Inhaled Heroin-Induced Status Asthmaticus: Five Cases and a Review of the Literature

doi:10.1378/chest.117.1.272

Chest

Volume 117, Issue 1, January 2000, Pages 272-275

https://doi.org/10.1378/chest.117.1.272 Get rights and content

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

Section snippets

Case 1

A 30-year-old, nonsmoking, African-American woman with a history of asthma and heroin abuse was well until “a few hours” prior to admission when she became acutely breathless after snorting heroin. Despite the use of an inhaled β-agonist, she was intubated in the field for respiratory arrest and brought to hospital. She was agitated in the emergency department with the following vital signs: temperature, 36.5°C; pulse, 130 beats/min; BP, 124/80 mm Hg; and respiratory rate, 29 breaths/min by

Discussion

The five cases reported above are examples of status asthmaticus triggered by inhalation of heroin. Common features of these cases include a history of asthma, the sudden and severe nature of the exacerbations, the general lack of responsiveness β-agonists, and peripheral blood eosinophilia (range, 6 to 11% of the total WBC count). Four of five patients were intubated (and the fifth nearly was intubated) for an average of 5 days (range, 2 to 8 days). This protracted course distinguishes these

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Cited by (62)

Bronchial diseases and heroin use. A systematic review
2023, Revue des Maladies Respiratoires
L’usage d’héroïne peut causer des complications respiratoires dont l’asthme, la bronchopneumopathie chronique obstructive (BPCO) et les bronchectasies (DDB).
Revue générale de la littérature exposant les données sur la relation entre la consommation d’héroïne et les complications bronchiques les difficultés du diagnostic et de la prise en charge.
Medline, période 1980–2022, mots-clés : « asthma » ou « bronchospasm » ou « COPD » ou « bronchiectasis » et « heroin » ou « opiate » ou « opiates », avec les limites « Title/Abstract ». Concernant l’asthme 26 études ont été retenues, 16 pour la BPCO et 5 pour les DDB.
La prévalence de l’asthme et de la BPCO est plus élevée chez les héroïnomanes ; ces patients sont moins observants de leur traitement. Une association positive existe entre la fréquence des exacerbations d’asthme, l’admission en soins intensifs et l’inhalation d’héroïne. Le diagnostic de BPCO est tardif ce qui aggrave le cours de la maladie ; la présence d’emphysème et de DDB sont des éléments de mauvais pronostic.
Les affections bronchiques doivent être mieux identifiées chez les consommateurs d’héroïne afin d’optimiser leur prise en charge qui comprend l’arrêt de substances toxiques.
Heroin use can cause respiratory complications including asthma, chronic obstructive pulmonary disease (COPD) and bronchiectasis (BD).
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.
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.
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.
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.
The pathophysiology of opioid-induced respiratory depression
2022, Handbook of Clinical Neurology
Citation Excerpt :
Although, it is unclear whether chronic use of opioids may lead to increased obstructive sleep apneas (Ahmad et al., 2021), perioperative management and the use of opioids differ between patients with and patients without history of sleep-disordered breathing (Gupta et al., 2018). At the lung level, chronic heroin use causes bronchospasms in patients, leading to airway constriction (Cygan et al., 2000). In summary, opioid drugs, are associated with substantial reduction in ventilation and subsequent oxygen desaturation, which can lead to complete respiratory arrest, brain hypoxemia and bradycardia, in particular when potent synthetic opioid drugs such as oxycodone and fentanyl are abused (Schiller et al., 2020).
Opiates, such as morphine, and synthetic opioids, such as fentanyl, constitute a class of drugs acting on opioid receptors which have been used therapeutically and recreationally for centuries. Opioid drugs have strong analgesic properties and are used to treat moderate to severe pain, but also present side effects including opioid dependence, tolerance, addiction, and respiratory depression, which can lead to lethal overdose if not treated. This chapter explores the pathophysiology, the neural circuits, and the cellular mechanisms underlying opioid-induced respiratory depression and provides a translational perspective of the most recent research. The pathophysiology discussed includes the effects of opioid drugs on the respiratory system in patients, as well as the animal models used to identify underlying mechanisms. Using a combination of gene editing and pharmacology, the neural circuits and molecular pathways mediating neuronal inhibition by opioids are examined. By using pharmacology and neuroscience approaches, new therapies to prevent or reverse respiratory depression by opioid drugs have been identified and are currently being developed. Considering the health and economic burden associated with the current opioid epidemic, innovative research is needed to better understand the side effects of opioid drugs and to discover new therapeutic solutions to reduce the incidence of lethal overdoses.
Asthma and cannabis, cocaine or heroin use
2020, Revue des Maladies Respiratoires
L’usage de cannabis, de cocaïne ou d’héroïne peut être responsable de complications pulmonaires parmi lesquelles figure l’asthme.
L’objectif de cette revue systématique de la littérature est d’exposer les données concernant la relation entre la consommation de cannabis, de cocaïne ou d’héroïne et l’asthme.
