AN AETIOLOGICAL SURVEY OF BURNS IN ABUSERS OF VARIOUS KINDS OF DRUGS ADMITTED TO THE TABRIZ SINA HOSPITAL BURNS WARD IN IRAN

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1 AN AETIOLOGICAL SURVEY OF BURNS IN ABUSERS OF VARIOUS KINDS OF DRUGS ADMITTED TO THE TABRIZ SINA HOSPITAL BURNS WARD IN IRAN Maghsoudi H.,* Raghifar R. Department of Surgery, Faculty of Medicine, University of Medical Sciences, Tabriz, Iran SUMMARY. A five-year prospective study (March 2003-March 2008) of burn victims hospitalized in a major burns centre in Iran was conducted in order to survey the aetiology and outcome of burns in patients who were drug addicts. Three hundred and thirty patients addicted to drugs were identified and stratified by age, sex, burn size, presence or absence of inhalation injury, kinds of abuse agents, and cause of burn. The mean patient age was 27.9 yr, and the male:female ratio was 7.6:1. There were 60 deaths overall (18.18%), the majority (47) among patients with flame burns. The mortality rate was significantly higher in multi-drug abusers than in single-drug abusers. Except for burn incidence, there were no significant differences between males and females. The mean burn size, 30.9%, was significantly larger in non-survivors than in survivors (57.8% versus 27.8%; p < 0.001). Inhalation injuries were strongly associated with large burns, and were present in all flame-burn fatalities. Flame burns were the most common type of burns in drug-addicted patients: incorrect use of a lighter and match and falling onto a brazier were the most common causes of flames. There were 11 deaths related to electrical injuries. Large burn size was the strongest predictor of mortality followed by the presence of inhalation injury. The most common agent of abuse was opium, followed by heroin and hashish; there was no difference between males and females in relation to the type of agent of which abuse was made. Keywords: burns, drug addiction, drug abuse, opiates Introduction The principal effects of opioids (opiate-like drugs) are a significant damping of pain perception along with modest levels of sedation and euphoria. Tolerance of any one opioid is likely to be generated to others (i.e., cross-tolerance is likely), and all present a similar pattern of drugrelated problems. Each of these opioid substances is capable of producing physical addiction, and the withdrawal syndrome after abstinence from any one of the substances can be treated by administering any of the others. 1 Stimulants are drugs that stimulate the central nervous system. These substances tend to increase alertness and physical activity. They include amphetamines, cocaine, crack, and some inhalants like amyl or butyl nitrites. Caffeine (present in tea, coffee, and many soft drinks) is also a mild stimulant drug. 2,3 Different stimulants act on the body in different ways. For example, nitrate inhalants cause the blood vessels to dilate, cocaine and crack interfere with normal levels of the neurotransmitter serotonin, and amphetamines cause the release of adrenalin. Nevertheless, broadly speaking, all these stimulants have a similar effect in that they cause mental and/or physical stimulation in the user. This may be felt as apparent increased physical energy and/or apparent clarity and speed of thought. 4 Hallucinogens - or psychedelics - are drugs that affect a person s perception of sights, sounds, touch, smell, etc. Some of the stronger hallucenogenics can exert a powerful effect on a drug-user s thinking and self-awareness. Hallucinogens have no legal medicinal uses and are therefore all classed as drugs of abuse. The most commonly seen are LSD, ecstasy, and psilocybin (magic mushrooms). Other hallucinogenic substances such as mescaline and DMT are not widely available on the illicit drug market in the United Kingdom. 3,5 Cannabis is a central nervous system depressant obtained from the plant Cannabis sativa, which grows in many parts of the world. It is available for use as a drug in three main forms: as the dried leaves and buds (known as grass or marijuana), as a solid resin (hashish or hash) which is collected from the buds and flower heads, and as a thick * Corresponding author: Hemmat Maghsoudi, MD, Sina Hospital, Azadi Street, P.O. Box 1548, Tabriz , East Azerbaijan, Iran. Tel.: ; fax: ; maghsoudih@yahoo.com 1

2 liquid prepared from the flowers or resin (hash oil). The main psychoactive (i.e. mind-altering) ingredient in cannabis is THC (delta-9-tetrahydrocannabinol), but more than 400 other chemicals are present in the plant. Hashish is made by taking the resin from the leaves and flowers of the cannabis plant and pressing it into cakes or slabs. It is usually stronger than herbal cannabis and may contain five to ten times as much THC. The effects of cannabis depend upon the amount used, its potency, the circumstances, and the user s expectations/mood. The attention paid by the general public, the government, and the media to heroin, cocaine, and ecstasy in recent years may have led some adults and young people to assume that cannabis is of less concern. Cannabis availability is at an all-time high. Among teenagers, those who smoke cigarettes are more likely to drink alcohol. Those who smoke and drink are more likely to use cannabis. And those who use all three are more likely to use other illicit drugs. Long-term studies show that young people s use of other illicit drugs almost never occurs unless they have first used cannabis. Using cannabis exposes the young to the company and influence of those who use and deal in illicit drugs and may encourage other dangerous and illegal activities. Some estimates suggest that more road accidents are caused by the use of cannabis than by that of alcohol. 