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Underner M, Perriot J, Peiffer G, Brousse G, Jaafari N. [Bronchial diseases and heroin use. A systematic review]. Rev Mal Respir 2023; 40:783-809. [PMID: 37925326 DOI: 10.1016/j.rmr.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 09/11/2023] [Indexed: 11/06/2023]
Abstract
INTRODUCTION Heroin use can cause respiratory complications including asthma, chronic obstructive pulmonary disease (COPD) and bronchiectasis (BD). OBJECTIVES 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. DOCUMENTARY SOURCES 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. RESULTS 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. CONCLUSION 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.
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Affiliation(s)
- M Underner
- Unité de recherche clinique Pierre-Deniker, centre hospitalier Laborit, 370, avenue Jacques-Cœur, CS 10587, 86021 Poitiers cedex, France.
| | - J Perriot
- Dispensaire Émile-Roux, CLAT, centre de tabacologie, 63100 Clermont-Ferrand, France
| | - G Peiffer
- Service de pneumologie, CHR Metz-Thionville, 57038 Metz, France
| | - G Brousse
- Service d'addictologie, CHU de Clermont-Ferrand, université Clermont Auvergne, 63100 Clermont-Ferrand, France
| | - N Jaafari
- Unité de recherche clinique Pierre-Deniker, centre hospitalier Laborit, 370, avenue Jacques-Cœur, CS 10587, 86021 Poitiers cedex, France
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2
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Haouzi P, Tubbs N. Effects of fentanyl overdose-induced muscle rigidity and dexmedetomidine on respiratory mechanics and pulmonary gas exchange in sedated rats. J Appl Physiol (1985) 2022; 132:1407-1422. [PMID: 35421320 DOI: 10.1152/japplphysiol.00819.2021] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The objective of our study was to establish in sedated rats the consequences of high-dose fentanyl-induced acute muscle rigidity on the mechanical properties of the respiratory system and on the metabolic rate. Doses of fentanyl that we have previously shown to produce persistent rigidity of the muscles of the limbs and trunk in the rat (150 -300 microg/kg iv), were administered in 23 volume-controlled mechanically ventilated and sedated rats. The effects of a low dose of the FDA approved central alpha-2 agonist, dexmedetomidine (3 microg/kg iv), which has been suggested to oppose fentanyl-induced muscle rigidity, were determined after fentanyl administration. Fentanyl produced a significant decrease in Crs in the 23 rats that were studied. In 13 rats, an abrupt response occurred within 90 seconds, consisting in rapid rhythmic contractions of most skeletal muscles, that were replaced by persistent tonic/tetanic contractions leading a significant decrease of Crs (from 0.51 ± 0.11 ml/cmH2O to 0.36 ± 0.08 ml/cmH2O, 3 minutes after fentanyl injection). In the other 10 animals, a Crs progressively decreased to 0.26 ± 0.06 ml/cmH2O at 30 minutes. There was a significant rise in V̇O2 during muscle tonic contractions (from 8.48 ± 4.31 to 11.29 ± 2.57 ml/min), which contributed to a significant hypoxemia, despite ventilation being held constant. Dexmedetomidine provoked a significant and rapid increase in Crs towards baseline levels, while decreasing the metabolic rate and restoring normoxemia. We propose that the changes in respiratory mechanics and metabolism produced by opioid-induced muscle rigidity contribute to fentanyl lethality.
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Affiliation(s)
- Philippe Haouzi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Pennsylvania State University, College of Medicine, Hershey, PA, United States
| | - Nicole Tubbs
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Pennsylvania State University, College of Medicine, Hershey, PA, United States
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3
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Abstract
In recent years the prescription opioid overdose epidemic has decreased, but has been more than offset by increases in overdose caused by fentanyl and fentanyl analogues. Opioid overdose patients should receive naloxone if they have significant respiratory depression and/or loss of protective airway reflexes. Patients who receive naloxone should be observed for recurrent opioid effects. Patients with opioid overdose may be admitted to the intensive care unit for naloxone infusions, treatment of noncardiogenic pulmonary edema, autonomic instability, or sequelae of hypoxia-ischemia or cardiac arrest. Primary and secondary prevention are important to reduce the number of people with life-threatening opioid overdose.
