Heroin Smoking and COPD

A Case for Targeted Screening Spirometry
  • Donald P. Tashkin
    Correspondence
    CORRESPONDENCE TO: Donald P. Tashkin, MD, FCCP, Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Los Angeles, CA 90095
    Affiliations
    Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
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      FOR RELATED ARTICLE, SEE PAGE 279
      Although tobacco smoking is the most important risk factor for the development of COPD,

      Global Initiative for Chronic Obstructive Lung Disease. GOLD 2017 Global strategy for the diagnosis, management and prevention of COPD. http://goldcopd.org/gold-2017-global-strategy-diagnosis-management-prevention-copd/. Accessed October 26, 2017.

      smoking other illicit substances is also associated with varying respiratory complications; however, there is little evidence that cannabis (the second most commonly smoked substance after tobacco) or crack cocaine, in the absence of tobacco, by itself leads to chronic airflow obstruction.
      • Tashkin D.P.
      Marijuana and the lung.
      • Tashkin D.P.
      • Simmons M.S.
      • Coulson A.H.
      • Clark V.A.
      • Gong Jr., H.
      Respiratory effects of cocaine "freebasing" among habitual users of marijuana with or without tobacco.
      In connection with the current opioid epidemic, another illicit substance that is increasingly commonly smoked is heroin, presumably as a harm-reduction strategy to avoid the well-known complications of needle injection (acquisition of bloodborne bacterial, viral [including HIV], or fungal infections; embolism; injection-site soft tissue injuries; etc). The smoking of heroin (referred to as chasing the dragon) originated in its modern day form in the 1950s in the Far East and spread to Europe in the 1980s and subsequently to the United States.
      • Strang J.
      • Griffiths P.
      • Gossop M.
      Heroin smoking by “chasing the dragon”: origins and history.
      The technique involves placing the drug powder on a surface (usually aluminum foil), applying a flame below the foil, and inhaling the vapor using a tube of some type.
      In contrast with findings from studies of marijuana or crack cocaine smokers,
      • Tashkin D.P.
      Marijuana and the lung.
      • Tashkin D.P.
      • Simmons M.S.
      • Coulson A.H.
      • Clark V.A.
      • Gong Jr., H.
      Respiratory effects of cocaine "freebasing" among habitual users of marijuana with or without tobacco.
      small-scale studies of relatively young habitual heroin smokers recruited from community drug services have shown a remarkably higher prevalence of impaired FEV1,
      • Buster M.C.
      • Rook L.
      • Giel H.A.
      • et al.
      Chasing the dragon, related to the impaired lung function among heroin users.
      spirometry-confirmed COPD,
      • Lewis-Burke N.
      • Vlies B.
      • Wooding O.
      • et al.
      A screening study to determine the prevalence of airway disease in heroin smokers.
      and symptoms consistent with COPD compared with tobacco smokers of a comparable age. Furthermore, in a cohort of relatively young chronic heroin smokers (mean age, 41 years) with clinician-diagnosed and spirometrically confirmed COPD, not only was the average degree of airflow obstruction severe (mean FEV1, 31.5% predicted), but high-resolution CT scan revealed that nearly one-half of the heroin smokers with COPD had moderate-to-severe predominantly upper-lobe emphysema. The mortality rate from COPD in these young heroin smokers was high.
      • Walker P.P.
      • Thwaite R.
      • Amin S.
      • et al.
      The association between heroin inhalation and early onset emphysema.
      In addition to COPD, a particularly high prevalence of asthma and airway hyperreactivity has also been reported among smokers of heroin with or without cocaine,
      • Lewis-Burke N.
      • Vlies B.
      • Wooding O.
      • et al.
      A screening study to determine the prevalence of airway disease in heroin smokers.
      • Boto de los Bueis A.
      • Pereira Vega A.
      • Sanchez Ramos J.L.
      • et al.
      Bronchial hyerreactivity in patients who inhale heroin mixed with cocaine vaporized on aluminum foil.
      and several cases of severe and even fatal asthma have been reported after heroin inhalation.
      • Krantz A.J.
      • Hershow R.C.
      • Prachand N.
      • et al.
      Heroin insufflation as a trigger for patients with life-threatening asthma.
      In this issue of CHEST, Burhan et al
      • Burhan H.
      • Young R.
      • Byrne T.
      • et al.
      Screening heroin smokers attending community drug services for COPD.
      report the results of a screening program for airways disease among a relatively large population (N = 753) of mostly middle-aged (mean, 46-49 years) habitual heroin smokers attending a community drug services program which provides assistance aimed at recovery from addiction. As part of this program, smokers underwent spirometry and completed questionnaires that included assessment of respiratory symptoms (modified Medical Research Council and COPD Assessment Test) and smoked substance abuse status (current, former, duration, quantity) for heroin, tobacco, cannabis, and crack cocaine. Most (approximately 90%) of the heroin smokers were also current smokers of tobacco and approximately a quarter were current smokers of cannabis and/or crack cocaine, therefore making it difficult to disentangle the impact of smoked heroin from that of the concomitantly smoked substances. Their findings indicate a particularly high prevalence (approximately 50%) of fixed airflow obstruction (consistent with COPD), along with respiratory symptoms (modified Medical Research Council and COPD Assessment Test scores > 2 and 15, respectively), in this early middle-aged population of polysubstance smokers. Approximately 30% of the heroin smokers with COPD were thought to have overlapping asthma, whereas 21% were considered to have asthma without COPD, a figure higher than the prevalence of asthma in the general population.