3-6 Heroin is a powerful painkiller that depresses the central nervous system. This produces a feeling of relaxation, security, and well-being. Opium addiction in Iran has long historical roots and is a major social and health problem. The Iranian government estimates that about 2% of Iranian citizens (i.e., about 1,354,000 people) are regular drug-dependent addicts. Other sources, including informed observers working on drug abuse in non-government organizations (NGOs) in Iran, would add perhaps 500,000/600,000 casual (i.e. nondependent) users, for a total of some 2,000,000 Iranians who abuse drugs. 2,7-10 The abuse of alcohol and drugs contributes to careless smoking behaviour by impairing mentation and has been reported to be a factor in 40% of residential fire deaths - this appears to contribute to the high weekend frequency of house fires. 11,12 Any condition or habit (e.g. alcohol, drug, and opiate abuse) that alters an individual s mental state may lead to burn injury. Numerous publications have documented the association between alcohol and drug abuse, particularly between alcohol and motor vehicle crashes, injuries to pedestrians and cyclists, falls, burns, drowning, suicides, assaults, domestic violence, and even murder. Most studies have examined the association between alcohol consumption and injury using hospital emergencydepartment admissions data. Our hypothesis was simply that when it comes to substance abuse, the consequences vary in relation to the substance and to the group of abusers - what the substance consists of may be an important factor in the user s final outcome. In particular, in the case of burn injury, we hypothesized that multi-drug abuse represented a more powerful risk factor for burn injury than single drug abuse. We also hypothesized that, considering the most severely affected substance abusers amongst patients receiving care in a burns unit, opium was the main cause. In this study, we planned to conduct an aetiological survey of burns suffered by abusers of various kinds of opioids, stimulant drugs, hallucinogens, and cannabinoids in patients admitted to the burns ward at Tabriz Sina Hospital, Iran. Materials and methods From 20 March 2003 to 20 March 2008, 3470 patients with burn injury including patients addicted to opium were admitted to the burns centre at Sina Hospital in Tabriz. Various kinds of abused drugs were classified as opium agents (including opium, morphine, codeine, heroin, opium residue, crack, petedine, and methadone), stimulant agents (amphetamine, crystal, cocaine, and ecstasy), and hallucinogenic agents (LSD, PCD). Between these dates a prospective study of all drugabusing patients with burn injuries presenting solely at the Tabriz Burns Centre was designed to analyse the association between age, percentage total body surface area (TBSA) burned, inhalation injury, causes of burn, type of opioid, the risk of death, and the epidemiology of burns. Survival was defined as discharge from the burns unit. A special dossier was prepared to study epidemiological, demographical, and therapeutic data. The patients were categorized by age, sex, percentage TBSA burned, presence or absence of inhalation injury, cause of burn, outcome, educational status, occupational status, length of hospital stay, type of opium addiction, and type of family. The diagnosis of the opiate abuser was made by one of two attending burns surgeons on the basis of the clinical history, which included the patterns of opiate usage, information regarding the possible existence of an antisocial personality disorder, history of chronic pain, search for physical stigmata of misuse (e.g., needle marks), and patient behaviour in hospital, i.e., withdrawal symptoms, including nausea and diarrhoea, coughing, lacrimation, rhinorrhoea, profuse sweating, twitching muscles, sensation of diffuse body pain, and changes in papillary size) requiring re-administration of sufficient opiate medication on day one or later in order to decrease the symptoms. The type of drug abused was determined on the basis of the patients history and of their re-use of the drug in hospital. A blood and urine screen was used to identify opiates 2

