Chronic obstructive pulmonary disease in heroin users: An underappreciated issue with clinical ramifications

Given the stigma associated with heroin use, and the consequent barriers to treatment in the general medical settings, co-care in settings that provide services to heroin users, such as opioid substitution clinics, residential rehabilitation and needle and syringe programs, may provide venues for the diagnosis and treatment of COPD. Regular screening by spirometry would appear good clinical practice in such settings. Although this has been proposed for heroin smokers [7], the high rates among injectors indicate that a broader approach is needed [1]. Such screening is relevant to the quality of life of heroin users and to their risk of death from opioid-induced respiratory depression. Many such venues would not currently have access to high-quality spirometry, but investment in such technology may reduce the overall burden of disease among this population. In terms of the treatment of heroin dependence, buprenorphine maintenance has been shown to have reduced overdose mortality risk compared to methadone maintenance for older patients and those with physical comorbidities [19]. This, in all probability, is because of the mixed antagonist/agonists properties of buprenorphine and its lower level of respiratory depression compared to methadone (a pure agonist). For heroin users with COPD, buprenorphine would appear the prudent clinical choice of a maintenance drug. The provision of take-home naloxone is warranted for all heroin users, but is particularly salient for those with COPD. Finally, tobacco smoking cessation is a priority. Although this may seem a secondary issue in light of heroin dependence, it is clearly one that has implications for the morbidity and mortality of the heroin using population.