Asthma in opiate addicts

[Bronchial diseases and heroin use. A systematic review]

INTRODUCTION

Heroin use can cause respiratory complications including asthma, chronic obstructive pulmonary disease (COPD) and bronchiectasis (BD).

OBJECTIVES

A general review of the literature presenting the data on the relationships between heroin consumption and bronchial complications, while underlining the difficulties of diagnosis and management.

DOCUMENTARY SOURCES

Medline, 1980-2022, keywords "asthma" or "bronchospasm" or "COPD" or "bronchiectasis" and "heroin" or "opiate" or "opiates", with limits pertaining to "Title/Abstract". Concerning asthma, 26 studies were included, as were 16 for COPD and 5 for BD.

RESULTS

Asthma and COPD are more prevalent among heroin addicts, who are less compliant than other patients with their treatment. The authors found a positive association between frequency of asthma exacerbations, admission to intensive care and heroin inhalation. Late diagnosis of COPD worsens the course of the disease; emphysema and BD are poor prognostic factors.

CONCLUSION

Bronchial diseases in heroin users can be identified by means of respiratory function exploration and chest CT scans. These tests should be performed frequently in view of optimizing their care, which includes their weaning themselves from addictive substances.

[Asthma and cannabis, cocaine or heroin use]

INTRODUCTION

The use of cannabis, cocaine or heroin can be responsible for many respiratory complications including asthma.

OBJECTIVES

The aim of this systematic literature review of data was to expose the relations between cannabis, cocaine or heroin use and asthma.

RESULTS

Cannabis, cocaine or heroin use by inhalation may be responsible for respiratory symptoms (cough, wheezing), asthma onset, acute asthma exacerbations (which may require intubation and invasive ventilation) or deaths related to asthma. Lower adherence to asthma treatment is also observed. Cannabis induces a rapid bronchodilator effect. In contrast, its chronic use may induce a decrease in specific airway conductance. Studies on forced expiratory volume in one second (FEV1) reduction or decline are discordant.

CONCLUSION

Cannabis, cocaine or heroin use must be considered in cases of acute respiratory symptoms or asthma exacerbation in young persons and practitioners must help illicit substance users to stop their consumption.

Prevalence of respiratory conditions among people who use illicit opioids: a systematic review

BACKGROUND AND AIMS

There are growing concerns over the respiratory health of people who use illicit opioids due to high rates of opioid inhalation and tobacco smoking in this group. This study aimed to summarize the evidence relating illicit opioid use with poor respiratory health.

METHODS

A systematic review of the literature on the association between illicit opioid use and respiratory health was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance (PROSPERO ID = CRD42017059953). Electronic searches of MEDLINE, Embase, PsycINFO, CINAHL and the Cochrane Library databases were undertaken (English language, published January 1980-November 2018). All study designs excluding case studies were considered. Studies were undertaken in community and hospital settings in the United States (n = 23), United Kingdom (n = 7), Australia (n = 7), the Netherlands (n = 2), Canada (n = 2), Ireland (n = 1), Spain (n = 1) and Iran (n = 1). Measurements of respiratory disease, including asthma and chronic obstructive pulmonary disease (COPD) and related symptoms were extracted. Data on respiratory-related deaths and hospital admissions were also extracted. Meta-analysis of prevalence data was undertaken using a random effects meta-analysis model with parameters estimated using Markov chain Monte Carlo simulation.

RESULTS

Meta-analyses estimated prevalence of asthma in people who inject illicit opioids as 8.5% [95% predictive interval (PrI) = 0.2%, 74.0%] and as 20.2% (95% PrI = 4.2%, 59.2%) in people who inhale illicit opioids. Prevalence of COPD in people who inject illicit opioids was estimated as 2.7% (95% PrI = 0.0%, 50.4%) and as 17.9% (95% PrI = 0.6%, 89.5%) in people who inhale illicit opioids. There was evidence of moderate to extreme heterogeneity across studies.

