Intravenous Drug Abuse

Aka: Intravenous Drug Abuse, Persons Who Inject Drugs, Intravenous Drug User, Injection Drug Abuse, IV Drug Abuse, IVDA, PWID

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II. Epidemiology

  1. Prevalence: 750,000 current injection drug users in U.S. (2014)
  2. Adults in U.S. who have used IV Drugs: 2% (or 6.5 Million)
  3. Mortality while actively injecting drugs: 2.6 per 100 person years

III. Causes

  1. Most commonly abused IV drugs
    1. Opioid Abuse
    2. Methamphetamine
  2. Other Illicit Drugs abused via injection
    1. Cocaine Abuse
    2. Ketamine Abuse

IV. Exam

  1. See Substance Abuse Evaluation
  2. See Skin changes suggestive of chemical dependency
  3. Observe for injection sites
    1. Localized Bruising or pigmentation changes
    2. Antecubital fossa (most common)
    3. Upper arms
    4. Hands
    5. Fingers
    6. Neck
    7. Groin
    8. Toes

V. Evaluation

  1. Screening Tools
    1. See Substance Abuse Screening
    2. Drug Abuse Screening Test (DAS-10)
    3. Single-Question Drug Abuse Screening Test (DAS-1)
    4. Modified Alcohol, Smoking and Substance Involvement Screening Test
      1. https://www.drugabuse.gov/sites/default/files/pdf/nmassist.pdf
  2. Evaluation
    1. See Substance Abuse Evaluation

VI. Complications: Infection

  1. Bloodbourne Pathogens
    1. Human Immunodeficiency Virus
    2. Viral Hepatitis
      1. Hepatitis B
      2. Hepatitis C
  2. Skin, soft tissue, Muscle and bone (Skin InfectionPrevalence 6-32%)
    1. Skin Abscess
      1. Polymicrobial infections
    2. Cellulitis
      1. Typically Staphylococcus or Streptococcus infections
    3. Necrotizing Fasciitis
    4. Septic Thrombophlebitis
    5. Wound Botulism
    6. Osteomyelitis
      1. Staphylococcus aureus and Streptococcus A and G are most common
      2. Pseudomonas aeruginosa, Eikenella corrodens and candida also occur in IVDA
    7. Pyomyositis
    8. Tetanus
  3. Lung
    1. Aspiration Pneumonia
    2. Pulmonary Tuberculosis
    3. Septic Pulmonary Embolism
    4. Community Acquired Pneumonia
      1. Typical CAP organisms, with a higher rate of Staphylococcus aureus and Anaerobic Bacteria
      2. Up to 2.1% annual Incidence, >5 fold higher than general population
  4. Cardiovascular
    1. Infectious Endocarditis (and septic emboli)
      1. Up to 12% lifetime Prevalence in injection drug users (and higher rates of reinfection)
      2. More commonly affects right sided Heart Valves (esp. tricuspid valve)
      3. Staphylococcus aureus is the causative organism in 68% of cases (only 28% in non-IVDA cases)
    2. Mycotic aneurysm
  5. Neurologic
    1. Epidural Abscess
    2. Brain Abscess
    3. Meningitis

VII. Complications: Non-infectious

  1. Skin
    1. See Dermatologic findings in chemical dependency
    2. Compulsive Skin Picking
    3. Contact Dermatitis
  2. Cardiopulmonary
    1. Cardiomyopathy or Myocarditis
    2. Chronic Venous Insufficency (>88%)
    3. Pulmonary Foreign Body Deposition (with secondary Foreign Body Granulomatosis)
      1. Unfiltered substance, crushed pill or talc/starch/cellulose contaminated injections
    4. Bullous Emphysema
    5. Severe or fatal Asthma Exacerbations
    6. Noncardiogenic Pulmonary Edema (Opioid Overdose)
  3. Psychiatric Conditions
    1. Substance Use Disorder
    2. Major Depression
    3. Generalized Anxiety Disorder
    4. Bipolar Disorder
    5. Posttraumatic Stress Disorder
    6. Dependent Personality Disorder
    7. Antisocial Personality Disorder
    8. Intimate Partner Violence
  4. Miscellaneous
    1. See specific agents
    2. Rhabdomylolysis (Cocaine, Methamphetamine)
    3. Splenic Abscess

VIII. Complications: Specific agent effects

  1. See specific agents for their complications
  2. Opioid Abuse
  3. Methamphetamine
  4. Ketamine Abuse
  5. Cocaine Abuse
    1. Splenic infarct (Cocaine)
    2. Perforated Peptic Ulcer Disease
    3. Cocaine-Induced Coronary Vasospasm

IX. Management

  1. See Chemical Dependency Brief Counseling
  2. See Substance Abuse Aftercare
  3. See Chemical Dependency Resources
  4. Specific management
    1. See Opioid Abuse
    2. See Methamphetamine
    3. See Cocaine Abuse
    4. See Ketamine Abuse

X. Prevention: General Measures

  1. Infectious disease screening
    1. HIV Enzyme Immunoassay
    2. Hepatitis B Serology (esp. HBsAg and consider HBeAg)
    3. Hepatitis C Antibody
    4. Tuberculosis (PPD or Quantiferon-TB)
  2. STD Screening
    1. Syphilis (VDRL or RPR)
    2. Gonorrhea PCR
    3. Chlamydia PCR
    4. Cervical Dysplasia (Pap Smear)
  3. Immunizations
    1. Hepatitis A Vaccine
    2. Hepatitis B Vaccine
    3. Tetanus Vaccine
    4. Pneumovax 23
    5. HPV Vaccine
  4. Other measures
    1. Naloxone Auto-Injector (or other home prescription)
    2. HIV Preexposure Prophylaxis (HIV PrEP)

XI. Prevention: Safer Injection Practices

  1. See Opioid Abuse, which describes safer injection techniques for those who refuse cessation and treatment
  2. Do not reuse or share needles
    1. Dispose of needles properly (in needle disposal containers) after single use
  3. Use new, sterile needles from reliable sources
    1. Needle exchange programs are available in many cities
  4. Alcohol swab injection site
  5. When preparing injection agent, use clean water and a new or disinfected container (cooker)

XII. References

  1. Visconti (2019) Am Fam Physician 99(2): 109-16 [PubMed]

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