3 in patients in whom misuse was suspected. The diagnosis of inhalation injury was made by one of the two attending burns surgeons, based on the history surrounding the burn event and the physical findings. The factors used to determine the presence of inhalation injury included burns sustained in an enclosed space, presence of facial burns, requirement of mechanical ventilation, carboxyhaemoglobin levels, and presence of carbonaceous sputum. We do not use bronchoscopy and the Xenon 133 lung scan in our institution. There is no accepted way of quantitating the severity of inhalation injury other than by determining whether inhalation injury is present or absent. We chose to use the clinical criteria demonstrated by Shirani et al. 13 of the Brooke Army Burn Unit to be accurate predictors of the presence of inhalation injury. Burn size and depth were determined clinically and refer to TBSA and grade I, II, III, and IV burn injury. Fluid requirements were estimated using the Parkland formula. Urine output was used as the principal resuscitation guideline. Burn cause was determined by history. Followup was obtained by examination in clinic. Follow-up examination was scheduled in all patients from 12 to 72 months. The findings were entered on a computer by means of a SPSS 10.5 database file designed by the author and analysed with the SPSS 10.5 program for Pearson s correlation analysis, chi-square test, logistic regression, and multiple logistic regressions. The statistical analyses were used to assess the relative predictive power of percentage TBSA burn, age, inhalation injury, type of opium, and cause of burn, as well as different combinations of these five variables, as predictors of mortality. The level of significance was set at Results During the five years of the study, 3470 patients were admitted, of whom 330 were drug addicts (9.5%) and 3140 (90.5%) non-addicts. The data regarding the 330 consecutive drug-addicted patients collected over the 5-yr year March 2003/March 2008 were reviewed. There were 290 male patients (88%) and 40 female patients (12%) (male:female ratio, 7.6:1, p < 0.001) versus the overall number of 1757 males (56%) and 1383 females (44%) (male:female ratio, 1.27:1, p < 0.05). In addicted patients, the mean age was 27.9 yr (SD, 10.56) in both males and females (range, 13 to 74 yr; males, 26.3 yr; females, 31 yr); in nonaddicted patients, the mean age was 34.8 yr (Table I). The largest single group of patients was the yr age group in both addicted and non-addicted patients. The most common cause of burns among the 330 addicted patients was flame (79.1%), followed by electrical burns (8.5%), and scalds (6.7%) (Table II), while in nonaddicted patients it was flame (81%) followed by scald (10.1%) (Table II). Of the 330 burn cases, 150 (46.5%) were caused by incorrect use of a lighter or match, 100 (30.3%) by falling onto a brazier, and 80 (24.2%) by other injury mechanisms. There were 47 (78.3%) flame fatalities in this series, followed death following electrical burns (11, 18.3%), contact burns (1, 1.7%), and chemical burns (1, 1.7%) (Table II). The most common substance abuse among the 330 addicted burn patients was that of opium (140/330 = 45.15%; TBSA, 31.6%; mortality rate, 18.1%), followed by heroin and hashish). The mean burn size was 30.9% (SD, 19.34; range, 7-75%), with males sustaining a mean burn size of 28.2% TBSA and females of 50.5% TBSA (p < 0.001). The mean burn size was 28.8% in non-addicted patients (Table II). The mean fatal size was 57.8%, which was not significantly smaller than the mean fatal injury in non-addicted patients (64.6%). The mean length of hospital stay was days (ranging from a few hours to 171 days) days in males, days in females. The mean length of hospital stay in addicted burn patients was days (SD, 10.82) and in non-addicted patients (SD, 9.7 (p < ). There were 60 deaths, with an overall mortality rate of 18.18% among addicted patients (41 males = 14.1%, 19 females = 47.5%), p < 0.001, and 507 deaths (16.15%) in non-addicted patients. Sixty patients (18.18%) had inhalation injuries, of whom 29 died (48.3%). There were 31 deaths among the patients without inhalation injury (mortality, 10.3%; p < 0.001). Inhalation injury was present in 29 of the 60 deaths (48.3%) and was significantly more common among non-survivors than survivors (48.3% versus 11.5%; p < 0.001) in non-addicted patients. Inhalation injury was present in 40.3% of the total patients and was significantly more common among non-survivors than survivors (71% v. 33%, p < 0.001). All patients with flame burns had associated inhalation injuries. Collectively, the mortality rate for all non-addicted patients with inhalation injury was 33%, while the rate for those without inhalation injury was only 8.9% (p < 0.001). However, inhalation injury was strongly associated with large burns. The distribution of patients by age group, average burn size, presence of inhalation injury, and mortality is shown in Table I. The distribution of patients by mean burn size, presence of inhalation injury, and mortality is shown in Table III. The mortality rate was significantly higher in multidrug abuse than in single drug abuse (36.4% in heroin + opium + methadone, 26.3% in crystal + heroin) versus crystal (23.3%), opium (18.1%), heroin (16%), and hashish (12.5%); p < 0.001). Large burn size was the strongest predictor of mortality, while inhalation injury, strongly linked to large burns, was found to be an independent predictor of death. Patient gender (when matched with burn size, age, type of agent used, and cause of burn) was not 3

