Earlier in the book, we learned that heart disease, for nearly one hundred years now, has been the number one killer of Americans and that half of all heart attacks may be “silent”—that is, asymptomatic, or without the chest pain typically associated with heart attacks. Still, great strides have been made over the last six decades in reducing the rate of death from cardiovascular disease through innovations in medications and diagnostics, as well as through you—that is, you the public, who have heeded warnings of how certain behaviors and lifestyle choices can increase the risk of developing silent heart disease and coronary heart disease in general.
In the last chapter, I discussed how much this progress has been undone by the epidemic of obesity. It’s a problem that has gradually but steadily grown since the early 1960s, and it had become obvious by the 1990s that obesity posed a major public health risk. The other scourge of the new millennium—drug addiction and particularly the opioid crisis—has followed another trajectory with equally devastating negative effects.
When I was a newly practicing physician in the 1960s, the idea that a huge swath of the American public would abuse illicit drugs—not to mention legally prescribed drugs—to the extent that it became a national health epidemic would have seemed incredible. In fact, the time-released opioid prescription pills that are fueling much of the nation’s drug epidemic hadn’t even been invented yet. And the two ancient but wildly popular substances with substantial potentials for addiction—nicotine and alcohol—still were not very well understood sixty years ago.
Today, nearly two hundred people die of a drug overdose every day. In 2018, drug overdoses killed more people than guns, car crashes, or HIV/AIDS combined, and in that single year, drug overdose deaths exceeded all U.S. military casualties in the Vietnam and Iraq Wars combined.
Approximately 21 million Americans—almost 8 percent of adolescents and adults—abuse some kind of legal or illegal substance. That number is similar to the number of people who suffer from diabetes and more than 1.5 times the annual prevalence of all cancers combined (14 million).
The abused drugs most associated with cardiovascular disease are opioids, legal (prescription pain medications like oxycodone) and illicit (heroin), and stimulants, notably cocaine and methamphetamine. Collectively these two classes of drugs may increase the risk of vascular and heart disorders by disrupting the balance of certain neurotransmitters, called catecholamines, in the body and brain. This may lead to dose-dependent changes in blood pressure, abnormalities in the rhythms of the heart or blood vessels, and increased blood clotting, arterial plaque formation, and risk of serious events such as heart attacks.
At last the medical profession has begun to realize the effects the opioid epidemic is having on the collective heart health of the nation, and just in time. In addition to the lingering opioid crisis, an old drug scourge that we thought had been left behind for the most part after its heyday in the 1980s, cocaine, is back with us again, but this time with a new and deadly twist.
However, we begin this chapter on substance abuse as a risk factor for silent heart disease and coronary heart disease with a look at two persistent substance abuse problems older than America itself: cigarette smoking and alcohol consumption.
When I was growing up, cigarette smoking was very glamorous—seemingly all the golden era movie stars smoked. Later it became very counterculturally cool—a symbol of youthful rebellion. Cigarettes delivered what seemed to be the perfect drug: nicotine. It could pick you up when you were tired or relax you when you were agitated. Sometimes heavy smokers noticed a persistent cough, but what could possibly be wrong with smoking a pack or two a day? OK, maybe cigarettes were not good for you, but too much coffee wasn’t either, right?
By the 1980s, the dangers of smoking and its deleterious effect on public health—including cardiovascular disease—had become widely known to just about everybody. The public also became aware of the tobacco industry’s efforts to mislead consumers about the health effects of smoking and to manipulate public policy for the short-term interests of the industry. The first successful lawsuits against tobacco companies over smoking-related illness were won at the close of the last century.
We can rejoice that today, because of the cumulative effects of all the educational efforts by many organizations, smoking rates have been cut in half since their apex in the 1960s, when an estimated 42 percent of Americans smoked cigarettes. Today, the proportion is down to just 15 percent. But here’s the bad news: that 15 percent, approximately 38 million Americans, somehow did not get the memo that smoking is a leading risk factor for coronary heart disease (not to mention lung cancer) and continue to smoke at least one cigarette per day.
