Primary Care for Persons Who Inject Drugs

 

Am Fam Physician. 2019 Jan 15;99(2):109-116.

  Related letter: Substance Use Disorders: Considerations in Maternity and Neonatal Care

Author disclosure: No relevant financial affiliations.

More than 750,000 persons in the United States inject opioids, methamphetamine, cocaine, or ketamine, and that number is increasing because of the current opioid epidemic. Persons who inject drugs (PWID) are at higher risk of infectious and noninfectious skin, pulmonary, cardiac, neurologic, and other causes of morbidity and mortality. Nonjudgmental inquiries about current drug use can uncover information about readiness for addiction treatment and identify modifiable risk factors for complications of injection drug use. All PWID should be screened for human immunodeficiency virus infection, latent tuberculosis, and hepatitis B and C, and receive vaccinations for hepatitis A and B, tetanus, and pneumonia if indicated. Pre-exposure prophylaxis for human immunodeficiency virus infection should also be offered. Naloxone should be prescribed to those at risk of opioid overdose. Skin and soft tissue infections are the most common medical complication in PWID and the top reason for hospitalization in these patients. Signs of systemic infection require hospitalization, blood cultures, and a comprehensive history and physical examination to determine the source of infection. PWID have a higher incidence of community-acquired pneumonia and are at risk of other pulmonary complications, including opioid-associated pulmonary edema, asthma, and foreign body granulomatosis. Infectious endocarditis is the most common cardiac complication associated with injection drug use and more often involves the right-sided heart valves, which may not present with heart murmurs or peripheral signs and symptoms, in PWID. Injections increase the risk of osteomyelitis, as well as subdural and epidural abscesses.

In the United States, more than 6.5 million persons have injected drugs, and more than 750,000 currently use injection drugs.1 The number of persons who inject drugs (PWID) has grown sharply in recent years with the rise of the opioid epidemic.2 Opioids and methamphetamines are the most commonly injected drugs. Cocaine and ketamine are also injected but less often.3

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidenceReferences

Buprenorphine or methadone should be offered to PWID for opioid detoxification and medication-assisted treatment. :

A

18, 19, 21

All PWID should be screened for

 Hepatitis B and C

B

2224

 Human immunodeficiency virus infection

A

25

 Latent tuberculosis

C

26, 27

All PWID should receive hepatitis A and hepatitis B vaccinations, and be up to date on tetanus vaccinations.

C

30, 32

All eligible PWID should be offered pre-exposure prophylaxis for human immunodeficiency virus infection.

B

34, 42

Naloxone should be prescribed to PWID at high risk of opioid overdose.

C

35

Safer injecting practices should be discussed with all PWID.

C

30, 43


PWID = persons who inject drugs.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidenceReferences

Buprenorphine or methadone should be offered to PWID for opioid detoxification and medication-assisted treatment. :

A

18, 19, 21

All PWID should be screened for

 Hepatitis B and C

B

2224

 Human immunodeficiency virus infection

A

25

 Latent tuberculosis

C

26, 27

All PWID should receive hepatitis A and hepatitis B vaccinations, and be up to date on tetanus vaccinations.

C

30, 32

All eligible PWID should be offered pre-exposure prophylaxis for human immunodeficiency virus infection.

B

34, 42

Naloxone should be prescribed to PWID at high risk of opioid overdose.

C

35

Safer injecting practices should be discussed with all PWID.

C

30, 43


PWID = persons who inject drugs.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

PWID have higher morbidity and mortality from numerous causes, including infections (predominantly human immunodeficiency virus [HIV] infection; hepatitis; endocarditis; and pulmonary, bone, and skin infections), psychiatric disorders (e.g., major depression, generalized anxiety disorder, posttraumatic stress disorder, personality disorders), violence, and accidents.46 PWID have higher mortality than the general population, with a crude mortality rate of 2.64 per 100 years of active injecting.7,8

Initial Evaluation

PWID are less likely to receive primary care than the general population.9 However, family physicians can screen patients for illicit drug use, as well as provide brief intervention and referral to treatment. Although the U.S. Preventive Services Task Force found in 2008 that the evidence was insufficient to merit a recommendation on illicit drug screening, it is currently reevaluating the evidence.10

Physicians can screen for injection drug use through routine, open-ended questions in the social history or through validated screening questionnaires such as the Drug Abuse Screening Test (available at https://www.uspreventiveservicestaskforce.org/Home/GetFileByID/228) or the modified Alcohol, Smoking and Substance Involvement Screening Test (available at https://www.drugabuse.gov/sites/default/files/pdf/nmassist.pdf).11,12 Nonjudgmental inquiries about current drug use can uncover information about readiness for addiction treatment and identify modifiable risk factors for complications of injection drug use. Some PWID may be ready to seek additional medical services for opioid use disorder, whereas others may be precontemplative.13 Using motivational interviewing techniques (e.g., collaboration, empathy) can help foster motivation for change.14

Physical signs of active injection drug use include recent injection sites, bruising, and patches of hyperpigmentation. These are most common in the antecubital fossa but can also be found elsewhere (e.g., upper arms, hands, neck, groin, fingers, toes) if venous sclerosis occurs at more easily accessible sites.15

Family physicians have multiple office-based options for patients with opioid use disorder who want treatment, including sublingual buprenorphine, oral naltrexone (Revia), and depot naltrexone (Vivitrol).16 Prescribing of buprenorphine was outlined in a previous issue of American Family Physician.17 Maintenance therapy with buprenorphine or methadone significantly reduces opioid use, increases treatment retention, lowers overall mortality, and improves physical and mental health.1820

Patients with opioid use disorder who request medically supervised withdrawal, or detoxification, can be treated with antiemetics (prochlorperazine, ondansetron [Zofran]), antidiarrheals (loperamide [Imodium]), and sedatives (trazodone, doxepin) to alleviate the specific symptoms of opioid withdrawal. Alpha-2 agonists such as lofexidine (Lucemyra) and clonidine (off-label use) can also be used. Buprenorphine tapers are significantly more effective than nonopioid therapy in decreasing the discomfort of opioid withdrawal and keeping patients in treatment.19,21

Preventive Care Recommendations

Preventive care such as infectious disease screening and treatment, vaccinations, and harm reduction interventions can reduce morbidity and mortality in PWID (Table 1).2235

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TABLE 1.

