"Dangerous relationships": asthma and substance abuse

Investigating the association between asthma and opioid use disorder with interactions of anxiety and depression among a national sample of the US population

INTRODUCTION

Previous studies have not examined the association between asthma and opioid use disorder (OUD) in a comprehensive national sample of the U.S. population. This study aims to investigate such an association.

METHODS

This is a matched retrospective cohort study, with a follow-up period of two years, utilizing longitudinal electronic medical records of a comprehensive national healthcare database in the U.S.-Cerner-Real World DataTM. Patients selected for analysis were ≥12 years old with a hospital encounter between January 2000 and June 2020. Adjusted risk ratios (aRRs) of incident OUD for those with asthma compared to those without asthma were calculated using a modified Poisson regressions with robust standard errors via the Huber-White sandwich estimator, and results were stratified by comorbid mental illnesses.

RESULTS

Individuals with asthma had a greater risk of OUD compared to those without asthma (aRR = 2.12; 95% CI 2.03-2.23). When stratified by anxiety and depression status, individuals with asthma and no anxiety or depression had a greater risk of incident OUD compared to individuals with asthma and either anxiety, depression, or both. Additionally, individuals with asthma medication had 1.29 (95% CI: 1.24, 1.35) greater overall risk for incident OUD compared to those without medication. Independent of comorbid mental illnesses, individuals with asthma medication had greater risk for incident OUD compared to those without medication among individuals without severe/obstructive asthma.

CONCLUSIONS

Individuals with asthma face a higher OUD risk compared to those without asthma. Comorbid mental illnesses modulate this risk. Caution is advised in opioid prescribing for asthma patients.

[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 in the intensive care unit: A review of patient characteristics and outcomes

Background

Most asthma-related deaths occur in low- and middle-income countries, and South Africa (SA) is ranked fifth in global asthma mortality. Little is known about the characteristics and outcome of asthma patients requiring intensive care unit (ICU) admission in SA.

Objectives

To identify and characterise patients with acute severe asthma admitted to the respiratory ICU at Groote Schuur Hospital, Cape Town, SA, in order to evaluate outcomes and identify predictors of poor outcomes in those admitted.

Methods

We performed a retrospective descriptive study of patients with severe asthma admitted to the respiratory ICU at Groote Schuur Hospital between 1 January 2014 and 31 December 2019.

Results

One hundred and three patients (110 admission episodes) were identified with an acute asthma exacerbation requiring ICU admission; all were mechanically ventilated. There was a female preponderance (53.6%; n=59/110), with a median (range) age overall of 33 (13 - 84) years. Of all admissions, 40 (36.4%) were current tobacco smokers and 16 (14.5%) patients with a history of substance abuse. Two thirds (60.0%; n=66/110) of the patients were using an inhaled corticosteroid (ICS). No predictors of mortality were evident in multivariate modelling, although those who died were older, and had higher Acute Physiology and Chronic Health Evaluation (APACHE II) scores and longer duration of admission. Only 59 of the surviving 96 individual patients (61.5%) attended a specialist pulmonology clinic after discharge.

Conclusion

Among patients admitted to the respiratory ICU at Groote Schuur Hospital for asthma exacerbations, there was a high prevalence of smokers and poor coverage with inhaled ICSs. Although mortality was low compared with general ICU mortality, more needs to be done to prevent acute severe asthma exacerbations.

Study synopsis

What the study adds. Intensive care unit (ICU) admission represents the most severe form of exacerbation of asthma. South Africa (SA) has a very high rate of asthma deaths, and this study demonstrates that admission to an ICU with a very severe asthma exacerbation frequently results in a good outcome. However, many of the patients admitted to the ICU were not adequately treated with background asthma medications prior to their admission. Implications of the findings. Death from asthma should be avoidable, and admission to an ICU is not associated with high mortality. Patients are therefore likely to be dying at home or out of hospital. Better education and access to medication and early access to health services rather than improved in-hospital care would potentially alter SA's high asthma mortality.

