Addiction to aerosol treatment: the asthmatic alternative to glue sniffing

The comparative effectiveness of initiating fluticasone/salmeterol combination therapy via pMDI versus DPI in reducing exacerbations and treatment escalation in COPD: a UK database study

Chronic obstructive pulmonary disease (COPD), a complex progressive disease, is currently the third leading cause of death worldwide. One recommended treatment option is fixed-dose combination therapy of an inhaled corticosteroid (ICS)/long-acting β-agonist. Clinical trials suggest pressurized metered-dose inhalers (pMDIs) and dry powder inhalers (DPIs) show similar efficacy and safety profiles in COPD. Real-world observational studies have shown that combination therapy has significantly greater odds of achieving asthma control when delivered via pMDIs. Our aim was to compare effectiveness, in terms of moderate/severe COPD exacerbations and long-acting muscarinic antagonist (LAMA) prescriptions, for COPD patients initiating fluticasone propionate (FP)/salmeterol xinafoate (SAL) via pMDI versus DPI at two doses of FP (500 and 1,000 μg/d) using a real-life, historical matched cohort study. COPD patients with ≥2 years continuous practice data, ≥2 prescriptions for FP/SAL via pMDI/DPI, and no prescription for ICS were selected from the Optimum Patient Care Research Database. Patients were matched 1:1. Rate of moderate/severe COPD exacerbations and odds of LAMA prescription were analyzed using conditional Poisson and logistic regression, respectively. Of 472 patients on 500 μg/d, we observed fewer moderate/severe exacerbations in patients using pMDI (99 [42%]) versus DPI (115 [49%]) (adjusted rate ratio: 0.71; 95% confidence interval: 0.54, 0.93), an important result since the pMDI is not licensed for COPD in the UK, USA, or China. At 1,000 μg/d, we observed lower LAMA prescription for pMDI (adjusted odds ratio: 0.71; 95% confidence interval: 0.55, 0.91), but no difference in exacerbation rates, potentially due to higher dose of ICS overcoming low lung delivery from the DPI.

Etiological characterization of acute poisonings in the emergency department

Introduction:

An investigation of emergency department (ED) poisonings was conducted to characterize poisoning demographics and evaluate correlations with select co-morbidities.

Methods:

The study population evaluated consisted of 649 poisoning cases admitted between 2004 and 2007 to an inner-city, level 1 emergency department.

Results:

Ethnicity, age, and gender had a substantial impact on the population distribution as poisoning cases were predominantly African Americans (79.9%) between 36 and 45 years old with a 1:3 male to female ratio. Intentional illicit drug overdose was the most prevalent cause of poisoning, heroin being the most frequent substance found in 35.4% (n = 230) of cases, followed by cocaine overdose at 31.7% (n = 206), concomitant heroin and cocaine overdose at 4.3% (n = 28), multiple drug poisoning at 5.5% (n = 36), and antidepressant/antipsychotic poisoning at 6% (n = 39). Significant correlations were found between heroin poisoning and asthma (F = 20.29, DF = 1, P = 0.0001), cocaine poisoning and hypertension (F = 33.34, DF = 1, P = 0.0001), and cocaine poisoning and cardiovascular disease (F = 35.34, DF = 1, P = 0.0001). A change in the pattern of illicit drug use from injection to inhalation was detected and the resulting increase of inhalation and insufflation of illicit substances may partially explain the correlation found between heroin use and asthma.

Conclusions:

These results provide supporting evidence that deliberate poisoning with illicit drugs remains a serious healthcare issue that significantly aggravates co-morbidities and raises treatment costs by increasing both the rate of hospitalization and hospital length of stay.

Endemic asthma inhaler abuse among antisocial adolescents

BACKGROUND

Approximately 40 million prescriptions were dispensed in the U.S. for asthma inhalers in 2006. Although the pervasive distribution of asthma inhalers warrants greater attention to possible misuse of these products, few investigations have examined asthma inhaler misuse. The purpose of this study was to describe the prevalence, correlates and consequences of asthma inhaler misuse among antisocial youth.

METHOD

A cross-sectional survey with face-to-face interviews assessing substance use, psychiatric symptoms, and antisocial behaviors among adolescents (N=723) in residential treatment.

RESULTS

More than 26% (N=193) of youth were diagnosed with asthma; 91.2% of asthmatic youth had received a prescription for an inhaler. Of the 373 youth who had used a prescribed or non-prescribed asthma inhaler, 23.6% (N=88) reported using an inhaler to get high (i.e., were inhaler misusers). Asthma inhaler misusers had an earlier onset of antisocial conduct, significantly greater levels of current psychiatric distress and lifetime suicidality, higher rates of lifetime substance use problems and volatile solvent abuse, and significantly higher levels of temperamental impulsivity and fearlessness than did inhaler non-users or users. Caucasian racial status, current level of psychiatric distress, and lifetime volatile solvent abuse significantly distinguished lifetime asthma inhaler users and misusers in multivariate logistic regression analyses. Asthma inhaler misusers were significantly more likely to report euphoria, memory problems, slurred speech, blurred vision, confusion, dizziness, and a variety of other acute reactions to asthma inhaler use than were asthma inhaler users.