Preventive Care Recommendations for PWID

Preventive measureRisk groupRecommendation
Disease screening

Hepatitis B22

All PWID

Initial visit, periodic rescreening per clinical judgment

Hepatitis C23,24

All PWID

Initial visit, annual or periodic rescreening

HIV25

All PWID

Initial visit, at least annually

Tuberculosis26,27

All PWID

Initial visit, rescreening per clinical judgment

Gonorrhea/chlamydia28,29

Sexually active females younger than 25 years, and females at high risk

Initial visit, rescreening per clinical judgment

Vaccinations

Hepatitis A and B30

All PWID

Obtain titers, vaccinate if low titers

Tetanus vaccine31,32

All PWID

Initial visit then every 10 years

23-valent pneumococcal polysaccharide vaccine (Pneumovax-23)33

PWID who have concurrent heavy alcohol use, cigarette smoking, lung or liverdisease, or other qualifying conditions as defined by the Advisory Committee on Immunization Practices

Once between 19 and 64 years of age

Other interventions

Pre-exposure prophylaxis for HIV34

All PWID

Continuous, daily regimen

Naloxone35

All PWID who inject opioids

Prescribe in case of overdose


HIV = human immunodeficiency virus; PWID = persons who inject drugs.

Information from references 22 through 35.

TABLE 1.

Preventive Care Recommendations for PWID

Preventive measureRisk groupRecommendation
Disease screening

Hepatitis B22

All PWID

Initial visit, periodic rescreening per clinical judgment

Hepatitis C23,24

All PWID

Initial visit, annual or periodic rescreening

HIV25

All PWID

Initial visit, at least annually

Tuberculosis26,27

All PWID

Initial visit, rescreening per clinical judgment

Gonorrhea/chlamydia28,29

Sexually active females younger than 25 years, and females at high risk

Initial visit, rescreening per clinical judgment

Vaccinations

Hepatitis A and B30

All PWID

Obtain titers, vaccinate if low titers

Tetanus vaccine31,32

All PWID

Initial visit then every 10 years

23-valent pneumococcal polysaccharide vaccine (Pneumovax-23)33

PWID who have concurrent heavy alcohol use, cigarette smoking, lung or liverdisease, or other qualifying conditions as defined by the Advisory Committee on Immunization Practices

Once between 19 and 64 years of age

Other interventions

Pre-exposure prophylaxis for HIV34

All PWID

Continuous, daily regimen

Naloxone35

All PWID who inject opioids

Prescribe in case of overdose


HIV = human immunodeficiency virus; PWID = persons who inject drugs.

Information from references 22 through 35.

INFECTIOUS DISEASE SCREENING AND TREATMENT

The U.S. Preventive Services Task Force recommends screening for HIV infection and hepatitis B and C in PWID.22,23,25 At least annual screening for HIV and hepatitis C is suggested.24,25 Latent tuberculosis testing is also recommended for PWID.26,27 Screening and behavioral counseling for gonorrhea and chlamydia are recommended for sexually active females younger than 25 years and for females engaged in high-risk sexual behaviors.28,29

PWID who test positive for HIV infection or hepatitis C should receive antiviral treatment. Active injection drug use is not a contraindication for HIV or hepatitis C treatment because successful treatment greatly reduces the risk of viral transmission, limiting spread in the community at large.3638

VACCINATIONS

All PWID should receive hepatitis A and B vaccinations if there is no evidence of immunity from vaccine titers30 and be up to date on tetanus vaccinations.31,32 Although PWID have an estimated 10-fold greater risk of community-acquired pneumonia,39 the Centers for Disease Control and Prevention does not consider active injection drug use alone as an indication for early pneumonia vaccine.33,39 However, a one-time 23-valent pneumococcal polysaccharide vaccine (Pneumovax-23) is indicated between 19 and 64 years of age in those with certain concurrent conditions, such as heavy alcohol use, cigarette smoking, or lung or liver disease.33

PRE-EXPOSURE PROPHYLAXIS FOR HIV

Of new HIV infections in the United States, 8% to 12% occur in PWID, as a result of injecting or injecting in conjunction with high-risk sexual practices.40,41 Pre-exposure prophylaxis with the tenofovir/emtricitabine combination (Truvada; preferred drug) dramatically reduces the risk of HIV transmission in PWID.42 The Centers for Disease Control and Prevention recommends daily, continuous pre-exposure prophylaxis for adults who have injected drugs within the previous six months, and have also shared injection or drug preparation equipment in the previous six months or engaged in high-risk sexual practices.34

Patients are eligible for pre-exposure prophylaxis if they have negative HIV test results, no signs of HIV infection within the previous four weeks, normal creatinine clearance, and laboratory evidence of immunity to hepatitis B virus or absence of infection without immunity (in which case they should be vaccinated against hepatitis B).34

Clinicians should monitor for symptoms suggestive of acute HIV infection (i.e., fever, fatigue, myalgias, skin rash, headache, pharyngitis, cervical adenopathy). For patients on a pre-exposure prophylaxis regimen, repeat HIV and pregnancy testing (if applicable) is indicated every three months, and creatinine clearance testing and sexually transmitted infection screening are recommended every six months.34 Centers for Disease Control and Prevention guidelines for prescribing pre-exposure prophylaxis are available at https://www.cdc.gov/hiv/risk/prep/index.html.

