Pulmonary effects of illicit drug use

Evidence for enduring cardiac and multiorgan toxicity after repeated exposure to the synthetic cannabinoid JWH-018 in male rats

The use of synthetic cannabinoid receptor agonists (SCRAs) represents a public health concern. Besides abuse liability and cognitive impairments, SCRAs consumption is associated with serious medical consequences in humans, including cardiotoxicity. The precise mechanisms underlying cardiac or other toxicities induced by SCRAs are not well understood. Here, we used in silico, in vivo, and ex vivo approaches to investigate the toxicological consequences induced by exposure to the SCRA JWH-018. Along with in silico predictive toxicological screening of 36 SCRAs by MC4PC software, adult male Sprague-Dawley rats were repeatedly exposed to JWH-018 (0.25 mg/kg ip) for 14 consecutive days, with body temperature and cardiovascular parameters measured over the course of treatment. At 1 and 7 days after JWH-018 discontinuation, multiorgan tissue pathologies and heart mitochondria bioenergetics were assessed. The in silico findings predicted risk of cardiac adverse effects specifically for JWH-018 and other aminoalkylindole SCRAs (i.e., electrocardiogram abnormality and QT prolongation). The results from rats revealed that repeated, but not single, JWH-018 exposure induced hypothermia and cardiovascular stimulation (e.g., increased blood pressure and heart rate) which persisted throughout treatment. Post-mortem findings demonstrated cardiac lesions (i.e., vacuolization, waving, edema) 1 day after JWH-018 discontinuation, which may contribute to lung, kidney, and liver tissue degeneration observed 7 days later. Importantly, repeated JWH-018 exposure induced mitochondrial dysfunction in cardiomyocytes, i.e., defective lipid OXPHOS, which may represent one mechanism of JWH-018-induced toxicity. Our results demonstrate that repeated administration of even a relatively low dose of JWH-018 is sufficient to affect cardiovascular function and induce enduring toxicological consequences, pointing to risks associated with SCRA consumption.

Changes in lung function in adolescents with substance use disorders: an exploratory study

OBJECTIVE

To compare lung function between adolescents with and without substance use disorder (SUD).

METHODS

This was an observational, cross-sectional exploratory study. The sample consisted of 16 adolescents with SUD and 24 age-matched healthy controls. The adolescents in the clinical group were recruited from a psychiatric inpatient unit for detoxification and rehabilitation; their primary diagnosis was SUD related to marijuana, cocaine, or polysubstance use. Questionnaires and pulmonary function tests were applied for clinical evaluation.

RESULTS

We found that FVC, FEV1, and their percentages of the predicted values were significantly lower in the adolescents with SUD than in those without. Those differences remained significant after adjustment for BMI and the effects of high levels of physical activity. The largest effect size (Cohen's d = 1.82) was found for FVC as a percentage of the predicted value (FVC%), which was, on average, 17.95% lower in the SUD group. In addition, the years of regular use of smoked substances (tobacco, marijuana, and crack cocaine) correlated negatively with the FVC%.

CONCLUSIONS

This exploratory study is innovative in that it demonstrates the early consequences of smoked substance use for the lung health of adolescents with SUD.

HIV-associated lung disease

Lung disease encompasses acute, infectious processes and chronic, non-infectious processes such as chronic obstructive pulmonary disease, asthma and lung cancer. People living with HIV are at increased risk of both acute and chronic lung diseases. Although the use of effective antiretroviral therapy has diminished the burden of infectious lung disease, people living with HIV experience growing morbidity and mortality from chronic lung diseases. A key risk factor for HIV-associated lung disease is cigarette smoking, which is more prevalent in people living with HIV than in uninfected people. Other risk factors include older age, history of bacterial pneumonia, Pneumocystis pneumonia, pulmonary tuberculosis and immunosuppression. Mechanistic investigations support roles for aberrant innate and adaptive immunity, local and systemic inflammation, oxidative stress, altered lung and gut microbiota, and environmental exposures such as biomass fuel burning in the development of HIV-associated lung disease. Assessment, prevention and treatment strategies are largely extrapolated from data from HIV-uninfected people. Smoking cessation is essential. Data on the long-term consequences of HIV-associated lung disease are limited. Efforts to continue quantifying the effects of HIV infection on the lung, especially in low-income and middle-income countries, are essential to advance our knowledge and optimize respiratory care in people living with HIV.

