The Emerging Role of Inhaled Heroin in the Opioid Epidemic: A Review

This article addresses encephalopathies: disease, damage, or malfunction of the brain. The authors attribute these problems to smoked/inhaled heroin which they label CTD (chasing the dragon). However, CTD (inhaling heroin fumes) has been occurring for decades in many parts of Southeast (Thailand, Malaysia, Myanmar, Laos, Cambodia, Vietnam, etc.) and Southwest (Afghanistan, Iran, Pakistan) Asia and none of these encephalopathies have been reported. This leads us to believe adulterants may be involved.

The article also addresses smoked heroin east of the Mississippi, where coincidentally most Colombian-originated heroin is distributed. Colombo Plan adulterant testing of "H" in Ecuador (with DEA-STL confirmation) in May 2016 detected the following composition of "H' heroin: heroin, cocaine, diltiazem, and phenacetin. More recent samples in Guayaquil, Ecuador analyzed by the local police drug testing lab are even more toxic than the May 2016 samples. In addition to heroin, they contain: Aminopyrine, Diltiazem, Tolycaine, Noxiptiline, and Diethyl Phthalate. 

Of importance, the majority of cases of encephalopathy reported in the literature arise from drug use, infection, liver damage, anoxia, or kidney failure. Aminopyrine that depletes white blood cells lead to various infections. Diethyl Phthalate is toxic to organs (liver). Phenacetin causes renal/kidney failure, etc. Also, PubChem notes that Diethyl Phthalate is toxic if inhaled (like inhaled/CTD heroin in attached article). In addition, ToxNet notes that aminopyrine, when heated to decomposition, emits toxic fumes. 

In summary, the encephalopathies addressed in the article are not necessarily due to inhaled/smoked heroin alone, but to a combination of adulterants that have been known to produce various encephalopathies as noted in the above paragraph. As previously noted, these encephalopathies have not been reported in decades of smoked/CTD heroin throughout Southeast and Southwest Asia, where their heroin was not cut with these adulterants.

Of particular interest, if the articles' encephalopathies are seen with smoked heroin only (and not injected or snorted heroin), it is probably due to various toxic adulterants being heated to decomposition as noted above. (Analysis by Thom Browne)