Injecting Drug Use Clinical Presentation

  • Author: Gloria J Baciewicz, MD; Chief Editor: Eduardo Dunayevich, MD   more...
 
Updated: Dec 15, 2011
 

History

  • Obtain a complete history of the individual's past alcohol and drug use, including the following:
    • Age of onset for each drug used
    • Frequency of use
    • Quantities used
    • Progression of use with time
    • Medical and psychiatric symptoms associated with use
    • Routes of administration for each drug
    • Means of obtaining drugs or money for drugs
    • Longest periods of abstinence from drug use
    • History of prior chemical dependency treatments
  • Ask those who report injecting drug use which injecting sites they use, whether they use new or used needles, and whether they share other items used in the preparation of drugs for injection (eg, cookers, cotton). Ask those who share needles and syringes whether they attempt to clean the needles (eg, by using a bleach kit distributed by outreach workers).
  • Other risks associated with injecting drug use include contaminated drug solutions, buying ready-filled syringes, and sharing rinse water. "Backloading" is a practice in which a dealer transfers the drug solution from a larger syringe to a syringe provided by the user. "Flashblood" is a practice initially reported among sex workers in Dar es Salaam, in which an individual draws blood back into the syringe after having injected heroin, and then passes the syringe to another individual to inject the blood in the belief that this will prevent withdrawal symptoms.
  • Individuals may inject substances that are not supposed to be injected, such as pulverized (and unsterile) pills mixed with liquid. The liquid used to prepare drugs for injection is usually water, although use of lemonade and vinegar for this purpose has also been reported.
  • Ask about a history of prior systemic or local infections secondary to injecting drug use.
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Physical

  • Begin with a standard physical assessment, paying special attention to signs of current injecting drug use, such as needle tracks. Other physical signs related to alcohol and drug use may also be present.
    • Common injection sites, such as the antecubital areas, should be inspected for evidence of recent injection. Some individuals may also use more unusual sites for injection, such as veins in the feet, hands, groin, and even the neck. As individuals who use injection drugs age and commonly used veins sclerose, these individuals may select progressively more dangerous sites. Hospitalized patients and patients who receive intravenous medication may inject drugs into their indwelling intravenous lines.
    • Check vital signs because changes are commonly associated with alcohol and drug intoxication and withdrawal, as well as with systemic infections secondary to injecting drug use. Stimulants, such as cocaine, may cause hyperthermia, an easily treatable yet easily overlooked condition. Persons who are intoxicated may also present with hypothermia, especially if they have been confused and wandering outside in cold weather.
  • Perform a mental status examination. Pay special attention to level of alertness because many drug and alcohol intoxication and withdrawal states can produce changes in alertness and orientation. Assess affect and mood and note whether suicidal ideation or intent is present. Drugs of abuse may cause or exacerbate depression and suicidal ideation. Determine the presence or absence of homicidal or violent intent and ask whether the patient has guns at home. Assess thought content and the presence or absence of hallucinations, delusions, or paranoid ideation and ask the patient whether these phenomena seem to be exacerbated or caused by drug use. Many patients with drug-induced delusions or hallucinations are in fact aware of the relationship between their drug use and the delusions or hallucinations.
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Causes

  • Individuals begin using addictive drugs for various reasons; some are seeking a high, some wish to relieve dysphoria, and some seek escape from intolerable feelings or thoughts.
    • Craving for addictive drugs is associated with increased activation of brain reward areas, including the nucleus accumbens and other brain areas. Drug use directly or indirectly elevates dopamine levels in the mesolimbic pathway of the brain, producing a pleasurable and positively reinforcing high.
    • Those who are at risk for developing dependence on addictive drugs may have a genetic predilection for this problem.
    • Neuronal changes in specific brain regions (ie, neuroadaptation) occur in response to repeated drug use. Thus differences exist in the brains of addicted and nonaddicted individuals, and these differences can be demonstrated by brain imaging techniques.
  • Those who use drugs experience a compulsion to use the addictive drug regardless of negative consequences.
  • Those who use drugs may make the transition from noninjecting drug use to injecting drug use as their dependence on the drug becomes more severe. Injecting drug use is a popular route of drug administration because the injected substance has almost 100% bioavailability, and the onset of the drug high is fairly rapid, generally 15-30 seconds.
  • Those who use drugs use nonsterile injecting equipment largely because of the scarcity of sterile needles and syringes. Many people will use sterile needles and syringes if provided access to them. Making sterile injecting equipment available, either for purchase or via a needle exchange program, decreases rates of HIV and hepatitis B infections.
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Contributor Information and Disclosures
Author

Gloria J Baciewicz, MD  Director of Addiction Psychiatry Program, Clinical Associate Professor, Department of Psychiatry, Strong Memorial Hospital, University of Rochester

Gloria J Baciewicz, MD is a member of the following medical societies: American Academy of Addiction Psychiatry, American Psychiatric Association, and American Society of Addiction Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Barry I Liskow, MD  Professor of Psychiatry, Vice Chairman, Psychiatry Department, Director, Psychiatric Residency Program, University of Kansas School of Medicine; Director, Psychiatric Outpatient Clinic, The University of Kansas Medical Center

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Harold H Harsch, MD  Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin

Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: lilly Honoraria Speaking and teaching; Forest Labs None None; Pfizer Grant/research funds Speaking and teaching; Northstar None None; Novartis Grant/research funds research; Pfizer Honoraria Speaking and teaching; Sunovion Speaking and teaching; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research; Merck Honoraria Speaking and teaching

Chief Editor

Eduardo Dunayevich, MD  Adjunct Assistant Professor, Department of Psychiatry, University of Cincinnati; Clinical Research Physician, Neuroscience, Lilly Research Laboratories

Eduardo Dunayevich, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: Nothing to disclose.

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