Amy Winehouse, Crack Cocaine and Emphysema

²Figure 15b: Advanced emphysema in a
relatively young (36-year-old) woman with
a history of heavy cocaine abuse and unrelated
mitral valve disease. Chest CT scan reveals
diffuse advanced emphysema.

The latest news in the celebrity drug-abuse world is that Amy Winehouse’s dad has informed the press that she has early stage emphysema. Her publicist has also confirmed the report.

Although health problems related to drug abuse are nothing novel in the world of musical entertainment, emphysema in a 24-year old is unusual, to say the least.

Unusual because the most salient reference point for emphysema is the long-term tobacco smoker. The Mayo clinic site on risk factors confirms the impression that emphysema is associated with a long tobacco smoking history:

Age. Although the lung damage that occurs in emphysema develops gradually, most people with tobacco-related emphysema begin to experience symptoms of the disease between the ages of 50 and 60.

Also see eMedicineHealth, MedlinePlus, MedicineNet, WebMD which confirm the impression of a slowly-developing disease which is associated with chronic tobacco smoking and tends to appear in later life; as emphysema.org describes it:

Emphysema doesn’t develop suddenly, it comes on very slowly. Years of exposure to the irritation of cigarette smoke usually precede the development of emphysema.

Now, it may be the case that Amy Winehouse has a genetic predisposition for early onset emphysema, indeed a genetic risk factor can interact with tobacco smoking to greatly enhance the chances of a younger person suffering from emphysema.

In a small percentage of people, emphysema results from low levels of a protein called alpha-1-antitrypsin (AAt), which protects the elastic structures in your lungs from the destructive effects of certain enzymes. A lack of AAt can lead to progressive lung damage that eventually results in emphysema. If you’re a smoker with a lack of AAt, emphysema can begin in your 30s and 40s.

It is quite likely in Winehouse’s case that her reported crack cocaine smoking played a specific and causal role.
For example, Taskin and colleagues reported¹ that even when you control for concurrent tobacco and marijuana smoking, free-base cocaine smoking confers substantial respiratory risk.

…heavy, habitual cocaine smoking was associated with the following: (1) a high frequency of acute respiratory symptoms (cough, black sputum, chest pain) in temporal association with freebase use; (2) an obstructive ventilatory abnormality involving the large airways; and (3) a mild but significant impairment in the diffusing capacity of the lung.

This was observed in a population which averaged 6.6 grams of cocaine per week over a 27 month interval so the fact that Amy Winehouse is so young is probably immaterial. A several year history of crack smoking may be sufficient to compromise lung function to a clinically significant extent.
A review by ²Restrepo and colleagues informs us of a number of critical issues including:

• The average size of generated particles is 2.3 µm, which is small enough to result in the deposition of particles in the alveolar region of the lung (Snyder et al, 1988).
• Respiratory symptoms include cough with production of carbonaceous material, chest pain, dyspnea, hemoptysis, wheezing, and exacerbation of asthma (Haim et al, 1995).
• Massive quantities of carbon pigment are often found at bronchoalveolar lavage (BAL) in patients with a history of crack cocaine abuse. During the smoking of crack, a dark and tarry residue is formed, which many addicts collect and then resmoke along with more crack. During the inhalation of these impurities, there is extensive accumulation of large amounts of intracellular (macrophages) and extracellular carbon pigment (Greenebaum et al, 1993).
• Pulmonary emphysema…has been reported in 2%-4% of intravenous drug abusers, with an upper lobe predominance and typically affecting young males and is associated in particular with methylphenidate injection (Goldstein et al, 1986; O’Donnell et al, 1988; Weisbrod et al, 1993).

Mitch Winehouse, the singer’s dad, was quoted in a way that indicates he is perhaps a bit naive about substance abuse:

He called on drug dealers to help her recovery by refusing to supply her with crack cocaine.
-snip-
“If she hadn’t done recent shows in Moscow and Portugal she could have been dead by now,” he said. “She abstains and regulates her drug use when she has to do a show.”

return to huntPerhaps she does use less when working, when out of contact with her regular suppliers and/or when inhibited by fears of getting arrested for drug possession while traveling. This is not, however, the solution to a drug addiction. She is not going to be cured this way. She cannot do this herself by working harder at her profession. Trying to appeal to the better nature of “drug dealers” is a losing proposition.
Mr. Winehouse, get your daughter in rehab and long-term recovery before she kills herself.
__

¹Tashkin DP, Gorelick D, Khalsa ME, Simmons M, Chang P. Respiratory effects of cocaine freebasing among habitual cocaine users. J Addict Dis. 1992;11(4):59-70.

²Restrepo CS, Carrillo JA, Martínez S, Ojeda P, Rivera AL, Hatta A. Pulmonary complications from cocaine and cocaine-based substances: imaging manifestations. Radiographics. 2007 Jul-Aug;27(4):941-56. The content of the Journals of the Radiological Society of North America (RSNA) appearing on this site is copyrighted by the RSNA, which reserves all rights therein.