The large spectrum of pulmonary complications following illicit drug use: Features and mechanisms

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Abstract

Damage to lungs may occur from systemic as well as inhalational exposure to various illegal drugs of abuse. Aspiration pneumonia probably represents the most common pulmonary complication in relation to consciousness impairment. Some pulmonary consequences may be specifically related to one given drug. Prolonged smoking of marijuana may result in respiratory symptoms suggestive of obstructive lung disease. Non-cardiogenic pulmonary edema has been attributed to heroin, despite debated mechanisms including attempted inspiration against a closed glottis, hypoxic damage to alveolar integrity, neurogenic vasoactive response to stress, and opiate-induced anaphylactoid reaction. Naloxone-related precipitated withdrawal resulting in massive sympathetic response with heart stunning has been mistakenly implicated. In crack users, acute respiratory syndromes called “crack-lung” with fever, hemoptysis, dyspnea, and pulmonary infiltration on chest X-rays have been reported up-to 48 h after free-base cocaine inhalation, with features of pulmonary edema, interstitial pneumonia, diffuse alveolar hemorrhage, and eosinophil infiltration. The high-temperature of volatilized cocaine and the presence of impurities, as well as cocaine-induced local vasoconstriction have been suggested to explain alveolar damage. Some other drug-related pulmonary insults result from the route of drug self-administration. In intravenous drug users, granulomatous pneumonia with multinodular patterns on thoracic imaging is due to drug contaminants like talcum. Septic embolism from right-sided endocarditis represents an alternative diagnosis in case of sepsis from pulmonary origin. Following inhalation, pneumothorax, and pneumomediastinum have been attributed to increased intrathoracic pressure in relation to vigorous coughing or repeated Valsalva maneuvers, in an attempt to absorb the maximal possible drug amount. In conclusion, pulmonary consequences of illicit drugs are various, resulting in both acute life-threatening conditions and long-term functional respiratory sequelae. A better understanding of their spectrum and the implicated mechanisms of injury should help to improve patient management.

Introduction

Illicit drug use represents a worldwide health problem, involving about 5% of the world’s adult population and contributing to crime, misery, insecurity and the spread of human immunodeficiency virus (HIV) [1]. The two most widely used illicit drugs are cannabis and amphetamine-type stimulants, with a global annual prevalence ranging from 2.6% to 5.0% and 0.3% to 1.2%, respectively. Consumption of both cocaine and opiates (including opium and heroin) has remained stable during the last few years, with ranges from 0.3–0.4% to 0.3–0.5%, respectively. However, new chemically engineered psychotropic substances, designed to remain outside international control recently emerged as recreational drugs. The most commonly identified drug families are piperazine derivatives, synthetic cannabinoids, and cathinones including 4-methylmethcathinone (mephedrone) and methylenedioxypyrovalerone (MDPV), sold as “bath salts” or “plant food” and used as stimulant substitutes [2].

Each year, between 99,000 and 253,000 deaths are attributed to the use of illicit drugs, accounting for 0.5–1.3% of all-causes of mortality in 15–64 year-old adults [1]. Besides the well-known risks of HIV and viral hepatitis transmission in intravenous drug use (IVDU) patients, illicit drugs may acutely or chronically alter organ function, leading to life-threatening conditions or persistent injuries. Pulmonary involvement accounts for a major part of illicit drug-related morbidities. Insults to the lung may be attributed either to a direct effect of the drug itself – and thus be mediated by one specific drug-related mechanism of toxicity – or to an indirect effect, generally in relation to its route of administration.

In this article, we aimed at reviewing the wide spectrum of illicit drug-related pulmonary complications, focusing on their mechanisms of injury and clinical presentations. We are aware that this mini-review cannot be considered as exhaustive, as thousands of clinical and experimental studies have investigated illicit drug-attributed pulmonary complications. However, we believe that our systematic approach to these complications could be helpful in achieving an early and accurate diagnosis, a mandatory step to improving patient outcome. The clinical approach is usually based on a complete clinical examination and thoracic imaging, plus if required, specific blood tests, bronchoalveolar lavage (BAL), respiratory function study, and lung biopsy for histological analysis.

Section snippets

Mechanisms of the pulmonary complications of illicit drug use

Lungs represent both a barrier to the external environment and a conduit into the systemic circulation. Their structure is based on conducting airways (trachea and bronchi) and gas exchange regions (respiratory bronchioles and alveolar tissue). The epithelium covering the conducting airways contains ciliated and mucus-secreting cells, aimed at trapping particles and limiting their access to the lower respiratory region. The alveolar epithelium includes type I (about 90%) and type II pneumocytes

Aspiration pneumonia

Among all pulmonary complications related to illicit drugs, aspiration pneumonia probably represents the most common one, usually in relation to the abuse of sedative drugs like opiates [10]. The risk of aspiration increases in relation to drug-related mental status impairment (ranging from psychosis to coma), inhibition of cough, and alteration in gag reflexes. Aspiration pneumonitis may resolve spontaneously or progress to ARDS. Gram-positive cocci, gram-negative rods, and anaerobic bacteria

Typical pulmonary syndromes related to illicit drug use

This section will focus on three remarkable but debated pulmonary syndromes attributed to each of the major illicit drugs: i – heroin-induced non-cardiogenic pulmonary edema (NCPE), ii – “crack lung”, and iii- altered respiratory function in marijuana smokers. Regarding amphetamines and especially inhaled methamphetamine (ice), complications are mainly systemic and pulmonary complications infrequently reported (Table 2), including NPCE and complications related to its route of consumption [8],

Conclusions

Because illicit drugs are widely consumed by an increasing number of persons, correct diagnosis and appropriate treatment planning in the presence of respiratory manifestations require familiarity with the wide spectrum of morbidities and pulmonary dangers associated with their abuse. Aspiration pneumonia and CAP probably represent the most common complications. Apart from the CNS depressant effect of opiates, crack cocaine is responsible for the most common respiratory complications, which

Conflicts of interest

None.

Financial funding

None.

Acknowledgment

The authors would like to thank Mrs. Alison Good (Scotland, United Kingdom) for her helpful review of the manuscript.

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    This work has been presented orally at the 14th Medical Chemical Defense Conference, Munich, 2013.

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