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, Wendy Walker, Adam Vallely Farrell and Vidya Acharya  

Definition/Description

Intraveneous (IV) drug use is the injection of chemicals into the body via a hypodermic needle into a vein.  Drugs can also be injected under the skin (also called "skin popping") or directly into the muscle (intramuscular injection).  Heroin is the illegal drug that is most commonly administered by intravenous injection but other drugs such as amphetamines, methamphetamines, and cocaine can be administered by IV injection.

The DSM V defines substance abuse as:

1. Using a substance longer than intended
2. Desire for or unsuccessful efforts to reduce or cease use of the substance
3. Large amount of time trying to obtain, use, or recover from a substance
4. The use of the substance results in a failure to fulfil life obligations
5. Use continues despite causing social disturbances (family, job, etc...)
6. Tolerance
7. Withdraw.

Prevalence

A multistage systematic review published in 2017 investigated the global prevalence of injecting drug use and sociodemographic characteristics in people who inject drugs. The study reviewed 55 671 papers and reports, and extracted data from 1147 eligible records.Evidence of IVDU was recorded in 179 of 206 countries or territories, which covers 99% of the population aged from 15–64 years. There was an increase of 31 countries (mostly in sub-Saharan Africa and the Pacific Islands) since the last review was completed in 2008. IVDU prevalence estimates were identified in 83 countries. We estimate that there are 15·6 million (95% uncertainty interval [UI] 10·2–23·7 million) PWID aged 15–64 years globally, with 3·2 million (1·6–5·1 million) women and 12·5 million (7·5–18·4 million) men. Globally, they estimated that 17·8% of people who inject drugs are living with HIV, 52·3% are HCV-antibody positive, and 9·1% are HBV surface antigen positive. Globally, they identified that 82·9% of those who inject mainly inject opioids and 33·0% mainly inject stimulants. Of those studies 27·9% are younger than 25 years. 21·7% had recently (within the past year) experienced homelessness or unstable housing, and 57·9% had a history of incarceration.

An older study in 2007 showed that from 1979-2002 the overall all prevalence of IV drug abuse was 1.5%.  The prevalence was highest in 35-49 year old age group with a rate 3.1%.  IV drug use was higher in males(prevalence of 2.0%) than females(1.0%).  It was also higher in caucasians (1.7%) than African Americans (0.8%) or Hispanics (1.1%).  The study also showed that only 0.19% of subjects reported using IV drugs in the past year.

Characteristics/Clinical Presentation

The clinical presentation for a patient abusing IV drugs will differ depending on the compound the patient uses.  This article will focus on on opioids and cocaine which are two of the most common drugs to be administered intravenously.

Clinical Presentation of an Opioid Abuser:

• Contracted pupils
• Lack of response of pupils to light
• Needle marks
• Sleeping at unusual times
• Sweating
• Vomiting
• Coughing
• Sniffling
• Twitching
• Loss of appetite
• Constipation
• Decreased breathing
  

Clinical Presentation of a Cocaine Abuser:

• Dilated pupils
• Hyperactivity
• Euphoria
• Irritability
• Anxiety
• Mood Swings
• Weight loss or decreased appetite
• Patient may complain of dry mouth and nose
• Needle marks (If IV administration)
• Insomnia

Associated Co-morbidities

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. The additives in street drugs may include substances that clog the blood vessels that lead to the lungs, liver, kidneys, or brain. This can cause infection or even death of small patches of cells in these organs. Immune reactions to these contaminants can cause arthritis or other rheumatologic problems.

Sharing of injection equipment or fluids can lead to infections with hepatitis B and C, HIV, and other blood-borne viruses, which drug abusers can then pass on to their sexual partners and children.

Long term heroin users may have lung problems such as pneumonia because of the respiratory system depression.  Many heroin users may also experience psychological issues such as depression.

Cocaine users may experience the following co-morbidities:

• Cardiac: Increased heart rate, blood pressue, arrythmia, and heart attacks in people with otherwise healthy hearts
• Brain: Strokes and seizures
• Gastrointestinal: Ulcers or perforation of the stomach or intestines
• Kidneys:  Cocaine can cause sudden kidney failure due to rhabdomyolysis.  Cocaine also can damage the kidneys by increasing renal blood pressure.