CONCLUSIONS

Asthma inhaler misuse for the purposes of getting high was prevalent among antisocial youth, co-occurred with other psychiatric and substance use problems, and was associated with adverse consequences.

Asthma inhaler misuse and substance abuse: a random survey of secondary school students

PURPOSE

To assess the relationship between prescription asthma inhaler misuse and other substance abuse.

METHODS

The study included a random sample of 5th through 10th grade students attending one, ethnically diverse school district in metropolitan Detroit (N=1017). A cross-sectional, web-based survey design was used. The survey included questions about the use and misuse of prescribed asthma inhalers (among other medications) as well as the use of alcohol, cigarettes, marijuana, and other drugs. We investigated four types of interaction with prescribed asthma inhalers: non-use, prescribed use, prescribed use and misuse, and misuse.

RESULTS

Students who misused asthma inhaler medication during their lifetimes were more likely to smoke cigarettes and marijuana as well as more likely to drink alcohol, binge drink and have used other illicit drugs. Students who used asthma inhaler medication solely as prescribed were no more likely to abuse drugs or alcohol than non-users of prescription asthma inhalers.

CONCLUSIONS

Our findings are of interest to clinicians who provide health care to adolescents. The present study also has implications for adults managing prescription asthma medication in households and schools.

Pilot study of abuse of asthma inhalers by middle and high school students

During a school-based survey, middle and high school students (n = 1536) reported on their nonprescribed, lifetime use of asthma inhalers. Approximately 15% of 8th and 9th graders reported using nonprescribed asthma inhalers; the odds for this behavior were significantly higher for these students (2.25 and 2.30, respectively) and the nonprescribed use of asthma inhalers was significantly associated with higher rates of other drug use.

Salbutamol inhaler abuse and psychosis

A case is described in which a man with asthma and a history of alcohol dependence presented with a paranoid psychosis refractory to standard neuroleptic treatment. Symptomatic improvement was achieved when abuse of salbutamol (Ventolin®) metered dose inhaler was discovered and an alternative β2-agonist delivery system prescribed. A contribution by salbutamol to the psychosis is proposed. It is suggested that increased awareness regarding psychiatric morbidity is needed when metered dose salbutamol inhalers are prescribed.

Volatile substance abuse

Volatile substance abuse has been reported in the literature over the past 20 years or so, and has apparently increased as countries have become more industrialised. This review attempts to clarify trends in volatile substance abuse, problems associated with this behaviour and possible solutions. Data sources included a Medline Search on volatile substance abuse over the last five years, Commonwealth publications, recent State and Territory inhouse publications, three research monographs from the National Institute on Drug Abuse (NIDA) and an article library from the author's workplace. Some 250 articles and monographs were identified, reviewed and categorised into sections relating to epidemiology (including mortality), physiological effects and responses to the problem. Articles were used for reference where they reflected the most up-to-date information or where they were seen as authoritative statements. While the body of knowledge concerning volatile substance abuse has improved, little progress has been made in finding effective solutions to the problem. The fact that users are typically young and that there is a real risk of sudden death associated with even initial use suggests that continuing research is needed to develop innovative approaches to the problem.

Aerosol addiction

A case of dependency on prescribed pressurised aerosols in a patient with asthma and mild mental handicap is reported. The majority of reported cases involve young asthmatics, abuse being reported mainly using salbutamol inhalers although other inhalers have also given cause for concern. The agent of addition is uncertain although it may be the fluorinated hydrocarbons used as propellants, rather than the active substance itself.

