Pulmonary Complications of Smoked Substance Abuse
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I. 5525 Addiction Medicine IL and the Primary Care Physician Pulmonary Complications of Smoked Substance Abuse DONALD P TASHKIN, MD, Los Angeles After tobacco, marijuana is the most widely smoked substance in our society. Studies conducted within the past 15 years in animals, isolated tissues, and humans indicate that marijuana smoke can injure the lungs. Habitual smoking of marijuana has been shown to be associated with chronic respiratory tract symptoms, an increased frequency of acute bronchitic episodes, extensive tracheobronchial epithelial disease, and abnormalities in the structure and function ofalveolar macrophages, key cells in the lungs' immune defense system. In addition, the available evidence strongly suggests that regularly smoking marijuana may predispose to the development of cancer of the respiratory tract. "Crack" smoking has become increasingly prevalent in our society, especially among habitual smokers of marijuana. New evidence is emerging implicating smoked cocaine as a cause of acute respiratory tract symptoms, lung dysfunction, and, in some cases, serious, life-threatening acute lung injury. A strong physician message to users of marijuana, cocaine, or both concerning the harmful effects of these smoked substances on the lungs and other organs may persuade some of them, especially those with drug-related respiratory complications, to quit smoking. (Tashkin DP: Pulmonary complications of smoked substance abuse, In Addiction Medicine [Special Issue]. West J Med 1990 May; 152:525-530) Humans smoke a variety of substances, including to- Marijuana bacco, cannabis (marijuana and hashish), alkaloidal Recent nationwide surveys show a continued decline in cocaine (freebase cocaine or "crack"), phencyclidine marijuana use3'4; nonetheless, marijuana remains one of the (PCP), heroin, opium, and, most recently, methampheta- most widely abused substances in our society. According to a mine ("ice"). The popularity of these smoked substances is recent survey,3 among high-school seniors about 50% were due, no doubt, to the pleasure derived from the psychoactive ever users of marijuana, slightly less than 40 % used it within components within the smoke, such as nicotine in tobacco the past year, 23 % used it within the past month, and 4 % (6 % and A9-tetrahydrocannabinol (THC) in cannabis, Which also of male students) reported using it daily. Although cannabis serve to reinforce the smoking habit through addiction, psy- products are sometimes taken orally, smoking is the pre- chological dependence, or both. ferred route of administration so that the lungs are exposed Because the lungs are the principal organ exposed to the first and foremost to its combustion products. These products combustion products of smoked substances, pulmonary include a number of known respiratory irritants and carcino- complications would be expected to be prominent among the gens' and many other compounds of which the pulmonary health consequences of smoking. Tobacco, the most widely effects are unknown. The smoke contents of marijuana are smoked substance in our society, has been studied exten- similar in many respects to those of tobacco with the major sively with regard to its adverse effects on the lungs, particu- exceptions that marijuana contains A9-THC and about 60 larly its link to chronic obstructive pulmonary disease and other cannabinoid compounds"'6 whereas tobacco contains lung cancer. I 2 Much less is known about the effects on the nicotine. That THC is itselfa respiratory irritant is suggested lungs of smoking other substances, although a body of evi- by the harsh respiratory sensations elicited by the smoking of dence is emerging implicating marijuana and crack cocaine high-potency cannabis preparations and the observation that as causes of respiratory tract disease. Because there is as yet THC administered in pure form as an aerosol generally pro- little published information regarding the pulmonary effects vokes cough and can cause bronchospasm in patients with of smoking other illicit substances, this article will focus asthma.' It is also noteworthy that most tobacco cigarettes mainly on our current state of knowledge concerning the currently in use are filter-tipped and have a relatively low tar respiratory complications of smoking marijuana and alkaloi- content, but marijuana cigarettes do not contain filters and dal cocaine; the latter are the most widely smoked substances generate about twice as much tar as tobacco per unit of in our society except for tobacco, the pulmonary effects of weight, assuming a similar smoking profile.8 Furthermore, which are already well known. the techniques for smoking marijuana and tobacco differ From the Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of California, Los Angeles, School of Medicine. Supported by United States Public Health Service grant ROI-DA-03018 from the National Institute of Drug Abuse. Reprint requests to Donald P. Tashkin, MD, Department of Medicine, UCLA School of Medicine, Los Angeles, CA 90024. 