Epidemiological associations of asthma status and tobacco use, substance use, and substance misuse among adults in the United States, 2015-2019

Objective: Adults with asthma have a higher prevalence of substance use. However, knowledge is scarce regarding the associations between adults with asthma and tobacco use, substance use, and substance misuse. This study aimed to use national samples of United States adults to assess the comprehensive use and misuse of substances in adults with asthma.Method: This cross-sectional study comprised data drawn from the 2015 to 2019 National Survey on Drug Use and Health. Weighted logistic regressions were used to measure the associations of asthma status (lifetime and current) with last month's tobacco use; substance use (alcohol, marijuana, cocaine, crack, heroin, hallucinogens, inhalants); and substance misuse (pain relievers, tranquilizers, stimulants, sedatives). All regression models were controlled for sociodemographic characteristics, comorbidity, last-month serious psychological distress, and co-substance use and misuse. Results: Adults with lifetime asthma (N_weighted = 115,600,887) were less likely to use cigarettes, cigars, smokeless tobacco, inhalants, and polyuse of any substance. In contrast, adults with current asthma (N_weighted = 765,096,31) were more likely to use pipe tobacco, cocaine, non-prescribed tranquilizers, and less likely to use polytobacco products. Adults with lifetime asthma were associated with fewer last-month tobacco and inhalant use than those without lifetime asthma. However, adults with current asthma were associated with greater last month's pipe tobacco, cocaine, and non-prescribed tranquilizers. Conclusion: Thus, further longitudinal studies are recommended among adults with asthma to effectively design tailored treatment and prevention interventions.

State-specific Prevalence and Factors Associated With Current Marijuana, ENDS, and Cigarette use Among US Adults With Asthma

Background

The use of marijuana (MJ), combustible cigarettes (hereafter cigarettes), and electronic nicotine delivery systems (ENDS) is widespread among United States (US) adults and linked to worsening respiratory symptoms, especially among adults with asthma. This study examined state-specific prevalence and factors associated with MJ, ENDS, and cigarette use among US adults with asthma.

Methods

We analyzed data of 41 974 adults aged ≥18 years having self-reported current asthma from the 2018 Behavioral Risk Factor Surveillance System (BRFSS). We reported weighted prevalence to account for complex survey design and performed multivariable logistic regression models to examine factors associated with current use of MJ, ENDS, and cigarettes.

Results

Overall prevalence of current MJ, ENDS, and cigarette use among adults with asthma was 14.5%, 6.6%, and 27.2%, respectively. Our results showed the US states and territories with highest and lowest use prevalence for MJ (California: 23.6% vs Guam: 3.2%), ENDS (Indiana: 12.8% vs North Dakota: 4.0%), and cigarettes (West Virginia: 42.1% vs Guam: 12.3%). Both MJ and ENDS users were more likely to be male, younger, and live in an urban area, but MJ users were more likely and ENDS users less likely to be Non-Hispanic (NH) American Indian/Alaskan Native. Cigarette users were more likely to be older, have at least 1 health condition, and were less likely to be NH Black or Hispanic and college-educated.

Conclusion

Many US adults with asthma use MJ, ENDS, and cigarettes. Our findings provide insights for clinicians about the urgent need for effective interventions to reduce tobacco and MJ use among adults with asthma.

Risk of asthma exacerbation associated with opioid and nonopioid analgesic use in children with current asthma

