Toxic Leukoencephalopathy After "Chasing the Dragon" With a Non-Heroin Opioid

In the United States, the rate of opioid use increases each year. With this, users are engaging in more non-traditional methods of usage. "Chasing the dragon" is a term used to describe opioid inhalation, where the user heats the opioid and then inhales the smoke. While this method of usage is typically associated with a quicker high and fewer adverse effects, it can also lead to toxic leukoencephalopathy (TLE). TLE is defined as a structural alteration of the brain's white matter due to toxic exposure, such as heroin. A 57-year-old woman with a history of polysubstance abuse was admitted to the hospital after weeks of erratic behavior. At presentation, her urine drug screen was found to be positive for oxycodone (which was prescribed to her) and fentanyl. A brain MRI was eventually done, which showed a periventricular leukoencephalopathy characteristic of opioid inhalation. Traditionally, opioid-related TLE is due to heroin, and patients are found to have very dramatic motor issues. As this patient did not report a history of heroin use and did not present with significant motor deficits, this report highlights the need to maintain a level of suspicion for TLE. As levels of opioid use continue to rise, it is likely that many presentations like that of the patient outlined in this report will be seen.