HEROIN INHALATION MAY TRIGGER
LIFE-THREATENING ASTHMA

CHICAGO--Intensivists are warning about a relatively new risk factor for life-threatening acute asthma: inhaled heroin. And the problem may not be confined to the inner cities. As increasingly pure forms of heroin are sold in this country, a growing number of suburbanites--including teenagers--are snorting or smoking heroin to get high.

In the past two years, physicians in the intensive care unit (ICU) at Cook County Hospital in Chicago have seen roughly one case of inhaled-heroin--induced acute asthma every two weeks, though the rate has slowed in recent months. "We're still unsure of the association between heroin and asthma, but it is clearly more than just chance," Cory Franklin, MD, the hospital's director of medical intensive care, told PULMONARY REVIEWS.

Indeed, about 15% of all acute asthma cases in Cook County's ICU during those two years occurred within a few hours of the patient snorting heroin. "During that time, between a third and a half of our asthmatic patients under age 50 years may have had some link with heroin insufflation," Dr. Franklin added.

The national incidence of acute asthma triggered by inhaled heroin is unknown because no studies of it have yet been completed. However, Chicago is not the only place in which this problem has been spotted; physicians in New York, Great Britain, and Finland have also seen cases of life-threatening asthma induced by heroin inhalation.

A SOMEWHAT ATYPICAL COURSE

A recent report in Chest described heroin-induced acute asthma in five patients with a history of asthma.[1] In each case, the patient developed a sudden severe exacerbation shortly after snorting or smoking heroin.

In these patients, "the rapid deterioration was not associated with rapid improvement," pointed out Thomas Corbridge, MD, one of the authors of the report and director of the medical intensive care unit at Northwestern University Medical School in Chicago. Extended mechanical ventilation (mean duration, five days) was required in four cases, and the mean time to discharge for the entire group was eight days. That is uncommon among patients with acute asthma, who usually recover within a day.

The patients in Dr. Franklin's ICU tended to recover more quickly--in 24 to 48 hours. Dr. Franklin's patients were unlike typical asthma patients in that many developed hypoxemia. "In classical severe asthma, patients tend to have trouble with ventilation, not hypoxemia," he explained.

His patients, as well as those of Dr. Corbridge, typically received standard acute asthma treatments. In addition to mechanical ventilation as necessary, these include ß-agonists and corticosteroids. In some cases, it was possible to substitute positive pressure ventilation with a mask for mechanical ventilation, Dr. Franklin explained. Only a few patients required detoxification, he added.

POSSIBLE MECHANISMS

Three potential explanations exist for the relationship between heroin inhalation and acute asthma:

• The heroin itself may precipitate asthma, possibly by stimulating mast cell activation or histamine release.
• The heroin may contain an irritant that triggers asthma, such as diphenhydramine powder, which is commonly used to cut heroin.
• Asthma patients who inhale heroin may neglect the treatment of their disease and ignore signs of imminent acute episodes because their judgment is impaired.

Because there have been only a few reports of inhaled-heroin--induced acute asthma to date, it is likely that specific adulterants are responsible for the outbreaks. However, it is also possible that the problem is simply unrecognized in many places, and thus a direct role for heroin cannot be ruled out.

IMPORTANCE OF SCREENING

Drs. Franklin and Corbridge recommend that both emergency department physicians and intensivists ask about and screen for heroin use in patients with severe asthma attacks who live in areas known for substance abuse. "If you don't look for it, you won't find it," warned Dr. Franklin. Many patients are reluctant to admit that they have used heroin, and thus careful probing may be necessary.

Even in areas not known for substance abuse, it may be wise to question patients with severe asthma attacks about the possibility of heroin use, especially among young adults. According to a recent report in the New York Times, heroin use--particularly inhalation--is increasing among suburban teenagers.[2] Currently, 2.3% of eighth graders and high school sophomores admit to having tried the drug.[2] And the average age at which heroin is first used has dropped to 17.6 years.[3]

Both physicians also stressed the need for good follow-up care--including referral for substance abuse programs--once these patients leave the ICU. "These patients need counseling to decrease heroin use as an acute asthma trigger," Dr. Corbridge told PULMONARY REVIEWS.

Future research, he speculated, will probably focus on the prevalence and mechanisms of heroin-induced asthma and whether this drug can trigger acute asthma in patients who do not already have the disease.

--Timothy Begany

References
1. Cygan J, Trunsky M, Corbridge T. Inhaled heroin-induced status asthmaticus: five cases and a review of the literature. Chest. 2000;117:272-275.
2. Wren CS. Face of heroin: it's younger and suburban; cheaper versions reach youths who haven't seen the drug's damage. New York Times. April 25, 2000.
3. National Institute on Drug Abuse. Research Report: Heroin Abuse and Addiction. Bethesda, Md: National Institutes of Health, 1997; Publication No. 97-4165.

 

Update from the NIDA on Heroin Use in the US

A recently released report from the National Institute on Drug Abuse (NIDA) highlights several trends in heroin use in this country:[1] Heroin is readily available, relatively inexpensive, and of high quality in all of the cities surveyed by the NIDA. White powder heroin has increased in purity in recent years. This has made heroin more appealing to young users and has made inhalation an increasingly popular route of administration. Between 1991 and 1998 (the most recent year for which data are available), reports of heroin use from emergency departments and coroners' offices increased by 413% in Miami, by 288% in Chicago, and by 238% in St. Louis. An increase in heroin use has been seen in high school and college students. Reports of such use have come from Baltimore, Boston, Denver, Philadelphia, St. Louis, and San Diego. Inhalation of heroin is particularly common on the East Coast. However, many Midwest states also report a growing prevalence of heroin inhalation. Polydrug use is increasing. Heroin and crack cocaine are commonly combined, but heroin may also be used with benzodiazepines, synthetic opiates, and alcohol. Heroin-related deaths are increasing in many areas. Several states, including Colorado and Texas, reported a record high number of deaths due to heroin in 1998.

Reference 1. National Institute on Drug Abuse. Epidemiologic Trends in Drug Abuse. Advance report, December 1999. Available at: http://165.112.78.61/CEWG/AdvancedRep/1299ADV/1299adv.html. Accessed May 19, 2000.

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