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Guarnera A, Podda P, Santini E, Paolantonio P, Laghi A. Differential diagnoses of COVID-19 pneumonia: the current challenge for the radiologist-a pictorial essay. Insights Imaging 2021; 12:34. [PMID: 33704615 PMCID: PMC7948690 DOI: 10.1186/s13244-021-00967-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 01/12/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND COVID-19 pneumonia represents the most severe pandemic of the twenty-first century and has crucial clinical, social and economical implications. The scientific community has focused attention and resources on clinical and radiological features of COVID-19 pneumonia. Few papers analysing the vast spectrum of differential diagnoses have been published. MAIN BODY Complexity of differential diagnosis lays in the evidence of similar radiological findings as ground-glass opacities, crazy paving pattern and consolidations in COVID-19 pneumonia and a multitude of other lung diseases. Differential diagnosis is and will be extremely important during and after the pandemic peak, when there are fewer COVID-19 pneumonia cases. The aim of our pictorial essay is to schematically present COVID-19 pneumonia most frequent differential diagnoses to help the radiologist face the current COVID-19 pneumonia challenge. CONCLUSIONS Clinical data, laboratory tests and imaging are pillars of a trident, which allows to reach a correct diagnosis in order to grant an excellent allocation of human and economical resources. The radiologist has a pivotal role in the early diagnosis of COVID-19 pneumonia because he may raise suspicion of the pathology and help to avoid COVID-19 virus spread.
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Affiliation(s)
- Alessia Guarnera
- Department of Surgical and Medical Sciences and Translational Medicine, Sapienza University of Rome - Sant'Andrea University Hospital, Via di Grottarossa, 1035-1039, 00189, Rome, Italy.
| | - Pierfrancesco Podda
- Department of Radiology, San Giovanni Addolorata Hospital, Via Dell'Amba Aradam 9, 00184, Rome, Italy
| | - Elena Santini
- Department of Radiology, San Giovanni Addolorata Hospital, Via Dell'Amba Aradam 9, 00184, Rome, Italy
| | - Pasquale Paolantonio
- Department of Radiology, San Giovanni Addolorata Hospital, Via Dell'Amba Aradam 9, 00184, Rome, Italy
| | - Andrea Laghi
- Department of Surgical and Medical Sciences and Translational Medicine, Sapienza University of Rome - Sant'Andrea University Hospital, Via di Grottarossa, 1035-1039, 00189, Rome, Italy
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PARK JUNYEONG, ROUHANI SABA, BELETSKY LEO, VINCENT LOUISE, SALONER BRENDAN, SHERMAN SUSANG. Situating the Continuum of Overdose Risk in the Social Determinants of Health: A New Conceptual Framework. Milbank Q 2020; 98:700-746. [PMID: 32808709 PMCID: PMC7482387 DOI: 10.1111/1468-0009.12470] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Policy Points This article reconceptualizes our understanding of the opioid epidemic and proposes six strategies that address the epidemic's social roots. In order to successfully reduce drug-related mortality over the long term, policymakers and public health leaders should develop partnerships with people who use drugs, incorporate harm reduction interventions, and reverse decades of drug criminalization policies. CONTEXT Drug overdose is the leading cause of injury-related death in the United States. Synthetic opioids, predominantly illicit fentanyl and its analogs, surpassed prescription opioids and heroin in associated mortality rates in 2016. Unfortunately, interventions fail to fully address the current wave of the opioid epidemic and often omit the voices of people with lived experiences regarding drug use. Every overdose death is a culmination of a long series of policy failures and lost opportunities for harm reduction. METHODS In this article, we conducted a scoping review of the opioid literature to propose a novel framework designed to foreground social determinants more directly into our understanding of this national emergency. The "continuum of overdose risk" framework is our synthesis of the global evidence base and is grounded in contemporary theories, models, and policies that have been successfully applied both domestically and internationally. FINDINGS De-escalating overdose risk in the long term will require scaling up innovative and comprehensive solutions that have been designed through partnerships with people who use drugs and are rooted in harm reduction. CONCLUSIONS Without recognizing the full drug-use continuum and the role of social determinants, the current responses to drug overdose will continue to aggravate the problem they are trying to solve.