BACKGROUND: In the United States, asthma occurs in a vast proportion of children and adolescents. Asthma exacerbation is an acute episodic event typically characterized by difficulty in breathing, chest tightness, coughing, or wheezing. Severe asthma exacerbation can be life-threatening and lead to service utilizations such as hospitalizations and emergency department (ED) visits. Opioid analgesic use can trigger an asthma exacerbation through 2 pharmacological mechanisms. Despite the potential mechanisms, there is lack of empirical evidence to determine the risk of asthma exacerbation and its association with opioid use. OBJECTIVE: To evaluate the risk of asthma exacerbation in children with current asthma receiving an opioid vs a nonopioid analgesic. METHODS: Eligible individuals aged under 18 years with current asthma and receiving an incident analgesic prescription were identified from a large Medicaid managed care database during 2013-2018. Current asthma was defined as receipt of an asthma diagnosis and an antiasthmatic medication in the 12 months before analgesic medication initiation. Asthma exacerbation was defined as a hospitalization or ED visit with asthma as either the primary or secondary diagnosis within 3 days of receipt of an analgesic prescription. A weighted multivariable logistic regression using inverse probability treatment weighting was performed to test the association between use of analgesic medication and risk of asthma exacerbation. RESULTS: This study included 13,359 children with current asthma who filled either an incident opioid (n = 5,363, 40.1%) or nonopioid analgesic (n = 7,996, 59.9%) prescription. Asthma exacerbation was observed in 24 (0.5%) opioid analgesic recipients and 22 (0.3%) nonopioid analgesic recipients within 3 days of analgesic initiation. Weighted logistic regression results showed that children receiving opioid analgesics (adjusted odds ratio = 1.6, 95% CI = 0.9-2.9) did not have a statistically significantly higher risk of asthma exacerbation than their nonopioid analgesic recipient counterparts in the propensity score-weighted multivariable analysis. CONCLUSIONS: Asthma exacerbation associated with analgesic use in children with current asthma was an uncommon event, and the risk was comparable among children receiving opioid vs nonopioid analgesics. DISCLOSURES: This study was supported and funded by the Agency for Healthcare Research and Quality (AHRQ), Project Number: 1R03HS026790-01A1. The study content was solely the responsibility of the authors, and AHRQ had no role in the design and conduct of the study. The authors have nothing to disclose.

Asthma Remission Disparities Among US Youth by Sexual Identity and Race/Ethnicity, 2009-2017

BACKGROUND

Sexual minority and racial/ethnic minority youth experience a higher burden of asthma. The frameworks of minority stress theory and intersectionality suggest that sexual minority and racial/ethnic minority youth may experience disparities in nonremitting asthma.

OBJECTIVE

To examine adjusted odds of nonremitting asthma by sexual identity, race/ethnicity, and their intersections, along with their relationship with traditional nonremitting asthma risk factors (weight status and smoking) and victimization (bullying, cyberbullying, and forced sex).

METHODS

We used data from the Youth Risk Behavior Survey pooled across 41 jurisdiction-years (biennially, 2009-2017), resulting in a sample of 21,789 US youth. The prevalence of nonremitting asthma was examined by sexual identity, race/ethnicity, and their intersections, stratified by sex. Bivariate associations and backward logistic regression models, stratified by sex, were built to examine nonremitting asthma disparities and the effects of selected traditional correlates and victimization variables.

RESULTS

At the intersections, 8 sexual minority and racial/ethnic minority subpopulations were significantly more likely to have nonremitting asthma compared with White heterosexual sex-matched peers. White gay males and Black lesbian females had the highest odds of nonremitting asthma. Traditional risks of nonremitting asthma and victimization were associated with attenuated odds of nonremitting asthma.

CONCLUSIONS

Many sexual minority and racial/ethnic youth subpopulations are more likely to have nonremitting asthma. Evidence suggests that traditional nonremitting asthma risk factors and victimization may partly explain disparities in nonremitting asthma. Asthma management guidelines should be updated to include population health disparities of sexual and racial/ethnic minorities.

Gender differences in the associations of early onset poly tobacco and drug use prior to age 18 with the prevalence of adult bronchitis in the United States

PURPOSE

We investigated the associations of early onset polysubstance use prior to age 18 with the prevalence of bronchitis among U.S. adults and tested whether the associations differ by gender.

METHODS

A total of 77,950 adults, of them 2,653 with bronchitis in the past year, were from the combined 2013 and 2014 National Survey on Drug Use and Health data. The variable cluster analysis was used to classify nine variables about substance use prior to age 18 (cigarettes, cigars, smokeless tobacco, marijuana, cocaine, heroin, methamphetamines, ecstasy, and phencyclidine). Weighted multivariate logistic regression analysis (MLR) was used to examine the associations with bronchitis.

RESULTS

Nine variables were divided into two clusters: early onset poly tobacco use (three tobacco use variables) and early onset poly drug use (six drug use variables). The overall prevalence of bronchitis was 3.8% (5.1% for females and 2.3% for males). MLR analysis showed that being female, elderly (ages 65 and above), obese, and early onset poly tobacco use were associated with increased odds of bronchitis (p < 0.05). Gender-stratified analyses showed that early-onset poly tobacco use was significantly associated with bronchitis only in males, whereas early onset poly drug use was associated with bronchitis only in females. Moreover, obesity and tobacco use in the past year revealed associations with bronchitis regardless of gender.