      CDC National Center for Health Statistics, National Health Interview Survey (NHIS). Child and adult asthma prevalence by age and sex: United States, 2006-2010. https://www.cdc.gov/asthma/Asthma_Prevalence_in_US.pptx. Accessed October 25, 2018.

      Moreover, screening revealed not only that a substantially higher proportion of the heroin smokers had COPD than had been diagnosed with COPD previously, but also that most of those with a previous diagnosis of COPD had been misclassified as having asthma. Therefore, the authors have confirmed previously published findings of a high prevalence of COPD in relatively young to middle-aged long-term heroin smokers
      • Buster M.C.
      • Rook L.
      • Giel H.A.
      • et al.
      Chasing the dragon, related to the impaired lung function among heroin users.
      • Lewis-Burke N.
      • Vlies B.
      • Wooding O.
      • et al.
      A screening study to determine the prevalence of airway disease in heroin smokers.
      who were also attending clinics for treatment of their addiction. However, the size of the authors’ population was much higher (N = 753) than the cohorts of heroin smokers who had been studied previously (N = 73-107), therefore adding substantially to the relatively scant data on the pulmonary consequences of heroin smoking than had been available previously.
      Taken together, these findings are remarkable because the prevalence of COPD in habitual heroin smokers is much higher than that reported among regular tobacco smokers in the same age group,
      • Ford E.S.
      • Mannino D.M.
      • Wheaton A.G.
      • et al.
      Trends in the prevalence of obstructive and restrictive lung function among adults in the United States. Findings from the National Health and Nutrition Examination Surveys from 1988-1994 to 2007-2010.
      and the average age of the heroin smokers is also much lower than that of tobacco smokers at the time of COPD diagnosis.
      • Ford E.S.
      • Mannino D.M.
      • Wheaton A.G.
      • et al.
      Trends in the prevalence of obstructive and restrictive lung function among adults in the United States. Findings from the National Health and Nutrition Examination Surveys from 1988-1994 to 2007-2010.
      In view of the remarkably high prevalence of COPD among young to middle-aged heroin smokers, a cogent case for screening spirometry targeted to this population at particularly high risk for COPD can be made, despite current recommendations that spirometry be reserved for case finding in symptomatic patients at risk.

      Global Initiative for Chronic Obstructive Lung Disease. GOLD 2017 Global strategy for the diagnosis, management and prevention of COPD. http://goldcopd.org/gold-2017-global-strategy-diagnosis-management-prevention-copd/. Accessed October 26, 2017.

      Moreover, although most of the heroin smokers in whom COPD was detected by spirometry in the current study were also highly symptomatic, one could also argue that spirometric evaluation in this specific population is appropriate from a case finding perspective in accordance with the general recommendation embodied in the Global Initiative for Chronic Obstructive Lung Disease report for confirming the clinical suspicion of COPD in at-risk patients.

      Global Initiative for Chronic Obstructive Lung Disease. GOLD 2017 Global strategy for the diagnosis, management and prevention of COPD. http://goldcopd.org/gold-2017-global-strategy-diagnosis-management-prevention-copd/. Accessed October 26, 2017.

      In either case, it is important to increase awareness by clinicians of the especially strong association of heroin smoking with COPD risk and of the unusually young age at which COPD may clinically and spirometrically manifest in this high-risk population. Such awareness should foster the taking of an illicit drug use history, spirometric screening in smokers of heroin therefore newly identified, and in known heroin smokers who are already participating in addiction treatment programs, and the implementation of appropriate preventative and therapeutic interventions, along with regular follow-up evaluation.

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