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Affiliation(s)
| | | | - LEO BELETSKY
- School of Law and Bouvé College of Health SciencesNortheastern University
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Heaton JD, Bhandari B, Faryar KA, Huecker MR. Retrospective Review of Need for Delayed Naloxone or Oxygen in Emergency Department Patients Receiving Naloxone for Heroin Reversal. J Emerg Med 2019; 56:642-651. [DOI: 10.1016/j.jemermed.2019.02.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 02/07/2019] [Accepted: 02/10/2019] [Indexed: 11/26/2022]
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Raja AS, Miller ES, Flores EJ, Wakeman SE, Eng G. Case 37-2017. A 36-Year-Old Man with Unintentional Opioid Overdose. N Engl J Med 2017; 377:2181-2188. [PMID: 29171813 DOI: 10.1056/nejmcpc1710563] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Ali S Raja
- From the Departments of Emergency Medicine (A.S.R., E.S.M.), Radiology (E.J.F.), Medicine (S.E.W.), and Pathology (G.E.), Massachusetts General Hospital, and the Departments of Emergency Medicine (A.S.R., E.S.M.), Radiology (A.S.R., E.J.F.), Medicine (S.E.W.), and Pathology (G.E.), Harvard Medical School - both in Boston
| | - Emily S Miller
- From the Departments of Emergency Medicine (A.S.R., E.S.M.), Radiology (E.J.F.), Medicine (S.E.W.), and Pathology (G.E.), Massachusetts General Hospital, and the Departments of Emergency Medicine (A.S.R., E.S.M.), Radiology (A.S.R., E.J.F.), Medicine (S.E.W.), and Pathology (G.E.), Harvard Medical School - both in Boston
| | - Efrén J Flores
- From the Departments of Emergency Medicine (A.S.R., E.S.M.), Radiology (E.J.F.), Medicine (S.E.W.), and Pathology (G.E.), Massachusetts General Hospital, and the Departments of Emergency Medicine (A.S.R., E.S.M.), Radiology (A.S.R., E.J.F.), Medicine (S.E.W.), and Pathology (G.E.), Harvard Medical School - both in Boston
| | - Sarah E Wakeman
- From the Departments of Emergency Medicine (A.S.R., E.S.M.), Radiology (E.J.F.), Medicine (S.E.W.), and Pathology (G.E.), Massachusetts General Hospital, and the Departments of Emergency Medicine (A.S.R., E.S.M.), Radiology (A.S.R., E.J.F.), Medicine (S.E.W.), and Pathology (G.E.), Harvard Medical School - both in Boston
| | - George Eng
- From the Departments of Emergency Medicine (A.S.R., E.S.M.), Radiology (E.J.F.), Medicine (S.E.W.), and Pathology (G.E.), Massachusetts General Hospital, and the Departments of Emergency Medicine (A.S.R., E.S.M.), Radiology (A.S.R., E.J.F.), Medicine (S.E.W.), and Pathology (G.E.), Harvard Medical School - both in Boston
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8
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Underner M, Perriot J, Peiffer G, Jaafari N. [Asthma and heroin use]. Presse Med 2017; 46:660-675. [PMID: 28734637 PMCID: PMC7126345 DOI: 10.1016/j.lpm.2017.06.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 05/11/2017] [Accepted: 06/21/2017] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Heroin use can be responsible for many respiratory complications including asthma. OBJECTIVES Systematic literature review of data on asthma in heroin users. DOCUMENTARY SOURCES Medline®, on the period 1980-2017 with the following keywords: keywords: "asthma" or "bronchospasm" and "heroin" or "opiate" or "opiates", limits "title/abstract"; the selected languages were English or French. Among 97 articles, 67 abstracts have given use to a dual reading to select 23 studies. RESULTS The seven case reports included 21 patients (mean age: 28 years [19-46 years]; sex-ratio: 2.5 [males: 71.5%]). Heroin was inhaled (71.4%), sniffed (19%) or injected by intravenous route (9.5%). Associated addictive substances were tobacco (81%), cannabis (38%), alcohol (4.7%) and cocaine (4.7%). Outcome was fatal in 3 subjects (14.3%). Other studies included one cross-sectional study, 3 case-control studies and 12 longitudinal studies (11 retrospective studies and one prospective study). The proportion of heroin users was higher in asthmatic subjects and the prevalence of asthma and bronchial hyperreactivity was higher in heroin users. Heroin use can be responsible