Dedicated esophageal imaging may be unnecessary in marijuana-associated spontaneous pneumomediastinum: Findings from a retrospective cohort study

Background

Marijuana use has become more common since its legalization, as have reports of marijuana-associated spontaneous pneumomediastinum. Non-spontaneous causes such as esophageal perforation are often ruled out on presentation due to the severe consequences of untreated disease. Here we seek to characterize the presentation of marijuana-associated spontaneous pneumomediastinum and explore whether esophageal imaging is necessary in the setting of an often benign course and rising healthcare costs.

Materials and Methods

Retrospective review was performed for all 18-55 year old patients evaluated at a tertiary care hospital between 1/1/2008 and 12/31/2018 for pneumomediastinum. Iatrogenic and traumatic causes were excluded. Patients were divided into marijuana and control groups.

Results

30 patients met criteria, with 13 patients in the marijuana group. The most common presenting symptoms were chest pain/discomfort and shortness of breath. Other symptoms included neck/throat pain, wheezing, and back pain. Emesis was more common in the control group but cough was equally prevalent. Leukocytosis was present in most patients. Four out of eight of computed tomography esophagarams in the control group showed a leak requiring intervention, while only one out of five in the marijuana group showed even a possible subtle extravasation of contrast but this patient ultimately was managed conservatively given the clinical picture. All standard esophagrams were negative. All marijuana patients were managed without intervention.

Discussion

Marijuana-associated spontaneous pneumomediastinum appears to have a more benign clinical course compared to non-spontaneous pneumomediastinum. Esophageal imaging did not change management for any marijuana cases. Perhaps such imaging could be deferred if clinical presentation of pneumomediastinum in the setting of marijuana use is not suggestive of esophageal perforation. Further research into this area is certainly worth pursuing.

Septic Pulmonary Embolism Causing Recurrent Pneumothorax in an Intravenous Drug User without Right-Sided Valvular Vegetation in Infective Endocarditis

The following report illustrates a case of a 36-year-old Caucasian male with intravenous drug use (IVDU) induced septic thrombophlebitis presenting with recurrent unilateral pneumothoraces from septic pulmonary embolism (SPE) without the presence of obvious right-sided valvular vegetation in infective endocarditis (IE), defined as tricuspid or pulmonary valve lesions. Pneumothorax (PTX) has been observed as a rare complication of SPE and is commonly associated with infective right-sided IE, IVDU, and intravascular indwelling catheters. However, this case is novel as it is the very rare documented case of recurrent, unilateral, spontaneous right PTX refractory to multiple chest tube placements in such a setting. Therefore, the absence of detectable right-sided valvular vegetation in IE does not obviate the risk of SPE-induced PTX in IVDU and further expands the realm of infectious and pulmonary consequences of SPE and IVDU.

The Impact of Substance Use Disorder on COVID-19 Outcomes

OBJECTIVE

The goal of this study was to examine the impact of substance use disorder on the risk of hospitalization, complications, and mortality among adult patients diagnosed as having COVID-19.

METHODS

The authors conducted a propensity score (PS)-matched double-cohort study (N=5,562 in each cohort) with data from the TriNetX Research Network database to identify 54,529 adult patients (≥18 years) diagnosed as having COVID-19 between February 20 and June 30, 2020.

RESULTS

Primary analysis (PS matched on demographic characteristics and presence of diabetes and obesity) showed that substance use disorder was associated with an increased risk of hospitalization (odds ratio [OR]=1.84, 95% confidence interval [CI]=1.69-2.01), ventilator use (OR=1.45, 95% CI=1.22-1.72), and mortality (OR=1.30, 95% CI=1.08-1.56).

CONCLUSIONS

The findings suggest that COVID-19 patients with substance use disorders are at increased risk for adverse outcomes. The attenuation of ORs in the model that matched for chronic respiratory and cardiovascular diseases associated with substance abuse suggests that the observed risks may be partially mediated by these conditions.

Septic pulmonary emboli causing recurrent bilateral pneumothoraces in a patient with right sided endocarditis: A case report and review of literature

Patients with a history of drug abuse and right sided endocarditis are prone to develop septic pulmonary emboli. Pneumothorax is a rare complication of septic pulmonary emboli reported in the literature, likely due to the rupture of thin-walled septic cavitary lesions resembling pneumatoceles into the pleural space. Only seven cases (including our case) of pneumothorax from septic pulmonary emboli due to right sided endocarditis have been described in the literature. Our patient is the first reported case of recurrent bilateral pneumothorax due to septic pulmonary emboli and tricuspid valve endocarditis.

