The effects of cocaine and heroin use on intubation rates and hospital utilization in patients with acute asthma exacerbations

BACKGROUND: The use of both heroin and cocaine has been associated with asthma exacerbations. However, the magnitude of this effect has not been adequately described. The purpose of this study was to examine the association between cocaine or heroin use and asthma severity. METHODS: We conducted a retrospective chart review of adult patients who had been admitted to an inner-city hospital and who subsequently had received a hospital discharge diagnosis of acute asthma exacerbation. Patients were classified as cocaine users if they had admitted to using cocaine within 24 h of symptom onset, or if a positive drug screen result was obtained. A similar classification was employed for heroin. The severity of asthma exacerbations among cocaine and heroin users was compared to severity among nonusers (ie, individuals without evidence of having used either drug within the 24 h preceding symptom onset). RESULTS: One hundred sixty-six unique patient encounters were identified, and 152 patient records were analyzed. Of these, 27.6% (42 of 152 patients) used cocaine with or without heroin and were classified as cocaine users, while 30.9% (47 of 152 patients) used heroin with or without cocaine and were classified as heroin users. Cocaine users had longer mean lengths of hospital stay than nonusers (3.4 days vs 2.5 days; p < 0.049). Intubation and ICU admission were more common among cocaine users than nonusers (21.4% vs 2.3%, respectively [p = 0.0006]; 31.0% vs 11.5%, respectively [p = 0.0068]). Heroin users were also intubated more frequently than nonusers (17.0% vs 2.3%, respectively; p = 0.0036). Neither the length of hospital stay nor the percentage of ICU admissions was significantly different between heroin users and nonusers. CONCLUSION: Heroin and cocaine use are common among adult asthmatic patients admitted to an inner-city hospital. Both cocaine and heroin are significantly associated with the need for intubation. Based on these findings, it may be prudent to screen adults with asthma presenting to an urban emergency department for cocaine and heroin use.     

Asthma associated with the use of cocaine,heroin, and marijuana: A review of the evidence

Objective: A review of the evidence was conducted regarding asthma associated with the use of cocaine, heroin, and marijuana. Data Sources: A search of the English literature was performed via PubMed/Medline and EMBASE using the search terms asthma AND cocaine, heroin, and marijuana. When pertinent articles were found, salient references in those articles were assessed. Study Selection: Due to the relatively small number of studies, we included all studies and cases. Results: For several decades, case reports, retrospective studies, and laboratory investigations have demonstrated that inhalation of cocaine or heroin is associated with increased asthma symptoms and reduced pulmonary function. Smoking crack cocaine, nasal insufflation of cocaine or heroin, and smoking heroin increases the risk of emergency department visits and hospitalizations for asthma. Although frequent smoking of marijuana may cause symptoms of cough, sputum production, and wheezing in the general population, more studies are needed specifically in patients with asthma. Smoking marijuana with concomitant tobacco use is common and further worsens the respiratory symptoms. Conclusions: Use of cocaine and heroin in patients with asthma should be avoided. Pending further studies, it would be prudent for patients with asthma to avoid smoking marijuana. Clinicians need to be vigilant regarding use of these drugs in their patients with hyperreactive airway disease.     

Pediatric Asthma Admissions: Chronic Severity and Acute Exacerbations

Factors resulting in intensive care unit (ICU) admissions for asthma exacerbations remain largely unclear. We compared ICU and general pediatric ward admissions for asthma exacerbations. Charts of 56 (2- to 18-year-old) patients admitted consecutively to the ICU during a 1-year period for asthma exacerbations were compared with charts of 56 age-, sex-, race-, and era-matched patients admitted to a general pediatric ward. Few patients in both groups received oral steroids before admission. Children with different chronic asthma severities had comparable severities of acute exacerbation. In conclusion, acute asthma exacerbations dissociate in severity from chronic asthma and are under-treated with systemic corticosteroids.     