for asthma onset, with a temporal relationship between the onset of heroin use and asthma onset in 28 to 31% of subjects. A positive association between inhaled heroin use and acute asthma exacerbation was observed. Asthma treatment observance was lower in heroin users. In case of asthma exacerbation, heroin users were more likely to seek care in the emergency department, to be admitted in intensive care units and to require intubation and invasive ventilation. Asthma deaths related to heroin use mainly occurred following an intravenous injection (especially in the case of overdose), but also following heroin use by nasal (sniff) or pulmonary route. CONCLUSION Heroin use may be responsible for asthma onset, acute asthma exacerbations (which may require intubation and invasive ventilation) or deaths related to asthma. Heroin use must be sought in case of asthma exacerbation in young persons and practitioners must help heroin users to stop their consumption.
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Affiliation(s)
- Michel Underner
- Université de Poitiers, unité de recherche clinique Pierre-Deniker, centre hospitalier Henri-Laborit, 370, avenue Jacques-Cœur, CS 10587, 86021 Poitiers cedex, France.
| | - Jean Perriot
- Centre de tabacologie, dispensaire Émile-Roux, 63100 Clermont-Ferrand, France
| | - Gérard Peiffer
- CHR Metz-Thionville, service de pneumologie, 57038 Metz, France
| | - Nematollah Jaafari
- Université de Poitiers, unité de recherche clinique Pierre-Deniker, centre hospitalier Henri-Laborit, 370, avenue Jacques-Cœur, CS 10587, 86021 Poitiers cedex, France
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9
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Abstract
In recent years, there has been a substantial increase in opioid use and abuse, and in opioid-related fatal overdoses. The increase in opioid use has resulted at least in part from individuals transitioning from prescribed opioids to heroin and fentanyl, which can cause significant respiratory depression that can progress to apnea and death. Heroin and fentanyl may be used individually, together, or in combination with other substances such as ethanol, benzodiazepines, or other drugs that can have additional deleterious effects on respiration. Suspicion that a death is drug-related begins with the decedent's medical and social history, and scene investigation, where drugs and drug paraphernalia may be encountered, and examination of the decedent, which may reveal needle punctures and needle track marks. At autopsy, the most significant internal finding that is reflective of opioid toxicity is pulmonary edema and congestion, and frothy watery fluid is often present in the airways. Various medical ailments such as heart and lung disease and obesity may limit an individual's physiologic reserve, rendering them more susceptible to the toxic effects of opioids and other drugs. Although many opioids will be detected on routine toxicology testing, more specialized testing may be warranted for opioid analogs, or other uncommon, synthetic, or semisynthetic drugs.
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Brent J, Burkhart K, Dargan P, Hatten B, Megarbane B, Palmer R, White J. Adverse Drug Reactions in the Intensive Care Unit. CRITICAL CARE TOXICOLOGY 2017. [PMCID: PMC7153447 DOI: 10.1007/978-3-319-17900-1_33] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Adverse drug reactions (ADRs) are undesirable effects of medications used in normal doses [1]. ADRs can occur during treatment in an intensive care unit (ICU) or result in ICU admissions. A meta-analysis of 4139 studies suggests the incidence of ADRs among hospitalized patients is 17% [2]. Because of underreporting and misdiagnosis, the incidence of ADRs may be much higher and has been reported to be as high as 36% [3]. Critically ill patients are at especially high risk because of medical complexity, numerous high-alert medications, complex and often challenging drug dosing and medication regimens, and opportunity for error related to the distractions of the ICU environment [4]. Table 1 summarizes the ADRs included in this chapter.
