime
non-occupational toxicities are reported. Opium-related lead toxicity has been reported in recent years. Here
we evaluated common clinical findings among oral opium addicts with proven lead toxicity.
Methods: We evaluated 17 cases of opium addict male patients (mean age of 49.82±11.52 years) with
abdominal pain and anemia visiting Imam Khomeini Hospital, Ardabil, Iran during April and May 2016.
Clinical manifestations, laboratory findings and treatment outcome were studied.
Results: The duration of addiction was 14.58±7.46 years. Mean lead level was 93.36±27.84 μg/dL (48.4-
144 μg/dL). All patients had anemia, abdominal pain and reduced appetite. Common manifestations were
irritability and sleep disturbance (76.5%), fatigue (70.6%), Constipation (64.7%), vomiting (58.8%),
abdominal cramp (52.9%) and muscle weakness (29.4%). Basophilic stippling was seen in 11 out of 17
cases. All patients were treated with D-Penicillamine 250 mg three times a day and significant improvement
of symptoms was observed during the first week of treatment. Conclusion: In conclusion, Lead poisoning
should be considered in patients with a history of opium abuse who present with abdominal pain and anemia.
Proper treatment should be initiated for these patients.
Supplementary resource (1)
... [13][14][15] Nowadays, lead poisoning is reported in opium users particularly in middle-and low-income countries including Iran. [16][17][18][19][20] Opium smugglers may add lead to opium to increase the weight for more profit leading to life-threatening adulteration. There is a variety of clinical signs and symptoms in lead-contaminated opium consumers. ...
... Farzaneh et al. indicated other signs including sleep disorders, irritability, anemia, kidney damage, seizure, and encephalopathy. 17 The severity of signs and symptoms depends on the amount of lead concentration and the duration of exposure. Although exposure to trivial amounts of lead does not cause significant signs/symptoms in adults, it may be harmful in children due to their vulnerability to lead toxic effects. ...
... Children may be exposed to opium Addict Health, Summer 2020; Vol 12, No 3 http://ahj.kmu.ac.ir, 05 July smoke or its accidental oral consumption. 16,17 In our study, the mean ± SD of BLL was 9.78 ± 3.44 µg/dl. Based on CDC, BLLs ≥ 5 μg/dl in children indicate high exposure to lead. ...
Background:
Lead poisoning is now more common due to accidental or intentional exposure to opium impregnated with lead. We aimed to determine the relationship between the blood lead levels (BLLs) and basic characteristics in opium-poisoned children.
Methods:
In this cross-sectional study, 32 children younger than 13 years old who had been admitted to Loghman Hakim Poison Center, Tehran, Iran, due to opium poisoning, were evaluated for BLLs. Patients' demographics, symptoms, signs, and lab tests were evaluated as well as the BLLs.
Findings:
The median and range of age in children with opium poisoning were 14 and 141 months with minimum and maximum age of 3 and 144 months, respectively, and 62.5% were boys. Their mean BLL was 9.78 ± 3.44 μg/dl and in 70% of opium-poisoned children, BLL was ≥ 5 μg/dl. There was a significant difference between mean BLLs in girls and boys (17.07 ± 6.57 μg/dl in girls and 6.61 ± 3.22 μg/dl in boys, P = 0.02). We found a significant correlation between BLL and hemoglobin (Hb) level. In very low Hb level (< 8 g/dl), the BLL was higher but with increasing Hb level, BLL increased as well; in Hb levels > 14 g/dl, BLL decreased again (P = 0.01).
Conclusion:
Although none of the children needed chelation therapy, strategies should be developed to prevent children from being exposed to opium and other materials impregnated with lead regarding its effects on all organs of children.
... As shown in Table 1, the majority of cases of lead poisoning due to leadcontaminated opium [9,11,[16][17][18][19][20][21][22][23][24][25][26][27][28] are surprisingly reported from Iran with the dominance of men. The case reports from The Netherlands [17,27] and the United Kingdom [23] also concerned two Iranians, one immigrant abusing opium from Iranian suppliers and one Persian citizen addicted to inhalational opium, respectively. ...
... Complications of lead poisoning are reversible, providing early diagnosis and appropriate treatments are made; however, neurotoxicity may be permanent following significantly elevated BLLs and delayed specific treatment [18] . Timely detection and proper therapies for lead poisoning in an opium-addicted individual with the chief complaint of abdominal pain cannot only obviate the need for [28] M: Male; F: Female; N/V: Nausea and/or vomiting; AP: Abdominal pain; BLL: Blood lead level; NA: Not available; DP: D-penicillamine. ...