CONCLUSIONS

Obesity, early onset poly tobacco use prior to age 18, and tobacco use in the past year were positively associated with bronchitis; furthermore, the associations of early onset polysubstance use with bronchitis differed by gender, which indicated that gender differences should be considered in developing effective prevention strategies.

[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.

A primary care database study of asthma among patients with and without opioid use disorders

Substance misuse is associated with poor asthma outcome and death. People with opioid use disorder (OUD) may be at particular risk, however, there have been no case-control studies of asthma care and outcomes in this patient group. A primary care database study of patients with asthma aged 16-65 years was conducted using a matched case-control methodology. The dataset comprised 275,151 adults with asthma, of whom 459 had a clinical code indicating a lifetime history of OUD. Cases with a history of OUD were matched to controls 1:3 by age, gender, smoking status and deprivation index decile. Attendance at annual review (30%) and for immunisation (25%) was poor amongst the overall matched study population (N = 1832). Compared to matched controls, cases were less likely to have attended for asthma review during the previous 12 months (OR = 0.60, 95% CI 0.45-0.80) but had similar immunisation rates. Higher rates of ICS (OR = 1.50, 1.13-1.98) and oral prednisolone use (OR = 1.71, 1.25-2.40) were seen amongst those with a history of OUD and 7.2% had a concurrent diagnosis of COPD (OR = 1.86, 1.12-2.40). We found that people with asthma and a history of OUD have worse outcomes on several commonly measured metrics of asthma care. Further research is required to identify reasons for these findings, the most effective strategies to help this vulnerable group access basic asthma care, and to better understand long-term respiratory outcomes.

COPD and asthma in patients with opioid dependency: a cross-sectional study in primary care

Patients treated for drug addiction have high asthma and COPD prevalence rates. The relative contributions of cigarette smoking, smoking intensity and possible smoking of other substances has not been described. We aimed to describe the prevalence and determinants of asthma and COPD in patients prescribed methadone as opioid substitution therapy (OST). In a cross-sectional study of an anonymised patient-level primary care dataset of UK inner-city general practices (n = 46), 321,395 patients aged ≥18 years were identified. A total of 676 (0.21%) had a record of a methadone ever issued in primary care. The association between respiratory disease and methadone prescribing was examined using logistic regression. Models were adjusted for potential effects of clustering by practice. A total of 97.3% of patients prescribed methadone were cigarette smokers, either current (81.2%) or ex-smokers (16.1%). The prevalences of asthma and COPD were higher in methadone patients (14.2% and 12.4%, respectively) compared to non-methadone patients (4.4% and 1.1%, respectively). Methadone was an independent determinant of asthma, adjusting for smoking status (OR 3.21; 95% CI: 2.52, 4.10) or for smoking intensity (3.08; 2.27, 4.19), and of COPD, adjusting for smoking status (6.00; 4.61, 7.80) or for smoking intensity (5.80; 4.12, 8.17). COPD and asthma prevalence were substantially higher in those prescribed methadone compared to those never prescribed methadone. Prescription of methadone was an independent predictor for both COPD and asthma, even after adjustment for smoking status and smoking intensity. Possible explanations include confounding by association with smoking of heroin or crack cocaine, both of which may have a causal association with COPD and asthma.

Cocaine-Induced Ventilation/Perfusion Mismatch Mimicking Pulmonary Embolism

Pulmonary complications from cocaine use can range from bronchospasm to vasospasm leading to pulmonary infarction. Profound vasospasm may also lead to perfusion defects presenting as pulmonary embolism on ventilation-perfusion scan. A 65-year-old patient with a past medical history of substance abuse and chronic kidney disease presents to the emergency department with sudden-onset chest pain and shortness of breath. Ventilation-perfusion scan revealed filling defect most notably in the lingual lobe. He was later discharged on warfarin for the management of pulmonary embolism. The patient presented to the emergency department 2 weeks later with similar complaints; the international normalized ratio was subtherapeutic, and urine drug screen was positive for cocaine. Repeat ventilation-perfusion scan revealed no filling defects. Follow-up bilateral venous Doppler of lower extremities and D-dimer were within normal limits.

