eMedicine Specialties > Psychiatry > Addiction

Injecting Drug Use: Follow-up

Author: Gloria J Baciewicz, MD, Director of Addiction Psychiatry Program, Clinical Associate Professor, Department of Psychiatry, Strong Memorial Hospital, University of Rochester
Contributor Information and Disclosures

Updated: Aug 5, 2008

Follow-up

Complications

  • Local problems associated with injecting drug use include abscess, cellulitis, septic thrombophlebitis, local induration, necrotizing fascitis, gas gangrene, pyomyositis, mycotic aneurysm, compartmental syndromes, and foreign bodies (eg, broken needle parts) in local areas. The most common causative organisms reported are Staphylococcus aureus or Staphylococcus epidermidis, streptococci, and gram-negative bacilli.
  • Systemic problems associated with injecting drug use are HIV infection, hepatitis B or C, pneumonia or lung abscess from septic emboli to the lung, acute and subacute bacterial endocarditis, group A beta-hemolytic streptococcal septicemia, osteomyelitis, septic arthritis, candidal and other fungal infections, tetanus, clostridial myonecrosis, malaria, and amyloidosis. The endocarditis that occurs in individuals who inject drugs involves the right-sided heart valves; a recent review found no explanation for this predilection.8 A rare case of needle embolization to the lung has been reported.

Patient Education

  • Chemical dependency treatment provides education and skills training regarding abstinence from drug use. For those individuals who are not yet able to abstain from injecting drug use, harm reduction approaches are used to educate about methods of safer injection, including the use of clean needles, sterile injection techniques, and safe disposal of needles.9 Such outreach approaches are effective in promoting behavior change and slowing the spread of HIV and other infections.10,11
  • Informal needle exchange programs in the United States began as early as the 1970s. In 1988, the New York City Health Department began the first government-sponsored needle exchange program in the United States. Usually, needle exchange programs operate by exchanging the used needles for an equal number of clean needles and syringes. Needle exchange programs may make referrals for chemical dependency treatment and medical treatment and may participate in other public health initiatives, such as distributing condoms and arranging HIV testing.
  • In some areas, needles and syringes are available for purchase from a pharmacy without a prescription. Those who purchase needles and syringes from pharmacies are less likely to participate in high-risk activities, such as using the services of crack houses or shooting galleries.
  • Several countries have developed harm reduction programs with different methods, including the introduction of syringe vending machines12 and safe injecting areas or rooms.
  • Programs that distribute injectable naloxone to individuals for use in suspected overdose situations have been implemented in many larger US cities.
  • To reduce risks associated with injecting drug use, clinicians and public health workers must raise awareness of the health consequences and risks of injection, make contact with the target population by improving access and outreach, provide the means to change risky behavior, and gain political and community support for the measures introduced.
  • For excellent patient education resources, visit eMedicine's Substance Abuse Center. Also, see eMedicine's patient education articles Drug Dependence and Abuse, Narcotic Abuse, and Substance Abuse.

Miscellaneous

Medicolegal Pitfalls

  • Consider denial and motivation. Some patients may initially report other medical or psychiatric problems, not admitting that they use drugs or alcohol. Others may seek controlled substances from medical providers reporting malingered medical or psychiatric illnesses. Still others may exaggerate the severity of their problems and seek hospital admission because they are having legal problems or difficulties on the street.
  • Some individuals may bring drugs or alcohol into clinical settings to use while waiting or when left alone. Visitors may bring drugs to the patient. Patients with IV lines may use this route of access to inject illicit drugs.
  • When an individual needs treatment for alcohol or drug withdrawal, remember that alcohol/hypnotic-sedative withdrawal can be life-threatening and should be treated aggressively. Opioid withdrawal can cause much subjective physical distress but does not by itself result in death. Excessive doses of opioids administered for treatment of withdrawal can, however, produce coma and death.
  • Avoid undertreatment of pain and other medical and psychiatric problems. Patients dependent on opioids may need higher doses of opioids for pain relief because of tolerance. Clinicians sometimes focus on the drug use itself and on associated behavioral problems, overlooking important and treatable medical and psychiatric problems.