NALOXONE FOR OPIOID OVERDOSE

Naloxone is a synthetic opioid antagonist with high opioid receptor affinity that reverses potentially fatal respiratory depression through competitive inhibition. It is available in several forms and strengths, including an intramuscular form, a preassembled intranasal kit (Narcan), and an autoinjector (Evzio). Naloxone can lead to unpleasant but nonfatal acute withdrawal symptoms in chronic opioid users, including agitation, anxiety, lacrimation, rhinorrhea, diarrhea, nausea, and vomiting. All patients should be instructed to seek medical attention after administration of naloxone given its shorter half-life compared with most opioids. Close observation is needed because readministration may be required. More information on prescribing naloxone is available at http://prescribetoprevent.org.

The American Academy of Family Physicians recommends providing access to appropriate overdose antidotes, such as naloxone prescriptions, for individuals at high risk of opioid overdose.35 Risk factors for overdose include recent abstinence from opioid use, hospitalization, or incarceration; history of overdose; chronic hepatic or pulmonary conditions; or mental health conditions.

SAFER INJECTING PRACTICES

Needle-syringe exchange programs reduce rates of HIV, hepatitis C, and high-risk injecting behavior without increasing drug use, number of PWID, or needles discarded in an unsafe manner.4345 The American Academy of Family Physicians supports the use of these exchange programs.46 Program locations can be found at https://www.nasen.org/map/.

Alternatively, physicians in the District of Columbia and all states except Delaware and Kansas are allowed to prescribe or dispense syringes to PWID. Information regarding the laws in each state is available at http://www.temple.edu/lawschool/aidspolicy/50statesataglance.htm.

Physicians should counsel PWID about safer injection practices such as never reuse or share syringes; only use new or sterile syringes from reliable sources; use clean water, a new or disinfected container (cooker), and a new filter (cotton) to prepare drugs; use an alcohol swab to clean the injection site; and dispose of syringes after a single use.30,43

Medical Complications of Injection Drug Use

Injection drug use can result in harmful infectious and noninfectious effects to almost every organ system (Table 2). All PWID exhibiting signs of systemic infection, including fever, tachycardia, tachypnea, hypotension, and leukocytosis, should be referred to an emergency department or admitted to an acute care hospital for blood cultures and a full history and physical examination to determine the source of potential infections.

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TABLE 2.

Medical Complications of Injection Drug Use

ComplicationClinical signsDiagnostics*

Skin and soft tissue

Infectious

 Abscess

Fluctuance, purulence, erythema, pain, induration

US or CT to evaluate underlying structures and retained products, with or without Gram stain or culture

 Cellulitis

Erythema, induration, pain, warmth

Clinical diagnosis

 Necrotizing soft tissue infection

Erythema, edema, pain out of proportion to examination findings, crepitus, rapid progression

AST, creatine kinase, lactate, C-reactive protein; surgical exploration with wound and tissue cultures; CT or MRI if diagnosis is unclear

 Septic thrombophlebitis

Linear erythema, pain

Duplex US to evaluate for thrombus

Noninfectious

 Contact dermatitis

Erythema, pruritus, edema

Clinical diagnosis

 Hyper/hypopigmentation

Hyperpigmented macules

Clinical diagnosis

 Lesions from pathologic skin picking (cocaine, methamphetamine)

Repetitive and compulsive picking of skin

Clinical diagnosis

 Phlebitis/thrombophlebitis

Venous-associated pain, tenderness, erythema

Duplex US to evaluate for thrombus

 Vasculitis (cocaine)

Levamisole-associated contamination: purpura/necrosis of ears, cheeks, nose, extremities

Perinuclear antineutrophil cytoplasmic antibodies, antimyeloperoxidase

 Venous insufficiency

Edema (hands, feet/legs), hyperpigmentation, ulceration, decreased peripheral pulses, delayed capillary refill

Duplex US, echocardiography

Pulmonary

Infectious

 Aspiration pneumonia

Abrupt-onset dyspnea, diffuse crackles, fever, altered mental status

Chest radiography if indicated

 Community-acquired pneumonia

Cough, dyspnea, sputum production, fever, pleurisy

Chest radiography if indicated, sputum Gram stain and culture, urine Streptococcus pneumoniae antigen, legionella if admitted

 Pulmonary tuberculosis

Fever, cough, hemoptysis, malaise, anorexia, weight loss

Chest radiography, sputum for acid-fast bacilli, culture, nucleic acid amplification tests, interferon-gamma release assay, or tuberculin skin test

 Septic pulmonary embolism

Fever, cough, and dyspnea, with or without murmur or peripheral stigmata of endocarditis

Chest radiography, echocardiography

Noninfectious

 Asthma

Intermittent wheezing, dyspnea, cough

Pulmonary function tests

 Bullous emphysema

Progressive dyspnea, cough, fatigue

Chest imaging, pulmonary function tests

 Foreign body granulomatosis

Progressive dyspnea, cough, fatigue

Chest imaging, pulmonary function tests

 Noncardiogenic pulmonary edema (opioids)

Acute shortness of breath, mental status change, respiratory depression, hypoxemia

Chest radiography

 Pulmonary embolism

Acute shortness of breath, tachypnea, tachycardia, palpitations

d-dimer test, CT with pulmonary angiography or ventilation-perfusion scan

Cardiovascular

Infectious

 Endocarditis

Fever, malaise, flulike illness, pleuritic chest pain, back pain, palpitations, Osler nodes, Janeway lesions, Roth spots, splinter hemorrhages

Transesophageal echocardiography, serial blood cultures, complete blood count

 Septic emboli

Right-sided: see septic pulmonary embolism; left-sided: neurologic deficits, splinter hemorrhages, Roth spots, Janeway lesions

Transesophageal echocardiography, serial blood cultures, complete blood count

Noninfectious

 Cardiomyopathy

Left ventricular systolic dysfunction, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, edema