Here’s the unique thing about smoking cigarettes—it’s absolutely, in the literal sense, dangerous. There’s no sliding scale as to how much is maybe OK and how much is really bad. It’s all really bad. There are no qualifiers, no equivocations. Medical studies have shown that even light or moderate smoking significantly increases the risk of heart disease.
New research published in 2018 in the British Medical Journal revealed that men who smoke one cigarette daily have a 48 percent higher risk of heart disease and a 25 percent higher risk of stroke than those who do not smoke. For women, the negative effects were even more pronounced.
Now, logically, you might suppose that smoking just one cigarette would carry one-twentieth the risk of smoking a pack, which contains twenty cigarettes. Nope. The researchers found that men who smoked one cigarette per day had nearly half the risk of developing coronary heart disease incurred by those who smoked twenty cigarettes a day; for women who smoked one cigarette daily, the figure was 31 percent of the risk of smokers of twenty per day. These patterns were roughly the same for stroke risk for men and women who smoked just one cigarette daily.
This particular study was a meta-study, a review of other published research whose data was then compiled and critically analyzed. It involved fifty-five publications, encompassing 141 studies, with the goal of determining the relative risk of cigarette smoking for cardiovascular disease.
The general mechanisms by which smoking results in cardiovascular events include narrowing of the coronary arteries and an overproduction of blood cells, which together create risk of acute thrombosis (blood clotting). The rapid decline in this risk after a patient stops smoking supports the role of cigarette smoking in blood clotting.
Chemicals in cigarette smoke cause the cells that line the blood vessels to become swollen and inflamed. This can narrow the blood vessels and lead to many cardiovascular conditions. Arteries narrow as plaque builds up, and blood can no longer flow properly to various parts of the heart. Smoking increases the formation of plaque in the coronary arteries.
Peripheral arterial disease (PAD) occurs when blood vessels become narrower and the flow of blood to arms, legs, hands, and feet is reduced. Cells and tissues are deprived of needed oxygen when blood flow is reduced. In extreme cases, an infected limb must be removed. Cigarette smoking is the most common preventable cause of PAD.
Abdominal aortic aneurysm is a bulge or weakened area in the portion of the aorta that is in the abdomen. The aorta is the main artery that carries oxygen-rich blood throughout the body. Smoking is a known cause of early damage to the abdominal aorta, which can lead to an aneurysm. A ruptured abdominal aortic aneurysm is life threatening; almost all deaths from abdominal aortic aneurysms are caused by smoking. Women smokers have a higher risk of dying from an aortic aneurysm than men who smoke. Autopsies have shown early narrowing of the abdominal aorta in young adults who smoked as adolescents.
Atherosclerosis, in which arteries narrow and become less flexible, occurs when fat, cholesterol, and other substances in the blood form plaque that builds up in the walls of arteries. The plaque buildup narrows vessels, so less blood can flow through. When a clot forms in one of these narrow places in an artery around the heart, the heart muscle becomes starved for oxygen. This can cause a heart attack.
Cigarette smoking produces a chronic inflammatory state that contributes to the promotion of fatty plaques in the coronary arteries and elevates levels of biomarkers of inflammation, known powerful predictors of cardiovascular events.
To summarize, smoking damages the heart and blood vessels very quickly, but here’s the good news: the damage is repaired quickly as well for most smokers who stop smoking. Even longtime smokers can see rapid health improvements when they quit. Within a year, heart attack risk drops dramatically. Within five years, most smokers cut their risk of stroke to nearly that of a nonsmoker. But again, having even a few cigarettes now and then damages the heart, so the most effective treatment is complete abstinence from cigarette smoking.
Tobacco for smoking was originally cultivated in North America, first by Native American tribes in the mid-Atlantic region and later by British colonists. With that kind of history, you might think there could be nothing new under the sun that could hook a whole new generation of Americans on smoking. Enter vaping, a particularly dangerous trend among young people with real cardiovascular risks. Preliminary research, while not yet definitive, does support the notion there is significant cardiovascular risk to vaping.