Special Concerns

  • Risk of sexually transmitted diseases from unprotected sexual activity
  • Risk of physical violence
  • Medical and psychosocial problems related to concurrent alcohol and noninjecting drug use
 


More on Injecting Drug Use

Overview: Injecting Drug Use
Differential Diagnoses & Workup: Injecting Drug Use
Treatment & Medication: Injecting Drug Use
Follow-up: Injecting Drug Use
References
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References

  1. Doherty MC, Garfein RS, Monterroso E. Correlates of HIV infection among young adult short-term injection drug users. AIDS. Apr 14 2000;14(6):717-26. [Medline].

  2. Williams I. Epidemiology of hepatitis C in the United States. Am J Med. Dec 27 1999;107(6B):2S-9S. [Medline].

  3. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2003. 2004;15:[Full Text].

  4. Bennett GA, Velleman RD, Barter G. Gender differences in sharing injecting equipment by drug users in England. AIDS Care. Feb 2000;12(1):77-87. [Medline].

  5. Becker Buxton M, Vlahov D, Strathdee SA. Association between injection practices and duration of injection among recently initiated injection drug users. Drug Alcohol Depend. Aug 16 2004;75(2):177-83. [Medline].

  6. Landau J, Garrett J, Shea RR. Strength in numbers: the ARISE method for mobilizing family and network to engage substance abusers in treatment. A Relational Intervention Sequence for Engagement. Am J Drug Alcohol Abuse. Aug 2000;26(3):379-98. [Medline].

  7. Centers for Disease Control and Prevention. Cases of HIV Infection and AIDS in the United States, by Race/Ethnicity, 2000-2004. HIV/AIDS Surveillance Supplemental report. 2006;12 (1):[Full Text].

  8. Frontera JA, Gradon JD. Right-side endocarditis in injection drug users: review of proposed mechanisms of pathogenesis. Clin Infect Dis. Feb 2000;30(2):374-9. [Medline].

  9. Macalino GE, Springer KW, Rahman ZS. Community-based programs for safe disposal of used needles and syringes. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;18 Suppl 1:S111-9. [Medline].

  10. Coyle SL, Needle RH, Normand J. Outreach-based HIV prevention for injecting drug users: a review of published outcome data. Public Health Rep. Jun 1998;113 Suppl 1:19-30. [Medline].

  11. Deren S, Cleland CM, Fuller C, Kang SY, Des Jarlais DC, Vlahov D. The impact of syringe deregulation on sources of syringes for injection drug users: preliminary findings. AIDS Behav. Nov 2006;10(6):717-21. [Medline].

  12. Obadia Y, Feroni I, Perrin V. Syringe vending machines for injection drug users: an experiment in Marseille, France. Am J Public Health. Dec 1999;89(12):1852-4. [Medline].

  13. Aceijas C, Friedman SR, Cooper HL, Wiessing L, Stimson GV, Hickman M. Estimates of injecting drug users at the national and local level in developing and transitional countries, and gender and age distribution. Sex Transm Infect. Jun 2006;82 Suppl 3:iii10-17. [Medline].

  14. Aceijas C, Oppenheimer E, Stimson GV, Ashcroft RE, Matic S, Hickman M. Antiretroviral treatment for injecting drug users in developing and transitional countries 1 year before the end of the "Treating 3 million by 2005. Making it happen. The WHO strategy" ("3 by 5"). Addiction. Sep 2006;101(9):1246-53. [Medline].

  15. Ball AL, Rana S, Dehne KL. HIV prevention among injecting drug users: responses in developing and transitional countries. Public Health Rep. Jun 1998;113 Suppl 1:170-81. [Medline].

  16. Beck EJ, Mandalia S, Williams I. Decreased morbidity and use of hospital services in English HIV-infected individuals with increased uptake of anti-retroviral therapy 1996-1997. National Prospective Monitoring System Steering Group. AIDS. Oct 22 1999;13(15):2157-64. [Medline].