An introduction to the clinical toxicology of volatile substances

Acute poisoning with organic solvents and other volatile compounds now usually follows deliberate inhalation (volatile substance abuse) or ingestion of these compounds. Solvents from adhesives, typewriter correction and dry cleaning fluids, cigarette lighter refills (butane) and aerosol propellants are commonly abused. The major risk is that of sudden death. Arrhythmias leading to cardiac arrest are thought to cause most deaths, but anoxia, respiratory depression and vagal stimulation leading to cardiac arrest may also contribute, as may indirect causes such as aspiration of vomit or trauma. In the United Kingdom (UK), 3.5 to 10% of young people have at least experimented with volatile substance abuse and mortality is more than 100 per annum. The products abused are cheap and readily available despite legislation designed to limit supply. Volatile substance abuse is not illegal and only a minority of abusers are known to progress to heavy alcohol or illicit drug use. Prevention of abuse by education, not only of children but also of parents, teachers, retailers and health care workers, is important in limiting the problem. However, volatile substance abuse-related deaths are still increasing in the UK despite many measures aimed at prevention. Clinically, volatile substance abuse is characterised by a rapid onset of intoxication and rapid recovery. Euphoria and disinhibition may be followed by hallucinations, tinnitus, ataxia, confusion, nausea and vomiting. It is important not to further alarm the patient if signs of serious toxicity are present, since a cardiac arrest may be precipitated. Further exposure should be prevented and the patient resuscitated and given supplemental oxygen if necessary. Cardiac arrhythmias should be treated conventionally and respiratory failure managed supportively. Long term exposure to n-hexane is associated with the development of peripheral neuropathy, while prolonged abuse (notably of toluene or chlorinated solvents) can cause permanent damage to the central nervous system, heart, liver, kidney and lungs. Knowledge of the routes of absorption, distribution and excretion of volatile compounds, and of the rates governing these processes, is important in understanding the rate of onset, intensity and duration of intoxication, and rate of recovery after volatile substance abuse. In addition, such knowledge is helpful when the clinician is attempting to interpret the results of toxicological analyses performed on samples (blood, other tissues, urine) from such patients. Many volatile substances are partly metabolised, the metabolites being eliminated in exhaled air or in urine. Although metabolism normally results in detoxification, enhanced toxicity may also result as with carbon tetrachloride, chloroform, dichloromethane, n-hexane, trichloroethylene and possibly halothane.(ABSTRACT TRUNCATED AT 400 WORDS)

Chronic non-neurological toxicity from volatile substance abuse

1. Most of the evidence for chronic non-neurological toxicity from volatile substance abuse is derived from case reports. 2. Factors important in assessing these reports are the marked variations in exposure conditions and in the composition of the products abused. 3. In a young and otherwise healthy population, any chronic organ toxicity arising from VSA has to be gross in order to become clinically apparent. This may partially explain the relatively low incidence of reporting. 4. Toluene and the chlorinated hydrocarbons 1,1,1-trichloroethane and trichloroethylene can cause permanent damage to the kidney, liver, heart and lung, in certain volatile substance abusers.

Aerosol treatment abuse

A 4 year old boy with excellent inhaler technique was found to be abusing his salbutamol and beclomethasone dipropionate inhalers. This resulted in aggressive behaviour and probable hallucinations.

Adverse reactions to beta 2-agonist bronchodilators

Beta 2-Agonists are safe and effective bronchodilator drugs. Their major adverse effects of skeletal muscle tremor, tachycardia and various metabolic effects are mediated by beta-adrenoceptor stimulation and are reversible. Skeletal muscle tremor is the most frequent dose-limiting side effect. It may be reduced by commencing treatment with a low dose and if it persists another beta 2-agonist may be tried. Other side effects such as cardiac arrhythmias and reduction in PaO2 are a serious potential problem in some susceptible asthmatics. However, they are infrequent or of a mild degree and are generally outweighed by the good control of asthma produced by beta 2-agonists. Side effects from beta 2-agonist therapy can be minimised by use of the inhaled route which selectively delivers the drug to the airways. Furthermore, selective tolerance develops to their side effects. The dose of a beta 2-agonist should be assessed on the basis of therapeutic effect and the level of tolerance to its side effects. Recommended doses of beta 2-agonists used for long term therapy do not cause clinically significant desensitisation of airway beta-adrenoceptors, although this may become a relevant problem in patients who are regularly receiving very high doses. Intravenous beta 2-agonists have a place in the treatment of severe asthma not responding to nebuliser therapy. In this life-threatening situation with severe airflow obstruction, monitoring of heart rate, PaO2, plasma potassium and the electrocardiogram should be mandatory and supplemental oxygen given so that serious adverse effects are presented.

Inhaled albuterol powder for the treatment of asthma--a dose-response study

Many patients are unable to obtain optimal benefit from inhaled bronchodilators as delivered by metered-dose aerosol spray because of difficulty in synchronizing release of medication with the start of inspiration. The Rotahaler is a flow-activated device that avoids this problem since the act of inspiration itself delivers medication to the lungs. In this randomized, double-blind, crossover study, each of 20 male patients with moderate to severe asthma, ages 12 to 23 yr, received a single treatment with 100, 200, or 400 mcg of albuterol powder or placebo by Rotahaler on 4 study days separated by 2 to 10 days. All patients stopped theophylline and inhaled beta-agonists as needed 24 and 12 hr, respectively, before study days. All patients emptied the Rotahaler with a single inhalation. Pulmonary functions were followed for 8 hr after medication. Statistical analyses of FEV1, FEF25-75, and FVC revealed that all doses of albuterol powder were superior to placebo within 5 min with a log dose-response trend for both degree and duration of bronchodilation.