CONCLUSIONS

There is evidence of increased burden of respiratory diseases in people who use illicit opioids. Due to the heterogeneity of study design and samples, it is difficult to gain accurate estimates of the prevalence of respiratory disease in this population.

[Asthma and cocaine use]

INTRODUCTION

Cocaine use can be responsible for many respiratory complications including asthma.

OBJECTIVES

Systematic literature review of data on asthma in cocaine users.

DOCUMENTARY SOURCES

PubMed/Medline search, on the period 1980-2017 with the following keywords: "asthma*" or "bronchospasm" and "cocaine" or "freebase*" or "crack", limits "title/abstract"; the selected languages were English or French. Among 108 articles, 43 abstracts underwent dual reading to select 22 studies.

RESULTS

In four case reports of asthma associated with cocaine use including 11 patients (mean age: 28.3 years [22-33 years]; sex-ratio: 2.5 [males: 71.5%]), cocaine was sniffed [snorted] (9%), smoked (36.5%) or both sniffed and smoked (54.5%). A medical history of childhood asthma was observed in 45.4% of the cases. Acute respiratory failure, requiring intubation and mechanical ventilation, was observed in 45.4% of the cases. Outcome was rapidly favorable in 82%; 9/11, progressively favorable in one patient, and fatal in another patient. Other studies included 6 cross-sectional studies, 4 case-control studies and 8 longitudinal studies (7 retrospective studies and one prospective study). The mean age was 36.6 years (women: 44.7%). Twenty percent of the subjects used cocaine exclusively, and 80% used cocaine combined with other addictive drugs (cocaine and heroin: 62%). The prevalence of cocaine users was higher in asthmatic subjects and the prevalence of asthma was higher in cocaine users. Cocaine use can be responsible for asthma onset and acute asthma exacerbation. In the case of asthma exacerbation, cocaine users were more likely to be admitted in intensive care units and to require intubation and invasive ventilation. Asthma exacerbations may be fatal in spite of resuscitation measures. Asthma treatment observance was lower in cocaine users.

CONCLUSION

Cocaine use may be responsible for asthma onset, acute asthma exacerbations (which may require intubation and invasive ventilation) or death related to asthma. Cocaine use must be systematically considered in the case of asthma exacerbation and practitioners must help cocaine users to stop their consumption.

Immune responses in fatalities involving opioids

In some cases of fatalities involving opioid use, the concentrations of detected opioids are not in the toxic range. Immune reactions can be triggered by opioid use, suggesting that immune response may be a factor in these cases. Autopsy cases from 2002–2012 were reviewed. Persons with physical, microscopic or serum evidence of allergic reactions and opioid use at autopsy were compared to persons who used opioids but had no such signs. Overall, 49 persons were identified who had used opioids, of which five had evidence of immune response. A medical history of asthma was significantly more common in persons with signs of immune response (P = 0.0244) and fatality (P = 0.0085) compared to normals. A history of asthma is suggestive of susceptibility to immunologic reactions to opioids, and correlates strongly with the cause of death.

[Asthma and heroin use]

INTRODUCTION

Heroin use can be responsible for many respiratory complications including asthma.

OBJECTIVES

Systematic literature review of data on asthma in heroin users.

DOCUMENTARY SOURCES

Medline®, on the period 1980-2017 with the following keywords: keywords: "asthma" or "bronchospasm" and "heroin" or "opiate" or "opiates", limits "title/abstract"; the selected languages were English or French. Among 97 articles, 67 abstracts have given use to a dual reading to select 23 studies.

