Expert: Dr Ian Jackson - please note UK based - 3/20/2004

Question
A 25-year-old Caucasian male presents with a very strong substance abuse problem.  Drugs of choice include occasional use of MDMA (ecstasy) and benzodiazepines,
alcohol, hydrocodone, oxycodone, and cocaine.  The emphasis being on the last four drugs and the benzodiazepines are used mainly to soften the “come down” from the cocaine.  The patient does not use methamphetamines.  Otherwise the patient has no significant medical history and is in excellent physical condition.  

The patient reports that after a 36-hour binge of cocaine and pain pills he began to feel “different”.  His speech began to slur, his left arm went numb and he was walking with an unsteady gait.  He chest was “pounding” and said, “I feel like I am dying”.  The patient discontinued his drug use and lay down to “ride out” the situation.  The patient was alone so the only history of the night was his own. It was an unwitnessed event.  After a “short while” his symptoms subsided and he began to feel “normal” again and then slept for about 10 hours.  The next day there was total resolution of his symptoms.

From that brief history it would seem to me that the patient suffered a TIA (Transient Ischemic Attack.  And that he is definitely on the right path to graduating to a full-blown CVA.  Assuming there is no underlying disease and that his physical problems likely stemmed from a vasospasm or thrombosis what treatment should be offered to him?  The obvious choice would be a visit with a neurologist and immediate treatment at a detox/drug addiction facility.  However the patient refuses all treatment and support for his addiction.

This case is truly hypothetical so a standard and “safe” reply is not what I am looking for.  But it would seem to me that a patient WITHOUT an addiction disorder, with hypertension, a vasospasm disorder, a coagulopathy and/or increase risk for throwing clots would be started on aspirin therapy.  So my question, again hypothetical, is this.  Can this patient with his drug addiction and dangerous consumption of cocaine benefit at all from taking an aspirin a day?  If the answer were yes, would it be an 81 or 325mg aspirin?  I do realize that we are not addressing the underlying problem of his addiction, but I am curious if a cocaine user could potentially benefit from aspirin therapy.

Thanks for your help.

Jason


Answer
Jason

A very well detailed question and a good one! However this is totally outside my area of expertise. With that known upfront I will make a sugestion.

I would agree that your diagnosis of the situation is fairly probable - with vasospasm due to the cocaine. However if he is using the IV route then remember the possibility of 'paradoxical embolism'.

A large number of people have a patent foramen ovale in the heart. It is kept closed due to the pressure differentials between the left and right atria. However if something happens to increase the pressure in the right side then it may open allowing 'substances or injected air' through to the left side and hence straight to the brain. This would also have caused his symptoms.

Aspirin may well help with your supposition but would not help with the latter.

To my mind this is academic anyway - no point treating with aspirin as patient unlikely to be compliant. You know the answer here is detox and the patient has to want to make it work.

Best of luck.