Vaping uses so-called e-cigarettes, or battery-operated devices that carry aerosolized vapor that users inhale and then exhale. In that way, they’re just like old-school tobacco cigarettes—except there’s no tobacco, just a vaporized form of nicotine. Because vaping is so new, having only become popularized in the last decade, there hasn’t been enough time to research the cardiovascular effects of it.
Smoking tobacco cigarettes was once promoted as a means of lowering blood pressure and stress. Vaping was originally positioned as an aid for smokers to kick the tobacco habit. It was a risk-benefit roll of the dice with the hope that there wouldn’t be any dangerous unintended consequences. As I write this chapter, news has broken of a fifth death due to a mysterious respiratory illness attributed to vaping. This follows the hospitalization of two hundred mostly young people, all experiencing a heretofore unidentified pulmonary affliction.
One theory is that the illness stems from a natural inflammatory response in the lungs, which are filled with blood vessels, due to the introduction of this aerosolized substance. When the lungs encounter bacteria or viruses, this inflammatory response is beneficial, with the body mounting an attack against the foreign and toxic invader. In this case, the body’s natural inflammatory response, triggered by the inhaled vapor, becomes the danger. The vaping industry is largely unregulated, and investigators are exploring whether a toxic contaminant might have been inadvertently introduced during the manufacturing process. There’s also the still-unanswered question as to what effect breathing in secondhand vaping smoke might have.
This brings us back full circle to the dangers of secondhand smoke. If you live with a smoker (most workers no longer have to worry about fellow employees’ smoking), let him or her know that your cardiac health is being putting at risk with every cigarette lit in your presence. Research now shows that exposure to secondhand smoke causes heart disease in nonsmokers. More than thirty-three thousand nonsmokers die every year in the United States from coronary heart disease caused by exposure to secondhand smoke, which leads to heart attacks and strokes in nonsmokers. That works out to about one American dying every fifteen minutes from coronary heart disease, including silent heart disease, caused by somebody else’s cigarette smoking habit.
Alcohol—spirts, wine, beer—is so embedded in our culture that it’s hard to imagine life without it (although large parts of the world largely refrain from it). In our country, there are religious groups, including the Seventh Day Adventists and Mormons, who reject even the recreational use of any alcohol. Still, alcohol seems to be everywhere in our popular culture, and unlike cigarette smoking, alcohol consumption has not experienced any significant decline over the past sixty years. On the contrary, per capita alcohol consumption in the United States has increased in the past couple of decades to reach a new record of 2.34 gallons of ethanol per capita in 2017.
By any measure the danger of excessive alcohol consumption dwarfs that of all drugs—legal and illegal—combined. In 2018, eighty-eight thousand Americans died because of alcohol abuse, from short-term issues like serious accidents and from long-term health complications, including liver failure, cancer, and heart disease. Of the 21 million people with a substance abuse disorder in 2015, nearly 16 million were in need of treatment for an alcohol problem compared to less than 8 million needing treatment for an illicit drug problem.
A study published in January 2020 in the journal Alcoholism: Clinical & Experimental Research found that alcohol-fueled deaths in the United States have doubled over the past twenty years, costing nearly one million lives. All demographic groups (by gender, race, and age) demonstrated increases in deaths by alcohol abuse, but white women registered the largest increases. Why women? The authors speculate that “because women reach higher blood alcohol levels than men of comparable weights after consuming the same amount of alcohol, their body tissues are exposed to more alcohol and acetaldehyde, a toxic metabolite of alcohol, after each drink.” This increased sensitivity also makes women more vulnerable to alcohol-related cardiovascular diseases.
The Journal of the American College of Cardiology recently reported that ending alcohol abuse would prevent seventy-three thousand clinical episodes of arterial fibrillation, leading to thirty-four thousand fewer heart attacks, and reduce the number of patients with chronic congestive heart failure by ninety-one thousand.