RESULTS

The seven case reports included 21 patients (mean age: 28 years [19-46 years]; sex-ratio: 2.5 [males: 71.5%]). Heroin was inhaled (71.4%), sniffed (19%) or injected by intravenous route (9.5%). Associated addictive substances were tobacco (81%), cannabis (38%), alcohol (4.7%) and cocaine (4.7%). Outcome was fatal in 3 subjects (14.3%). Other studies included one cross-sectional study, 3 case-control studies and 12 longitudinal studies (11 retrospective studies and one prospective study). The proportion of heroin users was higher in asthmatic subjects and the prevalence of asthma and bronchial hyperreactivity was higher in heroin users. Heroin use can be responsible for asthma onset, with a temporal relationship between the onset of heroin use and asthma onset in 28 to 31% of subjects. A positive association between inhaled heroin use and acute asthma exacerbation was observed. Asthma treatment observance was lower in heroin users. In case of asthma exacerbation, heroin users were more likely to seek care in the emergency department, to be admitted in intensive care units and to require intubation and invasive ventilation. Asthma deaths related to heroin use mainly occurred following an intravenous injection (especially in the case of overdose), but also following heroin use by nasal (sniff) or pulmonary route.

CONCLUSION

Heroin use may be responsible for asthma onset, acute asthma exacerbations (which may require intubation and invasive ventilation) or deaths related to asthma. Heroin use must be sought in case of asthma exacerbation in young persons and practitioners must help heroin users to stop their consumption.

Opium use and risk of mortality from digestive diseases: a prospective cohort study

OBJECTIVES

Opium use, particularly in low doses, is a common practice among adults in northeastern Iran. We aimed to investigate the association between opium use and subsequent mortality from disorders of the digestive tract.

METHODS

We used data from the Golestan Cohort Study, a prospective cohort study in northeastern Iran, with detailed, validated data on opium use and several other exposures. A total of 50,045 adults were enrolled during a 4-year period (2004-2008) and followed annually until December 2012, with a follow-up success rate of 99%. We used Cox proportional hazard regression models to evaluate the association between opium use and outcomes of interest.

RESULTS

In all, 8,487 (17%) participants reported opium use, with a mean duration of 12.7 years. During the follow-up period 474 deaths from digestive diseases were reported (387 due to gastrointestinal cancers and 87 due to nonmalignant etiologies). Opium use was associated with an increased risk of death from any digestive disease (adjusted hazard ratio (HR)=1.55, 95% confidence interval (CI)=1.24-1.93). The association was dose dependent, with a HR of 2.21 (1.57-3.31) for the highest quintile of cumulative opium use vs. no use (Ptrend=0.037). The HRs (95% CI) for the associations between opium use and malignant and nonmalignant causes of digestive mortality were 1.38 (1.07-1.76) and 2.60 (1.57-4.31), respectively. Increased risks were seen both for smoking opium and for ingestion of opium.

CONCLUSIONS

Long-term opium use, even in low doses, is associated with increased risk of death from both malignant and nonmalignant digestive diseases.

"Dangerous relationships": asthma and substance abuse

Commonly abused drug are cocaine, marijuana, cigarettes, heroin, and alcohol. The review emphasizes the importance for clinicians to be alert to the possibility of this substance as a precipitating factor for acute asthma. Substance use disorders to characterize illnesses associated with drug use. The use of drugs of abuse increases risk of developing more severe symptoms, higher frequency of exacerbations and having and significant effect on care resources due to clinicians visits and frequent hospital admissions. Abused drug has been shown to accelerate the decline in lung function and to increase numbers of life-threatening asthma attacks, and greater asthma mortality.

Opioid effect on lungs

Opioids are widely used for their analgesic properties for the management of acute and chronic pain related to a variety of illnesses. Opioid usage is associated with adverse effects on respiration which are often attributed to depression of the central nervous system. Recent data indicate that opioid use has increased over the last two decades. There is also increasing evidence that opioids have a variety of effects on the lungs besides suppression of respiration. Opioids can affect immune cells function, increase histamine release causing bronchospasm, vaso-constriction and hypersensitivity reactions. Together, these actions have a variety of effects on lung function. Here, we provide a comprehensive review of the effects of opioids on the lungs including the respiratory centre, immune function, airways and pulmonary vasculature.

