Injecting Drug Use 

Updated: Mar 31, 2016
Author: Gloria J Baciewicz, MD; Chief Editor: Eduardo Dunayevich, MD 

Overview

Background

The hypodermic syringe was invented in the mid-1800s. By the late 1800s and early 1900s in the United States, the public could purchase hypodermic needles and syringes legally, and opiates and cocaine were widely available. The Harrison Act in 1914 allowed narcotics to be dispensed only by a prescription from physicians or dentists. Several states also developed legislation preventing the sale of hypodermic syringes and needles without a prescription.

Most individuals who use injection drugs inject their drugs intravenously, but subcutaneous injection (ie, "skin-popping") is also common, and intramuscular injection may occur intentionally or when the individual misses the vein or the subcutaneous space. Injecting drug use is associated with many local and systemic complications for the individual and is also associated with the transmission of infectious diseases via needle sharing and sexual activity. The most commonly injected drug is heroin, but amphetamines, buprenorphine, benzodiazepines, barbiturates, cocaine, and methamphetamine also are injected. Any water-soluble drug may be injected. Treatment of individuals who use injection drugs may be complicated by social and political barriers to treatment and by a lack of resources for public health approaches to treatment.

Both illegal drug production and injecting drug use have been globalized in recent years. Injecting drug use has diffused to countries that formerly had little problem with it. Both injecting drug use and HIV infection can spread rapidly within a community. Introduction of and rapid increase in injecting drug use is believed to be responsible for dramatic increases in HIV infection in some areas. In China, in Central Asia, and in several countries of Eastern Europe, injecting drug use is the primary risk factor for HIV infection.

See related Medscape CME activity, The Dark Side of Drug Addicition.

Pathophysiology

When injecting a drug intravenously, the individual introduces a bolus of the drug into the vein, producing a rapid and powerful drug high. The onset of drug effects is about 15-30 seconds for the intravenous route and 3-5 minutes for the intramuscular or subcutaneous route. Drug effects from inhaling (ie, smoking) a drug begin in 7-10 seconds, and drug effects from intranasal use (ie, transmucosal absorption) begin in 3-5 minutes.

Injecting drug use causes medical problems by introducing pathogens and other contaminants into the body via shared needles and a lack of sterile preparation and injection techniques. Medical problems also arise from damage caused by the drugs themselves (eg, morbidity and mortality associated with drug overdose). The injected drugs also may not be pure; they may be cut with irritants, such as talc, lactate, or quinine.

Death from the direct toxic effects of a heroin overdose itself is usually associated with respiratory depression, coma, and pulmonary edema. Death from the direct effects of cocaine is often associated with cardiac dysrhythmias and conduction disturbances, leading to myocardial infarction and stroke.

Epidemiology

Frequency

According to the 2015 World Drug Report of the United Nations Office on Drugs and Crime (UNODC), a total of 246 million people used an illicit drug in 2013.[1]

The joint UNODC/WHO/UNAIDS/World Bank estimate for the number of people who inject drugs (PWID) worldwide for 2013 is 12.19 million (range: 8.48-21.46 million). This corresponds to 0.26% (range: 0.18-0.46 per cent) of the adult population aged 15-64 years. This estimate is based on reporting of information on current injecting drug use from 93 countries covering 84% of the global population aged 15-64.[1]

By far the highest prevalence of PWID continues to be found in Eastern and South-Eastern Europe, where 1.27% of the general population aged 15-64 is estimated to be injecting drugs, a rate nearly five times the global average.[1]

Mortality/Morbidity

Morbidity and mortality may result from infection secondary to injecting drug use, sequelae of injection with adulterants added to the drug mixture, sequelae of the drug use itself, drug overdose, or violence associated with drug use.

  • About 1.65 million (range: 0.92-4.42 million) PWID were estimated to be living with HIV worldwide in 2013, which would correspond to 13.5% of PWID being HIV positive.[1] Besides direct transmission of HIV, injecting drug use also contributes to the spread of HIV infection by perinatal transmission and by sexual contact with individuals who do not inject drugs.[2] Injecting drug use is also associated with increased levels of high-risk sexual behavior.

  • Worldwide, 40-60% of individuals who use injection drugs are estimated to be positive for hepatitis B, and 60-70% are positive for hepatitis C virus (HCV). HCV rates are high even in countries with low HIV seroprevalence. Injecting drug use is responsible for approximately 60% of HCV infections in the United States. New HCV infections in the United States have declined since 1989[3] , but the incidence and prevalence of HCV remains high. The spread of HCV is rapid among those who are new to injecting drugs; in the United States, following initiation of injecting drug use, 50-80% become infected with HCV within 6-12 months. Reductions in risky injection-related practices among young users may improve both the burden of chronic HCV infection-related liver disease and elevated viral load-related poor treatment response.[4] Another option for reducing HCV transmission is encouraging users to use intranasal drugs as analternative to injection drugs.[5] For related information, see Medscape's Hepatitis B and Hepatitis C Resource Centers.