Abusing alcohol, or drinking more than just moderately, doubles the risk of heart attack through several factors. Alcohol contributes to high blood pressure, doubles the risk of atrial fibrillation (irregular, rapid heartbeat), and brings a 2.3-fold increased risk of congestive heart failure—all increasing the risk of heart attack later in life. To frame it another way, the excessive consumption of beer, wine, and spirits directly contributes to a 1.4-fold increase in cardiac episodes. Heavy drinking is also linked to an elevated risk of hypertension, diabetes, cardiovascular disease, stroke, and death after a heart attack, according to the latest research.
However, key to understanding these statistics are the terms “heavy drinking” and “abusive drinking.” Unlike cigarette smoking, where the tiniest amount—for example, one cigarette per day (and who smokes only one cigarette every twenty-four hours?)—is dangerous, the consumption of alcohol is much more nuanced. Indeed, as counterintuitive as it might sound, light to moderate drinking can even benefit heart health, as I explain below.
First, however, let’s define terms. According to the Centers for Disease Control and Prevention, a standard drink is equal to 14.0 grams (0.6 ounces) of pure alcohol. Generally, this amount of pure alcohol is found in
•12 ounces of beer (5 percent alcohol content)
•8 ounces of malt liquor (7 percent alcohol content)
•5 ounces of wine (12 percent alcohol content)
•1.5 ounces, or a “shot,” of eighty-proof (40 percent alcohol content) distilled spirits or liquor (for example, gin, rum, vodka, whiskey)
“Moderate” alcohol consumption is defined as up to one drink per day for women and up to two drinks per day for men. This definition refers to the amount consumed on any single day and is not intended as an average over several days. However, the dietary guidelines do not recommend that people who do not drink alcohol start drinking for any reason.
For men, “heavy” drinking is typically defined as consuming fifteen drinks or more per week (using the formula above). For women, heavy drinking is typically defined as consuming eight drinks or more per week. The term “heavy drinking” is defined in terms of a week’s consumption versus a day’s because, in theory, one could binge drink one day, return to light or moderate drinking for the next six days, and still qualify as a moderate drinker. We’ll get more into the difference between heavy drinking and binge drinking in a minute. Suffice it to say, both are significant risk factors for coronary heart disease, but one is much worse.
“Severe alcohol use disorder,” also known as alcohol dependence or alcoholism, is a chronic disease, just like drug addiction, with both a genetic and an environmental component. Some of the signs and symptoms of severe alcohol use disorder could include the following:
•Inability to limit drinking
•Continuing to drink despite personal or professional problems
•Needing to drink more to get the same effect
•Wanting a drink so badly you can’t think of anything else
Heavy or extreme alcohol consumption is associated with a vast array of cardiovascular conditions and events, including the following:
•Arrhythmia (irregular heartbeat)
•Cardiomyopathy (a disease of the heart muscle that makes it harder for your heart to efficiently pump blood to the rest of your body)
•Hypertension
•Increased triglyceride levels (associated with clogged arteries)
•Peripheral artery disease
•Death associated with acute cardiovascular events, including sudden cardiac arrest
A concern in the management of any chronic disease, including cardiovascular disease, is drug combining, which increases the risks of adverse effects due to drug interactions. This may include the combination of alcohol with illicit drugs or with prescription drugs. The legal substances may include medications indicated for cardiovascular disorders, which often interact with alcohol to produce negative effects.
A review of data from the American National Health and Nutrition Examination Survey found that the rate of alcohol/prescription drug combination was 41.5 percent. This rate, when adjusted for age (sixty-five years or more), was 77.8 percent. In many cases, the medications in question were for cardiovascular conditions. Another major study on aging found that 72 percent of its approximately thirty-eight hundred participants used medications that interact with alcohol, most often drugs for cardiovascular or neurological conditions. Approximately one in five of these people combined heavy alcohol consumption with anticlotting agents and other drugs for cardiovascular disease. Older people (who are at a higher risk of cardiovascular disease) often have an increased probability of drug/alcohol interaction due to age-related decreases in the ability to absorb and metabolize these compounds.