4 Table I - Distribution of non-abuser and abuser patients by age group, mean percentage TBSA burned, inhalation injury, and mortality Non-abusers / abusers Age group (yr) Number Percentage Mean TBSA (%) Inhalation injury (%) Mortality (%) Total p <0.001 <0.001 Table II - Distribution of non-abuser and abuser patients by cause of burns, mean percentage TBSA burned, and mortality Non-abusers / abusers Cause of burns Number Percentage Mean TBSA (%) Mortality (%) Kerosene Domestic gas Benzene Scalds Contact burns Electrical burns Chemical burns Total predictive of mortality in either addicted or non-addicted patients. There was no difference between males and females according to the type of agent abused. The distribution of patients by type of agent used, inhalation injury, and mortality is shown in Table IV. Discussion The United Nations Office on Drugs and Crime (UN- ODC) estimated that 2.8% of the Iranian population over age 15 used opiates in This figure is more than five times the estimate (0.5%) for the United States. Only Laos and Russia come close to Iran s estimated drug abuse, with 2% of Laos s over-15 population estimated to have used opiates in the last year and 1.8% of Russia s. The government of Iran seems particularly concerned over the sharp increase in intravenous drug abuse. Revised figures show that in 2002 the number of deaths from drug abuse in Iran increased by 370% to 2989 individuals from 633 deaths in 2000, reflecting a shift in Iran towards abuse of hero- 4

5 Table III - Distribution of non-abuser and abuser patients by percentage TBSA burned, inhalation injury, and mortality Non-abusers / abusers Percentage TBSA Number Inhalation injury (%) Mortality (%) Inhalation injury was significantly more common among non-survivors than survivors and significantly more common in large burns (p<0.001). Table IV - Distribution of patients by type of burn agent, mean percentage TBSA burned, and mortality Type of agent Number Percentage Average TBSA (%) Mortality (%) Opium Heroin Crystal Hashish Methadone Heroin + Opium + Methadone Crystal + Heroin Total The mortality rate was significantly higher in multi-drug than in single drug abuse (p<0.001) in, especially intravenous abuse. 2,14 Most observers place the number of drug users in Iran at about 2,000,000, the great majority males. Opium smoking is the traditional manner of drug of abuse in Iran, but opium is also drunk, dissolved in tea. Opium and its residue are also injected, dissolved in water, by a small number of addicts. Heroin is sniffed, smoked, and injected. Ninety-three per cent of opiate addicts are male, with a mean age of 33.6 years (SD, 10.5 yr), and 1.4% (about 21,000 individuals) are HIV positive, almost as many as in our study. 2,11,12,14 Sociologically, a close correlation has been established between joblessness and drug consumption in all societies. In Iran the situation is exacerbated not only by rampant unemployment but also by general apathy and lack of confidence in the future. The quality of Iranian education is high compared to that of western countries, and the despair of highly skilled young graduates forced to accept menial jobs in small shops is thus reflected more in the drug addiction rates than in employment statistics. 2,13 One study found that in a group of 180 patients who were substance abusers or who were neurologically or mentally impaired, in-patient care was more costly, more complicated, and more protracted. 3,15 Another study observed that alcohol and drug use was associated with increased mortality and morbidity due to thermal injury. To determine whether substance users (SU) differed from controls, 398 burn patients were studied, of whom 161 had a positive drug screen for ethanol, cannabinoids, cocaine metabolites, amphetamines, phencyclidine, or benzodiazepines. A comparison between SU and controls showed no difference regarding age, but SU presented a significantly higher percentage of TBSA burned (25% versus 17%), inhalation injury (29% versus 7%), and mortality (14% versus 3%). 14,17 In our prospective study, a total of 330 cases are described over a five-year period, corresponding to an average number of 66 cases per year, with a total of 60 5

6 deaths. In our prospective study, the SU were significantly younger than non-addicted patients (27.9% versus 34.8), which was due to the younger population of addicts in our area. In this study, a comparison of SU with non-users showed a significantly larger TBSA burned (30.9% versus 28.8%), but also a significantly lower incidence of inhalation injury (18.18% versus 40.3%). The greater incidence of inhalation injury in non-abusers may be due to the greater incidence of suicide in our patients, which presented a higher mean percentage of TBSA burned (65.5%). Burns in opiate-addicted patients have frequently been reported in the literature, which indicates in relation to opiate addiction that men are more likely to become addicts than women, as in our study. 2,10,15,17 As expected, we found that increased burn size led to an increased risk of mortality among addicted and nonaddicted patients, a finding confirmed by other studies. 