Pediatric Asthma Admissions: Chronic Severity and Acute Exacerbations

Factors resulting in intensive care unit (ICU) admissions for asthma exacerbations remain largely unclear. We compared ICU and general pediatric ward admissions for asthma exacerbations. Charts of 56 (2- to 18-year-old) patients admitted consecutively to the ICU during a 1-year period for asthma exacerbations were compared with charts of 56 age-, sex-, race-, and era-matched patients admitted to a general pediatric ward. Few patients in both groups received oral steroids before admission. Children with different chronic asthma severities had comparable severities of acute exacerbation. In conclusion, acute asthma exacerbations dissociate in severity from chronic asthma and are under-treated with systemic corticosteroids.     

Mechanical ventilation in children with severe asthma

Hospital admissions for childhood asthma have increased during the past few decades. The aim of this study was to describe the need for mechanical ventilation for severe asthma exacerbation in children in Finland from 1976 to 1995. We reviewed medical records and collected data retrospectively from all 5 university hospitals in Finland, thus covering the entire population of about 5 million. The endpoints selected were the number of admissions and readmissions leading to mechanical ventilation, duration of stay in the hospital, and mortality. Moreover, asthma medications prescribed prior to admission and administered in the intensive care unit (ICU), as well as the etiology of the exacerbation associated with mechanical ventilation were examined. Mechanical ventilation was required in 66 ICU admissions (59 patients). This constituted approximately 10% of all 632 admissions for acute asthma to an ICU. The number of admissions decreased from 1976 to 1995: 41 admissions between 1976 and 1985 vs. 25 admissions during the next 10-year period. The mean age at admission to the ICU was 3.6 years, and 46% of the patients were boys. Prior to the index admission, 70% of the patients had used asthma medication such as oral bronchodilator (50%), inhaled bronchodilator (20%), theophylline (38%), inhaled glucocorticoid (18%), oral glucocorticoid (5%), and cromoglycate (7%). Respiratory infection was by far the most common cause of all the exacerbations (61%), followed by food allergy (8%) and gastroesophageal reflux (3%). In 28% of cases the cause of the severe asthma exacerbation could not be identified. In the mechanically ventilated patients readmissions occurred 38 times between 1976 and 1985 vs. 5 times between 1986 and 1995. Five of the patients who received mechanical ventilation died, and in 3 of these patients asthma was the event causing death. In conclusion, there has been decrease in the number of first and repeat ICU admission for asthma requiring mechanical ventilation between 1970 and 1995. This trend occurred despite a simultaneous 5% yearly increase in hospital admissions for childhood asthma during these 2 decades.     

Identifying An At-Risk Population of Children With Recurrent Near-Fatal Asthma Exacerbations

Background. Children are frequently admitted to hospitals for treatment of severe asthma exacerbations. Anecdotally, a cohort of these children are thought to have multiple readmissions to the intensive care unit (ICU), yet this group of children has not been characterized. The purpose of this study was to examine the factors related to recurrent ICU admissions in children with asthma. Methods. The authors conducted a retrospective study of all children admitted to the pediatric ICU for asthma between April 1997 and December 2007. Children with more than one ICU admission were defined as having recurrent near-fatal asthma exacerbations. Results. During this period, 306 children with asthma were admitted to the ICU on 350 occasions; 269 children had only one ICU admission and 33 children (11%) had two or more ICU admissions. To predict who might require readmission, the authors compared the first hospitalization of all children. When compared with children admitted to the ICU only once, children admitted to the ICU more than once were more likely to be overweight (odds ratio [OR] 2.3; 95% confidence interval [CI] 1.1, 4.9), to have public insurance (OR 3.6; 95% CI 1.5, 8.5), and less likely to be Caucasian (OR 0.34; 95% CI 0.14, 0.86). There was no difference in Nation Heart, Lung and Blood Institute (NHLBI) asthma classification, admission illness severity, durations of therapy, or length of stay (LOS) that might identify those who would require readmission. To determine the effect of readmission analysis on subsequent hospitalization, the authors used multiple logistic regression to identify factors associated with increased LOS in all hospitalizations of the subset of children with recurrent near-fatal asthma exacerbations. In this analysis, LOS was most closely associated with admission severity of illness (p = .002), but not with number of hospitalizations. Conclusions. In this single hospital cohort, there were identifiable factors in children admitted to the ICU that are associated with an increased risk of developing recurrent near-fatal asthma exacerbations. Specifically, overweight children with public insurance were more likely and Caucasian children less likely to be readmitted to the ICU for asthma. These children may represent a group to which specific interventions should be targeted prospectively to prevent readmission.     