Echocardiography

 Dysrhythmias

Variable; chest pain, palpitations, nausea, diaphoresis

Electrocardiography

 Myocarditis/myocardial ischemia (cocaine)

Severe retrosternal chest pain, nausea, diaphoresis

Electrocardiography changes, abnormal echocardiography findings, elevated serum troponin I, occasional coronary artery occlusion

 Mycotic aneurysms

Tender, enlarging, pulsatile mass; femoral vein most commonly affected

Doppler US, CT, or magnetic resonance angiography

 Post–infectious endocarditis valvular heart disease

Heart failure, atrial fibrillation, pulmonary hypertension, dilated cardiomyopathy

Echocardiography

Musculoskeletal

Infectious

 Epidural abscess

Back pain and local tenderness, fever, late neurologic compromise

MRI with contrast media, then CT-guided biopsy

 Osteomyelitis

Musculoskeletal pain and fever, with or without overlying skin/soft tissue infection

MRI with contrast media (preferred) or bone scintigraphy, bone biopsy

 Pyomyositis

Deep, aching muscle pain

MRI with contrast media, CT with contrast media, or US

 Tetanus

Muscle spasms, stiffness, pain, fever, seizures

Clinical diagnosis

Noninfectious

 Rhabdomyolysis (cocaine, methamphetamine)

Myalgias, swelling, weakness, and brown or red urine, with or without fever, abdominal pain, nausea/vomiting

Creatine kinase, creatinine, AST, ALT, urinalysis

Other

Infectious

 Acute HIV

Fever, fatigue, myalgias, skin rash, headache, pharyngitis, cervical adenopathy

HIV RNA, HIV fourth-generation antibody/antigen test (may be negative in acute infection)

 Brain abscess

Fever, headache, focal neurologic deficits

Lumbar puncture, neuroimaging

 Hepatitis A, B, or C

Jaundice, fever, abdominal pain

Liver function tests, hepatitis serology or polymerase chain reaction test (if acute); liver ultrasonography

 Meningitis

Fever, headache, neck stiffness, altered mental status

Lumbar puncture, neuroimaging

 Splenic abscess

Fever, left upper abdominal pain, left shoulder pain (Kehr sign)

Ultrasonography or CT

 Wound botulism

Symmetric neurologic deficits, responsiveness to stimuli, blurred vision, presence of a wound

Anaerobic wound culture, serum toxin assay

Noninfectious

 Elevated transaminase/bilirubin levels (methamphetamine)

Asymptomatic

AST, ALT, bilirubin, albumin, hepatitis serologies

 Perforated duodenal and gastric ulcers (cocaine)

Sudden, severe abdominal pain, tachycardia, hypotension

Upright abdominal radiography, CT or US

 Splenic infarct (cocaine)

Asymptomatic or fever and left upper abdominal pain

US or CT


ALT = alanine transaminase; AST = aspartate transaminase; CT = computed tomography; HIV = human immunodeficiency virus; MRI = magnetic resonance imaging; US = ultrasonography.

*—Blood cultures for all suspected infectious processes with signs of systemic infection.

TABLE 2.

Medical Complications of Injection Drug Use

ComplicationClinical signsDiagnostics*

Skin and soft tissue

Infectious

 Abscess

Fluctuance, purulence, erythema, pain, induration

US or CT to evaluate underlying structures and retained products, with or without Gram stain or culture

 Cellulitis

Erythema, induration, pain, warmth

Clinical diagnosis

 Necrotizing soft tissue infection

Erythema, edema, pain out of proportion to examination findings, crepitus, rapid progression

AST, creatine kinase, lactate, C-reactive protein; surgical exploration with wound and tissue cultures; CT or MRI if diagnosis is unclear

 Septic thrombophlebitis

Linear erythema, pain

Duplex US to evaluate for thrombus

Noninfectious

 Contact dermatitis

Erythema, pruritus, edema

Clinical diagnosis

 Hyper/hypopigmentation

Hyperpigmented macules

Clinical diagnosis

 Lesions from pathologic skin picking (cocaine, methamphetamine)

Repetitive and compulsive picking of skin

Clinical diagnosis

 Phlebitis/thrombophlebitis

Venous-associated pain, tenderness, erythema

Duplex US to evaluate for thrombus

 Vasculitis (cocaine)

Levamisole-associated contamination: purpura/necrosis of ears, cheeks, nose, extremities

Perinuclear antineutrophil cytoplasmic antibodies, antimyeloperoxidase

 Venous insufficiency

Edema (hands, feet/legs), hyperpigmentation, ulceration, decreased peripheral pulses, delayed capillary refill

Duplex US, echocardiography

Pulmonary

Infectious

 Aspiration pneumonia

Abrupt-onset dyspnea, diffuse crackles, fever, altered mental status

Chest radiography if indicated

 Community-acquired pneumonia

Cough, dyspnea, sputum production, fever, pleurisy

Chest radiography if indicated, sputum Gram stain and culture, urine Streptococcus pneumoniae antigen, legionella if admitted

 Pulmonary tuberculosis

Fever, cough, hemoptysis, malaise, anorexia, weight loss

Chest radiography, sputum for acid-fast bacilli, culture, nucleic acid amplification tests, interferon-gamma release assay, or tuberculin skin test

 Septic pulmonary embolism

Fever, cough, and dyspnea, with or without murmur or peripheral stigmata of endocarditis

Chest radiography, echocardiography

Noninfectious

 Asthma

Intermittent wheezing, dyspnea, cough

Pulmonary function tests

 Bullous emphysema

Progressive dyspnea, cough, fatigue

Chest imaging, pulmonary function tests

 Foreign body granulomatosis

Progressive dyspnea, cough, fatigue

Chest imaging, pulmonary function tests

 Noncardiogenic pulmonary edema (opioids)