11,17 The average lethal burn size in the present series was 57.8%, and only 7 of the 60 deaths were caused by burns of less than 30% TBSA. The non-survivors with small burns in this series are an important reminder that addicted burn patients can die from small burns. The mortality in our overall patient population (18.18%) and various subgroups as well as the incidence of inhalation injury and associated mortality is similar to that reported by others. 3,11-18 Like other researchers, 13,14,16,18 we found that the incidence of inhalation injury rose with increasing burn size, but not with advancing age. This is not surprising since, as has already been suggested, larger burns and inhalation injury are more likely to be seen in less mobile patients burned in fires. In the addicted burn population, most burns are flame burns and most are associated with inhalation of smoke. 13,19 Our study indicates that an increase in percentage TBSA burned and the presence of inhalation injury were all significantly associated with increased mortality following burn injury. In addition, we demonstrated that in our series of 330 addicted burn patients, the most important predictor of mortality following thermal injury was TBSA burned, with inhalation injury adding little to the accuracy of this in addicted patients. In our study, the mortality rate was significantly higher in multi-drug abusers than in single drug abusers. The most important factors influencing the incidence of thermal injuries are age, sex, and economic status. Addicted patients are the most prone to thermal injury. The greater amount of addiction in burn patients in our study may be due to the higher incidence of addiction in Iran, for various reasons: land routes across Iran constitute the single most important conduit for southwest opiates en route to European markets. Entering from Afghanistan (Iran s eastern neighbour country, with more than 90% of the world s opiate production) and Pakistan into eastern Iran, heroin, opium, and morphine are smuggled overland, usually to Turkey. 2,13,19 The relationship between median family income and burn rate is strong and linear. Addicted burn patients from poor or low-to-middle income families are exposed to burns. We determined that the cause of burns was not an independent predictor of mortality i.e., a flame injury was neither worse nor better per se than a scald or electrical injury, when burn size and depth were considered. We were surprised by the finding that there was no mortality among the 22 patients with scalds presenting a mean burn size of 18.6%. Other studies 13,16-18 concluded that the presence of inhalation injury significantly increased mortality and suggested that inhalation injury was the single most important determinant of mortality following thermal injury. In the present study, we too found that inhalation injury was important and that inhalation injury was significantly associated with mortality following thermal injury. However, we found that although inhalation injury was a significant predictor of outcome, it was less important than the size of the burn in predicting mortality. In our study, one key finding was that after burn injury more problems were associated with multi-drug use than with single drugs. The mortality rate was significantly higher in multi-drug abusers. We conjectured that personality traits in drug-abuse dependent persons accounted for the prevalence of the injury to a greater extent than the consumption itself. This is a clear finding, but the issue will require further study. Such individuals constitute a prime opportunity to focus on burn injury prevention within the confines of treatment programmes directly linked to substance abuse. The recognition of the burns centre as place to offer prevention is a unique contribution to this particular field of study. This includes educating patients about the risks of injury as well as making assessments of their living conditions, in order to prevent burn injuries. Identifying patients with depressive symptoms and impulsive behaviour may also be beneficial, so that additional counselling sessions can be provided. Future studies should look at the various prevention strategies offered in detoxification programmes in order to verify their capacity to decrease the consumption of abused drugs and the burn injury rate. Conclusions In conclusion, our data suggest that although increases in the percentage of TBSA burned and the presence of inhalation injury were associated with increasing mortality, the most important single predictor of mortality in drugaddicted burn patients was the percentage of TBSA burned, while the presence of inhalation injury added little to the possibility of predicting mortality. In no addicted burn patient, no matter how large the burn, what sort of abuse agent, or what type of inhalation injury, could an accurate prediction be made at the time of admission as to whether the patient would live or die. Despite some differences in demographics, the same 6