Lead may contaminate opium, heroin and illicit opiates and is particularly observed in Iran. Lead, a natural heavy metal is able to interfere with several organ functions after ingestion or inhalation. Lead poisoning manifestations are non-specific and thus lead poisoning remains difficult to diagnose. Among the manifestations, abdominal pain is almost the most frequent symptom causing patients to seek medical care. In patients with a history of opium addiction presenting with moderate-to-severe abdominal pain, lack of diagnosis of lead toxicity may thus result in time-consuming and unnecessary medical work-ups that can end up in invasive surgery. This paper aims to briefly review abdominal pain as an emergency issue and the leading symptom of lead poisoning that brings most of the patients to healthcare facilities. All published adult cases and case series of opium addicts admitted with abdominal pain due to lead-adulterated opium consumption have been reviewed. A trend of increasing numbers of lead poisoning cases has recently emerged among opium addicts in Iran. Due to the non-specific manifestations and hazardous effects, psychiatrists and emergency physicians should consider lead poisoning in patients with a past or present history of opium addiction referred for acute abdominal pain, particularly in case of colicky abdominal pain.
... In these patients, biliary violation, increased liver enzymes, and abdominal pain were attributed to lead poisoning from an etiological point of view. Therefore, it is important to measure the blood lead level in drug users by atomic absorption spectrometry as the gold standard (21)(22)(23). ...
... Similarly, Farzaneh et al. found similar outcomes in their research. According to the findings of this study, the concentration of blood Pb in addicts is higher than in non-addict persons [34]. ...
... Similarly, Farzaneh et al. found similar outcomes in their research. According to the findings of this study, the concentration of blood Pb in addicts is higher than in non-addict persons [34]. ...
While a large body of literature has shown the health problems of illicit drug use, research is needed on how substance abuse impacts DNA damage and contaminants in blood, especially given Pb-contaminated opium. This pilot study aimed to evaluate the levels of lead (Pb), 8-hydroxy di-guanine (8-oxo-Gua), and malondialdehyde (MDA) in the blood serum of opium addicts and non-addict people. The current study is a case-control study with a cross-sectional design. A sample of 50 opium-addicted and non-addict adults were chosen for this study using convenience and random sampling methods. Participants were divided into two groups: addicts and non-addicts. The atomic absorption spectroscopy method was used to measure the quantity of Pb, and the Enzyme-Linked Immunosorbent Assay (ELISA) method was used to measure the amount of 8-oxo-Gua and MDA. The data were analyzed using an independent t-test. The results show that the amount of Pb in the blood serum of addicted women and men was higher than levels in non-addict men and women, for the study participants (p-value = 0.001). Blood levels were not significantly different between addicts and non-addicts for men or women for 8-oxo-Gua (p-value = 0.647 for women and p-value = 0.785 for men) and MDA (p-value = 0.867 for women and p-value = 0.995 for men). In general, addicts' blood Pb levels were found to be substantially higher than those of normal non-addict persons in this pilot study. As a result, testing for blood Pb levels in addicts may be informative in instances when symptoms are inconclusive. Citation: Hesaruiyeh, F.A.; Rajabi, S.; Motamed-Jahromi, M.; Sarhadi, M.; Bell, M.L.; Khaksefidi, R.; Sarhadi, S.; Mohammadi, L.; Dua, K.; Mohammadpour, A.; Martelletti, P.
... adults; it has no serious adverse effects. Therefore, using this drug can be beneficial, especially in cases with a high prevalence of lead poisoning and limited access to other antidotes [20,21]. In a study on 84 lead-poisoned patients treated with D-Penicillamine, Shannon et al. reported that in one-third of the patients, complications, such as transient leucopenia, thrombocytopenia, rash, enuresis, and abdominal pain were observed [19]. ...
Background: Lead poisoning was on the rise in recent years. There exists a lack of easy access to some of the main chelator drugs in developing countries. Thus, this study aimed to explore the comparative effects of Succimer and D-Penicillamine on acute lead poisoning patients from 2013 to 2018.
Methods: This descriptive study was conducted in the Clinical Toxicology Department of Khorshid Hospital in Isfahan City, Iran. Adult patients with acute lead poisoning were included in the study. Patients in the 3 treatment groups of D-Penicillamine, D-Penicillamine with succimer, and succimer were compared concerning demographic characteristics as well as clinical and laboratory findings at admission time and two weeks later.
Results: In total, 163 patients were evaluated in this research. There was no significant difference between the treatment groups respecting improvement in clinical symptoms. The mean blood lead levels during hospitalization and two weeks after the treatment did not significantly differ between the three groups; however, there was a significant reduction in all study groups after two weeks of treatment (P
... There are frequent reports of locking or movement restriction of lower and upper limbs, low back pain, myalgia, tremor, trismus, and weakness. In addition, irritability, sleeplessness, coma, and generalized seizure have been reported in more severe cases; therefore, they should be considered in the differential diagnoses in the ED (28,30,52). ...
Background
Restrictive regulations and the increased price of opioids have resulted in the addition of impurities to illicit opioids by drug dealers. Among the adulterants, lead salts are optimal agents to make packages heavier. Consequently, lead toxicity has emerged in the opioid-user population.