Route of drug use and its implications for drug effect, risk of dependence and health consequences

Route of administration has a profound, but often overlooked, influence on the actual experience of the drug use itself, on the risk of resulting development of dependence, and on the nature of the harms to which drug users are exposing themselves. These three areas are reviewed. The influence of route of administration on drug effect is considered first with regard to overall effectiveness of absorption, and also with regard to speed of onset of effect. The implications for risk of dependence cover animal and human laboratory studies of reinforcement schedules, epidemiological studies, the attitudes of drug users themselves to the different routes of possible drug use and associated dependence risk and the postulated influences on progression to dependence. Finally, the relationship between route of drug use and health sequelae is explored for the three most widely used routes of administration of illicit drugs-snorting, smoking and injecting.

The effects of methadone and its role in fatalities

Methadone is a synthetic opioid, used both as an analgesic in severe pain relief and now mainly in the treatment of opiate dependence. Such use of the drug has increased as its advantages have become widely recognized. There are undesirable outcomes from its greater use, including a substantial market in diverted methadone and a high number of deaths where the drug has been implicated. It is important to understand how and why methadone causes death so that such fatalities can be minimized, and to disseminate such information. This paper presents an overview of the chief effects of methadone on the human body, considering its metabolism, drug interactions and tolerance. The principal mechanisms by which methadone causes death are discussed: respiratory depression, aspiration of vomit, pulmonary oedema, bronchopneumonia, cardiac problems and renal failure. Many such deaths are preventable, if drug interactions and polydrug use are avoided, its longer period of metabolism and individuals' tolerance levels are considered. It is hoped that this paper will (a) help guide health professionals in their management and treatment of patients participating in methadone treatment programmes, and (b) provide some basic information for those dealing with individuals who have consumed methadone.

Acute respiratory failure from abused substances

Acute respiratory failure is a common complication of drug abuse. It is more likely to develop in the setting of chronic lung disease or debility in those with limited respiratory reserve. Drugs may acutely precipitate respiratory failure by compromising respiratory pump function and/or by causing pulmonary pathology. Polysubstance overdoses are common, and clinicians should anticipate complications related to multiple drugs. Impairment of respiratory pump function may develop from central nervous system (CNS) depression (suppression of the medulla oblongata, stroke or seizures) or respiratory muscle fatigue (increased respiratory workload, metabolic acidosis). Drug-related respiratory pathology may result from parenchymal (aspiration-related events, pulmonary edema, hemorrhage, pneumothorax, infectious and non-infectious pneumonitides), airway (bronchospasm and hemorrhage), or pulmonary vascular insults (endovascular infections, hemorrhage, and vasoconstrictive events). Alcohol, cocaine, amphetamines, opiates, and benzodiazepines are the most commonly abused drugs that may induce events leading to acute respiratory failure. While decontamination and aggressive supportive measures are indicated, specific therapies to correct seizures, metabolic acidosis, pneumothorax, infections, bronchospasm, and agitation should be considered. Drug-related respiratory failure when due to CNS depression alone may portend well, but in patients with drug-related significant pulmonary pathology, a protracted course of illness may be anticipated.

Heroin insufflation as a trigger for patients with life-threatening asthma

STUDY OBJECTIVES

To determine the prevalence of self-reported, heroin-associated asthma symptoms among inner-city patients treated for life-threatening asthma, and to compare the rates of drug use between ICU patients with asthma and ICU control patients with diabetic ketoacidosis (DKA).

DESIGNS

Study 1 was a sequential case series of patients requiring ICU admission for asthma (January to June 1999). Study 2 was a retrospective, case-control study of drug use among asthma patients and control subjects with DKA requiring ICU care (1997 to 1998).

SETTING

Inner-city, public hospital ICU.