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Affiliation(s)
- Jeffrey Brent
- Department of Medicine, Division of Clinical Pharmacology and Toxicology, University of Colorado, School of Medicine, Aurora, Colorado USA
| | - Keith Burkhart
- FDA, Office of New Drugs/Immediate Office, Center for Drug Evaluation and Research, Silver Spring, Maryland USA
| | - Paul Dargan
- Clinical Toxicology, St Thomas’ Hospital, Silver Spring, Maryland USA
| | - Benjamin Hatten
- Toxicology Associates, University of Colorado, School of Medicine, Denver, Colorado USA
| | - Bruno Megarbane
- Medical Toxicological Intensive Care Unit, Lariboisiere Hospital, Paris-Diderot University, Paris, France
| | - Robert Palmer
- Toxicology Associates, University of Colorado, School of Medicine, Denver, Colorado USA
| | - Julian White
- Toxinology Department, Women’s and Children’s Hospital, North Adelaide, South Australia Australia
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11
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Betten DP, Vohra RB, Cook MD, Matteucci MJ, Clark RF. Antidote Use in the Critically Ill Poisoned Patient. J Intensive Care Med 2016; 21:255-77. [PMID: 16946442 DOI: 10.1177/0885066606290386] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The proper use of antidotes in the intensive care setting when combined with appropriate general supportive care may reduce the morbidity and mortality associated with severe poisonings. The more commonly used antidotes that may be encountered in the intensive care unit ( N-acetylcysteine, ethanol, fomepizole, physostigmine, naloxone, flumazenil, sodium bicarbonate, octreotide, pyridoxine, cyanide antidote kit, pralidoxime, atropine, digoxin immune Fab, glucagon, calcium gluconate and chloride, deferoxamine, phytonadione, botulism antitoxin, methylene blue, and Crotaline snake antivenom) are reviewed. Proper indications for their use and knowledge of the possible adverse effects accompanying antidotal therapy will allow the physician to appropriately manage the severely poisoned patient.
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Affiliation(s)
- David P Betten
- Department of Emergency Medicine, Sparrow Health System, Michigan State University College of Human Medicine, Lansing, Michigan 48912-1811, USA.
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12
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Mégarbane B, Chevillard L. The large spectrum of pulmonary complications following illicit drug use: features and mechanisms. Chem Biol Interact 2013; 206:444-51. [PMID: 24144776 DOI: 10.1016/j.cbi.2013.10.011] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 09/16/2013] [Accepted: 10/10/2013] [Indexed: 10/26/2022]
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 48h 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.
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Affiliation(s)
- Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, Paris-Diderot University, Paris, France; INSERM U1144, Paris-Descartes University, Variability of the response to psychotropic drugs, Paris, France.
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13
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Abstract
Opioids are widely used for their analgesic properties for the management of acute and chronic pain related to a variety of illnesses. Opioid usage is associated with adverse effects on respiration which are often attributed to depression of the central nervous system. Recent data indicate that opioid use has increased over the last two decades. There is also increasing evidence that opioids have a variety of effects on the lungs besides suppression of respiration. Opioids can affect immune cells function, increase histamine release causing bronchospasm, vaso-constriction and hypersensitivity reactions. Together, these actions have a variety of effects on lung function. Here, we provide a comprehensive review of the effects of opioids on the lungs including the respiratory centre, immune function, airways and pulmonary vasculature.
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Affiliation(s)
- Travis Yamanaka
- Department of Veterans Affairs, Jesse Brown VA Hospital, Section of Pulmonary, Critical Care, and Sleep Medicine, University of Illinois, Chicago Section of Pulmonary and Critical Care Medicine, University of Florida, Gainesville, Florida 32608, USA
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14
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Radke JB, Owen KP, Sutter ME, Ford JB, Albertson TE. The Effects of Opioids on the Lung. Clin Rev Allergy Immunol 2013; 46:54-64. [DOI: 10.1007/s12016-013-8373-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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15
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Lassen CL, Zink W, Wiese CHR, Graf BM, Wiesenack C. [Naloxone-induced pulmonary edema. Case report with review of the literature and critical evaluation]. Anaesthesist 2012; 61:129-36. [PMID: 22354400 DOI: 10.1007/s00101-012-1982-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Revised: 12/30/2011] [Accepted: 01/04/2012] [Indexed: 11/30/2022]
Abstract
A case of pulmonary edema after the administration of naloxone for laparoscopic splenectomy is reported. Previous reports of naloxone-induced pulmonary edema are listed and reviewed. The clinical course is compared to other forms of non-cardiogenic pulmonary edema. Uncertainty remains about the underlying pathophysiological process and the true impact of naloxone on the development of pulmonary edema.