526526SMOKEDSMOKED SUBSTANCE ABUSE gens, including a higher concentration of polyaromatic hy- ABBREVIATIONS USED IN TEXT drocarbons, such as benzpyrene and benzanthracene, and a DLCO = diffusing capacity for carbon monoxide comparable amount of the volatile N-nitrosamines.s Second, THC = A9-tetrahydrocannabinol in studies involving the Ames Salmonella microsome assay, marijuana produced mutations comparable in number with substantially: on the average, with marijuana the inhalation, those produced by an equivalent amount of tobacco smoke or "puff," volume is about two-thirds larger, the depth of condensate."6'17 Third, marijuana smoke condensate (tar) smoke inhalation about 40% greater, and breath holding painted on the skin of mice has shown tumorigenicity and about four times longer than those characteristic of tobacco tumor-promoting activity.5'18 Fourth, long-term exposure of smoking.9 These differences in filtration and smoking tech- hamster lung cell cultures to marijuana smoke induced nique can result in about a fourfold greater amount of tar changes in the genetic material ofthe cell followed by irregu- delivered to and retained in the lungs from the smoking of larities in cell division that progressed to malignant transfor- marijuana than from a comparable amount of tobacco, thus mation within three to six months of exposure; similar but potentially amplifying the harmful effects of marijuana on less prominent abnormalities were noted during comparable the lungs. exposures to tobacco.19 Because malignant transformation A wealth of epidemiologic, pathologic, clinical, and ex- also occurred in the control cultures at 12 to 24 months, the perimental studies have established tobacco smoking as the smoke of marijuana (and tobacco) appears to have acceler- most important cause of lung cancer and chronic obstructive ated rather than initiated the malignant change. pulmonary disease, including chronic bronchitis and emphy- Studies in Humans sema.1'2 Because of the rough similarity in smoke contents between marijuana and tobacco and the differences in filtra- Physiologic Effects tion and smoking techniques that augment delivery of the Several studies have addressed the short- and long-term volatile and particulate contents of marijuana smoke to the effects of marijuana smoking on lung function. While the A1- respiratory tract, there is concern that the habitual smoking THC in smoked marijuana initially relaxes airway smooth of marijuana may have adverse effects on the lungs similar to muscle in both healthy persons20'21 and stable asthmatic pa- those caused by tobacco smoking. The long-term respiratory tients,22 causing bronchodilation, this bronchodilator effect consequences of tobacco smoking generally do not become is relatively short-lived and diminishes with the repeated use clinically apparent until two or more decades after the smok- of marijuana (tachyphylaxis).23 In contrast to its acute bron- ing habit is initiated. Because the habitual smoking of mari- chodilator effect, regular marijuana smoking has been juana by a sizable segment of our society is a relatively recent shown to cause abnormal decrements in lung function, most phenomenon compared with regular tobacco smoking, suf- likely due to damaging effects on airways having long-term ficient time may not have transpired for the potentially harm- exposure to noxious components within the smoke. After an ful long-term effects of marijuana smoking on the lungs to 11-day period ofabstinence, 28 healthy young men who were become clinically apparent. Nonetheless, the results of stud- experienced cannabis users had mild but statistically signifi- ies in animals, isolated tissues, and humans during the past cant airflow obstruction develop after smoking marijuana ad 15 years show that marijuana smoke has injurious effects on libitum (mean of 5.2 "joints" per day) for 6 to 8 weeks, and the lungs. I have summarized the results of these studies. the decrements in lung function were correlated with the average daily amount of marijuana smoked.23 Cessation of Animal and Tissue Studies (or reduction in) smoking for a month led to a restoration of In rats with exposure to marijuana smoke for three months the baseline level of lung function, indicating that the mild in doses comparable with those used by humans, Fleischman impairment in airway dynamics caused by several weeks of and co-workers noted focal inflammatory changes involving heavy daily marijuana smoking is reversible.