Why young people's substance use matters for global health

During puberty, when young people are completing their education, transitioning into employment, and forming longer-term intimate relationships, a shift in emotional regulation and an increase in risky behaviour, including substance use, is seen. This Series paper considers the potential effects of alcohol, tobacco, and illicit drug use during this period on: social, psychological, and health outcomes in adolescence and young adulthood; role transitions, and later health and social outcomes of regular substance use initiated in adolescence; and the offspring of young people who use substances. We sourced consistent support for causal relations between substance use and outcomes and evidence of biological plausibility from different but complementary research designs. Many adverse health and social outcomes have been associated with different types of substance use. The major challenge lies in deciding which are causal. Furthermore, qualitatively different harms are associated with different substances, differences in life stage when these harms occur, and the quality of evidence for different substances and health outcomes varies substantially. The preponderance of evidence comes from a few high-income countries, thus whether the same social and health outcomes would occur in other countries and cultures is unclear. Nonetheless, the number of harms that are causally related to substance use in young people warrant high-quality research design interventions to prevent or ameliorate these harms.

Emerging and Underrecognized Complications of Illicit Drug Use

Illicit drug use can result in a wide range of medical complications. As the availability, synthesis, and popularity of illicit drugs evolve over time, new syndromes associated with their use may mimic infections. Some of these symptoms are anticipated drug effects, and others are complications of adulterants mixed with drugs or complications from the method of using drugs. Some illicit drugs are associated with rare infections, which are difficult to diagnosis with standard microbiological techniques. The goal of this review is to orient a wide range of clinicians-including general practitioners, emergency medicine providers, and infectious diseases specialists-to complications of illicit drug use that may be underrecognized. Improving awareness of infectious and noninfectious complications of illicit drug can expedite diagnosis and medical treatment of persons who use drugs and facilitate targeted harm reduction counseling to prevent future complications.

The health consequences of injecting tablet preparations: foreign body pulmonary embolization and pulmonary hypertension among deceased injecting drug users

AIMS

To determine: (1) the characteristics of cases presenting to the Department of Forensic Medicine Sydney (1997-2013) with foreign body pulmonary embolization; (2) the extent and locations of embolization; and (3) the relationship between extent, and use of other injection sites, with pathology.

DESIGN

Analysis of consecutive case presentations with foreign body pulmonary embolization.

SETTING/PARTICIPANTS

Sydney, Australia, with a total of 373 cases (271 males, 102 females).

MEASUREMENTS

Full autopsy reports, microscopy of tissue samples, and full toxicology. The extent and locations of embolization, inflammatory responses, clinical signs of pulmonary hypertension and signs of right-sided heart failure were examined.

FINDINGS

Cases increased from three (1997) to 58 (2013). In 43.4%, foreign particles were moderate-abundant in extent. Cases with moderate-abundant emboli were more likely to have injection sites other than the cubital fossa [odds ratio (OR) = 2.4]. In 6.9% of cases emboli were also found in other organs. A foreign body inflammatory response was present in 45.3%, vascular scarring in 8.0%, signs of pulmonary hypertension in 10.2% and signs of right-sided heart pathology in 5.4%. Cases with moderate-abundant deposition were more likely to have emboli in other organs (OR = 7.9), a foreign body inflammatory response (OR = 5.3), vascular scarring (OR = 3.4), signs of pulmonary hypertension (OR = 5.4) and right-sided heart pathology (OR = 5.3).

CONCLUSIONS

Cases of foreign body pulmonary embolization (resulting from injecting crushed tablets meant for oral use, such as benzodiazepines and pharmaceutical opioids) in Sydney, Australia increased markedly from 1997 to 2013. In a large proportion there were clinical consequences. More extensive embolization was associated with higher levels of pulmonary hypertension and right-sided heart pathology.

Pulmonary effects of i.v. injection of crushed oral tablets: "excipient lung disease"

OBJECTIVE

When crushed oral tablets are injected i.v., their filler material (excipient) can induce a potentially fatal foreign-body reaction in pulmonary arterioles, presenting as dyspnea and pulmonary hypertension with centrilobular nodules on CT. We will describe the imaging and pathologic features of "excipient lung disease."