Medications

Medications used to treat heroin abuse are as follows:

• Methadone- Methadone is a slow acting opioid agonist.  Although it effects opioid receptors it does not produce a pronounced "high."  Methadone also prevents symptoms of withdraw.
• Buprenorphine- A partial opioid agonist.  Buprenorphrine relieves cravings without producing a "high" or other dangerous side effects. Buprenorphine also includes naloxone.
• Naloxone- An opioid antagonist.  It blocks opiod action and is not sedating and does not cause dependence.
  

There are several medications under study for the treatment of cocaine abuse and withdraw:

• Baclofen-  A muscle relaxer that has been shown to reduce the amount of dopamine released by cocaine use.
• Tiagabine- A seizure medication which was shown to be moderately effective for improving abstinence in cocaine and opiate users.
• Disulfiram-  A medication used alcoholism that makes the side effects of alcohol very unpleasant has also been shown to increase anxiety in cocaine users to intolerable levels.

Diagnostic Tests/Lab Tests/Lab Values

Addiction or abuse of a drug cannot be determined by a lab test, but use of the drug can be determined by testing of biological specimens from a subject.  Blood, urine, hair, saliva can all be used to determine whether a drug or metabolites of the drug are present.  A urinalysis is the most commonly used way to determine drug use in sports and the work place.

The Substance Abuse and Mental Health Services Administration (SAMHSA) sets the guidelines for drug testing for federal agnecies and requires testing for:

• Amphetamines (including methamphetamines, ecstasy)
• THC
• Cocaine
• Opiates (heroin, opium, codeine, morphine)
• Phencyclidine (PCP)
  

Many employers commonly use an eight panel test which often includes the previously listed substances and the following:

• Barbiturates
• Benzodiazepines (tranquilizers like Valium and Xanax)
• Methaqualone (Quaaludes)

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.
• Male- Men are twice as likely to abuse drugs
•  Mental disorder- A psychological problem, such as 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)
  

There is also evidence that using opiate based pain relievers, such as Vicodin and Oxycontin, can lead to heroin use because heroin is less expensive and easier to obtain than the prescription alternatives.

Systemic Involvement

The effects on the body systems will vary based on the type and quantity of drug injected intravenously.  The following information on systemic effects of heroin and cocaine use is based on publications from the National Institute on Drug Abuse (NIDA).

Heroin

Heroin, an opioid drug, will act on the nervous system when it binds to MORs (mu-opioid receptors), thus releasing dopamine to trigger a rewarding pleasure sensation. The following short term effects are commonly seen with heroin use: flushed skin, dry mouth, a sensation of heavy limbs, itching of the skin, drowsiness, nausea, and vomiting. Heroin also affects the brain stem, causing a decrease in respiratory and heart rates. In the several hours following injection, a heroin user will likely experience mental confusion and impaired judgement.
Long term heroin use has multiple systemic effects. Hormonal imbalances occur with long term use and are not easily reversed. Women may experience amenorrhea, while men may develop sexual dysfunction. The limbic system in the brain is affected so that depression, mood swings, and antisocial personality disorder may develop over time. The integumentary system is affected by repeated injection sites, leading to scarring of the skin and an increase risk of bacterial infections. The vascular system is affected when veins collapse with chronic injections, as well as the clogging of vessels with unknown additives mixed into the injected drugs. The immune system may respond to these unknown additives in the drugs by the development of arthritis or other rheumatic diseases. Withdrawal will occur with long term use if the drug is then taken away in as little as several hours. The psychosocial domain of a heroin user is affected by an intense need to seek more of the drug at all costs. This leads to a decrease in the function of the individual and a decrease in overall health.

Cocaine

Cocaine, like heroin, affects the part of the brain that causes the release of dopamine to produce a pleasurable "rush". Cocaine is a stimulant, so its short term effects on an individual include increase in energy, alertness, sensations, and talkativeness.  The user has reduced need for sleep and food intake.  Physiological effects on the nervous system cause dilated pupils, constricted blood vessels, increased body temperature, heart rate, and blood pressure.