Acute shortness of breath, mental status change, respiratory depression, hypoxemia

Chest radiography

 Pulmonary embolism

Acute shortness of breath, tachypnea, tachycardia, palpitations

d-dimer test, CT with pulmonary angiography or ventilation-perfusion scan

Cardiovascular

Infectious

 Endocarditis

Fever, malaise, flulike illness, pleuritic chest pain, back pain, palpitations, Osler nodes, Janeway lesions, Roth spots, splinter hemorrhages

Transesophageal echocardiography, serial blood cultures, complete blood count

 Septic emboli

Right-sided: see septic pulmonary embolism; left-sided: neurologic deficits, splinter hemorrhages, Roth spots, Janeway lesions

Transesophageal echocardiography, serial blood cultures, complete blood count

Noninfectious

 Cardiomyopathy

Left ventricular systolic dysfunction, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, edema

Echocardiography

 Dysrhythmias

Variable; chest pain, palpitations, nausea, diaphoresis

Electrocardiography

 Myocarditis/myocardial ischemia (cocaine)

Severe retrosternal chest pain, nausea, diaphoresis

Electrocardiography changes, abnormal echocardiography findings, elevated serum troponin I, occasional coronary artery occlusion

 Mycotic aneurysms

Tender, enlarging, pulsatile mass; femoral vein most commonly affected

Doppler US, CT, or magnetic resonance angiography

 Post–infectious endocarditis valvular heart disease

Heart failure, atrial fibrillation, pulmonary hypertension, dilated cardiomyopathy

Echocardiography

Musculoskeletal

Infectious

 Epidural abscess

Back pain and local tenderness, fever, late neurologic compromise

MRI with contrast media, then CT-guided biopsy

 Osteomyelitis

Musculoskeletal pain and fever, with or without overlying skin/soft tissue infection

MRI with contrast media (preferred) or bone scintigraphy, bone biopsy

 Pyomyositis

Deep, aching muscle pain

MRI with contrast media, CT with contrast media, or US

 Tetanus

Muscle spasms, stiffness, pain, fever, seizures

Clinical diagnosis

Noninfectious

 Rhabdomyolysis (cocaine, methamphetamine)

Myalgias, swelling, weakness, and brown or red urine, with or without fever, abdominal pain, nausea/vomiting

Creatine kinase, creatinine, AST, ALT, urinalysis

Other

Infectious

 Acute HIV

Fever, fatigue, myalgias, skin rash, headache, pharyngitis, cervical adenopathy

HIV RNA, HIV fourth-generation antibody/antigen test (may be negative in acute infection)

 Brain abscess

Fever, headache, focal neurologic deficits

Lumbar puncture, neuroimaging

 Hepatitis A, B, or C

Jaundice, fever, abdominal pain

Liver function tests, hepatitis serology or polymerase chain reaction test (if acute); liver ultrasonography

 Meningitis

Fever, headache, neck stiffness, altered mental status

Lumbar puncture, neuroimaging

 Splenic abscess

Fever, left upper abdominal pain, left shoulder pain (Kehr sign)

Ultrasonography or CT

 Wound botulism

Symmetric neurologic deficits, responsiveness to stimuli, blurred vision, presence of a wound

Anaerobic wound culture, serum toxin assay

Noninfectious

 Elevated transaminase/bilirubin levels (methamphetamine)

Asymptomatic

AST, ALT, bilirubin, albumin, hepatitis serologies

 Perforated duodenal and gastric ulcers (cocaine)

Sudden, severe abdominal pain, tachycardia, hypotension

Upright abdominal radiography, CT or US

 Splenic infarct (cocaine)

Asymptomatic or fever and left upper abdominal pain

US or CT


ALT = alanine transaminase; AST = aspartate transaminase; CT = computed tomography; HIV = human immunodeficiency virus; MRI = magnetic resonance imaging; US = ultrasonography.

*—Blood cultures for all suspected infectious processes with signs of systemic infection.

SKIN AND SOFT TISSUE COMPLICATIONS

Skin and soft tissue infections are the most common medical complication affecting PWID and the top reason for hospitalization in these patients.47 Between 6% and 32% of PWID have an active skin and soft tissue infection at any time.48,49 Risk factors include female sex, frequent injecting, infrequent skin cleaning, subcutaneous (skin popping) or intramuscular injecting because of the inability to access veins, injecting heroin compared with stimulants, HIV-positive status, and needle sharing.50

Although Staphylococcus and group A streptococci are most commonly associated with superficial skin infections, abscesses are usually polymicrobial and can contain oral flora and anaerobes.51,52 Management of skin and soft tissue infections should follow guidelines from the Infectious Diseases Society of America, which are described in a previous issue of American Family Physician.53,54 Cellulitis and abscesses without signs of systemic infection can be managed on an outpatient basis, with an awareness of the possibility of retained products in the site. Patients with signs of systemic infection should be hospitalized with appropriate sepsis management and evaluation for other sources of infection.

Delayed complications from injecting include hyperpigmentation from postinflammatory changes, scarring along vascular distributions, and deposition of foreign materials in the dermis.50 Chronic venous insufficiency affects 88% to 93% of PWID, with a higher prevalence and severity associated with increased duration of injecting.55,56

Chronic venous insufficiency and impaired lymphatic drainage can predispose PWID to venous ulceration with impaired healing of upper and lower extremities.

PULMONARY COMPLICATIONS

The annual incidence of community-acquired pneumonia is 1.4% to 2.1% in PWID, compared with 0.3% in the general population.57,58 Although the microbiology of pneumonia in PWID is largely similar to that in the general population, Staphylococcus aureus and anaerobic organisms are more common in PWID.57,58 Additionally, respiratory depression predisposes PWID to aspiration pneumonia.

