Accelerated development of pulmonary complications due to illicit intravenous use of pentazocine and tripelennamine

Pulmonary effects of i.v. injection of crushed oral tablets: "excipient lung disease"

OBJECTIVE

When crushed oral tablets are injected i.v., their filler material (excipient) can induce a potentially fatal foreign-body reaction in pulmonary arterioles, presenting as dyspnea and pulmonary hypertension with centrilobular nodules on CT. We will describe the imaging and pathologic features of "excipient lung disease."

CONCLUSION

The radiologist has a critical role in recognizing and reporting excipient lung disease because the referring clinician may be unaware of the patient's i.v. drug abuse.

Signal detection in post-marketing surveillance for controlled substances

Signal detection for pharmaceutical controlled substances presents unique challenges compared to other pharmacovigilance programs because risks are present in the patient and non-patient populations. Defining signals for controlled substances has been difficult because no specific empirical criteria have been established through regulatory actions or guidances. We start with a review of data sources available for decision making to regulators and industry. In this paper we present a framework for processing signals received during post-marketing surveillance: signal identification, verification and assessment, followed by intervention and evaluation. Signal identification involves processing qualitative and quantitative information in order to generate hypotheses describing concerns with controlled substances. Integration of heterogeneous data sources makes this process difficult and we describe multiple approaches utilized in practice today. Signal verification currently relies heavily on telephone interviews with stakeholders in local communities. Once information on a potential signal has been gathered signal assessment is a higher order process conducted with an eye towards broader societal expectations and the ability to intervene or further study the problem. Intervention and evaluation complete the cycle of signal assessment and triage. This paper is intended as a primer of the current practice of signal assessment in the post-marketing surveillance for controlled substances.

Pulmonary effects of illicit drug use

The lungs are at considerable risk from the use of injected or inhaled illicit drugs. The extent and clinical significance of illicit drug induced lung damage is not known completely. Drug use leads to an increase in infectious pulmonary disease, historically in relation to nonsterile injection techniques, and, more recently, in relation to HIV infection and its pulmonary manifestations. Barotrauma related to "smoking topography" or errant injections also represents a real risk of drug use. Although granulomatous disease that involves the pulmonary vasculature and interstitium is probably common in injection drug users, the clinical consequence of such is difficult to estimate. What effect smoked or injected illicit drugs have on short- and long-term pulmonary function also is hard to ascertain. The ubiquitous use of tobacco among users of illicit drugs certainly has confounding effects. Given that illicit drug use is common and that the "popular" drugs of abuse change from generation to generation, the pulmonary physician must remain informed about, and alert for, the effects of drugs of abuse.

HIV in illicit drug users

Illicit drug users comprise a substantial and growing proportion of the HIV-infected population. Although they develop pulmonary complications common to all HIV transmission groups, they also have unique respiratory illnesses due to the direct effect of the illicit drugs on the lung. Bacterial infections, tuberculosis, and noninfectious complications all have a major effect on morbidity and mortality in this portion of the HIV-infected population.