eMedicine Specialties > Psychiatry > Addiction
Injecting Drug Use: Treatment & Medication
Updated: Aug 5, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- Medical care of individuals who use injection drugs should focus on initial management of local or systemic complications of injecting drug use and then on referral to appropriate chemical dependency treatment programs.
- Some patients may have multiple medical problems and poor socioeconomic status. They may lack medical insurance and a stable place to live, and they may have mental health problems, either preexisting or associated with chronic substance use. Therefore, each patient requires a comprehensive physical examination as well as a thorough history. The patient possibly does not know what he or she has injected because many of the street drugs are altered or laced with other substances.
- These individuals may have undergone many poorly coordinated episodes of prior medical, mental health, and chemical dependency treatments by several different providers. Facilitating coordination of medical, mental health, and chemical dependency care can avoid duplication of services and, hopefully, assist the patient in adhering to the treatment regimen.
- Individuals treated in hospital emergency departments for acute illness may be difficult to evaluate because of medical problems, poor nutrition, debilitation, and drug and alcohol intoxication or withdrawal. Also, at times, they may be unwilling to accept further treatment. Many localities have legal provisions for holding such individuals in the emergency department while they are intoxicated, until they can be stabilized enough for a safe discharge. Once the withdrawal symptoms and other medical symptoms are under control, referrals for chemical dependency treatment may be made.
- Treatment of alcohol and drug dependence is generally voluntary, unless psychiatric reasons are present that justify involuntary admission to psychiatric or mentally ill, chemically addicted (MICA) units. Some countries mandate forms of inpatient and outpatient chemical dependency treatment, such as the drug court system in many parts of the United States. Such involuntary treatment can be effective.
- Using the strengths of families and natural support systems can help engage individuals in treatment.6 Employee assistance programs may also be helpful in treatment engagement.
- Because addiction is a complex biopsychosocial problem, effective drug treatment must be comprehensive and must attend to the multiple needs of the individual. Comprehensive treatment might include behavioral therapy; pharmacotherapy; substance use monitoring; self-help groups; family therapy; parenting groups; case management; mental health services; medical services; screening for infectious diseases; and assistance with housing, legal problems, educational needs, and child care. Drug treatment teaches individuals to cope with drug cravings, to avoid relapse to drug use, and to deal with relapse if it occurs.
- Addiction is a treatable disease. Treatment for drug addiction reduces the risk of HIV infection. Drug treatment reduces criminal activity and also improves the individual's chances for employment.
- In 2005, the Centers for Disease Control and Prevention recommended use of a 28-day course of antiretroviral therapy to prevent HIV infection in those who have had substantial risk for HIV exposure via injecting drug use. The antiretroviral therapy must be initiated within 72 hours of exposure.7
Consultations
- Consultation with an expert in chemical dependency, if available, may help with collecting a complete chemical use history, determining the level of chemical dependency treatment needed, and negotiating the logistics of referral to addiction treatment facilities and self-help groups.
- Consultation with an infectious disease specialist may be needed to determine the diagnosis and treatment of infectious diseases associated with injecting drug use.
- A consultation with a psychiatrist, if psychiatric symptoms are present, helps determine whether these symptoms are preexisting or whether they are drug induced. A psychiatrist will recommend appropriate treatment for these problems.
- Many psychiatric symptoms and mental status changes may occur in alcohol and drug intoxication and withdrawal states. Intoxication with opioids, sedative hypnotics, and alcohol produces central nervous system depression, resulting in slurred speech, ataxia, and decreased alertness. Alcohol and sedative hypnotic withdrawal may produce delirium. Stimulants such as cocaine and amphetamines may cause or exacerbate mood symptoms, producing euphoria or irritability in the intoxicated state and irritability or depression in the withdrawal state.