PATIENTS

Twenty-three patients (26 ICU admissions) with asthma (age range, 16 to 50 years) admitted to the ICU from January to June 1999, and 84 patients (104 ICU admissions) with asthma and 42 patients with DKA (age range, 15 to 50 years) admitted to the ICU during 1997 to 1998. Outcomes studied: Self-reported, heroin-associated exacerbations, history of heroin or cocaine use, and urine drug screen (UDS) results.

MEASUREMENTS AND RESULTS

In the sequential ICU admissions, 13 of 23 patients (56%) described asthma exacerbations associated with heroin insufflation. In the case-control study, asthmatics were significantly more likely to report heroin use (41.3% vs 12.5%; p = 0.006) and had a significantly higher prevalence of UDS results positive for opiates (60% vs 7%; p = 0.001) compared to subjects with DKA. The rates of cocaine use by history and UDS results did not differ significantly between the two groups.

CONCLUSIONS

At least since 1997, heroin insufflation is a common asthma trigger in this inner-city ICU and should be considered in the care of patients with life-threatening asthma.

Sinopulmonary complications of illicit drug use

Illicit drug use is frequently complicated by sinopulmonary illnesses. These complications fall into two major categories: (1) direct effects of drug exposure, and (2) indirect effects caused by HIV-induced immunosuppression. This article reviews the more common sinopulmonary syndromes associated with illicit drug use.

A comparison of heroin chasers with heroin injectors in Switzerland

In a cross-sectional multicentre study, we compared the characteristics of heroin chasers and heroin injectors. Subjects were 162 primarily opioid-dependent volunteers for whom either chasing (n = 85) or injecting (n = 77) was the principal route of heroin administration. Each subject was rated by means of the Swiss version of the European Addiction Severity Index. Additionally, subjects completed a questionnaire battery including the Severity of Dependence Scale, the Symptom Checklist SCL-90-R, a self-constructed peergroup questionnaire and a semantic differential list to assess the connotative meaning of heroin chasers and injectors. The heroin injectors were older and more likely to use one or more other drugs besides heroin than the chasers. They had longer heroin-using careers, a longer duration of detention and a higher prevalence of some type of hepatitis. In conclusion, the differences between chasers and injectors were rather related to a longer history of heroin use than to the route of heroin administration.

Inhaled heroin-induced status asthmaticus: five cases and a review of the literature

We report five cases of status asthmaticus (four requiring mechanical ventilation) that were triggered by inhaled heroin and review the pertinent literature. These cases share common features of sudden and severe asthma exacerbations temporally related to heroin use, stress the importance of considering illicit drug use in like cases, and call attention to a public health issue.

Incidence and risk factors for pneumonia in HIV infected and non-infected drug users

OBJECTIVE

To study the incidence and risk factors for pneumonia in a cohort of HIV infected and non-infected drug users (DU).

DESIGN

A prospective epidemiological study.

SETTING AND PATIENTS

Injecting and non-injecting DU who attended the Municipal Health Service in Amsterdam for follow-up visits in the study.

MAIN RESULTS

203 HIV infected and 437 non-infected DU were followed for a total of 1749 person-years. HIV infected DU reported 111 episodes of pneumonia, which required hospitalization in 29 cases, and HIV negative DU reported 55 episodes, which required hospitalization in nine cases. The incidences among HIV positive and HIV negative DU were 0.19 and 0.05 per person-year respectively. With multivariate Poisson regression current injecting (RR 2.13), recent seroconversion (RR 3.92), asthmatic constitution (RR 2.72), CD4+ cell count between 200-500 (RR 1.67 compared to > 500), CD4+ cell count less than 200 (RR 2.23 compared to > 500) and a previous history of pneumonia (RR 2.43) were independently associated with self-reported pneumonia among HIV infected DU. Among HIV negative DU heroin smoking (RR 1.87), asthmatic constitution (RR 3.62) and a previous history of pneumonia (RR 2.84) were independently associated with self-reported pneumonia. Also a higher Quetelet Index (QI) appeared to be protective (QI > or = 21 RR 0.42, QI 19-21 RR 0.82 compared to QI < 19) among HIV negative DU. Risk factors for reported and hospitalized cases of pneumonia were comparable among HIV positive DU.