CONCLUSION

The radiologist has a critical role in recognizing and reporting excipient lung disease because the referring clinician may be unaware of the patient's i.v. drug abuse.

Pulmonary Function in HIV-Infected Recreational Drug Users in the Era of Anti-Retroviral Therapy

BACKGROUND

Individuals with HIV infection commonly have pulmonary function abnormalities, including airflow obstruction and diffusion impairment, which may be more prevalent among recreational drug users. To date, the relationship between drug use and pulmonary function abnormalities among those with HIV remains unclear.

OBJECTIVE

To determine associations between recreational drug use and airflow obstruction, diffusion impairment, and radiographic emphysema in men and women with HIV.

METHODS

Cross-sectional analysis of pulmonary function and self-reported recreational drug use data from a cohort of 121 men and 63 women with HIV. Primary outcomes were the presence (yes/no) of: 1) airflow obstruction, (pre- or post-bronchodilator forced expiratory volume in 1 second/forced vital capacity<0.70); 2) moderate diffusion impairment (diffusing capacity for carbon monoxide <60% predicted); and 3) radiographic emphysema (>1% of lung voxels <-950 Hounsfield units). Exposures of interest were frequency of recreational drug use, recent (since last study visit) drug use, and any lifetime drug use. We used logistic regression to determine associations between recreational drug use and the primary outcomes.

RESULTS

HIV-infected men and women reported recent recreational drug use at 56.0% and 31.0% of their study visits, respectively, and 48.8% of men and 39.7% of women reported drug use since their last study visit. Drug use was not associated with airway obstruction or radiographic emphysema in men or women. Recent crack cocaine use was independently associated with moderate diffusion impairment in women (odds ratio 17.6; 95% confidence interval 1.3-249.6, p=0.03).

CONCLUSIONS

In this cross-sectional analysis, we found that recreational drug use was common among HIV-infected men and women and recent crack cocaine use was associated with moderate diffusion impairment in women. Given the increasing prevalence of HIV infection, any relationship between drug use and prevalence or severity of chronic pulmonary diseases could have a significant impact on HIV and chronic disease management.

Stimulants and the lung : review of literature

Illicit stimulants, such as cocaine, amphetamine, and their derivatives (e.g., "ecstasy"), continue to exact heavy toll on health care in both developed and developing countries. The US Department of Health and Human Service reported over one million illicit drug-related emergency department visits in 2010, which was higher than any of the six previous years. Both inhaled and intravenous forms of these substances of abuse can result in a variety of acute and chronic injuries to practically every part of the respiratory tract, leading potentially to permanent morbidities as well as fatal consequences--including but not limited to nasal septum perforation, pulmonary hypertension, pneumothorax, pneumomediastinum, interstitial lung disease, alveolar hemorrhage, reactive airway disease, pulmonary edema, pulmonary granulomatosis, infections, foreign body aspiration, infections, bronchoconstriction, and thermal injuries. Stimulants are all rapidly absorbed substances that can also significantly alter the patient's systemic acid-base balance and central nervous system, thereby leading to further respiratory compromise. Mounting evidence in the past decade has demonstrated that adulterants coinhaled with these substances (e.g., levamisole) and the metabolites of these substances (e.g., cocaethylene) are associated with specific forms of systemic and respiratory complications as well. Recent studies have also demonstrated the effects of stimulants on autoimmune-mediated injuries of the respiratory tract, such as cocaine-induced midline destructive lesions. A persistent challenge to studies involving stimulant-associated respiratory toxidromes is the high prevalence of concomitant usage of various substances by drug abusers, including tobacco smoking. Now more than ever, health care providers must be familiar with the multitude of respiratory toxidromes as well as the diverse pathophysiology related to commonly abused stimulants to provide timely diagnosis and effective treatment.

"Pills" and the air passages

Aspiration of a medication in the airways in any form produces a variety of adverse effects, both local and systemic. Furthermore, specific reaction of the airways to each type of pill strongly affects the outcome. It is crucial for pulmonologists and emergency medicine specialists to acknowledge this clinical entity. In addition, airways have been increasingly used to deliver medications such as insulin and prostacycline. These aerosolized medications can also cause local as well as systemic side effects. We review the local and systemic reactions of these "pills" accessing the airways either by incidental aspiration or iatrogenic administration. We address clinical presentation, mechanism of injury, diagnosis, and management of complications of these pills in the air passages.

