Unveiling the crisis: cocaine abuse's deadly connection to heart disease in Pakistan

1. Introduction

Cocaine abuse has emerged as a significant societal concern within our community. As a nation grappling with multifaceted health challenges, it is crucial to comprehend the intricate interplay between substance abuse and cardiovascular health. In Pakistan, while cocaine abuse’s prevalence is lower compared with other forms of drug misuse, it remains a concerning issue. According to a 2012–13 survey conducted by UNODC, there were approximately 6.7 million drug abusers, including 13,000 cocaine users, primarily originating from the Kashmir region [1].

Cocaine, an alkaloid tropane, is derived from the leaves of the Andean shrub Erythroxylon coca in South America. Originally employed as a surgical anesthetic in local procedures during the 1880s, cocaine later transitioned into a recreational drug in the 1970s. It can be administered through various methods, such as smoking, intravenous injection, nasal inhalation or oral consumption [2].

2. Prevalence & impact

In Pakistan, heart disease claimed a staggering 240,720 lives annually in 2016, constituting 19% of all deaths. Astonishingly, within a mere 3 years, that figure witnessed a dramatic 29% surge, soaring to a nearly harrowing half a million deaths per year (406,870), as reported by the World Health Organization (WHO) [3].

Furthermore, a survey conducted in 2011 among drug users in Karachi unveiled that 20% admitted to cocaine use, with 15% specifically mentioning crack cocaine [4]. Despite these disquieting statistics, Pakistan’s research endeavors focusing on drug abuse and its correlation with heart disease remain conspicuously limited, with recent data being conspicuously scarce. Disturbingly, the nation confronts approximately 700 daily deaths attributed to drug-related issues, as reported in a study conducted during 2012–13 [1,5].

3. Mechanisms of cocaine-induced cardiovascular damage

Cocaine exerts a robust influence on the sympathetic nervous system, functioning both as an inotrope, affecting myocardial contractions’ force, and a chronotrope, influencing heart rate. Additionally, it prompts vasoconstriction and disrupts normal blood vessel relaxation, impeding vasorelaxation [6]. These combined effects result in reduced oxygen supply due to the constriction of coronary blood vessels, restricting blood flow. Simultaneously, cocaine increases the demand for oxygen by elevating heart rate and blood pressure. This cascade of effects, known as cocaine-induced coronary vasoconstriction, is particularly pronounced in segments already compromised by atherosclerosis, potentially leading to endothelial injury and cardiac hypertrophy, contributing to cardiovascular disease development [7]. Apart from cocaine induced discrepancy ischemia, cocaine can induce arrhythmias by enhancing sympathetic tone and altering ion channel function. This includes ventricular ectopies, QT interval prolongation, and potentially fatal arrhythmias like ventricular fibrillation [8]. The magnitude of this problem can be highlighted by a study in which a significant proportion of individuals (0.8–13%) who were admitted with chest pain associated to cocaine had persistent ventricular arrhythmias, which may be a sign of MI [9].

Moreover chronic cocaine use can lead to cardiomyopathy, characterized by myocardial hypertrophy and necrosis, often exacerbated by elevated catecholamine levels and oxidative stress. Left Ventricular Failure also happens due to the negative inotropic effects of cocaine, along with its impact on calcium handling in cardiac myocytes. Cocaine can also induce acute hypertension and promote thrombosis, increasing the risk of cerebrovascular accidents such as strokes. Cocaine also potentiates sympathetic nervous system activity, leading to acute and potentially chronic hypertension, which can cause further cardiovascular complications. Cocaine use also has been associated with valvular heart disease, likely due to its effects on the vascular system and potential for inducing inflammatory processes. The drug’s ability to cause severe hypertension and increased vascular stress can also lead to aortic dissection [8].

4. Cocaine usage & co-occurring health consequences

In addition to cardiovascular conditions, cocaine usage can lead to neurological, psychological, cognitive impairment, respiratory issues, gastrointestinal problems, and psychiatric consequences [10]. Cocaine users often consume other substances concurrently, exacerbating the impact on coronary arteries’ narrowing. This synergism often involves cigarette smoking, alcohol consumption, heroin, and amphetamine use. The co-use of cocaine and ethanol, in particular, intensifies health risks, potentially exacerbating myocardial ischemia through increased oxygen demand, altered blood vessel responsiveness, and the production of cocaethylene, a metabolite [11].

5. Impact of other substances

Amphetamines, similar to cocaine, can elevate catecholamine release and hinder catecholamine reuptake, potentially leading to myocardial ischemia due to increased oxygen consumption from tachycardia and systemic hypertension. Acute myocardial damage is also observed with heroin abuse, which is of significant concern [12], given Pakistan’s high addiction rates [13].