Noninfectious pulmonary complications include pulmonary edema, foreign body deposition, emphysema, pulmonary embolism, and fatal asthma exacerbations. Noncardiogenic pulmonary edema can occur from opioid overdose within minutes to hours of opioid use, even if naloxone is given. Foreign body deposition within the pulmonary vasculature is common among PWID and is caused by injecting unfiltered substances or crushed pill preparations that include water-insoluble compounds such as talc, cornstarch, and cellulose that can result in granuloma formation.39,59 Patients with foreign body granulomatosis often present with progressive dyspnea on exertion, productive cough, and fatigue. In patients with foreign body granulomatosis, pulmonary function testing can show restrictive or obstructive lung patterns with occasional pulmonary hypertension, often with decreased diffusing capacity.60 Bullous emphysema and fatal asthma exacerbations are also more prevalent in PWID.61,62

CARDIOVASCULAR COMPLICATIONS

Infectious endocarditis is the most common cardiac complication associated with injection drug use. In the United States, the annual incidence of infectious endocarditis in PWID is estimated to be 1%, with a lifetime prevalence of 12%.63,64 Infectious endocarditis accounts for 5% to 15% of hospitalizations for acute infection in PWID.65

Compared with the general population, infectious endocarditis in PWID is more often caused by Staphylococcus (68% vs. 28% of cases) and more often involves the right-sided heart valves, particularly the tricuspid valve.66,67 Diagnosis of infectious endocarditis in PWID requires a higher index of suspicion because heart murmurs and peripheral signs and symptoms may not be present with right-sided infections. Although cardiac sequelae are less with right-sided infectious endocarditis, PWID have higher rates of reinfection (hazard ratio = 6.20; 95% confidence interval, 2.56 to 15.00) and valve-related complications (hazard ratio = 3.82; 95% confidence interval, 1.95 to 7.49).68

Transitioning from inpatient to outpatient treatment for infectious endocarditis may be complicated by concerns about discharging PWID with intravenous access for completion of parenteral antibiotic treatment. Patients with infectious endocarditis should initially be evaluated and stabilized in the hospital, and those with an adequate support system and home health care services and who will reliably follow up with medical visits can be discharged for completion of therapy.69 The risk of resuming unsafe injection drug use practices must be weighed against the cost of prolonged hospitalization for completion of treatment. Short-course intravenous or oral antibiotic regimens may be considered in some uncomplicated cases.69 Persons with severe valvular regurgitation from infectious endocarditis should be referred for valve replacement.

Noninfectious cardiovascular complications, such as myocarditis or myocardial ischemia, mycotic aneurysm rupture, cardiomyopathy, and dysrhythmias, may also occur in PWID, particularly with cocaine or amphetamine use.70,71

BONE AND SKELETAL INFECTIONS

Bone and skeletal infections are more common in PWID, primarily from hematogenous spread of bacteria from other sites, such as infected heart valves or skin and soft tissues. A high index of suspicion is necessary in these patients because positive blood culture and radiology findings and systemic symptoms may not be present initially, and a delay in diagnosis may result in neurologic compromise.

Most skeletal infections are caused by S. aureus and group A and G streptococci, whereas gram-negative bacilli (e.g., Pseudomonas aeruginosa) , Eikenella corrodens, and Candida are less common but increasingly reported in PWID.7274 Tuberculosis, which is more prevalent in PWID, may also cause skeletal infections. Multiple bony sites, including vertebrae, may be involved, leading to abscess formation in the subdural or epidural spaces.

Data Sources: A comprehensive search was completed, including the Cochrane Database of Systematic Reviews, Essential Evidence Plus, and recommendations from the U.S. Preventive Services Task Force, Infectious Diseases Society of America, Centers for Disease Control and Prevention/Advisory Committee on Immunization Practices, and American Association for the Study of Liver Diseases. A PubMed search was completed using the following terms: primary care, injection drug, injection drug use, heroin injection, cocaine injection, ketamine injection, people who inject drugs. Search dates: October 2017 to March 2018.

The Authors

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ADAM J. VISCONTI, MD, MPH, is chief medical officer of the HIV/AIDS, Hepatitis, STD, and TB Administration at the District of Columbia Department of Health in Washington, DC. At the time this article was written, he was an assistant professor in the Department of Family and Community Medicine at the University of Maryland School of Medicine, Baltimore....

JARRETT SELL, MD, is an associate professor in the Department of Family and Community Medicine at Penn State Health Milton S. Hershey Medical Center, Hershey, Pa.

AARON DAVID GREENBLATT, MD, is an assistant professor in the Department of Family and Community Medicine and in the Department of Psychiatry, Division of Addiction Research and Treatment, at the University of Maryland School of Medicine.

Address correspondence to Adam J. Visconti, MD, MPH, DC Health, 899 N. Capital St. NE, Washington, DC 20002 (e-mail: adam.visconti@dc.gov). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Lansky A, Finlayson T, Johnson C, et al. Estimating the number of persons who inject drugs in the United States by meta-analysis to calculate national rates of HIV and hepatitis C virus infections. PLoS One. 2014;9(5):e97596....

2. Jones CM, Logan J, Gladden RM, Bohm MK. Vital signs: demographic and substance use trends among heroin users - United States, 2002–2013. MMWR Morb Mortal Wkly Rep. 2015;64(26):719–725.

3. Lankenau SE, Wagner KD, Jackson Bloom J, Sanders B, Hathazi D, Shin C. The first injection event: differences among heroin, methamphetamine, cocaine, and ketamine initiates. J Drug Issues. 2010;40(2):241–262.

4. Degenhardt L, et al. Global burden of disease attributable to illicit drug use and dependence. Lancet. 2013;382(9904):1564–1574.

5. Mackesy-Amiti ME, et al. Prevalence of psychiatric disorders among young injection drug users. Drug Alcohol Depend. 2012;124(1–2):70–78.