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Affiliation(s)
- C L Lassen
- Klinik für Anästhesiologie, Universitätsklinikum Regensburg, Deutschland.
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16
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Novak SP, Kral AH. Comparing injection and non-injection routes of administration for heroin, methamphetamine, and cocaine users in the United States. J Addict Dis 2011; 30:248-57. [PMID: 21745047 PMCID: PMC3225003 DOI: 10.1080/10550887.2011.581989] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Research examining the demographic and substance use characteristics of illicit drug use in the United States has typically failed to consider differences in routes of administration or has exclusively focused on a single route of administration?injection drug use. Data from National Survey on Drug Use and Health were used to compare past-year injection drug users and non-injection drug users' routes of administration of those who use the three drugs most commonly injected in the United States: heroin, methamphetamine, and cocaine. Injection drug users were more likely than those using drugs via other routes to be older (aged 35 and older), unemployed, possess less than a high school education, and reside in rural areas. IDUs also exhibited higher rates of abuse/dependence, perceived need for substance abuse treatment, and co-occurring physical and psychological problems. Fewer differences between IDUs and non-IDUs were observed for heroin users compared with methamphetamine or cocaine users.
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Affiliation(s)
- Scott P. Novak
- RTI International, Behavioral Health Epidemiology, Post Office Box 12194, Research Triangle Park, NC 27709-2194 USA
| | - Alex H. Kral
- RTI International, Urban Health Program, 114 Sansome Street, Suite 500, San Francisco, CA 94104-38122 USA
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17
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Wampler DA, Molina DK, McManus J, Laws P, Manifold CA. No Deaths Associated with Patient Refusal of Transport After Naloxone-Reversed Opioid Overdose. PREHOSP EMERG CARE 2011; 15:320-4. [DOI: 10.3109/10903127.2011.569854] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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18
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Feeney C, Ani C, Sharma N, Frohlich T. Morphine-induced cardiogenic shock. Ann Pharmacother 2011; 45:e30. [PMID: 21586652 DOI: 10.1345/aph.1q022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Although animal and human models suggest that direct suppression of myocardial contractility may occur with morphine administration, to our knowledge, clinical observation of this potentially important effect has not been reported. This case report presents a unique case of morphine-induced transient reversible cardiogenic shock. CASE SUMMARY A 44-year-old woman with a history of hypertension, diabetes, and asthma presented with a 3-day history of epigastric pain. Initial investigation results revealed elevated serum lipase level and computed tomography imaging that was consistent with a diagnosis of mild acute pancreatitis. Intravenous fluids and morphine, via patient-controlled analgesia, were started and the patient was admitted. The next day, she developed cardiogenic shock with a globally reduced left ventricular ejection fraction (LVEF) of 26% and was admitted to the intensive care unit. Morphine was discontinued and norepinephrine and naloxone were concurrently administered. Over the next 24 hours her clinical status improved, and an echocardiogram 29 hours after the initial echocardiogram showed normal LV function (LVEF 62%). DISCUSSION To our knowledge, this represents the first reported case of clinically significant morphine-induced cardiogenic shock. An objective causality assessment using the Naranjo probability scale suggests that the cardiogenic shock was probably related to morphine. Other causes of shock were ruled out. Additionally, the fact that the transient nature of the observed LV dysfunction reversed with discontinuation of morphine and administration of naloxone provides further support, particularly with the evidence that opiates may depress cardiac myocytes and cardiac output in animal and human models. CONCLUSIONS Opiates can cause severe LV dysfunction. Physicians should consider emergent evaluation for myocardial depression in patients who are receiving opioids and present with persistent hypotension or pulmonary edema without other known etiology.
