Injection Drug Use Treatment & Management

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. ^{[16, 17]}

• Some patients may have multiple medical problems and contributory socioeconomic status. They may lack medical insurance and/or a stable place to live; this may be further complicated by psychiatric illness including a substance use disorder. Therefore, each patient requires a comprehensive physical examination including a mental status exam as well as a thorough history. The patient possibly may 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. Some countries mandate forms of inpatient and outpatient chemical dependency treatment, such as the drug court system in many parts of the United States.

Using the strengths of families and natural support systems can help engage individuals in treatment. ^[18] Employee assistance programs may also be helpful in treatment engagement.

In April 2014, the FDA approved naloxone (Evzio) as an autoinjector dosage form for home use by family members or caregivers. The product delivers 0.4 mg that may be administered either IM or SC in the anterolateral aspect of the thigh. The device includes visual and voice instruction, including directions to seek emergency medical care immediately after use. ^[19]

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. ^[20]

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.