6. Buckingham E, Schrage E, Cournos F. Why the treatment of mental disorders is an important component of HIV prevention among people who inject drugs. Adv Prev Med. 2013;2013:690386.

7. Mathers BM, Degenhardt L, Bucello C, et al. Mortality among people who inject drugs. Bull World Health Organ. 2013;91(2):102–123.

8. Smyth B, Hoffman V, Fan J, Hser YI. Years of potential life lost among heroin addicts 33 years after treatment. Prev Med. 2007;44(4):369–374.

9. Saitz R, Mulvey KP, Samet JH. The substance-abusing patient and primary care Subst Abus. 1997;18(4):187–195.

10. USPSTF. Drug use, illicit: screening. January 2008. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/drug-use-illicit-screening. Accessed August 30, 2018.

11. Staley D, el-Guebaly N. Psychometric properties of the Drug Abuse Screening Test in a psychiatric patient population. Addict Behav. 1990;15(3):257–264.

12. Newcombe DA, Humeniuk RE, Ali R. Validation of the World Health Organization Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Drug Alcohol Rev. 2005;24(3):217–226.

13. Connors GJ, et al. Substance Abuse Treatment and the Stages of Change. 2nd ed. New York, NY: Guilford; 2015.

14. Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed. New York, NY: Guilford Press; 2012.

15. Darke S, Ross J, Kaye S. Physical injecting sites among injecting drug users in Sydney, Australia. Drug Alcohol Depend. 2001;62(1):77–82.

16. Schuckit MA. Treatment of opioid-use disorders. N Engl J Med. 2016;375(4):357–368.

17. Zoorob R, Kowalchuk A, Mejia de Grubb M. Buprenorphine therapy for opioid use disorder. Am Fam Physician. 2018;97(5):313–320.

18. Nielsen S, Larance B, Degenhardt L, Gowing L, Kehler C, Lintzeris N. Opioid agonist treatment for pharmaceutical opioid dependent people. Cochrane Database Syst Rev. 2016;(5):CD011117.

19. Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014;(2):CD002207.

20. Degenhardt L, Bucello C, Mathers B, et al. Mortality among regular or dependent users of heroin and other opioids. Addiction. 2011;106(1):32–51.

21. Gowing L, Ali R, White JM, Mbewe D. Buprenorphine for managing opioid withdrawal. Cochrane Database Syst Rev. 2017;(2):CD002025.

22. LeFevre ML. Screening for hepatitis B virus infection in nonpregnant adolescents and adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;161(1):58–66.

23. Moyer VA. Screening for hepatitis C virus infection in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;159(5):349–357.

24. American Association for the Study of Liver Diseases. Infectious Diseases Society of America. HCV guidance: recommendations for testing, managing, and treating hepatitis C. https://www.hcvguidelines.org/evaluate/testing-and-linkage. Accessed October 4, 2018.

25. Moyer VA. Screening for HIV: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;159(1):51–60.

26. Kahwati LC, Feltner C, Halpern M, et al. Primary care screening and treatment for latent tuberculosis infection in adults. JAMA. 2016;316(9):970–983.

27. Centers for Disease Control and Prevention. Latent tuberculosis infection: a guide for primary health care providers. https://www.cdc.gov/tb/publications/ltbi/targetedtesting.htm. Accessed January 29, 2018.

28. LeFevre ML. Screening for chlamydia and gonorrhea: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;161(12):902–910.

29. LeFevre ML. Behavioral counseling interventions to prevent sexually transmitted infections: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;161(12):894–901.

30. Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015 [published correction appears in MMWR Recomm Rep. 2015;64(33):924]. MMWR Recomm Rep. 2015;64(RR-03):1–137.

31. Centers for Disease Control and Prevention. Tetanus among injecting-drug users—California, 1997. MMWR Morb Mortal Wkly Rep. 1998;47(8):149–151.

32. Hamborsky J, Kroger A, Wolfe C. Epidemiology and Prevention of Vaccine-Preventable Diseases: The Pink Book. 13th ed. Washington, DC: Public Health Foundation; 2015:484.

33. Centers for Disease Control and Prevention; Advisory Committee on Immunization Practices. Updated recommendations for prevention of invasive pneumococcal disease among adults using the 23-valent pneumococcal polysaccharide vaccine (PPSV23). MMWR Morb Mortal Wkly Rep. 2010;59(34):1102–1106.

34. Centers for Disease Control and Prevention. U.S. Public Health Service. Preexposure prophylaxis for the prevention of HIV infection in the United States—2017 update. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf. Accessed October 4, 2018.

35. AAFP. Chronic pain management and opioid misuse: a public health concern (position paper). http://www.aafp.org/about/policies/all/pain-management-opioid.html. Accessed January 30, 2018.

36. Centers for Disease Control and Prevention. HIV treatment as prevention. https://www.cdc.gov/hiv/risk/art/index.html. Accessed January 29, 2018.

37. Cohen MS, Chen YQ, McCauley M, et al. Antiretroviral therapy for the prevention of HIV-1 transmission. N Engl J Med. 2016;375(9):830–839.

38. Rodger AJ, Cambiano V, Bruun T, et al.; PARTNER Study Group. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy [published corrections appear in JAMA. 2016;316(6):667, and JAMA. 2016;316(19):2048]. JAMA. 2016;316(2):171–181.

39. Hind CR. Pulmonary complications of intravenous drug misuse. 2. Infective and HIV related complications. Thorax. 1990;45(12):957–961.

40. Centers for Disease Control and Prevention. HIV surveillance reports. 2016 edition, volume 28. November 2017. http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Accessed January 30, 2018.

41. Strathdee SA, Stockman JK. Epidemiology of HIV among injecting and non-injecting drug users. Curr HIV/AIDS Rep. 2010;7(2):99–106.

42. Choopanya K, Martin M, Suntharasamai P, et al. Antiretroviral prophylaxis for HIV infection in injecting drug users in Bangkok, Thailand (the Bangkok Tenofovir Study). Lancet. 2013;381(9883):2083–2090.