  17. Brunton C, Kemp R, Raynel P. Cumulative incidence of hepatitis C seroconversion in a cohort of seronegative injecting drug users. N Z Med J. Mar 24 2000;113(1106):98-101. [Medline].

  18. Carrieri MP, Moatti JP, Vlahov D. Access to antiretroviral treatment among French HIV infected injection drug users: the influence of continued drug use. MANIF 2000 Study Group. J Epidemiol Community Health. Jan 1999;53(1):4-8. [Medline].

  19. Cherington M. Clinical spectrum of botulism. Muscle Nerve. Jun 1998;21(6):701-10. [Medline].

  20. Contoreggi C, Rexroad VE, Lange WR. Current management of infectious complications in the injecting drug user. J Subst Abuse Treat. Mar-Apr 1998;15(2):95-106. [Medline].

  21. Des Jarlais DC, Friedman SR. Fifteen years of research on preventing HIV infection among injecting drug users: what we have learned, what we have not learned, what we have done, what we have not done. Public Health Rep. Jun 1998;113 Suppl 1:182-8. [Medline].

  22. Gostin LO, Lazzarini Z, Jones TS. Prevention of HIV/AIDS and other blood-borne diseases among injection drug users. A national survey on the regulation of syringes and needles. JAMA. Jan 1 1997;277(1):53-62. [Medline].

  23. Gowing L, Farrell M, Bornemann R. Substitution treatment of injecting opioid users for prevention of HIV infection. Cochrane Database Syst Rev. 2004;CD004145. [Medline].

  24. Hughes PH, Rieche O. Heroin epidemics revisited. Epidemiol Rev. 1995;17(1):66-73. [Medline].

  25. Hughes RA. Drug injectors and the cleaning of needles and syringes. Eur Addict Res. Mar 2000;6(1):20-30. [Medline].

  26. Hulse GK, English DR, Milne E. The quantification of mortality resulting from the regular use of illicit opiates. Addiction. Feb 1999;94(2):221-9. [Medline].

  27. Kaye S, Darke S. A comparison of the harms associated with the injection of heroin and amphetamines. Drug Alcohol Depend. Feb 1 2000;58(1-2):189-95. [Medline].

  28. Lennings CJ. Harm minimization or abstinence: an evaluation of current policies and practices in the treatment and control of intravenous drug using groups in Australia. Disabil Rehabil. Jan 10-20 2000;22(1-2):57-64. [Medline].

  29. Lert F, Kazatchkine MD. Antiretroviral HIV treatment and care for injecting drug users: an evidence-based overview. Int J Drug Policy. Aug 2007;18(4):255-61. [Medline].

  30. Leshner AI. Science-based views of drug addiction and its treatment. JAMA. Oct 13 1999;282(14):1314-6. [Medline].

  31. Martin V, Cayla JA, Bolea A. Mycobacterium tuberculosis and human immunodeficiency virus co-infection in intravenous drug users on admission to prison. Int J Tuberc Lung Dis. Jan 2000;4(1):41-6. [Medline].

  32. Massad E, Rozman M, Azevedo RS. Seroprevalence of HIV, HCV and syphilis in Brazilian prisoners: preponderance of parenteral transmission. Eur J Epidemiol. May 1999;15(5):439-45. [Medline].

  33. Mast EE, Alter MJ, Margolis HS. Strategies to prevent and control hepatitis B and C virus infections: a global perspective. Vaccine. Mar 26 1999;17(13-14):1730-3. [Medline].

  34. Mclean L, Sharma S. Mycotic pulmonary arterial aneurysms in an intravenous drug user. Canadian Respiratory J. 1998;5(4):307-11.

  35. Metzger DS, Woody GE, McLellan AT. Human immunodeficiency virus seroconversion among intravenous drug users in- and out-of-treatment: an 18-month prospective follow-up. J Acquir Immune Defic Syndr. Sep 1993;6(9):1049-56. [Medline].

  36. Moatti JP, Carrieri MP, Spire B. Adherence to HAART in French HIV-infected injecting drug users: the contribution of buprenorphine drug maintenance treatment. The Manif 2000 study group. AIDS. Jan 28 2000;14(2):151-5. [Medline].