Outcomes for older trauma patients in the emergency department screening positive for alcohol,cocaine, or marijuana use

Background: Substance use among older adults is an increasing concern, with the prevalence of substance use in older populations expected to double in the next decade. Drug and alcohol use is associated with trauma risk and outcomes, but little is known about the specific risk for older trauma patients. Objectives: To evaluate the association between drug and alcohol use and trauma outcomes among adults aged 55 years and older. Methods: This retrospective observational study included older adults from the Illinois Trauma Registry between 1999 and 2009. Exclusion criteria were age younger than 55 years or absent date of birth, ethanol level, or urine drug screen (UDS). Alcohol intoxication was defined as ethanol level greater than 80?mg/dL. UDS was used to screen cocaine and marijuana use. Analyses, for both the alcohol and the marijuana/cocaine groups, compared outcomes for patients with negative vs. positive screens. Results: 21?320 patients were included in the alcohol analysis and 17?077 in the drug analysis. Compared to non-intoxicated patients, alcohol-intoxicated patients had significantly (p?0.001) lower in-hospital mortality, decreased ICU admission, decreased intubation rate, and shorter hospital length of stay. Patients screening positive for cocaine or marijuana had significantly longer lengths of stay with increased ICU admission compared with those who screened negative. Conclusion: Among older trauma patients, this study shows significant associations with multiple trauma outcomes, including one between elevated ethanol concentrations and improved outcomes. Future research into the causes of these findings could inform the care of older trauma patients and aid in prevention of injuries.     

Bronchial hyperreactivity in patients who inhale heroin mixed with cocaine vaporized on aluminum foil

BACKGROUND: In our area, inhaling heroin mixed with cocaine vaporized on aluminum foil, known as rebujo, is becoming more and more common. AIM: To define the prevalence and the characteristics of bronchial disease (wheezing, bronchial hyperreactivity [BHR], and asthma) present in subjects inhaling heroin mixed with cocaine vaporized on aluminum foil. MATERIALS AND METHODS: Ninety-one subjects who inhaled the drug mixture were included in the study: 62 subjects were from a drug rehabilitation center (INH-I group), and 29 subjects were among patients admitted to our hospital for a variety of reasons (INH-II group). A questionnaire was completed in both groups, as well as IgE determination and lung function tests (spirometry and methacholine challenge). The control group consisted of 122 individuals who did not inhale the drug mixture, and were chosen randomly from the general population (NO-INH group). All subjects were tobacco smokers. RESULTS: In the INH-I group, there was a 41.9% prevalence of wheezing over the past 12 months, a 44.4% prevalence of BHR, and a 22.02% prevalence of asthma, defined as wheezing plus BHR. In the NO-INH group, these values were 32.78% (p = 0.22), 15.57% (p < 0.0001), and 8.19% (p < 0.01), respectively. Of the subjects who inhaled the drug mixture and denied having symptoms prior to the use of the drug mixture, 31.4% had wheezing develop after commencing use of the drug, following a mean latency of 4.09 months. Wheezing remitted in only 7.6% after discontinuation of the drug. CONCLUSIONS: (1) There is a real increase in BHR in subjects who inhale heroin mixed with cocaine vaporized on aluminum foil; and (2) this BHR is associated with wheezing that develops after a variable period of latency, once drug inhalation begins, and persists despite discontinuation of the drug.     

Changing patterns of illicit substance use among schizophrenic patients: 1984-1996

Over 1,700 psychiatric emergency room visits of schizophrenic and schizoaffective patients between 1984 and 1996 were reviewed, and urine drug screens (UDS) were recorded. Illicit drug use increased significantly over the 12-year period, with a large increase for cocaine (0% to 73% of positive UDS), a decline for amphetamines (60% to 0%), and a small increase for marijuana (0% to 27%). Opiate and sedative use remained unchanged. The results support the impression that cocaine use increased dramatically among urban schizophrenic patients beginning in 1988 and continuing to the present. Furthermore, cocaine seems to have replaced amphetamines as the preferred drug of abuse among schizophrenic persons following the crack epidemic.     

International trends in admissions and drug sales for asthma.