6. Case study

In a reported case, a 41 year old male individual exhibited violent, aggressive, and threatening behavior in a public place, which led to his admission to the emergency department after experiencing a cardiac arrest. He was resuscitated by the medical team prior to his arrival at the hospital. Upon admission to the emergency department, a urine screening test was performed, which revealed positive results for cocaine. The patient was also found to have a high blood alcohol concentration of 1.99 g/l. During his hospitalization, he was treated with pharmacological interventions, including the administration of inotropes and rehydration therapy. Despite these efforts, the patient died suddenly due to cardiac arrest approximately 14 hours after his admission to the emergency department. It was found out in his autopsy reports that he was diagnosed with ARVC (Arrhythmogenic right ventricular cardiomyopathy), a worsened condition due to cocaine use, resulting in a severe cardiovascular event leading to their demise, which was confirmed through postmortem molecular analysis revealing a mutation in the DSG2 gene. There is no specific mention of the patient taking prescription medications at the time of his death. ARVC involves the conversion of right ventricular muscle tissue into fatty tissue. Its presentation varies among individuals. Genetic screening of established genes shows that about 60% of clinically diagnosed ARVC cases possess at least one pathogenic genetic variation (PGV) linked to the ailment. These genes include desmosomal genes like PKP2, DSP, DSC2, DSG2, and PG encoded by the JUP gene, alongside non-desmosomal genes such as TMEM43, TGFB3, CTNNA3, DES, LMNA, TTN, and PLN. This condition follows an autosomal dominant inheritance pattern. Along with this genetical pathology, this case study showed the drug’s stimulant properties can trigger electrical disturbances in the heart, particularly in those with structural heart abnormalities, increasing the likelihood of fatal arrhythmias [14].

7. Intervention strategies

Pakistan is actively exploring various intervention measures in collaboration with international partners to combat drug abuse. Initiatives include establishing addiction treatment and rehabilitation centers, strategic awareness campaigns, and legislation aimed at preventing drug abuse, particularly among the youth and within educational institutions [15–17].

Pakistan is actively exploring various intervention measures and is committed to implementing policies aimed at curbing drug abuse. These efforts are being undertaken in collaboration with international partners who provide aid and support. The country is dedicated to addressing the challenges posed by drug abuse and addiction through a range of strategic initiatives and policy actions, all with the goal of reducing the prevalence and harmful effects of drug abuse within its borders. The Government of Pakistan also has constitutionally mandated the Anti Narcotics Force (ANF) to combat narcotics in all its aspects and across the entire spectrum. The ANF has set up three Model Addiction Treatment & Rehabilitation Centers, offering complimentary treatment, meals, lodging, and rehabilitation services to individuals struggling with drug addiction [17].

In 2015, the UNODC, with support from the US Department of State, partnered with Pakistan’s Ministry of Interior and Narcotics Control to launch a drug prevention campaign across nine cities in the Sindh Province. This initiative included strategic billboard placements, local language awareness messages on FM radio and local TV stations, community-based activities in schools and colleges, and the establishment of a hotline to raise awareness about drug abuse [15].

Drug usage tends to have a heightened susceptibility among individuals at a young age, with a significant impact on students within educational institutions. To address this critical issue, the Federal Government of Pakistan took proactive steps by enacting two key pieces of legislation: the Control of Narcotics Act of 1997 and the Drugs Act of 1976. These legal frameworks serve as crucial tools in the government’s efforts to combat drug abuse and trafficking, particularly among the youth and within the educational system. They provide a legal foundation for various measures aimed at preventing drug abuse, ensuring the control of narcotics, and safeguarding the well-being of the country’s younger generation [16].

8. The need for comprehensive data collection

The gaps in data and statistics serve as an emphatic call to action, underlining the imperative for more exhaustive research to validate these findings. Such research is critical to unravel the intricate relationship between drug abuse and the onset of heart disease within the Pakistani context. Notably, there is currently no recent research material available linking these factors in Pakistan. The scarcity of up-to-date research data on heart disease mortality further exacerbates this issue, as the mortality rates are likely to have significantly increased. With cocaine availability on the rise in recent years, the risk of mortality due to heart diseases in individuals using cocaine is a matter of considerable concern [1,3,4].

9. A potential solution

One approach to address this data gap is to establish a comprehensive data collection system similar to the CDC WONDER in the USA. Such a system would provide detailed mortality data, including causes of death, gender, race, age, and more. By implementing such a system in Pakistan, vital information can be collected, analyzed, and used to inform evidence-based interventions, potentially leading to a significant reduction in drug-related heart disease mortality within a decade [18]. This proactive step would greatly enhance our understanding of the problem and guide effective policy measures.

10. Conclusion

In conclusion, the crisis of cocaine abuse and its lethal connection to heart disease in Pakistan is a pressing issue that demands immediate attention. The article effectively highlights the severity of the problem, the mechanisms involved, and the ongoing efforts to combat it. It also emphasizes the need for better data collection to inform evidence-based interventions.

To conclude the article, it could be stated that while Pakistan has made significant strides in addressing drug abuse and its associated health risks, including heart disease, there is still much work to be done. With a concerted effort, continued international collaboration, and the establishment of comprehensive data collection systems, Pakistan can hope to mitigate the deadly consequences of cocaine abuse on its population and ultimately improve public health outcomes.

We foresee significant advancements in the field of cocaine abuse and cardiovascular health research in Pakistan over the next 5–10 years. This progress will be driven by comprehensive data collection systems similar to CDC WONDER, extensive research initiatives, and robust intervention and prevention strategies. Emphasizing the importance of international collaboration, we highlight the value of partnerships with organizations like UNODC and support from countries such as the USA. Public health policies and legislation, multidisciplinary approaches, and public awareness campaigns are pivotal in addressing this issue. With these measures, we anticipate a substantial reduction in drug-related heart disease mortality rates, ultimately improving public health outcomes in Pakistan.

Author contributions

JG Shaikh conceived the topic and wrote the original manuscript. AA Raza did the literature search, wrote the original manuscript, reviewed, edited and referenced the article. MA Qadeer reviewed the article and did the supervision.

Financial disclosures

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Competing interests disclosure

The authors have no other competing interests or relevant affiliations with any organization or entity with the subject matter or materials discussed in the manuscript apart from those disclosed.