Substance Use and Lung Transplant: Facts, Honesty, and Healing

Alongside  the extraordinary circumstances of living with a lung transplant, recipients experience many of the same joys and struggles as the rest of the population.

In honor of National Recovery Month, a recent Transplant Talk webinar brought together medical experts and patient advocates to address a critical, yet often stigmatized topic: substance use and abuse before and after a lung transplant. The webinar featured insights from Dr. Erin Lowery, Medical Director of the Lung Transplant Program at UW Health, and Bob Murphy, a double lung transplant recipient who shared his personal journey with alcohol use leading up to his transplant. Understanding how substances like alcohol, nicotine, marijuana, and prescription medications interact with anti-rejection treatments can make a significant difference in achieving long-term health after transplant.

Key Takeaways

• Open Communication Builds Trust: Disclosing substance use to your medical team is not about punishment or eligibility denial; it is about establishing a safe care plan to protect your new lungs.
• Alcohol Interacts with Essential Medications: Alcohol alters liver enzymes that break down primary immunosuppressants like tacrolimus, creating dangerous spikes or drops in medication blood levels.
• Tobacco and Nicotine Harm Lung Function: Smoking damages the lung’s cilia, blunts natural clearing reflexes, and significantly raises the risk of post-transplant infections and blood clots.
• CBD and Cannabis Carry Hidden Risks: Unregulated CBD and THC products interact with liver metabolic pathways, leading to fluctuating anti-rejection drug levels even when used topically or in edible form.
• Recovery and Help Are Available: Substance use disorder is a valid medical condition, and transplant teams offer dedicated resources to support long-term recovery and alternative coping mechanisms.

The Medical Impact of Substance Use Post-Transplant

How Alcohol Affects Anti-Rejection Drugs and Lung Health

Many patients wonder why alcohol abstinence is strictly emphasized following transplant surgery. Alcohol is processed by the liver using CYP enzymes, the same pathway responsible for metabolizing key immunosuppressive medications like tacrolimus and cyclosporine. Consuming alcohol inhibits these enzymes, causing tacrolimus levels to spike. Elevated tacrolimus levels increase the risk of severe side effects, including kidney toxicity, high blood pressure, tremors, headaches, and opportunistic infections. Additionally, alcohol impairs the movement of cilia—the tiny hair-like structures that clean the airways—and dampens natural cough reflexes, raising the risk of pneumonia tenfold.

Nicotine, Marijuana, and Prescription Drug Interactions

Nicotine creates a profound physical dependence, and returning to tobacco smoking after transplant directly damages airway clearance mechanisms. Cigarette smoke induces liver enzymes that lower the efficacy of over 80 medications, including treatments for mental health and interstitial lung disease. Complete nicotine abstinence before transplant is essential to prevent post-surgery relapse.

Similarly, cannabis and non-FDA-regulated CBD products compete for the same metabolic pathways as tacrolimus. CBD in particular potently alters liver enzymes, leading to unpredictable anti-rejection drug concentrations. Using prescription drugs like benzodiazepines (e.g., Xanax, Valium) outside of how they are prescribed presents additional hazards by depressing breathing rates, worsening sleep apnea, increasing fall risks during recovery, and posing high risks of physical dependence.

A Patient’s Perspective: The Power of Honesty

Bob Murphy received a double lung transplant at UPMC Presbyterian on September 3, 2025. While Bob successfully quit smoking and overcame a nicotine habit prior to listing, he continued to consume alcohol daily without informing his transplant team.

When his call for transplant arrived, Bob had consumed alcohol the day before surgery. Following the procedure, Bob experienced two weeks of intense post-operative delirium, nightmares, and severe medical complications, including a rapid heart rate event requiring emergency intervention. Medical providers were initially unaware that alcohol withdrawal was fueling these complications until Bob’s wife informed the team.

Reflecting on his experience, Bob emphasizes that his story is not about shame, but about saving lives through honesty. Today, Bob is over a year post-transplant, walking six to seven miles daily, riding his bike, and maintaining an open, trusting relationship with his care team. His primary message to pre- and post-transplant patients is clear: disclose everything to your team so they can help keep you safe.

How Transplant Teams Evaluate and Support Patients: Transplant programs systematically screen candidates using clinical questionnaires (such as the AUDIT or CAGE tests) and lab screenings (such as Phosphatidylethanol / PETH testing for alcohol or cotinine testing for nicotine). The primary goal of screening is not to disqualify candidates, but to identify risk factors, establish accountability, and provide mental health support or addiction resources prior to the stress of surgery.

Watch the full Transplant Talk recording here:

If you or a loved one are navigating lung disease, substance use, or post-transplant recovery, support is available, and most importantly you are not alone.