The effects resulting from cardiovascular drug interactions may include the following:
•Increased blood alcohol levels
•Liver damage
•Gastrointestinal damage and bleeding
•Increased risk of the adverse effects of cardiovascular drugs
•Reduced efficacy of the drugs in question
In 2018, about 67 million Americans twelve years or older were binge drinkers in the past month, and 16.6 million were heavy drinkers in the past month. What’s the difference?
Binge drinking is the quick, high-volume intake of alcohol. The National Institute on Alcohol Abuse and Alcoholism defines binge drinking as consuming five or more drinks for men or four or more drinks for women in about two hours. One research study found that binge drinking six or more cocktails in one evening—servings of hard liquor due to generous pours in bars—increased the risk of heart attack and stroke about 30 percent for the next twenty-four hours and continued a significant increase in the risk of a heart attack or stroke for seven days after the event.
In another study researchers at Harvard University looked at interview data from nearly four thousand people across the United States hospitalized for heart attacks over a three-year period. They looked at the number of alcoholic drinks participants drank in the hour before their heart attack symptoms appeared as well as how much alcohol they drank in the past year. Their findings revealed that people who binge drink are 72 percent more likely to have a heart attack than those who don’t.
Now, as alarming as binge drinking sounds, and it is, heavy drinking poses an even greater risk for developing symptoms of heart disease. The daily consumption of large amounts of alcohol, day in and day out, is even worse than the occasional “lost weekend.”
If you have a friend or family member in Alcoholics Anonymous (AA) or who follows another kind of program that requires total abstinence from alcohol of any kind, and you’re thinking of lending him or her this book, best to delete this next section. (A few snips of scissors should do the trick.) What I’m about to suggest here—that moderate alcohol consumption actually has a cardiac health benefit—will be viewed by AA and its disciples as nothing less than heresy. I get it, but the science about the benefits of moderate drinking does not lie. Read on, if you dare.
The incidence of heart disease in those who drink moderate amounts of alcohol (no more than two drinks per day for men or one drink per day for women) is lower than in nondrinkers. Over the past several decades, many studies have been published in science journals about how light to moderate drinking of alcohol may be associated with reduced mortality due to heart disease in some populations.
Some researchers have suggested that red wine, consumed moderately, might be especially beneficial. Their thinking is that red wine contains flavonoids and other antioxidants associated with reduced risk of heart disease. Other studies point to moderate consumption of red wine as promoting an increase in HDL (“good”) cholesterol, important because of its anticlotting properties.
How alcohol or wine affects cardiovascular risk needs further research, but right now you can rest assured that if you drink moderately, it will not contribute to heart disease and may even benefit your heart health. That’s not to suggest that those who do not drink alcohol—because of cultural or religious convictions or because they simply do not like the taste of it or how it makes them feel—should begin consuming alcohol to prevent heart disease. There are other means, including regular physical activity and eating a whole-foods diet, to achieve the same results. And speaking of diet, alcohol of any kind is loaded with calories. (There’s no such thing as a “beer weight-loss plan” for good reason.) For all people, alcohol can lower blood sugar, and so for people with diabetes, it is recommended that any alcohol be consumed with a meal.
Earlier we discussed the fundamental difference between cigarette smoking and alcohol consumption. Smoking presents an absolute danger—even one cigarette a day can pose a risk to cardiac health. On the other hand, while heavy and binge drinking are absolutely a cardiac risk factor, light to moderate drinking has proven to be beneficial to the heart.
However, there’s one exception to this more nuanced view of alcohol, and it’s for a group of people that crosses all ethnic, racial, and geographic boundaries—pregnant women. There are no exceptions and no excuses for pregnant women to drink alcohol, because doing so can seriously harm the fetus. Fetal alcohol syndrome is a serious birth defect caused by the consumption of alcohol by the pregnant mother. About half of babies who suffer from fetal alcohol syndrome have a heart problem.
I recall reading a news story about a gentleman who was so disenchanted by the results of a recent election that he became a virtual hermit in our Information Age, refusing to read, hear, or see any news accounts about anything. He’s probably the only person at this point who hasn’t heard that the nation continues to be gripped by a drug problem of epic proportions.