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Affiliation(s)
- Colin Feeney
- Critical Care Division, Alameda County Medical Center, Oakland, CA, USA.
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Dünser MW, Hasibeder WR. Sympathetic overstimulation during critical illness: adverse effects of adrenergic stress. J Intensive Care Med 2009; 24:293-316. [PMID: 19703817 DOI: 10.1177/0885066609340519] [Citation(s) in RCA: 322] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The term ''adrenergic'' originates from ''adrenaline'' and describes hormones or drugs whose effects are similar to those of epinephrine. Adrenergic stress is mediated by stimulation of adrenergic receptors and activation of post-receptor pathways. Critical illness is a potent stimulus of the sympathetic nervous system. It is undisputable that the adrenergic-driven ''fight-flight response'' is a physiologically meaningful reaction allowing humans to survive during evolution. However, in critical illness an overshooting stimulation of the sympathetic nervous system may well exceed in time and scope its beneficial effects. Comparable to the overwhelming immune response during sepsis, adrenergic stress in critical illness may get out of control and cause adverse effects. Several organ systems may be affected. The heart seems to be most susceptible to sympathetic overstimulation. Detrimental effects include impaired diastolic function, tachycardia and tachyarrhythmia, myocardial ischemia, stunning, apoptosis and necrosis. Adverse catecholamine effects have been observed in other organs such as the lungs (pulmonary edema, elevated pulmonary arterial pressures), the coagulation (hypercoagulability, thrombus formation), gastrointestinal (hypoperfusion, inhibition of peristalsis), endocrinologic (decreased prolactin, thyroid and growth hormone secretion) and immune systems (immunomodulation, stimulation of bacterial growth), and metabolism (increase in cell energy expenditure, hyperglycemia, catabolism, lipolysis, hyperlactatemia, electrolyte changes), bone marrow (anemia), and skeletal muscles (apoptosis). Potential therapeutic options to reduce excessive adrenergic stress comprise temperature and heart rate control, adequate use of sedative/analgesic drugs, and aiming for reasonable cardiovascular targets, adequate fluid therapy, use of levosimendan, hydrocortisone or supplementary arginine vasopressin.
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Affiliation(s)
- Martin W Dünser
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Anichstrasse, Innsbruck, Austria.
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Hainer C, Wente MN, Hallscheidt PJ, Schmidt J, Martin E, Büchler MW, Weigand MA. Morphine-induced acute lung injury. J Clin Anesth 2008; 20:300-3. [PMID: 18617131 DOI: 10.1016/j.jclinane.2007.10.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2006] [Revised: 10/18/2007] [Accepted: 10/24/2007] [Indexed: 11/25/2022]
Abstract
A 38-year-old woman who had familial adenomatous polyposis was admitted to the intensive care unit with an episode of severe sepsis 5 days after undergoing a pancreas-preserving duodenectomy. Laparotomy with removal of an intra-abdominal abscess, followed by closed postoperative continuous lavage for 10 days, was performed. During two courses of planned tracheal extubation, the patient developed an acute lung injury, making a reintubation necessary. In both events, the patient received small doses of continuous morphine before the extubation. Morphine may induce the development of an acute lung injury in patients, whereas the exact pathophysiologic and pharmacologic mechanisms remain unclear.