7 general rules for rehabilitation apply to the opiate abuser. The basic strategy includes detoxification and general family support. It is also important to establish realistic patient goals and a programme of counselling to increase motivation toward abstinence. A long-term commitment to rebuilding a life-style without the substance is essential for preventing recidivism. Since 1995, public awareness campaigns and the attention of two successive Iranian Presidents, as well as cabinet ministers and the Iranian parliament, have given appeals for reduction of drug abuse a significant boost. Under the UNODC s Norouz narcotics assistance project, the government of Iran spent more than $68 million dollars in the first year for demand reduction and community awareness. The prevention department of Iran s Social Welfare Association runs 12 treatment and rehabilitation centres, as well as 39 out-patient treatment programmes in all major cities. Eighty-eight out-patient treatment centres are now operational. Some 30,000 people are treated per year, and some programmes have three-month waiting lists. Narcotics Anonymous and other self-help programmes can be found in almost all districts as well, and several NGOs focus on drug demand reduction. 2,7,8,13,19 Understanding how opiates cause addiction could lead to greater insight into the brain processes of addiction to other dependence-producing drugs, and to discovering how to prevent dependence from occurring. Also, research into opiate addiction could increase understanding of the brain networks involved in pain, as opiates and opiate receptors in the brain and spinal cord are involved in pain processes. With a better knowledge of addiction and of pain - another urgent public health issue - scientists will be able to develop specific medication to treat these distinct disorders. Only continued funding for research will help develop better treatments that are selectively targeted, helping more addicts to stay drug-free. Health care practitioners - particularly family physicians and trauma personnel - play a valuable role in detecting substance-abusing patients, intervening on their behalf, and referring them to appropriate care. Addiction is a brain disease. There are many things that can place someone at risk of developing an addiction, and we now know that it can have a genetic basis. It is a chronic disease, just like heart disease, diabetes, and other diseases, and we should bring it out into the open, just as we have done with diseases such as breast cancer and heart disease. Owing to the wide variety of causes of burn injuries related to drug abuse, diverse interventions targeted at those at highest risk (e.g., young people) are likely to be needed. As public health workers are the most important people involved in such programmes, using them to their full capacity and also using the full capacity of the health system network in Iran are advised if these injuries are to be reduced. RÉSUMÉ. Pendant une période de cinq ans (mars 2003-mars 2008) les Auteurs ont effectué une étude prospective des patients brulés hospitalisés dans un grand centre des brûlés en Iran dans le but d étudier l étiologie et le résultat final des patients toxicomanes. Trois cent trente patients toxicomanes ont été identifiés et divisés par âge, sexe, extension de la brûlure, présence ou absence de lésions par inhalation, type de drogue utilisé et cause des brûlures. L âge moyen des patients était de 27,9 ans (rapport hommes:femmes 7.6:1), avec un nombre total de décès de 60 (18,18%), dont la majorité (47) patients atteints de brûlures causées par les flammes. Le taux de mortalité était significativement plus élevé parmi ceux qui abusaient de plusieurs substances par rapport à ceux qui se limitaient à une seule substance. Sauf pour ce qui concerne la fréquence des brûlures, aucune différence significative n a été observée entre les deux sexes. L extension moyenne des brulures, 30,9%, était significativement majeure chez les patients non-survivants que chez les survivants (57,8% versus 27,8%, p <0,001). Les lésions par inhalation étaient fortement associées aux brûlures de grande extension et étaient présentes dans tous les cas de décès causés par les flammes. Les brûlures les plus communes chez les patients toxicomanes étaient les brûlures par flamme: la mauvaise utilisation des briquets et des allumettes et les chutes accidentelles dans un brasero constituaient les causes les plus fréquentes des brulures provoquées par les flammes. Onze décès étaient liés à des lésions provoquées par l électricité. L extension considérable de la brûlure constituait l indicateur le plus évident de la mortalité, suivie par la présence de lésions par inhalation. La substance dont les personnes se servaient le plus communément pour se droguer était l opium, suivi par l héroïne et le haschisch. Il n existait aucune différence entre les deux sexes pour ce qui concerne le type de substance utilisé dans l abus de drogues. Mots-clés: brûlures, la toxicomanie, abus de drogues, opiacés BIBLIOGRAPHY 1. Oliverio A et al.: Psychobiology of opioids. Int Rev Neurobiol, 25: 277, Mokri A: Brief overview of the status of drug abuse in Iran. Arch Iranian Med, 5: , Brezel BS, Kassenbrock JM, Stein JM. Burns in substance abusers and in neurologically and mentally impaired patients. J Burn Care Rehabil, 9: , Shewan D, Dalgarno P: Evidence for controlled heroin use? High levels of negative health and social outcomes among non-treatment heroin users in Glasgow. Br J Health Psychology, 10: 33-48,

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