For the record, let’s recap what this unprecedented drug epidemic looks like. From 1999 through 2016, the age-adjusted rate of drug-overdose deaths in the United States more than tripled from 6.1 per 100,000 to 19.8 per 100,000. The only comparable recent epidemic in modern times to spike so dramatically with such devastating consequences was HIV/AIDS, and, as noted earlier, opioids have killed many more than AIDS.
As with the obesity epidemic, the opioid epidemic is a worldwide problem but is much worse in the United States than in any other country. When it comes to overprescribing prescription painkillers, the United States leads the way. A recent study on overprescription of opioids by U.S. physicians showed that Americans are seven times more likely to get opioids after surgery than Swedish patients, and not only more pills but higher dosages as well.
Opioids mimic the body’s natural endorphins by binding to pain receptors to inhibit their signaling to the brain. Some of the earliest drugs, including heroin, are opioids. These drugs have neurological effects besides analgesia, which may include euphoria, lethargy, respiratory problems, and withdrawal symptoms. However, in excessive doses, opioids’ action on the nervous system can produce several other effects, including sedation, depressed breathing, seizures, confusion, vomiting, pinpoint pupils, and stupor. Death from an opioid overdose most often occurs during an opioid-induced stupor, in which the respiratory drive becomes so thoroughly depressed that breathing simply slows down or even stops.
Given the national spotlight on deaths due to opioid overdose, the many cardiac problems caused by these substances have received little attention. However, opioids are now associated with several kinds of potentially life-threatening heart problems.
Opioid use over time can increase the risk of cardiovascular disease by increasing the concentrations of low-density lipoproteins and free triglycerides in the body, both associated with increased risks of atherosclerosis, stroke, and heart attack. A study comparing 117 coronary artery bypass patients who also abused opioids with 208 similar patients who did not abuse these substances found that low-density lipoprotein and average triglyceride levels were significantly higher in the substance-abusing patients.
While opioids by themselves have little effect on the ability of the heart muscle to contract forcefully, this ability can be suppressed when opioids are combined with benzodiazepines (drugs like Valium). This combination is not uncommon in people chronically taking opioids. In people who have an underlying heart problem that produces some degree of weakness in cardiac function, such as cardiomyopathy, the combination of an opioid and a benzodiazepine can precipitate overt heart failure.
Bradycardia, or a slow heart rate, is seen fairly frequently in people taking opioids. Generally, this condition is due to a slowing of impulses from the sinus node, as is seen in sick sinus syndrome. Opioid bradycardia rarely causes symptoms at rest, but it can lead to poor exercise tolerance, since the heart rate may be incapable of increasing normally with exercise.
Opioid use is a risk factor in vasodilation, or dilation of the blood vessels. This condition can cause hypotension (low blood pressure). Because opioids also can produce bradycardia along with vasodilation, a person on opioids who stands up quickly may experience a sudden drop in blood pressure—a condition called orthostatic hypotension.
Two opioids in particular (methadone and buprenorphine) can induce a phenomenon on the electrocardiogram (EKG) called QT prolongation. In some people, QT prolongation can be associated with a dangerous form of ventricular tachycardia called torsades de pointes. This type of cardiac arrhythmia commonly produces episodes of severe lightheadedness, temporary loss of consciousness, or even sudden death.
Atrial fibrillation is a rapid, irregular heart rhythm caused by a disrupted electrical signal in the heart’s atria (the upper cardiac chambers). People who take opioids are at a higher risk of the condition. People with atrial fibrillation have a relatively high incidence of stroke and possibly of heart attacks.
Infectious endocarditis is an infection of the heart valves, a relatively rare but life-threatening condition seen mainly in the elderly. Recently, however, many more young people than ever before—particularly young, white women—have been diagnosed with the condition. The common denominator among these young people with endocarditis? They have abused intravenous opioids, especially heroin. Infectious endocarditis has a high mortality rate, and survivors are commonly left with chronic cardiac disease.