Cocaine Use in Adolescents and Young Adults

Cocaine use by adolescents and young adults continues to be a significant public health issue and the cause of medical and psychological morbidity and mortality. Although use rates are lower than those seen with alcohol, tobacco, and other illicit substances such as marijuana, cocaine is highly addictive and presents significant acute and long-term medical and psychological effects. This article reviews the epidemiology of cocaine use among adolescents and young adults, discusses the pharmacology and neurobiology of cocaine use and dependence, provides information regarding acute intoxication and systemic effects seen with more chronic use, and describes current assessment and treatment approaches.

Cannabis-Associated Asthma and Allergies

Inhalation of cannabis smoke is its most common use and the pulmonary complications of its use may be the single most common form of drug-induced pulmonary disease worldwide. However, the role of cannabis consumption in asthma patients and allergic clinical situations still remains controversial. To review the evidence of asthma and allergic diseases associated with the use of marijuana, we conducted a search of English, Spanish, and Portuguese medical using the search terms asthma, allergy, marijuana, marihuana, and cannabis. Entries made between January 1970 and March 2017 were retrieved. Several papers have shown the relationship between marijuana use and increase in asthma and other allergic diseases symptoms, as well as the increased frequency of medical visits. This narrative review emphasizes the importance to consider cannabis as a precipitating factor for acute asthma and allergic attacks in clinical practice. Although smoking of marijuana may cause respiratory symptoms, there is a need for more studies to elucidate many aspects in allergic asthma patients, especially considering the long-term use of the drug. These patients should avoid using marijuana and be oriented about individual health risks, possible dangers of second-hand smoke exposure, underage use, safe storage, and the over smoking of marijuana.

Update on the approach to smoking in patients with respiratory diseases

Smoking is the leading cause of respiratory disease (RD). The harmful effects of smoking on the respiratory system begin in utero and influence immune responses throughout childhood and adult life. In comparison with “healthy” smokers, smokers with RD have peculiarities that can impede smoking cessation, such as a higher level of nicotine dependence; nicotine withdrawal; higher levels of exhaled carbon monoxide; low motivation and low self-efficacy; greater concern about weight gain; and a high prevalence of anxiety and depression. In addition, they require more intensive, prolonged treatment. It is always necessary to educate such individuals about the fact that quitting smoking is the only measure that will reduce the progression of RD and improve their quality of life, regardless of the duration and severity of the disease. Physicians should always offer smoking cessation treatment. Outpatient or inpatient smoking cessation treatment should be multidisciplinary, based on behavioral interventions and pharmacotherapy. It will thus be more effective and cost-effective, doubling the chances of success.

[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.

Trends in the use of cigarettes, cigars, and marijuana among students with and without asthma, 2003-2017

Aim: Asthma has symptoms that can be exacerbated by using combustible products such as tobacco and marijuana. This study assessed the prevalence and trends in current use of cigarettes, cigars, and marijuana among U.S. high school students with and without asthma. Methods: The national Youth Risk Behavior Survey (YRBS) is a biennial, school-based, nationally representative survey of U.S. students in grades 9-12. Trends during 2003-2017 in current (past 30-day) use of cigarettes, cigars, and marijuana among students with and without asthma were examined using logistic regression. Asthma was defined as reporting that a doctor or nurse ever told the student they had asthma. T-tests were used to compare cigarette, cigar, and marijuana use by asthma status and year, frequency of use, and student characteristics. Results: During 2003-2017, both current cigarette and cigar smoking decreased (p < 0.05) with rates that were similar among students with and without asthma. There was no significant linear change in current marijuana use, irrespective of asthma status. During most years, cigarette, cigar, and marijuana use were more common among students with asthma than without. In 2017, the most frequent use of cigarettes, cigars, and marijuana was among those with asthma than without. Differences in cigarette, cigar, and marijuana use by asthma status were apparent by demographic subgroups. Conclusions: Given the adverse respiratory effects of tobacco and marijuana smoking, efforts to educate all youth about the dangers of using these substances is critical, particularly among those with asthma.

[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.