  37. Molitor F, Ruiz JD, Flynn N. Methamphetamine use and sexual and injection risk behaviors among out-of-treatment injection drug users. Am J Drug Alcohol Abuse. Aug 1999;25(3):475-93. [Medline].

  38. Neaigus A, Gyarmathy VA, Miller M, Frajzyngier V, Zhao M, Friedman SR. Injecting and sexual risk correlates of HBV and HCV seroprevalence among new drug injectors. Drug Alcohol Depend. Jul 10 2007;89(2-3):234-43. [Medline].

  39. Powis B, Strang J, Griffiths P. Self-reported overdose among injecting drug users in London: extent and nature of the problem. Addiction. Apr 1999;94(4):471-8. [Medline].

  40. Rhodes F, Deren S, Wood MM. Understanding HIV risks of chronic drug-using men who have sex with men. AIDS Care. Dec 1999;11(6):629-48. [Medline].

  41. Shapiro CN, Coleman PJ, McQuillan GM. Epidemiology of hepatitis A: seroepidemiology and risk groups in the USA. Vaccine. 1992;10 Suppl 1:S59-62. [Medline].

  42. Smith AM, Lindsay J, Rosenthal DA. Same-sex attraction, drug injection and binge drinking among Australian adolescents. Aust N Z J Public Health. Dec 1999;23(6):643-6. [Medline].

  43. Smith DK, Grohskopf LA, Black RJ. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States: recommendations from the U.S. Department of Health and Human Services. MMWR Recomm Rep. Jan 21 2005;54(RR-2):1-20. [Medline].

  44. Stimson GV, Fitch C, Rhodes T. The rapid assessment and response guide on injecting drug use. World Health Organization, Substance Abuse Department; 1998.

  45. Strang J, Powis B, Best D. Preventing opiate overdose fatalities with take-home naloxone: pre-launch study of possible impact and acceptability. Addiction. Feb 1999;94(2):199-204. [Medline].

  46. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. The NSDUH report: Demographic and Geographic Variations in Injection Drug Use. 2007;[Full Text].

  47. Thorne LB, Collins KA. Speedballing with needle embolization: case study and review of the literature. J Forensic Sci. Sep 1998;43(5):1074-6. [Medline].

  48. UNAIDS. AIDS Epidemic Update: Special Report on HIV/AIDS. December 2006;[Full Text].

  49. UNAIDS. Report on the Global AIDS Epidemic 2006. May, 2006.

  50. United Nations Office on Drugs and Crime. 2007 World Drug Report. [Full Text].

  51. Vlahov D, Junge B. The role of needle exchange programs in HIV prevention. Public Health Rep. Jun 1998;113 Suppl 1:75-80. [Medline].

  52. White JM, Irvine RJ. Mechanisms of fatal opioid overdose. Addiction. Jul 1999;94(7):961-72. [Medline].

  53. Whynot EM. Women who use injection drugs: the social context of risk. CMAJ. Aug 25 1998;159(4):355-8. [Medline].

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Further Reading

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Keywords

intravenous drug use, IV drug use, injecting drug user, IDU, heroin, opiate, opioid, methadone, syringes, needles, needle sharing, hypodermic syringe, hypodermic needle, cocaine, heroin, amphetamines, buprenorphine, benzodiazepines, barbiturates, methamphetamine, HIV infection, talc, lactate, quinine, respiratory depression, coma, pulmonary edema, cardiac dysrhythmias, conduction disturbances, myocardial infarction, stroke

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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.

Medical Editor

Barry I Liskow, MD, Vice Chairman, Director Psychiatry Residency Program, Professor, Department of Psychiatry, University of Kansas Medical School
Barry I Liskow, MD is a member of the following medical societies: American Academy of Addiction Psychiatry
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing 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.

CME Editor

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; BMS Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Other; Northstar Grant/research funds Other; Novartis  Other; Pfizer Honoraria Speaking and teaching

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
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