OBJECTIVE: To test whether national patterns of asthma drug use, particularly inhaled corticosteroids (ICS), are related to the rate of acute severe asthma exacerbations. DESIGN: The relation of international trends in hospital admissions for asthma with asthma drug sales was examined using country-specific regressions over the period 1990-1999. Pooled estimates of the regression coefficients were calculated using random effects models. RESULTS: Data on asthma admissions and asthma drug sales (including the sub-category ICS) were obtained from 11 countries. There was a negative relationship between falling admissions and rising sales of respiratory drugs and ICS in 9 of these 11 countries. A pooled estimate of the change in asthma admission rate per 10,000 associated with a unit increase in sales rate was -6.3 (95% CI -10.4 - -2.3) for all asthma drugs and -11.2 (95% CI -19.7 - -2.8) for ICS. CONCLUSION: At the national level, there is good evidence that over the last decade, increased sales of asthma drugs, and ICS in particular, were associated with a decline in rates of hospital admission for asthma. This is consistent with a beneficial effect of increasing use of asthma drugs, but other explanations such as decreasing prevalence could also be responsible.     

Drug network characteristics as a predictor of cessation of drug use among adult injection drug users: a prospective study.

Few studies have examined recovery from opiate and cocaine dependence without treatment, referred to as "natural recovery," "spontaneous recovery," and "spontaneous remission." The present study examined the relationship between network characteristics and cessation of heroin, cocaine, and crack use in a sample of underclass inner-city injection drug users in Baltimore, Maryland. Participants were enrolled in an experimental human immunodeficiency virus (HIV) preventive intervention. Between the baseline and follow-up interviews, which averaged 5.2 months, 24 (7%) of 335 participants reported ceasing to use heroin, cocaine, and crack. Individuals who had reported cessation of drug use at follow-up had reported at baseline a smaller proportion of their network members with whom they used drugs (p < .02). Using multiple logistic regression analyses and adjusting for baseline drug use, enrollment in drug treatment, and demographic and background variables, cessation of drug use was associated with a lower proportion of personal network members in one's drug network (odds ratio [OR] = 25.4, p < .05). The data from this study suggest that network members have potential for social influence on the cessation of drug use.     

Association of ongoing drug and alcohol use with non-adherence to antiretroviral therapy and higher risk of AIDS and death: results from ACTG 362

Drug and alcohol use have been associated with a worse prognosis in short-term and cross-sectional analyses of HIV-infected populations, but longitudinal effects on adherence to antiretroviral therapy (ART) and clinical outcomes in advanced AIDS are less well characterized. We assessed self-reported drug and alcohol use in AIDS patients, and examined their association with non-adherence and death or disease progression in a multicenter observational study. We defined non-adherence as reporting missed ART doses in the 48 hours before study visits. The association between drug use and ART non-adherence was evaluated using repeated measures generalized estimating equation (GEE) models. The association between drug and alcohol use and time to new AIDS diagnosis or death was evaluated via Cox regression models, controlling for covariates including ART adherence. Of 643 participants enrolled between 1997 and 1999 and followed through 2007, at entry 39% reported ever using cocaine, 24% amphetamines, and 10% heroin. Ongoing drug use during study follow-up was reported by 9% using cocaine, 4% amphetamines, and 1% heroin. Hard drug (cocaine, amphetamines, or heroin) users had 2.1 times higher odds (p=0.001) of ART non-adherence in GEE models and 2.5 times higher risk (p=0.04) of AIDS progression or death in Cox models. Use of hard drugs was attenuated as a risk factor for AIDS progression or death after controlling for non-adherence during follow-up (HR = 2.11, p=0.08), but was still suggestive of a possible adherence-independent mechanism of harm. This study highlights the need to continuously screen and treat patients for drug use as a part of ongoing HIV care.     