Drug-/radiation-induced interstitial lung disease in the United Kingdom general population: incidence, all-cause mortality and characteristics at diagnosis

BACKGROUND AND OBJECTIVE

Radiotherapy and an increasing number of substances are implicated in the pathogenesis of interstitial lung disease (ILD). While the frequency of published data on more common ILD entities such as the idiopathic interstitial pneumonias has increased in recent years, less attention has been given to relatively rarely occurring forms such as drug-/radiation-induced ILD.

METHODS

Data from the UK-based General Practice Research Database (GPRD) was used to estimate the incidence of drug-/radiation-induced ILD over a 12-year period (1997-2008). Crude incidence rates were stratified by gender, age group and calendar period, and rate ratios were adjusted using Poisson regression. All-cause mortality was modelled using Cox regression, and characteristics at diagnosis were compared with a random sample of matched, non-ILD controls using conditional logistic regression.

RESULTS

A total of 128 patients with an incident diagnosis of drug-/radiation-induced ILD were identified, and the overall incidence density during the study period was 4.1 (95% confidence interval 3.4-4.9) per million person-years. Incidence rates increased during the time period 1997-2005 and decreased thereafter. The adjusted all-cause mortality was >4 times higher in cases compared with controls.

CONCLUSIONS

This UK population-based study characterizes patients diagnosed with drug-/radiation-induced ILD and quantifies incidence and all-cause mortality during 1997-2008. No statistically significant time trend in incidence was found, despite having observed numeric increases in incidence rates during the study window. Future research using the GPRD and other data sources is required to better understand the disposition of patients diagnosed with drug-/radiation-induced ILD and to investigate potential trends incidence and mortality over time.

Interstitial lung disease: the initial approach

In the last decade, significant progress has been made toward a better understanding of interstitial lung disease (ILD). A valuable tool for the clinician is high-resolution computed tomography, which aids in narrowing the differential diagnosis in patients with ILD and obviates the need for surgical lung biopsy when a usual interstitial pneumonia pattern is present. Clinicians evaluating and caring for patients with ILD need to recognize associated comorbidities. Substantial evidence shows that implementation of a multidisciplinary approach provides a high standard of care for patients, leading to improvements in the accuracy of clinical diagnosis that can significantly affect patient outcome.

Stimulant abuse: pharmacology, cocaine, methamphetamine, treatment, attempts at pharmacotherapy

The high prevalence of stimulant abuse and its harmful consequences make the screening, diagnosis, and referral for treatment of persons with stimulant abuse a top concern for primary care providers. Having a working knowledge of use patterns, clinical symptomatology, end-organ effects, and advances in treatment of stimulant abuse is essential. Although cocaine and amphetamine have different use patterns, duration of action, and so forth, the consequences of use are remarkably similar. Primary care is at the forefront of screening, brief risk reduction interventions, and diagnosis of medical sequelae, with referral to addiction specialist treatment when necessary.

The prevalence and correlates of buprenorphine inhalation amongst opioid substitution treatment (OST) clients in Australia

BACKGROUND

Diversion and injection of buprenorphine (Subutex(®)) and buprenorphine-naloxone (Suboxone(®)) have been well documented. Recent international research and local anecdotal evidence suggest that these medications are also used by other routes of administration, including smoking and snorting.

METHODS

A cross-sectional sample of 440 opioid substitution treatment (OST) clients was recruited through pharmacies and clinics in three Australian jurisdictions, and interviewed face-to-face using a structured questionnaire. Eligible participants were those aged 18 or over, who had resided in their home state for at least six months, and had been in their current treatment episode for at least 4 weeks. We compared differences in characteristics between clients who had ever inhaled (smoked or snorted) buprenorphine (including buprenorphine-naloxone) and other OST clients. Logistic regression was used to identify correlates of buprenorphine inhalation. Sixty-eight clients who had never used buprenorphine were excluded from analysis.

RESULTS

Sixty-five clients (18%) reported having ever inhaled buprenorphine, with Subutex(®) smoking being most common, reported by 50 clients (77%). In multivariable logistic regression, those who reported ever inhaling buprenorphine were significantly more likely to: be aged 35 or younger, have ever been in prison and have ever injected buprenorphine. Clients from New South Wales and Victoria were significantly less likely to have ever inhaled buprenorphine than those from South Australia.