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Affiliation(s)
- Christian Hainer
- Department of Anaesthesiology, University of Heidelberg, D-69120 Heidelberg, Germany
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Mell HK, Sztajnkrycer MD. Clinical Images in Medical Toxicology: Heroin Overdose with Non-Cardiogenic Pulmonary Edema. Clin Toxicol (Phila) 2008; 44:399. [PMID: 16809144 DOI: 10.1080/15563650600671803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Howard K Mell
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN 55905, USA
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22
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"The life they save may be mine": diffusion of overdose prevention information from a city sponsored programme. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2008; 20:137-42. [PMID: 18502635 DOI: 10.1016/j.drugpo.2008.02.004] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2007] [Revised: 02/08/2008] [Accepted: 02/19/2008] [Indexed: 11/20/2022]
Abstract
BACKGROUND Overdose remains the leading cause of death among injection drug users (IDUs) in the United States. Overdose rates are consistently high in Baltimore, MD, USA. The current qualitative study examines diffusion of information and innovation among participants in Staying Alive, an overdose prevention and naloxone distribution programme in Baltimore, MD. METHODS In-depth interviews were conducted between June 2004 and August, 2005 with 25 participants who had completed the Staying Alive training and had reported using naloxone to revive an overdose victim. Interviews were taped and transcripts were transcribed verbatim. RESULTS Participants were 63% male, 63% African American, and the median age was 41 years old. Participants successfully shared information on overdose prevention and management, particularly the use of naloxone, to their peers and family. CONCLUSIONS The current study demonstrates IDUs' interest in and ability to diffuse overdose prevention information and response skills to the injection drug use community. The study underscores the importance of promoting the diffusion of information and skills within overdose prevention programmes.
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Sherman SG, Cheng Y, Kral AH. Prevalence and correlates of opiate overdose among young injection drug users in a large U.S. city. Drug Alcohol Depend 2007; 88:182-7. [PMID: 17110058 PMCID: PMC1950747 DOI: 10.1016/j.drugalcdep.2006.10.006] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2006] [Revised: 10/16/2006] [Accepted: 10/18/2006] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The current study examines the prevalence and correlates of witnessing and experiencing opiate overdoses among a sample of young, injection drug users (IDUs) and non-injection drug users (NIDUs) in Baltimore, MD. METHODS Data were derived from a longitudinal study of 15-30 year old IDUs and NIDUs (N=309) who had initiated heroin, cocaine, and/or crack use within 5 years prior to study enrollment. Chi-square and Wilcoxon rank-sum tests were used in bivariate analyses of demographic and drug use variables with each of the two dependent variables. Multivariate logistic regression models were used to identify correlates of experiencing and witnessing overdose. RESULTS Twenty-nine percent of participants reported having ever experienced an opiate overdose and 57% reported having ever witnessed an overdose. Having ever experienced an opiate overdose was independently associated with being White (Adjusted Odds Ratio [AOR]=3.2; 95% Confidence Interval [CI]: 1.6, 6.4) recent homelessness (AOR=2.9; 95%CI: 1.5, 5.7); and length of injection, 5.6-6.9 years versus <5.6 years (AOR=4.0; 95%CI: 1.8-8.9); injecting 7.0-7.9 years versus <5.6 years (AOR=2.5; 95%CI: 1.03-6.1); injecting >8 versus <5.6 years (AOR=4.7; 95%CI: 2.2-10.2). Having witnessed an opiate overdose was independently associated with being White (AOR=2.4; 95%CI: 1.4, 4.1) and injecting >8 years versus <5.6 years (AOR=2.2; 95%CI: 1.2, 4.0). CONCLUSIONS This study documents the high prevalence of witnessing and experiencing opiate overdoses among young, newly initiated IDUs and NIDUs. The results could inform the growing number of overdose prevention efforts throughout the U.S.
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Affiliation(s)
- Susan G Sherman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street E6543, Baltimore, MD 21205, USA.
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Abstract
Pulmonary complications of therapy for RA or other benign conditions are often difficult to diagnose and treat. Clinical presentation of lung disease that is due to noncytotoxic drugs may vary from a mild, nonspecific cough to fulminant respiratory failure. The differential diagnosis of pulmonary disease should include drug toxicity, progression of the primary illness, and opportunistic infection. An objective assessment of the patient's baseline pulmonary status, as well as his treatment history, is crucial to differentiate drug-induced pathology from the primary process. Diagnostic work-up should include chest radiograph, repeat pulmonary function testing, and high-resolution CT of the chest. Bronchoscopy for tissue pathology or specific BAL cytokine markers also may yield useful information; occasionally, open-lung biopsy is required. If pulmonary disease that results from noncytotoxic drug therapy is suspected, the drug should be discontinued until the disease process is understood clearly.
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Affiliation(s)
- Brion J Lock
- Pulmonary Section, Birmingham Veterans Administration Medical Center, AL 35233, USA
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