  • The mortality from all causes in individuals who use injection drugs is estimated to be 3-4% per year.

Race

The National Survey on Drug Use and Health (NSDUH) found no differences in injection drug use reports by race or ethnicity in the United States in 2002 and 2003.

Sex

Combined 2002-2005 data from NSDUH indicate that US males were twice as likely as females to report injection drug use in the past year.

The Centers for Disease Control and Prevention in the United States reports that 24% of males and 25% of females living with HIV/AIDS in 2003 used injection drugs.[6] Another significant source of HIV infection for women is sex with partners who use injection drugs. An estimated 61% of AIDS cases in women can be attributed to injecting drug use or to sex with partners who use injection drugs. Females may use more shared injecting drug use equipment than males.[7]

Worldwide, 70-90% of those who use injection drugs are believed to be male.

Age

The purity of heroin has been increasing, and its cost has been decreasing. Because of these factors and because of their initial desire to avoid injecting drug use, many adolescents and young adults in the United States and Europe using heroin for the first time try snorting, sniffing, or smoking heroin. New noninjecting heroin users risk making a transition to injecting drug use when their need for heroin use intensifies.

Among adolescents who inject drugs, early school truancy and expulsion may be a predictor of injecting drug use. A younger age of initiation into injecting drug use is associated with more frequent reports of risky drug use and sexual practices, as well as higher rates of HIV infection.[8]

 

Presentation

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.

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.

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.

 

Workup

Laboratory Studies

See the list below:

  • Sequential Multiple Analysis–twelve-channel biochemical profile (SMA 12)

  • CBC count with differential

  • Hepatitis B surface antigen and surface antibody

  • Hepatitis C antibody

  • Rapid plasma reagent (RPR) test

  • HIV serum antibody test (performed in 2 steps, with a screening test such as the enzyme-linked immunosorbent assay [ELISA] and a confirmatory test such as the Western blot)

  • Purified protein derivative (PPD) test

  • Urine screen for common drugs of abuse

Other Tests

See the list below:

  • Electrocardiogram

 

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.[9, 10]

  • 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.[11] 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.[12]

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.[13]

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

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Opioid replacement therapy

Class Summary

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.

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.

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.

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.

Opioid Reversal Agents

Class Summary

Inhibit opioid effects by inhibiting opioid agonists at receptor sites. FDA approval of extended-release IM naltrexone for the prevention of relapse to opioid dependence was based on data from a 6-month, multicenter, randomized, phase 3 study, which met its primary efficacy endpoint and all secondary efficacy endpoints. Once monthly treatment with extended-release IM naltrexone showed statistically significant higher rates of opioid-free urine screens compared with placebo (p< 0.0002).

Naltrexone (Revia, Vivitrol)

Used in combination with clonidine for rapid (4-5 d) detoxification.

Very effective long-acting opioid antagonist that was thought to be an ideal maintenance agent because it blocks receptor sites and, hence, opioid reinforcing properties. However, clinical results are not very promising when compared with methadone maintenance. Craving may continue during naltrexone maintenance. For groups of patients such as health care professionals or business executives for whom external incentives to stay away from drugs are important, naltrexone therapy has been very effective.

Long-acting parenteral suspension indicated for prevention of relapse to opioid dependence following opioid detoxification. Also indicated for treatment of alcohol dependence in patients who have been able to abstain from alcohol in an outpatient setting prior to treatment initiation.

Naloxone (Evzio, Narcan)

Naloxone is a short-acting, pure opioid antagonist that is used to reverse opioid intoxication. If patients do not respond to multiple doses of naloxone, consider alternative causes of unconsciousness. Need of ongoing substance abuse treatment should be established while caring for overdose. The injectable solution is available in vials and syringes (0.4 mg/mL, 1 mg/mL) for IV/IM/SC administration by healthcare providers. It is also available as an autoinjector (delivers 0.4 mg IM/SC) for home use by family or caregivers.

 

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.[14] 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.[15] Such outreach approaches are effective in promoting behavior change and slowing the spread of HIV and other infections.[16, 17]

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 machines[18] 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, see eMedicineHealth's patient education articles Drug Dependence and Abuse, Narcotic Abuse, and Substance Abuse.