CONCLUSIONS

HIV infected DU are at increased risk for pneumonia and the rate increases with lower CD4 cell counts. Also behavioural characteristics, such as injecting drug use and smoking heroin, and clinical history variables, such as a history of pneumonia or an asthmatic constitution, are risk factors for pneumonia among DU. Pneumococcal vaccination should not only be focused on HIV positive DU but also on the identified risk groups among HIV negative DU.

Immunologic analyses of peripheral leukocytes from workers at an ethical narcotics manufacturing facility

Little information exists about possible adverse health effects associated with workplace exposure to opiate compounds. We have previously reported opiate-specific IgG antibodies, positive epicutaneous tests, and pulmonary function decrements in workers exposed occupationally to opiates. In the present work, we extended these findings to investigate the effect of occupational opiate exposure on lymphocyte subpopulations and mitogen-induced lymphoblastogenesis. Thirty-three opiate-exposed workers and 8 nonexposed control workers were evaluated for lymphocyte subpopulation absolute numbers and percentages, by evaluating cell surface antigen expression with flow cytometry. A complete blood count with differential, common clinical chemistry parameters, and serum immunoglobulin levels were also evaluated. Opiate-exposed workers showed significantly (p < .05) increased absolute numbers and percentages of HLA-DR+ cells (MHC class II histocompatibility antigen), significantly (p < .01) decreased percentages of T helper-inducer (CD4+) cells, and significantly (p < .05) decreased numbers of basophils, compared with nonexposed opiate workers from the same factory. A trend toward reduction in the T helper-inducer (CD4+)/T cytotoxic-suppressor (CD8+) lymphocyte ratio was also evident. There was also a significant decrease in lymphocyte activity stimulated by pokeweed mitogen (p < .05) in opiate-exposed workers. These data indicate that occupational opiate exposure may change the number and types of circulating peripheral blood leukocytes, or alternatively, alter the expression of receptors on the surface of these cells. In addition, occupational opiate exposure appears to decrease the sensitivity of B-cells to pokeweed mitogen stimulation.(ABSTRACT TRUNCATED AT 250 WORDS)

Pulmonary complications of intravenous drug misuse. 1. Epidemiology and non-infective complications

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Antibodies to morphine in workers exposed to opiates at a narcotics manufacturing facility and evidence for similar antibodies in heroin abusers

According to the International Narcotics Control Board, over 45,000 kg of morphine and 54,000 kg of codeine were ethically manufactured in 1986 at three facilities in the United States. Little information exists about possible adverse health effects associated with workplace exposure to opiate compounds in this industry. Because there are no specific federal standards for workplace exposure to narcotic dusts, exposure-control defaults to the nuisance dust standard (10 mg/m3, as an 8 hr time-weighted average). Narcotics manufacturing workers were evaluated for anti-morphine IgG before and 10 mo. after the implementation of an improved respiratory protection program (RPP). Significantly elevated IgG levels were measured before the improved RPP (P less than 0.005). After the improved RPP, a significant reduction was observed (P less than 0.001), suggesting that specific antibody levels could be used as biomarkers of exposure. Inhibition studies showed that the antibodies were specifically directed against morphine with some cross reactivity with morphine derivatives. Preliminary results are also shown which indicate that similar anti-morphine antibodies are present in the sera of intravenous heroin abusers. Elevated levels (P less than 0.05) of anti-morphine antibodies were detected in sera from heroin abusers, providing evidence that similar antibodies may be produced from non-occupational exposure to opiates. These finding have potentially far-reaching implications for addiction research and drug testing.