- Psychiatric symptoms related to alcohol and drug use generally decrease and gradually resolve in the first few days and weeks of abstinence from alcohol and drugs. However, these symptoms may be quite severe initially and may require psychotropic medication or hospitalization. Differentiating acute drug-related symptoms from symptoms related to a preexisting psychiatric disorder may be difficult. Obtaining information about past periods of alcohol and drug abstinence from the patient and family may be helpful. If during a prolonged period of abstinence, psychiatric symptoms gradually improved without medication, these symptoms might be secondary to alcohol or drug use. If the psychiatric symptoms remained consistent or worsened during the period of abstinence, an independent psychiatric illness might be present.
- History of drug-related violence, suicidal ideation or attempts, and the presence of weapons in the home also are important areas to assess because they are related to admission, referral, and treatment decisions.
- Alcohol and drug use may worsen the psychiatric symptoms and clinical course for patients with preexisting serious psychiatric illnesses, such as affective disorder and schizophrenia. Alcohol and drug use in patients with severe psychiatric disorders has been associated with increased unemployment, housing problems, violence, and psychiatric rehospitalization.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Opioid replacement therapy
Individuals who have injected heroin or other opioids for long periods may need referral for opioid replacement therapy with methadone, buprenorphine, or buprenorphine/naloxone where such programs are available. In the United States, physicians who wish to prescribe buprenorphine must take a certification course. Levo-alpha-acetylmethadol (LAAM) has also been used for opioid replacement therapy, but use of LAAM has been less common because of concerns about severe QT prolongation secondary to LAAM.
Opioid replacement therapy reduces injecting drug use and thus reduces the mortality and morbidity associated with injecting drug use, including the transmission of HIV and HCV.
When individuals who are opioid dependent (including those who are on opioid replacement therapy) need analgesia, the clinician should be aware that these individuals may be tolerant to the analgesic effects of opioids; thus, they may require higher doses for pain control. Individuals taking naltrexone (an opioid antagonist) for opioid or alcohol dependence, also require higher doses of opioid analgesics to overcome the opioid blockade and provide pain relief.
Methadone (Dolophine)
Inhibits ascending pain pathways, diminishing the perception of and response to pain. In most countries, methadone is administered initially in the setting of a drug treatment program, both to prevent diversion (selling) of supply and to assure that counseling and other services also are provided.
Rate of dose increase and maximum dose often depend on program regulations and on federal and state regulations in the United States.
Patients who cannot take anything by mouth may be administered methadone IM, usually in a divided dose.
Adult
20-30 mg PO qd initially, gradually increase (depending on presence of opioid withdrawal symptoms) to 60-120 mg qd; higher doses may be used with the approval of the state authority within the United States
Pediatric
Not recommended
Phenytoin, rifampin, and pentazocine may decrease blood levels; phenothiazines, TCAs, MAOIs, and CNS depressants may increase toxicity
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with severe liver disease; because of its relatively long half-life, titrate dose slowly
Buprenorphine (Subutex)
Mixed agonist-antagonist narcotic with central analgesic effects for moderate to severe pain. Used sublingually for the initial detoxification treatment of opioid addiction. Produces agonist/antagonist effects at the opioid mu receptor. The agonist effect is limited by a ceiling effect (ie, higher doses [>16 mg] do not produce more analgesia). The sublingual product is called Subutex.
Adult
12-16 mg/d SL as a single dose during induction (supervised) phase, then begin buprenorphine and naloxone SL (Suboxone) during maintenance (unsupervised) phase
Pediatric
<16 years: Not established
>16 years: Administer as in adults
Phenothiazines may antagonize analgesic effects of opiate agonists; TCAs, MAOIs, and other CNS depressants may potentiate adverse effects; metabolized to norbuprenorphine by CYP3A4; CYP3A4 inhibitors (eg, ketoconazole, erythromycin, ritonavir, indinavir) may increase serum levels
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with hepatic or renal insufficiency, respiratory limitations (eg, bronchial asthma, obstructive respiratory conditions, cyanosis), neurologic injury, and Addison disease; causes respiratory depression; avoid use in patients with constipation and urinary retention; may precipitate abstinence syndrome in patients who are dependent on narcotics; may decrease pulse or blood pressure
Buprenorphine and naloxone (Suboxone)
Used sublingually for the maintenance detoxification treatment (unsupervised phase) of opioid dependence following induction with sublingual buprenorphine (Subutex). Contains both buprenorphine (an opiate agonist/antagonist) and the opiate antagonist naloxone. Naloxone has been added to guard against IV abuse of buprenorphine by individuals physically dependent on opiates.