L’usage de cannabis, de cocaïne ou d’héroïne par voie inhalée peut être responsable de symptômes respiratoires (toux, sifflements thoraciques), favoriser le développement d’un asthme, augmenter le risque d’exacerbation aiguë d’asthme (pouvant nécessiter une intubation et une ventilation invasive), voire des décès par asthme et diminuer l’observance du traitement de l’asthme. Le cannabis a un effet bronchodilatateur rapide. En revanche, sa consommation chronique provoque une diminution de la conductance spécifique des voies aériennes. Les études portant sur la diminution ou le déclin du volume expiratoire maximal par seconde (VEMS) sont discordantes.
Une consommation de cannabis, de cocaïne ou d’héroïne doit être recherchée devant des symptômes respiratoires survenant chez des sujets jeunes et les praticiens doivent aider les usagers de ces substances illicites à arrêter leur consommation.
The use of cannabis, cocaine or heroin can be responsible for many respiratory complications including asthma.
The aim of this systematic literature review of data was to expose the relations between cannabis, cocaine or heroin use and asthma.
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.
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.
Screening Heroin Smokers Attending Community Drug Clinics for Change in Lung Function: A Cohort Study
2020, Chest
Heroin smokers have high rates of COPD, respiratory morbidity, hospital admission, and mortality. We assessed the natural history of symptoms and lung function in this population over time.
A cohort of heroin smokers with COPD was followed for 18 to 24 months. At baseline and follow-up, respiratory symptoms were measured by the Medical Research Council Dyspnea Scale (MRC) and the COPD Assessment Tool (CAT), and postbronchodilator spirometry was performed. Frequency of health-care-seeking episodes was extracted from routine health records. Parametric, nonparametric, and linear regression models were used to analyze the change in symptoms and lung function over time.
Of 372 participants originally recruited, 161 were assessed at follow-up (mean age, 51.0 ± 5.3 years; 74 women [46%]) and 106 participants completed postbronchodilator spirometry. All participants were current or previous heroin smokers, and 122 (75.8%) had smoked crack. Symptoms increased over time (MRC score increased by 0.48 points per year, P < .001; CAT score increased by 1.60 points per year, P < .001). FEV₁ declined annually by 90 ± 190 mL (P < .001). This deterioration was not associated with change in tobacco or heroin smoking status or use of inhaled medications.
Heroin smokers experience a high and increasing burden of chronic respiratory symptoms and a decline in FEV₁ that exceeds the normal age-related decline observed among tobacco smokers with COPD and healthy nonsmokers. Targeted COPD diagnostic and treatment services hosted within opiate substitution services could benefit this vulnerable, relatively inaccessible, and underserved group of people.
Clinical Toxicology and Its Relevance to Asthma and Atopy
2016, Clinics in Laboratory Medicine
The association between heroin inhalation and early onset emphysema
2015, Chest
Citation Excerpt :
Our findings are also salient in the context of the recent rise in vaping using electronic cigarettes, where safety is not established.18 Asthma is common, and what evidence exists addressing the pulmonary effects of heroin smoking almost exclusively relates to asthma.5–9 As a consequence, we specifically focused on subjects not just with spirometry but with some other measure consistent with COPD and emphysema, such as HRCT scan evidence of emphysema or reduced Dlco.
Inhalation/smoking has become the most common method of recreational opiate consumption in the United Kingdom and other countries. Although some heroin smokers appear to develop COPD, little is known about the association.
We present data from a cohort of 73 heroin smokers with clinician-diagnosed and spirometrically confirmed COPD, seen within our clinical service, where symptoms developed before the age of 40 years.
The whole group mean age at diagnosis was 41 years, subjects had smoked heroin for 14 years, and mean FEV₁ was 1.08 L (31.5% predicted), with mean FEV₁/FVC of 0.4. No subject was found to have severe α₁-antitrypsin deficiency. Forty-four subjects had either a high-resolution CT (HRCT) scan (32) or measurement of lung diffusion (12). Overall HRCT scan emphysema score averaged across the upper, middle, and lower part of the lung was 2.3 (5%-25% emphysema), with 47% subjects having an upper lobe emphysema score ≥ 3 (25%-50% emphysema). Median diffusing capacity of the lung for carbon monoxide was 48% of predicted value.
Recreational smoking of heroin appears to lead to early onset COPD with a predominant emphysema phenotype. This message is important to both clinicians and the public, and targeted screening and education of this high-risk population may be justified.

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Chest

Selected ReportsInhaled Heroin-Induced Status Asthmaticus: Five Cases and a Review of the Literature

Section snippets

Case 1

Discussion

Lancet

J Psychosom Res

Ann Allergy Asthma Immunol

Chest

State of the art: the assessment and management of adults with status asthmaticus

Am J Respir Crit Care Med

Heroin inhalation, and asthma

BMJ

The role of pharmacology and forensics in the death of an asthmatic

J Anal Toxicol

Allergy to heroin

Allergy

Acute eosinophilia pneumonia in a heroin smoker

Eur Respir J

Selected Reports
Inhaled Heroin-Induced Status Asthmaticus: Five Cases and a Review of the Literature