Addressing unmet needs in understanding asthma mechanisms: From the European Asthma Research and Innovation Partnership (EARIP) Work Package (WP)2 collaborators

Asthma is a heterogeneous, complex disease with clinical phenotypes that incorporate persistent symptoms and acute exacerbations. It affects many millions of Europeans throughout their education and working lives and puts a heavy cost on European productivity. There is a wide spectrum of disease severity and control. Therapeutic advances have been slow despite greater understanding of basic mechanisms and the lack of satisfactory preventative and disease modifying management for asthma constitutes a significant unmet clinical need. Preventing, treating and ultimately curing asthma requires co-ordinated research and innovation across Europe. The European Asthma Research and Innovation Partnership (EARIP) is an FP7-funded programme which has taken a co-ordinated and integrated approach to analysing the future of asthma research and development. This report aims to identify the mechanistic areas in which investment is required to bring about significant improvements in asthma outcomes.

Mental Health Services Claims and Adult Onset Asthma in Ontario, Canada

BACKGROUND

Living with asthma is associated with a decrease in quality of life due to reductions in activities of daily living and increased psychological stress, both of which are associated with poor mental health outcomes.

OBJECTIVE

The objective of this study was to quantify the burden of mental disorders on the adult asthma population and compare the risk of mental health services claims (MHSCs) in the 1 year before and 1 year after asthma diagnosis.

METHODS

Ontario residents aged 25 to 65 years with incident physician-diagnosed asthma between April 1, 2005, and March 31, 2012, were included. MHSCs, which consisted of hospitalizations, emergency department (ED), and outpatient physician visits, were identified from universal health administrative data. Poisson regression models with repeated measures were used to estimate the relative risk (RR) of MHSCs for 2 time periods: 1 year after asthma diagnosis compared with the 1 year before and 2 years after compared with 2 years before.

RESULTS

A total of 145,881 adults had incident asthma. In the 1 year after asthma diagnosis, 27% had an MHSC. The risk of ED visits for any mental disorders increased by 13% in the 1 year after asthma diagnosis compared with the 1 year before (adjusted RR [aRR], 1.13; 95% confidence interval [CI], 1.06-1.21). This increased risk of ED visits was not found when comparing 2 years after asthma diagnosis with 2 years before. The risk for outpatient physician visits for substance-related disorders increased by 21% at 1 year (aRR, 1.21; 95% CI, 1.14-1.28) and 37% at 2 years (aRR, 1.37; 95% CI, 1.28-1.46).

CONCLUSIONS

The significant comorbid burden of mental disorders in adults with newly diagnosed asthma highlights the need for primary care physicians to assess mental health needs and provide appropriate care.

Characteristics of heroin-dependent patients seeking asthma care in the ED

BACKGROUND

Limited data suggest that heroin worsens asthma severity, but little is known about heroin-dependent patients who seek emergency department (ED) care for asthma.

OBJECTIVES

To describe what heroin-dependent patients know about their asthma and how they use health care resources.

METHODS

A prospective study of heroin-dependent patients seeking care for "asthma" at an urban ED with 130000 annual visits was conducted. Eligible subjects were English-speaking heroin-dependent adults seeking care for mild to moderate asthma symptoms. A closed-format survey instrument to assess opioid use, asthma knowledge, and health care use was developed by content experts, piloted for study performance, revised, and then administered to eligible patients prior to ED discharge. Descriptive analysis was done.

RESULTS

Thirty subjects participated. Mean age was 47.5 years; 21 (70%) were male. Most used heroin several times weekly. Intranasal was the most common route (93%). Almost half (47%) stated that their asthma was diagnosed in the ED, 13% by a primary care physician, 13% by a lung specialist, and 27% did not know how diagnosed. The ED was used as the primary source for asthma medications in 73% cases; 43% used the ED for breathing issues at least once per month. Most subjects (77%) felt that heroin worsened their asthma symptoms. Only 7 (23%) also abused prescription opioids, and only 7 (23%) knew about prescription naloxone.

CONCLUSION

Patients with heroin dependence frequently use the ED for their health care needs related to asthma. Most do not have other health care providers, most have limited health literacy, and all would benefit from referral to a primary care provider and substance abuse resources.

A Health-Related Quality of Life Measure for Older Adolescents With Asthma: Child Health Survey for Asthma-T (Teen Version)

BACKGROUND

Although adolescent substance use can have direct effects on asthma symptoms and interact with medications used to treat asthma, no validated health-related quality of life (HRQL) instrument exists for adolescents 17 to 19 years of age with asthma.