43. Fernandes RM, Cary M, Duarte G, et al. Effectiveness of needle and syringe programmes in people who inject drugs. MC Public Health. 2017;17(1):309.

44. Wilson DP, Donald B, Shattock AJ, Wilson D, Fraser-Hurt N. The cost-effectiveness of harm reduction. Int J Drug Policy. 2015;26(suppl 1):S5–S11.

45. Wodak A, Cooney A. Do needle syringe programs reduce HIV infection among injecting drug users. Subst Use Misuse. 2006;41(6–7):777–813.

46. AAFP. Substance abuse and addiction. 2016. https://www.aafp.org/about/policies/all/substance-abuse.html#syringe. Accessed January 30, 2018.

47. Takahashi TA, et al. US hospitalizations and costs for illicit drug users with soft tissue infections. J Behav Health Serv Res. 2010;37(4):508–518.

48. Hope VD, Hickman M, Parry JV, Ncube F. Factors associated with recent symptoms of an injection site infection or injury among people who inject drugs in three English cities. Int J Drug Policy. 2014;25(2):303–307.

49. Binswanger IA, Kral AH, Bluthenthal RN, Rybold DJ, Edlin BR. High prevalence of abscesses and cellulitis among community-recruited injection drug users in San Francisco. Clin Infect Dis. 2000;30(3):579–581.

50. Larney S, Peacock A, Mathers BM, Hickman M, Degenhardt L. A systematic review of injecting-related injury and disease among people who inject drugs. Drug Alcohol Depend. 2017;171:39–49.

51. Schnall SB, Holtom PD, Lilley JC. Abscesses secondary to parenteral abuse of drugs. J Bone Joint Surg Am. 1994;76(10):1526–1530.

52. Summanen PH, Talan DA, Strong C, et al. Bacteriology of skin and soft-tissue infections. Clin Infect Dis. 1995;20(suppl 2):S279–S282.

53. Ramakrishnan K, Salinas RC, Agudelo Higuita NI. Skin and soft tissue infections. Am Fam Physician. 2015;92(6):474–483.

54. Stevens DL, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections. Clin Infect Dis. 2014;59(2):e10–e52.

55. Pieper B, Templin T. Chronic venous insufficiency in persons with a history of injection drug use. Res Nurs Health. 2001;24(5):423–432.

56. Pieper B, Templin T. Lower extremity changes, pain, and function in injection drug users. J Subst Abuse Treat. 2003;25(2):91–97.

57. Selwyn PA, Feingold AR, Hartel D, et al. Increased risk of bacterial pneumonia in HIV-infected intravenous drug users without AIDS. AIDS. 1988;2(4):267–272.

58. Boschini A, Smacchia C, Di Fine M, et al. Community-acquired pneumonia in a cohort of former injection drug users with and without human immunodeficiency virus infection. Clin Infect Dis. 1996;23(1):107–113.

59. Darke S, Duflou J, Torok M. The health consequences of injecting tablet preparations. Addiction. 2015;110(7):1144–1151.

60. Overland ES, Nolan AJ, Hopewell PC. Alteration of pulmonary function in intravenous drug abusers. Am J Med. 1980;68(2):231–237.

61. Goldstein DS, Karpel JP, Appel D, Williams MH Jr. Bullous pulmonary damage in users of intravenous drugs. Chest. 1986;89(2):266–269.

62. Levine M, Iliescu ME, Margellos-Anast H, et al. The effects of cocaine and heroin use on intubation rates and hospital utilization in patients with acute asthma exacerbations. Chest. 2005;128(4):1951–1957.

63. Barocas JA, Hull SJ, Sosman JM, et al. Medical and legal consequences of ongoing drug use among young injection drug users infected with hepatitis C virus. In: Abstracts from the 36th Annual Meeting of the Society of General Internal Medicine. April 24–27, 2013. Denver, Colorado, USA. J Gen Intern Med. 2013;28(suppl 1):S120.

64. Phillips KT, Stein MD. Risk practices associated with bacterial infections among injection drug users in Denver, Colorado. Am J Drug Alcohol Abuse. 2010;36(2):92–97.

65. Brown PD, Levine DP. Infective endocarditis in the injection drug user. Infect Dis Clin North Am. 2002;16(3):645–665.

66. Murdoch DR, Corey GR, Hoen B, et al. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century. Arch Intern Med. 2009;169(5):463–473.

67. Ortiz-Bautista C, López J, García-Granja PE, et al. Current profile of infective endocarditis in intravenous drug users. Int J Cardiol. 2015;187:472–474.

68. Kim JB, Ejiofor JI, Yammine M, et al. Surgical outcomes of infective endocarditis among intravenous drug users. J Thorac Cardiovasc Surg. 2016;152(3):832–841.e1.

69. Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis in adults [published corrections appear in Circulation. 2015;132(17):e215, and Circulation. 2016;134(8):e113]. Circulation. 2015;132(15):1435–1486.

70. Maraj S, Figueredo VM, Lynn Morris D. Cocaine and the heart. Clin Cardiol. 2010;33(5):264–269.

71. Hawley LA, Auten JD, Matteucci MJ, et al. Cardiac complications of adult methamphetamine exposures. J Emerg Med. 2013;45(6):821–827.

72. Ziu M, Dengler B, Cordell D, Bartanusz V. Diagnosis and management of primary pyogenic spinal infections in intravenous recreational drug users. Neurosurg Focus. 2014;37(2):E3.

73. Patel AR, Alton TB, Bransford RJ, et al. Spinal epidural abscesses. Spine J. 2014;14(2):326–330.

74. Miller DJ, Mejicano GC. Vertebral osteomyelitis due to Candida species. Clin Infect Dis. 2001;33(4):523–530.

 

 

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