Here’s some good news about the opioid epidemic: the number of opioid prescriptions actually peaked in 2012 and has declined ever since. Opioids, both legal (notably, oxycodone) and illicit (notably, heroin), initially fueled the nation’s twenty-first-century drug epidemic. Cocaine, on its own or mixed with illicit synthetic forms of the powerful opioid fentanyl, has overtaken opioids, killing nearly thirty-two thousand Americans in 2018.
As cocaine use increases in the United States, researchers have begun to examine associated demographic trends. Using nationally representative survey data encompassing responses about substance use collected from 281,242 people between 2011 and 2015, they found that cocaine use had increased the most among three groups: women, people between the ages of eighteen and twenty-five, and people over age fifty.
An Australian study presented at the American Heart Association’s Scientific Sessions in 2012 was the first to document cardiovascular abnormalities in seemingly healthy regular cocaine users long after the immediate effects of cocaine had worn off. Researchers—who called cocaine “the perfect heart attack drug”—showed how users had higher rates of multiple factors associated with higher risks of heart attack and stroke:
•30 to 35 percent increase in aortic stiffening,
•8 mmHg higher systolic blood pressure, and
•18 percent greater thickness of the heart’s left ventricle wall.
The abuse of cocaine is also linked to the increased risk of infections of heart muscle and other cardiac tissues. This leads to conditions such as endocarditis, which in turn may result in increased risk of hospital readmission for conditions such as stroke, arrythmia, heart attack, and heart failure.
Cocaine is the illegal drug most often associated with visits to U.S. hospital emergency departments. Cocaine use has been associated with chest pain and myocardial infarction. In 2011, it was involved in an estimated 40.3 percent of illicit-drug-related emergency department visits (505,224 visits) versus about 36.4 percent (455,668 visits) for marijuana and about 20.6 percent (258,482 visits) for heroin.
Cocaine-induced heart attacks are not just a risk for individuals who’ve used the drug for years. A first-time user can experience a cocaine-induced heart attack. Cocaine use quadruples sudden death in users fifteen to forty-nine years of age, due primarily to resulting cardiovascular disease.
The most significant damage to the heart, however, may be occurring silently. This lasting damage may be difficult to detect. A 2011 study found that medical tests rarely show damage to a cocaine user’s blood vessels or heart.
The use of cocaine also complicates cardiovascular treatments. For example, people who use cocaine cannot take beta-blockers, a critical medication for lowering blood pressure by blocking the effects of the hormone adrenaline. Blocking adrenaline slows the heart rate and allows the heart to pump less forcefully. In individuals who’ve used cocaine, beta-blockers may actually lead to greater blood vessel constriction, which can increase blood pressure even more.
In 2016, the number of overdose deaths involving cocaine almost doubled from two years prior, jumping from 5,892 to 11,316. Forty percent of these deaths also involved a newly emerging synthetic version of fentanyl, an opioid fifty times more potent than morphine. This latest wave of substance abuse is too new for much research to have been done on its effect on cardiac health beyond, of course, those cases resulting in death by overdose. But the most recent statistics show clearly that cocaine and fentanyl are being mixed together in a deadly cocktail, often without the knowledge of buyers, who think they are getting pure cocaine.
Fentanyl first captured the nation’s attention when the death of pop music star Prince in 2016 was determined to have been caused by an overdose of the drug. However, the overdose was from a prescribed form of the drug, which he was taking for pain from numerous injuries suffered while performing. The cheap, synthetic forms of the drug flooding into the United States are imported mainly from legal and illicit sources in China.
How the nation will emerge from the triple wave of the drug crisis of the last decade—prescription pain killers, cocaine, and fentanyl—is anyone’s guess at this point. In the case of the latter, pushers haven’t even had time to come up with a street idiom for the drug—they call it fentanyl too.
Research into marijuana and its potential to affect cardiac health is also lacking. Banned as a Schedule 1 drug (right up there with heroin, LSD, and methamphetamine), which hampered its study by medical researchers, marijuana, or cannabis, as a risk factor in cardiovascular disease is just coming under the microscope as individual states have begun to decriminalize its recreational use.