Adding COPD Screenings to Drug Clinic Appointments Yields Benefits for Patients

A UK study found that adding respiratory health screenings to drug clinic appointments for those trying to recover from heroin use was effective at uncovering chronic obstructive pulmonary disease (COPD ) in this group of patients.

The research found that a majority of heroin users who had been smoking the drug had COPD, asthma, or asthma-COPD overlap syndrome, typically in the mild-to-moderate range.

This study had multiple aims: to see if this sort of screening was deliverable and acceptable to patients, to establish the prevalence of COPD in a large cohort of heroin and crack cocaine smokers, and to examine the relationship between drug exposure and lung health.¹

The authors noted that with the rise over the past 3 decades of inhalation becoming a primary vehicle for heroin use, versus injection, there has been a corresponding rise in respiratory disease in this group. Other studies have shown a high level of respiratory symptoms, a lack of accurate diagnosis, as well undertreatment.

Health workers assessed drug exposure, respiratory symptoms, health status, and COPD prevalence at 31 sites in Liverpool. The study was funded by the local National Health Service (NHS) healthcare provider, Liverpool Clinical Commissioning Group, which plans and buys most healthcare services.

Potential participants had a shared healthcare agreement between their primary care team and a local independent drug service provider, and were currently or recently treated with methadone or buprenorphine. They were current or previous smokers of heroin or crack cocaine.

Every client was offered a single study appointment at their usual site, at their usual time, with their usual drug counselor. Counselors at the sites were educated about COPD and the role of spirometry. Participants completed the COPD Assessment Tool (CAT) quality of life questionnaire, the Medical Research Council (MRC) Dyspnea Score, a questionnaire detailing respiratory symptoms, current and previous respiratory diagnoses and treatment, and a questionnaire detailing use of cigarettes, heroin, crack, and cannabis.

Subjects were asked to not use a short-acting bronchodilator within 8 hours of the visit or a long-acting bronchodilator within 24 hours prior.

If the subject did not use inhalers or had not taken their bronchodilator(s) as directed, they performed pre-bronchodilator spirometry. If the spirometry was abnormal, they were given 400 mcg salbutamol administered via a spacer. Post-bronchodilator was performed 15 minutes later. If the subject had taken a bronchodilator before the visit, they did not perform pre-bronchodilator spirometry. They were given 400 mcg salbutamol and post-bronchodilator spirometry was again performed after waiting at least 15 minutes.

A total of 1082 clients were eligible to take part in the study; 753 completed the screening process.

Of the 753 participants:

• 260 (35%) had COPD, using forced expiratory volume in 1 second (FEV₁) /forced vital capacity (FVC) of less than 0.7
• 293 (39%), using a lower limit of normal, had airflow obstruction consistent with COPD and post-bronchodilator FEV1/FVC ratio of 0.7 or greater
• 112 (15%) had asthma-COPD overlap (ACO) with features of COPD and asthma

Compared to those with normal spirometry, COPD subjects were more breathless (MRC score 3.1 vs. 1.9; P <.001) and had worse health status (CAT score 22.9 vs. 1.4; P <.001). Individuals with COPD had smoked cigarettes (P <.001), heroin (P <.001) and crack (P =.03) for longer, and were more likely to still be smoking heroin (P <.01).

The majority of patients were happy to have the screenings combined with their other clinic appointments.

The researchers noted that addressing the healthcare needs of this particular population is challenging, and that they don’t frequently interact with traditional models of healthcare delivery, including disease prevention and screening.

However, receiving methadone is contingent on regular engagement with drug counselors. Therefore, co-locating physical health services with existing drug services is “an attractive model to address current challenges,” the authors wrote, and could be used in other populations that are difficult to reach.

The findings of this study are “remarkable,” said Donald P. Tashkin, MD, of the division of pulmonary and critical care medicine, David Geffen School of Medicine, UCLA, in an accompanying editorial.² COPD prevalence in habitual heroin smokers is much higher than that reported among regular tobacco smokers in the same age group; in addition, the average age of the heroin smokers is much lower than that of tobacco smokers at the time of COPD diagnosis. A case for screening spirometry targeted to this population at particularly high risk for COPD can be made, he said.

Reference

1. Burhan H, Young R, Byrne T, et al. Screening heroin smokers attending community drug services for COPD. Chest. 2019;155(2):279-287. doi: 10.1016/j.chest.2018.08.1049.
2. Tashkin DP. Heroin smoking and COPD: A case for targeted screening and spirometry. Chest. 2019;155(2):247-248. doi: 10.1016/j.chest.2018.08.1039.