Drug Network Characteristics as a Predictor of Cessation of Drug Use Among Adult Injection Drug Users: A Prospective Study

Few studies have examined recovery from opiate and cocaine dependence without treatment, referred to as “natural recovery,” “spontaneous recovery,” and “spontaneous remission.” The present study examined the relationship between network characteristics and cessation of heroin, cocaine, and crack use in a sample of underclass inner-city injection drug users in Baltimore, Maryland. Participants were enrolled in an experimental human immunodeficiency virus (HIV) preventive intervention. Between the baseline and follow-up interviews, which averaged 5.2 months, 24 (7%) of 335 participants reported ceasing to use heroin, cocaine, and crack. Individuals who had reported cessation of drug use at follow-up had reported at baseline a smaller proportion of their network members with whom they used drugs (p <. 02). Using multiple logistic regression analyses and adjusting for baseline drug use, enrollment in drug treatment, and demographic and background variables, cessation of drug use was associated with a lower proportion of personal network members in one's drug network (odds ratio [OR] = 25.4, p. 05). The data from this study suggest that network members have potential for social influence on the cessation of drug use.     

Persistence of drug use during imprisonment: relationship of drug type, recency of use and severity of dependence to use of heroin, cocaine and amphetamine in prison

AIM: To investigate the persistence of use of heroin, cocaine and amphetamine drugs during imprisonment, and to identify factors associated with increased levels of persistence. DESIGN: The use of heroin, cocaine and amphetamine by current prison inmates has been examined and, in particular, the relationship between drug use within prison and the type of drug used prior to imprisonment, recency of use and severity of dependence. SETTING AND PARTICIPANTS: A randomly selected sample of 1009 adult male prisoners in 13 prisons in England and Wales during 1994/95; structured confidential interviews conducted by independent research staff. Enquiry about prior use of heroin, cocaine or amphetamine focused on three time-periods (ever, last year and last month pre-prison) and the use of these drugs during the first month of imprisonment. FINDINGS: A total of 557 (55%) of the 1009 prisoners had used previously one of the three drugs selected for study: 58% had used heroin, 69% cocaine and 75% amphetamine. More than half (59%; 327/557) had used these drugs in the month before the current imprisonment. Drug use in prisons was most likely to occur among those who had used in the month prior to imprisonment. The persistence of heroin use in prison occurred more frequently (70%) than use of cocaine (20%) or amphetamine (15%). Of those using heroin pre-imprisonment, 67% considered they were dependent, compared to 15% and 22%, respectively, for cocaine and amphetamine users. CONCLUSIONS: Changes in the drug-taking behaviour of drug users after imprisonment vary according to the type of drug being taken. Prisoners were much more likely to continue to use heroin than either cocaine or amphetamines while in prison. Heroin was most likely to be used by those who had been using heroin during the immediate pre-imprisonment period, and particularly by the two-thirds of heroin users who considered themselves dependent. In view of the high prevalence of prior use of these drugs by individuals currently imprisoned, continuing attention is required to study of their behaviour and of the impact of interventions that may be introduced during or following their incarceration.     

Severe Exacerbations in Children with Mild Asthma: Characterizing a Pediatric Phenotype

Background: NHLBI guidelines classify asthma in children as intermittent, mild persistent, moderate persistent, and severe persistent asthma based on baseline symptoms and pulmonary function. However, this may not capture the spectrum of asthma in children, since even mild baseline disease can have significant effects on quality of life. Our objective was to describe a population of children with mild asthma admitted to the ICU with severe exacerbations. Methods: We examined data from all children with asthma who were admitted to the ICU with an acute exacerbation between April 1997, and December 2006. Children were defined as having mild asthma if their disease was classified as intermittent or mild persistent according to NHLBI criteria. Results: Of the 298 children admitted to the ICU with asthma, 164 (55%) were classified as having mild baseline asthma. Compared with children with more severe baseline asthma, mild asthmatic children were younger and less likely to have been previously admitted to the hospital for asthma. Other demographics, including admission severity of illness, gender, and prevalence of overweight, were similar in the two groups. There were no differences between the groups in ICU length of stay, hospital length of stay or types of therapies received. Thirteen children with mild asthma were intubated, although less frequently than those with more severe disease. Conclusions: Children with mild asthma have severe exacerbations. This suggests that chronic asthma severity does not necessarily predict asthma phenotypes during acute exacerbations.     