CONCLUSIONS

Our data indicates that the inhalation of buprenorphine has occurred in a significant minority of Australian OST clients. The motivations, contexts and potential health consequences of buprenorphine use by these atypical routes of administration, particularly in a correctional setting, warrant further exploration.

Inhalant abuse: a case of hemoptysis associated with halogenated hydrocarbons abuse

An 18-year-old man presented to a community emergency department with increasing shortness of breath and fever. His condition was diagnosed, and he was treated as an inpatient for bilateral pneumonia associated with hypoxemia. When his condition became worse, he acknowledged to deliberate inhalation of keyboard cleaner and to having hemoptysis. Before his death on hospital day 11, known causes of alveolar hemorrhage were excluded. We postulated a cause-and-effect relationship, adding alveolar hemorrhage to the known complications of inhalant abuse.

Large community outbreak of Streptococcus pneumoniae serotype 5 invasive infection in an impoverished, urban population

BACKGROUND

Streptococcus pneumoniae is a common cause of sporadic invasive infections, but outbreaks of invasive pneumococcal disease are infrequent. In August 2006, a sudden increase in the number of patients presenting with invasive pneumococcal disease was noted at St. Paul's Hospital (Vancouver, Canada). Most patients with severe disease resided in an area referred to as the Downtown Eastside, a neighborhood known for its high rates of poverty and illicit drug use.

METHODS

Prospective, laboratory-based surveillance for invasive pneumococcal disease was initiated, including on-site serotyping of S. pneumoniae isolates. A vaccination campaign using 23-valent polysaccharide pneumococcal vaccine was launched in the Downtown Eastside. Multiple logistic regression was used to examine the association of sociodemographic variables and medical risk factors with S. pneumoniae serotype status.

RESULTS

A single S. pneumoniae serotype (serotype 5) was responsible for 78% of invasive pneumococcal disease cases (137 of 175 cases) during the outbreak period of August 2006-July 2007. The outbreak strain, although fully susceptible to penicillin, caused significant morbidity and placed considerable strain on the acute care system within the Vancouver Coastal Health region. Crack cocaine use was found to be the main independent risk factor associated with invasive pneumococcal disease due to S. pneumoniae serotype 5 (odds ratio, 12.4; 95% confidence interval, 2.22-69.5).

CONCLUSIONS

A targeted vaccination campaign using polysaccharide pneumococcal vaccine appeared to help control this outbreak. In urban centers with high rates of illicit drug use, vaccination strategies for preventing invasive pneumococcal disease may need to be refined to include individuals who use crack cocaine.

Smoking risk and the likelihood of quitting among African-American female light and heavy smokers

While African-American females are more likely to be light smokers compared to their counterparts of other racially classified social groups (RCSGs), they are more likely to carry a heavier burden of smoking-related morbidity and mortality. Thus, it is critical that African-American female light smokers are targeted to engage in smoking cessation. Research has revealed that African-American women are less likely to have a successful quit attempt following a cessation intervention than females from other RCSGs. It has been postulated that the low smoking cessation rates among African-American female light smokers may be due to the lack of appropriate psychosocioculturally tailored cessation interventions that address issues of stress and coping that explain why they smoke and continue to smoke that may differ from their heavy smoker counterparts. The purpose of this study was to ascertain whether African-American female light smokers differed from their heavy smoker counterparts on psychosociocultural stress and coping factors. Findings revealed no differences in the sociodemographic variables of age, income, education and BMI; in the psychosociocultural measures of acculturative stress, race-related stress and coping; or in the smoking characteristics of menthol smoking status, cotinine level and CYP2A6 metabolic functioning between light and heavy smokers. However, the study found that African-American female light smokers take longer to smoke their first cigarette of the day, have a lower smoking risk, are more likely to quit, and exhibit lower carbon monoxide levels than African-American female heavy smokers. The current study suggests that other than the obvious factors of greater likelihood of quitting, lower smoking risk, longer latency to smoke and lower carbon monoxide levels, specific smoking cessation programs may not need to be differentially psychosocio-culturally tailored for African-American female light smokers compared to their heavy-smoking counterparts.

