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A Vitamin Profile of Heroin Addiction

AHMED EL NAKAH, MD, OSCAR FRANK, PHD, DONALD B. LOURIA, MD,


MARK A. QUINONES, PHD, AND HERMAN BAKER, PHD

deficiency and liver disease.** Hepatic abnormalities were


Abstract: Circulating thiamine, riboflavin, nicotinates, judged to be present if serum transaminase levels (serum glu-
folates, vitamin B,2, B6, A, and carotenes of 149 heroin tamic-pyruvate or serum glutamic-oxalacetic) were above 50
addicts aged 17-60 years were compared to 204 healthy IU/L and/or y-glutamyl transpeptidase level was above 50
subjects not using drugs or vitamins. Only 24 per cent of the mU/ml. Twenty-six (65 per cent) of the Caucasians, 62 (65
addicts had no evidence of hypovitaminemia; 45 per cent per cent) Blacks, and 7 (54 per cent) Hispanics had no im-
and 37 per cent had vitamin B6 and folate deficit respec- paired liver function while 14 Caucasians, 34 Blacks, and 6
tively, whereas deficits of thiamine, vitamin B12, riboflavin, Hispanics had impaired liver function. Two hundred four
and nicotinate were recorded for 13-19 per cent of the addict subjects of the same age group as the addict population, cho-
population; impaired liver function in addicts did not in- sen from hospital and laboratory personnel and volunteers
fluence these results. (Am. J. Public Health 69:1058-1060, residing in the New York-New Jersey area, served as a com-
1979.) parison group; this group consisted of healthy subjects who
stated they did not take drugs or vitamins, ingested a good
diet, and had no history of gastrointestinal disease or sur-
gery. The comparison group (105 males, 99 females) was giv-
en the same standard laboratory tests described for the ad-
Based on assessment of dietary intake and clinical ob- dicts.
servations, it has been concluded that malnutrition is com- Blood, obtained from an antecubital vein, was drawn in
mon in drug addicts.' 2 However, the precise nature of the VacutainersR (Becton, Dickinson & Co., Rutherford, NJ)
malnutrition has not been defined. In this study we ascertain containing 14 mg of disodium (ethylenedinitrilo) tetra-acetic
the vitamin status of 149 heroin addicts in the interests of acid powder. Blood was analyzed for thiamine, nicotinates,
providing objectivity, as done in other nutritional sur- vitamin B6, riboflavin, vitamin B12 by protozoological meth-
veys.3-5 ods6 and for folates with Lactobacillus casei6; Vitamins A
and carotenes were determined chemically.6 A vitamin defi-
cit (hypovitaminemia) is defined as a blood concentration
Methods less than the 95 per cent confidence limit as established in the
204 subjects in the comparison group; subjects denoted as
One hundred forty-nine subjects who were not taking hypovitaminemic by these criteria often exhibit clinical signs
vitamin supplements were selected from those admitted to characteristic of vitamin deficits.4'6'7 Therefore, this ap-
the Multi-Modality Drug Rehabilitation Center in Newark, pears to us to be a reasonable definition of hypovitaminemia.
NJ*; they were selected into the study because they admit- As in previous surveys,3'8'9 vitamin values for both popu-
ted to: a) no vitamin supplementation, and b) chronic heroin lations studied here were listed in ascending and descending
addiction. Demographic characteristics of the addict popu- order and the frequency of occurrence in each population
lation are shown in Table 1; it consisted of 95 subjects with plotted. The mean and 95 per cent confidence limits were
no evidence of liver disease and 54 subjects with liver dis- derived from cumulative frequency points on semi-log
ease (vide infra). Each patient was given a medical examina- coordinates. A straight line drawn through the intersect es-
tion, with special attention being paid to signs of nutritional tablishes the mean at the 50 per cent intersect and 95 per cent
confidence limits at the 2.5 per cent and 97.5 per cent inter-
sects.
*All heroin addicts were referred to us by their physicians for
physical examination and for detoxification treatment.
**Laboratory tests included determination of serum glucose, Results
urea nitrogen, uric acid, cholesterol, calcium, phosphorus, total and
direct bilirubin, albumin, globulin, lactic acid dehydrogenase, alka- Aside from elevated transaminases in 54 of the 149 ad-
line phosphatase, transaminases, y-glutamyl transpeptidase, and he-
moglobin, hematocrit, red- and white-blood cell count. dicts, other laboratory values were within normal limits. Pre-
liminary tabulation ruled out age, sex, and race as factors
From the Departments of Preventive Medicine and Community affecting the vitamin results; results were therefore not dif-
Health and Medicine, College of Medicine and Dentistry, New Jer- ferentiated by these criteria.
sey Medical School, Newark, NJ. Address reprint requests to Dr.
Herman Baker, New Jersey Medical School, 88 Ross Street, East Table 2 lists the means and ranges (95 per cent con-
Orange, NJ 07018. This paper, submitted to the Journal December fidence limits) of the circulating vitamins in the reference
26, 1978, was revised and accepted for publication March 30, 1979. population. The frequency of hypovitaminemia in 149 heroin

