Pulmonary Medicine

Pulmonary Complications of Illicit Drug Use

What every physician needs to know:

According to the 2009 National Survey on Drug Use and Health, 21.8 million Americans age twelve years or older use illicit drugs. Pulmonary complications of illicit drug use are common because the lungs are exposed to both the environment and the circulation; hence, all illicit drugs that are inhaled or injected are potentially damaging to the lungs. Physicians should be aware of the pulmonary complications of illicit drug use in order to diagnose these disorders correctly and manage them in a timely fashion.

Classification:

Non-infectious pulmonary complications

  • acute non-cardiogenic pulmonary edema

  • pulmonary granulomatosis

  • pulmonary alveolar hemorrhage

  • bronchiolitis obliterans organizing pneumonia

  • pulmonary arterial hypertension

  • emphysema and bullous lung disease

  • airways disease

  • inhalation injuries

  • pleural disease

Infectious pulmonary complications

  • pneumonia and bronchitis

  • septic pulmonary emboli

  • pulmonary tuberculosis

Are you sure your patient has a pulmonary complication of illicit drug use? What should you expect to find?

Patients with pulmonary complications of illicit drug use are often recognized because of other signs and symptoms of that drug use. However, because patients often abuse illicit drugs surreptitiously, the pulmonary complications are often recognized only with careful questioning of the patient and/or use of laboratory screening for the presence of illicit drugs. Patients who inject heroin or other narcotics or methamphetamine may present with acute pulmonary edema, which may be fatal unless they present to emergency care in a timely fashion, in which case the edema will usually reverse while the patient is receiving supportive care.

Injection drug use with narcotics or with other illicit drugs, particularly crushed oral tablets, may lead to the development of pulmonary granulomatosis. Patients with this condition have progressive shortness of breath with interstitial or emphysematous abnormalities seen on chest imaging. Lung tissue shows the presence of foreign body granulomas that are usually due to talc, in the interstitium and alveolar walls.

Pulmonary arterial hypertension that is due to the presence of talc granulomas in the vascular walls is a rare complication of injection drug use. Pulmonary hypertension may also develop in these patients because of co-morbidity with HIV infection. Severe bullous emphysema is another complication of injection drug use that is related to the presence of talc granutomata. Precocious emphysema, which has been reported in injectors of heroin and methyphenidate, can lead to pneumothorax. Chronic bronchitis and acute bronchospasm are side effects of both injection and inhalation drug use.

Patients who smoke crack cocaine may present with hemoptysis that is due to pulmonary alveolar hemorrhage. Bronchiolitis obliterans organizing pneumonia has also been associated with cocaine use.

Extensive studies have been done in chronic drug abusers to investigate the role of injection and smoked illicit substances on lung function. Chronic marijuana smoking may add to the airway effects of tobacco smoking, while inhaled heroin and inhaled cocaine have been reported to cause acute wheezing. Inhalation injury, including thermal damage to the upper airway and trachea, can be caused by "freebasing" cocaine. Exposure to methamphetamine laboratories has caused inhalation injury in illicit drug users and public safety officers. Pleural complications of illicit drug abuse include direct injury to the pleura and resultant pneumothorax from injection and from spontaneous pneumothorax complicating bullous lung disease.

Patients who use injected and inhaled drugs are more susceptible to pulmonary infections, including pneumonia and bronchitis, than are those who do not. Aspiration pneumonia is a complication of illicit drug use that results from the altered mental status caused by the drug. Septic pulmonary emboli that is due to the injection of contaminated illicit drugs via infected needles is another infectious complication of injection illicit drug use. Smoking of crack cocaine and other illicit drugs has been implicated in an increased prevalence of pulmonary tuberculosis.

Beware: there are other diseases that can mimic a pulmonary complication of illicit drug use:

Patients with pulmonary complications from abuse of illicit drugs may also be infected with HIV, so the pulmonary complications of HIV infection can overlap with the pulmonary complications of the drug use. The non-infectious and infectious complications of illicit drug use are not unique, as all of these disorders may be seen in patients who do not abuse illicit drugs. Health care providers should be aware of the relationship between illicit drug use and these relatively common pulmonary disorders.

How and/or why did the patient develop a pulmonary complication of illicit drug use?

Injected and inhaled illicit drugs cause direct damage to the pulmonary vasculature, airways and alveoli. Injected drugs can affect the pulmonary vascular permeability and result in pulmonary edema. Sympathomimetic drugs like cocaine and amphetamines can raise the pulmonary arterial pressure. Intravenous injection of foreign material causes septic pulmonary emboli and formation of granuloma along the pulmonary vasculature.

Inhalation drug use results in direct airway inflammation and damage; thermal injury to the upper airway and trachea have also been seen in those who "freebase" cocaine. Injected and inhaled drugs can cause granuloma formation in the alveolar walls, resulting in thinning of those walls, which manifests as emphysema. Inflammation of the interstitium and fibrosis development may also be caused by the injection or inhalation of drugs.

Which individuals are at greatest risk of developing a pulmonary complication of illicit drug use?

All individuals who use illicit drugs can develop pulmonary complications. HIV co-infection may be an additive risk factor, particularly for pulmonary vascular and infectious pulmonary complications. Injection drug users who reuse and/or share needles and syringes are at particular risk for infectious complications. Chronic heavy smokers of marijuana may be at risk for obstructive lung disease later in life, while habitual smokers of cocaine can develop chronic airway disease, chronic alveolar hemorrhage, and medial hypertrophy of the pulmonary arteries.

What laboratory studies should you order to help make the diagnosis, and how should you interpret the results?