Return to Galileo? The Inquisition of the International Narcotic Control Board

Nearly 400 years after Galileo Galilei of Florence was arraigned and convicted of suspected heresy by the ten member Congregation of the Holy Office (Inquisition), the International Narcotic Control Board (INCB) is similarly inserting itself into matters pertaining to innovations in healthcare and the public health response to addiction throughout the world. Like that earlier Inquisition of 1633 that convicted Galileo of heresy for holding that the sun is the centre of the universe with the earth revolving around it (in contradiction to church doctrine of the time) the INCB and its thirteen-member panel, now rails against any evidence out of sync with the established doctrine of the war on drugs--particularly those innovations in public health called harm reduction. The latest healthcare and harm reduction practices to attract the ire of the INCB Inquisition are elements of Canada's most effective and innovative measures to minimize the harms of drugs in Vancouver--supervised injection facilities and, recently, the potential establishment of supervised inhalation rooms--along with the long established practice of providing safer mouthpieces for pulmonary inhalation in British Columbia. This is particularly significant as it comes in the midst of a crucial battle between municipal and provincial authorities in BC with the federal government in Ottawa, which seems determined to undermine all the most effective HR programs that are the result of years of steady local and governmental support in Vancouver and now threatens to derail all these programs and spread doubt about their usefulness despite the overwhelmingly positive findings of serous research.

The validity of cocaine dependence subtypes

Cocaine dependence (CD) is a multifactorial disorder, variable in its manifestations, and heritable. We examined the concurrent validity of homogeneous subgroups of CD as phenotypes for genetic analysis. We applied data reduction methods and an empirical cluster-analytic approach to measures of cocaine use, cocaine-related effects, and cocaine treatment history in 1393 subjects, from 660 small nuclear families. Four of the six clusters that were derived yielded heritability estimates in excess of 0.3. Linkage analysis showed genome-wide significant results for two of the clusters. Here we examine the concurrent validity of the six clusters using a variety of demographic and substance-related measures. In addition to being differentiated by a variety of cocaine-related measures, the clusters differed significantly on measures that were independent of those used to generate the clusters, i.e., demographic features and prevalence rates of co-morbid substance use and psychiatric disorders. These findings support the validity of the methods used to derive homogeneous subgroups of CD subjects and the resulting CD subtypes. Independent replication of these findings would provide further validation of this approach.

Chronic obstructive pulmonary disease in patients who have HIV infection

An increased prevalence of chronic obstructive pulmonary disease (COPD) among persons who have HIV infection has raised the possibility that HIV may predispose to the development or progression of COPD. This article reviews the evidence that supports an association between HIV infection and COPD-namely emphysema and chronic bronchitis-and studies that suggest an association between HIV infection and small airways abnormalities and nonspecific airway hyper-responsiveness. Risk factors for COPD and potential reasons for an increased risk for COPD in HIV-positive patients are discussed. In addition, issues in the management of COPD in HIV-positive patients are reviewed.

Effects of marijuana smoking on pulmonary function and respiratory complications: a systematic review

BACKGROUND

The relationship between marijuana smoking and pulmonary function or respiratory complications is poorly understood; therefore, we conducted a systematic review of the impact of marijuana smoking on pulmonary function and respiratory complications.

METHODS

Studies that evaluated the effect of marijuana smoking on pulmonary function and respiratory complications were selected from the MEDLINE, PsychINFO, and EMBASE databases according to predefined criteria from January 1, 1966, to October 28, 2005. Two independent reviewers extracted data and evaluated study quality based on established criteria. Study results were critically appraised for clinical applicability and research methods.

RESULTS

Thirty-four publications met selection criteria. Reports were classified as challenge studies if they examined the association between short-term marijuana use and airway response; other reports were classified as studies of long-term marijuana smoking and pulmonary function or respiratory complications. Eleven of 12 challenge studies found an association between short-term marijuana administration and bronchodilation (eg, increases of 0.15-0.25 L in forced expiratory volume in 1 second). No consistent association was found between long-term marijuana smoking and airflow obstruction measures. All 14 studies that assessed long-term marijuana smoking and respiratory complications noted an association with increased respiratory symptoms, including cough, phlegm, and wheeze (eg, odds ratio, 2.00; 95% confidence interval, 1.32-3.01, for the association between marijuana smoking and cough). Studies were variable in their overall quality (eg, controlling for confounders, including tobacco smoking).

