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Heroin smoking linked to emphysema

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Emphysema from sources other than cigarettes needs more research

This case series of heroin smokers who developed early-onset emphysema may offer insights into the development of COPD and emphysema in cigarette smokers who don’t smoke opiates.

How might narcotic use contribute to the development of COPD and emphysema? There are several possible explanations. Smokers of heroin and other illicit substances typically take a deep inhalation, combined with a Valsalva maneuver to enhance absorption of the drug into the body. This behavior has been described previously in heroin users and users of other smoked substances. In addition, these agents often burn at a very high temperature, with the potential to cause damage deep within the lung.

The depth of inhalation, dynamic hyperinflation, and barotrauma may be important factors in some patients who develop emphysema related to cigarette smoking or other factors, as well. Physicians should be aware of this problem, and the public must be educated about the dangers associated with the inhalation of these and other burned substances.

Dr. David M. Mannino is the chair of preventative medicine and environmental health in the department of epidemiology at the University of Kentucky in Lexington. He disclosed having served as a consultant for Boehringer Ingelheim GmbH, GlaxoSmithKline, AstraZeneca, Novartis AG, Merck, and Forest Pharmaceuticals, and has received research grants from GSK, Novartis, Boehringer Ingelheim, Forest Pharmaceuticals, and Pfizer. He is also compensated by Up-to-Date, has served as an expert in tobacco-related cases, and is on the board of the COPD Foundation. He made his remarks in an editorial published with the study.


 

FROM CHEST

References

Inhalation or smoking of heroin can lead to early onset chronic obstructive pulmonary disease (COPD), according to Dr. Paul P. Walker and his colleagues from the University Hospital Aintree and the University of Liverpool, England.

“We believe that we have accumulated sufficient evidence of both physiologic impairment and structural damage to identify a discrete form of early onset COPD, commonly involving emphysema, which can be attributed to inhaled opiate use,” the researchers wrote. “The widespread use of opiates as recreational drugs in some communities means that we are likely to see more obstructive lung disease in the future.”

Recreational use of opiates has been linked to asthma, but there has not been a definitive link to airway disease. “Little is known about the association between heroin inhalation and COPD beyond a study by Buster et al. [and] no previous study has examined measures of emphysema, such as detailed lung function testing or CT scan,” the researchers wrote (Chest. 2015 Nov;148[5]:1156-1163).

The researchers studied 73 individuals who were aged 40 years or younger when they developed symptoms, were diagnosed with COPD, and smoked heroin regularly within the last 2 years. The mean history of smoking heroin was 14 years. The study participants additionally were regular smokers for at least 5 years, most were heavy smokers, and did not have a primary clinical diagnosis of asthma. All had completed spirometry on at least one occasion when clinically stable.

Data was collected during 2005-2013, via lung function testing done when subjects were both clinically stable and a minimum of 4 weeks postexacerbation. Lung function testing was done in 12 subjects via spirometry, either prebronchodilator or postbronchodilator. High-resolution CT scans (slice thickness was no greater than 2 mm) were performed in 32 subjects each analyzed by two thoracic radiologists. Emphysema was scored on a scale of 1-5 based on guidelines produced by Sakai et al., which requires examination of a cranial level taken 1 cm above the superior margin of the aortic arch, a middle level taken 1 cm below the carina, and a caudal level taken about 3 cm above the top of the diaphragm.

Data were available from 44 of the initial 73 subjects. In the 32 who had high-resolution CT scans, their mean score – taking into account the scans of the upper, middle, and lower lung – was 2.3, indicating a 5%-25% chance of emphysema; 15 of 32 individuals had a score greater than 3, indicating a 25%-50% likelihood of emphysema, in the upper lung alone.

In the 12 subjects who underwent lung function testing, the range of the diffusing capacity of the lung for carbon monoxide was 35.5-63.0, with a median of 48.0 and a mean of 50.7. Eleven of these subjects (92%) had score that qualified as “abnormal.”

As a result of “lifestyle and varying motivation” not all subjects completed the planned sequence of the investigation or returned for follow-up spirometric measurement, the researchers wrote. “Taking a history of inhaled drug use is important in patients with early-onset COPD, as is the provision of appropriate education about this new hazard of opiate use among drug users and their caretakers. In some areas and populations there may be a role for case finding using spirometry.”

Dr. Walker and his coauthors did not report any relevant financial disclosures.

dchitnis@frontlinemedcom.com

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