1 058 AJPH October 1979, Vol. 69, No. 10


PUBLIC HEALTH BRIEFS

TABLE 1-Race, Age, Sex of 149 Heroin Addicts in the Study TABLE 2-Circulating Vitamins in 204 Subjects without Evi-
Population dence of Malnutrition or Vitamin Supplementation
Age (years) Vitamin Mean Range* Concentration

Race Sex 17-20 21-25 26-30 31-40 41-60 Total Vitamin B12 210 105-660 pg/mI
Thiamin 40 25-71 ng/ml
Caucasian M 2 15 8 2 1 28 Riboflavin 205 110-420 ng/ml
F 2 4 4 2 0 12 Nicotinates 4.0 3.4-6.4 pg/ml
Black M 7 36 14 9 3 69 Vitamin B6 38 29-83 ng/ml
F 6 16 5 0 0 27 Folates 8.0 5.0-21.0 ng/ml
Hispanic M 3 7 1 1 0 12 Vitamin A 45 25-84 p4gIdl
F 0 1 0 0 0 1 ,8-Carotene 95 40-200 4gIdl
TOTAL* 20(13) 79(53) 32(22) 14(9) 4(3) 149(100)
*95% Confidence limits
*Percentage shown in parentheses

addicts with and without liver disease is given in Figure 1, as trition which occurred far more frequently than overt malnu-
well as the cumulative results for this entire addict popu- trition; nevertheless, 7 per cent of the addicts showed signs
lation. Figure 1 shows that liver disease did not influence of deficiency disease e.g., glossitis, cheilosis, dermatitis.
vitamin levels of this population. Only 23-24 per cent of the Surprisingly, abnormal liver function in addicts did not
addict population showed no evidence of hypovitaminemia further depress vitamin titers. In contrast, alcoholics with
when their values were evaluated against the comparison liver disease often show nutritional deficiencies and severe
group. Folate and vitamin B6 deficits were most common; hypovitaminosis presumably reflecting intensified demands
these deficits occurred in 37-47 per cent of the addict popu- for vitamins needed for liver repair.'0"'
lation (Figure 1). Figure 2 shows that multiple vitamin defi- Little is known about the precise nutritional status and
cits exist in the addict population. Fifty per cent of this popu- food habits of drug addicts. General malnutrition, anemia,
lation had two or more significantly depressed blood vitamin decreased appetite, gastro-intestinal distress, and emacia-
levels. tion have been reported2; conspicious decreased nutrient in-
take was also commonly found,2 e.g., nutrient intake was
below two-thirds the normal recommended allowances. Our
Discussion results suggest that clinical signs of folate, B6, and thiamine
depletion could become common in the addict population if
Vitamin malnutrition, as judged from circulating levels, addiction and malnutrition were prolonged enough. One now
was common in the addict population. This is especially so wonders: Are the depressed vitamin titers in the addict pop-
for folate, vitamin B6, and thiamine. The sensitivity of these ulation due to heroin, i.e., does the heroin affect liberation
methods permits detection of this type of subclinical malnu- from food, absorption, distribution, metabolism, and rapid
elimination of vitamins? This thought is suggested by find-
ings that ethanol may not only damage liver directly'2 but
that ethanol induced vitamin malabsorption may also con-
tribute to liver damage. 1' It remains to be seen if heroin dif-

EA
M N ".
v
I
A
T
E "_2 %
N E >4
FIGURE 1-Vitamin Deficits in Heroin Addicts with and without FIGURE 2-Distribution of the Number of Vitamin Deficits
Liver Disease in Heroin Addicts