PURPOSE

The American Academy of Pediatric's HRQL instrument, the Child Health Survey for Asthma (CHSA)-Child version, was modified with a substance use subscale to address outcomes specific to adolescents ages 17 to 19 years with asthma.

METHODS

Two cohorts (N = 70) were recruited for instrument testing at pediatric primary care practices and two university clinics. A small methodological study with 24 adolescents was conducted to obtain initial support of the psychometric properties for the CHSA-Teen version at baseline, day 14, and day 16. A follow-up study included 46 teens to provide further support.

RESULTS

The psychometric properties of the CHSA-Teen version were good and comparable with the CHSA-Child version for feasibility, reliability, and validity.

CONCLUSIONS

Health care providers need to be aware of each adolescent's substance use to personalize counseling related to asthma medications.

Preventable hospitalizations among adult Medicaid beneficiaries with concurrent substance use disorders

OBJECTIVE

We aim to examine the relationships between substance use disorders and preventable hospitalizations for Ambulatory Care Sensitive Conditions among adult Medicaid beneficiaries.

METHODS

Cross-sectional analysis using de-identified Medicaid claims data in 2012 from 177,568 beneficiaries in Missouri was conducted. Logistic regression models were estimated for the associations of substance use disorder status with Ambulatory Care Sensitive Conditions, demographics, chronic physical and mental illnesses. Zero-inflated negative binomial regressions assessed substance use disorders, hospitalization for Ambulatory Care Sensitive Conditions, and length of hospital stay for Ambulatory Care Sensitive Conditions adjusting for co-morbid physical illnesses, mental illnesses and demographics.

RESULTS

Over 12% of the sample had been diagnosed for substance use disorder. Beneficiaries with substance use disorder were more likely than Nonsubstance use disorder beneficiaries to have admissions for chronic conditions including short/long-term complications of diabetes, uncontrolled diabetes, hypertension, chronic obstructive pulmonary disease/asthma, but not for acute conditions. While substance use disorder beneficiaries were more likely than Nonsubstance use disorder beneficiaries to be hospitalized for any Ambulatory Care Sensitive Conditions; there were no statistical differences between the two groups in terms of length of hospital stays.

CONCLUSIONS

Substance use disorder is statistically associated with hospitalizations for most Ambulatory Care Sensitive Conditions but not with length of hospital stay for Ambulatory Care Sensitive Conditions, after adjusting for covariates. The significant associations between substance use disorder and Ambulatory Care Sensitive Condition admissions suggest unmet primary health care needs for substance use disorder beneficiaries and a need for integrated primary/behavioral healthcare.

Asthma and smoking--healthcare needs and preferences of adults with asthma who smoke

OBJECTIVE

People with asthma smoke at least as much as, if not more than, people without asthma. The aim of this study was to explore the unique healthcare needs and preferences of smokers with asthma, in terms of smoking topography and initiation, perceived interplay between asthma and smoking, motivation and readiness to quit, and proposed smoking cessation techniques.

METHODS

Qualitative, semi-structured, in-depth telephone interviews with adult smokers who have concurrent asthma were conducted. Participants were recruited through flyers displayed at community pharmacies, general practice surgeries, university campuses, and respiratory clinics of tertiary hospitals and through an advertisement on the "Asthma Foundation" website. Recorded interviews were transcribed verbatim and analysed using NVivo 10 software (QSR International, Melbourne, Victoria, Australia). Obtained data were content-analysed for emergent themes using the 'framework approach'.

RESULTS

Twenty-four semi-structured interviews were conducted. Most participants believed that smoking often worsens their asthma and increases the frequency and severity of their symptoms. Fear of asthma-related exacerbations and poor self-control appeared to be the major triggers for quitting smoking. Most patients reported being motivated to quit smoking; however, in many cases, determination and strong will power need to be coupled with public, social, professional, and therapeutic support to achieve and maintain success.

CONCLUSIONS

Given the unique needs of people with asthma who smoke, it is imperative that evidence-based smoking cessation programs be designed and tailored to assist them in effectively quitting smoking.