Airway effects of marijuana, cocaine, and other inhaled illicit agents

Several substances besides tobacco are inhaled for recreational purposes, including marijuana, crack cocaine, amyl and butyl nitrites, heroin, methamphetamine, and phencyclidine. Abuse of most of these inhaled substances has risen in recent years, thereby increasing concern about potential pulmonary and other medical complications. Regular marijuana use can lead to extensive airway injury and alterations in the structure and function of alveolar macrophages, potentially predisposing to pulmonary infection and respiratory cancer. Crack cocaine use can lead to a variety of acute pulmonary complications, including severe exacerbations of asthma and an acute lung injury syndrome associated with a broad spectrum of histopathologic changes ("crack lung"). Habitual cocaine smoking may also produce more subtle long-term pulmonary consequences due to chronic alveolar epithelial and microvascular lung injury. Heroin inhalation can induce severe and even fatal exacerbations of asthma. Pulmonary consequences of inhaled amyl and butyl nitrites, crystalline methamphetamine (ice), and phencyclidine have been less well documented.     

Drug withdrawal, cocaine and sedative use disorders increase the need for mechanical ventilation in medical patients

Aims   Alcohol use disorders increase the need for mechanical ventilation (MV) in critically ill medical, surgical and trauma patients. Studies examining other drug use disorders (DUD) in trauma patients have not demonstrated heightened rates of intensive care unit (ICU) complications. Patients with asthma and concurrent cocaine or heroin use disorders have an increased need for MV. The objective of this study is to determine if the presence of DUD and drug withdrawal syndromes are associated with increased need for MV in medical patients.
Design   Analysis of a national database.
Setting   The Nationwide Inpatient Sample, the largest all-payer in-patient database was utilized for the years 2002–2004.
Participants   Adult patients with one of the six common diagnoses associated with medical ICU admission were included.
Intervention   None.
Measurements   Univariate analysis and multivariate logistic regression were performed to determine if DUD and drug withdrawal were associated independently with the use of MV.
Findings   A total 1 218 875 patients fulfilled one of the six diagnoses; 22 827 (1.9%) had DUD, and 102 841 (8.4%) underwent MV. Independent of the medical diagnosis, DUD was associated with an increased risk for requiring MV by univariate analysis (relative risk = 1.50, P  < 0.0001). By multivariate analyses, sedative and cocaine use disorders remained associated with increased need for MV. Independent of medical diagnosis and substance, drug withdrawal was associated with increased odds of MV by both univariate and multivariate analysis (odds ratio = 2.94, P  < 0.0001).
Conclusions   DUD are associated with increased need for MV in medical patients. This study demonstrates the importance of screening all medical patients for DUD.     

Inhaled heroin-induced status asthmaticus: five cases and a review of the literature

We report five cases of status asthmaticus (four requiring mechanical ventilation) that were triggered by inhaled heroin and review the pertinent literature. These cases share common features of sudden and severe asthma exacerbations temporally related to heroin use, stress the importance of considering illicit drug use in like cases, and call attention to a public health issue.     

Hair testing and self-report of cocaine use by heroin users

Aim Failure to disclose cocaine use can have a negative impact on medical care and research validity. This study was performed to identify predictors of cocaine non‐disclosure among individuals who self‐reported heroin use during a medical care encounter. Design A prospective comparison of self‐report of cocaine use among heroin users and hair analysis for cocaine. Setting Four health‐care clinics at an academic, inner‐city hospital. Participants Patients presenting for a health‐care visit who were willing to self‐report use of heroin and were not engaged in any form of drug treatment. Measurements (1) Self‐report using standardized instruments: the Drug Addiction Severity Test (DAST), the Addiction Severity Index (ASI) and quantity/frequency questions for heroin and cocaine use. (2) Biochemical evidence: analysis of hair by radioimmunoassay (RIA) for cocaine and opiate levels. Findings Among 336 heroin users who tested positive for cocaine in hair, 34.2% did not report their recent cocaine use. The mean cocaine level for discordant individuals was significantly lower than for concordant individuals (109.6 ng/10 mg versus 470.57 ng/10 mg; P < 0.0001). Multivariate predictors of disclosure included opiate and cocaine levels in hair and the ASI drug severity subscore. Conclusions Although self‐report has been validated for treatment system patients, almost a third of the out‐of‐treatment heroin users in this medical clinic study failed to disclose concomitant cocaine use. The likelihood of non‐disclosure was greatest for heavy users of heroin and light users of cocaine. Confirmation of self‐report with biochemical analysis in the medical setting may be necessary to improve both clinical care and research validity.