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

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.

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