Adult
Progressively adjust by increments/decrements of 2-4 mg/d SL to a target dose of 16 mg/d; adjust to the lowest dose that keeps patients in treatment while suppressing withdrawal effects; dosage may range from 4-24 mg/d
Pediatric
<16 years: Not established
>16 years: Administer as in adults
Increases toxicity of other CNS depressants (eg, barbiturates, benzodiazepines); metabolized to norbuprenorphine by CYP3A4; CYP3A4 inhibitors (eg, ketoconazole, erythromycin, ritonavir, indinavir) may increase serum levels
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hepatic or renal dysfunction, elderly patients, pulmonary diseases, biliary tract dysfunction, or neurologic injury; may precipitate abstinence syndrome in patients dependent on narcotics; may decrease pulse or blood pressure
Levomethadyl (ORLAAM)
Indicated for management of opioid dependence. No other recommended uses exist. In most countries, levomethadyl is administered initially in the setting of a drug treatment program, both to prevent diversion (selling) of supply and to assure that counseling and other services also are provided.
Adult
Patients with unknown tolerance to opioids: 20-40 mg PO 3 times qwk or qod initially, gradually increase by 5-10 mg if opioid withdrawal symptoms persist
Patients with known tolerance to opioids: Convert patients already on methadone maintenance to levomethadyl at 1.2-1.3 times the patient's dose of methadone; not to exceed 120 mg initially
Pediatric
Not recommended
Phenothiazines, TCAs, MAOIs, and other CNS depressants increase toxicity
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Peak activity is not immediate; use of other psychoactive drugs, including alcohol, may result in fatal overdose; may increase QT interval
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
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].
Williams I. Epidemiology of hepatitis C in the United States. Am J Med. Dec 27 1999;107(6B):2S-9S. [Medline].
Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2003. 2004;15:[Full Text].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
Cherington M. Clinical spectrum of botulism. Muscle Nerve. Jun 1998;21(6):701-10. [Medline].
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].
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].
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].
Gowing L, Farrell M, Bornemann R. Substitution treatment of injecting opioid users for prevention of HIV infection. Cochrane Database Syst Rev. 2004;CD004145. [Medline].
Hughes PH, Rieche O. Heroin epidemics revisited. Epidemiol Rev. 1995;17(1):66-73. [Medline].
Hughes RA. Drug injectors and the cleaning of needles and syringes. Eur Addict Res. Mar 2000;6(1):20-30. [Medline].
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].
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].
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].
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].
Leshner AI. Science-based views of drug addiction and its treatment. JAMA. Oct 13 1999;282(14):1314-6. [Medline].
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].
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].
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].
Mclean L, Sharma S. Mycotic pulmonary arterial aneurysms in an intravenous drug user. Canadian Respiratory J. 1998;5(4):307-11.
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].
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].
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].
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].
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].
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].
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].
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].
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].
Stimson GV, Fitch C, Rhodes T. The rapid assessment and response guide on injecting drug use. World Health Organization, Substance Abuse Department; 1998.
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].
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].
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].
UNAIDS. AIDS Epidemic Update: Special Report on HIV/AIDS. December 2006;[Full Text].
UNAIDS. Report on the Global AIDS Epidemic 2006. May, 2006.
United Nations Office on Drugs and Crime. 2007 World Drug Report. [Full Text].
Vlahov D, Junge B. The role of needle exchange programs in HIV prevention. Public Health Rep. Jun 1998;113 Suppl 1:75-80. [Medline].
White JM, Irvine RJ. Mechanisms of fatal opioid overdose. Addiction. Jul 1999;94(7):961-72. [Medline].
Whynot EM. Women who use injection drugs: the social context of risk. CMAJ. Aug 25 1998;159(4):355-8. [Medline].
Further Reading
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