CONCLUSIONS

Short-term exposure to marijuana is associated with bronchodilation. Physiologic data were inconclusive regarding an association between long-term marijuana smoking and airflow obstruction measures. Long-term marijuana smoking is associated with increased respiratory symptoms suggestive of obstructive lung disease.

Increased COPD among HIV-positive compared to HIV-negative veterans

BACKGROUND

Limited data prior to highly active antiretroviral therapy (HAART) suggested the possibility of an increased risk of COPD among those persons with HIV infection. We sought to determine whether HIV infection is associated with increased prevalence of COPD in the era of HAART.

METHODS

Prospective observational study of 1,014 HIV-positive and 713 HIV-negative men who were enrolled in the Veterans Aging Cohort 5 Site Study. COPD was determined by patient self-report and International Classification of Diseases, ninth revision (ICD-9), diagnostic codes. Cigarette smoking and injection drug use (IDU) were determined by self-report, and alcohol abuse was determined by ICD-9 diagnostic codes. Laboratory and pharmacy data were obtained from electronic medical records.

RESULTS

The prevalence of COPD as determined by ICD-9 codes was 10% in HIV-positive subjects and 9% in HIV-negative subjects (p = 0.4), and as determined by patient self-report was 15% and 12%, respectively (p = 0.04). After adjusting for age, race/ethnicity, pack-years of smoking, IDU, and alcohol abuse, HIV infection was an independent risk factor for COPD. HIV-infected subjects were approximately 50 to 60% more likely to have COPD than HIV-negative subjects (by ICD-9 codes: odds ratio [OR], 1.47; 95% confidence interval [CI], 1.01 to 2.13; p = 0.04 ; by patient self-report: OR, 1.58; 95% CI, 1.14 to 2.18; p = 0.005).

CONCLUSIONS

HIV infection was an independent risk factor for COPD, when determined either by ICD-9 codes or patient self-report. Health-care providers should be aware of the increased likelihood of COPD among their HIV-positive patients. The possibility that HIV infection increases susceptibility to and/or accelerates COPD deserves further investigation and has implications regarding the pathogenesis of COPD.

Elevated incidence of lung cancer among HIV-infected individuals

PURPOSE

People with HIV infection in the United States frequently smoke tobacco. We sought to characterize lung cancer incidence among HIV-infected individuals, examine whether cancer risk was related to HIV-induced immunosuppression, and assess whether the high prevalence of smoking explained elevated risk.

METHODS

We conducted a retrospective cohort study at an HIV specialty clinic in Baltimore, MD (1989-2003). Incident lung cancers were identified using hospital records. We used negative binomial regression to compare incidence across subgroups defined by demographics, use of highly active antiretroviral therapy (HAART), and HIV markers. Standardized incidence ratios (SIRs) compared incidence with an urban reference population (Detroit, MI). We adjusted SIRs for the effect of smoking, using smoking prevalences estimated from part of the cohort and the general population. 95% CIs and P values were two sided.

RESULTS

Thirty-three lung cancers were observed among 5,238 HIV-infected patients (incidence: 170 per 100,000 person-years). Incidence increased with age (P < .0001), but did not differ by sex, race, or CD4 count. Incidence tended to increase with calendar year (P = .09) and HAART use (P = .10), and was inversely related to HIV viral load (P = .03), but these associations were attenuated with age adjustment. The SIR was 4.7 (95% CI, 3.2 to 6.5) versus the general population. Twenty-eight lung cancer patients (85%) and 69% of the cohort were smokers. After smoking adjustment, risk remained elevated (SIR, 2.5; 95% CI, 1.6 to 3.5).

CONCLUSION

Lung cancer risk was substantially elevated in HIV-infected individuals. Incidence was unrelated to HIV-induced immunosuppression. Notably, incidence remained high after adjustment for smoking, suggesting the involvement of additional factors.

Drug-induced and iatrogenic infiltrative lung disease

At present more than 350 drugs are known to cause injury of the lung parenchyma,upper and lower airways, pulmonary circulation, pleura, mediastinum, lymph nodes,and neuromuscular system. Infiltrative lung disease (ILD) is the most common pattern of drug-induced injury. This article, which is clinically oriented rather than drug oriented, reviews the patterns of ILD produced by therapeutic drugs and radiation therapy.