AJPH October 1979, Vol. 69, No. 10 1059


PUBLIC HEALTH BRIEFS

fers from ethanol in these respects. Vitamin deficits may also 5. Quinones MA, El Nakah A, Louria DB, et al: A preliminary
impair host immune mechanisms'4; further studies are study of circulating vitamins in a Puerto Rican migrant farm
population in New Jersey. Am J Public Health 66:172-173,
needed to determine whether those drug abusers who suffer 1976.
from vitamin deficits show a greater proclivity to develop 6. Baker H and Frank 0: Clinical Vitaminology: Methods and In-
infections e.g., hepatitis, and whether these infections once terpretation. New York: John Wiley & Sons, Inc., 1968.
acquired are more virulent and persistent and refractory to 7. Baker H and Frank 0: Vitamin status in metabolic upsets.
antimicrobials. In any case it is unlikely that hypovitamin- World Rev Nutr 9:124-160, 1968.
8. Baker H, Frank 0, Thomson AD, et al: Vitamin profile of 174
emia is doing the drug abuser any good. These data suggest mothers and newborns at parturition. Amer J Clin Nutr 28:56-
that a large percentage of the drug-dependent population 65, 1975.
show multiple deficiencies that warrant vitamin supplemen- 9. Ziffer H, Frank 0, Christakis G, et al: Data analysis for nutrition
tation. survey of 642 New York City school children. Amer J Clin Nutr
20:858-865, 1967.
10. Leevy CM, Thomson AD and Baker H: Vitamins and liver in-
REFERENCES jury. Amer J Clin Nutr 23:493-499, 1970.
1. Aylett A: Some aspects of nutritional state in "hard" drug ad- 11. Leevy CM and Baker H: Nutritional deficiencies in liver dis-
dicts. Brit J Addiction 73:77-81, 1978. ease. Med Clin N Amer 54:467-477, 1970.
2. Gambara SE and Clarke JK: Comments on dietary intake of 12. Lieber CS: Alcohol and malnutrition in the pathogenesis of liver
drug-dependent persons. J Amer Diet Assoc 68:155-157, 1976. disease. JAMA 233:1077-1082, 1975.
3. Baker H, Frank 0, Feingold S, et al: Vitamins, total cholesterol, 13. Baker H, Frank 0, Zetterman RK, et al: Inability of chronic
and triglycerides in 642 New York City school children. Amer J alcoholics with liver disease to use food as a source of folate,
Clin Nutr 20:850-857, 1967. thiamin, and vitamin B6. AmerJ Clin Nutr 28:1377-1380, 1975.
4. Leevy CM, Cardi L, Frank 0, et al: Incidence and significance 14. Axelrod AE: Nutrition in relation to acquired immunity. In:
of hypovitaminemia in a randomly selected municipal hospital Modern Nutrition in Health and Disease (Eds. R. S. Goodhart
population. Amer J Clin Nutr 17:259-271, 1965. and M. E. Shils) Lea & Febiger, Philadelphia, 1973.

Yale Offers New MPH Program in Long-Term Care I


Yale University Medical School, Department of Epidemiology and Public Health, announces a
new graduate Master of Public Health degree program to train students to become planners, evaluators
and policy analysts in the area of long-term care. The program is not focused on developing institutional
managers.
Long-term care is defined as community and/or personal health services for chronically ill, aged,
disabled or retarded people in an institution or at home, on a long-term basis. Graduates will seek
positions in health systems and other planning agencies, Professional Standards Review Organizations,
health care cost control and certificate-of-need agencies, health care institutions, health insurance and
prepayment agencies, governmental agencies (local, state, federal) plus voluntary, professional and
other agencies concerned with long-term planning, evaluation and policy analysis.
Admission requirements include a baccalaureate degree from an accredited college or university
with a minimum grade point average of 3.0 (based on a 4.0 scale). Because the program is analytically
oriented, applicants should have completed undergraduate or graduate courses in at least two of the
following areas: mathematics, statistics, operations research, computer science, economics, financial
management and/or accounting. Courses in the humanities and social sciences are desirable, as is prior
experience in human services.
Persons interested in applying for admission or wanting additional information should contact:
David A. Pearson, Ph.D., Associate Professor of Public Health, Department of Epidemiology and
Public Health, Yale University School of Medicine, 60 College Street, New Haven, CT 06510.

1060 AJPH October 1979, Vol. 69, No. 10


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