There are no routine blood or sputum tests that diagnose the pulmonary complications of illicit drug use. Urine and blood testing to detect illicit drugs may be helpful, particularly in surreptitious users.

What imaging studies will be helpful in making or excluding the diagnosis of a pulmonary complication of illicit drug use?

Routine chest radiography may show findings consistent with the pulmonary complications of drug use, particularly interstitial disease, nodular infiltrates, bullous emphysema, and pulmonary infections. Computed tomography (CT) of the chest is particularly helpful in diagnosing the more subtle manifestations of these conditions. Nodules of varying sizes, ground-glass opacities, consolidation, air trapping, and emphysema are all detected by CT scanning, particularly using protocols that provide high-resolution, thin-cut images.

What non-invasive pulmonary diagnostic studies will be helpful in making or excluding the diagnosis of a pulmonary complication of illicit drug use?

Pulmonary function testing is helpful in detecting the type and severity of the pulmonary manifestations of illicit drug use. Abnormalities of airflow detected by spirometry confirm the presence of airways disease, and lung volume and diffusing capacity (DLCO) measurements quantify the degree of interstitial disease and or emphysema. Increased residual volume, increased functional residual capacity, and reduced DLCO are seen in emphysema, while reduced total lung capacity and reduced DLCO are consistent with interstitial disease.

Echocardiography is used to detect vegetations on cardiac valves that cause septic pulmonary emboli. Echocardiograms are also useful in evaluating cardiac function when patients present with pulmonary edema. Indirect measurement of pulmonary artery pressures are also helpful when illicit drug users are suspected of having pulmonary arterial hypertension; a right heart catheterization can confirm the presence of pulmonary arterial hypertension.

What diagnostic procedures will be helpful in making or excluding the diagnosis of a pulmonary complication of illicit drug use?

Bronchoscopy with bronchoalveolar lavage and transbronchial biopsy is useful in the evaluation of interstitial lung disease and pulmonary infections. Surgical lung biopsy is rarely required, as the history of drug use coupled with the radiographic and bronchoscopic findings are generally sufficient to confirm the disease type. Right heart catheterization is necessary to confirm pulmonary arterial hypertension.

What pathology/cytology/genetic studies will be helpful in making or excluding the diagnosis of a pulmonary complication of illicit drug use?

Bronchoalveolar lavage and transbronchial or surgical lung biopsy are useful in detecting infections. Transbronchial or surgical lung biopsy can also confirm the presence of talc or other foreign bodies and or granulomatous inflammation and differentiate between airway and alveolar diseases.

If you decide the patient has a pulmonary complication of illicit drug use, how should the patient be managed?

Cessation and abstinence from illicit drug use may result in disease reversal or stabilization, but otherwise, treatment options depend on the specific diagnosis.

Non-infectious complications - Airway disease may benefit from bronchodilator and steroid inhaled therapy, while interstitial diseases may benefit from systemic steroids (unless there is fixed fibrosis). Pulmonary vascular disease may benefit from vasodilator and endothelian receptor antagonist therapies, and infectious complications require targeted antibiotic therapy.

The risks of these management options are the same in illicit drug users as in the general population.

What is the prognosis for patients managed in the recommended ways?

The prognoses for the various pulmonary complications are the same as for patients in the general population.

What other considerations exist for patients with a pulmonary complication of illicit drug use?

None

What’s the evidence?

Degenhardt, L, Hall, W. "Extent of illicit drug use and dependence, and their contribution to the global burden of disease". Lancet. vol. 379. 2012. pp. 55-70.

A global perspective on the prevalence and adverse health effects of illicit drug use.

"CDC Grand Rounds: Prescription drug overdoses--a U.S. epidemic.". MMWR. vol. 61. 2012. pp. 10-13.

US perspective on the spectrum of licit and illicit drug overdoses.

Wolff, AJ, O' Donnell, AE. "Pulmonary effects of illicit drug use". Clin Chest Med. vol. 25. 2004. pp. 203-216.

Review of pulmonary complications of illicit injection and inhaled drug use.

Sporer, KA, Dorn, E. "Heroin related non cardiogenic pulmonary edema: a case series". Chest. vol. 120. 2001. pp. 1628-1632.

Case series of heroin-overdose patients who presented with pulmonary edema.

Cygan, J, Trunsky, M, Corbridge, T. "Inhaled heroin-induced status asthmaticus: five cases and a review of the literature". Chest. vol. 117. 2000. pp. 272-275.

One of the first case series to alert clinicians to the association between inhaled heroin and asthma.

Story, A, Bothamley, G, Hayward, A. "Crack cocaine and infectious tuberculosis". Emerg Infect Dis. vol. 14. 2008. pp. 1466-1469.

A case series of crack cocaine users who developed active TB.

Chin, KM, Channick, RN, Rubin, LJ. "Is methamphetamine use associated with idiopathic pulmonary arterial hypertension?". Chest. vol. 130. 2006. pp. 1657-1663.

An early description of methamphetamine induced PAH.

"Centers of Disease Control and Prevention. HIV infection and HIV-associated behaviors among injecting drug users--20 cities, United States, 2009.". MMWR. vol. 61. 2012. pp. 133-138.

An update on the association between illicit drug use and HIV infection.

Pletcher, MJ, Vittinghoff, E, Kalhan, R. "Association between marijuana exposure and pulmonary function over 20 years". JAMA. vol. 307. 2012. pp. 173-181.

An up-to-date longitudinal study of habitual marijuana smokers that shows that occasional and low marijuana use did not have adverse effects on pulmonary function.
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