Intraveneous Drug Abuse

Original Editors - Sarah Boone & Jeremy Randolph from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Jeremy Randolph, Sarah Boone, Lucinda hampton, Kim Jackson, Elaine Lonnemann, WikiSysop, Vidya Acharya, Wendy Walker and Adam Vallely Farrell  

Introduction

Intravenous drug use involves injecting a substance into a vein using a syringe. This method of administration produces rapid and heightened effects because it bypasses the process of first pass metabolism that all orally administered drugs undergo, in which the drug must first be absorbed in the intestines, carried to the liver and subjected to hepatic metabolic processing before reaching the bloodstream. Injecting a drug allows it to enter the bloodstream immediately, which increases the speed of delivery to the brain. The effects can often be felt within a minute of injecting the drug. Due to the rapidly felt, intensely rewarding effects, shooting up a drug such as heroin can raise the user’s risk of developing an addiction, as well as the likelihood of experiencing overdose.

Prevalence

There has been a marked increase in the amount of evidence documenting injecting drug use (IDU) and the prevalence of HIV, Hepatitis infection in PWID.

• There is now evidence of IDU in 179 countries that contain 99% of the world's population aged 15–64 years, up from 148 countries in 2007, with the increase largely due to low-income and middle-income countries.
• It is estimated the number of people who inject drugs (PWID) globally to be 15·6 million and that roughly one in six are living with HIV, more than half have been exposed to HCV, and one in ten have active HBV.
• It is estimated that most PWID are exposed to environments that increase their risk of drug-related harm.

• There is clear variation in the age and gender profile of PWID, with a tendency for PWID in high-income countries to be older and to include a higher proportion of women than in lower-income countries. Over roughly the past 5 years, increases in IDU and outbreaks of HIV have occurred in the USA, which are related to large-scale prescription of pharmaceutical opioids and subsequent transition to heroin use and IDU.
• Compared with the general population, PWID are at greater risk of police arrest, incarceration, sex work, and the experience of homelessness or unstable housing, all of which are associated with increased blood-borne virus transmission. Notably, these experiences were often more common in high-income countries, including those in North America.

Characteristics/Clinical Presentation

The clinical presentation for a patient abusing IV drugs will differ depending on the compound the patient uses.  See eg Substance Abuse Disorder; Opioid use disorder; Methamphetamine Abuse;

Chronic Injection Consequences

Medical consequences of chronic injection use include scarred and/or collapsed veins, infections of the blood vessels and heart valves, abscesses, and other soft-tissue infections.

Dangers common to drugs prepared with many adulterant chemicals, binders and other toxic substances (eg black tar heroin) contribute to widespread damage to the following organs:

• Liver.
• Kidneys.
• Lungs.
• Brain.

Long Term Health Risks

Chronic, repeated injection of drugs such as heroin may lead to venous sclerosis, or a loss of veins to inject in, users will often switch to injecting intramuscularly or subcutaneously as opposed to intravenously. This increase in intramuscular injection can lead to the following dangers:

• Necrotizing fasciitis.
• Wound botulism: The bacteria, Clostridium botulinum, which enters a wound caused by needle puncture, can lead to paralysis and death.
• Gas gangrene: This potentially fatal infection is often caused by Clostridium perfringens, and can lead to tissue death.
• Tetanus.

Chronic intravenous drug users are at risk for developing long-term health problems associated with continued and persistent use. Although different kinds of drugs have varying long-term health risks, some examples of potential consequences include:

• AIDS as a result of HIV.
• Chronic hepatitis leading to liver cancer or cirrhosis.
• Malnourishment.
• Severe weight loss.
• Increased risk of suicide.
• Sexual dysfunction.
• Decay of white matter in the brain (this negatively impacts behavioral regulation and decision-making).

Risk Factors

The causes of or risk factors for Drug abuse according to the Mayo clinic are:

• Family- Drug addiction is more common in some families and likely involves the effects of many genes. If an individual has a blood relative, such as a parent or sibling, with alcohol or drug problems, he or she is at greater risk of developing a drug addiction.
• Men are twice as likely to abuse drugs
• Mental health disorder eg depression, attention-deficit/hyperactivity disorder or post-traumatic stress disorder, increases the risk of drug abuse
• Peer pressure- Young people are more susceptible to peer pressure and it is a powerful factor in using and abusing drugs.
• Lack of family involvement. A lack of attachment with parents may increase the risk of addiction.
• Anxiety, depression and loneliness. Using drugs can become a way of coping with overpowering emotions.
• Using highly addictive drugs. Some drugs can cause addiction more quickly than others (Heroin, cocaine)

Prevention

If you or someone you know is an intravenous drug user, there are some ways in which the harms of needle injecting can be reduced. Syringe exchange programs can help prevent the spread of infections and will oftentimes offer preventative services, such as:

• Counseling.
• Testing for HIV, Hepatitis C, STDs (eg syphilis, HIV), and tuberculosis.
• Referrals to drug addiction treatment programs.
• Hepatitis A and B vaccinations.

Drug addiction recovery programs include:

• Inpatient treatment: These programs require that you live at the facility for the duration of the treatment program while receiving services, such as detox, therapy, group counseling, medical maintenance, and aftercare planning.
• Outpatient treatment: These programs work around your schedule so that you don’t have to abandon your home, work, or school responsibilities in order to receive rehab services. May not be suitable for those suffering from a severe drug addiction.
• 12-Step programs: Focus on group support/mentors that can provide a source of assistance with the maintenance of abstinence
• Individual therapy: A therapist will use a variety of techniques to help uncover the underlying issues related to the addiction, and builds coping skills for use in stressful situations.
• Group counseling

Physical Therapy Management

Due to the nature of physical therapy, therapists often spend more time treating and getting to know patients than other healthcare professionals. For this reason, physical therapists have the opportunity to build trust in the therapist-patient relationship.

• Patients may be more likely to disclose their illicit drug use with a therapist whom they trust. According to the CDCs guidelines for healthcare professionals on risk assessment for illicit drug use, "patients might not be forthcoming about illicit use of drugs; the reasons include fear of legal consequences and concerns about confidentiality." Patients "need to feel comfortable about their privacy and confidentiality of their data to share their behaviors with their providers".
• Use screening tools such as the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) to identify individuals who abuse substances.
• Part of evidence based management of individuals who use drugs illicitly involves brief counseling by the healthcare professional. This may be a simple dialogue with a patient that informs them of the potential health risks and consequences of illicit drug use. See Motivational interviewing

Lastly, it is of utmost importance for a physical therapist to be able to refer the individual to the appropriate treatment sources in the community. 

Resources

• National Institute on Drug Abuse
• For Teens
  The Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Treatment
• Heroin Information
• Cocaine Information