Long term systemic effects of cocaine use include malnourishment and weight loss due to the user's decreased appetite.  Cocaine is extremely addictive; it can have a serious long term affect on the user's mental health.  Anxiety, paranoia, hallucinations, irritability, and even a psychosis can develop as the user loses touch with reality in search for more of the drug.

As with heroin use, cocaine injection can lead to the same risks of infection and blood vessel collapse from repeated injections.

Medical Management

In a Centers for Disease Controls and Prevention (CDC) report in 2011, a summary of current guidelines for the prevention and control of HIV, viral hepatitis, STDs, and TB for persons who use drugs illicitly was published to attempt to integrate prevention services, screening, and treatment amongst healthcare professionals.
This report found that science-based approaches to prevent and treat substance abuse is supported by evidence.
This science-based approach uses the acronym SBIRT (screening, brief intervention, referral, and treatment) to assist primary care settings in identifying individuals who use drugs illicitly, providing brief counseling, and referring them to appropriate treatment sources.
The current best medical management of illicit drug use involves a combination of pharmacological agents (if appropriate), cognitive behavioral therapy, motivational interviewing, and community reinforcement and outreach (see alternative/holistic management for more information on community outreach programs).

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." The report suggests that patients "need to feel comfortable about their privacy and confidentiality of their data to share their behaviors with their providers".
It is suggested to provide patients with a screening tool 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. Motivational interviewing is a technique that is supported by evidence. 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.  (See Resources)

Health Risks & Community Programmes

One of the greatest risks to intravenous drug users is the risk of contracting bloodborne pathogens through shared needles. Commonly contracted pathogens among this population include HIV, viral hepatitis, STDs, and TB. (2). Management for the control and prevention of these diseases can include counseling on safe practices, hepatitis A, B and HPV vaccinations, access to sterile syringes, and specified education for pregnant females.
Community outreach programs have proven to be an effective treatment source when used in combination with medical management. Community outreach consists of peer educators or or other people who have gained trust among drug users. Peer educators are often volunteers in the community who may have been former drug users themselves and who can relate to the current users. The outreach volunteers can provide drug users with sterile syringes, needles, condoms, and naloxone, as well as providing them with counseling or referral to appropriate treatment centers.
Environmental factors that are common among intravenous drug users are unstable living conditions, a predisposition to addiction (usually manifested first in alcohol or smoking addiction), and limited access to sterile drug preparation equipment. Holistic treatment may include addressing each of these factors with drug users and referring them to appropriate sources to address these needs. (See Resources)
Also shown to be an effective treatment is cognitive behavioral therapy. This treatment method is especially useful for modifying behavior and helping individuals cope with and manage stresses in their lives. 

Differential Diagnosis

A physical therapist should use caution in jumping to conclusions when drug use is suspected. Therapists should gain trust and rapport with patients so that they feel confident in their privacy and confidentiality. In this way, patients may be more likely to openly answer questions regarding their illicit drug use. As suggested previously, (see Physical Therapy Management) therapists can use the ASSIST screening tool to identify drug users.

The signs and symptoms that an active intravenous drug user could present with may mimic several serious medical conditions.  Because heroin and cocaine both affect heart rate, blood pressure, and respiratory rate in different ways, the patient may appear to have acute respiratory distress syndrome (ARDS), which can lead to a hypoxic event.  ARDS is associated with diffuse alveolar damage and pulmonary hypertension. 

A patient using intravenous drugs may also present with varying levels of consciousness, arousal, and mental clarity.  These signs and symptoms may also be present in individuals with head trauma, diabetic ketoacidosis, hypoglycemia, electrolyte imbalances, mental disorders, and exposure to other toxic substances.

Case Reports/ Case Studies

1. Two newborns of heroin-addicted mothers suffering neonatal withdrawal syndrome.
2. Avascular necrosis of the femoral head due to the bilateral injection of heroin into the femoral vein: A case report.
3. Craving and self-efficacy in the first five weeks of methadone maintenance therapy: a daily process study.

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