Objectives
Our goal was to review the related literature and describe patients with common presentations of opioid-related lead poisoning to provide a basis to prepare optimal management.
Methods
A narrative review was performed aiming to study opioid lead poisoning. PubMed and Google Scholar databases were explored with two Medical Subject Heading terms, lead poisoning and substance-related disorders to find a broad but relevant spectrum of articles. Then, the reference lists within those articles were checked to upgrade our literature pool on this issue.
Results
Ultimately, among English-language articles, 16 were case series and case reports of patients with lead intoxication after opioid consumption. Data pertaining to disease characteristics, diagnosis, and treatment protocols were extracted.
Conclusions
The clinical presentation of opioid lead intoxication can vary from rather asymptomatic to severely debilitating gastrointestinal or neurologic symptoms. The diagnosis is made by checking lead blood levels after obviating other critical diagnoses and should be considered in each drug user in endemic regions of opioid addiction, such as the Middle East. Management protocols are suggested to cover both features of opioid-related complications and lead toxicity.
Lead is one of the most toxic heavy metals in the environment. The present review aimed to highlight hazardous pollution sources, management, and review symptoms of lead poisonings in various parts of the world. The present study summarized the information available from case reports and case series studies from 2009 to March 2020 on the lead pollution sources and clinical symptoms. All are along with detoxification methods in infants, children, and adults. Our literature compilation includes results from 126 studies on lead poisoning. We found that traditional medication, occupational exposure, and substance abuse are as common as previously reported sources of lead exposure for children and adults. Ayurvedic medications and gunshot wounds have been identified as the most common source of exposure in the United States. However, opium and occupational exposure to the batteries were primarily seen in Iran and India. Furthermore, neurological, gastrointestinal, and hematological disorders were the most frequently occurring symptoms in lead-poisoned patients. As for therapeutic strategies, our findings confirm the safety and efficacy of chelating agents, even for infants. Our results suggest that treatment with chelating agents combined with the prevention of environmental exposure may be an excellent strategy to reduce the rate of lead poisoning. Besides, more clinical studies and long-term follow-ups are necessary to address all questions about lead poisoning management.
PurposeLead Poisoning is a major health problem in Iran. We aimed to compare efficacy of a standard regimen (Succimer) with that of a low-priced combination of D-penicillamine and Garlic in outpatients with lead poisoning.Methods
In this retrospective cross-sectional study, year-long clinical files of outpatients with lead poisoning in two referral toxicology clinics in Mashhad, Iran were reviewed. A total of 79 patients (all men), received either Succimer or a combination of D-penicillamen plus garlic (DPN + Gar), for 19 and 30 days, respectively. Clinical and laboratory data, including blood lead level (BLL), were analyzed and treatment expanses were compared between the two regimens.ResultsOf 79 male patients, 42 were treated by DPN + Gar and 37 received Succimer. Mean BLL of DPN + Gar group before treatment (965.73 ± 62.54 µg/L) was higher than that of the Succimer group (827.59 ± 24.41) (p < 0.001). After treatment, BLL in both groups significantly reduced to 365.52 ± 27.61 µg/L and 337.44 ± 26.34 µg/L, respectively (p < 0.001). The price of a 19-day treatment with Succimer was approximately 28.6 times higher than a one-month course of treatment with garlic plus DPN. None of the treatments caused serious side effects in the patients.Conclusion
Combination therapy with DPN + Gar is as effective as Succimer in Pb poisoning, while treatment with Succimer is significantly more expensive.Graphical abstract
Lead is a common toxin which has detrimental effects on human health. Since lead poisoning is not associated with specific symptoms, diagnosing elevated blood lead concentration (EBLC) should be taken seriously. The purpose of this study was to propose a prediction model for EBLC based on demographic and clinical variables through a decision-tree model.
In this cross-sectional study, 630 subjects (above 40 years old) living in South Khorasan Province, Iran in 2017 were selected via cluster random sampling method. From among the 630 participants who met the inclusion criteria, 70% (N = 456) were chosen randomly to achieve a set for developing the decision tree and multiple logistic regression (MLR). The other 30% (N = 174) were placed in a holdout sample to examine the function of the decision tree and MLR models. The predictive performance for various models was studied using the Receiver Operating Characteristic (ROC) curve.
In the decision tree model, the parameters of hematocrit (HCT), White Blood Cell (WBC), Red Blood Cell (RBC), Mean corpuscular volume (MCV), creatinine concentration, abdominal pain, gender, route of administration, and history of cigarette smoking were the most critical factors in identifying people at risk of EBLC. The HCT concentration was the most critical variable, which was chosen as the root node of the tree. Based on the ROC curve, the decision tree model had better predictive accuracy than the logistic regression model.
Our results indicated that the decision tree model offers far greater predictive precision than the logistic regression model. Doctors should pay more attention to some factors including the hematological parameters such as MCV, RBC, HCT, leukocytosis, creatinine levels, male sex, history of cigarette, and opium consumption for the screening of EBLCs.
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